Triggering final oocyte maturation with gonadotropin-releasing hormone agonist (GnRHa) versus human chorionic gonadotropin (hCG) in breast cancer patients undergoing fertility preservation: an extended experience.

PURPOSE: To analyze the cycle outcomes and the incidence of ovarian hyperstimulation syndrome (OHSS), when oocyte maturation was triggered by gonadotropin-releasing hormone agonist (GnRHa) versus human chorionic gonadotropin (hCG) in breast cancer patients undergoing fertility preservation. METHODS: One hundred twenty-nine women aged ≤ 45 years, diagnosed with stage ≤ 3 breast cancer, with normal ovarian reserve who desired fertility preservation were included in the retrospective cohort study. Ovarian stimulation was achieved utilizing letrozole and gonadotropins. Oocyte maturation was triggered with GnRHa or hCG. Baseline AMH levels, number of oocytes, maturation and fertilization rates, number of embryos, and the incidence of OHSS was recorded. RESULTS: The serum AMH levels were similar between GnRHa and hCG groups (2.7 ± 1.9 vs. 2.1 ± 1.8; p = 0.327). There was one case of mild or moderate OHSS in the GnRHa group compared to 12 in the hCG group (2.1 % vs. 14.4 %, p = 0.032). The maturation and fertilization rates, and the number of cryopreserved embryos were significantly higher in the GnRHa group. CONCLUSIONS: GnRHa trigger improved cycle outcomes as evidenced by the number of mature oocytes and cryopreserved embryos, while significantly reducing the risk of OHSS in breast cancer patients undergoing fertility preservation.

Ovarian stimulation and fertility preservation with the use of aromatase inhibitors in women with breast cancer.

Breast cancer is the most common malignancy diagnosed in women in the United States. Many breast cancer survivors are concerned that cancer treatment will compromise their reproductive potential. Despite this concern, most women receive limited information addressing preservation of fertility before initiating adjuvant chemotherapy. Historically, the supraphysiologic levels of estrogens associated with ovarian stimulation have precluded the use of assisted reproductive technologies in the presence of breast cancer. In an effort to mitigate the potential effects of elevated estrogen levels during ovulation induction, we developed a novel ovarian stimulation protocol for women with breast cancer, with the use of aromatase inhibitors. Our studies suggest that in the short term, aromatase inhibitors plus gonadotropins are safe and effective agents for ovarian stimulation in fertility preservation cycles. In this review, we outline the data supporting the use of aromatase inhibitors for ovarian hyperstimulation in women with breast cancer before initiating adjuvant chemotherapy.

Lower abdominal and pelvic pain with advanced pelvic organ prolapse: a case-control study.

OBJECTIVE: The objective of the study was to compare the relative frequencies of pain in women with and without pelvic organ prolapse (POP). STUDY DESIGN: This was an ancillary analysis of a case-control study investigating functional bowel disorders in women with and without POP. Cases were defined as subjects with stage 3 or 4 POP and controls were subjects with normal pelvic support. RESULTS: Women with POP were more likely to experience lower abdominal or pelvic pain that was significantly bothersome and interfered with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI], 4.7-20.4). After controlling for confounders, women with prolapse were more likely to report pressure in the lower abdomen (OR, 2.3; 95% CI, 1.6-3.2), heaviness in the pelvic region (OR, 3.3; 95% CI, 2.3-4.3), and pain in the lower abdomen (OR, 2.6; 95% CI, 1.8-4.1). CONCLUSION: Women with prolapse are more likely to report pain, pressure, or heaviness in the lower abdomen or pelvis compared with women with normal support.

Robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse: initial report and technique.

The objective of our study is to describe the peri-operative and early postoperative surgical outcomes following robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse. This was a retrospective cohort study of ten women with symptomatic Stage 2 or greater pelvic organ prolapse and concomitant rectal prolapse who desired combined robotic surgery, at a single institution. The mean age of the subjects was 55.3 ± 19.2 years (range 19-86)  and the mean body mass index was 25.8 ± 5.7 kg/m(2). Preoperatively, the women had Stage 2 or greater pelvic organ prolapse and the average length of rectal prolapse was 2.1 ± 1.9 cm. There were no conversions to conventional laparoscopy or laparotomy. The mean operating room time was 307 ± 45 min with an estimated blood loss of 144 ± 68 ml. The average length of stay was 2.4 ± 0.8 days. Preliminary data suggest that robotic sacrocolpoperineopexy with ventral rectopexy is a feasible procedure with minimal operative morbidity for the combined treatment of rectal and pelvic organ prolapse. Longer follow-up is needed to ensure favorable long-term subjective and objective outcomes.

Primary stress urinary incontinence: what to do and why.

Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine on effort, exertion, sneezing, or coughing. SUI is the most common cause of urinary incontinence in younger women and the second most common cause in older women. Surgery offers high cure rates and is considered by many to be the first-line therapy for uncomplicated SUI in women. Currently, a variety of surgical procedures are available to treat symptomatic SUI. This article reviews the process of choosing a primary surgical procedure for women with SUI.

Congenital anomalies of the female reproductive tract in a patient with Goltz syndrome.

BACKGROUND: Goltz syndrome, or focal dermal hypoplasia, is a rare congenital mesoectodermal syndrome. It is characterized primarily by extensive cutaneous and musculoskeletal defects. CASE: We report on a 17-year-old menarchal girl diagnosed with a severe form of Goltz syndrome who was referred to the Gynecology Division at the Children's Hospital Boston. A complete evaluation revealed a septate hymen, a normal vagina with a single cervix, a bicornuate uterus, and a unilateral kidney. To our knowledge, there have been no documented cases of congenital anomalies of the female reproductive tract in patients with Goltz syndrome. CONCLUSIONS: The development of the female reproductive tract is a complex process involving all three embryonic cell layers. Female patients with multiple abnormalities of ectodermal and mesodermal origin warrant complete evaluations of their reproductive tracts.

Advantage of conservative surgical management of large ovarian neoplasms in adolescents.

OBJECTIVE: To measure the postoperative size and volume of the ovary after cystectomy for a neoplasm >or=10 cm. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENT(S): Nine patients who underwent surgical management for an ovarian neoplasm at Children's Hospital Boston between November 2003 and November 2007. INTERVENTION(S): Patients were evaluated by ultrasound postoperatively. MAIN OUTCOME MEASURE(S): Sonographic size and volume of the ovary after cystectomy for an ovarian neoplasm >or=10 cm. RESULT(S): The mean age of the patients was 14.2 +/- 2.2 years, ranging between 10 and 17 years. The mean preoperative size of the ovarian neoplasm was 14.8 +/- 3.8 cm, ranging between 10 and 20 cm. Serum tumor markers were negative in seven out of nine patients. There were no borderline tumors or malignancies identified. There was no statistically significant difference between the size or volume of the affected ovary and the contralateral ovary at the time of postoperative evaluation. CONCLUSION(S): Postoperative ultrasound revealed that the affected ovary resumed its normal size and volume despite the attenuated appearance of the ovarian cortex at the time of surgery. Ovarian cystectomy should be the preferred surgical approach for adolescents to ensure conservation of ovarian tissue.

Development of a high-throughput Alamar blue assay for the determination of influenza virus infectious dose, serum antivirus neutralization titer and virus ca/ts phenotype.

FluMist is an intranasal influenza live vaccine containing two Influenza A strains (currently H1N1 and H3N2) and one B strain (Yamagata or Victoria lineage). Characterization of the vaccine requires determination of the median tissue culture infectious dose (TCID(50)) titer, serum antivirus neutralization titer and vaccine cold adapted/temperature sensitive (ca/ts) phenotype. Visual cytopathic effect (CPE) readings are used widely in viral assays, but these are subjective and labor intensive. In response to the need for an efficient, inexpensive and high-throughput assay, a 96-well microplate assay was developed that uses Alamar blue dye staining as a replacement for CPE observation in the determination of influenza virus infectious dose, serum antivirus neutralization titer and virus ca/ts phenotype. Relative operating characteristic curves verified that there was a clear distinction between the fluorescence readings of the Alamar blue stained CPE positive and CPE negative wells. Virus titer was determined by use of both Alamar blue staining and CPE-based TCID(50) assays for wild-type and FluMist influenza vaccine strains as well as a plasmid-rescued influenza FluMist A strain containing a H5N1 derived hemmaglutinin and neuramidinase. Correlation of the two assays was measured by regression analysis and resulted in R(2) values of 0.814 (Influenza A), 0.983 (Influenza B) and 1.000 (H5N1), respectively. Serum microneutralization as well as virus ca/ts phenotype assays also showed a high concordance between readings based on CPE observation and Alamar blue staining. The Alamar blue dye assay is user friendly, environmentally safe and sensitive. Also, it is adaptable to automation, which could provide a high-throughput platform for analysis of pre-clinical and clinical samples.

Reduced bone mineral density is associated with breast arterial calcification.

BACKGROUND: Arterial calcification, a marker of atherosclerosis, results from a complex process of biomineralization resembling bone formation. Breast arterial calcification (BAC) has been associated with angiographic and clinical cardiovascular disease. The purpose of this study was to determine the association between reduced bone mineral density (BMD) and BAC, which may share a common pathophysiology. METHODS: We conducted a retrospective study of 228 women (55% Hispanic, mean age 64 +/-10 yr) who had both mammography and BMD evaluation at Columbia University Medical Center from 2001-2003. Each mammogram was reviewed for the presence of BAC using standardized methods. BMD was measured using dual-energy x-ray absorptiometry and categorized as normal, low bone density (osteopenia), or osteoporosis as defined by the World Health Organization. Univariate and multivariate logistic regression analyses were performed to evaluate the association between reduced BMD and BAC. RESULTS: The prevalence of BAC, low bone density (osteopenia), and osteoporosis was 39, 42, and 29%, respectively. Women with BAC were significantly more likely to be older, Hispanic, and postmenopausal and have osteoporosis as compared with women without BAC. In age-adjusted analyses, women with BAC were more likely to have reduced BMD (odds ratio 3.0, P < 0.01) as compared with women without BAC. Furthermore, osteoporosis was strongly associated with the presence of BAC (odds ratio 3.5, P < 0.01). CONCLUSION: These data suggest that osteoporosis and arterial calcification are strongly and independently correlated. Reduced BMD may identify women at risk of vascular disease.

Prevalence of breast arterial calcifications in an ethnically diverse population of women.

PURPOSE: Breast arterial calcifications (BAC) identified on routine mammography have been associated with coronary heart disease (CHD) risk factors including diabetes and hypertension, angiographically defined CHD, and increased cardiovascular mortality. Accumulating evidence suggests that the mammogram may be an important tool to identify women at risk for CHD, however, the epidemiology of BAC has been poorly defined and previous studies limited to white populations. METHODS: The mammograms of 1905 consecutive women (51.2% Hispanic, 25.8% white, 15.3% black, 5.4% other, 2.2% Asian, ages 35-92 years) were evaluated for the presence of BAC and the number of calcified arteries. RESULTS: The overall prevalence of BAC was 29.4% and was significantly higher for Hispanics compared with whites (34.5% vs. 24.0%, p=0.0002) and lower for Asians compared with whites (7.1% vs. 24.0%, p < 0.02). Among BAC-positive women aged 65 years or less, blacks had more calcified arteries than whites (p < 0.01). The presence of BAC increased with age (p for trend < 0.0001). In age-adjusted models, older Hispanics were more likely to be BAC-positive than whites of similar age (p < 0.02). CONCLUSION: These results indicate that BAC varies significantly by age and race/ethnicity. These findings should be taken into consideration when designing future studies of BAC and CHD.