The COVID-19 pandemic has stressed healthcare systems in the United States and globally. Limited hospital resources, increasing patient surge, and growing demands on healthcare providers have led to the United States Surgeon General and the Centers for Medicare & Medicaid Services calling for suspension of all nonessential adult elective surgery and medical procedures. As of March 27, 2020, 30 states had issued similar declarations related to elective procedures in the setting of the continuing COVID-19 pandemic. Two major questions have emerged as these events have unfolded: (1) What is the definition of an "elective" procedure? and (2) Are there specialty-specific considerations for obstetric and gynecologic procedures? This article provides insights into each of these questions and provides a working framework for obstetrician/gynecologists to advocate for their patients and coordinate with their hospital systems to develop "elective" procedure guidelines that incorporate considerations for women's and maternal health.

OBJECTIVE: To uncover potential genes and biological processes that contribute to breast cancer development. STUDY DESIGN: We studied gene expression profiles, which are publicly available from the Gene Expression Omnibus database, for the 2 most prevailing subtypes of breast cancer: lobular and ductal invasive breast carcinomas. RESULTS: We identified a total of 98 genes that shared regulation pattern in both subtypes of breast carcinoma. Further functional annotations indicated that 124 biological processes and 8 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were over-represented, such as cell surface receptor signaling pathway. We also identified unique gene expression profiles in each subtype of breast cancer. A total of 460 genes were solely differentially expressed between ductal cancer cells and normal cells, and 75 biological processes and 10 KEGG pathways were enriched by these 460 differential genes, including cell proliferation and regulation of cell death. Meanwhile, 308 genes were found to be differentially expressed between lobular cancer cells and normal cells. Intriguingly, only 11 biological processes and 8 KEGG pathways showed overrepresentation among these 308 genes, such as collagen metabolic process. CONCLUSION: Cumulatively, our results indicate that the invasive lobular and ductal carcinomas share a similar profile of gene expression and pathway alteration but also harbor subtype-specific mechanisms of tumorigenesis.

OBJECTIVE: To analyze the related causes for no embryos transferred in assisted reproductive technology (ART) in order to provide corresponding coping measures for infertile couples. STUDY DESIGN: The data of 607 couples who underwent ART and had no embryos transferred in our reproductive center between January 2010 and January 2014 were retrospectively analyzed. RESULTS: The cycles of no embryos transferred accounted for 3.99% (607/15,224) of total cycles. Of those, complete fertilization failure, oocyte retrieval failure, and complete abnormal fertilization accounted for 28.3% (172/607), 25.7% (156/607) and 22.24% (135/607), respectively. The incidence of complete abnormal fertilization was higher in IVF than in ICSI (p<0.05). In both IVF and ICSI cycles, the incidences of no embryos transferred were higher in the patients retrieving ≤3 oocytes than in the patients retrieving >3 oocytes (p<0.05). In IVF cycles the incidences of no embryos transferred were higher in the patients with primary infertility than in those with secondary infertility (p<0.05). CONCLUSION: The main causes of no embryos transferred are complete fertilization failure, oocyte retrieval failure, and complete abnormal fertilization. Retrieving adequate number of mature oocytes is the key to success of ART. Patients who experienced complete abnormal fertilization in IVF or the patients with primary infertility who experienced complete fertilization failure or normal fertilization without cleavage should receive ICSI in the next treatment.

OBJECTIVE: To investigate the trend of cesarean section (CS) delivery rate and CS indications between January 2009 and December 2013 at Hassan II Hospital, Settat, Morocco. STUDY DESIGN: The demographic characteristics of women who gave birth at the hospital during the study period were collected. A total of 36,965 puerperal patients (aged 14–52 years at 33–42 weeks’ gestation) were enrolled. Delivery outcomes and the indication for CS delivery were studied. RESULTS: The CS rate increased from 11.48% in 2009 to 14.76% in 2013 (p<0.05), and the perinatal mortality rate decreased from 3.34% in 2009 to 2.24% in 2013 (p<0.05). The 3 most common indications for CS delivery were previous lower segment CS, cephalopelvic disproportion, and intrauterine growth restriction. CONCLUSION: There is a trend of increasing CS rate at Hassan II Hospital. Previous lower segment CS, cephalopelvic disproportion, and intrauterine growth restriction are the 3 most common CS indications.

OBJECTIVE: To evaluate whether magnetic resonance imaging (MRI) contributes to ultrasound for the evaluation of fetal central nervous system (CNS) anomalies. The secondary objective was to investigate whether MRI adds more information regarding the evaluation of specific pathologies or conditions. STUDY DESIGN: We retrospectively compared fetal MRI findings with ultrasound findings in CNS anomalies with respect to certain pathologic groups. Additionally, we evaluated diagnostic accuracy by comparing fetal MRI and ultrasound findings with postnatal findings. RESULTS: A total of 34 patients had 40 provisional diagnoses by fetal ultrasound, and of those patients 14 had a provisional diagnosis of ventriculomegaly and 14 had a provisional diagnosis of cerebellar or posterior fossa anomalies. MRI added to or changed the diagnosis in 52.5% of the patients with CNS abnormalities. The contribution rate in ventriculomegaly was 71.4%, and MRI changed the diagnosis in all indefinite diagnoses by ultrasound. Additionally, of the 15 patients with postnatal findings, there were no cases in which only the ultrasound findings were correct, but the MRI findings were incorrect. CONCLUSION: MRI contributes to ultrasound in the diagnosis of CNS anomalies. Cases of indefinite diagnosis and ventriculomegaly by ultrasound had greater benefit from MRI.

While prenatal 3D ultrasonography results in improved diagnostic accuracy, no data are available on biometric assessment of the fetal frontal lobe. This study was designed to assess feasibility of a standardized approach to biometric measurement of the fetal frontal lobe and to construct frontal lobe growth trajectories throughout gestation.

OBJECTIVE: To investigate if administration of an additional dose of gonadotropins concomitantly to human chorionic gonadotropin (hCG) trigger increases pregnancy rates in patients undergoing intrauterine insemination (IUI) with controlled ovarian hyperstimulation (COH). STUDY DESIGN: This is a retrospective cohort study of all gonadotropin-IUI cycles performed by a single physician in a private practice between January 2012 and September 2013. Control cycles were those in which follicle-stimulating hormone (FSH) was discontinued prior to the day of hCG trigger shot, and study cycles received continuous FSH including the day of hCG trigger shot. A total of 423 cycles from 239 patients were included; 275 (65.5%) were control cycles (137 patients), and 146 (34.7%) were study cycles (102 patients). RESULTS: Pregnancy rates were comparable in both control and study groups (15.27% vs. 15.07%, respectively, p=0.956). There was a 42% increase in multiple gestations in the study group; however, the difference was not statistically significant (p=0.155). Upon multivariate logistic regression, male factor infertility was the only variable that was associated with pregnancy outcomes. CONCLUSION: Continuous administration of FSH including the day of hCG trigger in patients undergoing COH with IUI does not seem to increase pregnancy rates. Our suggested protocol might be beneficial in patients with poor ovarian response.

OBJECTIVE: To evaluate the correlation between em-bryo morphology and antepartum biomarker levels and obstetric outcomes following single embryo transfers (SETs). STUDY DESIGN: In vitro fertilization patients who delivered at the study site’s partnering hospital were included. Embryo morphology was compared to antepartum biomarkers and pregnancy outcomes. RESULTS: At a single academic reproductive endocrinology/infertility center, 2,882 SETs (day 3, 5, or 6) were performed from July 1, 2001, to June 30, 2013. Embryologic, serologic, and obstetric outcomes were available for 78 patients (cleavage [n=23]; blastocyst [n=55]). Embryos with a lower quality inner cell mass (ICM) demonstrated higher second trimester maternal serum alpha-fetoprotein (AFP) (p=0.0241) and AFP multiple of median (MoM) (p= 0.0036). After adjusting for age, body mass index, parity, and smoking status, this statistical significance remained (p=0.0319 for AFP; p=0.0026 for AFP MoM). CONCLUSION: Embryo morphokinetics did not correlate with perinatal outcome or a majority of placental biomarkers. A low ICM score was associated with higher second trimester maternal serum AFP values. This warrants further investigation, especially due to the risks of potential adverse obstetric outcomes associated with high AFP levels. Despite these findings, no difference in obstetric outcomes between low and high ICM scores was observed after controlling for maternal confounding variables. Patients should be reassured that embryo implantation, regardless of morphological score, results in similar obstetric outcomes.

OBJECTIVE: To investigate the histomorphometric alterations induced in testicular tissues by variable sizes of silver nanoparticles (SNPs). STUDY DESIGN: Male mice (BALB/C) were treated with SNPs (1 mg/kg) using 5 different sizes (10, 20, 40, 60, and 100 nm) for 35 days. Testicular biopsies from all mice under study were examined histomorphologically. RESULTS: SNPs sized 10 and 20 nm had provoked morphometric changes in the testes of the subjected mice together with the following histological alterations: seminiferous tubules, degeneration, spermatocyte cytoplasmic vacuolation, spermatocyte sloughing, and spermatid giant cell formation. Larger SNPs (40, 60, and 100 nm) induced little or no testicular histomorphometric alterations. CONCLUSION: The findings of the present work may indicate that subchronic exposure to SNPs could have a deleterious impact on the testicular tissues and spermatogenic process that could affect fertility and reproduction, with smaller SNPs being more toxic than larger ones.

OBJECTIVE: To evaluate the effects of 1.765 GHz microwave on fetal testicular gene expression in mice. STUDY DESIGN: We used a 1.765 GHz microwave generator with 26.7 dBm output power on average and with the estimated specific absorption rate of 0.38–1.71 W/kg. Twelve mice in the experimental group had been exposed to 1.765 GHz micro-waves for 8 hours every day. The testicular gene expression extracted from the neonates separated from all the offspring were compared with microarray and reverse transcription polymerase chain reaction (RT-PCR). RESULTS: There was no significant difference between the mice in the 2 groups in regards to birthweight of offspring, number of offspring, the pregnancy period, or maternal body temperature during the experimental period. The differences of the numbers of testicular gene expression between the 2 groups were observed using measurements obtained by the microarray. We found 3 (Tssk2, Ovol1, and Mea1) downregulated genes confirmed by real-time RT-PCR. CONCLUSION: The expression of Tssk2, Ovol1, and Mea1 in the experimental group was downregulated lower than those in the control group by real-time RT-PCR.

OBJECTIVE: To determine if autologous endometrial cell coculture improves embryo development and clinical outcomes. STUDY DESIGN: Patients who met the inclusion criteria were randomized to either traditional in vitro fertilization (IVF) (control, n=73) or autologous endometrial cell coculture (AECC) (n=61). All patients underwent endometrial biopsy on cycle day 5–10 post luteinizing hormone surge. A total of 129 patients underwent embryo transfer (69 control, 60 AECC). Clinical outcomes as well as embryonic quality measures were then compared between the 2 groups. RESULTS: The mean age, day 3 follicle-stimulating hormone, number of oocytes collected, and clinical outcomes were similar between the 2 groups. Embryo development was overall similar, with the exception that embryonic grade was significantly better with AECC than with control: 1.5 (0.04) vs. 2.6 (0.03), p<0.0001. There was no difference in implantation, live birth or multiple gestation rates. CONCLUSION: This is one of the largest prospective randomized controlled trials of AECC versus traditional IVF. There was significant improvement in embryo morphology in the coculture group, although clinical outcomes were similar between the groups. Further studies are necessary to achieve enough power to fully delineate the effects of coculture on IVF outcome.

BACKGROUND: Birth-related injuries are a well-known complication of vaginal breech deliveries but are not anticipated during cesarean breech deliveries. However, long bone fractures in the neonate can result from delivery of the breech presentation by cesarean section. CASES: We report 2 cases of long bone fractures that occurred during cesarean section for breech presentation. No underlying bone pathology or systemic illness could be identified in either case. There were no other predisposing risk factors for fractures except breech presentation. Both infants were managed with cast application and outpatient physical therapy and recovered without any residual deformity. CONCLUSION: Obstetricians should be aware of the possibility of long bone fractures with abdominal breech deliveries. Their prompt recognition and conservative management, including physical therapy, can prevent bone deformities.

BACKGROUND: Homologous Robertsonian translocation carriers have been considered to have no chance, theoretically, of having a normal embryo. For these carriers, traditional genetic counseling would suggest using donated sperm or oocyte rather than using their own gametes. CASE: This study reports the case of a 45,XY,t(21;21)(q10;q10) homologous Robertsonian translocation carrier who had an approximately normal offspring with a mosaic karyotype: 46,XX,[86]/46, XX,t(21;21)[14]. CONCLUSION: Carriers of homologous Robertsonian translocations might have a chance of having normal offspring. For these carriers, besides traditional assisted reproductive technology such as using gametes from a donor, preimplantation genetic diagnosis might have clinical value.

OBJECTIVE: To determine whether the Bayes classifier can be used to distinguish between an ectopic and intrauterine pregnancy following embryo transfer based on early human chorionic gonadotropin (hCG) levels. STUDY DESIGN: Retrospective chart review of patients undergoing in vitro fertilization and diagnosed with a singleton intrauterine or with an ectopic pregnancy. Blood was drawn for hCG levels between days 12 and 20 after transvaginal oocyte aspiration. Statistical analysis was performed using a mixed effects model and the Bayes classifier. RESULTS: Singleton intrauterine (n=91) and ectopic gestations (n=14) were analyzed. hCG levels increased by 51% daily in both groups, but levels in ectopic pregnancies were only 14% of those from the control group on the same day (p<1×10-15). Using the Bayes classifier, an hCG value <18 IU/L indicated a large probability (>75%) that the pregnancy was ectopic. There was no statistically significant difference in regards to endometrial thickness (p=0.77), fresh or frozen embryo transfer (p=0.53), number of embryos transferred (p=0.13), donor or autologous oocytes (p=0.76), or the day of hCG draw (p=0.13 and 0.43 for first and second measurement). CONCLUSION: The Bayes classifier can be used as a tool to alert the healthcare provider of a possible ectopic gestation.

OBJECTIVE: To compare the resection margin (RM) status and postoperative severe hemorrhage using different loop electrosurgical excision procedure (LEEP) techniques for cervical intraepithelial neoplasia (CIN) 2/3 treatment. STUDY DESIGN: We retrospectively reviewed 278 patients who underwent LEEPs for CIN 2/3 treatment at our institute between 2005–2014. In type A surgery (N=148), a ring-shaped loop was used. If the first pass failed to remove the entire lesion, separate loop excisions for the intracervical portion were performed. In type B surgery (N=130), a right-angled triangular loop in a single pass was used. Surgical outcomes and postoperative severe hemorrhage were compared between the two groups. Logistic regression analysis was performed to identify the independent predictors of RM status. RESULTS: The mean LEEP depth was larger after type A surgery (2.2 vs. 2.0 cm, respectively; p=0.04). Type B surgery showed lower rate of 30-day postoperative hemorrhage (13.8% vs. 26.4%, p<0.05) and higher rate of negative RM (68.9% vs. 82.3%, p<0.05). Multivariate analysis identified the surgery type (p=0.01, OR=0.45 [0.24–0.83]) and a postoperative pathological diagnosis of CIN3 (p=0.01, OR=2.53 [1.22–5.26]) as independent risk factors for positive RM. CONCLUSION: LEEPs using a right-angled triangular loop could reduce positive RMs.

OBJECTIVE: To evaluate the role of capecitabine in the management of gestational trophoblastic neoplasia (GTN). STUDY DESIGN: The medical records of 155 patients with GTN were reviewed. All patients were treated and followed at our center. RESULTS: All patients were scored and stratified with the FIGO 2000 staging and risk factor scoring system for gestational trophoblastic disease. In the low-risk group (118 patients), 4 selected patients received capecitabine as second line of treatment, with a 75% response rate and long-term disease-free survival, and 1 of those patients needed EMA/CO to achieve cure. The cure rate was 100%. In the high-risk group 37 patients were reviewed. Capecitabine was indicated after EMA/CO or EMA/PE failure in the second, third, or sixth line. Six patients received capecitabine, with a 50% response rate, and remain as long-term survivors. Two patients who progressed with capecitabine were cured with TP/TE and EMA/PE regimens. One patient was refractory to all lines of chemotherapy. CONCLUSION: The use of capecitabine avoids multi-ple drug schemes and further toxicity for patients with curative disease, where long-term effects of therapy should be considered a second target. Its convenient oral route of administration and efficacy make capecitabine a drug to be taken into account in future studies of patients with GTN showing progression to standard regimens. Its use as new regimen in these patients must be evaluated. A greater number of cases and ideally a randomized study is needed to confirm our observation.

OBJECTIVE: To evaluate the efficacy of varicocele repair in patients with nonobstructive azoospermia. STUDY DESIGN: Ten patients with nonobstructive azoospermia and clinical varicoceles who underwent varicocele repair were retrospectively investigated. According to the postoperative appearance of motile spermatozoa in the ejaculate, the patients were divided into 2 groups: Responder and Nonresponder. The outcomes of each group were investigated. RESULTS: There were 4 (40%) patients in the Responder group. Serum follicle-stimulating hormone levels were significantly higher in the Nonresponder group than in the Responder group (19.9±6.4 IU/mL vs. 10.8± 4.0 IU/mL, p<0.05). Mean sperm concentration was 5.4 million spermatozoa/mL in the Responder group. One patient achieved a spontaneous pregnancy, and another achieved an assisted pregnancy. In the Nonresponder group 5 patients underwent microdissection testicular sperm extraction (micro-TESE) postoperatively. In 1 patient, motile spermatozoa were successfully retrieved. Histopathological findings in the other 4 patients were Sertoli-cell-only. CONCLUSION: The present study suggested that varicocele repair could be considered in men with nonobstructive azoospermia who have clinical varicoceles. Moreover, varicocele repair seemed to improve sperm retrieval rate during micro-TESE for those in the Nonresponder group.

Glauco Baiocchi, M.D., Ph.D., Maria Dirlei Begnami, M.D., Ph.D., Michael Jenwei Chen, M.D., Elza Mieko Fukazawa, M.D., Ph.D., Levon Badiglian-Filho, M.D., Ph.D., Antonio Cassio Assis Pellizzon, M.D., Ph.D., Fernando Augusto Soares, M.D., Ph.D., and Ademar Lopes, M.D., Ph.D. OBJECTIVE: To evaluate HER-2 expression as a predictor of the response to radiotherapy and its value as a prognostic marker. STUDY DESIGN: A retrospective analysis was performed in a series of 34 individuals with advanced stage cervical cancer who underwent radiotherapy followed by radical hysterectomy. HER-2 expression was measured by immunohistochemistry in biopsies from all patients prior to radiotherapy and in 14 patients with residual tumors after radiotherapy. The presence of gene amplification was also examined. RESULTS: Eighteen (53%) patients had residual disease after radical hysterectomy. HER-2 was expressed in 26.5% of cases. Gene amplification by FISH was detected in 2.9% of cases. HER-2 expression was associated with a higher risk of residual disease after radiotherapy (p= 0.019). HER-2 expression did not correlate with the risk of recurrence or death. CONCLUSION: The prevalence of HER-2 expression is low in cervical cancer, and although HER-2 can predict the response to radiotherapy, it does not correlate with poor outcomes.

OBJECTIVE: To investigate the function and underlying mechanism of transforming growth factor–beta (TGF-β)/bone morphogenetic protein (BMP) signaling pathway in early unexplained miscarriage. STUDY DESIGN: Expression profiles of genes involved in TGF-β/BMP signaling pathway were compared between placental villous tissue samples from 2 women with missed abortion and those from 2 women with induced abortion by microarray assay. The protein expression level of the most downregulated gene—LEFTY1—was further measured using western blotting in another 8 women with missed abortion and 7 women with induced abortion. RESULTS: A total of 24 genes showed differential expression level between the 2 groups. Their functions were further investigated, of which 6 of 13 upregulated genes were TGF-β responsive genes. The most reduced gene is LEFTY1, an antagonist of TGF-β ligand. The protein expression level of LEFTY1 was confirmed to show the same trend as microarray using western blotting. CONCLUSION: A reduced expression of LEFTY1 in women with missed abortion was identified as com-pared with women with induced abortion, which may result in a dysregulation of TGF-β signaling and may be the underlying mechanism of missed abortion.

OBJECTIVE: To review the safety and efficacy of administering various prostaglandin formulations to achieve cervical ripening and spontaneous vaginal delivery in women near or at term. STUDY DESIGN: Peer-reviewed clinical research articles in English and searchable on PubMed.com. A thorough literature search was conducted on PubMed.com using the following terms: [misoprostol], [dinoprostone], [prostaglandin E1], [prostaglandin E2], [PGE1], [PGE2], [cervical ripening], [induction of labor]. RESULTS: The review shows conflicting opinions concerning the safety and efficacy of current standard-of-care formulations for cervical ripening. A gold standard option for optimal treatment has not been confirmed. CONCLUSION: While the clinical evidence suggests that prostaglandin E1 (PGE1) and E2 (PGE2) both could be used for cervical ripening when no contraindications are present, PGE2 formulations remain the only commercially available prostaglandin products for cervical ripening approved by the U.S. Food and Drug Administration. We conclude that more research is warranted on the risks of treatment-emergent adverse events and serious complications during induction of labor.

OBJECTIVE: To evaluate the effect of obesity on clinical parameters and pregnancy rates in infertile women with polycystic ovary syndrome (PCOS), who have undergone ovulation induction. STUDY DESIGN: This retrospective study included 177 women with PCOS who presented to our gynecological endocrinology outpatient clinic for diagnosed infertility. All of the patients initially received clomiphene citrate (CC), and if CC resistance was noted, gonadotropins were used. The patients were classified into 2 groups according to BMI (<30 kg/m2=control group and ≥30 kg/m2=study group). Pregnancy was assessed by β-hCG levels and a visible gestational sac in the endometrium. RESULTS: The demographic and hormonal parameters were similar between the groups. The mean duration of infertility was longer in the study group (p<0.05). In the study group, cycle cancellation due to CC resistance (p=0.039) and mean baseline LH levels (p=0.026) was statistically more likely than in the control group. On follow-up, 4 (9.3%) patients in the study group had conceived and 26 (19.4%) patients in the control group had conceived (p=0.041). CONCLUSION: Obesity adversely affects pregnancy rates in women with PCOS who undergo ovulation induction cycles. Clinicians should recommend weight loss in these patients before ovulation induction.