Ginny L. Ryan

Role, epidemiology, and natural history of benign uterine mass lesions.

IntroductionBoth major tissue types of the uterine corpus-the endometrium and the myometrium-can develop nonmalignant mass lesions, especially during a womans fertile years. Endometrial polyps, consisting of endometrial glands, fibrotic stroma, and central thick-walled vascular channels, protru

Five-years of a mandatory single-embryo transfer (mSET) policy dramatically reduces twinning rate without lowering pregnancy rates

OBJECTIVE To report the outcomes of a program policy instituted in 2004 mandating single-embryo transfer (mSET) for all women aged <38 years, with at least seven zygotes, no prior failed fresh cycle at our center, and at least one good-quality blastocyst. DESIGN Retrospective cohort study. SETTING Academic medical center. PATIENT(S) All women <38 years old undergoing a fresh cycle with autologous oocytes and all women undergoing a fresh cycle with donor oocytes from June 1, 1999, to May 31, 2004 (before mSET) and from June 1, 2004, to May 31, 2009 (after mSET). INTERVENTION(S) mSET policy implementation. MAIN OUTCOME MEASURE(S) Live-birth rate, multiple pregnancy rate, clinical volume, and outcomes of all mSET fresh IVF transfers were analyzed. RESULT(S) Clinical volume was unchanged between the two time groups. After implementation of mSET, live-birth rates improved from 51.1% to 55.9% and multiple-birth rates dropped from 34.8% to 17.5%. A total of 364 mSET fresh transfers were performed with a live-birth rate of 64.6% and a multiple-birth rate of 3.4%. CONCLUSION(S) A mandatory SET policy based on prognostic factors can be instituted with no drop in clinical volume and no negative effect on delivery rates. Multiple gestation rates can be dramatically lowered.

Eating disorders in the obstetric and gynecologic patient population

The eating disorders anorexia nervosa and bulimia nervosa and eating disorders not otherwise specified disproportionately affect women, have profound effects on the overall well-being of women and their children, and can have mortality rates as high as those found with major depression. These disorders may present to obstetrician-gynecologists (ob-gyns) clinically as menstrual dysfunction, low bone density, sexual dysfunction, miscarriage, preterm delivery, or low birth weight in offspring. Ninety percent of eating disorders develop before the age of 25 in otherwise healthy young women, a group that characteristically seeks the majority of their health care from ob-gyns. For all of these reasons, ob-gyns must have a greater awareness of these disorders and a lower index of suspicion for screening their patients than they currently do. Otherwise, they may miss life-threatening illness, treat characteristic amenorrhea inappropriately, or inadvertently intervene to help these women conceive, contributing to maternal and fetal risks. As providers of both primary and specialty care for women, ob-gyns have the opportunity to play a vital role in prevention and diagnosis of eating disorders and in the multidisciplinary management required to effectively manage these disorders.

Clinical predictors of human blastocyst formation and pregnancy after extended embryo culture and transfer

OBJECTIVE To determine the clinical factors associated with blastocyst development and pregnancy. DESIGN Evaluation of a prospectively collected IVF database. SETTING An academic IVF practice. PATIENT(S) Couples (n = 529) undergoing their first IVF cycle who qualified for extended embryo culture (more than six zygotes) over the past 5 years. INTERVENTION(S) Seven or eight zygotes were cultured for 5 days, assessed for quality, and then transferred with excess zygotes cryopreserved at the pronuclear stage. MAIN OUTCOME MEASURE(S) Clinical predictors of blastocyst development and pregnancy. RESULT(S) The mean blastocyst development rate was 49.8%, with a median number of total and good-quality blastocysts of 4 and 2, respectively. Clinical factors that were significantly associated with good-quality blastocyst formation were younger female age, increased parity, standard insemination, and lower doses of gonadotropins. Clinical factors that were significantly associated with successful pregnancy were younger female age, higher antral follicle counts, greater numbers of total and good-/excellent-quality blastocysts, and absence of male factor infertility. CONCLUSION(S) Several clinical factors are associated with the development of good-quality blastocysts after extended embryo culture and successful pregnancy outcome. These patient and cycle characteristics may be very useful in selecting the best candidates for extended embryo culture and single blastocyst transfers, thus optimizing outcomes while reducing the risks associated with multiple pregnancies.

Progression of atypical endometrial hyperplasia to adenocarcinoma despite intrauterine progesterone treatment with the levonorgestrel-releasing intrauterine system.

BACKGROUND: Intrauterine progesterone therapy has been proposed as a potential uterine-sparing treatment for atypical endometrial hyperplasia and adenocarcinoma. CASE: We present a case of an infertility patient with atypical endometrial hyperplasia who was treated with the levonorgestrel-releasing intrauterine system for 6 months. At follow-up, she was noted to have an increasing endometrial thickness on ultrasonography, and biopsy revealed progression of her lesion to adenocarcinoma. CONCLUSION: Although there is a need for uterine-sparing treatment for atypical endometrial hyperplasia and early adenocarcinoma, especially in the setting of desired fertility, caution should be exercised. We do not recommend using the levonorgestrel-releasing intrauterine system as a treatment for atypical hyperplasia or adenocarcinoma until further studies demonstrate the efficacy of this treatment.

Intrinsic differences in the response of the human lutropin receptor versus the human follitropin receptor to activating mutations.

In contrast to the human lutropin receptor (hLHR), very few naturally occurring activating mutations of the structurally related human follitropin receptor (hFSHR) have been identified. The present study was undertaken to determine if one aspect underlying this discrepancy might be a general resistance of the hFSHR to mutation-induced constitutive activity. Five different mutations were introduced into both the hLHR and hFSHR (four based on activating mutations of the hLHR gene, one based on an activating mutation of the hFSHR gene). Our results demonstrate that hFSHR constitutively activating mutants (CAMs) were not as active as hLHR CAMs containing the comparable mutation. Furthermore, although all hFSHR CAMs exhibited strong promiscuous activation by high concentrations of the other glycoprotein hormone receptors, hLHR CAMs showed little or no promiscuous activation. Our in vitro findings are consistent with in vivo observations of known pathophysiological conditions associated with hLHR CAMs, but not hFSHR CAMs, and with promiscuous activation of hFSHR CAMs, but not hLHR CAMs. Computational experiments suggest that the mechanisms through which homologous mutations increase the basal activity of the hLHR and the hFSHR are similar. This is particularly true for the strongest CAMs like L460(3.43)R. Disparate properties of the hLHR versus hFSHR CAMs may, therefore, be due to differences in shape and electrostatics features of the solvent-exposed cytosolic receptor domains involved in the receptor-G protein interface rather than to differences in the nature of local perturbation at the mutation site or in the way local perturbation is transferred to the putative G protein binding domains.

Ultrasound is the optimal choice for guidance in difficult hysteroscopy

To compare costs and complications associated with ultrasound‐guided hysteroscopy vs laparoscopy‐guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae.

Human Papillomavirus Vaccination and Sexual Behavior in Young Women

STUDY OBJECTIVE To compare sexual attitudes and behaviors of young women who have received or declined the HPV vaccine. DESIGN Cross-sectional survey. SETTING Obstetrics and gynecology and pediatrics clinics at a large, Midwestern, academic health center. PARTICIPANTS 223 young women (ages 13-24): 153 who had received HPV vaccination and 70 with no prior HPV vaccination. MAIN OUTCOME MEASURES Sexual behaviors; attitudes toward sexual activity. RESULTS Vaccinated young women were slightly but significantly younger than unvaccinated (mean age 19.2 vs 20.0). Both groups showed a large percentage of participants engaging in high-risk sexual behavior (75% vs 77%). The mean age at sexual debut was not significantly different between the groups (16.8 vs 17.0) nor was the average number of sexual partners (6.6 for both). Unvaccinated participants were more likely to have been pregnant (20% vs 8.6%, P = .016), although this difference was not significant in multivariate analysis CI [0.902-5.177]. Specific questions regarding high-risk sexual behaviors and attitudes revealed no significant differences between the groups. CONCLUSION We found that sexual behaviors, including high-risk behaviors, were similar between young women who had and had not received HPV vaccination. Our findings provide no support for suggestions that the vaccine is associated with increased sexual activity. Importantly, we found that young women in our population are sexually active at a young age and are engaged in high-risk behaviors, affirming the importance of early vaccination.

An unusual cause of adolescent dysmenorrhea.

A 14-year-old girl presented to the emergency room for an episode of severe dysmenorrhea that was unresponsive to nonsteroidal anti-inflammatory drugs (NSAIDs). The patient had undergone menarche at age 11 but did not develop dysmenorrhea until she was 13 years old. The pain gradually worsened with each menses causing her to miss school monthly. Her family practitioner prescribed oral contraceptives shortly after the dysmenorrhea developed. Three to four months later the patient developed acute venous thrombosis with total venous obstruction of the right lower extremity and was diagnosed with antithrombin III deficiency. She discontinued her oral contraceptives underwent clot lysis with placement of an inferior vena cava filter in interventional radiology and began anticoagulation therapy with heparin and tissue plasminogen activator acutely followed by long-term warfarin therapy. (excerpt)

The Impact of Social Media on the Sexual and Social Wellness of Adolescents

For most adolescents in the United States, the use of social media is an integral part of daily life. While the advent of the Internet has enhanced information dispersal and communication worldwide, it has also had a negative impact on the sexual and social wellness of many of its adolescent users. The objective of this review is to describe the role of social media in the evolution of social norms, to illustrate how online activity can negatively impact adolescent self-esteem and contribute to high-risk adolescent behaviors, to elucidate how this activity can result in real-world consequences with life-long results, and to provide guidance regarding social media use for those who care for adolescents. Although research is now aimed at use of social media for positive health and wellness interventions, much work needs to be done to determine the utility of these programs. Adolescent healthcare providers are important contributors to this new field of study and must resolve to stay informed and to engage this up-and-coming generation on the benefits and risks of social media use.