Understanding gestational surrogacy in the United States: a primer for obstetricians and gynecologists.

As gestational surrogacy (a process by which intended parents contract with a woman to carry a fetus that the intended parents will raise) increases across the United States, it is imperative that obstetrician/gynecologists understand the unique nuances of caring for patients who are gestational surrogates. Gestational surrogacy offers a route to parenthood for individuals and families who may otherwise have limited options. Understanding surrogacy requires multiple ethical considerations about the potential medical and psychosocial effects on gestational surrogates as well as the families built through surrogacy. There is a dearth of research on the subject, particularly in the United States and other countries that practice compensated surrogacy. Here we seek to review the process of gestational surrogacy in the United States, including the legal landscape, current trends in gestational surrogacy use, and what is known about the medical and social effects of this process on all participants. We also aim to highlight the limitations of available data and to identify topics for future research to provide optimal evidence-based and just care for these patients.

Embryo transfer by reproductive endocrinology fellows vs attending physicians: are live birth rates comparable?

OBJECTIVE: To compare live birth rates following ultrasound-guided embryo transfer (ET) by reproductive endocrinology and infertility fellows versus attending physicians. STUDY DESIGN: Women who underwent their first day-3, fresh, nondonor ET between Oct. 1, 2005, and April 1, 2011, at our academic center were included in this retrospective cohort study. Embryos were designated high quality if they had 8 cells, less than 10% fragmentation, and no asymmetry. ET was performed with the afterload technique under ultrasound guidance. Categorical variables were evaluated with the χ(2) test and continuous variables with the Student t test. Logistic regression was performed to assess the relationship between ET physician and live birth rate while adjusting for potential confounders. RESULTS: Seven hundred sixty women underwent ET by an attending physician, and 104 by a fellow. Baseline characteristics were similar between the groups. The live birth rate was 31% following ET by an attending physician, compared with 34% following ET by a fellow (P = .65). Logistic regression adjusting for potential confounders demonstrated no significant association between ET physician and live birth rate. CONCLUSION: This retrospective study demonstrated no significant difference in live birth rates following ultrasound-guided ET by fellows vs attending physicians at our institution. These data suggest that academic practices using the afterload method and ultrasound guidance can train fellows to perform ET without compromising success rates.

Knowledge of obesity and its impact on reproductive health outcomes among urban women.

This prospective survey study assessed the knowledge of reproductive outcomes that are affected by obesity among women in an urban community. A total of 207 women attending a community fair on the south side of Chicago participated in the study. A survey assessing knowledge of BMI and of the effects of obesity on general, cardiometabolic and reproductive health outcomes was administered. Subjects ranged in age from 18 to 70 years (mean ± SD, 48.6 ± 12.9 years) and ranged in BMI from 17.3 to 52.1 kg/m(2) (mean ± SD, 31.2 ± 6.7 kg/m(2)). The following percentages of women were aware that obesity increases the risk of miscarriage (37.5 %), irregular periods (35.8 %), infertility (33.9 %), cesarean section (30.8 %), breast cancer (28.0 %), birth defects (23.7 %), stillbirth (14.1 %), and endometrial cancer (18.1 %). This study found that while women in an urban community are aware of the cardiometabolic risks associated with obesity, they demonstrate limited knowledge of the effects of obesity on reproductive outcomes. Public education is needed to increase knowledge and awareness of the reproductive consequences of obesity. Women of reproductive age may be uniquely responsive to obesity education and weight loss intervention.

Infertility patients' knowledge of the effects of obesity on reproductive health outcomes.

OBJECTIVE: The objective of the study was to assess the infertility patient knowledge of reproductive outcomes affected by obesity. STUDY DESIGN: This was a prospective survey study of 150 female infertility patients in an academic medical center. Subjects were administered the Rapid Estimate of Adult Literacy in Medicine-Short Form and a questionnaire on the health risks of obesity, and investigators obtained height and weight measurements. RESULTS: Subjects' age ranged from 21 to 45 years (mean 34.8 ± 4.94 SD) and body mass index ranged from 17.9 to 62.9 kg/m(2) (mean 26.5 ± 7.54 SD). The following percentages of women were aware that obesity increases the risk of infertility (82.7%), irregular periods (70.0%), miscarriage (60.7%), cesarean section (48.7%), breast cancer (38.7%), birth defects (29.3%), stillbirth (22.7%), and endometrial cancer (20.7%). CONCLUSION: Among women with infertility, there is limited knowledge of reproductive outcomes affected by obesity. Public education is needed to increase awareness. Women undergoing fertility treatment are motivated for reproductive success and may be uniquely receptive to obesity education and weight loss intervention.

Characterization of functionally typical and atypical types of polycystic ovary syndrome.

CONTEXT: The typical polycystic ovary syndrome (PCOS) phenotype includes 17-hydroxyprogesterone (17OHP) hyperresponsiveness to GnRH agonist (GnRHag) testing. Functionally atypical PCOS lacks this feature. OBJECTIVE: The hypothesis was tested that the typical PCOS ovarian dysfunction results from intrinsically increased sensitivity to LH/human chorionic gonadotropin (hCG) due to a flaw in FSH action. PARTICIPANTS/DESIGN/INTERVENTIONS/MAIN OUTCOME MEASURES: After phenotyping a cohort of 60 women, steroid and inhibin-B responses to gonadotropins were evaluated in representative typical (n = 7) and atypical (n = 5) PCOS and healthy controls (n = 8). Submaximal hCG testing before and after an FSH test dose was performed in random order before and after prolonged ovarian suppression by depot GnRHag. SETTING: The study was performed at a Clinical Research Center. RESULTS: Of our PCOS cohort, 68% were the typical type. Typical PCOS had 17OHP hyperresponsiveness and, unlike controls, significant androgen and estradiol responses to hCG. FSH increased inhibin-B and did not inhibit free testosterone or enhance estradiol responsiveness to hCG, all unlike controls. After ovarian suppression, 17OHP, androstenedione, and inhibin-B responsiveness to gonadotropin testing persisted. Atypical PCOS had significantly higher body mass index but lower ovarian volume and plasma free testosterone than typical PCOS. Steroid responses to hCG were insignificant and similar to controls. FSH suppressed free testosterone but stimulated inhibin-B. The estradiol level after combined hCG-FSH was subnormal. Free testosterone was less GnRHag suppressible than in typical PCOS. CONCLUSIONS: Typical PCOS is characterized by intrinsic ovarian hypersensitivity to hCG to which excessive paracrine FSH signaling via inhibin-B may contribute. Atypical PCOS is due to a unique type of ovarian dysfunction that is relatively gonadotropin hyposensitive.

Disclosure decisions among pregnant women who received donor oocytes: a phenomenological study.

OBJECTIVE: To investigate the controversy surrounding disclosure among donor oocyte recipients. This controversy is escalating worldwide, yet little research has sought to understand the disclosure experience of pregnant, donor oocyte recipient women. This study aims to provide an in-depth description of the disclosure experience, and identify factors that were significant to recipient women which influenced their reasoning as they formulated disclosure decisions. DESIGN: Qualitative, naturalistic design, using a phenomenological approach. SETTING: The home or private office of the recipient woman. PATIENT(S): Donor oocyte recipient women between 9-23 weeks of gestation. RESULT(S): Disclosure decisions were influenced by multiple factors emerging from the women's values and beliefs and their social and cultural environment. Values and beliefs consisted of the right to know and the duty to protect. Social and cultural factors included social support, culture of the family, evolution of the social process, and personal testimonials. Women's age and selection of donor type were interrelated with disclosure decisions. CONCLUSION(S): Disclosing women voiced the right of the child to know, and perceived social and cultural factors as conducive to disclosure. Nondisclosing and undecided women emphasized protecting normative relationships, perceived a social stigma, and were unable to identify a benefit to disclosing. Women's age and choice of oocyte donor should be considered when counseling recipient women.

Studies of gene expression in human cumulus cells indicate pentraxin 3 as a possible marker for oocyte quality.

OBJECTIVE: To search for differentially expressed genes in cumulus cells from two groups of oocytes with different developmental outcome in vitro. DESIGN: Analyses of gene expression in human cumulus cells from oocytes that failed to fertilize in vitro (group A) and those that developed into normal-appearing embryos on day 3 (group B). SETTING: University-based facilities for clinical service and research. PATIENT(S): Women undergoing IVF treatment for infertility. INTERVENTION(S): Cumulus cells were collected from oocytes that were aspirated from ovarian follicles for IVF. The oocytes were cultured individually for IVF and embryo development. Total RNA was extracted from the cumulus cells for gene expression analyses. MAIN OUTCOME MEASURE(S): General gene expression profiles and relative abundance of pentraxin 3 (Ptx3) mRNA. RESULT(S): DNA microarray analysis identified 160 genes, including Ptx3, that were differentially expressed between cumulus cells in group A and group B. Quantitative analysis confirmed that the relative abundance of Ptx3 mRNA in cumulus cells was highly associated with oocyte development. CONCLUSION(S): This study demonstrated that changes in the expression levels of 160 genes, including particularly Ptx3, in human cumulus cells may be indicative of the quality of their enclosed oocyte.

The diagnosis and management of hirsutism.

Approximately 10% of women of childbearing age are hirsute, which is defined as the presence of coarse terminal hairs in androgen-dependent areas on the face and body. It not only is a source of psychological discomfort but also may be a sign of an underlying medical condition. This article reviews the pathophysiology, diagnosis, evaluation, and treatment of hirsutism.

The role of LH and FSH in ovarian androgen secretion and ovarian follicular development: clinical studies in a patient with isolated FSH deficiency and multicystic ovaries.

Inactivating mutations have proven to be instructive in elucidating the role of FSH in human ovarian function. We performed a detailed reproductive endocrine evaluation of a patient with inactivating mutations in the FSH beta-subunit gene who was hypo-estrogenic and had LH excess. The patient underwent a pelvic ultrasound and overnight frequent blood sampling followed by a human chorionic gonadotrophin (HCG) stimulation test. One month later she received human recombinant FSH, followed 24 h later by a second HCG stimulation test. Despite a mean LH serum concentration and LH pulse characteristics typical for polycystic ovaries (PCOS), baseline and dexamethasone-suppressed free testosterone were low-normal. The administration of HCG led to minimal stimulation of 17-hydroxyprogesterone and androgens. The patient had multicystic ovaries containing follicles 3-5 mm in diameter and responded to FSH with prompt increases in estradiol and inhibin B. There were no clinical or laboratory consequences of LH excess in this FSH-deficient woman. These findings support the hypothesis that excessive LH stimulation alone does not cause ovarian hyperandrogenism. We also found that follicular development was present in the absence of FSH. These antral follicles had apparently developed normally, since estradiol and inhibin B increased promptly after FSH administration.