M. Elizabeth Fino

Surviving childhood and reproductive-age malignancy: effects on fertility and future parenthood

Annually, more than 50,000 cancer diagnoses are made in the USA in patients under the age of 35 years. Despite this staggering statistic, medical advancements have substantially improved survival rates. Thus, for both male and female patients with cancer, quality-of-life issues, such as fertility preservation and parenthood, have become an essential component of treatment. Unfortunately, many of the treatments to eradicate malignant processes can also compromise reproductive function. In these cases, fertility preservation should be discussed and initiated with early treatment planning, to allow the best chance for future parenthood, when appropriate. The effects of cancer and cancer treatments on fertility and future parenthood, including health risks for patients, their gametes, and offspring are discussed.

Comparison of pregnancy outcomes in elective single blastocyst transfer versus double blastocyst transfer stratified by age.

OBJECTIVE To determine whether there is a difference in pregnancy outcomes, stratified by age, between women undergoing elective single blastocyst transfer (eSBT) versus those undergoing double blastocyst transfer (2BT). DESIGN Retrospective analysis. SETTING University IVF center. PATIENT(S) A total of 1,141 nondonor IVF cycles in women aged <40 years from January 2004-March 2007. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Eggs retrieved, embryos cryopreserved, implantation rates, clinical pregnancy rates (PR), live birth rates (LBR), spontaneous abortion rates (SAB). RESULT(S) Pregnancy outcomes in 52 cycles of women <40 years of age who underwent eSBT were compared with 1,086 cycles of women who underwent 2BT in fresh IVF cycles from January 2004-March 2007. Overall, the eSBT was associated with a statistically significant 92% reduction in the twinning rate (from 25%-2%) while maintaining a high clinical PR (63% in the eSBT group vs. 61% in the 2BT group). CONCLUSION(S) Women who are <40 years of age undergoing nondonor fresh IVF cycles can electively choose to transfer a single blastocyst for the purpose of significantly reducing their risk of multiples without compromising their PR.

Debate Preparation/Participation: An Active, Effective Learning Tool

Background: Passive educational techniques (such as lectures) are thought to be less productive than active learning. Purpose: We examined whether preparing for and participating in a debate would be an effective, active way to learn about a controversial topic. Methods: We compared quiz performance in residents who attended a lecture to residents who prepared for/participated in a debate. Twelve residents each participated in one lecture session and one debate session. Learning was evaluated via a quiz. Quizzes were given twice: before the debate/lecture and 1 week after the debate/lecture. Quiz scores were compared using repeated measures analysis of variance, with a p value of < .05 considered significant. A survey evaluating the usefulness of debating was given to all participants. Results: There was a statistically significant difference in the pretest mean quiz score between the debate and lecture groups: 78.3% and 52.5%, respectively ( p = .02). Similarly, on posttest quizzes, the average debater scored 85.8%, versus 61.7% for the lecture group ( p = .003). Although no one in the debate group scored lower on a follow-up quiz, 3 residents in the lecture group did worse on follow-up. Conclusions: When learning about a controversial topic, residents who prepared for/participated in a debate achieved higher quiz scores and were better at retaining information than those who attended a lecture. When faced with teaching a controversial topic, organizing a debate may be more effective than giving a lecture.

Successful Oocyte Cryopreservation in Reproductive-Aged Cancer Survivors.

OBJECTIVE: To demonstrate that oocyte cryopreservation is a feasible reproductive option for patients with cancer of childbearing age who require gonadotoxic therapies. METHODS: This study is a university-based retrospective review of reproductive-aged cancer patient treatment cycles that included ovarian stimulation, transvaginal oocyte retrieval, oocyte cryopreservation, and, in some cases, subsequent oocyte thaw, in vitro fertilization, and embryo transfer. Outcome measures included ovarian stimulation response, number of oocytes retrieved, cryopreserved, and thawed, and pregnancy data. RESULTS: From 2005 to 2014, 176 reproductive-aged patients with cancer (median age 31 years, interquartile range 24–36) completed 182 oocyte cryopreservation cycles. Median time between consult request and oocyte retrieval was 12 days (interquartile range 10–14). Median peak stimulation estradiol was 1,446 pg/mL (interquartile range 730–2,687); 15 (interquartile range 9–23) oocytes were retrieved and 10 (interquartile range 5–18) metaphase II oocytes were cryopreserved per cycle. Ten patients (11 cycles) have returned to attempt pregnancy with their cryopreserved oocytes. Among thawed oocytes, the cryopreservation survival rate was 86% (confidence interval [CI] 78–94%). Nine of 11 thaw cycles resulted in embryos suitable for transfer. The embryo implantation rate was 27% (CI 8–46%) and the live birth rate was 44% (CI 12–77%) per embryo transfer. Chance for live birth with embryos created from cryopreserved oocytes was similar between the patients with cancer in this study and noncancer patients who underwent the same treatment at our center (44% [CI 12–77%] compared with 33% [CI 22–44%] per embryo transfer). CONCLUSION: Oocyte cryopreservation is now a feasible fertility preservation option for reproductive-aged patients with cancer who require gonadotoxic therapies.

Chronic isolated fallopian tube torsion

OBJECTIVE To describe a case of chronic isolated fallopian tubal torsion in a woman without identifiable risk factors and discuss the difficulty of diagnosis. DESIGN Case report. SETTING University-based reproductive endocrinology and infertility center. PATIENT(S) Multiparous woman with no risk factors of torsion of the fallopian tube presenting with chronic right lower quadrant pain. INTERVENTION Laparoscopy with subsequent salpingectomy. MAIN OUTCOME MEASURE(S) Resolution of symptoms. Preservation of ovary and future fertility. RESULT(S) Patients symptoms resolved after salpingectomy. Information regarding future fertility is pending. CONCLUSION(S) Isolated fallopian tube torsion is rare and often difficult to diagnose. Despite ultrasonographic evidence of arterial and/or venous flow to the adnexa, adnexal torsion cannot be ruled out. If clinical suspicion for torsion is high, early diagnosis and treatment via laparoscopy is encouraged as a means of preserving fallopian tube integrity and maintaining fertility, especially in reproductive-age women.

Comparison of pregnancy outcomes in anonymous shared versus exclusive donor oocyte in vitro fertilization cycles

OBJECTIVE To determine whether there is a difference in pregnancy outcomes between women undergoing a shared versus exclusive donor oocyte cycle. DESIGN Retrospective analysis. SETTING University IVF center. PATIENT(S) Women undergoing either a shared (n=656 cycles), exclusive (n=225 cycles), or shared converted to exclusive (n=22 cycles) donor oocyte cycle from January 2000-December 2005. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Number of eggs retrieved, eggs fertilized, embryos transferred, embryos cryopreserved, clinical pregnancy rates (PR), live birth rates, spontaneous abortion rates. RESULT(S) Pregnancy outcomes in 656 shared cycles were compared with 225 exclusive cycles and 22 shared converted to exclusive donor oocyte cycles. Overall, there was no difference in the clinical PR among the three groups; however, the exclusive group did have a significantly greater number of embryos cryopreserved and this event occurred more frequently in such a cycle. CONCLUSION(S) Women undergoing a donor oocyte IVF cycle can choose to share the donors oocytes with another recipient without compromising their PR; however, the probability of cryopreservation in such a shared donor oocyte cycle is significantly reduced. Therefore, the recipient must weigh the financial burden of an exclusive cycle with the desires for cryopreservation in an IVF cycle.

Use of hormone suppression then oocyte freezing to preserve reproductive capability in an adolescent girl with ovarian luteinized thecoma associated with sclerosing peritonitis

OBJECTIVE To describe a case of ovarian luteinized thecoma, a rare ovarian neoplasm, which is only the 26th reported case associated with sclerosing peritonitis. DESIGN Case report. SETTING NYU Fertility Center and Memorial Hospital for Cancer and Allied Diseases, New York. PATIENT(S) A 17-year-old woman presenting with a large pelvic mass and abdominal pain. INTERVENTION(S) Conservative surgical treatment with laparotomy, unilateral salpingooophorectomy, and biopsy of contralateral ovary. Gonadotropin-releasing hormone agonist suppression. Ovarian hyperstimulation with oocyte retrieval/freezing to preserve biologic fertility. MAIN OUTCOME MEASURE(S) Response to conservative therapy and oocyte cryopreservation as a method of fertility preservation. RESULT(S) At laparotomy, obvious unilateral ovarian involvement was present, and a left salpingoophorectomy was performed. Biopsy of the contralateral ovary confirmed bilateral disease. The initial pathological review was complicated by extensive ovarian edema. The patient was treated with gonadotropin-releasing hormone agonist suppression plus intermittent estradiol supplementation. When she became intolerant of hormone therapy and when removal of the remaining ovary became a possibility, she underwent ovarian hyperstimulation; oocyte retrieval and freezing were performed to preserve her biologic fertility. Thirty-eight eggs were obtained. CONCLUSION(S) Surgically diagnosed luteinized thecoma can be managed medically. Oocyte cryopreservation as a means of fertility preservation should be considered in young women with this diagnosis who are at risk for bilateral gonad removal.

Interactive case-based learning improves resident knowledge and confidence in reproductive endocrinology and infertility*

Abstract Resident physicians’ scores on the REI section of the CREOG exam are traditionally low, and nearly 40% of house staff nation-wide perceive their REI knowledge to be poor. We aimed to assess whether an interactive case-based group-learning curriculum would narrow the REI knowledge gap by improving understanding and retention of core REI concepts under the time constraints affecting residents. A three-hour case-based workshop was developed to address four primary CREOG objectives. A multiple-choice test was administered immediately before and after the intervention and 7 weeks post-workshop, to evaluate both knowledge and confidence. Following the intervention, residents self-reported increased confidence with counseling and treatment of PCOS, ovulation induction cycle monitoring, counseling and treatment of POI, and breaking bad news related to infertility (p < 0.05). The multiple-choice exam was re-administered 7 weeks post-intervention, and scores remained significantly improved compared to pre-workshop scores (p < 0.05). At that time, all residents either strongly agreed (91.7%) or agreed (8.3%) that the case-based interactive format was preferable to traditional lecture-based teaching. In conclusion, a nontraditional curriculum aimed at teaching core REI concepts to residents through interactive case-based learning can be successfully integrated into a residency curriculum, and significantly improves knowledge and confidence of critical concepts in REI.