Urinary tract infection (UTI) and invasive bacterial infection (IBI) prevalence lessened in infants during the COVID-19 pandemic, according to a recent study.

Annually, about 200,000 infants aged under 60 days showing signs of fever are analyzed in United States emergency departments (EDs). On average, 7% to 10% of these infants present with UTI, and 2% with IBI. Age effects IBI prevalence, with infants aged under 21 days having an IBI rate of 4% and infants aged 29 to 60 days having an IBI rate of 2%.

After the start of the COVID-19 pandemic in March 2020, the transmission of respiratory infections decreased, leading to a lower number of febrile infants being evaluated in EDs. This cause a greater proportion of UTI and IBI to be observed in infants for the following year.

Studies observing higher UTI and IBI rates were conducted at a single health system, and none took place beyond March 2021. Therefore, knowledge on UTU and IBI prevalence across the pandemic is necessary for accurate decisions to be made on hospitalizations and other treatment factors.

To evaluate UTI and IBI prevalence in infants aged 8 to 60 days throughout the pandemic, investigators conducted a multicenter cross-sectional study. The study period took place from November 1, 2020, to March 31, 2022, across 97 hospitals.

Participants included full-term infants aged 8 to 60 days with an observed temperature of over 38 degrees Celsius in the previous 24 hours, who were previously healthy and well-appearing. Infants present with bronchitis, specific bacterial infections, receipt of antibiotics or immunizations in the previous 48 hours, or those ill-appearing were excluded.

Data included demographic information, along with urine, blood, and cerebrospinal fluid (CSF) results. COVID-19 testing results were also included, and if an infant had a return visit within 7 days, they were tested for UTI and IBI.

UTI and IBI prevalence was the primary outcome, examined in the overall study population and in separate age groups. Changes in the prevalence of UTI, overall IBI, and bacteremia both with and without meningitis were the secondary outcomes. Presence of a positive urinalysis determined UTI, while a priori defined pathogen growth in the blood or CSF determined IBI.

Of the 9112 infants included in the study, 18% were aged 8 to 21 days, 12% were aged 22 to 28 days, and 70% were aged 39 to 60 days. All US census regions were included in the sample, and 5% of infants were born in Canada. Freestanding children’s hospitals evaluated 61% of infants, operationally dependent hospitals evaluated 29%, and general hospitals evaluated 10%.

UTI was seen in 603 infants, bacteremia without meningitis in 163, and bacterial meningitis in 43. As age increased, prevalence of every infection type decreased. A 14.9% infection rate was seen in infants aged 8 to 21 days, which decreased to 11.2% in infants aged 22 to 28 days, and 5.6% in infants aged 29 to 60 days.

Chances of all infection types decreased each month from November 2020 to March 2022. The UTI infection rate was 11.2% in November 2020, which was the highest infection rate during the study period. This reached a low of 3% in January 2022.

Bacteremia without meningitis reached its highest rate of 4.5% in November 2020, and its lowest rate of 0.3% in August 2021. Bacteremia meningitis reached its highest rate of 1.7% in February 2021, and its lowest rate of 0% in March 2022. IBI reached its highestrate of 6.1% in February 2021, and its lowest rate of 0.4% in January 2022.

The UTI rate was 4.1% in March 2022, while the IBI rate was 1.4%. This showed an overall decrease in UTI and IBI prevalence during the COVID-19 pandemic.

Aronson PL, Kerns E, Jennings B, Magee S, Wang ME, McDaniel CE, et al. Trends in prevalence of bacterial infections in febrile infants during the COVID-19 pandemic. 

 2022;150(6). doi:10.1542/peds.2022-059235

Articles

In a recent study, rates of urinary tract infections and invasive bacterial infections in infants aged under 60 days saw a downward trend monthly after the start of the COVID-19 pandemic.

Infant UTI and IBI prevalence decreased during COVID-19 pandemic

You can reach her a lcarr@mjhlifesciences.com.

Investigators conducted a study to gather a baseline assessment of abortion incidence and service delivery prior to 

They collected data from all facilities known to have provided abortion services in the US in 2019 and 2020 and examined abortion incidence by state, region, and nationally and combined data on number of abortions with population data to estimate abortion rates. Additionally, they looked at the number of abortion clinics, trends in medication abortion and service disruptions and changes in abortion protocols due to COVID-19. They then compared their findings to the previous Abortion Provider Census from 2017.

As for their findings, they ultimately documented 930,160 abortions in 2020, which was an 8% increase from 2017. Abortion incidence, investigators found, increased in all 4 regions of the country and in majority of states between 2017 and 2020. The total number of clinics providing abortion care stayed stable nationally, but increased in the Midwest and West, declining in the Northeast and South. For medication abortions, investigators found a total of 492,210 in 2020, which was a 45% from 2017. They also found that a substantial minority of clinics adjusted protocols in response to COVID-19, most commonly adopting remote pre- and post-abortion counseling.

The investigators ultimately found that the long-term decline in abortion in the US has reversed. The number of abortions increased overall between 2017 and 2020 and the abortion rate increased 7%. They also found that the overwhelming majority of abortions (96%) were provided by abortion clinics, and they play an important role in access to care. According to investigators, while there were changes in clinic numbers for many states, they were not always in ways that suggested increased abortion.

Perhaps most interestingly, investigators found that medication abortions provided in a clinical setting increased substantially during the study period, and for the first time, accounted for the majority of abortions in 2020.

Jones RK, Kirstein M, Philbin J. Abortion incidence and service availability in the United States, 2020. 

Perspectives on Sexual and Reproductive Health

. Published online November 20, 2022. doi:10.1363/psrh.12215

Investigators conducted a study to gather a baseline assessment of abortion incidence and service delivery prior to Roe v Wade being overturned earlier this year. 

Pre-Roe abortion services and trends in US 

Uterine anomalies are associated with higher rates of pregnancy complications, including spontaneous abortion, ectopic pregnancy, preterm labor, malpresentation, and abruption. Obstetricians should understand the embryology, incidence, classifications, and management of patients with uterine anomalies during pregnancy.

The process of uterine and vaginal development begins in the first trimester. The bilateral müllerian (paramesonephric) ducts develop into the uterus, fallopian tubes, cervix, and proximal vagina. These ducts fuse and internal canalization of each duct will produce 2 channels divided by longitudinal septum. The septum will typically resorb throughout the second trimester. The urogenital sinus will also separate into the distal vagina and urethra. Resorption anomalies represent persistence of the longitudinal uterine or vaginal septum. Transverse anomalies include obstructing vaginal septa or
cervical atresia.

Classification and diagnosis of uterovaginal anomalies

The American Society for Reproductive Medicine (ASRM) Müllerian Anomalies Classification (MAC) system, updated in 2021,

 categorizes the range of anomalies by descriptive terms and includes müllerian agenesis, cervical agenesis, unicornuate uterus, uterus didelphys, bicornuate uterus, septate uterus, longitudinal vaginal septum, transverse vaginal septum, and complex anomalies. An online interactive classification is available online. To view the ASRM MAC 2021 online, please scan the QR code.

To differentiate uterine anomalies, imaging or direct visual examination of the contour of external uterus and the endometrial cavity is required. To differentiate the bicornuate from septate from arcuate uterus, ideally, a line can be drawn from cornua to cornua. If the external contour indents more than 10 mm, the uterus is bicornuate. If there is less than 10-mm external contour indentation and less than a 10-mm fundal cavitary indentation with the leading angle of the indentation greater than 90°, the diagnosis is arcuate uterus. If the indentation extends more than 10 mm into the cavity and the leading angle is less than 90°, the diagnosis is septate uterus.

Optimal tests include 3D transvaginal ultrasound, MRI, saline sonohysterography, or laparoscopy or laparotomy combined with hysteroscopy or hysterosalpingogram (HSG; 

 Less sensitive diagnostic tests include 2D transvaginal ultrasound, clinical assessment at cesarean section, as well as hysteroscopy or HSG without external uterine contour evaluation.

 A pregnancy will alter the contour of the uterine fundus and repeat imaging after resolution of the pregnancy is more likely to result in an accurate diagnosis.

MRI images allow visualization of the patent and nonpatent uterine anatomy. This image is diagnostic for a left unicornuate uterus with patent vagina (outlined arrow) and a functional right noncontiguous uterine horn (solid arrow).

(Image courtesy of Anne-Marie Amies Oelschlager, MD.)

A complete septate uterus. The arrow points to the septum at the level of the internal os of the cervix. The septum extends into the cervix. Note that the leading angle of the septum in the endometrial cavity is less than 90°, and there is a flat external fundal contour.

Studies using optimal imaging have identified uterine anomalies in
5.5% to 9.8% of the general population, in 16.7% of those with recurrent miscarriage, and in 24.5% of those with a history of miscarriage and infertility.

 A study of uterine evaluation during cesarean sections noted that 5% were found to have a uterine anomaly: 71.0% were septate uteri, 19.4% were bicornuate uteri, 6.4% were unicornuate uteri, and 3.2% were didelphic uteri.

Anorectal, cardiac, limb, ear, skeletal, and especially renal anomalies have all been commonly associated with müllerian anomalies. Obstetricians should have a low threshold to consider renal imaging, as they may be present in
30% of those with fusion anomalies.

Arcuate uterus is the most common anomaly identified, but it does not appear to be associated with a higher rate of infertility or miscarriage by prospective studies.

 In general, the arcuate uterus is considered a benign variant; however, the remaining uterine anomalies confer a significantly higher risk of obstetric complications. The incidence of preterm birth before
37 weeks is approximately 40% for patients with known uterine anomalies. The highest risk of preterm labor is associated with uterine didelphys (56%), unicornuate uterus (43%), bicornuate uterus (39%), and septate uterus (31%).

 Congenital uterine anomalies are also associated with increased risk of first and second trimester loss, cervical insufficiency, premature rupture of membranes, fetal malpresentation, fetal growth restriction, placental abruption, placenta previa, retained placenta, and cesarean birth
(

 For this reason, consultation with a maternal-fetal medicine specialist during pregnancy is recommended.

Limited data suggest that cervical length screening for short cervix (< 25 mm) and fetal fibronectin screening may be useful for predicting preterm birth in those with septate uteri. The data have not shown a consistent predictive benefit for those with unicornuate, didelphic, or bicornuate uteri.

Most studies of 17-hydroxyprogesterone caproate (17-OHPC) for prevention of premature birth did not include those with a history of congenital uterine anomalies. In a small retrospective cohort study of 48 women with congenital uterine anomalies, there was an equally high rate of recurrent preterm birth in those who received 17-OHPC and those who did not. 17-OHPC has not been demonstrated to prolong pregnancy in women with uterine malformations or prenatal diethylstilbestrol exposure.

Patients with a history of cervical atresia may have had reconstructive surgery to create a patent cervix. In those who can become pregnant, case reports have suggested that abdominal cerclage with planned cesarean delivery is warranted.

 There are limited data to suggest that cerclage may decrease the rate of preterm delivery in those with bicornuate uteri with cervical incompetence.20

Historically, hysteroscopic uterine septum resection has been recommended for those with a history of recurrent pregnancy loss, preterm labor, and infertility.

 In case control studies, hysteroscopic metroplasty has been associated with a higher live birth rate and lower spontaneous abortion rate but has also been associated with higher rates of preterm delivery, cesarean section, and fetal malpresentation compared with those with uterine septum who did not have surgery.

A multinational multicenter trial randomly assigned 80 women with a septate uterus to septum resection or expectant management. Live births occurred in 31% who had septum resection compared with 35% who did not have surgery.

 It appears that uterine septum resection may benefit select patients with recurrent fetal loss, but their risk of obstetric complications is still significantly elevated. If the septum extends into the cervix, resection of the cervical component has not been typically recommended due to concern for an increased risk of cervical incompetence.

The incidence of cesarean delivery in those with uterine anomalies is significantly higher, likely because of a combination of higher rates of abruption, preterm labor, and malpresentation. The risks of abruption and failure of external cephalic version (ECV) may be higher in patients with uterine anomalies; however, there have been case reports of successful ECV.

If a longitudinal vaginal septum is identified during a pregnancy, the septum can be resected prior to labor in the operating room or during the first stage or early second stage of labor prior to pushing. Clamping and resecting the intervening septal tissue should be done with extreme care to avoid the bowel, urethra, and the cervices. Use of the LigaSure device (Medtronic) has also been described.

 After vaginal delivery, the vagina should be carefully inspected, hemostasis assured, and gaps in the mucosa should be reapproximated using absorbable suture.

Many patients with obstructive uterovaginal anomalies will present in adolescence or prior to puberty. Some patients may have had vaginal septum resection for a transverse vaginal septum or may have had a vaginal pull-through procedure for distal vaginal atresia. Interposition vaginal grafts, including buccal mucosa or bowel grafts, may have been used to bridge the gap between the upper and lower vagina. 

In these situations where interposition grafts or residual septal tissue is present, and there is a concern for vaginal obstruction, planned cesarean delivery is recommended. Additionally, for those who have had anorectal malformations with a history of anoplasty or reconstructive urological procedures where continence may be negatively impacted by vaginal delivery, planned cesarean delivery should be offered. For any patient with a uterovaginal anomaly, aberrant urologic anatomy, including pelvic kidneys and ectopic and duplicate ureters, are common. Obstetricians should be vigilant during operative deliveries to avoid injury to the urinary system.

Obstetricians should be prepared for an increased rate of retained placenta after vaginal delivery in patients with uterine anomalies. Ultrasound-guided management of instrumentation during removal of retained placental tissue is recommended

Management of therapeutic and spontaneous abortion

For those with 2 cervices, a history of vaginal septum resection, or long interposition vaginal grafts, uterine evacuation can be challenging, with increased difficulty visualizing and dilating 1 or both cervices. For those with a uterine septum, bicornuate uterus, or uterine didelphys, care must be taken to avoid inadvertent instrumentation of the wrong cervix and uterine horn. For those with congenital reproductive tract anomalies, procedures should be performed with ultrasound guidance.

 Operative hysteroscopy may facilitate guided entry into the cavity if dilation with ultrasound guidance alone is not successful.

 Although rare, there are case reports of ectopic pregnancies occurring in asymmetric or noncommunicating uterine horns. MRI may be useful if a pregnancy is visualized by ultrasound but is not accessible through uterine instrumentation and cannot be visualized through hysteroscopy.

Uterine anomalies are common in the general population and are associated with a higher risk of obstetric complications. Optimal imaging is recommended for accurate diagnoses. Consultation with a maternal-fetal medicine specialist is recommended during pregnancy. 

Pfeifer SM, Attaran M, Goldstein J, et al. ASRM müllerian anomalies classification 2021.

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Kougioumtsidou A, Mikos T, Grimbizis GF, et al. Three-dimensional ultrasound in the diagnosis and the classification of congenital uterine anomalies using the ESHRE/ESGE classification: a diagnostic accuracy study. 

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Imboden S, Müller M, Raio L, Mueller MD, Tutschek B. Clinical significance of 3D ultrasound compared to MRI in uterine malformations. 

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Mohamed MA, AbdelRahman MY. Frequency and types of uterine anomalies during caesarean section. 

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Chan YY, Jayaprakasan K, Zamora J, Thornton JG, Raine-Fenning N, Coomarasamy A. The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review. 

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Dreisler E, Stampe Sørensen S. Müllerian duct anomalies diagnosed by saline contrast sonohysterography: prevalence in a general population.

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Saravelos SH, Cocksedge KA, Li TC. Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal. 

. 2008;14(5):415-429. doi:10.1093/humupd/dmn018

Jaslow CR, Kutteh WH. Effect of prior birth and miscarriage frequency on the prevalence of acquired and congenital uterine anomalies in women with recurrent miscarriage: a cross-sectional study.

. 2013;99(7):1916-22.e1. doi:10.1016/j.fertnstert.2013.01.152

Acién P, Acién M, Mazaira N, Quesada-Rico JA. Reproductive outcome in uterine malformations with or without an associated unilateral renal agenesis.

Heinonen PK. Pregnancies in women with uterine malformation, treated obstruction of hemivagina and ipsilateral renal agenesis. 

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Prior M, Richardson A, Asif S, et al. Outcome of assisted reproduction in women with congenital uterine anomalies: a prospective observational study. 

. 2018;51(1):110-117. doi:10.1002/uog.18935

Hua M, Odibo AO, Longman RE, Macones GA, Roehl KA, Cahill AG. Congenital uterine anomalies and adverse pregnancy outcomes. 

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Kim MA, Kim HS, Kim YH. Reproductive, obstetric and neonatal outcomes in women with congenital uterine anomalies: a systematic review and meta-analysis.

. 2021;10(21):4797. doi:10.3390/jcm10214797

Takami M, Aoki S, Kurasawa K, Okuda M, Takahashi T, Hirahara F. A classification of congenital uterine anomalies predicting pregnancy outcomes. 

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Panagiotopoulos M, Tseke P, Michala L. Obstetric complications in women with congenital uterine anomalies according to the 2013 European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy classification: a systematic review and meta-analysis. 

. 2022;139(1):138-148. doi:10.1097/AOG.0000000000004627

Hughes KM, Kane SC, Haines TP, Sheehan PM. Cervical length surveillance for predicting spontaneous preterm birth in women with uterine anomalies: a cohort study. 

. 2020;99(11):1519-1526. doi:10.1111/aogs.13923

Ridout AE, Ibeto LA, Ross GN, et al. Cervical length and quantitative fetal fibronectin in the prediction of spontaneous preterm birth in asymptomatic women with congenital uterine anomaly. 

. 2019;221(4):341.e1-341.e9. doi:10.1016/j.ajog.2019.05.032

Hynes JS, Schwartz AR, Abdalla A, Manuck TA, Dotters-Katz SK. 17-hydroxyprogesterone caproate for women with congenital uterine anomalies: does it impact the risk of recurrent preterm birth? 

. 2021;3(1):100278. doi:10.1016/j.ajogmf.2020.100278

Schaible B, Haught E, Vozar A, et al. Abdominal cerclage in a patient with a neocervix with planned cesarean hysterectomy at delivery. 

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Yassaee F, Mostafaee L. The role of cervical cerclage in pregnancy outcome in women with uterine anomaly. 

Hickok LR. Hysteroscopic treatment of the uterine septum: a clinician’s experience. 

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Loddo A, D’Alterio MN, Neri M, Masala F, Cane FL, Melis GB. Pregnancy complications after hysteroscopic metroplasty: a ten-year case-control study. 

Carrera M, Pérez Millan F, Alcázar JL, et al. Effect of hysteroscopic metroplasty on reproductive outcomes in women with septate uterus: systematic review and meta-analysis. 

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Rikken JFW, Kowalik CR, Emanuel MH, et al. The randomised uterine septum transsection trial (TRUST): design and protocol. 

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Mirzai S, Wolf SB, Mili S, Rifai AO. Successful external cephalic version in a patient with uterus didelphys and fetal malpresentation. 

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Ryu S, Baek HW, Lee I, et al. Operative hysteroscopy-assisted pregnancy termination after failed surgical abortion in missed abortion of woman with complete septate uterus. 

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Clinical pearls for assessment and management of the pregnant patient with a uterovaginal anomaly.

Uterine anomalies in pregnancy

; Professor and Chair of Obstetrics and Gynecology; and Gillette Professorship of Obstetrics and Gynecology at 

Emerging from a period during which routines were upturned, rules discarded, and reality significantly altered, we as leaders try to piece together the new normal. Many leaders and employees alike yearn for a return to the old way of doing things, but it is clear that people appreciate and want to continue with remote work, telework, telemeetings, and flexible schedules. Given the competitive workforce, changing personal priorities, and decreased loyalty to employers, leaders must adapt to the current environment if they want to retain staff.

Leading now is different than leading during the crisis of the COVID pandemic. Looking back at those who succeeded leading during the pandemic, we can see that they took bold, decisive—and often surprising and unexpected—action. For instance, the season suspension by the NBA commissioner on March 11, 2020—the same day the World Health 

Organization formally designated coronavirus as a pandemic but before public gatherings were restricted—reduced the spread of the virus and resulted in others taking similar actions. Bold leaders acted decisively and did not downplay risk or delay action. They sought novel solutions in keeping with the requirements of the moment and the changing workplace.

Leading in the post-pandemic climate requires the assimilation of a workplace that has altered dramatically. A survey by McKinsey & Company asked people why they were leaving their jobs without another one to replace it 

 Respondents said they did so due to uncaring leaders, unsustainable work performance, and a lack of career progression and meaningful work. 

Leaders who push to return to the pre-pandemic workplace face resistance from individuals who want to continue working remotely or in a hybrid model. This need must be balanced by the desire for inclusivity, to feel part of a team, and connected to the practice or institution. Walking the line between providing flexibility and inclusivity is a major challenge for us today.

As obstetrician-gynecologist leaders in our offices, hospitals, clinics, and academic institutions, we are now also challenged by the current political and social climate

Identifying opportunities to ensure access to care and training, and navigating the new laws and regulations means an added layer of requirements, which keep leaders for our specialty in crisis mode. Thus, we must remember the lessons learned during the pandemic and those the current climate presents to us.

Be decisive, identify a course, continually monitor progress, and adjust the course as needed

Leverage the crisis to create opportunities

Be transparent, honest, and
admit mistakes

However, in the meantime we must embrace crisis leadership that fits for the current climate. This includes creating an environment that engages employees, recognizes that flexibility is critical, and offers opportunities for inclusivity and a sense of belonging. As leaders we must make the workplace welcoming, issue clear messaging that assures employees they are important to the organization, and develop opportunities for their growth. An environment that encourages two-way communication is likewise essential, as employees who have a voice are more likely to feel—and be—engaged and less likely to leave. 

Furthermore, their ideas are often valuable and instrumental to progress. Two qualities that are essential for leaders in obstetrics and gynecology are empathy and getting your hands dirty. Empathy goes a long way toward helping employees understand we are human and can see their point of view. Helping when needed enhances our approachability and gives us insight into the challenges and opportunities faced daily by staff.

In short, although it feels good to leave the pandemic behind, as obstetric and gynecology leaders we continue to have crisis issues to handle as well as new expectations to meet from a changed workforce. The new laws and regulations keep us in crisis mode. However, we can and must incorporate the lessons the pandemic taught us to create post-pandemic opportunities. 

Catherine Y. Spong, MD,editor in chief, is professor and vice chair in the Department of Obstetrics and Gynecology and chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas, Texas. She holds the Gillette Professorship of Obstetrics and Gynecology.
Email her at cspong@mjhlifesciences.com

1. De Smet A, Dowling B, Mugayar-Baldocchi M, Schaninger B. Gone for now, or gone for good? How to play the new talent game and win back workers. McKinsey & Company. March 9, 2022. Accessed November 1, 2022. https://www.mckinsey.com/capabilities/people-and-organizational-performance/our-insights/gone-for-now-or-gone-for-good-how-to-play-the-new-talent-game-and-win-back-workers

Although leadership in our post-pandemic climate is probably no more challenging than at any other time, it certainly feels that way.

Leadership in the new reality

A large, retrospective cohort study published in 

 concluded that infertile women with adenomyosis have adverse fertility outcomes, especially an increase likelihood of miscarriage and obstetric complications from assisted reproductive technology (ART) treatment.

The authors noted that although adenomyosis is common among infertile women, it is unclear whether the condition has a detrimental effect on 

 fertilization and embryo transfer (IVF-ET) results.

The study was conducted at Peking University Third Hospital’s Reproductive Centre, in China, where the investigators assessed the medical records of all women who had their first cycle of IVF/intracytoplasmic sperm injection (ICSI) treatment between January 2011 and December 2020.

Patients were identified via the hospital’s online record system. The three inclusion criteria were women with adenomyosis, aged 40 years or younger at the time they began IVF/ICSI treatment; women diagnosed by at least two experienced sonographers and indicating a uterine volume of ≥ 56 cm3; and women with freshly stimulated and day 3 cleavage-stage transfer cycles and tubal factor infertility screened by hysterosalpingography or laparoscopy.

The study enrolled 1,146 patients with adenomyosis and 1,146 frequency-matched control women in a 1:1 ratio, based on age, body mass index (BMI) and basal follicle-stimulating hormone (FSH) level.

The control group had a normal uterus and received IVF treatment for tubal factor infertility, but otherwise met the same selection criteria.

There was no significant difference in clinical pregnancy rate between the two groups: 38.1% for women with adenomyosis and 41.6% for controls (

However, the implantation rate and live birth rate were significantly lower in women with adenomyosis than in the controls: 25.6% vs. 28.6% (

The miscarriage rate in the adenomyosis group was also higher than in the control group: 29.1% vs. 17.2% (

But after adjusting for confounding factors, multivariate analysis showed the clinical pregnancy rate was not statistically different between the two groups: odds ratio (OR) = 0.852 (

Still, in the adenomyosis group, the rate of miscarriage, placenta previa and preeclampsia were increased significantly compared to the control group: OR = 1.877 (

Conversely, the live birth rate among women with adenomyosis was reduced significantly in contrast to the control group: OR = 0.541 (

Two feasible mechanisms for increased miscarriage risk in adenomyosis are that disruptions at the endometrial–myometrium interaction influence endometrial features and that inflammatory responses and inordinate free radical formation can lead to abnormal implantation and miscarriage, according to the authors.

“Alterations in the inner myometrium in women with adenomyosis may be at the root of faulty reshaping of the myometrial spiral arteries from the initiation of decidualization, resulting in vascular resistance and an increased risk of defective deep placentation,” wrote the authors.

The study offers comprehensive insight into the adverse effect of adenomyosis on IVF-ET outcomes and obstetric complications, thus underscoring the importance of full consultation and active use of ART for women with adenomyosis.

Clinical and basic studies are also needed to develop more effective treatments for adenomyosis and improve outcomes.

Liang T, Zhang W, Pan N, et al. Reproductive outcomes of 

 fertilization and fresh embryo transfer in infertile women with adenomyosis: a retrospective cohort study. 

The authors noted that although adenomyosis is common among infertile women, it is unclear whether the condition has a detrimental effect on in vitro fertilization and embryo transfer (IVF-ET) results.

IVF and fresh embryo transfer for women with adenomyosis

Exploring Ibrexafungerp for the Treatment of Vulvovaginal Candidiasis

Michael L. Krychman, MD, and Jack D. Sobel, MD, review the mechanisms of ibrexafungerp and how it might fit in the treatment spectrum for RVVC.

Impact of state mandatory IVF insurance coverage

State infertility insurance mandates are critical for improving access to infertility care. They also help to advance gender equality and reproductive rights.

IVF for women with previous recurrent ectopic pregnancy

Women with previous recurrent ectopic pregnancy (EP) have a significantly lower risk of EP following in vitro fertilization (IVF), compared to women with previous single EP, according to a retrospective cohort study published in the journal PLOS One.

Pre-Roe abortion services and trends in US

Investigators conducted a study to gather a baseline assessment of abortion incidence and service delivery prior to Roe v Wade being overturned earlier this year.

In case you missed it: December 4 to December 9

Prevalence of Candida species with IUD placement

Three months after copper intrauterine device (IUD) insertion, nearly 1/3 of women were diagnosed with vulvovaginal candidiasis, compared to nearly 25% of women who received a hormonal IUD, according to a prospective study published in the journal Cellular and Molecular Biology.

Not only for football and safety but also for productivity and efficiency.

Laparoscopy remains the gold standard for diagnosis and treatment of the disease.

Stay tuned for more articles as they go live! 

Take a look inside this month's issue of Contemporary OB/GYN. 

Inside the issue: December 2022

Michelle Kendall was a scientist. She had a scientific mindset and tackled problems strategically. When she was diagnosed with ovarian cancer, she took those skills and put them to use. She followed the doctor’s treatment plans until they stopped working and then she started her own scientific pursuit into medical cannabis research—going so far as to personally fund research in Israel with Dr. Hinanit Koltai of the Volcani Institute. Michelle also documented her experience in the film Schedule 1, which is available for free on 

. Tragically, Michelle passed away from her ovarian cancer before seeing the research efforts fully come to fruition. However, her husband Bruce Kendall and Professor Koltai are continuing the efforts that Michelle started and hoping to one day find improved treatment options for patients with ovarian cancer. Here, Bruce and Professor Koltai share their story and the current state of their research into medical cannabis.

This research is still moving forward today, with the most recent findings published in early November 2022 in the journal 

 (1). That article was part of a special issue called “Natural Compounds with Activity against Ovarian Cancer: In Memory of Michelle Kendall, an Ovarian Cancer Warrior” (2).

Bruce, can you tell us about your background and how you and your wife, Michelle Kendall, started Canna Onc Research?

: I'm a professor of environmental science and ecology at University of California, Santa Barbara. That's completely unrelated to how we got into cannabis medicine. But I do have a background broadly in biology, and Michelle also worked in the environmental field. So, we were both environmental scientists.

Back in the winter of 2016 Michelle was diagnosed with advanced stage ovarian cancer. She responded well to the initial treatment, but had a recurrence after about a year, setting a pattern in motion of repeated treatment, remission, and recurrence.

Toward the end of her second remission, Michelle was introduced to the idea of medical cannabis by a neighbor who was a retired physician. Never having used anything stronger than alcohol, she started taking cannabis with great trepidation, hoping for nothing more than better sleep. At the same time, she was getting bloodwork for a cancer marker every three weeks. At this point, the levels were starting to increase as her next recurrence began. She quickly noticed that the rate at which the marker increased or even whether it increased at all was dramatically affected by whether she was using cannabis during those three weeks and what sort of cannabis she was taking—whether it was high tetrahydrocannabinol (THC), high cannabidiol (CBD), or so forth. She talks about this quite a bit in the movie we produced called “Schedule 1.” She started reading about cannabis and cancer online, discovering “crazy” patient testimonials claiming that cannabis cured their cancer. But with a background in science, she was unfazed by the peer-reviewed literature and dove into PubMed reading the preclinical studies on cannabis and cancer that, at that point, were just starting to accelerate. Michelle also watched lots of videos of talks by the scientists who were working in this field.

So that was exciting because we really saw that cannabis had potential through our personal experiences. And all through this I was cheering her on, but she was really leading the charge to learn about medical cannabis. When she showed me the literature on the endocannabinoid system, I realized that there's real science, there's a real biological mechanism here. I really became convinced. So, there we were. The challenge was, as we know, that cannabis is a complex plant biochemically and cancer is also very complex. And every cancer, it seems like, is different in its underlying mode of action. So, finding a cannabinoid-based treatment for glioblastoma doesn't necessarily say anything about what's going to work for ovarian cancer. And it was clear that there were probably some key cannabinoids that she needed to be focusing on. But at that time, as far as we could find, nobody was doing research on cannabis in ovarian cancer.

So, in the summer of 2020, Michelle started contacting scientists who were working in the cannabis and cancer space, and Professor Hinanit Koltai (PhD) responded enthusiastically. From there, she and Michelle had a series of conversations about what Michelle was looking for in terms of finding which cannabinoids might be most effective in treating ovarian cancer. Professor Koltai’s laboratory at the Volcani Institute in Israel is leading research on cannabis and cannabinoids to identify optimal combinations of cannabis compounds for the treatment of different medical conditions. Professor Koltai came up with a proposed research plan, and we came up with some money from our personal savings. Then we then formed the company Canna Onc Research as a venue to contract with Professor Koltai’s organization to fund research in her lab to identify the key cannabinoids that are most effective in killing ovarian cancer cells in lab culture. So, that was how it all got started—it was Michelle trying to hack her way to finding the set of cannabinoids that might treat her disease.

Professor Koltai, can you share a little bit about your background, how you how you felt about getting involved with the Kendalls, and an update on where things stand with your research?

: Yes, I'm a senior research scientist at Volcani Institute. Volcani Institute is a governmental institute in Israel for agricultural research. I have been a scientist at Volcani for more than 20 years now and I have worked on several different subjects during my career. At some point, when I became a full professor grade scientist, I began to feel that I was not fulfilling my destiny. I worked on the very interesting subject of plant hormones, but I felt that it was not enough. So, my lab and I turned to the research of medicinal plants.

This gave me and my team the clear aim of having products that could benefit people, could benefit patients. We bear this aim in mind. The interest in cannabis started to rise worldwide. When I started to read more about it, most of the research papers were quite old at that time. When I started to read and study the subject of medical cannabis use, I realized that there was a gap in knowledge in the medical use of this plant, among other things of course. This gap was based on the lack of knowledge about the active compounds. What I mean is that there were quite a number of scientific papers that were describing the use of the whole flower, of the inflorescence as we call it, or maybe full spectrum extracts. There were quite a number of scientific papers that described the use of a single compound from cannabis such as THC or CBD. But nobody looked at the composition of compounds from cannabis that could be efficient, beneficial, or optimal for the treatment of different medical conditions.

Cannabis produces hundreds of different compounds as a species, and in each strain you can find several dozen compounds that are being produced. And yet, even today, for medical use, people are looking primarily at CBD or THC. You can find high CBD extract or flowers or high THC extract or flowers. This is maybe fine for recreational use, but it's not good enough for medical use. This is because we know and we have found that cannabis compounds can act in synergy and therefore, finding the best combination of compounds for the treatment of specific disease is highly important. We believe that finding that best combination can lead to proper and efficient use of cannabis. So here I laid out in a few words our basic thinking and hypothesis as well as the aims that drive our research.

About two years ago or so, I got an email. At that time, I used to get quite a number of emails from different entities or commercial companies that asked me about our activity. One of the emails asked me very shortly if we're working on ovarian cancer. And of course, this email was from Michelle. I answered her as I answered everybody and said, no, unfortunately, we have not yet started working on ovarian cancer. Although even at that time, I have to say that we had up until today, two main questions: One, what is the best composition of compounds from cannabis for the treatment of inflammation? And two, what is the best composition of compounds from cannabis that may act as an anti-cancer agent? But at that time, indeed, we were not working on ovarian cancer.

So, Michelle asked me if maybe I would be interested in working on cannabis and this disease. And I said, let's talk. Then we had a Zoom meeting and from the first moment, I was completely captivated by Michelle’s personality, by her hope, and interest in cannabis. I was completely convinced after talking with her that this should be one of the avenues that we should take on with our research. So, since then, we have been collaborating. In the last year of Michelle's life, we were able to move forward together and to uncover initial findings.

Can you please share some of the most interesting findings from the study so far? And how do those relate back to Michelle's journey?

: During our collaboration, what we were able to find is the actual combination of compounds, of vital cannabinoids, and cannabinoids from cannabis that act efficiently and specifically against ovarian cancer cells. We started with cell lines, with cells of ovarian cancer, and looked for different composition of compounds from cannabis.

In this recent interview, Bruce Kendall and Dr. Hinanit Koltai of the Volcani Institute share the inspiring story of the late Michelle Kendall and how her passion for science and research brought them all together to study medical cannabis as a potential treatment for ovarian cancer.

In case you missed it: December 4 to December 9

Inside the issue: December 2022

Ovarian cancer and medical cannabis research: Michelle Kendall’s legacy of research, advocacy, and change

The importance of huddles

Surgical treatments for endometriosis

Infant UTI and IBI prevalence decreased during COVID-19 pandemic

Pre-Roe abortion services and trends in US

Uterine anomalies in pregnancy

Leadership in the new reality

IVF and fresh embryo transfer for women with adenomyosis