Body mass index restrictions in fertility treatment: a national survey of OB/GYN subspecialists.

PURPOSE: To explore the attitudes of reproductive endocrinology and infertility (REI) and maternal-fetal medicine (MFM) subspecialists regarding the necessity and appropriateness of body mass index (BMI) cutoffs for women seeking fertility treatment. METHODS: Members of the Society for Reproductive Endocrinology and Infertility (SREI) and the Society for Maternal Fetal Medicine (SMFM) were invited to participate in a survey querying their knowledge of existing institutional or clinic BMI policies and personal opinions regarding upper and lower BMI cutoffs for a range of fertility treatments, including oral ovulation agents, gonadotropins, and in vitro fertilization. RESULTS: Respondents included 398 MFMs and 201 REIs. The majority of REI and MFM providers agreed with upper limit BMI cutoffs (72.5% vs 68.2%, p = 0.29), but REIs were twice as likely to support lower limit BMI restrictions compared to MFMs (56.2% vs 28.4%, p < 0.0001). Those who supported upper BMI restrictions were more likely to be female and report existing institutional BMI cutoffs. The majority of respondents (99.3%) believed that an official statement to guide clinicians should be issued by a national professional organization. CONCLUSIONS: Although practice patterns widely vary, the majority of REIs and MFMs believe that there should be a BMI cutoff above which women should not be offered immediate fertility treatment. Furthermore, there is a reported need for a written statement by a national professional organization to guide clinical practice and to ensure that OB/GYN subspecialists are providing consistent, fair, and safe recommendations to infertile women at the extremes of BMI.

The relationship between facility delivery and infant immunization in Ethiopia.

OBJECTIVE: To determine whether facility delivery is related to compliance with recommended infant immunizations, particularly those that occur weeks or months after delivery. METHODS: In a retrospective analysis, multivariate logistic regression was used to assess data from the 2011 Ethiopia Demographic and Health Survey (EDHS) to determine the strongest correlates of facility delivery. These correlates were then used, along with facility delivery itself, to determine the relationship between facility delivery and infant immunization. RESULTS: In total, 3334 women delivered a newborn 12-24months before the 2011 EDHS: 90.2% (3007) delivered at home, and 9.8% (327) delivered in a facility. Education, wealth status, urban residence, and number of children under 5years living in the household were the factors most strongly associated with facility delivery. When facility delivery and its strongest correlates were entered into multivariate logistic regression models with infant immunizations as the outcome, facility delivery was significantly associated with increased likelihood of DPT-HepB-Hib, polio, and measles vaccination, and increased likelihood of being fully immunized (all P<0.01). Facility delivery was the strongest single factor associated with infants being immunized, doubling the odds of full immunization. CONCLUSION: The impact of facility delivery on health outcomes transcends the immediate delivery and postpartum period.

Physician and patient use of and attitudes toward complementary and alternative medicine in the treatment of infertility.

OBJECTIVE: To determine use of and attitudes toward complementary and alternative medicine (CAM) among infertility patients and subspecialty physicians. METHODS: Infertility patients were asked to complete anonymous written surveys at an academic infertility practice; members of the Society for Reproductive Endocrinology and Infertility were electronically surveyed. Both groups were assessed regarding their use of and attitudes toward CAM. RESULTS: The response rate was 32.1% (115/358) among patients and 22.6% (225/995) among physicians (P<0.05). In total, 105 (91.3%; 95% confidence interval [CI], 85.8-96.2) patients used CAM, and 84 (73.0%; 95% CI, 64.9-81.1) regarded it as beneficial to their fertility treatment. However, only 30 (26.1%; 95% CI, 18.0-34.0) patients reported CAM use to physicians, with the most common reason being that they were "never asked." Overall, 202 (89.8%; 95% CI, 85.9-93.8) physicians reported inquiring about CAM. CONCLUSION: Significant discrepancies exist between subfertile patients and physicians in attitudes toward the use of CAM. The current prevalence of CAM use among infertility patients requires greater physician attention and justifies further study on the risks and benefits of integrating CAM into the biomedical treatment of infertility.

A systematic review of the evidence for complementary and alternative medicine in infertility.

BACKGROUND: The use of complementary and alternative medicine (CAM) by patients and physicians has increased markedly in recent years. Many case reports, case series, and uncontrolled trials of varying quality have been completed; however, there is now a slowly increasing number of randomized controlled trials (RCTs) examining the use of CAM. OBJECTIVES: To identify, survey, and review RCTs investigating the use of CAM for infertility treatment. SEARCH STRATEGY: The MEDLINE and Cochrane databases were electronically searched. SELECTION CRITERIA: RCTs examining modalities for treatment or improvement of health status were reviewed. DATA COLLECTION AND ANALYSIS: RCTs were included based on use of objective measures, articles written in English, availability through the University of Michigan database, and clear published clinical outcomes. MAIN RESULTS: Thirty-seven articles assessing a variety of CAM modalities met inclusion criteria. Acupuncture, selenium supplementation, weight loss, and psychotherapeutic intervention had 3 or more studies demonstrating beneficial effect. Other interventions had been studied less and evidence for them was limited. CONCLUSIONS: Although there is preliminary evidence of the effectiveness of some CAM interventions among infertile patients, many of these interventions require further investigation before they can be considered for routine clinical use.

Dipeptide forms of glycine support mouse preimplantation embryo development in vitro and provide protection against high media osmolality.

PURPOSE: To examine potential benefits of dipeptide forms of amino acids for embryo culture by determining ability of dipeptide glycine forms to support embryo development, act as osmolytes, and reduce ammonia production. METHODS: Frozen thawed 1-cell mouse embryos were cultured in media with varying osmolality with glycine and dipeptide forms of glycine and development assessed. Ammonia levels were measured in various media. RESULTS: Dipeptide forms of glycine, alanyl- and glycyl-glycine, can support mouse embryo development in vitro. Additionally, dipeptide glycine can act as an organic osmolyte in developing embryos, permitting blastocyst formation in high osmolality media. Interestingly, as evidenced by decreased embryo development, dipeptides are not as efficient as osmolytes as their constituent individual amino acids. Dipeptide glycine produced less ammonia than glycine. CONCLUSION: Though dipeptides can provide osmoregulation in preimplantation embryos, efficacy may be lower than individual amino acids. The mechanism by which embryos transport and utilize dipeptide amino acids remains to be identified.

Ovarian Damage During chemotherapy in Autoimmune Diseases: Broad Health Implications beyond Fertility.

Women with autoimmune diseases such as lupus, scleroderma, and vasculitis receiving cyclophosphamide for severe disease manifestations risk primary ovarian insufficiency(POI) due to gonadotoxicity of this therapy. In addition to loss of reproductive potential, POI is associated with increased risk of morbidity and mortality. Practitioners caring for women requiring gonadotoxic therapies should be familiar with long-term health implications of POI and strategies for ovarian preservation. Accumulating evidence supports the effectiveness of adjunctive gonadotropin releasing hormone analog (GnRH-a) for ovarian protection during gonadotoxic therapy in cancer and autoimmune populations. GnRH-a is less costly and invasive than assisted reproductive technologies used for achievement of future pregnancies, but is not Food and Drug Administration approved for ovarian preservation. This review focuses on POI comorbidities and strategies for mitigation of related sequelae, which can accumulate over decades of hypoesteogenism. These issues are arguably more pronounced for women with chronic autoimmune diseases, in whom superimposed POI further heightens risks of cardiovascular disease and osteoporosis. Therefore, even if future pregnancy is not desired, ovarian protection during gonadotoxic therapy should be a major goal of disease management.

Medical, ethical, and legal considerations in fertility preservation.

The past 2 decades have seen a significant rise in cancer survival rates, and an increasing proportion of survivors at reproductive age are interested in childbearing. Although assisted reproduction provides physicians with an array of potential possibilities to help patients whose fertility is compromised by cancer treatment, there is still a dearth of regulation regarding the application of this technology. The present paper reviews the current options for fertility preservation, with a particular focus on the legal and ethical challenges that confront providers of this type of care.

Inhibitory effect of valproic acid on ovarian androgen biosynthesis in rat theca-interstitial cells.

The objective of the study was to evaluate the effect of valproic acid (VPA) on ovarian androgen biosynthesis in primary cultures of theca-interstitial (T-I) cells isolated from rat ovaries. Ovarian T-I cells were cultured with VPA in the presence or absence of hCG. VPA did not increase basal or hCG-stimulated androgen synthesis when added to primary cultures of T-I cells. However, the addition of VPA caused a marked concentration-dependent inhibitory effect on hCG-stimulated androstendione synthesis. Treatment of T-I cells with 8-Bromo-cAMP resulted in a marked increase in the production of androstenedione, and VPA inhibited this stimulatory effect, suggesting that the mechanism of VPA's inhibitory effect on androstenedione production occurs at a step after second messenger activation. Treatment of T-I cells with hCG resulted in a significant increase in the mRNA expression of steroidogenic enzymes CYP17A1 and 17ß-hydroxysteroid dehydrogenase. Addition of VPA sharply blunted the stimulatory effect of hCG, reducing the mRNA expression of the steroidogenic enzymes to basal levels. In conclusion, VPA exerts an inhibitory effect on hCG-stimulated androgen synthesis in rat T-I cells.

Oocyte cryopreservation in a woman with mosaic Turner syndrome: a case report.

BACKGROUND: Turner syndrome (TS) is the most common sex chromosome anomaly. Spontaneous pregnancies have been reported in a small percentage of women with TS, particularly those with mosaicism. However, due to accelerated follicular atresia, the majority of TS patients undergo ovarian failure prior to or around the time of puberty. In vitro fertilization with donor oocytes and subsequent embryo transfer has been the predominant fertility option for such patients. We report a case of oocyte cryopreservation for a patient with mosaic TS including the evaluation, treatment decisions and ovarian response. CASE: A 28-year-old woman with mosaic TS and oligomenorrhea chose oocyte cryopreservation for fertility preservation. Ovarian reserve testing revealed a day 3 FSH of 4.3 mIU/mL and an antral follicle count of 40. She underwent controlled ovarian stimulation and had a vigorous response to a gonadotropin/gonadotropin-releasing hormone antagonist protocol, with a peak estradiol level of 4507 pg/mL. Transvaginal oocyte retrieval produced 15 oocytes, 13 of which met the criteria for vitrification. CONCLUSION: Oocyte cryopreservation offers TS patients a new option to preserve future fertility; however, this new technology requires extensive counseling regarding not only its investigational nature but also risks specific to it and implications for this patient population.

PPAR-gamma receptor ligand induces regression of endometrial explants in baboons: a prospective, randomized, placebo- and drug-controlled study.

OBJECTIVE: To determine the effects of a thiazolidinedione (TZD) agonist of peroxisome proliferator-activated receptor (PPAR)-gamma, rosiglitazone, in a baboon model of established endometriosis. DESIGN: Prospective, randomized, placebo-controlled study. SETTING: Experimental surgery laboratory at the Institute of Primate Research in Nairobi, Kenya. ANIMAL(S): Endometriosis was induced using intrapelvic injection of eutopic menstrual endometrium in 12 female baboons with a normal pelvis that had undergone at least one menstrual cycle since the time of captivity. INTERVENTION(S): Induction of endometriosis by laparoscopy was performed in 12 baboons with a normal pelvis. Endometrial tissue was extracted from each baboon by curettage, and a standard amount of endometrium was then seeded onto several peritoneal sites. About 34-68 days after the induction of laparoscopy, a pretreatment laparoscopy (baseline disease assessment) was performed in the baboons to record the extent of endometriotic lesions. The 12 baboons were randomized into three groups and treated from the day after the staging laparoscopy for a total duration of 30 days. They received phosphate-buffered saline tablets (n = 4, placebo control; placebo tablets once a day by mouth for 30 days), GnRH-antagonists (n = 4, active control; ganirelix acetate 125 microg/day for 30 days), or rosiglitazone (n = 4, test drug, 2 mg by mouth each day for 30 days). A third and final laparoscopy on day 30 after the start of treatment was performed to record the extent of endometriosis. The type of lesion (typical, red, white, or suspicious) was recorded. Biopsies were obtained to confirm the histological presence of endometriosis. MAIN OUTCOME MEASURE(S): A videolaparoscopy was performed 30 days after treatment to document the number and surface area of endometriotic lesions as well as to calculate the revised American Society for Reproductive Medicine score and stage. RESULT(S): The surface area of endometriotic lesions was statistically significantly lower in rosiglitazone-treated baboons when compared with the placebo group. Baboons treated with rosiglitazone or ganirelix had a greater negative relative change in surface area of peritoneal endometriotic lesions than controls. The overall weighted appearance of the lesion types suggests that rosiglitazone may deter the development of newer endometriotic lesions. CONCLUSION(S): A PPAR-gamma ligand, rosiglitazone, effectively diminishes the burden of endometriosis disease in a baboon endometriosis model. This animal model holds promise that a TZD drug may be helpful in women with endometriosis.

Estrogen treatment success in recurrent and persistent labial agglutination.

STUDY OBJECTIVE: To estimate the success rate of conservative medical management and indications for surgery in cases of recurrent and/or persistent labial agglutination. DESIGN: A retrospective chart review was performed of girls treated for labial agglutination between 1996 and 2004. Records were reviewed for age, length of time of symptoms, previous treatments, results of topical estrogen therapy, and indications for surgery. SETTING: The study was performed in a tertiary care teaching university hospital. PARTICIPANTS: Charts of 67 girls with labial agglutination who were treated at the pediatric and adolescent gynecology clinic between 1996 and 2004 were reviewed. The average age was 4.1 years (range 0.6-14 years). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Improvement of persistent or recurrent agglutination labial agglutination with estrogen. RESULTS: Out of the 67 charts reviewed, 48 had recurrent or persistent disease. Within those 48 girls, initial treatments included: topical estrogen in 40 (83%), oral and topical estrogen in 1 (2%), topical estrogen in addition to manual separation in 5 (10%), and treated with manual separation alone in 2 (4%). Five girls were immediately treated surgically due to urinary problems or parents declining further topical treatment. Forty-three were treated with topical estrogen therapy with the following results: 15 opened either partially or completely, 9 required surgery, and 19 did not follow up. In the subset of girls with prior manual separation, 2 had resolution of adhesions with estrogen, 3 required surgery, and 2 had no follow-up. CONCLUSION: This study suggests that re-treatment of persistent or recurrent labial agglutination with topical estrogen therapy following detailed application instruction leads to avoidance of surgical intervention in at least 35% of cases. Even in cases which previously required manual separation, an attempt at conservative medical management may be considered.

Cystic myometrial lesion in the uterus of an adolescent girl.

The clinical course and radiographic appearance of a cystic myometrial lesion in a 13-year-old adolescent girl are described. Hormone suppression with continuous oral contraceptive (OC) pills resulted in partial regression of the lesion, as well as control of symptoms.