Ursula Balthazar

Trends of socioeconomic disparities in referral patterns for fertility preservation consultation

BACKGROUND While oncologists are aware that cancer treatments may impact fertility, referral rates for fertility preservation consultation (FPC) remain poor. The goal of this study was to identify predictors associated with FPC referral. METHODS This is a retrospective, cohort study of women aged 18-42 years diagnosed with a new breast, gynecologic, hematologic or gastrointestinal cancer at our institution between January 2008 and May 2010. Exclusion criteria included history of permanent sterilization, documentation of no desire for future children, stage IV disease, short interval (<4 days) between diagnosis and treatment and treatment that posed no threat to fertility. Demographic, socioeconomic and cancer variables were evaluated with respect to FPC. Logistic regression was used to determine the odds of referral for FPC based on specified predictors. RESULTS One hundred and ninety-nine patients were eligible for FPC and of those, 41 received FPC (20.6%). Women with breast cancer were 10 times more likely to receive FPC compared with other cancer diagnoses [odds ratio (OR) 10.1; 95% confidence interval (CI) 3.8-26.8]. The odds of FPC referral were approximately two times higher for Caucasian women (OR 2.4; 95% CI 0.9-6.2), three times higher for age <35 years (OR 3.3; 95% CI 1.4-7.7) and four times higher in nulliparous women (OR 4.6; 95% CI 1.9-11.3). There was no association between BMI, income, distance to our institution, being in a relationship and referral for FPC. CONCLUSIONS Overall referral rates for FPC are low, and there appear to be significant discrepancies in referral based on ethnicity, age, parity and cancer type. This highlights a need for further provider education and awareness across all oncologic disciplines.

Fertility preservation: a pilot study to assess previsit patient knowledge quantitatively

OBJECTIVE To provide a quantitative assessment of patient knowledge about fertility and fertility preservation treatment options before the initial fertility preservation consultation at a university-based fertility preservation center. DESIGN Prospective pilot survey containing 13 items assessing patient knowledge about fertility preservation, including the available treatment options and their requirements, success rates, and associated risks. SETTING University-based IVF center. PATIENT(S) Women aged 18 to 41 years with illnesses requiring treatments posing a serious threat to future fertility who were referred for fertility preservation consultation between April 2009 and June 2010. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Knowledge score. RESULT(S) Forty-one eligible patients were identified, and all completed surveys before their consultation. A knowledge score was generated for each patient with 1 point awarded for each correct answer. Overall, patients had poor previsit fertility preservation knowledge (mean score 5.9±2.7). Higher knowledge scores were correlated with personal experience with infertility and previous exposure to fertility preservation treatment information. There was no correlation between knowledge score and age, relationship status, pregnancy history, education, or income. CONCLUSION(S) Patients seen for fertility preservation consultation at our university-based center generally tend to be in their early 30s, white, well educated, and married. Previsit knowledge about fertility preservation treatment options was poor and did not correlate with age, education, and relationship status.

Robotic resection of adnexal masses during pregnancy.

OBJECTIVE To characterize the safety and feasibility of robotic adnexal surgery during pregnancy, and to compare surgical and obstetric outcomes for robotic versus laparoscopic treatment of adnexal masses during pregnancy. STUDY DESIGN A retrospective cohort study of all cases of robotic resection of adnexal masses in gravid patients performed at our institution between 2006 and 2009 compared with 50 consecutive historic laparoscopic controls performed between 1999 and 2007. RESULTS During the study period, 19 parturients underwent planned robotic resection of adnexal masses, all of which were uncomplicated. Compared with 50 consecutive laparoscopic controls, no differences in operative time, conversion to laparotomy, intraoperative or postoperative complications, or observed obstetric outcomes were apparent. The robotic cohort had a significantly shorter length of hospital stay (p < 0.01) and estimated blood loss (p = 0.02). CONCLUSION Robotic resection of adnexal masses during pregnancy appears both safe and feasible, with similar surgical outcomes when compared with a historic laparoscopic cohort.

Periconceptional changes in thyroid function: a longitudinal study

BackgroundLimitations in our current knowledge of normative physiologic changes in thyroid function during the periconception window narrow our ability to establish an optimal approach to screening and diagnosis of thyroid disease in pregnant women. The objective of this study was to characterize changes in thyroid function during the transition from the pre-pregnant to pregnant state in normal fertile women.MethodsWomen (N = 60) ages 30-42 years without a history of thyroid disease, who were planning pregnancy, were observed prospectively before and during early pregnancy. Thyroid function (thyroid stimulating hormone, TSH and free thyroxine, FT4) was measured before conception and between 6 and 9 weeks gestation. Pre-pregnancy samples were analyzed for thyroid antibodies. Bivariate analyses and longitudinal curves (general estimating equation models) were used to analyze changes in thyroid function during the periconception window by antibody status.ResultsPre-pregnancy TSH values were significantly higher than early pregnancy TSH (p < 0.001), but FT4 values did not differ (p = 0.53). TSH declined as gestational age increased (P < 0.01). Thyroid antibody positive women had a higher pre-pregnancy TSH compared to antibody negative women (p < 0.01). Periconceptional change in thyroid function was more variable among women with antibodies (p < 0.001). 50% of women with elevated pre-pregnancy TSH values (TSH > 3.0 mIU/L) had normal TSH values (TSH < 2.5 mIU/L) in pregnancy.ConclusionsTSH values decline during the transition from pre-pregnancy to early pregnancy. The change in TSH appears to be less predictable in women with thyroid antibodies. Periconceptional changes in thyroid function should be considered in formulating prenatal thyroid screening guidelines.

Effect of randomized serum progesterone concentration on secretory endometrial histologic development and gene expression

STUDY QUESTION What doses of secretory phase progesterone (P) in women are associated with altered endometrial structure and/or function? SUMMARY ANSWER Consistently delayed histological maturation was seen at the lowest tested daily P dose (2.5 mg), whereas consistently altered functional response, as reflected by microarray analysis of gene expression was seen at both the 5 and 2.5 mg doses. WHAT IS KNOWN ALREADY Progesterone is absolutely required for normal embryo implantation and pregnancy survival. Progesterone supplementation is beneficial in ART cycles. STUDY DESIGN, SIZE, DURATION In this case-control experimental trial, 46 healthy young female volunteers (age 19-34) underwent a single modeled endometrial cycle after GnRH down-regulation or monitored in natural cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS In a university hospital, modeled cycles were obtained by GnRH agonist down-regulation, transdermal estradiol (E2) (0.2 mg/d), and daily injections of P in oil for 10 days: 2.5 mg (n = 6), 5 mg (n = 6), 10 mg (n = 12) or 40 mg (n = 12), after the 10th day of E2. Ten healthy, ovulatory women were used as controls. Endometrial biopsies were obtained on the 10th day of P exposure, or urinary LH surge (in controls). Analysis included histological dating, serum progesterone levels, microarray analysis of the whole genome, RT-PCR, western blot and comparison with the GEO database. MAIN RESULTS AND THE ROLE OF CHANCE In endometrial biopsies, a morphological delay appears in the 2.5 mg/day of P group. Higher sub-physiological levels of P (≥5 mg/day) resulted in normal histology, but aberrant gene expression. P levels required for consistent histological delay were lower than those in all ovulatory women. Gene expression abnormalities occurred at higher sub-physiological P concentrations, without a change in histology, a functional-morphological disassociation. The expression of some endometrial receptivity-associated genes appeared multiphasic, with peak or nadir of mean or median expression levels between the lowest and highest doses, suggesting sustained supraphysiological doses seen in ART treatment cycles may not be optimal. LARGE SCALE DATA GEO DataSets ID: 200056980; GSE 56980. LIMITATIONS, REASONS FOR CAUTION These results were obtained in fertile women, who may respond differently from infertile subjects. WIDER IMPLICATIONS OF THE FINDINGS The dose of P required for normal endometrial structure (5 mg/day) corresponds to a P concentration well below that seen in ovulatory women, suggesting that persistently delayed mid-secretory histology cannot be solely due to inadequate P concentrations in an ovulatory cycle. Endometrial gene expression is differentially regulated by different doses of progesterone. The apparent multiphasic response of some genes to P dose suggests the possibility that P concentration kinetics may play a role in normal endometrial preparation for receptivity. These findings strongly confirm that histologic development is not a reliable measure of endometrial P action. STUDY FUNDING/COMPETING INTEREST(S) Supported by The Eunice Kennedy Shriver National Institute for Child Health and Disease, National Institute of Health, USA (NICHD/NIH) (R01HD067721 and U54HD30476; SLY and BAL) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) 240239/2012-1 (RFS). All authors have no competing interests.