Molly Quinn

Contraception after cancer treatment: describing methods, counseling, and unintended pregnancy risk.

OBJECTIVE The objective was to describe contraceptive methods utilized by young female cancer survivors and determine whether pretreatment fertility counseling decreases unintended pregnancy risk. METHODS One thousand and forty-one nongynecologic cancer survivors between 18 and 40 years of age responded to a survey of reproductive health, contraceptive methods utilized and history of fertility counseling before cancer treatment. Subjects who had resumed menstrual bleeding following treatment and had not undergone surgical sterilization were defined at risk of unintended pregnancy if they reported unprotected vaginal intercourse in the prior month but did not desire conception. Statistical methods utilized were Students t test and χ(2). RESULTS Overall, 918 women (88%) received treatment with potential to affect fertility (chemotherapy, radiation or sterilizing surgery). Of 476 women younger than 40 years old who still had menses, 58% did not want to conceive; of these 275 women, 21% reported unprotected intercourse in the prior month and were defined at risk of unintended pregnancy. This compares to the 7.3% risk of unintended pregnancy reported by the National Center for Health Statistics. Increasing age was associated with greater risk of unintended pregnancy (odds ratio 1.07, p=.006). The following contraceptive methods were reported: barrier (25.5%), hormonal (24.5%), tubal ligation (21.3%) vasectomy (17.5%), intrauterine device (7.2%) and other (4.0%). Sixty-seven percent of women received pretreatment fertility counseling. Counseling prior to treatment did not decrease risk of unintended pregnancy (p=.93). CONCLUSIONS Sexually active cancer survivors are at threefold increased risk of unintended pregnancy compared to the US population. Contraceptive counseling in this high-risk population is recommended posttreatment. IMPLICATIONS Sexually active cancer survivors are at considerable risk of unintended pregnancy. Patient report of pretreatment counseling regarding fertility was not associated with a decline in risk of unintended pregnancy, highlighting the importance of clear recommendations regarding content and timing of counseling.

Response to ovarian stimulation is not impacted by a breast cancer diagnosis.

STUDY QUESTION Does a breast cancer diagnosis impact ovarian function in the setting of fertility preservation? SUMMARY ANSWER Ovarian reserve and ovarian stimulation outcomes are similar in patients with a new diagnosis of breast cancer and patients undergoing elective fertility preservation. WHAT IS KNOWN ALREADY Prior studies, with small study populations, lack of controlling for individual differences in ovarian reserve and infertile controls, have reported conflicting outcomes for cancer patients undergoing ovarian stimulation for fertility preservation. STUDY DESIGN, SIZE, DURATION This retrospective cohort analysis included 589 patients undergoing ovarian stimulation for fertility preservation between 2009 and 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with a recent breast cancer diagnosis (n = 191) and women desiring elective fertility preservation (n = 398) underwent ovarian stimulation with an antagonist protocol at an academic medical center. The aromatase inhibitor letrozole was administered to breast cancer patients with estrogen-sensitive disease. MAIN RESULTS AND THE ROLE OF CHANCE Baseline antral follicle count (AFC) was not different between the breast cancer patients and controls (15.4 ± 10.4 [mean ± SD] vs 15.4 ± 10.0, P = NS), even after categorization by age. Total (19.4 ± 0.9 [mean ± SEM] vs 17.0 ± 0.5, P = NS) and mature (MII) oocytes retrieved (13.7 ± 0.7 vs 13.2 ± 0.4, P = NS), adjusted for age, BMI and total gonadotropin dose, were also similar between the two groups. Letrozole use was associated with a decreased maturity rate (MII/total oocytes retrieved) compared to elective cryopreservation (0.71 ± 0.01 vs 0.77 ± 0.01, P < 0.001), although the mature oocyte yield [MII/AFC] was comparable (1.01 ± 0.06 vs 0.93 ± 0.03, P = NS). LIMITATIONS, REASONS FOR CAUTION The single center design may impact generalizability. Additionally, the lack of subsequent embryo and pregnancy data is an inherent weakness. WIDER IMPLICATIONS OF THE FINDINGS In females, a breast cancer diagnosis does not impact gonadal function as measured by AFC or ovarian stimulation outcomes. Breast cancer patients should be counseled that their response to ovarian stimulation for fertility preservation is similar to that of patients undergoing elective oocyte cryopreservation. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER N/A.

Determinants of dynamic hyperinflation during metronome-paced tachypnea in COPD and normal subjects.

In COPD, dynamic hyperinflation (DH) occurs during exercise and during metronome-paced tachypnea (MPT). We investigated the relationship of DH with breathing pattern and ventilation (V˙E) in COPD and normal subjects (NS). In 35 subjects with moderate COPD and 17 younger healthy volunteers we measured inspiratory capacity (IC), breathing frequency (fR), expiratory time (TE), ventilation (V˙E) and end-tidal carbon dioxide tension (PETCO2) at baseline and after 30s of MPT at 40breaths/min with metronome-defined I:E ratios of 1:1 and 1:2. A reduction in IC (ΔIC) was taken to indicate DH. In COPD subjects, DH correlated with TE but not with V˙E or PETCO2, and was best predicted by total lung capacity. NS also showed DH (although less than in COPD), which correlated with PETCO2 but not with fR, TE or V˙E. We conclude that MPT evokes DH in both NS and patients with COPD. TE is the most important determinant of DH during MPT in patients with COPD.

Raising threshold for diagnosis of polycystic ovary syndrome excludes population of patients with metabolic risk

OBJECTIVE To characterize the population of patients excluded from a diagnosis of polycystic ovary syndrome (PCOS) when follicle number criteria are increased to 25 per ovary as suggested by the Androgen Excess and Polycystic Ovary Syndrome Societys recent task force. DESIGN Cross-sectional study. SETTING Tertiary academic center. PATIENT(S) A total of 259 women with PCOS according to Rotterdam criteria who were systematically examined from 2007 to 2015, with 1,100 ovulatory women participating in the Ovarian Aging (OVA) Study as controls. INTERVENTION(S) Anthropometric measurements, serum testing, ultrasonic imaging, and comprehensive dermatologic exams. MAIN OUTCOME MEASURE(S) Body mass index (BMI), waist to hip ratio (WHR), serum cholesterol, fasting glucose and insulin, follicle count per ovary, biochemical hyperandrogenemia, and hirsutism. RESULT(S) Forty-seven of 259 women meeting the Rotterdam criteria (18.1%) were excluded from a diagnosis of PCOS when the follicle number criteria was increased to 25. These women had clinical evidence of hyperandrogenism (68.1%) and biochemical hyperandrogenemia (44.7%), although fewer reported oligoanovulation (26.8%). The excluded women had elevated total cholesterol, fasting insulin, and homeostatic model of insulin resistance (HOMA-IR) when compared with controls despite controlling for age and BMI. CONCLUSION(S) The women excluded from the PCOS diagnosis by raising the threshold of follicle number per ovary to ≥25 continue to show evidence of metabolic risk.

Racial and ethnic disparities in assisted reproductive technology access and outcomes.

Infertility is a global problem affecting all ethnic, racial, and religious groups. Nevertheless, only a minority of the U.S. population has access to treatment. Additionally, for those who do engage in treatment, outcomes are disparate among various ethnic and racial groups. This article addresses racial and ethnic disparities regarding rates of fecundity and infertility, access to care, and assisted reproductive technology outcomes.

A New Approach to Learning How to Teach: medical students as instructional designers

Abstract As students at the David Geffen School of Medicine at UCLA, the student authors were given the opportunity to develop their own creative projects which would be used to teach future medical students. They chose their own topics, planned and researched their projects, and then implemented the projects in interactive digital Adobe Flash files. In the first project they created interactive case-based radiology teaching files. In the second project they integrated photographic images into the existing illustrative anatomy files. Students in subsequent years have learned from these files on computers both at home and in the schools anatomy lab. The experience of creating the files served as an opportunity for hands-on learning for the student authors, both of the material and of the practice of teaching. In this paper they describe why they undertook these projects, what exactly they did, and the impact their creation had on them. The projects demonstrate that student-driven educational materials are both possible and beneficial. Furthermore, their experience has allowed them to conclude that faculty at other medical schools should consider providing students with opportunities to develop their own creative projects that contribute to the curriculum.

Age‐stratified thresholds of anti‐Müllerian hormone improve prediction of polycystic ovary syndrome over a population‐based threshold

Due to its consistent elevation in polycystic ovary syndrome (PCOS) and correlation with polycystic ovarian morphology (PCOM), anti‐Mullerian hormone (AMH) has been proposed as a marker of the syndrome. However, prior studies reporting thresholds of AMH for a PCOS diagnosis have been limited by small sample size, inappropriate controls, and heterogeneous AMH assays. We sought to evaluate the suitability of a standardized AMH assay as a biomarker of PCOS.

Differential rate in decline in ovarian reserve markers in women with polycystic ovary syndrome compared with control subjects: results of a longitudinal study

OBJECTIVE To estimate rates of ovarian aging in polycystic ovary syndrome (PCOS) subjects versus a community control population. DESIGN Longitudinal. SETTING Tertiary academic center. SUBJECT(S) PCOS subjects diagnosed according to the 2004 Rotterdam criteria were systematically enrolled in a PCOS cohort study. The comparison control subjects were from the Ovarian Aging study, a prospective longitudinal study of ovarian aging in healthy women with regular menstrual cycles. INTERVENTION(S) Clinical data collection over two study visits. MAIN OUTCOME MEASURE(S) Antral follicle count (AFC), ovarian volume (OV), and antimüllerian hormone level (AMH). RESULT(S) PCOS subjects were found to have higher baseline values for all ovarian reserve markers compared with control subjects. Univariate models indicated that, compared with control subjects, PCOS patients experienced significantly faster rates of decline for both AFC and AMH. Change in OV did not differ significantly. To account for potential confounder effects, multiple analysis of covariance models were evaluated for the best fit, considering age, body mass index, and baseline ovarian reserve markers. Adjusted models demonstrated that PCOS patients do not experience a significant difference in AFC decline compared with control subjects, but they do experience a faster rate of decline in AMH (P<.01) and slower rate of decline in OV (P<.01). CONCLUSION(S) Ovarian aging in PCOS is characterized by a more rapid decline in AMH and a slower decline in OV compared with control subjects.

Gamete and Embryo Manipulation

Abstract This chapter describes the procedures performed in the in vitro fertilization (IVF) laboratory. Ideal laboratory conditions are discussed to highlight the enormity of the undertaking required to create an environment for optimal clinical outcomes. Procedures performed in the laboratory are introduced in sequence. The conceptual framework underlying each procedure and the details surrounding their execution are delineated. In addition, the current status of preimplantation genetic testing (PGT) is described.

Declining Fertility with Reproductive Aging: How to Protect Your Patient’s Fertility by Knowing the Milestones

Protection of fertility shares many of the same concepts as optimization of general health, such as smoking cessation, maintenance of a healthy body weight, and moderation of alcohol intake. Increasing attention has been placed on minimizing exposures to known reproductive toxicants. There are few conclusive data to support specific diet patterns or supplements for fertility. Ovarian reserve testing has been explored as potential diagnostic tests for assessment of reproductive aging with some controversy. Finally, the development of vitrification in the assisted reproduction laboratory has increased the success and, therefore, access to fertility preservation by way of oocyte or embryo cryopreservation.