Success of the two-dose methotrexate protocol for treatment of ectopic pregnancy in women with a history of prior ectopic pregnancy.

OBJECTIVE: Women with prior ectopic pregnancy (EP) have an increased failure rate when treated with single-dose methotrexate (MTX) for subsequent EP. We sought to determine whether previous EP remained a risk factor for failure when using the two-dose MTX protocol. STUDY DESIGN: Retrospective cohort study of women managed with two-dose MTX. Risk factors for MTX failure were evaluated in univariable analysis and multivariable regression modeling. RESULTS: A total of 234 women with EP between 1999 and 2009 were studied. Of those, 37 (15.8%) had a prior EP. In univariable analysis, prior EP was associated with a greater than twofold increased risk of MTX failure (RR 2.67, 95% CI 1.20-3.77). Higher hCG levels and ultrasound visualization of EP also increased the risk of MTX failure. In multivariable analysis hCG level remained associated with MTX failure, while prior EP did not (adjusted RR 0.97, 95% CI 0.33-2.82). CONCLUSION: Prior EP is not independently associated with MTX failure in women receiving two-dose MTX therapy after controlling for known risk factors.

Antimüllerian hormone as a measure of reproductive function in female childhood cancer survivors.

OBJECTIVE: To evaluate the utility of measuring antimüllerian hormone (AMH) in childhood cancer survivors to assess ovarian reserve, pubertal status, and fertility potential. DESIGN: Cross-sectional study. SETTING: Academic medical center. PATIENT(S): Fifty-three female childhood cancer survivors, median age 13.9 years (range: 9-25 years) recruited at least 1 year from completion of cancer therapy. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Serum AMH, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estradiol measurements, pubertal/menstrual history and Tanner staging, with risk of gonadotoxicity classified as low or high based on chemotherapy agent and pelvic/abdominal radiation. RESULT(S): Thirty-one of the 53 patients (58%) in the cohort had diminished ovarian reserve (DOR) detected by an AMH value <1 ng/mL. We detected DOR by a FSH value of >12 IU/mL in 17 patients (32%). The patients exposed to high-risk chemotherapy or pelvic radiation were at statistically significantly higher risk for DOR as measured by their AMH level. The AMH level was also statistically significantly lower in the patients who had delayed puberty. CONCLUSION(S): Using the serum gonadotropins level to screen childhood cancer survivors for ovarian failure is a suboptimal method. The AMH value identified the patients at risk for delayed puberty and those who could benefit from fertility preservation counseling, which makes AMH perhaps the optimal screening tool for assessing ovarian reserve in this population.

Role of female pelvic anatomy in infertility.

Infertility is defined as a couple's failure to achieve pregnancy after one year of regular, unprotected intercourse. The etiology of infertility can be due to female factors, male factors, combined male and female factors, or have an unknown etiology. This review focuses on the role of female pelvic anatomy in infertility. Normal anatomy and the physiology of reproduction will be discussed, as well as the anatomic and pathophysiologic processes that cause infertility including ovulatory disorders, endometriosis, pelvic adhesions, tubal blockage, mullerian anomalies, and abnormalities affecting the uterine cavity such as leiomyomata and endometrial polyps.

Infertility evaluation.

Infertility is a common condition, affecting 15% of couples trying to conceive. The infertility evaluation includes an assessment of both the female and the male partner to discern the factors contributing to their difficulty in conceiving. The basic evaluation includes a careful history of both partners, physical examination of the female partner, investigation of ovulatory function and tubal status, and semen analysis. A more detailed investigation is performed as dictated by individual factors.

Fertility preservation in women of reproductive age with cancer.

Advances in cancer care have improved survival, driving the need to mitigate the side effects of cancer therapy to improve the quality of life of cancer survivors. Use of fertility preservation has grown given the potential gonadotoxicity of chemotherapy and radiation, the increasing rate of treatment success, and the strong desire for childbearing in cancer survivors. Current options include embryo and oocyte cryopreservation, ovarian tissue cryopreservation, gonadal suppression, and ovarian transposition. Consultation with a reproductive endocrinology and infertility specialist trained in fertility preservation provides cancer patients an individualized risk assessment for future gonadal failure and discussion of potential fertility preservation options.

Ovarian preservation in a young patient with Gorlin syndrome and multiple bilateral ovarian masses.

OBJECTIVE: To report a case of bilateral ovarian fibromas and ovarian leiomyomas in a young patient with Gorlin syndrome and to highlight issues of fertility preservation, ovarian conservation, and preimplantation genetic diagnosis in this population. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 15-year-old female patient with Gorlin syndrome and bilateral ovarian masses. INTERVENTION(S): Ultrasound, magnetic resonance imaging, hormone analysis, and laparotomy with resection of ovarian fibromas. MAIN OUTCOME MEASURE(S): Preservation of ovarian function, pathologic diagnosis. RESULT(S): Our patient represented an adolescent case of bilateral ovarian fibromas and leiomyomas in Gorlin syndrome presenting with menstrual irregularities. She was managed surgically with resection of the lesions and conservation of normal ovarian tissue. CONCLUSION(S): In Gorlin syndrome, ovarian fibromas are a common clinical manifestation. Patients with ovarian involvement may present with complex gynecologic needs and may have decreased fertility potential. Careful surgical management, follow-up, and counseling on options for future fertility should be offered to all patients.

Effect of methotrexate exposure on subsequent fertility in women undergoing controlled ovarian stimulation.

OBJECTIVE: To evaluate the pregnancy rate, ovarian responsiveness, and endometrial thickness in infertility patients with a history of methotrexate exposure who subsequently underwent controlled ovarian stimulation. DESIGN: Retrospective cohort study. SETTING: University reproductive endocrinology and infertility program. SUBJECT(S): Forty-eight women with infertility undergoing ovarian stimulation after receiving methotrexate treatment for ectopic gestation. INTERVENTION(S): Methotrexate administration and controlled ovarian stimulation. MAIN OUTCOME MEASURE(S): Pregnancy rate, cycle day 3 FSH levels, number of oocytes retrieved, and endometrial thickness. RESULT(S): The cumulative intrauterine pregnancy rate achieved with controlled ovarian stimulation at 2 years after methotrexate exposure was 43%, with a mean time to conceive of 181 days. Thirty-five patients with similar fertility treatments pre- and post-methotrexate were identified. Within this group, when an IVF cycle occurred within 180 days of methotrexate exposure, a significant decline in oocytes retrieved was observed. Cycles performed later than 180 days after methotrexate exposure did not exhibit a decrease in oocyte production. Endometrial development was similar at all time points examined. CONCLUSION(S): These findings suggest a time-limited and reversible impact of methotrexate on oocyte yield. If confirmed by larger clinical series and/or animal data, these results may impact the management of ectopic gestation in the patient with a history of infertility or the timing of subsequent treatments.