ABSTRACT
INTRODUCTION: We wish to report the first live births from genetically screened human euploid blastocysts obtained by uterine lavage. The embryos transferred to infertile women were previously obtained using a novel fully automated uterine lavage catheter and fluid recovery device developed for this indication. The objective of this portion of the research was to confirm embryo implantation and live births with these unique in vivo conceived blastocysts obtained by uterine lavage. METHODS: In vivo conceived embryos recovered by uterine lavage 5 days after intrauterine insemination were available for embryo donation. In vivo embryos were the result of prior controlled ovarian stimulation cycles in oocyte donors and intrauterine insemination with donor sperm. An observational case series of nine embryo transfer procedures was performed at an outpatient fertility center. One to two embryos were transferred to eight infertile women since one woman had two separate embryo transfer procedures. RESULTS: Nine embryo transfer procedures were performed with 14 blastocysts in eight women resulting in a blastocyst implantation rate of 36% (5/14) and live birth rate of 44% (4/9). Five infants have been born from the four delivered pregnancies with one set of twins. CONCLUSIONS: This is the first report of live births from genetically screened human euploid blastocysts obtained by uterine lavage. The nonsurgical uterine lavage office procedure represents the only current approach to obtain in vivo conceived embryos and can provide a benchmark for comparison to standard in vitro cultured blastocysts. Live births of in vivo conceived blastocysts represent the validation that the nonsurgical uterine lavage procedure allows simplified access to naturally conceived embryos without performing the surgical procedure of an oocyte aspiration. Owing to its simplicity, uterine lavage may be useful in screening embryos for preimplantation genetic testing for aneuploidy in fertile and infertile couples. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (Identifier NCT03426007).
The overall goal of this research was to develop a procedure that would allow collection of naturally conceived human embryos and compare them to embryos that result from the standard process of in vitro fertilization (IVF). IVF is a procedure where eggs are surgically removed from the ovaries and fertilized with sperm in a laboratory. Embryos from IVF are cultured for 37 days before they are placed back into a woman's uterus to establish a pregnancy. Uterine lavage is a different procedure where the sperm fertilizes an egg in the normal process of conception and the uterus is rinsed with fluid to recover the embryo before implantation. The embryos reported in this study were the first to be obtained in over 30 years owing to many improvements in the overall uterine lavage procedure. Until our initial study findings reported in 2020, the vast majority of information on embryo development was based on embryos fertilized and cultured in a laboratory. Our prior report of embryos obtained by uterine lavage compared with IVF embryos from the same women demonstrated a significantly better appearance of the embryos recovered by lavage. This current report documents the first live births from these genetically screened naturally conceived human embryos. The live births provide evidence that uterine lavage allows ready access to normal embryos without performing the surgical procedure IVF. Owing to the simplicity of uterine lavage, the procedure may improve access to genetic testing of embryos before pregnancy.
Subject(s)
Infertility, Female , Live Birth , Female , Humans , Male , Pregnancy , Blastocyst , Embryo Disposition , Fertilization in Vitro , Semen , Therapeutic IrrigationABSTRACT
OBJECTIVE: Rapid sequence intubation (RSI) is often required in managing critically ill patients in the prehospital setting. Although etomidate is a commonly used induction agent for RSI, ketamine has gained new interest in prehospital management with reported neutral hemodynamic effects. Limited data exist to support ketamine as an alternative to etomidate, particularly in the prehospital setting. The purpose of this study was to evaluate hemodynamic changes after the administration of ketamine versus etomidate in prehospital RSI. METHODS: This retrospective study evaluated adult patients undergoing prehospital RSI over 13 months within a regional emergency transport medicine service. Hypotension was defined as a 20% decrease in systolic blood pressure (SBP) within 15 minutes of receiving ketamine or etomidate. Hemodynamic data were collected 15 minutes before and 15 minutes after administration or until additional sedative medications were given. Data were analyzed using SPSS software (Version 21; IBM Corp, Armonk, NY), with P < .05 considered significant. RESULTS: One hundred thirteen patients met the inclusion criteria (ketamine, n = 33; etomidate, n = 80), with the primary reasons for intubation being respiratory failure and trauma. There was no difference between the incidence of patients who experienced a 20% decrease in SBP (16% etomidate vs. 18% ketamine, P = .79). There were no significant differences in SBP pre- to postadministration between ketamine and etomidate. CONCLUSION: No hemodynamic differences occurred between patients who received ketamine versus etomidate for prehospital RSI. Neither drug was associated with an increased need for additional sedatives, and neither drug was associated with an increased first-pass intubation success rate. Larger, prospective, powered studies are required to identify patients who may benefit from either ketamine or etomidate.
Subject(s)
Emergency Medical Services , Etomidate , Ketamine , Adult , Etomidate/adverse effects , Hemodynamics , Humans , Hypnotics and Sedatives/therapeutic use , Intubation, Intratracheal , Ketamine/adverse effects , Prospective Studies , Rapid Sequence Induction and Intubation , Retrospective StudiesABSTRACT
STUDY QUESTION: After controlled ovarian stimulation (COS) and IUI, is it clinically feasible to recover in vivo conceived and matured human blastocysts by uterine lavage from fertile women for preimplantation genetic testing for aneuploidy (PGT-A) and compare their PGT-A and Gardner scale morphology scores with paired blastocysts from IVF control cycles? SUMMARY ANSWER: In a consecutive series of 134 COS cycles using gonadotrophin stimulation followed by IUI, uterine lavage recovered 136 embryos in 42% (56/134) of study cycles, with comparable in vivo and in vitro euploidy rates but better morphology in in vivo embryos. WHAT IS KNOWN ALREADY: In vivo developed embryos studied in animal models possess different characteristics compared to in vitro developed embryos of similar species. Such comparative studies between in vivo and in vitro human embryos have not been reported owing to lack of a reliable method to recover human embryos. STUDY DESIGN, SIZE, DURATION: We performed a single-site, prospective controlled trial in women (n = 81) to evaluate the safety, efficacy and feasibility of a novel uterine lavage catheter and fluid recovery device. All lavages were performed in a private facility with a specialized fertility unit, from August 2017 to June 2018. Subjects were followed for 30 days post-lavage to monitor for clinical outcomes and delayed complications. In 20 lavage subjects, a single IVF cycle (control group) with the same ovarian stimulation protocol was performed for a comparison of in vivo to in vitro blastocysts. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Women were stimulated with gonadotrophins for COS. The ovulation trigger was given when there were at least two dominant follicles ≥18 mm, followed by IUI of sperm. Uterine lavage occurred 4-6 days after the IUI. A subset of 20 women had a lavage cycle procedure followed by an IVF cycle (control IVF group). Recovered embryos were characterized morphologically, underwent trophectoderm (TE) biopsy, vitrified and stored in liquid nitrogen. Biopsies were analyzed using the next-generation sequencing technique. After lavage, GnRH antagonist injections were administered to induce menstruation. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 134 lavage cycles were performed in 81 women. Uterine lavage recovered 136 embryos in 56 (42%) cycles. At the time of cryopreservation, there were 40 (30%) multi-cell embryos and 96 (70%) blastocysts. Blastocysts were of good quality, with 74% (70/95) being Gardener grade 3BB or higher grade. Lavage blastocysts had significantly higher morphology scores than the control IVF embryos as determined by chi-square analysis (P < 0.05). This is the first study to recover in vivo derived human blastocysts following ovarian stimulation for embryo genetic characterization. Recovered blastocysts showed rates of chromosome euploidy similar to the rates found in the control IVF embryos. In 11 cycles (8.2%), detectable levels of hCG were present 13 days after IUI, which regressed spontaneously in two cases and declined after an endometrial curettage in two cases. Persistent hCG levels were resolved after methotrexate in three cases and four cases received both curettage and methotrexate. LIMITATIONS, REASON FOR CAUTION: The first objective was to evaluate the feasibility of uterine lavage following ovarian stimulation to recover blastocysts for analysis, and that goal was achieved. However, the uterine lavage system was not completely optimized in our earlier experience to levels that were achieved late in the clinical study and will be expected in clinical service. The frequency of chromosome abnormalities of in vivo and IVF control embryos was similar, but this was a small-size study. However, compared to larger historical datasets of in vitro embryos, the in vivo genetic results are within the range of high-quality in vitro embryos. WIDER IMPLICATIONS OF THE FINDINGS: Uterine lavage offers a nonsurgical, minimally invasive strategy for recovery of embryos from fertile women who do not want or need IVF and who desire PGT, fertility preservation of embryos or reciprocal IVF for lesbian couples. From a research and potential clinical perspective, this technique provides a novel platform for the use of in vivo conceived human embryos as the ultimate benchmark standard for future and current ART methods. STUDY FUNDING/COMPETING INTEREST(S): Previvo Genetics, Inc., is the sole sponsor for the Punta Mita, Mexico, clinical study. S.M. performs consulting for CooperGenomics. J.E.B. and S.A.C. are co-inventors on issued patents and patents owned by Previvo and ownshares of Previvo. S.N. is a co-author on a non-provisional patent application owned by Previvo and holds stock options in Previvo. S.T.N. and M.J.A. report consulting fees from Previvo. S.T.N., S.M., M.V.S., M.J.A., C.N. and J.E.B. are members of the Previvo Scientific Advisory Board (SAB) and hold stock options in Previvo. J.E.B and S. M are members of the Previvo Board of Directors. A.N. and K.C. are employees of Previvo Genetics. L.V.M, T.M.M, J.L.R and S. S have no conflicts to disclose. TRIAL REGISTRATION NUMBER: Protocol Registration and Results System (PRS) Trial Registration Number and Name: Punta Mita Study TD-2104: Clinical Trials NCT03426007.
Subject(s)
Aneuploidy , Therapeutic Irrigation , Blastocyst , Female , Fertilization in Vitro , Genetic Testing , Humans , Prospective StudiesABSTRACT
OBJECTIVE: To determine whether the Bayes classifier can be used to distinguish between an ectopic and intrauterine pregnancy following embryo transfer based on early human chorionic gonadotropin (hCG) levels. STUDY DESIGN: Retrospective chart review of patients undergoing in vitro fertilization and diagnosed with a singleton intrauterine or with an ectopic pregnancy. Blood was drawn for hCG levels between days 12 and 20 after transvaginal oocyte aspiration. Statistical analysis was performed using a mixed effects model and the Bayes classifier. RESULTS: Singleton intrauterine (n=91) and ectopic gestations (n=14) were analyzed. hCG levels increased by 51% daily in both groups, but levels in ectopic pregnancies were only 14% of those from the control group on the same day (p<1×10-15). Using the Bayes classifier, an hCG value <18 IU/L indicated a large probability (>75%) that the pregnancy was ectopic. There was no statistically significant difference in regards to endometrial thickness (p=0.77), fresh or frozen embryo transfer (p=0.53), number of embryos transferred (p=0.13), donor or autologous oocytes (p=0.76), or the day of hCG draw (p=0.13 and 0.43 for first and second measurement). CONCLUSION: The Bayes classifier can be used as a tool to alert the healthcare provider of a possible ectopic gestation.
Subject(s)
Bayes Theorem , Chorionic Gonadotropin , Embryo Transfer , Pregnancy, Ectopic , Chorionic Gonadotropin/blood , Female , Fertilization in Vitro , Humans , Pregnancy , Retrospective Studies , Risk AssessmentABSTRACT
BACKGROUND: Delay in appropriate antibiotic therapy is associated with an increase in mortality and prolonged length of stay. Automatic dispensing machines decrease the delivery time of intravenous (IV) antibiotics to patients in the emergency department (ED). However, when IV antibiotics are not reviewed by pharmacists before being administered, patients are at risk for receiving inappropriate antibiotic therapy. The objective of this study was to determine if a difference exists in the time to administration of appropriate antibiotic therapy before and after implementation of prospective verification of antibiotics in the ED. METHODS: This retrospective, institutional review board-approved preimplementation vs postimplementation study evaluated patients 18years or older who were started on IV antibiotics in the ED. Patients were excluded if pregnant, if the patient is a prisoner, if no cultures were drawn, or if the patient was transferred from an outside facility. Appropriate antibiotic therapy was based on empiric source-specific evidence-based guidelines, appropriate pharmacokinetic and pharmacodynamic properties, and microbiologic data. The primary end point was the time from ED arrival to administration of appropriate antibiotic therapy. RESULTS: Of the 1628 evaluated, 128 patients met the inclusion criteria (64 pre vs 64 post). Patients were aged 65.2±17.0years, with most of infections being pneumonia (44%) and urinary tract infections (18%) and most patients being noncritically ill. Time to appropriate antibiotic therapy was reduced in the postgroup vs pregroup (8.1±8.6 vs 15.2±22.8hours, respectively, P=.03). In addition, appropriate empiric antibiotics were initiated more frequently after the implementation (92% post vs 66% pre; P=.0001). There was no difference in mortality or length of stay between the 2 groups. CONCLUSION: Prompt administration of the appropriate antibiotics is imperative in patients with infections presenting to the ED. The impact of prospective verification of antibiotics by pharmacists led to significant improvement on both empiric selection of and time to appropriate antibiotic therapy.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/classification , Emergency Service, Hospital/standards , Pneumonia/drug therapy , Urinary Tract Infections/drug therapy , Administration, Intravenous , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Retrospective Studies , Time FactorsABSTRACT
OBJECTIVE: To study the association between paternal medical comorbidities and the outcomes of assisted reproductive technology (ART). DESIGN: Retrospective cohort study. SETTING: Academic reproductive medicine center. PATIENT(S): We analyzed fresh ART cycles uszing freshly ejaculated sperm from the male partner of couples undergoing ART cycles from 2004 until 2014. We recorded patient and partner demographic characteristics. The cohort was linked to hospital billing data to obtain information on selected male partners' comorbidities identified using ICD-9-CM codes. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Fertilization, clinical pregnancy, miscarriage, implantation, and live-birth rates as well as birth weights and gestational ages. RESULT(S): In all, we identified 2,690 men who underwent 5,037 fresh ART cycles. Twenty-seven percent of men had at least one medical diagnosis. Men with nervous system diseases had on average lower pregnancy rates (23% vs. 30%) and live-birth rates (15% vs. 23%) than men without nervous system diseases. Lower fertilization rates were also observed among men with respiratory diseases (61% vs. 64%) and musculoskeletal diseases (61% vs. 64%) relative to those without these diseases. In addition, men with diseases of the endocrine system had smaller children (2,970 vs. 3,210 g) than men without such diseases. Finally, men with mental disorders had children born at an earlier gestational age (36.5 vs. 38.0 weeks). CONCLUSION(S): The current report identified a possible relationship between a man's health history and IVF outcomes. As these are potentially modifiable factors, further research should determine whether treatment for men's health conditions may improve or impair IVF outcomes.
Subject(s)
Fathers , Fertility , Fertilization in Vitro , Health Status , Infertility/therapy , Abortion, Spontaneous/etiology , Academic Medical Centers , Adult , Comorbidity , Embryo Implantation , Female , Fertilization in Vitro/adverse effects , Humans , Infertility/diagnosis , Infertility/physiopathology , Live Birth , Male , Middle Aged , Pregnancy , Pregnancy Rate , Retrospective Studies , Risk Factors , Treatment Outcome , Young AdultABSTRACT
PURPOSE: Significant pharmacy department contributions to a medical center's efforts to attain certification as a primary stroke center (PSC) are described. SUMMARY: As part of an initiative to improve outcomes in patients with stroke and earn the PSC designation, the pharmacy department of an 855-bed community teaching hospital participated in developing a multifaceted "Code Stroke" program. Pharmacists deployed in the emergency department (ED), intensive care units, and medical units are involved in all aspects of stroke care from admission to discharge. Pharmacists attend ED responses to Code Stroke alerts, assisting in patient evaluation and helping to ensure timely tissue plasminogen activator (t-PA) administration and prompt computed tomography scanning. Throughout the hospital stay of a patient with stroke, pharmacists are involved in verifying that applicable Joint Commission core measures are met. Once a patient with stroke is deemed ready for discharge, a transitions-of-care pharmacist ensures that the patient receives the assistance necessary to obtain newly prescribed medications and counseling to promote postdischarge compliance. Implementation of the Code Stroke program was associated with improvements in stroke care quality measures, including a reduction in the median time from hospital arrival to t-PA administration and improved core measure compliance. CONCLUSION: By participating in the implementation of a number of transformative initiatives, the pharmacy department played an important role in enabling the medical center to provide consistent, excellent care for all patients with stroke as it prepared for certification as a PSC.
Subject(s)
Hospitals, Community/standards , Pharmacists/standards , Pharmacy Service, Hospital/standards , Professional Role , Stroke/therapy , Hospitals, Community/methods , Humans , Patient Discharge/standards , Pharmacy Service, Hospital/methodsABSTRACT
OBJECTIVE: To identify the current and future state of the practice of reproductive medicine. DESIGN: Cross-sectional survey. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): The survey included 57 questions designed to assess practice patterns/metrics and professional satisfaction and morale. RESULT(S): A total of 336/1,100 (31%) responded, and they were 38% women, 61% men, and 76% Caucasian, with a mean age of 54. Respondents averaged 2.3 jobs and averaged 53 hours of work per week: 44% work in academia and 50% in private groups. Average practice size was 5.5, with an average of 470 fresh IVF cycles performed per year. Percent effort included 63% infertility, 10% endocrinology, 10% surgery, and 9% research. Respondents performed an average of 13 major surgeries, 69 minor surgeries, and 128 oocyte retrievals per year. A total of 60% were salaried, and 40% were equity partners. Compensation was highly skewed. Greater than 84% had a positive morale and had a positive view of the future, and 92% would again choose REI as a career. The most satisfying areas of employment were patient interactions, intellectual stimulation, interactions with colleagues, and work schedule. The least satisfying areas were work schedule and financial compensation. Training was felt to be too focused on female factor infertility and basic research with insufficient training on embryology, genetics, male factor infertility, and clinical research. In the next 5 years, 57% suggested that the need for specialists would stay the same, while 20% predicted a decrease. A total of 58% felt we are training the correct number of fellows (37% felt we are training a surplus). Compared with academia, those in private practice reported higher compensation, less major surgery, more IVF, less endocrinology, and less research. Men worked more hours, conducted more surgery and IVF cycles, and had higher compensation than women. Morale was similar across age, gender, practice type, and geography. CONCLUSION(S): Our subspecialty has an extremely high morale. We are a middle-aged subspecialty with disparate compensation and a focused practice. Some respondents sense a need for a change in our training, and most anticipate only mild growth in our field.
Subject(s)
Endocrinologists/psychology , Endocrinology , Infertility/therapy , Personal Satisfaction , Practice Patterns, Physicians' , Societies, Medical , Adult , Aged , Aged, 80 and over , Cross-Sectional Studies , Endocrinologists/trends , Endocrinology/trends , Female , Health Workforce/trends , Humans , Infertility/epidemiology , Male , Middle Aged , Practice Patterns, Physicians'/trends , Societies, Medical/trendsABSTRACT
BACKGROUND: This case report describes a relatively novel indication for oocyte cryopreservation. CASE: A couple undergoing infertility treatment at our institution was opposed to embryo cryopreservation for religious reasons. After multiple unsuccessful infer- tility treatment cycles in- cluding ovulation induction combined with' artificial insemination as well as cycles of therapy with in vitro maturation, we were able to offer them fertilization of a limited number of oocytes followed by oocyte cryopreservation. Since our initial fresh embryo transfer was unsuccessful, the thawing of a limited number of these oocytes prevented a second oocyte retrieval. The couple had 3 oocytes thawed and fertilized and had a successful term birth. CONCLUSION: Elective oocyte cryopreservation is a feasible option for successful pregnancy in patients opposed to embryo cryopreservation.
Subject(s)
Cryopreservation , Embryo Transfer , Live Birth , Female , Fertilization in Vitro , Humans , Oocyte Retrieval , Oocytes , PregnancyABSTRACT
OBJECTIVES: Safe and effective contraceptive options for obese women are becoming more important due to the obesity epidemic within the United States. This study evaluated the impact of body mass index (BMI) on efficacy, safety and bleeding patterns during use of an ultra-low-dose combined oral contraceptive (COC). STUDY DESIGN: Data are from a Phase 3 clinical efficacy and safety study of an ultra-low-dose COC containing 1.0-mg norethindrone acetate and 10-mcg ethinyl estradiol. Pearl Indices, adverse events and bleeding profile were calculated for BMI ranges of <25, 25-30 and >30 kg/m(2). RESULTS: Of the 1581 participants included in the analysis, 28.3% were overweight, and 18.0% were obese. For women aged 18-45 years, the Pearl Indices were 2.49, 2.32 and 1.89 for women with a BMI <25, 25-30 and >30 kg/m(2), respectively. The ultra-low dose of ethinyl estradiol did not impact scheduled bleeding or intensity of bleeding, but we observed a slight decline in amenorrhea and slight increase in unscheduled bleeding in obese women compared with other BMI categories. CONCLUSIONS: Our analysis of an ultra-low-dose COC did not find clinically important differences in contraceptive failure rates, adverse events or bleeding profile with increasing BMI. IMPLICATIONS: Our analysis of an ultra-low ethinyl estradiol dose COC did not find clinically important differences in contraceptive failure rates, adverse events or bleeding profile with increasing BMI. An ultra-low-dose COC provides another safe and effective contraceptive option for obese women.
Subject(s)
Body Mass Index , Contraceptives, Oral, Combined/administration & dosage , Contraceptives, Oral, Synthetic/administration & dosage , Estrogens/administration & dosage , Ethinyl Estradiol/administration & dosage , Norethindrone/analogs & derivatives , Adolescent , Adult , Amenorrhea/chemically induced , Contraceptives, Oral, Combined/adverse effects , Contraceptives, Oral, Synthetic/adverse effects , Estrogens/adverse effects , Ethinyl Estradiol/adverse effects , Female , Humans , Menstruation/drug effects , Metrorrhagia/chemically induced , Middle Aged , Norethindrone/administration & dosage , Norethindrone/adverse effects , Norethindrone Acetate , Obesity/complications , Pregnancy , Pregnancy, Unplanned/drug effects , Young AdultABSTRACT
OBJECTIVE: To report a live birth after in vitro maturation (IVM) of oocytes retrieved from extracorporeal ovarian tissue aspiration in the setting of fertility preservation. DESIGN: Observational study. SETTING: Academic center. PATIENT(S): A 23-year-old woman. INTERVENTION(S): IVM from extracorporeal ovarian tissue aspiration. MAIN OUTCOME MEASURE(S): Live birth after IVM. RESULT(S): A 23-year-old woman conceived with embryos derived from extracorporeal oocyte aspiration followed by IVM, embryo freezing, and frozen embryo transfer. CONCLUSION(S): A healthy live birth from extracorporeal aspiration of immature oocytes, IVM, and a frozen embryo transfer after 5 years was documented. Consideration of this technique should be made as a primary or adjunct intervention in the setting of fertility preservation.
Subject(s)
Cryopreservation , Cystadenoma, Mucinous/surgery , Fertility Preservation/methods , In Vitro Oocyte Maturation Techniques , Ovarian Neoplasms/surgery , Ovariectomy , Ovary/cytology , Cystadenoma, Mucinous/pathology , Embryo Transfer , Female , Humans , Infant, Newborn , Live Birth , Male , Ovarian Neoplasms/pathology , Pregnancy , Sperm Injections, Intracytoplasmic , Time Factors , Treatment Outcome , Young AdultABSTRACT
This article focuses on the cause, pathophysiology, differential diagnosis of, and treatment options for vasomotor symptoms. In addition, it summarizes important points for health care providers caring for perimenopausal and postmenopausal women with regard to health maintenance, osteoporosis, cardiovascular disease, and vaginal atrophy. Treatment options for hot flashes with variable effectiveness include systemic hormone therapy (estrogen/progestogen), nonhormonal pharmacologic therapies (selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, clonidine, gabapentin), and nonpharmacologic therapy options (behavioral changes, acupuncture). Risks and benefits as well as contraindications for hormone therapy are further discussed.
Subject(s)
Estrogen Replacement Therapy/methods , Hot Flashes/therapy , Menopause/physiology , Vasomotor System/drug effects , Adrenergic alpha-Agonists/therapeutic use , Cyclohexanecarboxylic Acids/therapeutic use , Evidence-Based Medicine , Female , Hot Flashes/etiology , Hot Flashes/physiopathology , Humans , Menopause/drug effects , Progestins/therapeutic use , Vasomotor System/physiopathology , Women's HealthABSTRACT
A 26-year-old woman with a history of cranial radiation and chemotherapy desired pregnancy. Pelvic ultrasound scanning demonstrated a small uterine volume of 7 mL. After 25 weeks of estrogen therapy, her uterine volume increased to 37 mL. The patient had an uncomplicated pregnancy with the use of donor oocytes and delivered a term healthy daughter.
Subject(s)
Estradiol/administration & dosage , Estrogens/administration & dosage , Live Birth , Uterus/drug effects , Uterus/growth & development , Administration, Intravaginal , Administration, Oral , Adult , Antineoplastic Agents/adverse effects , Blastocyst , Cerebellar Neoplasms/drug therapy , Cerebellar Neoplasms/radiotherapy , Embryo Transfer , Female , Humans , Infant, Newborn , Infertility, Female/etiology , Infertility, Female/therapy , Medulloblastoma/drug therapy , Medulloblastoma/radiotherapy , Oocyte Donation , Pregnancy , Primary Ovarian Insufficiency/complications , Primary Ovarian Insufficiency/etiology , Ultrasonography , Uterus/diagnostic imagingABSTRACT
OBJECTIVE: To assess the efficacy, safety, and tolerability of an extended-duration, combined hormonal oral contraceptive pill (OCP) that reduces the estrogen exposure by almost half compared with other OCPs. METHODS: This open-label, uncontrolled, multicenter study used an ultra low-dose OCP (1.0 mg norethindrone acetate and 10 micrograms ethinyl E2). The OCP was administered in a regimen of 24 days of a 28-day cycle followed by 10 micrograms ethinyl E2 for 2 days and an inactive tablet for 2 days. The study included healthy, heterosexually active women aged 18-45 years who were at risk of pregnancy. RESULTS: The discontinuation rate was 41.7% (692/1,660 patients). Twenty-six pregnancies occurred in 1,555 participants during 15,596 at-risk cycles, resulting in a Pearl Index of 2.2 and a cumulative pregnancy rate of 2.1 for the overall population. Participants experienced an average of 2.6 days of intracyclic (unscheduled) bleeding or spotting per cycle over treatment cycles 213. Intracyclic bleeding was more common in users new to OCPs than in users switching from another OCP and in women aged 18-35 years compared with those aged 36 years or older. The frequency of bleeding episodes decreased after cycle 2 and throughout treatment in all subpopulations. CONCLUSION: The findings of this study demonstrate that this ultra low-dose OCP regimen is effective in preventing pregnancy with a safety and tolerability profile that is comparable with that reported for other low-dose OCPs. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00391807. LEVEL OF EVIDENCE: III.
Subject(s)
Contraceptives, Oral, Synthetic/administration & dosage , Ethinyl Estradiol/administration & dosage , Norethindrone/analogs & derivatives , Adolescent , Adult , Contraceptives, Oral, Synthetic/adverse effects , Ethinyl Estradiol/adverse effects , Female , Humans , Menstruation Disturbances/chemically induced , Middle Aged , Norethindrone/administration & dosage , Norethindrone/adverse effects , Norethindrone Acetate , Pregnancy , Pregnancy Rate , Young AdultSubject(s)
Endometriosis/surgery , Postoperative Complications/etiology , Skin Diseases/etiology , Adult , Female , Humans , Robotics , Sunbathing , Uterine MyomectomyABSTRACT
PROBLEM: Increasing evidence supports the involvement of complex antibody-mediated immunologic events at the decidua-trophoblast interface. Our objective is to define the humoral immune responses of pregnant women with a history of recurrent pregnancy loss (RPL) compared with gestation-age-matched and non-pregnant controls in terms of trophoblast-derived antigenic targets and IgG subclasses. METHOD OF STUDY: Immunoprecipitation and Western immunoblotting were performed to characterize IgG subclass reactivity to Sw.71 trophoblast-derived fetal fibronectin and alpha-2-macroglobulin, using serum obtained from first-trimester pregnant RPL subjects, gestation-age-matched controls, and non-pregnant controls. RESULTS: Using a generalized linear model, sera from women with a history of RPL exhibited increased IgG(3) immunoreactivity to trophoblast-derived fetal fibronectin and alpha-2-macroglobulin compared with controls (P < 0.001 and P < 0.001, respectively). CONCLUSION: IgG(3) reactivity in women with RPL may play a significant role in aberrant immune-regulatory mechanisms in early pregnancy. Further investigations into the role of autoantibodies against trophoblast-derived proteins in implantation and pregnancy are warranted.
Subject(s)
Abortion, Habitual/immunology , Autoantibodies/immunology , Fibronectins/immunology , Immunoglobulin G/immunology , Trophoblasts/immunology , Trophoblasts/metabolism , alpha-Macroglobulins/immunology , Abortion, Habitual/epidemiology , Adult , Autoantibodies/classification , Decidua/immunology , Decidua/metabolism , Female , Fibronectins/metabolism , Gestational Age , Humans , Immunoglobulin G/classification , Pregnancy , Pregnancy Trimester, First , Young Adult , alpha-Macroglobulins/metabolismABSTRACT
OBJECTIVE: To evaluate the scientific literature on current methods of uterine cavity and tubal patency assessment. DESIGN: Review of literature and appraisal of relevant articles using MEDLINE, OVID, EMBASE, and Cochrane on-line databases. RESULT(S): Current pelvic imaging subfertility investigations are compared with the gold standard laparoscopy. The technical aspects, associated risks, potential advantages, and weighted utility of each screening study are discussed. A comprehensive analysis of the clinical evidence regarding the safety, tolerance, and accuracy of hysterosalpingo-contrast sonography compared with alternative screening studies and/or laparoscopy is reviewed. CONCLUSION(S): Increasing evidence supports the more recently described hysterosalpingo-contrast sonography procedure as an acceptable screening study for the subfertile patient with the potential advantage that it is a comprehensive evaluation, methodologically simple, cost effective, and time efficient.
Subject(s)
Diagnostic Techniques, Obstetrical and Gynecological , Fallopian Tubes , Infertility, Female/diagnosis , Pregnancy, Tubal/diagnosis , Uterus , Contrast Media , Fallopian Tubes/diagnostic imaging , Fallopian Tubes/pathology , Female , Humans , Hysterosalpingography , Laparoscopy , Predictive Value of Tests , Pregnancy , Ultrasonography , Uterus/diagnostic imaging , Uterus/pathologyABSTRACT
The current study was undertaken to investigate the use of beta human chorionic gonadotrophin (beta-HCG) concentration and other significant factors to predict the likelihood of an IVF pregnancy progressing to detection of cardiac activity by ultrasound, and to create data tables which can be used for patient counselling. A retrospective data analysis was undertaken of 1374 IVF cycles performed from January 1997 to July 2007, resulting in 662 pregnancies. Maternal age (P = 0.0005), day-14 (P < 0.001) and day-16 (P < 0.001) post-oocyte aspiration beta-HCG concentrations were found to be significant in predicting pregnancy outcome. Multiple logistic regression modelling revealed that the most accurate predictive model used a single day-14 beta-HCG concentration and maternal age. Day-14 and day-16 beta-HCG concentrations were highly correlated, with the addition of a day-16 concentration adding no additional predictive value. Ongoing pregnancy rates were proportional to day-14 beta-HCG concentration and inversely proportional to maternal age. The multiple pregnancy incidence increased proportionally with the initial beta-HCG concentration. Thus, for the counselling of patients following IVF, a single day-14 post-oocyte-aspiration beta-HCG concentration and maternal age are most predictive of the pregnancy continuing to detection of cardiac activity by ultrasound.
Subject(s)
Chorionic Gonadotropin/administration & dosage , Fertilization in Vitro , Maternal Age , Adult , Female , Heart/embryology , Humans , Likelihood Functions , Pregnancy , Pregnancy Outcome , Retrospective Studies , Ultrasonography, PrenatalABSTRACT
BACKGROUND: Immunosenescence is an age-associated disorder occurring primarily in T cell compartments, including altered subset composition, functions, and activation. In women, evidence implicates diminished estrogen in the postmenopausal period as a contributing factor to diminished T cell responsiveness. Since hypoestrogenism is present in postmenopausal women, our objective focused on whether T cell activation, defined as signalling molecule expressions and activation, and function, identified as IL-2 production, were affected by low estrogen. METHODS: Using Jurkat 6.1 T cells, consequences of 4 pg/ml (corresponding to postmenopausal levels) or 40 pg/ml (premenopausal levels) of estradiol (E(2)) were analyzed on signalling proteins, CD3-zeta, JAK2, and JAK3, determined by Western immunoblotting. These consequences were correlated with corresponding gene expressions, quantified by real time-polymerase chain reaction. Tyrosine phosphorylation of CD3-zeta was defined by immunoprecipitation and western immunoblotting following activation by T cell receptor (TcR) cross-linking. CD3-zeta expression and modulation was also confirmed in T cells from pre- and postmenopausal women. To assess functional consequences, IL-2 production, induced by PMA and ionomycin, was determined using enzyme-linked immunosorbent spot assay (ELISpot). RESULTS: At 40 pg/ml E(2), the level of signalling protein CD3-zeta was elevated 1.57-fold, compared with cells exposed to 4 pg/ml E(2). The CD3-zeta proteins also exhibited altered levels of activation-induced phosphorylation in the presence of 40 pg/ml E(2) versus 4 pg/ml: 23 kD phosphorylated form increased 2.64-fold and the 21 kD form was elevated 2.95-fold. Examination of kinases associated with activation signalling also demonstrated that, in the presence of 40 pg/ml E(2), JAK2 protein expression was increased 1.64-fold (p < 0.001) and JAK3 enhanced 1.79-fold (p < 0.001) compared to 4 pg/ml. mRNA levels for CD3-zeta, JAK2, and JAK3 were significantly increased following exposure to 40 pg/ml E(2) (2.39, 2.01, and 2.21 fold, respectively) versus 4 pg/ml. These findings were confirmed in vivo, since T cells from postmenopausal women exhibited 7.2-fold diminished CD3-zeta expression, compared to pre-menopausal controls and this expression was elevated 3.8-fold by addition of 40 pg/ml E(2). Functionally, Jurkat cells exposed to 40 pg/ml E(2) and activated exhibited significantly elevated numbers of IL-2 producing colonies compared to 4 pg/ml (75.3 +/- 2.2 versus 55.7 +/- 2.1 colonies, p < 0.0001). CONCLUSION: Jurkat T cells exposed to 4 pg/ml E(2) expressed significantly diminished activation signalling proteins, correlating with reduced IL-2 production. Lower signalling protein levels appear to result from decreased CD3-zeta, JAK2, and JAK3 gene expressions. These findings may provide a molecular basis for immunosenescence associated with the postmenopausal state.