Current Opinion in Obstetrics and Gynecology (CURR OPIN OBSTET GYN )

Publisher: Lippincott, Williams & Wilkins


Topics Covered: Gynecologic oncology and pathology; Maternal-fetal medicine and prenatal diagnosis; Prenatal diagnosis; Fertility; Reproductive endocrinology; Endoscopic surgery; Adult and pediatric gynecology; Urogynecology; General Obstetrics.

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    Current opinion in obstetrics & gynecology, Current opinion in obstetrics and gynecology
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Lippincott, Williams & Wilkins

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Publications in this journal

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    Current Opinion in Obstetrics and Gynecology 01/2009; 21(1):1-3.
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    ABSTRACT: To present the options and the results in the management of poor responders in in-vitro fertilization. There is no controlled ovarian hyperstimulation protocol which is best suited for all poor responders. Low dose gonadotropin-releasing hormone agonist regimes appear to be most advantageous. Prediction of compromised response prior to cycle initiation by a thorough assessment of ovarian reserve as well as a careful review of past responses could allow for a more appropriate selection of a controlled ovarian hyperstimulation protocol for each individual patient. Optimistic data have been presented by the use of high doses of gonadotropins, flare up gonadotropin-releasing hormone agonist protocols (standard or microdose), stop protocols, luteal onset of gonadotropin-releasing hormone agonist, and short protocols. Natural cycle also seems to be an appropriate strategy to be considered. There is no universal definition for the 'poor responder'. Numerous strategies have been proposed to improve ovarian stimulation in poor responders, but none of them is the ideal for all such patients. More data from good quality controlled trials are needed.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):374-8.
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    ABSTRACT: By the current review we aim to describe different options for laparoscopic hysterectomy in patients with endometrial cancer and discuss the reported risk factors and limitations of laparoscopic hysterectomy in surgical staging of endometrial cancer. Laparoscopic techniques and equipment have matured over the last 15 years and are now widely used to treat patients with endometrial cancer, thereby potentially reducing perioperative morbidity and postoperative pain, and providing shorter hospital stay, faster recovery and improved quality of life compared with the corresponding open procedures. However, some risk factors are postulated to limit the use of laparoscopic hysterectomy in staging of endometrial cancer. Surgical staging of endometrial cancer by laparoscopic hysterectomy is feasible and well tolerated. This surgical approach does not seem to affect recurrence and overall survival rates. Limitations of laparoscopic hysterectomy in management of endometrial cancer need to be evaluated.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):337-44.
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    ABSTRACT: To review current available literature on the relationship between fibroids and infertility with particular emphasis on the benefits of myomectomy. Pregnancy complications related to the presence of these lesions and to their removal are also addressed. There is a biological plausibility supporting a causal relationship between fibroids and infertility. From a clinical point of view, this association is mostly supported by studies comparing pregnancy rate following IVF in women with and without fibroids. The emerging view is that submucosal, intramural and subserosal fibroids interfere with fertility in decreasing order of importance. There is one randomized controlled trial supporting the benefits of myomectomy in infertile women with fibroids. The beneficial effects of surgery are further supported by insights from clinical series showing that the pregnancy rate following myomectomy is satisfactory and by the strong benefits documented in the few nonrandomized comparative studies. An increased rate of obstetric complications has been reported in women carrying fibroids. Data regarding the course of pregnancy in operated women are scanty. The most significant (although rare) complication is rupture of the uterus during pregnancy or labour. At present, owing to the lack of adequately designed trials aimed to clearly establish that lesions benefit from surgery, a comprehensive and personalized approach should be adopted. The most important variables to be considered are the age of the woman, the characteristics of the fibroids, the concomitant presence of fibroids-related symptoms and the presence of other causes of infertility.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):379-85.
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    ABSTRACT: In the practice of 'bioidentical hormone therapy', it is our belief that pharmacists are compounding bioidentical hormone therapy with the best intentions. These pharmacists are, however, ill informed regarding the lack of scientific underpinning associated with the efficacy and safety of the practice of bioidentical hormone therapy. It is the purpose of this review to systematically examine the scientific rigor of the arguments posed by the proponents of bioidentical hormone therapy, and to differentiate the practice of bioidentical hormone therapy from the legitimate practice of pharmacy compounding. Most medical organizations have in essence refuted the bioidentical hormone therapy claims as unsubstantiated. The profession of pharmacy needs to address this issue in an authoritarian, scientific way, outside of the compounding issue. Bioidentical or natural hormones are expected to have similar efficacy and safety profiles as the commercially available hormonal therapies that have been studied in clinical trials, regardless of whether the active principle hormones are compounded by individual pharmacies or manufactured by large companies. Estriol is a weak estrogen that is not Food and Drug Administration approved for use as a prescription drug in the United States; thus, clinical trials are necessary to demonstrate the efficacy and safety profile for estriol. Further, supplementary clinical trials are necessary to determine whether there are efficacy or safety differences between natural progesterone and synthetic progestin, as studies to date are inconclusive.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):400-7.
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    ABSTRACT: Two hundred and fifty thousand gynaecological laparoscopies are performed yearly in the UK, many of them diagnostic. Unless a patient has major endometriosis and needs advanced surgery, the Royal College of Obstetricians and Gynaecologists suggest a 'see and treat' policy. Thus, gynaecologists who undertake laparoscopy should be competent at performing intermediate level laparoscopic surgery, including excision of endometriosis, adhesions and benign ovarian tumours, rather than converting to laparotomy or referring patients to another unit. In order to reduce operative risk and make best use of resources, preoperative assessment should triage patients into those with unlikely pelvic pathology who do not require laparoscopy in the first instance, those with severe endometriosis, who need referral to a specialist centre and the intermediate group who is best served with a 'see and treat' policy. Appraisal of alternatives to diagnostic laparoscopy in infertility assessment and recent reports of modified ultrasound scanning improve the predictive value and will help to avoid unnecessary laparoscopies. Preoperative predictors for severe endometriosis can determine who needs specialist referral. 'See and treat' laparoscopies require adequate education, and workable training methods are under investigation. Negative laparoscopies should be avoided and 'see and treat' laparoscopy should replace diagnostic procedures. Thorough preoperative assessment helps to identify women suitable for 'see and treat' laparoscopy.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):325-30.
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    ABSTRACT: To review operative procedures, specific risks, complications and evaluation of efficacy of Essure tubal sterilization performed simultaneously with endometrial ablation. Dysfunctional uterine bleeding is a significant health problem in premenopausal women. Endometrial ablation is an effective therapeutic option for the management of menorrhagia and an alternative to hysterectomy. Most women undergoing endometrial ablation are of reproductive age, and, because pregnancy after endometrial ablation could be complicated, many of these women require permanent birth control. Since the introduction of Essure tubal sterilization, this permanent contraception method has been widely used and offers an hysteroscopic approach similar to endometrial ablation techniques. Combining these two procedures offers the advantage of performing the two procedures simultaneously, but inherent rules and technical procedures must be followed to avoid any kind of injury such as heat conduction, material injuries, specific complications and specific follow-up. The combination of safety and efficacy of endometrial ablation and hysteroscopic sterilization makes a compelling argument for their concomitant use.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):359-63.
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    ABSTRACT: Multifetal pregnancies have skyrocketed over the past two decades as a consequence of infertility treatments. Multifetal pregnancy reduction has lowered the complications considerably. Here, we review the historical and current literature to determine reasonable statistics upon which to counsel patients Several papers in the past year have updated the database of outcomes, shown that prenatal diagnosis by fluorescent in-situ hybridization prior to reduction improves outcomes and examined the psychological and emotion frame through which patients view the circumstances and options available to them. Multifetal pregnancy reduction in experienced hands continues to dramatically improve the outcome of multiple pregnancies. The development of coping strategies for patients to deal with complex options and risks challenging their religious and other core beliefs now allows us to better counsel patients.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):386-93.
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    ABSTRACT: The purpose of this review is to discuss the evolutionary changes that have taken place in the area of electrosurgery. The distinct differences between devices along with disadvantages and ways of minimizing hazards will be analyzed. Since the first surgical application of electricity in the 1880s, the use of radiofrequency current in surgery has grown. Although monopolar and bipolar energy form the backbone of electrosurgery, various modifications have been made to both the electrosurgical generators and the hand instruments. Much of the driving force behind these modifications has been the goal of minimizing possible complications while improving surgical efficiency. Recently, the ability to obtain vessel sealing has dramatically impacted clinical practice in open, laparoscopic, and vaginal surgery. Current evidence demonstrates the effectiveness and safety of electrosurgical devices in gynecologic surgery. Technology has evolved to allow vessel sealing capability through various instruments. Critical to the successful use of these advanced electrosurgical devices is a thorough understanding of their individual differences and nuances in order to obtain the desired tissue effects. Further studies are needed to determine the most appropriate applications and surgical procedures for these devices.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):353-8.
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    ABSTRACT: Recently, various types of tension free vaginal tapes via retropubic and transobturator route (inside-out technique; outside-in technique) have been adopted for treatment of stress urinary incontinence. The aim of this review is to assess the recent evidence on effectiveness and complications of these tapes in stress urinary incontinence. There was no significant difference found between tension free vaginal tapes and colposuspension for the cure of stress urinary incontinence at 5 years in a multicentre randomized controlled trial. Vault and posterior vaginal wall prolapse were commoner after colposuspension. A recent systematic review and meta-analysis reported that subjective cure for inside-out technique (five randomized controlled trials) and outside-in technique (six randomized controlled trials) at 2-12 months was no better when compared with tension free vaginal tapes (odds ratio: 0.85; 95% confidence interval: 0.60-1.21). Bladder injuries (odds ratio: 0.12; 95% confidence interval: 0.05-0.33) and voiding difficulties (odds ratio: 0.55; 95% confidence interval: 0.31-0.98) were less common, whereas groin/thigh pain (odds ratio: 8.28; 95% confidence interval: 2.7-25.4) and vaginal injuries or mesh erosion (odds ratio: 1.96; 95% confidence interval: 0.87-4.39) were more common in transobturator tapes. Sexual function was overall improved; the pain being more with outside-in technique than inside-out technique route. The tension free tapes are effective in treating stress urinary incontinence; evidence for superiority of transobturator over retropubic tapes is currently limited.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):331-6.
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    ABSTRACT: To summarize our current knowledge about the predictability of intermittent ovarian function and the response to ovulation induction agents in patients with premature ovarian failure. In addition to clinical, histological or ultrasonographic features, a new biological marker anti-Müllerian hormone, was evaluated as a marker for ovarian reserve in premature ovarian failure patients with encouraging results. Moreover, even if no treatment has proven to be effective enough to restore ovarian function, a recent study has presented a therapeutic protocol leading to a significant increase in ovulation and a higher pregnancy rate. Intermittent ovarian function can be spontaneously observed in premature ovarian failure patients. Clinical, biological and ovarian ultrasonographic features may allow an assessment of the presence of ovarian activity, but are not necessarily correlated with a higher ovulation or pregnancy rate. Nevertheless, it appears essential to characterize these patients to determine whether some of them could be candidates who benefit from a particular therapeutic strategy, although most such strategies have not yet demonstrated their efficiency.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):416-20.
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    ABSTRACT: The purpose of this study is to review the impact of chemotherapy on fertility and to update the reader on the current state of fertility preservation techniques. Chemotherapy results in irreversible damage to ovarian follicles and stromal function, and alkylating agents cause the most significant damage to ovarian reserve. Options for fertility preservation range from well established techniques such as embryo cryopreservation to experimental ones such as ovarian tissue freezing. The safety and effectiveness of concomitant use of gonadotropin-releasing hormone analogues to prevent chemotherapy-induced follicle death is still debated. In-vitro maturation of germinal vesicle oocytes can be an option in patients who do not have sufficient time for ovarian stimulation. The impact of chemotherapy on future fertility is much more significant than is widely believed. Because of this, young females should be counseled about fertility preservation options. Fertility preservation requires an individualized approach. If possible these patients should be encouraged to utilize the most established assisted reproductive techniques. Although success of IVF with frozen-thawed embryos now approaches that of using fresh embryos, success rates with oocyte freezing are lower but these rates are on the rise. Even though ovarian tissue cryopreservation is still an experimental technique, currently it is the only fertility preservation option in children.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):408-15.
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    ABSTRACT: To review the current reproductive advances in insulin-sensitizing agents for treatment of polycystic ovary syndrome patients. To date, among insulin-sensitizing drugs, only metformin should be used to improve reproductive function in well selected polycystic ovary syndrome patients. Preliminary data seem to show beneficial effects of thiazolidinediones in improving metabolic and hormonal patterns and in restoring regular menses. The use of insulin-sensitizing drugs offers a new perspective for the treatment of polycystic ovary syndrome-related reproductive disorders. However, further data are needed before we can draw definitive conclusions regarding their clinical role.
    Current Opinion in Obstetrics and Gynecology 08/2008; 20(4):364-73.
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    ABSTRACT: In-vitro maturation of oocytes was primarily developed to make in-vitro fertilization safer and simpler for women with polycystic ovaries and high risk of ovarian hyperstimulation syndrome. In-vitro maturation has potentially many advantages over conventional in-vitro fertilization. A simple protocol with decreased or no hormonal stimulation before oocyte retrieval and thus lower cost of the treatment cycle are clear benefits. More importantly, the risk of ovarian hyperstimulation syndrome is entirely avoided. The clinical outcome has substantially improved in recent years with pregnancy rates between 20 and 54%. The birth of approximately 400 children has been reported in the literature, but about three times as many are known to have been born. The postnatal follow-up studies of the children have been reassuring. Although good results have been reported by some clinics, in-vitro maturation has not yet become a mainstream fertility treatment. The most important reason for this is the lower chance of a live birth per treatment compared with conventional in-vitro fertilization. Several aspects of the clinical in-vitro maturation need to be improved to give in-vitro maturation a place among assisted reproduction techniques it deserves.
    Current Opinion in Obstetrics and Gynecology 07/2008; 20(3):242-8.
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    ABSTRACT: The present review gives an overview of the potential use of traditional Chinese medicine in the treatment of infertility, including an evidence-based evaluation of its efficacy and tolerance. Recent studies demonstrated that traditional Chinese medicine could regulate the gonadotropin-releasing hormone to induce ovulation and improve the uterus blood flow and menstrual changes of endometrium. In addition, it also has impacts on patients with infertility resulting from polycystic ovarian syndrome, anxiety, stress and immunological disorders. Although study design with adequate sample size and appropriate control for the use of traditional Chinese medicine is not sufficient, the effective studies have already indicated the necessity to explore the possible mechanisms, that is, effective dose, side effect and toxicity of traditional Chinese medicine, in the treatment of infertility by means of prospective randomized control trial. The growing popularity of traditional Chinese medicine used alone or in combination with Western medicine highlights the need to examine the pros and cons of both Western and traditional Chinese medicine approaches. Integrating the principle and knowledge from well characterized approaches and quality control of both traditional Chinese medicine and Western medical approaches should become a trend in existing clinical practice and serve as a better methodology for treating infertility.
    Current Opinion in Obstetrics and Gynecology 07/2008; 20(3):211-5.
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    ABSTRACT: To perform a systematic review of the literature on the relationship between cigarette smoking and reproductive function. Whenever possible, this review is focused on the most recently published studies (mainly the past 2 years). Nevertheless, in many instances older literature was too relevant not to be taken into account. Tobacco compounds exert a deleterious effect on the process of ovarian follicle maturation. This effect is expressed by worse in-vitro fertilization parameters in cycles performed on women with smoking habits. Also, uterine receptiveness is significantly altered by the smoking habit. In men, cigarette smoking reduces sperm production, increases oxidative stress, and DNA damage. Spermatozoa from smokers have reduced fertilizing capacity, and embryos display lower implantation rates. Even in-utero exposition to tobacco constituents leads to reduced sperm count in adult life. A strong body of evidence indicates that the negative effect of cigarette smoking on fertility comprises fairly every system involved in the reproductive process. Couples in reproductive age should be strongly discouraged to smoke.
    Current Opinion in Obstetrics and Gynecology 07/2008; 20(3):281-91.
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    ABSTRACT: To investigate the impact of intrauterine devices on subsequent fertility. Intrauterine devices are safe, well tolerated and used by millions of women worldwide. Subsequent fertility is studied among women who remove the intrauterine contraceptive device for planning pregnancy or among women who have removed the intrauterine contraceptive device because of intrauterine contraceptive device-related complications and later on have become pregnant. Study participants are recruited from randomized clinical trials on intrauterine contraceptive device performance or in case series among women who remove the intrauterine contraceptive device. Pregnancy rates after removal are high and are similar to time-to-pregnancy rates in the general population. The birth rates are high with a normal distribution of preterm deliveries, normal birth weight and sex ratio of newborns. The ratio of extra-intrauterine pregnancies and the need for infertility work up are low, and the distribution of infertility causes among fully investigated couples is as seen in the general population. Despite small sample size of studies investigating impact of intrauterine contraceptive devices on subsequent fertility, the results are consistent and reassuring on high pregnancy rates, and a normal distribution of pregnancy outcomes. There are limited data on return of fertility after usage of medicated intrauterine contraceptive devices--more studies are warranted among women who have used hormone-releasing intrauterine contraceptive devices.
    Current Opinion in Obstetrics and Gynecology 07/2008; 20(3):275-80.