Anupama S.Q. Kathiresan

Pregnancy outcomes by intravaginal and intrauterine insemination in 82 couples with male factor infertility due to spinal cord injuries

OBJECTIVE To report our centers pregnancy rates (PR) by intravaginal insemination (IVI) or intrauterine insemination (IUI) in 82 couples with male partners with spinal cord injuries. DESIGN Retrospective analysis. SETTING Major medical center. PATIENT(S) Male patients with spinal cord injuries and their female partners. INTERVENTION(S) Intravaginal insemination and IUI. MAIN OUTCOME MEASURE(S) Pregnancy and live birth outcomes. RESULT(S) Overall, 31 of the 82 couples (37.8% PR) achieved 39 pregnancies. Sperm were obtained by masturbation, penile vibratory stimulation, or electroejaculation in 4 men (4.9%), 42 men (51.2%), and 36 men (43.9%), respectively. Intravaginal insemination, performed mostly at home by selected couples, was undertaken in 45 couples, 17 of whom (37.8% PR) achieved 20 pregnancies. Intrauterine insemination was performed in 57 couples, 14 of whom (24.6% PR) achieved 19 pregnancies, with a cycle fecundity of 7.9%. Eighteen and 21 live births occurred by IVI and IUI, respectively. CONCLUSION(S) The methods of IVI and IUI are reasonable options for this patient population. These methods warrant consideration before proceeding to assisted reproductive technologies (ART).

Prognostic value of beta-human chorionic gonadotropin is dependent on day of embryo transfer during in vitro fertilization

OBJECTIVE To determine threshold β-hCG levels predictive of an ongoing pregnancy (OP), live birth (LB), and multiple gestation (MG) in IVF cycles resulting from day-3 (D3) vs. day-5 (D5) embryo transfers (ET), to compare IVF cycle characteristics and pregnancy outcomes in D3 vs. D5 ET groups, and to assess the degree to which maternal characteristics and cycle parameters were predictive of higher β-hCG levels. DESIGN Retrospective analysis. SETTING Infertility center. PATIENT(S) Women who had ET performed for IVF cycles between July 2004 and January 2010. INTERVENTION(S) Embryo transfer performed on either D3 or D5 after oocyte fertilization. MAIN OUTCOME MEASURE(S) Beta-hCG on day 15 after oocyte fertilization. RESULT(S) Beta-hCG levels were significantly higher with D5 ET compared with D3 ETs (D3: 103.6 ± 4.4 IU/L vs. D5: 198.0 ± 10.6 IU/L), and a multivariate analysis demonstrated that D5 ET was a significant predictor of higher β-hCG levels. The β-hCG thresholds predictive of OP were 78 IU/L and 160 IU/L for D3 and D5 ET, which predicted OP in 96% and 91% of cases, respectively. Similarly, for LB, the β-hCG thresholds were 94 IU/L (79% positive predictive value [PPV]) and 160 IU/L (88% PPV), and for MG were 250 IU/L (18% PPV) and 316 IU/L (34% PPV), respectively. CONCLUSION(S) Initial β-hCG levels are dependent on the day of ET and are a reliable and highly predictive tool for OP outcomes.

The association of gestational weight gain per institute of medicine guidelines and prepregnancy body mass index on outcomes of twin pregnancies.

OBJECTIVE To determine if current recommendations for weight gain in twin pregnancies according to maternal prepregnancy body mass index (PPBMI) influence perinatal outcomes. METHODS We identified women with twins enrolled in a maternity risk screening and education program with initial screening and prenatal care initiated at <20 weeks and delivery at >23.9 weeks. Women with normal, overweight, or obese PPBMI were included (n = 5129). Pregnancy outcomes were compared between those women with weight gain meeting or exceeding 2009 Institute of Medicine recommendations and patients who did not meet weight gain guidelines. RESULTS Rates of spontaneous preterm delivery at <35 weeks were higher in all PPBMI groups for those with weight gain below guidelines. In all PPBMI groups, numbers of pregnancies with both infants weighing >2500 g or >1500 g were significantly higher for women gaining weight at or above guidelines. Logistic regression analysis was utilized to assess multivariate impact on outcome of spontaneous preterm delivery at <35 weeks showing that regardless of PPBMI level, women who gain below recommended guidelines are 50% more likely to deliver spontaneously at <35 weeks. CONCLUSION In twin pregnancies, weight gain below recommended guidelines determined by maternal PPBMI is associated with higher rates of spontaneous preterm delivery at <35 weeks.

Giant cell bone tumor of the thoracic spine presenting in late pregnancy.

BACKGROUND: We report a case of a large giant cell tumor of the thoracic spine presenting with spinal cord compression during pregnancy. CASE: A 24-year-old woman presented at term with lower back pain, bilateral lower extremity weakness, numbness, and bowel and bladder incontinence. Magnetic resonance imaging revealed a spinal soft tissue mass compressing the spinal cord. The patient delivered a healthy girl by cesarean then underwent a T8-T9 laminectomy, posterior spinal decompression, and instrument fusion. Two days later, she had a thoracotomy, corpectomy of the vertebral body, and anterior tumor debulking. Ultimately, the patient was discharged to inpatient rehabilitation with improved lower extremity strength and returned bowel and bladder function. CONCLUSION: Obstetricians should be vigilant regarding progressive neurologic symptoms during pregnancy.

The influence of maternal age on pregnancy outcome in nulliparous women with twin gestation.

We sought to determine if outcomes of nulliparous twin pregnancies differ based on maternal age. Nulliparous women with current twin pregnancies were identified from a database of women enrolled for outpatient nursing surveillance. Data were stratified into four groups by maternal age: less than 20, 20 to 34, 35 to 39, and greater than or equal to 40 years. Maternal and neonatal outcomes for women less than 20, 35 to 39, and 40 or more were compared with 20- to 34-year-old controls using Kruskal-Wallis, Mann-Whitney, and Pearson chi-square analyses. We analyzed 2144 nulliparous twin pregnancies. Patients ≥35 years (34 to 39, 78.5% or ≥40, 85.9%) were more likely to have cesarean deliveries compared with controls 20 to 34 years old (71.2%). Women aged 35 to 39 were less likely to deliver at <37 weeks, and women in the ≥40 group were less likely to deliver at <35 weeks due to spontaneous preterm labor compared with the controls. Neonates born to women aged 35 to 39 had a greater gestational age at delivery and larger average birth weight than controls. Maternal and neonatal outcomes were not adversely influenced by advanced maternal age in nulliparous women carrying twin gestations.

Semen quality in ejaculates produced by masturbation in men with spinal cord injury

Study design:Retrospective study.Objectives:Most men with spinal cord injury are anejaculatory. Much has been reported about their semen quality collected by penile vibratory stimulation and electroejaculation (EEJ). What is not well-described is the nature of semen quality in SCI patients who can ejaculate by masturbation. This study was performed to understand the degree to which their semen quality differed from that of anejaculatory SCI patients versus that of healthy non-SCI control subjects.Setting:University of Miami.Methods:Retrospective chart review of Male Fertility Research Program participants from 1991 to 2011.Results:Of 528 SCI subjects, 444 met inclusion criteria of completing an algorithm in which ejaculation occurred by masturbation than the PVS group or EEJ group as the PVS group and control group than the PVS group or EEJ group (41%, P<0.001).Conclusion:This is the first report focusing on semen quality obtained by masturbation in men with SCI. Sperm motility was higher in men with SCI who could, versus could not, ejaculate by masturbation. Completeness of injury may contribute to this difference.

Virilization from partner's use of topical androgen in a reproductive-aged woman

A woman presented with virilization symptoms and elevated testosterone; however, a neoplastic source of excess androgen was not found on imaging. Eventually, the patient revealed she was exposed to transdermal testosterone used by her partner. This case highlights the importance of considering exogenous androgens in the differential diagnosis of virilization.

Vasopressin versus a combination of vasopressin and tourniquets: a comparison of blood loss in patients undergoing abdominal myomectomies.

Objective:  To compare blood loss and need for blood transfusions in women who underwent abdominal myomectomies after receiving vasopressin or combined vasopressin and tourniquet.

Anejaculatory infertility due to multiple sclerosis

There are few reports of pregnancy outcomes in couples with anejaculatory infertility secondary to multiple sclerosis and no longitudinal reports of semen quality in this population. We report our experience with one such case. The couple achieved two live births from spermatozoa obtained with electroejaculation: the first by intrauterine insemination and the second by in vitro fertilisation with intracytoplasmic sperm injection of donor oocytes. Linear regression analysis showed no progressive decline in semen parameters across 26 semen retrievals performed over 7.7 years. Years of disease do not appear to cause progressive decline in semen quality.

Characteristics of Donor Oocyte In Vitro Fertilization Cycles Resulting in Pregnancy: Optimum Number of Oocytes and Embryos [351]

INTRODUCTION: The objective of this study was to compare characteristics of donor in vitro fertilization (IVF) cycles that did and did not result in pregnancy. Additionally, we sought to identify the optimal number of retrieved oocytes and good-quality embryos needed to maximize pregnancy rates in fresh donor IVF cycles. METHODS: We conducted a retrospective analysis of donor oocyte cycles at a single large private fertility clinic between 2010 and 2013. Parametric and nonparametric statistical analyses were used to compare cycles that did and did not result in pregnancy. Receiver operating characteristic curves were used to evaluate the optimal number of retrieved oocytes and good-quality embryos predictive of pregnancy. RESULTS: An overall clinical pregnancy rate of 58.5% was found among the 318 fresh donor cycles analyzed. There was no difference in donor age, number of total or mature oocytes retrieved, fertilization rate, or number of embryos transferred or frozen between the two groups. There was a trend toward higher number of good-quality embryos in the pregnant group (6.3 compared with 7.2, P=.06). The optimal number of retrieved oocytes and good-quality embryos predictive of pregnancy was 18 oocytes and 5.5 embryos, respectively (area under the curve [confidence interval] 0.55 [0.49–0.61] and 0.57 [0.50–0.63]). CONCLUSION AND IMPLICATION: Donor egg banks should consider avoiding cycles that result in extremely high numbers of retrieved oocytes because this does not improve pregnancy outcomes. Larger studies are needed to validate our findings and to demonstrate the optimal use of a limited quantity of viable, pregnancy-producing oocytes.