Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

APAGE Symposium(Didactic)

PROGRAM CHAIRS

Chyi-Long Lee, MD & Mitsuru Shiota, MD

MODERATOR

C.Y. Liu, MD

Bernard Chern, MD Anusch Yazdani, MD Chih-Feng Yen, MD

Professional Education Information   Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology.  

Table of Contents 

 Course Description ........................................................................................................................................ 1  Endometriosis: The Impact of Endometrioma to Infertility A. Yazdani ...................................................................................................................................... 2  Endometriosis: The Optimal Treatment of Recurrent Endometrioma in Infertile Patients B. Chern ......................................................................................................................................................... 6  Fibroid: The Proper Time to Conceive after Laparoscopic Myomectomy M. Shiota ....................................................................................................................................................... 9  Fibroid: The Choice of Delivery Method after Laparoscopic Myomectomy C.F. Yen  ....................................................................................................................................................... 12  Cultural and Linguistics Competency  ......................................................................................................... 15   

 

APAGE Symposium

Moderator: C.Y. Liu Co-Chairs: Chyi-Long Lee (Taiwan) and Mitsuru Shiota (Japan)

Faculty: Bernard Chern (Singapore), Anusch Yazdani (Australia), Chih-Feng Yen (Taiwan) Endometrioma and uterine leiomyomata are the most common gynecologic tumors treated with laparoscopy, and many of the patients have the desire for further fertility. However, debates existed for long time regarding the optimal treatment for the infertile patient with endometrioma, mainly arising from the controversies between surgical removal of endometrioma and ovarian reserve. Though many patients can conceive uneventfully after laparoscopic myomectomy, the potential risk of uterine rupture on previous myomectomy site is a major concern. To date, the real incidence and cause of subsequent uterine rupture after laparoscopic myomectomy are not clear. These two are practical and important issues for our daily practice and deserve for in-depth discussion. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Identify the influenced of endometrioma and uterine myoma on infertility; 2) select appropriate patients to undergo the optimal treatment; 3) realize the potential risks of laparoscopic myomectomy for the future delivery; and 4) apply information presented to optimize method of future delivery.

Course Outline 1:10 Welcome, Introductions and Course Overview C.L. Lee, C.Y. Liu

1:15 Endometriosis: The Impact of Endometrioma to Infertility A. Yazdani

1:25 Endometriosis: The Optimal Treatment of Recurrent Endometrioma in Infertile Patients B. Chern

1:35 Fibroid: The Proper Time to Conceive after Laparoscopic Myomectomy M. Shiota

1:45 Fibroid: The Choice of Delivery Method after Laparoscopic Myomectomy C.F. Yen

1:55 Questions & Answers All Faculty

2:10 Adjourn

1

Endometriosiseverything you wanted to know about deep infiltrative 

endometriosis but were afraid to ask

Anusch YazdaniMBBS (Hons) FRANZCOG CREI

QFG Research Foundation, Australia

EndometriomaThe effect of endometriomata on fertility

Anusch YazdaniMBBS (Hons) FRANZCOG CREI

QFG Research Foundation, Australia

• Appointments

– Director, Eve Health Australia

– Clinical Director of Research & Development, QFG Research Foundation

– Clinical Director, Reproductive Endocrinology & Infertility, RBWH

– Program Director, Reproductive Endocrinology & Infertility (QLD)

– Vice President, Australasian Gynaecological Endoscopy & Surgical Society

– Councillor, Royal Australian & New Zealand College of Obstetricians and Gynaecologists

– Associate Professor, University of Queensland

– Consultant, Health Quality and Complaints Commission

• Third Party Funding

– MSD

– Merck‐Serono

– AGES Society Research Foundation

13:8:24:4

13:8:24:5

Conception

• sperm• egg

• reproductive organs

13:8:24:6

ConceptionReproductive Organs

• egg

• reproductive organs

• sperm

endometriosis

2

13:8:24:7

Fertility

• functional

• dyspareunia

• altered sexuality in chronic pain

• anatomic distortion• pelvic adhesions and endometriomataendometriosis

13:8:24:8

Fertility

• chemical factors

• ? increased volume of peritoneal fluid

• increased peritoneal fluid concentration of activated macrophages

• increased peritoneal fluid concentration of prostaglandin, interleukin‐1, tumor necrosis factor, and proteases

• production of substances (eg, prostanoids, cytokines, growth factors) affect:

• ovulation: ? retarded follicular growth

• corpus luteum function

• fertilization

• impaired sperm function

• embryonic development

• implantation

13:8:24:9

Fertility

• cellular factors

• increased activation of macrophages 

• cytokines recruit macrophages and lymphocytes

• macrophages from women with endometriosis secrete interleukin‐1 which is toxic to mouse embryos

13:8:24:10

Fertility

• uterus

• abnormal eutopic endometrium

• ? Müllerian tract "field defect" 

• abnormal peristaltic activity

• hyperperistalsis and dysfunctional peristalsis

• involved in the development of pelvic endometriosis, uterine adenomyosis and infertility

• ovary• reduced ovarian reserve

• AMH

• impaired ovarian capacitance

13:8:24:11

Fertility

• endometriosis

fertilization

embryo quality

implantation

oocyte quality

13:8:24:12

Fertility

• endometriosis

• endometrioma

fertilization

embryo quality

implantation

oocyte quality

3

13:8:24:13

Fertility

• endometriosis

• endometrioma

• different genetics

• different pathogenesis

superficial implant

adhesion formation

invagination of cortex

progressive distension of cyst 

fibrosis of wall

13:8:24:14

Fertility

• endometriosis

• endometrioma

• different genetics

• different pathogenesis

• 10% of endometriomataare formed by a different mechanism:

• ?deep implants

• ?colonisation of a ruptured follicle by endometrial cells

13:8:24:15

Fertility

• endometriosis

• endometrioma

• different genetics

• different pathogenesis

• different clinical course

13:8:24:16

Fertility

• endometriosis

• endometrioma

• different genetics

• different pathogenesis

• different clinical course• natural conception 

• reduced fecundability/ cycle

• ovulatory 20‐25%

• endometriosis 2‐10%

13:8:24:17

Fertility

• endometriosis

• endometrioma

• different genetics

• different pathogenesis

• different clinical course• assisted conception

• IVF in women with endometriosis

• endometrioma 82%

• endometrioma + DIE  69%

Fertil Steril 2012 97:367

Observational Surgery avoid surgery

lower FSH doses

increased E2

increased follicles

exclude malignancy

relieve symptoms

reduce the risk of cyst 

complications

facilitate transvaginal access to 

ovarian follicles

improved embryo quality

pain

no histological diagnosis

pelvic infection following 

egg collection

ovarian failure due to destruction 

of normal ovarian tissue

Reduced AMH in 70%

reduced number of eggs collected

risks of surgery

13:8:24:18

Fertility

• increasingly conservative

• primary laparoscopy• open, drain, excison / destruction of lining

• excision of other endometriosis

• 3 month suppression• GnRHa

• second look laparoscopy• removal of residual disease

4

13:8:24:19

Management of Endometriomata

Consensus statement on Endometriosis and Infertility Koch J, Rowan K, Rombauts L, Yazdani A, Chapman M, Johnson N, on behalf of the Australasian CREI Consensus Expert Panel on Trial Evidence (ACCEPT) group

ANZJOG 2012 

13:8:24:20

Management of EndometriomataStatement Evidence

Hormonal suppression of endometriosis does not improve spontaneous pregnancy rates

Level 1

Laparoscopic excision of endometriomata is superior to ablation with regards to spontaneous pregnancy rate

Level 1

There is insufficient evidence to recommend the surgical treatment of endometriomas prior to IVF to improve pregnancy rates  (see discussion)

Level 2

Pre‐treatment with GnRH analogues for at least 3 months improves subsequent IVF outcomes

Level 1

IVF treatment does not increase the recurrence rate of endometriosis symptoms

Level 3

Repeat surgery suggests less benefit with regards to pregnancy rates as compared to first line surgery

Level 3

13:8:24:21

5

ENDOMETRIOSIS : The Optimal Treatment of Recurrent Endometrioma in Infertile 

Patients 

A/PROF. BERNARD CHERN

Infertility

• Up to 50% of those with endometriosis may suffer from infertility

– Distorted pelvic anatomy/impaired oocyte release or inhibit ovum pickup and transport

– Altered peritoneal function

– Endocrine and anovulatory disorders, including LUF

– Impaired implantation

– Progesterone resistance

– Decreased levels of cellular immunity

– Very limited information is available on the of second‐line of management for recurrent endometriosis.

THE PRAGMATIC APPROACH SURGERY Vs IVF

• Core question is whether surgery adds anything of value for infertile women with recurrent endometriosis???

• Simple truth is that we do not know!!

• Very limited information on the effect of second‐ line surgery for recurrent endometrioma in infertile women.

• A COMMON TENET IS THAT RE‐OPERATIONS ARE TECHNICALLY MORE DEMANDING AND POTENTIALLY MORE RISKY!

• According to ASRM, for infertile women with recurrent endometriosis and prior one or more fertility surgeries done, IVF‐ET is a better therapeutic option.

• RCTs are desperately needed to solve this issue.

Surgery before or after IVF ?

• Lack of randomized trials to investigate benefits of surgical management .

• 2 questions should be answered –

• 1) does the presence of endometrioma impair the results of IVF?

• 2) Is IVF outcome affected after removal of endometrioma?

• Studies have shown that presence of small endometrioma <4cm does not impair IVF outcomes.

• Reduced ovarian reserve after cystectomies.

• However, few studies show that laparoscopy should be considered for the treatment of endometriosis‐ associated infertility even after multiple IVF failures.

• Role of operative laparoscopy before or after IVF is controversial and the available evidence on this issue is generally inconsistent.

Objective is the baby

WHY NOT IVF?Few studies suggest that IVF‐ET without prior surgery would be the best option !

6

Surgery Vs IVF for recurrent endometriosis

• Perplexities arise during counselling of infertile women with recurrent endometriosis when they have failed to conceive after a first surgical procedure. 

• Common tenet that re‐operations for endometriosis are technically more demanding and potentially more risky.

• According to the ASRM clinical guidelines, for infertile women who have moderate to severe endometriosis and have previously had one or more infertility operations, IVF‐ET is often a better therapeutic option than another infertility operation (The Practice Committee of the American Society for Reproductive Medicine, 2004). 

• The likelihood of conception is not the only factor that should be considered before advocating surgery prior to IVF. There is general agreement that an endometrioma with a diameter of >4 cm may create difficulties during oocyte retrieval, as the cyst may be punctured,withsubsequent possible rupture, infection and follicular fluidcontamination (Somigliana et al., 2006).

MEDICAL TREATMENT FOR ENDOMETRIOSIS

• No evidence that medical treatment improves fertility.

• In actuality, fertility is essentially eliminated during treatment because all medical treatment for endometriosis inhibit ovulation.

• Combined medical ( pre/post op) and surgical treatment , although may sound advantageous theoretically, there is no evidence in literature and it may delay fertility further !

What EXPERTS Say ... ENDOMETRIOMA EXCISION AND OVARIAN RESERVE :A DANGEROUS RELATION• Intriguing and controversial issue !!• Excisional surgery for endometrioma is the preferential 

approach.• Currently no definitive data to clarify that the damage to 

ovarian reserve is due to surgery or the disease or BOTH!• However, reported prevalance of post‐surgical ovarian failure 

as high as 2.4%.• Apart from surgical skills, surgery –related local inflammation 

and electrosurgical coagualation may be responsible.

• Electrosurgical coagulation during hemostasis  could play an important role in damage to ovarian stroma and vascularization.

• Particular attention in case of bilateral endometriotic cysts. Increased rates of ovarian failure in such cases treated surgically.

• Various markers used‐ FSH, LH, FSH/LH, AMH, AFC,PSV, Mean ovarian diameter, Ovarian volume, Inhibin B.

• Ovarian volume – a reliable indicator in many studies.

• In IVF cases ovarian response to hyperstimulation is a reliable indicator.  

Cryopreservation‐ An eye to future

• Advances in reproductive technology have made fertility preservation techniques a real possibility.

• Three possibilities for preserving their fertility: cryopreservation of their oocytes, embryos, and, most recently,ovarian tissue.

• There have been various reports of successful  pregnancy with cryopreserved oocytes/ ovarian tissue.

A number of questions remain unanswered,but of critical importance, to bring this technique into mainstream use. For example:• How long can the tissue remain frozen and still function 

after thawing?• Where is the best location to transplant the tissue strips? • How much ovarian tissue is required to provide enough 

oocytes for successful pregnancy? How long will the tissue function after transplantation?, and manymore.• ETHICAL ISSUES

7

PATIENT’S ROLE..

• Need for Unbiased and Informative Counselling.

• Both surgery and ART should be offered to infertile patients.

• Detailed and thorough patient information is always of utmost importance when choosing among therapeutic alternatives.

• Uncertainities deriving from lack of reliable evidence should be discussed.

• Complete and detailed information on risks and benefits of treatment alternatives must be offered to patients, giving a realistic estimate of chances of success of repetitive surgery and of multiple IVF cycles  in order to allow unbiased choices between different possible options.

DILEMMA Continues !!

An individualized treatment plan should be developed taking into account patient age, duration of infertility, previous pregnancies and specific clinical conditions and wish.

THE FINAL REMARKS….

• Still an open problem not only for the patient but also for the surgeon who must deal with it!

• Regrettably, given the scanty methodological quality of most of the available studies on the effect of surgery for endometriosis‐associated infertility, only limited conclusions can be drawn.

• NO CONSENSUS EXISTS FOR MOST SUITABLE TREATMENT!

• Individualised patient management. 

LET’S THINK.. 

AND THEN TREAT…

8

The Proper Time to Conceive after Laparoscopic Myomectomy

Mitsuru SHIOTA, M.D.

Department of Gynecologic OncologyKawasaki Medical School

Okayama, Japan

Conflict of interest disclosure

Neither  I, nor a member of my family, have a 

financial interest, arrangement or affiliation with

any commercial organization that offer 

support and/or participate in any of the entities

By the end of this session the participant will 

• realize the recurrent risks of laparoscopic myomectomy

• realize the potential risks of laparoscopic myomectomy for the future delivery

Purpose

Uterine myoma is a common gynecologic disease. Myomectomy is selected to preserve the uterus, and with recent advances in laparoscopic technology, laparoscopic myomectomy (LM) has become a common treatment. However, myoma can recur after LM, and to date, reports on post‐LM recurrence rates and risk factors have been inconsistent. This retrospective study examines post‐LM recurrence rates and the possible risk factors for recurrence.

Material

Between 1995 and 2010, 250 patients who underwent LM at a single institution were followed from the postoperative 6th

month to the 5th year semiannually for recurrence by ultrasound/MRI. Mean age, BMI, preoperative gonadotropin releasing hormone agonist (GnRHa) therapy, operative time, blood loss, number of removed myomas, and largest myoma diameter were compared between patients with recurrence and those without. Recurrence rates were also investigated by individual risk factors, including patient age, GnRHa therapy, number of removed myomas, and largest tumor diameter. 

Figure 1 Cumulative recurrence rates after laparoscopic myomectomy (post-LM recurrence rates)15.3±2.5%, 43.8±4.5%, and 62.1±6.7% at postoperative years 1, 3, and 5, respectively.

9

Overall Recurrence group Non-recurrence group P value

n=250 n=74 n=176

Age (Unit:year)(Range)

36.6±5.1(26-51)

37.5±4.6(27-46)

36.1±5.0(26-51) n.s.

BMI (Unit: kg/m2)(Range)

21.4±3.0(16.4-35.7)

22.1±3.4(16.6-32.9)

21.3±3.1(16.4-35.7) n.s.

GnRH (Unit: %)(Range)

27.2(68/250)

33.8(25/74)

24.4(43/176)

n.s.

Operative time (Unit: min)(Range)

155±60(65-422)

176±62(80-422)

151±59(65-405) <0.01

Blood loss (Unit: ml)(Range)

183±210(9-1250)

249±258(10-1250)

156±174(9-800) <0.01

Number of myomas(Range)

3.1±3.5(1-31)

3.7±3.4(1-16)

2.7±3.4(1-31) 0.03

Largest diameter (Unit: cm)(Range)

6.8±2.5(1.5-14.8)

7.0±2.1(2.4-12.1)

6.6±2.4(1.5-14.8) n.s.

n.s.: no significant difference

Table 1 Comparison of results between the recurrence and non-recurrence groups

Age<35 years Age>35 years P value

18.8%(Range: 16/85)

35.2%(Range: 58/165) <0.01

BMI<25 BMI>25

28.0%(Range: 60/214)

38.9%(Range: 14/36)

n.s.

Without GnRHa With GnRHa

26.9%(Range: 49/182)

36.8%(Range: 25/68)

n.s.

Number of myoma=1 Number of myoma>2

23.0%(Range: 26/113)

35.0%(Range: 48/137) 0.04

Myoma diameter<10cm Myoma diameter>10cm

28.1%(Range: 66/235)

53.5%(Range: 8/15) 0.04

n.s.: no significant difference

Table 2 recurrence rates by risk factor.

Recurrence time > 1 year > 1 year and < 3 years

< 3 years and > 5 years

Total

Number of cases (%)28

(37.8)38

(51.4)8

(10.8) 74

Mean diameter at recurrence (cm) ±1.1 SD

2.2±1.1 2.2±1.3 2.4±1.0 2.2±1.2

Table 3 Number of recurrence cases and the mean myoma diameter at recurrence in the three recurrence group

Result

Cumulative post‐LM recurrence rates were 15.3%, 43.8%, and 62.1% at postoperative years 1, 3, and 5, respectively. There were significant differences in operative time, blood loss, and number of removed myomas between patients with recurrence and those without. Analysis of risk factors revealed significant correlation between recurrence rates and patient age, number of myomas, and myoma size.

Conclusion

Risk of post‐LM recurrence increases over time. Risk factors are age, myoma size, and number of tumors. Particular attention to recurrence is required for patients with uterine myomas of > 10 cm diameter, with numerous myomas, and of 35 years or older.

the potential risks of laparoscopic myomectomy for the future delivery

• The real incidence and cause of subsequent uterine rupture after laparoscopic myomectomy

• EBM?

10

• Shiota M, Kotani Y, Umemoto M, et al. Recurrence of uterine myoma after laparoscopic myomectomy: What are the risk factor?. GMIT 2012;1:34‐36.

11

Fibroid: The Choice of Delivery Method after 

Laparoscopic Myomectomy

Chih-Feng Yen, MD

Associate professor,Chang Gung Memorial Hospital at Linkou,

Taiwan

10/24/2013 1顏志峰

Presenters do not have relevant financial relationships 

to disclose. 

10/24/2013 2顏志峰

At the conclusion of this activity, the participant will be able to ‐

1. realize the potential risks of LM for the future delivery; 

2. select optimal method of future delivery for appropriate patients

10/24/2013 3顏志峰

A major challenge‐

• Patients conceived after LM  risk of uterine rupture!

• If the healed wound is durable enough for:

– The progressively distended process during pregnancy

– The vigorous pulling and shearing power during labor

10/24/2013 4顏志峰

Possible Affecting Factors ‐• Surgical technique (Surgeons usu. Emphasized) :

– Avoid dead space/ hematoma.

– Limited usage of electrocautery

– meticulous multi‐layered sutures

• Background situation may be different:

– Myoma location, number, size, depth? 

– Time between surgery and pregnancy.

• History of vaginal delivery?

• Biological factor – wound healing.10/24/2013 5顏志峰

VBAM is different from VBAC• C‐section  lower/ passive segment

• Myomectomy  upper/ active segment?

• Classical C‐section:

– has a high risk of uterine rupture

– is a contraindication of VBAC.

10/24/2013 6顏志峰

12

QUESTION: 

1. Should all the patients conceived after LMundergo Cesarean section? 

2. What kind of patients can try vaginal delivery?

10/24/2013 顏志峰 7

• 115 women underwent LM, (infertiltiy: 29.6%)

– Mean number of myoma: 3.04, Mean size: 5.943.18 cm,

– subserosal 47.36%, Intramural 42.11%.

• 42 pregnancies in 31 patients (27.0%).

– Vaginal delivery : 6 at term. (pedunculate or subserosal)

– C/S (intramu) : 22 cases, (21: term, 1: at 26 weeks)

– 2 unknown mode of delivery,

– 1 ectopic, 8 first trimester loss, 1 elective termination.

• No uterine rupture was noted.

10/24/2013 8顏志峰

• N=136, 2002/01 – 2003/03, Symptomatic myoma or unexp. Infertility

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Case 1 : Delivery mode – Vaginal delivery

• 31 y/o, G2P1 (SD)

• 2002/04/18 LM: 50%  intramural myoma, 6.7 cm in diameter.

• 2 ‐layer continuous sutures, with 0 monocryl.

• LMP 2003/07/09: Spontaneous conception. 

• U/s evaluate uterine wall thickness (?)

• 2004/04/20: Spontaneous Vaginal delivery at 40 weeks, uneventful.

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Case 2 : Delivery mode – Vaginal delivery

• 33 y/o, G2P1 (SD)

• 2012/07/17 LM: – 10‐cm myoma (10% intramural @ post‐fundus), 

– 5‐cm myoma (100% intramural @ anterior wall).

• Multi‐layer, continuous sutures, with 0 monocryl.

• LMP 2012/12/15: Spontaneous conception.

• U/s evaluate uterine wall thickness (?)

• 2013/09/13: Spontaneous Vaginal delivery at 40 weeks, uneventful. (3520 gm)

10/24/2013 11顏志峰 10/24/2013 顏志峰 12J Minim Invasive Gynecol. 2010 Sep-Oct;17(5):551-4

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Case report ‐ Uterine rupture after LM

10/24/2013 13顏志峰 10/24/2013 顏志峰 14J Minim Invasive Gynecol. 2012 Nov-Dec;19(6):762-7.

Conclusion• The risk really exists, with uncertain incidence.

• This is not only an issue of surgical technique, but somehow the biophysics of tissue healing.

– Surgical techniques is important, but not all.

• If want to try vaginal delivery‐ select carefully !

– Myoma location, number, size, depth? 

– Reliable surgical techniques, with trustable wound healing.

– individual wound healing characteristics ?

– Informed consent.

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1. Parker WH, Einarsson J, Istre O, Dubuisson JB. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol. 2010 Sep‐Oct;17(5):551‐4.

2. Pistofidis G, Makrakis E, Balinakos P, Dimitriou E, Bardis N, Anaf V. Report of 7 uterine rupture cases after laparoscopic myomectomy: update of the literature. J Minim Invasive Gynecol. 2012 Nov‐Dec;19(6):762‐7.

3. Palomba S, Zupi E, Falbo A, Russo T, Marconi D, Tolino A, et al. A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes. Fertil Steril. 2007 Oct;88(4):933‐41.

4. Nezhat CH, Nezhat F, Roemisch M, Seidman DS, Tazuke SI, Nezhat CR. Pregnancy following laparoscopic myomectomy: preliminary results. Hum Reprod. 1999 May;14(5):1219‐21.

5. Zwart JJ, Richters JM, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Uterine rupture in The Netherlands: a nationwide population‐based cohort study. BJOG. 2009 Jul;116(8):1069‐78; discussion 78‐80.

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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