Kevin Dominique Tjandraprawira

Background: Vaginismus is a gynecologic disorder with persistent vaginal spasm whenever any penetration is attempted. This leads to a failure of penetration. Vaginismus’ true prevalence is unknown and reporting heavily biased. A similar condition is happening in Indonesia, where our facility treats > 200 new cases/year. No standardized vaginismus treatment protocol is available internationally, so this retrospective study evaluates our multidisciplinary assisted dilatation protocol and the obstetric outcomes of our patients. Methods: This is a retrospective cohort study of all patients presenting with vaginismus undergoing assisted dilatation between 01/01/2022 and 31/12/2023. Diagnosis is through the presence of vaginal muscle spasms precluding penetration and/or severe penetrative pain, as confirmed by history and physical examination. We included all patients undergoing assisted dilatation in this timeframe. We employed a standardised multidisciplinary approach involving gynaecologist, psychiatrist and specialist nurses. It combines botulinum toxin A injections, dilator exercises and psychiatric medications. Patients are followed up 6– 8 weeks post-dilatation and their obstetric outcomes are recorded through an online questionnaire. Results: We included 513 patients. 85.4% (438/513) presented due to failure of penetration. The average age at consultation was 30.39 ± 4.75 years. Most patients came from the island of Java (76.8%; 394/513), were undergraduates (83.3%; 309/371) and worked in the private sector (49.5%; 254/513). The median duration of vaginismus prior to presenting for treatment was 36 months (range 1– 252 months). 45.8% (235/315) had experienced medical trauma previously, 46.6% (239/513) had marital trauma and 56.7% (291/513) had social trauma. 61.2% (314/513) attended follow-up and 89.4% (281/314) achieved penetration post-discharge. 23.7% (52/219) displayed involuntary movements during follow-up examination. Patients required a median of 4 weeks to achieve penetration and most achieved penetration at 1^st attempt. 51% (159/312) reported pregnancy post-procedure with 85.1% (120/141) achieving it spontaneously. 9.2% (13/141) experienced splash pregnancies. 88% (102/116) of pregnancies were term but 94.2% (98/104) opted for caesarean section. Conclusion: Our assisted dilatation protocol, emphasizing on both multidisciplinary and multimodal approach, may be offered for standardized vaginismus treatment.

Introduction: Female technology or ‘femtech’ is the availability of mobile applications (apps) to monitor specific aspects of women’s health. It touts the benefits of technology to empower women with regards to their health, while also allowing close collaboration between patients and physicians. Endometriosis‐specific apps is a channel by which female patients discover their endometriosis diagnosis. However, there is currently a paucity of high‐quality and evidence‐based endometriosis apps. This study assessed the current state and overall quality of such apps. Materials and Methods: This retrospective study assessed patient‐centred endometriosis apps on the Apple iTunes Store, in January 2023, excluding certain categories such as conference guidance, gaming, private healthcare, and clinical trial apps. The key term “endometriosis” was used. All patient‐centred apps were included. The apps were assessed using the APPLICATIONS scoring system, considering objective factors like pricing, subscriptions, literature references, in‐app purchases, connectivity, advertisements, search fields, interoperability, and subjective elements such as navigation ease and presentation. The maximum score is 16 and all applications were assessed in English. Results: Out of the initial 22 apps, 12 (54.5%) were excluded, leaving 10 (45.5%) for analysis. Most apps lacked comprehensiveness, but two apps (LUNA‐endometriosis and Frendo) stood out with high scores. These apps incorporated certified scoring systems, provided recommendations for tests and follow‐up visits, and offered evidence‐based literature on endometriosis. The remaining apps scored poorly, focusing on alternative treatments, healthy diets, or functioning solely as symptom diaries, with limited information on diagnosis and management. Only a few apps allowed booking follow‐up visits, and most lacked the capability to export patient‐specific data. Few apps measured the likelihood of endometriosis whilst others relied on previous diagnoses. The majority of apps were free, whilst in‐app purchases centred around alternative treatments. Overall, the apps were user‐friendly, featuring vibrant colours and intuitive interfaces. Conclusions: Only two patient‐centred endometriosis apps scored highly in the APPLICATIONS scoring system as they were high‐quality, evidence‐based and incorporated valid medical recommendations. Other applications scored low as their recommendations lacked quality scientific evidence.

Introduction: Coexistence of Mayer-Rokitansky-Kuster-Hauster syndrome (MRKH) with other conditions is rare, especially when MRKH was found in a young woman presenting with ovarian malignancy. This case report wishes to highlight MRKH complicated with giant mucinous cystadenoma and bilateral inguinal hernia. Case report: A 22-year-old nulligravid woman was admitted with primary amenorrhea and abdominal mass. Abdominal examination revealed a cystic mass 25 × 25 × 20 cm in size and a vagina 1 cm in length. Pelvic magnetic resonance imaging (MRI) showed a giant multiloculated left ovarian mass amidst the absence of uterus. During the surgery, the giant multiloculated cystic mass was identified as mucinous cystadenoma on frozen section. Bilateral medial inguinal hernia was also identified. Discussion: MRKH coexisting with other disease is rare but considering other structures arising from paramesonephric duct (PMD) may exist, allows the possibility of other structural anomalies. Conclusions: The present report illustrates a rare case of MRKH syndrome with giant ovarian cystadenoma and inguinal hernia.

Background. This study is to compare the time to pregnancy (TTP) between patients with endometriosis and nonendometriosis undergoing in vitro fertilisation (IVF).Material and Methods.This is an observational retrospective cohort study. We included 291 patients (53 with endometriosis and 238 without endometriosis) achieving biochemical pregnancy, whether singleton or multifetal (serum beta‐hCG >5 mIU/mL), between 1st January 2014 and 31st March 2020. We excluded patients with incomplete case notes and those declining participation. Time to pregnancy is the interval between the time when infertility was established to the date of confirmed biochemical pregnancy, expressed in months. Endometriosis diagnosis includes any form of endometriosis through surgical confirmation. A statistical analysis was done through the Mann–Whitney U test. Time to pregnancy was assessed through the Kaplan–Meier test. A p value Results. Endometriosis patients had a shorter infertility duration (4 years vs. 5 years, p = 0.024). Both groups had similar median age and body mass index at presentation. There was no significant difference in the TTP between endometriosis and nonendometriosis groups (57.7 vs. 70.9 months, p = 0.060), further confirmed by a Cox regression test incorporating confounders (IVF protocol (OR: 1.482, 95% CI 0.667–3.292, and p = 0.334) and type of the cycle (OR 1.071, 95% CI 0.803–1.430, and p = 0.640)). The endometriosis group reached the maximum cumulative pregnancy rate at around 169 months postinfertility diagnosis, whilst the nonendometriosis group at around 255 months postinfertility diagnosis. Conclusion. Time to pregnancy between endometriosis and nonendometriosis is not significantly different. However, infertility among patients with endometriosis tends to be shorter.

Female genital tuberculosis is a disease caused by Mycobacterium tuberculosis infection in the female reproductive tract. The disease burden among women leads to infertility is significant, especially in developing countries. The bacteria can spread from the lung into the reproductive organ through lymphatic or hematogenous. Many patients present with atypical symptoms, which mimic other gynecological conditions. Several investigations are needed to establish the diagnosis. Almost all cases of genital TB affect the fallopian tube and cause infertility in patients and endometrial involvement. Current treatment still relies on antituberculosis therapy with a combination of tubal surgery. The present review describes the epidemiological data, clinical presentation, diagnosis, and currently available treatment to cure the disease and for in vitro fertilization.

Introduction: and importance: Foetal hydrocolpos and anorectal malformation are difficult to diagnose prenatally due to abundance of differential diagnoses. This case report presents the challenges of diagnosing such disorders.Case presentation: A G3P2A0 woman came at 32 weeks of pregnancy with a referral for foetal ovarian cyst. Ul-trasound revealed a singleton breech pregnancy, estimated foetal weight 3528 g. A septate abdominal cyst measuring 11.31 x 7.17 cm and polyhydramnios were present. Elective caesarean section delivered a female baby weighing 2820 g and measuring 43 cm. Neonatal examination revealed a right lateral suprapubic mass and a rectovestibular fistula. A sinoscopy revealed a suspected hydrocolpos. An abdominal hydrocolpos drainage was performed; a patent urachus and normal bilateral adnexa were present.Clinical discussion: Hydrocolpos is a rare congenital disorder due to distal obstruction of various etiologies. It may be mistaken with other pathologies, including fetal ovarian cysts. A genitourinary congenital abnormality may occur in conjunction with other abnormalities, including gastrointestinal tract anomalies. The presence of imperforate anus and/or fistula should alert the clinician of a possible association with VACTERL syndrome.Conclusion: Hydrocolpos is a rare congenital genitourinary disorder with various differential diagnoses. Simul-taneous presence of other abnormalities is likely, with possible association to other syndromes.

Introduction and importance: Growth hormone (GH) deficiency is the most common hypopituitarism disorder. We highlight the challenges to its diagnosis and management in the setting of a developing country.Case description: A 14-year-old came with a chief complaint of inability to menstruate. Menarche was at 12-years old, lasted 7 days, soaking 2 pads/day which discontinued shortly after. Thelarche was at 12-years-old and her breast is at Tanner stage 3. Her axillary and pubic hair are at Tanner stage 1. Height was 120 cm, weight 34.8 kg, height for age z-score < -3. Her lab results were normal for estradiol, luteinizing hormone (LH), folliclestimulating hormone (FSH) and prolactin. Bone age was suitable for age. Magnetic resonance imaging revealed pituitary gland hypoplasia (5.3 mm). A hormonal panel 3 years prior showed abnormally low GH level but normal cortisol and thyroid hormone levels. She was diagnosed with isolated growth hormone deficiency (IGHD) with delayed puberty. She was treated with medroxyprogesterone tablets once daily, after which her menstruation restarted. However, due to her economic background, she declined genetic tests, discontinued her medication and amenorrhea recurred.Clinical discussion: Amenorrhea present after a brief menarche should alert gynaecologists of a possible multihormone disorder with an underlying structural abnormality. IGHD may be due to a structural abnormality, such as pituitary gland hypoplasia. Unfortunately, economic reasons prevented the patient from receiving optimal treatment.Conclusion: IGHD rarely presents with a gynaecological complaint. Hormonal and genetic tests along with imaging should be undertaken. Growth hormone supplementation is the treatment of choice.

Family. Patients may present with amenorrhea and ambiguous genitalia. This case report is aimed to highlight the genetic aspects of the disease, the challenges to diagnostics and the various management options for the patients. Methods: Case series of three siblings with DSD 46, XY with relevant discussion. Outcomes: Three sisters, aged nineteen, seventeen, and fifteen years old came with an identical complaint of late menarche. Their physical examinations revealed elementary breast development and little axillary hair. The external genitals consisted of vulva, major and minor labia. Clitoromegaly was present with short (20). Karyotype was 46,XY. Diagnoses of DSD 46, XY due to type 2 5-α reductase deficiency were established. Patient 1 chose female as the gender of choice whilst patients 2 and 3 chose male. All patients are due for corrective surgery along with psychotherapy and psychoeducation. Conclusion: DSD 46, XY due to type 2 5-α reductase deficiency is a rare autosomal recessive genetic disorder requiring comprehensive diagnostics and holistic management to improve patient quality of life. HIGHLIGHTS Disorder of sexual development (46,XY) due to type 2 5-α reductase deficiency is rare.It requires a multidisciplinary team involving a battery of tests, imaging and genetic tests, e.g. karyotyping.Informed consent and collaboration with other disciplines are pivotal for holistic management....

Introduction and importance: Genital tuberculosis (TB) exerts significant damage in the reproductive organs, particularly the Fallopian tubes and endometrium. Infertility is one of the most common presenting causes, often subsequently requiring assisted reproductive technology (ART). However, we have not had many experiences with genital TB despite being a country endemic for TB. This case series highlights the challenges we face and the solutions we wish we had. Case presentation: In this case series, we recruited 7 patients undergoing in vitro fertilisation (IVF) treatment previously diagnosed with TB between January 01, 2014 and June 30, 2021. Patients were recruited at the beginning of their IVF treatments. Of 7 patients, 2 patients (28.6%) achieved live birth. 5 patients (71.4%) failed to conceive. All patients had good and/or excellent quality embryos upon transfer but only 2/7 managed to conceive and delivered. Clinical discussion: Genital TB is often silent and only encountered during workup for infertility. Genital TB often produces extensive damage on the linings of the endometrium and Fallopian tubes, accounting for the recurrent implantation failures associated with the disease. Whilst antitubercular treatment may improve the prognosis, many women still fail to conceive. Conclusion: Genital tuberculosis remains a significant issue in infertility. Cases are often silent and management is often delayed. IVF is often required due to the longstanding damage caused beforehand yet prognosis may remain poor. HIGHLIGHTS Genital tuberculosis is a significant yet underdiagnosed etiology of infertility. Its profound severity often requires in vitro fertilisation for conception. Poor prognosis may still be found despite IVF due to recurrent implantation failures.