Use of antimüllerian hormone to predict the menopausal transition in HIV-infected women.

BACKGROUND: HIV infection has been associated with early menopausal onset, which may have adverse long-term health consequences. Antimüllerian hormone, a biomarker of ovarian reserve and gonadal aging, is reduced in HIV-infected women. OBJECTIVE: We sought to assess the relationship of antimüllerian hormone to age of menopause onset in HIV-infected women. STUDY DESIGN: We used antimüllerian hormone levels measured in plasma in 2461 HIV-infected participants from the Women's Interagency HIV Study to model the age at final menstrual period. Multivariable normal mixture models for censored data were used to identify factors associated with age at final menstrual period. RESULTS: Higher antimüllerian hormone at age 40 years was associated with later age at final menstrual period, even after multivariable adjustment for smoking, CD4 cell count, plasma HIV RNA, hepatitis C infection, and history of clinical AIDS. Each doubling of antimüllerian hormone was associated with a 1.5-year increase in the age at final menstrual period. Median age at final menstrual period ranged from 45 years for those in the 10th percentile of antimüllerian hormone to 52 years for those in the 90th percentile. Other factors independently associated with earlier age at final menstrual period included smoking, hepatitis C infection, higher HIV RNA levels, and history of clinical AIDS. CONCLUSION: Antimüllerian hormone is highly predictive of age at final menstrual period in HIV-infected women. Measuring antimüllerian hormone in HIV-infected women may enable clinicians to predict risk of early menopause, and potentially implement individualized treatment plans to prevent menopause-related comorbidities and to aid in interpretation of symptoms.

Challenging cell phone impact on reproduction: a review.

PURPOSE: The radiofrequency electromagnetic radiation (RF-EMR) produced by cell phones can enhance the excitability of the brain and has recently been classified as carcinogenic. The suggested use of hands-free kits lowers the exposure to the brain, but it might theoretically increase exposure to the reproductive organs. This report summarizes the potential effects of RF-EMR on reproductive potentials in both males and females. METHODS: A critical review of the literature pertaining to the impact of cell phone RF-EMR on reproduction in male and female animals and humans was performed, with a focus on gonad metabolism, apoptosis of reproductive cells, fertility status, and serum reproductive hormones. RESULTS: While some animal and human studies revealed alterations in reproductive physiology in both males and females, others did not report any association. The in vitro and in vivo studies to date are highly diverse, very inconsistent in conduct and, in many cases, report different primary outcomes. CONCLUSION: The increasing use of cell phone warrants well-designed studies to ascertain the effect of their RF-EMR on reproduction.

Computed tomography-assisted laparoscopic removal of intraabdominally migrated levonorgestrel-releasing intrauterine systems.

PURPOSE: To report three cases of migrated levonorgestrel intrauterine device (LNG-IUS) into the pelvic/abdominal cavity removed laparoscopically with the aid of preoperative computed tomography (CT) scan imaging. METHODS AND RESULTS: Three patients presenting with a missing LNG-IUS on examination and pelvic ultrasound are presented. A preoperative CT scan was performed, what helped in a successful removal of the LNG-IUS. The patients were discharged home the same day of the procedure. CONCLUSION: Our cases reinforce, besides the diagnosis of a migrated LNG-IUS by ultrasound, the fact that preoperative CT scan imaging assists in the diagnosis of the precise location of a migrated LNG-IUS into the pelvic/abdominal cavity and helps the physician in the prediction of the difficulty of the laparoscopic removal.

Effect of clinical-decision support on documentation compliance in an electronic medical record.

OBJECTIVE: To investigate the efficacy of enhancing an existing prompt system in our obstetric electronic medical record in regard to documentation of estimated fetal weights and indications for labor induction. METHODS: Preintervention rates of documentation of indications for labor induction and estimated fetal weight were established at two hospital sites that used the same obstetric electronic medical record system. A compliance adherence mechanism with an enhanced prompting system was installed at the intervention hospital. Changes in the percentage of records with completed documentation were then calculated at the intervention and control hospitals. Additionally, the effects of the intervention on the pattern of documentation of indications for labor induction and on the accuracy of estimated fetal weight were tested. RESULTS: In the intervention hospital, the documentation rate increased from 42% to 69.4% for indications for labor induction, and from 55.7% to 77% for estimated fetal weight (both P<.001) during the study period although the estimated fetal weight documentation rate did not reach the level seen at base in the control hospital (92.5%). In the control hospital, there were no significant changes in rates of estimated fetal weight during the study period, but there was a decrease in indications for labor induction documentation rates. The accuracy of estimated fetal weights did not change with the enhanced documentation compliance mechanism. CONCLUSION: Increasing the frequency and modifying the methodology of prompts in an electronic medical record increased the documentation of both estimated fetal weight and indications for labor induction but did not lead to full compliance with documentation. LEVEL OF EVIDENCE: I.

Effect of bariatric surgery on peripheral blood lymphocyte subsets in women.

BACKGROUND: The use of bariatric surgery to treat refractory obesity is increasingly common. The great weight loss that can result from these procedures has been shown to ameliorate certain deleterious effects of obesity. However, the effect of surgery on immune status is unclear. We investigated the relationship between surgical weight loss and peripheral blood lymphocyte percentages in women. METHODS: Women (n=20, age range 25-59 years, body mass index [BMI] range 36.4-68.2 kg/m2) who had undergone either gastric banding (n=14) or gastric bypass (n=6) were enrolled in a prospective study to determine the percentages of their peripheral blood T cells (CD3+, CD4+, and CD8+), CD19+ B cells, and CD3-/CD16+CD56+ natural killer precursor cells before and 85+/-7 days (3 months) postoperatively using flow cytometry. The data are expressed as the percentage of total lymphocytes+/-the standard error of the mean. RESULTS: A decrease in the BMI at 3 months postoperatively was 12% in the overall study population and 8% and 20% in the banding and bypass groups, respectively. No significant changes were found in the CD4+ or CD8+ T cells (P=.9 and P=.5, respectively), CD19+ B cells (P=.6), or natural killer precursor cells (P=.25) in the overall population or among the patients when stratified by surgical procedure (gastric banding or bypass). The change in CD3+ T cells approached significance (P=.06). A "same direction" (negative) correlation was found between the decrease in BMI and changes in the CD4+ T cell percentages between the pre- and postoperative levels in all the participants, and in the bypass and banding groups separately. However, it only reached statistical significance in the bypass group (r=-.96, P=.002). When studying the correlation between the decrease in BMI and the changes in CD3+ T cell percentages between the pre- and postoperative levels, a borderline significant negative correlation was found for all participants (r=-.44, P=.05) and in the bypass group (r=-.76, P=.08). The rate of change in the CD4+ and CD3+ T cells was greatest among those with the least weight loss and decreased with greater weight loss. CONCLUSION: An inverse relationship exists between the change in certain T cells (CD4+ and CD3+) and the amount of weight lost after bariatric surgery, mainly gastric bypass surgery. The greater the decrease in BMI, the lower the change in these T cells.

Challenging oral contraception after weight loss by bariatric surgery.

As surgical weight loss becomes more commonly performed in fertile women, adequate contraception is more frequently becoming an issue. The purpose of this article is to appraise the literature to ascertain whether the use of oral contraception is effective and adequate after bariatric surgery. The literature search revealed that the combination of lower oral contraception dosages and surgical gastrointestinal disturbances might place patients at higher risks of unintended pregnancy. Until clinical trials show its efficacy, physicians should use oral contraception with prudence after bariatric surgery.

Effect of weight loss by bariatric surgery on the risk of miscarriage.

The aim of this paper is to appraise the literature with a view to establish whether weight loss by bariatric surgery has a beneficial effect on lowering the risk of miscarriage in morbidly obese women. Literature review revealed that weight loss by bariatric surgery on miscarriage rate has not been studied enough.

Syncopal episode as the presenting symptom of jugular vein thrombosis in pregnancy: a case report.

BACKGROUND: Jugular vein thrombosis has been reported to occur in pregnant women who conceived with assisted reproductive technology (ART). CASE: A 28-year-old woman at 17 weeks' gestation presented to the emergency room with a syncopal episode. She reported no arm pain or swelling, no neck pain or swelling, and no dyspnea or difficulty swallowing. Doppler sonography of the neck vasculature revealed acute bilateral internal jugular vein thromboses. Thrombophilia workup was normal. Intravenous anticoagulation with heparin was initiated, and the patient was discharged on low-molecular-weight heparin. CONCLUSION: Though rare, jugular vein thrombosis should be considered in the differential diagnosis of syncopal episodes even in women who conceive without ART.

Mechanisms of premature ovarian failure: reappraisal and overview.

OBJECTIVE: To present an overview of the potential etiologies of premature ovarian failure (POF), with an emphasis on the chromosomal abnormalities, gene mutations and autoimmune disorders. STUDY DESIGN: This article is based on a literature review of articles on POF using PubMed and MEDLINE for the years 1966-2005 using the keywords premature ovarian failure, trying to ascertain the possible mechanisms of POF reported to date. RESULTS: The etiology of POF is still under investigation, even though a wide range of etiologies has been unveiled, encompassing genetic mutations, chromosomal abnormalities, autoimmune disorders, and iatrogenic (irradiation, chemotherapy) and idiopathic causes. CONCLUSION: In the majority of POF cases, the etiology remains subtle.

The role of uterine fundal pressure in the management of the second stage of labor: a reappraisal.

UNLABELLED: Among the maneuvers that are used in the second stage of labor, uterine fundal pressure is one of the most controversial. The prevalence of its use is unknown. We reviewed the existing literature to assess whether there is justification for the use of fundal pressure in the contemporary management of the second stage of labor. Only one randomized, controlled study and a few prospective studies, review articles, and case reports have been published. No confirmed benefit of the procedure has been documented and a few adverse events have been reported in association with its use. Alternative management strategies in the second stage of labor exist and should be considered whenever possible. In conclusion, the role of fundal pressure is understudied and remains controversial in the management of the second stage of labor. We believe that caution should be exercised using this maneuver until it is proven to be safe and effective. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall that there is a scarcity of literature related to the efficacy and safety of using fundal pressure during the second stage of labor, state that there is no confirmed benefit of the procedure and there may be some adverse maternal/fetal effects, and explain that there are alternative strategies for management of the second stage of labor.

Male adiposity impairs clinical pregnancy rate by in vitro fertilization without affecting day 3 embryo quality.

OBJECTIVE: Male adiposity is detrimental for achieving clinical pregnancy rate (CPR) following assisted reproductive technologies (ART). The hypothesis that the association of male adiposity with decreased success following ART is mediated by worse embryo quality was tested. DESIGN AND METHODS: Retrospective study including 344 infertile couples undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles was performed. Cycle determinants included number of oocytes retrieved, zygote PN-score, total number of embryos available on day 3, number of embryos transferred, composite day 3 grade for transferred embryos, composite day 3 grade per cycle, and CPR. RESULTS: Couples with male body mass index (BMI) over 25 kg m(-2) (overweight and obese) exhibited significantly lower CPR compared to their normal weight counterparts (46.7% vs. 32.0% respectively, P = 0.02). No significant difference was observed for any embryo quality metrics when analyzed by male BMI: mean zygote PN-scores, mean composite day 3 grades for transferred embryos or composite day 3 grades per cycle. In a multivariable logistic regression analysis adjusting for female age, female BMI, number of embryos transferred and sperm concentration, male BMI over 25 kg m(-2) was associated with a lower chance for CPR after IVF (OR = 0.17 [95% CI: 0.04-0.65]; P = 0.01) but not after ICSI cycles (OR = 0.88 [95% CI: 0.41-1.88]; P = 0.75). In this cohort, male adiposity was associated with decreased CPR following IVF but embryo quality was not affected. CONCLUSIONS: Embryo grading based on conventional morphologic criteria does not explain the poorer clinical pregnancy outcomes seen in couples with overweight or obese male partner.

Circulating vitamin D correlates with serum antimüllerian hormone levels in late-reproductive-aged women: Women's Interagency HIV Study.

OBJECTIVE: To study the correlation between circulating 25-hydroxyvitamin D (25OH-D) levels and serum antimüllerian hormone (AMH) in women enrolled in the Women's Interagency HIV Study. DESIGN: Cross-sectional study. SETTING: None. PATIENT(S): All premenopausal women (n = 388) with regular menstrual cycles were included and subdivided into three groups: group 1 with age <35 years (n = 128), group 2 with age 35-39 years (n = 119), and group 3 with age ≥40 years (n = 141). INTERVENTION(S): Serum for 25OH-D, AMH, fasting glucose and insulin, and creatinine levels. MAIN OUTCOME MEASURE(S): Correlation between 25OH-D and AMH before and after adjusting for HIV status, body mass index, race, smoking, illicit drug use, glucose and insulin levels, estimated glomerular filtration rate, and geographic site of participation. RESULT(S): After adjusting for all covariates, the regression slope in all participants for total 25OH-D predicting log(10)AMH for 25-year-olds (youngest participant) was -0.001 (SE = 0.008); and for 45-year-olds (oldest participant) the corresponding slope was +0.011 (SE = 0.005). Fasting insulin level was negatively correlated with serum AMH. The regression slope for the correlation between 25OH-D and AMH in group 1 was +0.002 (SE = 0.006); in group 2 was +0.006 (SE = 0.005); and in group 3 was +0.011 (SE = 0.005). There was no association between HIV and AMH. CONCLUSION(S): A novel relationship is reported between circulating 25OH-D and AMH in women aged ≥40 years, suggesting that 25OH-D deficiency might be associated with lower ovarian reserve in late-reproductive-aged women.

Changes in plasma müllerian-inhibiting substance and brain-derived neurotrophic factor after chemotherapy in premenopausal women.

Eight premenopausal women with cancer had blood drawn for analysis of brain-derived neurotrophic factor (BDNF) and müllerian-inhibiting substance (MIS) before and 3 months after receiving chemotherapy. Unlike MIS, BDNF levels were not reduced after chemotherapy.

Gulf Coast oil disaster: impact on human reproduction.

The catastrophic British Petroleum oil spill in the Gulf of Mexico has reached the shores of the United States, along with unpredictable effects on the health of local communities. The potential impact of the disaster on female and male reproduction will be discussed in this report, to provide greater clinician awareness about the potential consequences of this calamity and to call for more research on this subject.

Age-related LH surge dysfunction correlates with reduced responsiveness of hypothalamic anteroventral periventricular nucleus kisspeptin neurons to estradiol positive feedback in middle-aged rats.

Female reproductive aging in rats is characterized by reduced gonadotropin releasing hormone (GnRH) neuronal activation under estradiol positive feedback conditions and a delayed and attenuated luteinizing hormone (LH) surge. The newly identified excitatory neuropeptide kisspeptin is proposed to be a critical mediator of the pubertal transition and the ovarian steroid-induced LH surge. We previously showed that estradiol induces less kisspeptin mRNA expression in the anterior hypothalamus [anatomical location of anteroventral periventricular nucleus (AVPV)] in middle-aged than in young rats and intrahypothalamic infusion of kisspeptin restores LH surge amplitude in middle-aged females. Thus, reduced kisspeptin neurotransmission may contribute to age-related LH surge abnormalities. This study tested the hypothesis that middle-aged females will also exhibit reduced numbers of kisspeptin immunopositive neurons in the AVPV under estradiol positive feedback conditions. Using immunohistochemistry, we demonstrate that middle-aged females primed with ovarian steroids have fewer AVPV kisspeptin immunopositive neurons than young females. Age did not affect kisspeptin mRNA expression in the pituitary, numbers of kisspeptin immunopositive neurons in the arcuate nucleus, or estradiol-dependent reductions in kisspeptin mRNA expression in the posterior hypothalamus (containing the arcuate nucleus). These data strongly suggest that age-related LH surge dysfunction results, in part, from a reduced sensitivity of AVPV kisspeptin neurons to estradiol and hence decreased availability of AVPV kisspeptin neurons to activate GnRH neurons under positive feedback conditions.

Hypothalamic insulin-like growth factor-I receptors are necessary for hormone-dependent luteinizing hormone surges: implications for female reproductive aging.

Brain IGF-I receptors are required for maintenance of estrous cycles in young adult female rats. Circulating and hypothalamic IGF-I levels decrease with aging, suggesting a role for IGF-I in the onset of reproductive senescence. Therefore, the present study investigated potential mechanisms of action of brain IGF-I receptors in the regulation of LH surges in young adult and middle-aged rats. We continuously infused IGF-I, the selective IGF-I receptor antagonist JB-1, or vehicle into the third ventricle of ovariectomized young adult and middle-aged female rats primed with estradiol and progesterone. Pharmacological blockade of IGF-I receptors attenuated and delayed the LH surge in young adult rats, reminiscent of the LH surge pattern that heralds the onset of reproductive senescence in middle-aged female rats. Infusion of IGF-I alone had no effect on the LH surge but reversed JB-1 attenuation of the surge in young females. In middle-aged rats, infusion of low doses of IGF-I partially restored LH surge amplitude, and infusion of JB-1 completely obliterated the surge. Intraventricular infusion of IGF-I or JB-1 did not modify pituitary sensitivity to exogenous GnRH or GnRH peptide content in the anterior or mediobasal hypothalamus in either young or middle-aged rats. These findings support the hypothesis that brain IGF-I receptor signaling is necessary for GnRH neuron activation under estrogen-positive feedback conditions and that decreased brain IGF-I signaling in middle-aged females contributes, in part, to LH surge dysfunction by disrupting estradiol-sensitive processes that affect GnRH neuron activation and/or GnRH release.

Impact of bariatric surgery on female reproduction.

OBJECTIVE: To evaluate the current literature on the impact and potential mechanisms of surgical weight loss on female reproduction, with a focus on changes in reproductive hormone profile, fertility status, measures of ovarian reserve, efficacy of oral contraception, sexuality, and pregnancy. DESIGN: Appraisal of articles relevant to surgical weight loss and female reproduction. RESULT(S): The altered reproductive hormone profile associated with morbid obesity seems to reverse, either partially or totally, after surgical weight loss. Although bariatric surgery seems to improve fertility status and many of the complications associated with obesity in pregnancy, it may be linked to oral contraceptive failure. Although müllerian-inhibiting substance is a direct measure of ovarian reserve, its level changes with obesity and after surgical weight loss. There is a decrease or no change in the risk of miscarriage after bariatric surgery. An improvement in sexual function may follow dramatic surgical weight reduction; however, the possibility of a detrimental influence afterward can occur. CONCLUSION(S): The increasing popularity of bariatric surgery in reproductive-age women calls for greater clinician awareness of its impact on female reproduction.

Subserosal misplacement of Essure device manifested by late-onset acute pelvic pain.

OBJECTIVE: To increase awareness of the potential to present with late-onset acute pelvic pain secondary to subserosal misplacement of an Essure device (Conceptus Inc., Mountain View, CA). DESIGN: Case report. SETTING: University-affiliated teaching hospital. PATIENT(S): A 30-year-old woman who was seen with severe left lower quadrant pain 4 months after elective sterilization with an Essure device placed under local anesthesia. Mild to moderate resistance was encountered in the placement of the device in the left fallopian tube. INTERVENTION(S): Hysterosalpingogram showing patency of the left fallopian tube and operative laparoscopy. MAIN OUTCOME MEASURE(S): Laparoscopic removal of the Essure device with left salpingectomy. RESULT(S): The patient was free of pain and was discharged home the same day of the laparoscopic procedure. CONCLUSION(S): This report reinforces the need to consider a misplaced Essure device in the differential diagnosis of late-onset acute pelvic pain in women who had difficult placement of the device.

Plasma brain-derived neurotrophic factor in women after bariatric surgery: a pilot study.

Eighteen morbidly obese women had plasma brain-derived neurotrophic factor (BDNF) measured before bariatric surgery and 3 months postoperatively. We analyzed plasma BDNF levels in all the participants then subdivided according to menopausal status and type of surgery. Brain-derived neurotrophic factor decreased significantly in all the participants and in the premenopausal group when looked at in isolation.