Disparities in Female Oncofertility Care in the United States: More Questions Than Answers.

As cancer therapies continue to improve, the survival rates of adolescent and young adult patients have increased. Consequently, considering patient quality of life after cancer, including family building, has become an essential aspect of establishing a treatment plan. However, the gonadotoxic nature of many chemotherapeutic agents limits the option of using one's own gamete for family building. In recent years, significant advancements have been made in oncofertility, particularly vitrification of oocytes. Unfortunately, as with many areas of medicine, health disparities limit those that can access and utilize fertility preservation prior to cancer treatment. This review aims to shed light on existing disparities in oncofertility for female patients, to offer recommendations to enhance education, access, and advocacy, as well as identify potential areas for future research.

Where Have All the Emergencies Gone? The Impact of the COVID-19 Pandemic on Obstetric and Gynecologic Procedures and Consults at a New York City Hospital.

STUDY OBJECTIVE: The purpose of this study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical volume and emergency department (ED) consults across obstetrics-gynecology (OB-GYN) services at a New York City hospital. DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center in New York City. PATIENTS: Women undergoing OB-GYN ED consults or surgeries between February 1, 2020 and April 15, 2020. INTERVENTIONS: March 16 institutional moratorium on elective surgeries. MEASUREMENTS AND MAIN RESULTS: The volume and types of surgeries and ED consults were compared before and after the COVID-19 moratorium. During the pandemic, the average weekly volume of ED consults and gynecology (GYN) surgeries decreased, whereas obstetric (OB) surgeries remained stable. The proportions of OB-GYN ED consults, GYN surgeries, and OB surgeries relative to all ED consults, all surgeries, and all labor and delivery patients were 1.87%, 13.8%, 54.6% in the pre-COVID-19 time frame (February 1-March 15) vs 1.53%, 21.3%, 79.7% in the COVID-19 time frame (March 16-April 15), representing no significant difference in proportions of OB-GYN ED consults (p = .464) and GYN surgeries (p = .310) before and during COVID-19, with a proportionate increase in OB surgeries (p <.002). The distribution of GYN surgical case types changed significantly during the pandemic with higher proportions of emergent surgeries for ectopic pregnancies, miscarriages, and concern for cancer (p <.001). Alternatively, the OB surgery distribution of case types remained relatively constant. CONCLUSION: This study highlights how the pandemic has affected the ways that patients in OB-GYN access and receive care. Institutional policies suspending elective surgeries during the pandemic decreased GYN surgical volume and affected the types of cases performed. This decrease was not appreciated for OB surgical volume, reflecting the nonelective and time-sensitive nature of obstetric care. A decrease in ED consults was noted during the pandemic begging the question "Where have all the emergencies gone?" Although the moratorium on elective procedures was necessary, "elective" GYN surgeries remain medically indicated to address symptoms such as pain and bleeding and to prevent serious medical sequelae such as severe anemia requiring transfusion. As we continue to battle COVID-19, we must not lose sight of those patients whose care has been deferred.

Oocyte cryopreservation in the setting of a vascular endothelial growth factor (VEGF)-producing paraneoplastic syndrome: a case report and review of literature.

BACKGROUND: Many reproductive aged women with new oncologic diagnoses choose to undergo emergency oocyte or embryo cryopreservation prior to initiating potentially gonadal toxic oncologic therapies. Ovarian hyperstimulation syndrome (OHSS) is a potential complication of these treatments and can be particularly dangerous in these patients due to their underlying medical illness and by delaying lifesaving oncology treatment. This case report details a multipronged approach to OHSS prevention in a patient with a paraneoplastic syndrome defined by overproduction of vascular endothelial growth factor (VEGF), which is also primarily responsible for OHSS. CASE PRESENTATION: A 29 year old nulligravid woman was diagnosed with a rare multisystem paraneoplastic syndrome (Polyradiculoneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder and skin changes, known as POEMS) and presented for fertility preservation consultation prior to autologous stem cell transplant. She successfully underwent oocyte cryopreservation without complications due to aggressive OHSS prophylaxis with both a dopamine agonist and aromatase inhibitor during and after stimulation and a gonadotropin releasing hormone agonist (GnRH-A) for final oocyte maturation, without delay in her subsequent oncology treatment. CONCLUSIONS: This is the first report of a patient with POEMS undergoing controlled ovarian hyperstimulation (COH). Oocyte cryopreservation was successful and without complications due to a combination of prophylactic measures against OHSS (cabergoline, letrozole and GnRH-A trigger) and close collaboration between reproductive endocrinology and oncology. This case demonstrates the use of combined measures in targeting VEGF overproduction and OHSS risk during COH.

Gender inequality in leadership and academic rank in academic reproductive endocrinology programs.

PURPOSE: To identify gender differences in leadership and academic rank within academic reproductive endocrinology (REI) programs with fellowships in the USA. METHODS: Official institutional websites of the 2017-2018 American Board of Obstetrics and Gynecology (ABOG)-accredited reproductive endocrinology fellowship programs were reviewed, and gender representation at each leadership position and academic rank (Division and Fellowship Director and Full, Associate, and Assistant Professor) was recorded. Univariate comparisons were performed using Chi-square tests, with significance at p < 0.05. RESULTS: Among 49 ABOG-accredited reproductive endocrinology programs, 263 faculty were identified, 129 (49.0%) male and 134 (51.0%) female. Division directors were 69.3% male and 30.7% female (p = 0.006). Similarly, fellowship directors were 65.3% male and 34.6% female (p = 0.03). Full professors (n = 101) were more frequently male (70.3% vs. 29.7%, p < 0.001). There was no difference in gender among associate professors (n = 60, 51.7% male vs. 48.3% female, p = 0.79), while significantly more assistant professors were female than male (n = 102, 73.6% vs. 26.4%, p < 0.001). CONCLUSION: While a majority of residents in obstetrics and gynecology and half of reproductive endocrinology academic faculty are female, women are still underrepresented among leadership positions and full professors in academic reproductive endocrinology programs with fellowship programs.

Virological response after 6 week triple-drug regimens for hepatitis C: a proof-of-concept phase 2A cohort study.

BACKGROUND: Direct-acting antiviral drugs have a high cure rate and favourable tolerability for patients with hepatitis C virus (HCV). Shorter courses could improve affordability and adherence. Sofosbuvir and ledipasvir with ribavirin have high efficacy when taken for 8 weeks but not for 6 weeks. We assessed whether the addition of a third direct-acting antiviral drug to sofosbuvir and ledipasvir would allow a shorter treatment duration. METHODS: In this single-centre, open-label, phase 2A trial, we sequentially enrolled treatment-naive patients with HCV genotype 1 infection into three treatment groups: 12 weeks of sofosbuvir and ledipasvir; 6 weeks of sofosbuvir, ledipasvir, and GS-9669; or 6 weeks of sofosbuvir, ledipasvir, and GS-9451. Patients and investigators were not masked to treatment assignment. The primary endpoint was the propotion of patients with sustained viral response at 12 weeks after treatment completion (SVR12), assessed by serum HCV RNA concentrations lower than 43 IU/mL (the lower limit of quantification). We did an intention-to-treat analysis for the primary endpoint and adverse events. This study is registered with ClinicalTrials.gov, number NCT01805882. FINDINGS: Between Jan 11, 2013, and Dec 17, 2013, we enrolled 60 patients, and sequentially assigned them into three groups of 20. We noted an SVR12 in all 20 patients (100%, 95% CI 83-100) allocated to sofosbuvir and ledipasvir for 12 weeks; in 19 (95%, 75-100) of the 20 patients allocated to sofosbuvir, ledipasvir, and GS-9669 for 6 weeks (one patient relapsed 2 weeks after completion of treatment); and in 19 (95%, 75-100%) of the 20 patients allocated to sofosbuvir, ledipasvir, and GS-9451 for 6 weeks (one patient was lost to follow-up after reaching sustained viral response at 4 weeks). Most adverse events were mild and no patients discontinued treatment. Two serious adverse events occurred (pain after a post-treatment liver biopsy and vertigo), both unrelated to study drugs. INTERPRETATION: In this small proof-of-concept study, two different three-drug regimens that were given for 6 weeks resulted in high cure rates for HCV infection with excellent tolerability. Addition of a third potent direct-acting antiviral drug can reduce the duration of treatment required to achieve sustained viral response in patients with chronic HCV genotype 1 infection without cirrhosis. FUNDING: National Institute of Allergy and Infectious Diseases (NIAID), National Cancer Institute and Clinical Center Intramural Program, German Research Foundation, National Institutes of Health, Gilead Sciences.

Abnormal B cell memory subsets dominate HIV-specific responses in infected individuals.

Recently, several neutralizing anti-HIV antibodies have been isolated from memory B cells of HIV-infected individuals. Despite extensive evidence of B cell dysfunction in HIV disease, little is known about the cells from which these rare HIV-specific antibodies originate. Accordingly, we used HIV envelope gp140 and CD4 or coreceptor (CoR) binding site (bs) mutant probes to evaluate HIV-specific responses in peripheral blood B cells of HIV-infected individuals at various stages of infection. In contrast to non-HIV responses, HIV-specific responses against gp140 were enriched within abnormal B cells, namely activated and exhausted memory subsets, which are largely absent in the blood of uninfected individuals. Responses against the CoRbs, which is a poorly neutralizing epitope, arose early, whereas those against the well-characterized neutralizing epitope CD4bs were delayed and infrequent. Enrichment of the HIV-specific response within resting memory B cells, the predominant subset in uninfected individuals, did occur in certain infected individuals who maintained low levels of plasma viremia and immune activation with or without antiretroviral therapy. The distribution of HIV-specific responses among memory B cell subsets was corroborated by transcriptional analyses. Taken together, our findings provide valuable insight into virus-specific B cell responses in HIV infection and demonstrate that memory B cell abnormalities may contribute to the ineffectiveness of the antibody response in infected individuals.