Staci E. Pollack

Onset of ovulation after menarche in girls: a longitudinal study.

INTRODUCTION Hypothalamic-pituitary axis maturity has been believed to be the rate-limiting step in the development of ovulatory menstrual cycles. We hypothesized that, given current nutritional conditions, hypothalamic-pituitary axis maturation would be relatively rapid in menarcheal girls. METHODS Daily urine and menstrual records were collected for 2 yr each from 10 girls aged 11-13 yr at study entry. Urinary excretion of LH, FSH, estradiol (E1c), and progesterone (Pdg) metabolites was measured using established ELISAs. An objective algorithm detected rises of LH, FSH, E1c, and Pdg consistent with follicular maturation and/or ovulation. RESULTS Nine of 10 girls enrolled into the study experienced the onset of menarche prior to or during the 2-yr collection period. LH and FSH surges, as well as small amplitude Pdg increments, were observed prior to menarche. Regular, ovulatory-appearing cycles with LH surges and gradually increasing and more sustained Pdg rises were observed over time after menarche, although duration of Pdg elevations remained shorter than in adult women (8.9 +/- 1.0 vs. 12.1 +/- 0.8 d, P = 0.043). E1c levels leading to LH/FSH surges were lower in perimenarcheal girls than adult controls, and bleeding episodes did not uniformly correlate with hormone patterns. Progressive increases in FSH and Pdg, but not LH or E1c, were observed in association with menarche. CONCLUSION Mature hormone patterns are established within several months of and even prior to menarche in normal-weight perimenarcheal girls. Factors determining menstrual bleeding in perimenarcheal girls may not be solely dependent on reproductive hormones or the neuroendocrine axis.

Actinomycosis pelvic abscess after in vitro fertilization.

OBJECTIVE To report a case of pelvic actinomycosis presenting as large, multiloculated abscesses after an in vitro fertilization (IVF) cycle for male factor infertility. DESIGN A case report and literature review. SETTING University hospital. PATIENT(S) A 31-year-old nulligravid woman presenting with urinary retention, pelvic pain, and fever 6 days after transvaginal oocyte retrieval and an embryo transfer for male factor infertility. INTERVENTION(S) Intravenous and oral antimicrobial therapy, and computed tomography (CT)-guided drainage of pelvic abscesses. MAIN OUTCOME MEASURE(S) Clinical and radiologic resolution of symptoms and infection. RESULT(S) The CT scan revealed several large, multiloculated pelvic and tuboovarian abscesses. The patient defervesced after 6 days of intravenous antibiotics, but the pelvic pain did not improve. After CT-guided drainage of the pelvic abscesses, the patients symptoms improved. The drained material was cultured, and the patient was diagnosed with pelvic actinomycosis tuboovarian abscesses, an infrequent cause of tuboovarian abscess and a rare complication of assisted reproductive technology (ART). The patient was switched from intravenous to oral antibiotics and discharged home. CONCLUSION(S) Pelvic Actinomyces israelii presenting as pelvic abscesses may occur as a rare complication of ART. Physicians should consider a diagnosis of tuboovarian abscess in a patient reporting fever and pelvic pain after IVF and embryo transfer.

Pituitary origin of persistently elevated human chorionic gonadotropin in a patient with gonadal failure

OBJECTIVE To report a case of persistently elevated low levels of hCG to increase awareness of pituitary origin of persistently elevated hCG in patients with gonadal failure. DESIGN Case report and literature review. SETTING Large university-affiliated infertility practice. PATIENT(S) A 16-year-old patient with primary amenorrhea, normal secondary sex characteristics, ovarian failure, and a 46,XY karyotype. Her past medical history was significant for focal segmental glomerulosclerosis, leading to a diagnosis of Frasier syndrome. INTERVENTION(S) At age 31 years, she desired pregnancy by oocyte donation and was found to have persistently elevated low levels of hCG (>35 mIU/mL). MAIN OUTCOME MEASURE(S) Pituitary hCG. RESULT(S) Both serum free β-hCG and hyperglycosylated hCG were undetectable. Total serum hCG diluted appropriately was not blocked by blocking agent and was detected in the urine. Subsequent treatment with exogenous E(2), in preparation of a donor oocyte cycle, suppressed her hCG levels (down to 8 mIU/mL). These results indicated a pituitary source of the serum hCG. CONCLUSION(S) This report reinforces the need to consider pituitary hCG as the origin of persistently elevated hCG levels in patients with gonadal failure. Although levels of hCG <14 mIU/mL have been considered normal in postmenopausal women, our case suggests that patients with gonadal failure at younger ages might have a higher pituitary output of hCG.

Near-peer role modeling: Can fourth-year medical students, recognized for their humanism, enhance reflection among second-year students in a physical diagnosis course?

Introduction Humanism is cultivated through reflection and self-awareness. We aimed to employ fourth-year medical students, recognized for their humanism, to facilitate reflective sessions for second-year medical students with the intention of positively influencing reflective process toward humanistic development. Methods/Analysis A total of 186 students were randomly assigned to one of three comparison arms: eight groups of eight students (64 students) were facilitated by a fourth-year student who was a Gold Humanism Honor Society member (GHHS); eight groups (64 students) by a volunteer non-GHHS student; and seven groups (58 students) were non-facilitated. Before sessions, second-year students set learning goals concerning interactions with patients; fourth-year students received training materials on facilitation. Groups met twice during their 10 clinical site visits. At the last session, students completed a reflective assignment on their goal progress. Comparative mixed method analyses were conducted among the three comparison arms on reflection (reflective score on in-session assignment) and session satisfaction (survey) in addition to a thematic analysis of responses on the in-session assignment. Results We found significant differences among all three comparison arms on students’ reflective scores (p=0.0003) and satisfaction (p=0.0001). T-tests comparing GHHS- and non-GHHS-facilitated groups showed significantly higher mean reflective scores for GHHS-facilitated groups (p=0.033); there were no differences on session satisfaction. Thematic analysis of students’ reflections showed attempts at self-examination, but lacked depth in addressing emotions. There was a common focus on achieving comfort and confidence in clinical skills performance. Discussion/Conclusions Near peers, recognized for their humanism, demonstrated significant influence in deepening medical students’ reflections surrounding patient interactions or humanistic development. Overall, students preferred facilitated to non-facilitated peer feedback forums. This model holds promise for enhancing self-reflection in medical education, but needs further exploration to determine behavioral effects.

Full-sibling embryos created by anonymous gamete donation in unrelated recipients

OBJECTIVE To report the rare occurrence of full-sibling embryos in unrelated women using independently chosen donor sperm and donor oocytes in two different cycles unintentionally created at our IVF program, and to discuss the concept of disclosure to the patients. DESIGN Case report. SETTING Academic IVF program. PATIENT(S) Two women independently undergoing donor recipient cycles with anonymous donor oocytes and donor sperm. INTERVENTION(S) Both women received oocytes from the same donor several months apart and then by coincidence selected the same anonymous sperm donor to create anonymous full-sibling embryos. MAIN OUTCOME MEASURE(S) Clinical pregnancy after donor-recipient IVF cycle. RESULT(S) Both women conceived using the same donor sperm and donor oocytes in independent cycles, resulting in simultaneous pregnancy of full siblings. CONCLUSION(S) As providers with the knowledge that anonymous full sibling embryos have been created, we may have an obligation to disclose this information to the patients.

Structure, Function, and Regulated Expression of the Steroidogenic Acute Regulatory (StAR) Protein

Steroid hormones produced in the adrenals, gonads, and placenta are important regulators of tissue differentiation, development, and homeostasis. The first committed step in the synthesis of these hormones in all tissue types is the conversion of cholesterol into pregnenolone. This reaction is catalyzed by the cytochrome P450 side-chain cleavage enzyme (P450 scc ), located on the matrix side of the inner mitochondrial membrane. This first step in steroidogenesis, which is highly regulated in a temporal and tissue-specific manner, is primarily controlled at the level of cholesterol availability to the inner-mitochondrial matrix rather than at the level of P450 scc enzyme activity. It has been known for decades that the acute regulation of steroid-hormone synthesis in the adrenals and gonads is dependent upon the synthesis of a protein(s) in response to trophic hormones and that this protein is fast-acting (minutes) and functionally short-lived. The recently cloned Steroidogenic Acute Regulatory (StAR) protein appears to be the “labile protein” essential for the acute steroidogenic response. Absence of functional StAR protein causes congenital lipoid adrenal hyperplasia (lipoid CAH), a disease characterized by marked impairment of adrenal and gonadal steroid hormone synthesis. Recent data implicate cAMP-mediated pathways in the regulation of StAR mRNA expression via a mechanism that depends upon the orphan nuclear hormone receptor, steroidogenic factor-1 (SF-1). Additional data suggest that cAMP-mediated pathways stimulate StAR function at the posttranslational level by initiating protein kinase A (PKA)-mediated phosphorylation of StAR. Although StAR has been shown to be imported and processed by mitochondria, this event is not essential to StAR function. It appears that StAR acts on the outer mitochondrial membrane, stimulating sterol desorption from the sterol-rich outer membrane and its transfer to the relatively sterol-poor inner membrane.

The Septate Uterus

The septate uterus is the most common of all the uterine anomalies, accounting for about 35 % of all uterine anomalies. It is associated with recurrent miscarriage and adverse pregnancy outcomes, including preterm delivery. The role of the septate uterus in infertility is controversial. It occurs in 1 % of the fertile population, 3 % of the infertility population, and 5.3 % of the recurrent miscarriage population. The best modalities for diagnosing a septate uterus include a 3D ultrasound, with or without saline infusion, and an MRI. Hysteroscopic metroplasty improves reproductive outcomes in women with recurrent miscarriage and is a simple, well-tolerated procedure with a low complication rate.