Anish A. Shah

Pregnancy outcomes decline in recipients over age 44: an analysis of 27,959 fresh donor oocyte in vitro fertilization cycles from the Society for Assisted Reproductive Technology.

OBJECTIVE To use a large and recent national registry to provide an updated report on the effect of recipient age on the outcome of donor oocyte in vitro fertilization (IVF) cycles. DESIGN Retrospective cohort study. SETTING United States national registry for assisted reproductive technology. PATIENT(S) Recipients of donor oocyte treatment cycles between 2008 and 2010, with cycles segregated into five age cohorts: ≤34, 35 to 39, 40 to 44, 45 to 49, and ≥50 years. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Implantation, clinical pregnancy, live-birth, and miscarriage rates. RESULT(S) In donor oocyte IVF cycles, all age cohorts ≤39 years had similar rates of implantation, clinical pregnancy, and live birth when compared with the 40- to 44-year-old reference group. Patients in the two oldest age groups (45 to 49, ≥50 years) experienced statistically significantly lower rates of implantation, clinical pregnancy, and live birth compared with the reference group. Additionally, all outcomes in the ≥50-year-old group were statistically significantly worse than the 45- to 49-year-old group, demonstrating progressive decline with advancing age. CONCLUSION(S) Recent national registry data suggest that donor oocyte recipients have stable rates of pregnancy outcomes before age 45, after which there is a small but steady and significant decline.

A truncated progesterone receptor (PR-M) localizes to the mitochondrion and controls cellular respiration.

The cDNA for a novel truncated progesterone receptor (PR-M) was previously cloned from human adipose and aortic cDNA libraries. The predicted protein sequence contains 16 unique N-terminal amino acids, encoded by a sequence in the distal third intron of the progesterone receptor PR gene, followed by the same amino acid sequence encoded by exons 4 through 8 of the nuclear PR. Thus, PR-M lacks the N terminus A/B domains and the C domain for DNA binding, whereas containing the hinge and hormone-binding domains. In this report, we have localized PR-M to mitochondria using immunofluorescent localization of a PR-M-green fluorescent protein (GFP) fusion protein and in Western blot analyses of purified human heart mitochondrial protein. Removal of the putative N-terminal mitochondrial localization signal obviated association of PR-M with mitochondria, whereas addition of the mitochondrial localization signal to green fluorescent protein resulted in mitochondrial localization. Immunoelectron microscopy and Western blot analysis after mitochondrial fractionation identified PR-M in the outer mitochondrial membrane. Antibody specificity was shown by mass spectrometry identification of a PR peptide in a mitochondrial membrane protein isolation. Cell models of overexpression and gene silencing of PR-M demonstrated a progestin-induced increase in mitochondrial membrane potential and an increase in oxygen consumption consistent with an increase in cellular respiration. This is the first example of a truncated steroid receptor, lacking a DNA-binding domain that localizes to the mitochondrion and initiates direct non-nuclear progesterone action. We hypothesize that progesterone may directly affect cellular energy production to meet the increased metabolic demands of pregnancy.

Heterotopic cervical pregnancy treated with transvaginal ultrasound-guided aspiration resulting in cervical site varices within the myometrium

OBJECTIVE To report a case of successful treatment of a heterotopic cervical pregnancy from IVF-embryo transfer and intracytoplasmic sperm injection (ICSI) that resulted in uterine varices at the cervical site. DESIGN Case report. SETTING Tertiary university clinical center. PATIENT(S) A 34-year-old with a history of infertility associated with oligospermia who developed a heterotopic cervical pregnancy diagnosed at 7 weeks gestation. INTERVENTION(S) Transvaginal ultrasound (TVS)-guided aspiration of the cervical pregnancy; preoperative placement of bilateral hypogastric artery occlusion balloons; cesarean section. MAIN OUTCOME MEASURE(S) Successful delivery of intrauterine pregnancy; conservation of the uterus. RESULT(S) Successful termination of the cervical site pregnancy was achieved with TVS-guided aspiration. However, the pregnancy was then complicated by development of uterine varices at the cervical site noted on serial obstetric ultrasounds and magnetic resonance imaging (MRI). Successful management of the pregnancy required a multidisciplinary approach and preoperative placement of bilateral hypogastric artery occlusion balloons. A scheduled high fundal classic cesarean section at 37 weeks allowed for safe delivery of a healthy infant. Complete spontaneous resolution of the uterine varices was noted after the delivery. CONCLUSION(S) It is unclear whether residual ectopic tissue contributed to this later complication; however, it cannot be ignored that the locations of the aborted site and the prominence of dilated venous vasculature in this same location suggests a correlation. The interventions applied are reasonable conservative treatments of a cervical heterotopic pregnancy and a management strategy for uterine varices.

Early polycystic ovary syndrome as a possible etiology of unexplained premenarcheal ovarian torsion.

STUDY OBJECTIVE To study evidence of polycystic ovary syndrome (PCOS) in premenarcheal adolescents with unexplained ovarian torsion. DESIGN Retrospective observational case series. SETTING Tertiary university clinical center PARTICIPANTS Six premenarcheal adolescents and six adults with acute ovarian torsion INTERVENTION A chart review. MAIN OUTCOME MEASURES Contralateral ovarian size, operative findings, ovarian pathology, hormone testing RESULTS Five of the six premenarcheal cases had no pathologic explanation for their ovarian torsion. In four of the cases, size measurements of the contralateral ovary were noted to be larger than the criterion of their respective age group. Three of the four cases had either an ovarian volume (28.5 cm(3)) or an area (16.0 cm(2) and 57.6 cm(2)) that was above the size criterion for a polycystic ovary (volume >10 cm(3) or area>5.5 cm(2)). Pathology of a wedge biopsy of one of the contralateral ovaries suggested evidence of polycystic ovary. Finally, hormone testing available in three of the cases revealed elevated testosterone levels in two. Among the adults, half of the cases had a pathologic explanation for ovarian torsion. One out of the five cases had a contralateral ovary that was significantly enlarged and this was noted in a woman with a diagnosis of PCOS. The remaining two cases had extensive necrosis of the torsed ovary and no other diagnosis was made. CONCLUSION We propose that premenarcheal girls presenting with ovarian torsion, without obvious ovarian pathology, be screened for ultrasound and biochemical evidence of PCOS. In those with evidence of PCOS, treatment with oral contraceptives should be considered taking into account the age and pubertal development, to decrease ovarian volume.

A feasibility study to evaluate pelvic peritoneal anatomy with a saline intraperitoneal sonogram (SIPS)

OBJECTIVE To prove the safety and feasibility of evaluating pelvic anatomy with a new imaging technique called saline intraperitoneal sonogram (SIPS). DESIGN Prospective clinical case series. SETTING Outpatient fertility clinic. PATIENT(S) Ten women with unexplained infertility and normal hysterosalpingograms (HSG). Five women with no known risk factors and five women with known risk factors for adhesive disease were enrolled. INTERVENTION(S) Step 1 required performing a sonohysterogram. Step 2 involved directing a 17-g oocyte retrieval needle into a pocket of peritoneal fluid under ultrasound guidance and infusing normal saline. The pelvic anatomy was evaluated with the three-dimensional and four-dimensional mode on pelvic ultrasound. MAIN OUTCOME MEASURE(S) Technical feasibility, safety, time, fluid infusion, and deficit volumes. RESULT(S) All 10 patients successfully completed the protocol. One of the five women with no risk factors for adhesive disease and a normal HSG was discovered to have a unilateral hydrosalpinx and filmy adhesive disease on SIPS. Both findings were confirmed on laparoscopy. Three out of the five women with known risk factors had abnormal SIPS imaging and were confirmed on laparoscopy to have significant adhesive disease. The average procedure time was 45 minutes (±15 minutes). CONCLUSION(S) This study demonstrates that SIPS is a safe, quick, and potentially cost-effective method for evaluating pelvic adhesive disease in an outpatient facility in women with unexplained infertility and a normal HSG.

Management of gynecologic surgery in the patient with factor XI deficiency: a review of the literature.

&NA; Factor XI deficiency is a rare bleeding disorder that is more commonly found in Ashkenazi Jews. Bleeding manifestations of this disorder are varied and poorly correlate with factor XI levels. Spontaneous bleeding is uncommon, whereas delayed postoperative bleeding is often the presentation of factor XI deficiency. To date, there are no standard recommendations for prophylactic treatment in women undergoing gynecologic surgery. Here, we review published cases of gynecological surgery in women with factor XI deficiency and discuss the risks and benefits of various therapeutic options. Target Audience: Obstetricians And Gynecologists. Learning Objectives: After participating in this activity, physicians should be better able to identify the pathophysiology of factor XI deficiency. Compare previous outcomes of prophylactic treatment in patients with factor XI deficiency undergoing gynecological surgery. Implement possible prophylactic therapies for patients with factor XI deficiency undergoing gynecological surgery.