ABSTRACT
OBJECTIVE: To evaluate a prospectively implemented clinical algorithm for early identification of ectopic pregnancy (EP) and heterotopic pregnancy (HP) after assisted reproductive technology (ART). DESIGN: Analysis of prospectively collected data. SETTING: Academic medical center. PATIENT(S): All ART-conceived pregnancies between January 1995 and June 2013. INTERVENTION(S): Early pregnancy monitoring via clinical algorithm with all pregnancies screened using human chorionic gonadotropin (hCG) levels and reported symptoms, with subsequent early ultrasound evaluation if hCG levels were abnormal or if the patient reported pain or vaginal bleeding. MAIN OUTCOME MEASURE(S): Algorithmic efficiency for diagnosis of EP and HP and their subsequent clinical outcomes using a binary forward stepwise logistic regression model built to determine predictors of early pregnancy failure. RESULT(S): Of the 3,904 pregnancies included, the incidence of EP and HP was 0.77% and 0.46%, respectively. The algorithm selected 96.7% and 83.3% of pregnancies diagnosed with EP and HP, respectively, for early ultrasound evaluation, leading to earlier treatment and resolution. Logistic regression revealed that first hCG, second hCG, hCG slope, age, pain, and vaginal bleeding were all independent predictors of early pregnancy failure after ART. CONCLUSION(S): Our clinical algorithm for early pregnancy evaluation after ART is effective for identification and prompt intervention of EP and HP without significant over- or misdiagnosis, and avoids the potential catastrophic morbidity associated with delayed diagnosis.
Subject(s)
Algorithms , Fertilization in Vitro , Infertility/diagnosis , Infertility/therapy , Prenatal Diagnosis/methods , Adult , Databases, Factual/statistics & numerical data , Early Diagnosis , Female , Fertilization in Vitro/statistics & numerical data , Humans , Infertility/epidemiology , Male , Middle Aged , Pregnancy , Pregnancy Tests/methods , Pregnancy, Ectopic/diagnosis , Pregnancy, Ectopic/epidemiology , Prenatal Diagnosis/statistics & numerical data , Retrospective Studies , Treatment Outcome , Young AdultABSTRACT
PURPOSE: Cathepsin L and ADAMTS-1 are known to play critical roles in follicular rupture, ovulation, and fertility in mice. Similar studies in humans are limited; however, both are known to increase during the periovulatory period. No studies have examined either protease in the follicular fluid of women with unexplained infertility or infertility related to advanced maternal age (AMA). We sought to determine if alterations in cathepsin L and/or ADAMTS-1 existed in these infertile populations. METHODS: Patients undergoing in vitro fertilization (IVF) for unexplained infertility or AMA-related infertility were prospectively recruited for the study; patients with tubal or male factor infertility were recruited as controls. Follicular fluid was collected to determine gene expression (via quantitative polymerase chain reaction), enzyme concentrations (via enzyme-linked immunosorbent assays), and enzymatic activities (via fluorogenic enzyme cleavage assay or Western blot analysis) of cathepsin L and ADAMTS-1. RESULTS: The analysis included a total of 42 patients (14 per group). We found no statistically significant difference in gene expression, enzyme concentration, or enzymatic activity of cathepsin L or ADAMTS-1 in unexplained infertility or AMA-related infertility as compared to controls. We also found no statistically significant difference in expression or concentration with advancing age. CONCLUSIONS: Cathepsin L and ADAMTS-1 are not altered in women with unexplained infertility or AMA-related infertility undergoing IVF, and they do not decline with advancing age. It is possible that differences exist in natural cycles, contributing to infertility; however, our findings do not support a role for protease alterations as a common cause of infertility.
Subject(s)
ADAM Proteins/metabolism , Cathepsin L/metabolism , Follicular Fluid/enzymology , Infertility/diagnosis , Infertility/enzymology , ADAM Proteins/genetics , ADAMTS1 Protein , Adult , Animals , Blotting, Western , Case-Control Studies , Cathepsin L/genetics , Female , Fertilization in Vitro , Follicular Fluid/chemistry , Humans , Immunoenzyme Techniques , Male , Maternal Age , Mice , Prognosis , Prospective Studies , RNA, Messenger/genetics , Real-Time Polymerase Chain Reaction , Reverse Transcriptase Polymerase Chain ReactionABSTRACT
The American College of Obstetricians and Gynecologists selected "Reentry Into Practice" as the subject for the 2012 Issue of the Year. Physician reentry programs in obstetrics and gynecology are driven by the fact that there is a projected physician shortage, and there are physicians who voluntarily leave clinical practice for a period of time. In planning formal reentry programs, evidence-based practice and highest regard for patient safety must be considered. Our department initiated a reentry fellowship program in 2010. This article describes the process of how we developed our program, the challenges encountered, and the solutions used to overcome these challenges. The formal instruction, evaluation, and documentation of competency are presented. Process improvement has been based on feedback and evaluation from the reentry fellows and from staff and residents. Bringing physicians back into the clinical realm will depend on the success of new programs implementing the guidelines recommended by national regulatory bodies. The guidelines recommend that the programs are accessible, collaborative, comprehensive, ethical, flexible, individualized, innovative, accountable, stable, and responsive. Our reentry program has been successful in helping fellows reestablish clinical practice and is a way to incorporate hands-on competency-based experiences for the reentering obstetrician-gynecologist (ob-gyn).
