Women's alcohol consumption and cumulative incidence of live birth following in vitro fertilization.

OBJECTIVE: The objective of this study was to determine the effect of alcohol consumption on outcomes among women undergoing in vitro fertilization (IVF). DESIGN: This study is a retrospective cohort study. SETTING: This study was performed in a private academically affiliated IVF center. PATIENTS: Patients included women presenting for their first IVF cycle from July 2004 through October 2012. INTERVENTION: Women completed self-administered questionnaires before their first IVF cycle, which included report of usual alcohol consumption. Women were categorized as non-drinkers, social drinkers, or daily drinkers, as well as by the number of drinks consumed per week. Competing risks analysis was used to calculate the cumulative incidence of live birth after 6 cycles stratified by alcohol consumption. MAIN OUTCOME MEASURES: Main outcome measures included spontaneous abortion, clinical pregnancy, and live birth following IVF. RESULTS: There were 591 (27.7%) non-drinkers, 1466 (68.7%) social drinkers, and 77 (3.6%) daily drinkers (total n = 2134). In the first cycle, compared to non-drinkers, daily drinkers had a twofold increased risk of spontaneous abortion (adjusted risk ratio [aRR] 2.2; 95% confidence interval [CI] 1.1-4.5) among all cycle starts, and while their risk of live birth was 30% lower (aRR 0.7; 95% CI 0.4-1.3), the sample size was small, and it was not significantly lower. By the end of 6 cycles, social drinkers and daily drinkers did not differ from non-drinkers in their cumulative incidence of live birth (56.1, 50.6, and 52.1%, respectively; both P ≥ 0.28). CONCLUSION: There was a trend towards lower risk of live birth among daily drinkers. Daily drinkers had an increased risk of spontaneous abortion in the first cycle, but the number of daily drinkers was small.

Investigating the Swimming of Microbial Pathogens Using Digital Holography.

To understand much of the behaviour of microbial pathogens, it is necessary to image living cells, their interactions with each other and with host cells. Species such as Escherichia coli are difficult subjects to image: they are typically microscopic, colourless and transparent. Traditional cell visualisation techniques such as fluorescent tagging or phase-contrast microscopy give excellent information on cell behaviour in two dimensions, but no information about cells moving in three dimensions. We review the use of digital holographic microscopy for three-dimensional imaging at high speeds, and demonstrate its use for capturing the shape and swimming behaviour of three important model pathogens: E. coli, Plasmodium spp. and Leishmania spp.

Increased frequency of occult fragile X-associated primary ovarian insufficiency in infertile women with evidence of impaired ovarian function.

BACKGROUND: The FMR1 premutation is associated with overt primary ovarian insufficiency (POI). However, its prevalence in women with occult POI (i.e. menstrual cycles, but impaired ovarian response) has not been examined. We hypothesized that both the FMR1 premutation and intermediate allele is more frequent in infertile women with occult POI than in controls, and that a repeat length cutoff might predict occult POI. METHODS: All subjects were menstruating women <42 years old and with no family history of unexplained mental retardation, autism or fragile X syndrome. Cases had occult POI defined by elevated FSH or poor response to gonadotrophin therapy (n = 535). Control subjects (n = 521) had infertility from other causes or were oocyte donors. Prevalence of the FMR1 premutation and intermediate alleles was examined and allele length was compared between controls and women with occult POI. RESULTS: The frequency of the premutation (7/535 versus 1/521; P< 0.05) and intermediate alleles (17/535 versus 7/521; P< 0.05) was higher in women with occult POI than in controls. The allele with the greatest number of CGG repeats was longer in women with occult POI compared with controls (32.7 ± 7.1 versus 31.6 ± 4.3; P < 0.01). A receiver operating characteristic curve examining repeat length as a test for occult POI had an area of 0.56 ± 0.02 (P < 0.01). A repeat cutoff of 45 had a specificity of 98%, but a sensitivity of only 5% to identify occult POI. The positive predictive value was only 21% for a fertility population that has ∼ 22% of its patients with occult POI. CONCLUSIONS: The data suggest that FMR1 premutations and intermediate alleles are increased in women with occult POI. Thus, FMR1 testing should be performed in these women as some will have fragileX-associated POI. Although the FMR1 repeat lengths were longer in women with occult POI, the data do not support the use of a repeat length cutoff to predict occult POI.

The cost of a hot drink scald.

Approximately 6400 children per year are admitted to UK hospitals for treatment of burns [National Burn Care Review Committee Report (NBCRC). Standards and Strategy for Burn Care: a review of burn care in the British Isles. 2001.]. This paper investigates the financial costs involved in the management of uncomplicated, minor paediatric scalds. Three cases (2-4% TBSA scalds) were studied to quantify consumables used, services required during management and costs obtained from appropriate Purchasing Departments and Directorate Accountants. Management in all cases involved a general anaesthetic for cleaning of wounds, application of BioBrane (Bertek Pharmaceuticals) and dressings, observation on Children's Ward and discharge following wound review at 48 h. The calculated mean average cost per case was pound1850. In the period 01/12/2002-30/11/2003, 144 children were admitted to Frenchay hospital, Bristol, for treatment of a minor burn or scald (less than 10%TBSA). This caseload is therefore estimated to currently cost pound266,400 per year. These findings may facilitate improved planning for future resource allocation and could also contribute evidence towards the cost effectiveness of prevention strategies.

Comparison of 0.2% ropivacaine and 0.25% bupivacaine for axillary brachial plexus blocks in paediatric hand surgery.

BACKGROUND: The purpose of this study was to compare the use of ropivacaine 0.2% with bupivacaine 0.25% for axillary brachial plexus block in children undergoing hand surgery. METHODS: In a double-blind, randomized study, 35 children undergoing hand surgery received axillary brachial plexus blocks with 0.5 ml.kg-1 of either 0.2% ropivacaine or 0.25% bupivacaine. Pain scores were noted at 0, 3, 6, 12 and 24 h after surgery. The time to first dose of codeine phosphate and the total doses of all analgesics given were recorded. RESULTS: There was no significant difference between the two groups in pain scores, the time to first dose of codeine phosphate or in analgesic requirements in the first 24 h. CONCLUSIONS: Ropivacaine 0.2% is as effective as bupivacaine 0.25% for axillary brachial plexus blocks in children undergoing hand surgery.

Advances in assisted reproductive technologies.

Several clinical advances in the field of assisted reproductive technology have improved the success rates of IVF. These advances include improvements in ovulation induction protocols, the introduction of recombinant gonadotropins, GnRH agonists, and, most recently, GnRH antagonists. ICSI has proved to be the most successful technique for the treatment of male infertility. The micromanipulation techniques developed in the embryology laboratory have facilitated advances in the field of preimplantation genetic diagnosis. Years of research in embryology laboratories have enabled the successful culture of embryos to the blastocyst stage. In the future, blastocyst transfer may have even more impact on overall success rates of IVF and multiple pregnancy rates. The field of assisted reproductive technologies has come a long way since the first successful IVF pregnancy. Future developments are expected to be equally dynamic as efforts continue to help couples conceive healthy pregnancies.

Implementation of the homeless families program: 1. Service models and preliminary outcomes.

The implementation and early outcomes of a large-scale, services-enriched housing program for homeless families are evaluated and examined across nine metropolitan sites. Differing models of case management and service access are described. Early reports on families' residential stability are high across all service models.

Implementation of the homeless families program: 2. Characteristics, strengths, and needs of participant families.

The characteristics and needs of homeless families participating in a large-scale services-enriched housing program are examined. Although not a representative sample, participants constitute one of the largest subsets of homeless families in the literature. Moreover, the sample, which encompasses nine sites, is focused on families with multiple problems who have been recurrently homeless. Differing constellations of needs and implications for service delivery are explored.

Micronized estradiol and progesterone: effects on carbohydrate metabolism in reproductive-age women.

OBJECTIVE: We assessed glucose utilization and insulin sensitivity in normal reproductive-age women after administration of micronized estradiol, micronized progesterone, or the combination of micronized estradiol and progesterone. METHODS: Hyperglycemic and euglycemic, hyperinsulinemic clamp studies were performed in normal, regularly cycling women both before and after a short course of either micronized estradiol (n = 8), micronized progesterone (n = 8), or micronized estradiol and progesterone (n = 7). All studies were performed after an overnight fast. Glucose and insulin were determined in the control period and then every 2-10 minutes in the hyperglycemic clamp studies and every 5-10 minutes in the euglycemic clamp studies. In the hyperglycemic clamp studies, hyperglycemia was maintained by a variable glucose infusion. In the euglycemic clamp studies, a primed 3-3H glucose infusion (25 microCi) followed by a 0.25-microCi continuous infusion was begun 120 minutes before initiation of the insulin infusion and variable glucose infusion. Samples for glucose radioactivity were measured during the control period and during the last 40 minutes of each step of the euglycemic clamp after establishment of a steady state. RESULTS: No differences in baseline glucose or insulin levels were detected in any of the study groups as compared with control. Glucose utilization as assessed by the hyperglycemic clamp model was not significantly different from control in the estradiol group, the progesterone group, or the group treated with the combination. In all of the treatment groups, no significant differences were noted under euglycemic, hyperinsulinemic conditions in glucose utilization, hepatic glucose production, or insulin sensitivity. CONCLUSIONS: Women of reproductive age do not demonstrate significant differences in basal levels of glucose or insulin when given a short course of micronized estradiol and progesterone, either alone or in combination. Under conditions of the hyperglycemic, hyperinsulinemic clamp, the pancreatic beta-cell response to hyperglycemia and glucose utilization is not significantly altered by exogenous administration of hormones. Conditions of the euglycemic, hyperinsulinemic clamp failed to elicit significant differences in glucose utilization and insulin sensitivity in any of the three treatment groups. These findings demonstrate that glucose homeostasis is not altered by the exogenous administration of natural hormones in reproductive-age women.

The value of increasing the dose of human menopausal gonadotropins in women who initially demonstrate a poor response.

OBJECTIVE: To evaluate the benefit of increasing the hMG dose in subsequent superovulation cycles for those individuals who demonstrate a poor response on up to three ampules of hMG daily. DESIGN AND SETTING: Retrospective analysis of all superovulation cycles at the University of Connecticut Health Center. PATIENTS: All women undergoing hMG therapy with IUI from January 1990 until December 1992. INTERVENTIONS: All patients were initially stimulated with up to three ampules of hMG daily. All patients who did not conceive on their first hMG cycle and demonstrated a poor response to hMG therapy were started on higher doses of hMG in an effort to obtain a good response. A maximum of eight ampules of hMG per day were used. MAIN OUTCOME MEASURES: Peak serum E2, the number of mature preovulatory follicles, and cycle fecundity were compared. RESULTS: The poor responders using up to three ampules daily had a peak E2 of 384 +/- 26 pg/mL (1,421 +/- 96 pmol/L), 1.4 +/- 0.1 mature follicles, and a cycle fecundity of 3.1% compared with an E2 of 900 +/- 83 pg/mL (3,330 +/- 307 pmol/L), 2.7 +/- 0.2 mature follicles, and a cycle fecundity of 4.3% when these poor responders had their dose increased to five or more ampules daily. Those individuals demonstrating a good response on less than or equal to three ampules of hMG daily had an average peak E2 of 1,159 +/- 41 pg/mL (4,288 +/- 151 pmol/L), 3.4 +/- 0.2 mature follicles, and a cycle fecundity of 16.5%. CONCLUSIONS: Despite significant improvement in peak E2 and the number of mature preovulatory follicles when the hMG dose was increased in poor responders, no significant increase in cycle fecundity was noted.

Evaluation of leuprolide acetate treatment on histopathology of uterine myomata.

OBJECTIVE: To determine if short-term, preoperative leuprolide acetate (LA) therapy alters the histologic appearance of uterine leiomyomata. DESIGN: Retrospective evaluation by a pathologist (who was blinded to patient history) of the histologic features of leiomyomata excised from 36 women, 12 who received preoperative LA and 24 age-matched controls. SETTING: Yale-New Haven Hospital, New Haven, Connecticut, from September 1989 to September 1990. MAIN OUTCOME MEASURE: The histologic specimens were evaluated for the presence of mitotic activity, cellular atypia, cellularity, and secondary changes including edema, fibrosis, calcification, hemorrhage, infarction, hyalinization, and vascular appearance. RESULTS: Of the 12 patients treated with LA, 10 (84%) demonstrated a reduction in uterine volume after 3 to 6 months of LA therapy. There was no difference in any of the histopathologic parameters evaluated between the LA-treated group and the untreated group. Exclusion of leiomyoma, which did not have a reduction in size during LA therapy, did not alter the analysis. Among patients treated with LA, those leiomyoma that did not respond to LA had a greater degree of hyalinization than those that responded. CONCLUSION: Reduction in uterine size by short-term LA therapy did not detectably alter histologic appearance of leiomyoma.

Principles of ultrasound.

Ultrasound is increasingly important as a diagnostic tool in the management of disorders of the female reproductive system. This paper reviews the basic principles of ultrasound to familiarize gynecologists with some of the currently available technology.

Laparoscopic management of ovarian cysts: an endocrinologist view.

The management of certain ovarian cysts has evolved from the traditional and often quite radical surgical approach to a more conservative approach. Much of this change can be attributed to the improvement in laparoscopic surgical technique. After a brief discussion of the differential diagnosis and clinical presentation of ovarian cysts, ultrasonographic features of certain ovarian cysts will be reviewed. Certainly the ability to characterize cysts ultrasonographically has facilitated gynecologists' ability to predict the neoplastic potential of a cyst and therefore to justify the more conservative approach. The various techniques of laparoscopic ovarian cyst aspiration, fenestration, and cystectomy will then be described.

Early pituitary desensitization and ovarian suppression with leuprolide acetate is associated with in vitro fertilization-embryo transfer success.

OBJECTIVE: To determine if the timing of the onset of pituitary desensitization and ovarian suppression using follicular phase leuprolide acetate (LA) is associated with in vitro fertilization-embryo transfer (IVF-ET) success for pregnancy. DESIGN: Retrospective series of IVF patients undergoing pituitary desensitization and ovarian suppression before beginning controlled ovarian hyperstimulation for IVF-ET. SETTING: Tertiary infertility practice. PATIENTS: Seventy-eight women for 80 cycles began LA on day 1 of their menstrual cycle. After 11 days of LA, 47 (59%) cycles in group I had suppressed serum estradiol (E2) levels less than 40 pg/mL, in contrast to 33 (41%) cycles in group II not adequately suppressed, thereby requiring additional days to achieve suppression. INTERVENTIONS: Controlled ovarian hyperstimulation was started when patients were satisfactorily suppressed, i.e., E2 less than 40 pg/mL. MAIN OUTCOME MEASURE(S): Mean E2 response, ampules of human menopausal gonadotropin, cancellation rates, number of oocytes retrieved, fertilization rates, and pregnancy rates (PRs) per cycle were examined between groups I and II. RESULTS: Group I demonstrated a greater mean E2 response on the day of human chorionic gonadotropin 1,735 pg/mL versus 1,470 pg/mL (P = 0.008), a greater fertilization rate 64% versus 55% (P = 0.02), and a higher PR per cycle 34% versus 12% (P = 0.036) compared with group II. CONCLUSIONS: Women who achieved desensitization-suppression within 11 days of initiating LA demonstrated a more favorable outcome for IVF-ET than those who did not.

Linear salpingostomy for ectopic pregnancy.

Linear salpingostomy is the procedure of choice for management of uncomplicated ectopic gestations if certain constraints are met. The procedure is straightforward and may be performed by laparotomy. However, laparoscopic salpingostomy is becoming the preferred approach. Additionally, laparoscopy decreased operative time, hospital stay, and patient recovery time. Postoperatively, patients should be observed with weekly assessment of beta-hCG titers to ensure complete resorption of any viable trophoblast. Failure of resorption may result in a persistent ectopic pregnancy. Reproductive outcome is preserved in most patients, with intra-uterine pregnancy rates that approach 60%. Recurrent ectopic gestation rates of 15% are acceptable in view of subsequent close surveillance in women who have undergone previous salpingostomies, which also facilitates earlier diagnosis.