Screening for Insulin Resistance in Polycystic Ovary Syndrome: Views of Physician Members of the American Society for Reproductive Medicine.

OBJECTIVE: To determine practice patterns for insulin resistance (IR) evaluation and management in women with polycystic: ovary syndrome (PCOS) among physician members of the American Society for Reproductive Medicine (ASRM). STUDY DESIGN: Cross-sectional survey using a web-based questionnaire. RESULTS: A total of 205 members responded. Respondents were board-certified (94%), or board-eligible (6%), in obstetrics and gynecology. Sixty-four percent of the respondents use the Rotterdam 2003 Criteria for a diagnosis of PCOS. Two-thirds (68%) screenfor IR in women with PCOS. Respondents who screen for IR were more likely to also screen for diabetes and impaired glucose tolerance (OR 3.37, 95% CI 1.48-7.21). The 2-hour oral glucose tolerance test with glucose and insulin concentrations was the most common IR screening test used (45%). Metformin therapy was used by 33% of respondents for, "all women with PCOS who have IR." The majority (68%) responded that there is a need for a committee opinion from ASRM on IR testing in PCOS. CONCLUSION: Two-thirds of ASRM physician members surveyed screen women with PCOS for IR in spite of the lack of general consensus on the need for such screening from endocrine societies.

Single-dose intramuscular methotrexate treatment of cervical ectopic pregnancy. A case report.

BACKGROUND: Cervical ectopic pregnancies (CEPs) are increasingly being managed conservatively. However, the efficacy of specific conservative approaches such as the single-dose intramuscular (IM) methotrexate (MTX) therapy has not been evaluated. We reportthe successful management of 2 consecutive CEPs in the same patient with single-dose IM MTX therapy, and review published cases of CEPs treated with a similar regimen, to determine the efficacy of this approach. CASE: In our case, both CEPs resolved with single-dose IM MTX, and the patient subsequently had a successful term delivery. A Medline/OVID English language search, covering the period 1982-2012, identified 38 additional cases of CEPs treated with single-dose IM MTX. Of the total 40 cases analyzed, including our 2 cases, 30 (75%) were successfully treated, with complete remission. Of the 27 cases with no embryonic cardiac activity, 25 (93%) were successfully treated with single-dose IM MTX. CONCLUSION: Appropriately selected cases of CEPs can be successfully managed with single-dose IM MTX with very low complication rates and preservation of future fertility potential.

Endometriosis: the role of neuroangiogenesis.

Endometriosis is a common cause of pelvic pain and infertility, affecting ∼10% of reproductive-age women. Annual costs for medical and surgical care in the United States exceed $20 billion. The disorder is characterized by implants of endometrial tissue outside the uterine cavity. Endometriotic lesions induce a state of chronic peritoneal inflammation, accompanied by elevated prostaglandin, cytokine, and growth factor concentrations. The current therapy is surgical ablation of ectopic implants and hormones that block the hypothalamic-pituitary-ovarian axis, but these approaches are expensive, carry perioperative risks, or have unpleasant side effects of hypoestrogenism. Recent evidence indicates that ectopic endometriotic implants recruit their own unique neural and vascular supplies through neuroangiogenesis. It is believed that these nascent nerve fibers in endometriosis implants influence dorsal root neurons within the central nervous system, increasing pain perception in patients. We consider the mechanisms and therapeutic implications of neuroangiogenesis in these lesions and propose potential treatments for the control or elimination of endometriosis-associated pain.

Defects in mitochondrial efficiency and H2O2 emissions in obese women are restored to a lean phenotype with aerobic exercise training.

The notion that mitochondria contribute to obesity-induced insulin resistance is highly debated. Therefore, we determined whether obese (BMI 33 kg/m(2)), insulin-resistant women with polycystic ovary syndrome had aberrant skeletal muscle mitochondrial physiology compared with lean, insulin-sensitive women (BMI 23 kg/m(2)). Maximal whole-body and mitochondrial oxygen consumption were not different between obese and lean women. However, obese women exhibited lower mitochondrial coupling and phosphorylation efficiency and elevated mitochondrial H2O2 (mtH2O2) emissions compared with lean women. We further evaluated the impact of 12 weeks of aerobic exercise on obesity-related impairments in insulin sensitivity and mitochondrial energetics in the fasted state and after a high-fat mixed meal. Exercise training reversed obesity-related mitochondrial derangements as evidenced by enhanced mitochondrial bioenergetics efficiency and decreased mtH2O2 production. A concomitant increase in catalase antioxidant activity and decreased DNA oxidative damage indicate improved cellular redox status and a potential mechanism contributing to improved insulin sensitivity. mtH2O2 emissions were refractory to a high-fat meal at baseline, but after exercise, mtH2O2 emissions increased after the meal, which resembles previous findings in lean individuals. We demonstrate that obese women exhibit impaired mitochondrial bioenergetics in the form of decreased efficiency and impaired mtH2O2 emissions, while exercise effectively restores mitochondrial physiology toward that of lean, insulin-sensitive individuals.

Thin endometrial stripe does not affect likelihood of achieving pregnancy in clomiphene citrate/intrauterine insemination cycles.

OBJECTIVE: To determine whether there is a correlation between preovulatory endometrial stripe thickness (EST) and pregnancy rates in clomiphene citrate (CC)/IUI cycles. DESIGN: Retrospective cohort. SETTING: Infertility clinic of an academic medical center. PATIENT(S): A total of 262 patients completed 562 transvaginal ultrasound-monitored CC/IUI cycles from January 2005 through December 2012. INTERVENTION(S): All patients received oral CC. In 362 of the cycles, a single dose of gonadotropin was administered on cycle day 9 (MinStim). A transvaginal ultrasound was performed on cycle day 10, 11, or 12. MAIN OUTCOME MEASURE(S): Pregnancy rate per initiated cycle. RESULT(S): A total of 91 pregnancies ensued, yielding a pregnancy rate of 16.2% per initiated cycle. Pregnancy rates did not vary with EST <6 mm, 6-9 mm, and >9 mm (14.8%, 16.3%, and 19.0%, respectively). There was no significant difference in mean EST between stimulation types (6.8 mm for CC vs. 6.7 mm for MinStim). When conception and nonconception cycles were compared, no difference in mean EST (6.9 mm vs. 6.8 mm, respectively) was observed. Area under the receiver operating characteristic curve for the probability of pregnancy based on EST was 0.51. CONCLUSION(S): Preovulatory EST had no significant correlation with pregnancy rates in CC/IUI cycles. The decision to switch from CC to another treatment strategy should be influenced by factors other than thin endometrial stripe.

Fertility drug use and the risk of ovarian tumors in infertile women: a case-control study.

OBJECTIVE: To assess the influence of infertility and fertility drugs on risk of ovarian tumors. DESIGN: Case-control study (Mayo Clinic Ovarian Cancer Study). SETTING: Ongoing academic study of ovarian cancer. PATIENT(S): A total of 1,900 women (1,028 with ovarian tumors and 872 controls, frequency matched on age and region of residence) who had provided complete information in a self-report questionnaire about history of infertility and fertility drug use. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Effect of infertility history, use of fertility drugs and oral contraception, and gravidity on the risk of ovarian tumor development, after controlling for potential confounders. RESULT(S): Among women who had a history of infertility, use of fertility drugs was reported by 44 (24%) of 182 controls and 38 (17%) of 226 cases. Infertile women who used fertility drugs were not at increased risk of developing ovarian tumors compared with infertile women who did not use fertility drugs; the adjusted odds ratio was 0.64 (95% CI, 0.37, 1.11). The findings were similar when stratified by gravidity and when analyzed separately for borderline versus invasive tumors. CONCLUSION(S): We found no statistically significant association between fertility drug use and risk of ovarian tumors. Further larger, prospective studies are needed to confirm this observation.

Epidermal inclusion cyst of the clitoris 30 years after female genital mutilation.

OBJECTIVE: To present a case report of a patient with epidermal inclusion cyst as a late complication of female circumcision, the management of the patient, and a review of the literature. DESIGN: Case report and literature review. SETTING: University hospital. PATIENT(S): A 37-year-old female from Guinea with a large clitoral mass of 6 months' duration. INTERVENTION(S): Complete history and physical exam of the patient and subsequent surgical resection of the cyst. MAIN OUTCOME MEASURE(S): Diagnosis, surgical management, and postoperative sexual function and emotional well-being. RESULT(S): Resolution of swelling and discomfort, satisfactory postoperative sexual function and emotional well-being. CONCLUSION(S): There should be awareness of one of the relatively common delayed complications of female genital circumcision and familiarity with its surgical management. Overall, surgical management appears to be effective, and there is no documented risk of recurrence.

Elective oophorectomy in the United States: trends and in-hospital complications, 1998-2006.

OBJECTIVES: To examine trends in rates of elective bilateral salpingo-oophorectomy in the United States and to assess the association of perioperative complications with elective bilateral salpingo-oophorectomy. METHODS: This cross-sectional study uses 1998-2006 data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, a nationally representative sample of inpatient hospitalizations. Analyses were limited to women aged 15 years or older at average risk for ovarian cancer who underwent hysterectomy for a benign gynecologic condition. Tests for trends in elective bilateral salpingo-oophorectomy rates were performed using weighted least squares regression for two time periods, 1998 to 2001 and 2002 to 2006. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for risks of complications associated with elective bilateral salpingo-oophorectomy were estimated using logistic regression. RESULTS: During the period from 1998 to 2006, 39% of the 2,250,041 women who underwent hysterectomy for benign gynecologic indications had elective bilateral salpingo-oophorectomy (rate, 8.3 per 10,000). The elective bilateral salpingo-oophorectomy rate increased from 7.8 per 10,000 in 1998 to 9.0 per 10,000 in 2001 (P trend <.05) and decreased from 9.0 per 10,000 in 2002 to 7.4 per 10,000 in 2006 (P trend <.05). The largest decline from 2002 to 2006 (20.3%) occurred among those aged 45 to 49 years. Compared with hysterectomy only, elective bilateral salpingo-oophorectomy was associated with an increased risk of complications when performed vaginally (OR 1.12; 95% CI 1.08-1.17) and a decreased risk of complications when performed abdominally (OR 0.91; 95% CI 0.89-0.94) or laparoscopically (OR 0.89; 95% CI 0.83-0.94). CONCLUSION: Elective bilateral salpingo-oophorectomy rates declined since 2002. However, the risks compared with the benefits of the procedure have not been clearly established. Prospective studies examining elective bilateral salpingo-oophorectomy with and without estrogen therapy are needed to guide practice patterns. LEVEL OF EVIDENCE: III.