Physicians' attitudes towards using elective oocyte cryopreservation to accommodate the demands of their career.

PURPOSE: Among medical professionals, there appears to be a significant lack of knowledge about oocyte cryopreservation. Medical professionals may be potential candidates for elective oocyte cryopreservation due to the demands and commitments of medical training. There is a paucity of data on this topic among medical professionals. The aim of this study was to assess knowledge, understanding, and beliefs towards elective egg freezing among medical professionals to assess whether they are potential candidates for elective egg freezing. METHODS: This is a cross-sectional descriptive study in a university-based training program. All medical students, residents, fellows, and faculty were included. An online survey was emailed to potential participants. It included demographic questions regarding childbearing decision-making factors, fertility knowledge, and attitudes towards using elective oocyte cryopreservation. RESULTS: A total of 1000 emails were sent. Of those, 350 completed surveys were received. On average, 33% of responders provided a correct answer to each fertility knowledge question. The duration of training and the heavy workload with long duty hours were the most common influencing factors when deciding the timing of childbearing. Overall, 65% of the male and female responders were concerned about their future fertility. Among those women who had future fertility concerns, 8% were not aware of egg freezing as a fertility option and wished they had had an opportunity to freeze their eggs at an earlier time. CONCLUSIONS: Physicians' childbearing decisions can be affected by the demands of their careers. Elective oocyte cryopreservation could be considered an option for family planning. Educational sessions and awareness programs are needed to provide information about available fertility preservation options, which can potentially decrease the rate of regret.

Misdiagnosis of cervical ectopic pregnancy.

PURPOSE: To determine the presenting symptoms as well as the frequency and reasons for the delayed diagnosis of cervical ectopic pregnancy (CEP) in order to increase detection and prevent treatment delay. METHODS: Retrospective case series of 15 women treated for CEP from January 1997 through December 2008 at a university teaching hospital. RESULTS: Fifteen patients were treated for CEP during the study period. Eight patients presented to the emergency department, of which 6 (75%) were initially misdiagnosed. The most common misdiagnosis was threatened miscarriage (n = 5). All patients with accurately diagnosed CEP presented with heavy vaginal bleeding; those misdiagnosed reported mild to moderate vaginal bleeding. Three of six patients misdiagnosed did not have an ultrasound performed upon presentation, and three patients had an ultrasound report not suggestive of CEP. CEP was diagnosed on follow-up ultrasound, delaying treatment 1-4 days. CONCLUSIONS: Misdiagnosis of CEP upon initial presentation is a common occurrence. Transvaginal ultrasound performed by a qualified practitioner may increase detection and prevent treatment delay.

Benzo(a)pyrene causes PRKAA1/2-dependent ID2 loss in trophoblast stem cells.

Benzo(a)pyrene (BaP), a cigarette smoke component, is metabolized to diol esters (BPDE) that bind to DNA and form mutagenic BPDE-DNA adducts. BaP activates stress enzymes including stress-activated protein kinase/jun kinase (MAPK8/9) in embryos, AMP-activated protein kinase alpha1/2 subunits (PRKAA1/2) in somatic cells, and inhibits the proliferation of trophoblast cell lineages. The loss of transcription factor inhibitor of differentiation (ID)2 is required for the initial differentiation of mouse trophoblast stem cells (TSC) in implanting mouse embryo to produce the first placental hormone, chorionic sommatomammotropin (CSH)1. Here we demonstrate that BaP activates PRKAA1/2 and causes ID2 protein loss in TSC in a time- and dose-dependent manner. Although PRKAA1/2 was activated at low BaP doses, PRKAA1/2-dependent ID2 protein loss occurred at a dose that was similar to the threshold that results in a significant decrease in TSC accumulation and decreased fraction of proliferating TSC. This suggests a possible relationship between stress-induced declines in cell accumulation and stem cell differentiation when BaP levels are high. The threshold BaP dose that induces significant ID2 loss is in the range of a 2-3 pack/day habit, suggesting that this mechanism may be involved with implantation failure in smoking women.

The role of hysteroscopic biopsy in obtaining specimens for cytogenetic evaluation in missed abortion prior to suction dilatation and curettage.

AIM: To estimate whether hysteroscopic-guided biopsy of gestational sac(s) in first trimester missed abortion increases the sensitivity of detecting aneuploidy compared to washing and careful specimen collection after suction dilatation and curettage (D&C). MATERIALS AND METHODS: Thirty-five patients with first trimester missed abortion of which 25 underwent 29 suction D&Cs and 10 underwent hysteroscopic-guided biopsy of 12 gestational sacs prior to suction D&C. The karyotype of products of conception specimens were analyzed by G-banding techniques. RESULTS: The percentage of specimens with 46,XX, 46,XY and aneuploidy were not significantly different in the hysteroscopic group [4/12 (33.3%), 3/12 (25.0%) and 5/12 (41.7%)] compared with the D&C group [8/29 (27.6%), 5/29 (17.2%) and 16/29 (55.2%)]. Although parity differed significantly between groups, it did not hold in a multivariable logistic regression model built to estimate whether the parity, gestational age and specimen collection method predict the likelihood of detecting a 46,XX chromosomal complement. CONCLUSIONS: Direct hysteroscopic-guided biopsies of gestational sac(s) do not increase the sensitivity of conventional cytogenetics for detecting aneuploidy when compared to specimens obtained by washing and microscopic identification of villi or fetal tissue after suction D&C.

Elective egg freezing: what is the vision of women around the globe?

AIM: The interest in oocyte cryopreservation (OC) for nonmedically indicated reasons is increasing. Knowing women's beliefs and knowledge from various geographic regions could help providers to understand the similarities and differences that could facilitate proper counseling. MATERIALS & METHODS: Articles about social egg freezing published over the past 18 years were extracted from the literature. RESULTS: We demonstrated that there are common rationales toward OC among women in the USA and other countries. The ultimate goal was to prolong fertility. The most commonly reported reasons were aging, lack of partner, career and financial status. CONCLUSION: The beliefs and rationales toward elective OC among women in the USA and other countries are consistent.

Ureterocele misdiagnosed as pelvic inflammatory disease in an adolescent.

BACKGROUND: Acute pelvic pain in reproductive-aged women presents a diagnostic challenge. In the case that follows, we report the management of a patient initially misdiagnosed with pelvic inflammatory disease. CASE: A 14-year-old nulligravida who presented with acute pelvic pain was diagnosed with pelvic inflammatory disease and possible tuboovarian abscess. Despite treatment with broad-spectrum parenteral antibiotics, the patient remained febrile with persistent pelvic pain. Com-puted tomography revealed a duplicated right collecting system with the upper pole of the kidney drained by a markedly dilated, tortuous ureter. An infected ureterocele was identified and incised during cystoscopy. CONCLUSION: An infected ureterocele was misdiagnosed as pelvic inflammatory disease. In patients with acute pelvic pain who do not respond to appropriate interventions, it is important to consider alternative diagnoses.

Placement of a permanent birth control device at a university medical center.

OBJECTIVE: To determine the Essure placement failure rate and analyze factors associated with failure in an urban, nonstudy population at a university medical center. STUDY DESIGN: A retrospective study was conducted of women who underwent attempted Essure hysteroscopic sterilization at the Detroit Medical Center (DMC) from January 1, 2003, to June 30, 2007. RESULTS: There were 316 Essure procedures attempted at the DMC from January 2003 through June 2007. Of the 316 attempted procedures, there were 22 device placement failures and 3 documented post-Essure pregnancies. Of the 22 placement failures, 11 were attributed to difficulty visualizing the tubal ostia. Other causes of failure included device malfunction, uterine perforation, tubal perforation, expulsion of the device, tubal spasm, tubal ostia too large for the device and unspecified. Difficulty visualizing the ostia (p < 0.001) and a longer procedure time (p = 0.008) were significantly associated with failure. CONCLUSION: The rate of successful placement of the Essure permanent birth control device at the DMC is 92.1%, with a post-Essure pregnancy rate of 0.95%. The majority of placement failures may be attributed to difficulty visualizing the tubal ostia.

The effect of paternal age on outcome in assisted reproductive technology using the ovum donation model.

OBJECTIVE: To determine the effect of paternal age (PA) on implantation and live birth rates in an ovum donation program. DESIGN: Retrospective study. METHODS: A total of 237 ovum donor cycles were reviewed. All donors were stimulated with gonadotrophin-releasing hormone agonist (GnRHa) downregulation and human menopausal gonadotropin. Recipients were prepared with GnRHa downregulation and estradiol/progesterone replacement. Embryo transfers were done at blastocyst stage under ultrasound guidance. The effect of PA on outcome was analyzed controlling for number and grade of embryos transferred. Outcome was not pregnant (NP), spontaneous abortion (SAb), and live births (LBs). RESULTS: Of the 237 cycles, 36 resulted in NP (15.2%), 39 in SAb (16.5%), and 162 in LB (68.4%). The mean PA (MPA) was significantly different between the 3 groups, and implantation rates also declined with increasing MPA (P =.01). Overall, the mean number and grade of embryos transferred were 2.1 ± 0.4 and 1.3 ± 0.4, respectively. The NP couples had more embryos of poorer grade than SAb and LB couples (P <.05), but there were no differences between SAb and NP couples (P >.85). Logistic regression analysis demonstrated a 26% lower odds of live birth rate with each 5-year increase in PA (P =.01). CONCLUSIONS: Advanced PA has an adverse impact on assisted reproductive technology (ART) outcome. After adjusting for number and embryo grades transferred, a younger PA has a more favorable ART outcome.

Conservative management of cervical ectopic pregnancy: utility of uterine artery embolization.

OBJECTIVE: To evaluate the use of uterine artery embolization (UAE) in conjunction with methotrexate in the conservative treatment of cervical ectopic pregnancy (CEP). DESIGN: Case series. SETTING: Tertiary-care university hospital. PATIENT(S): Cases of CEP treated at Hutzel Women's Hospital between January 1997 and December 2008. INTERVENTION(S): Multidose methotrexate treatment with or without UAE and intra-amniotic potassium chloride injection (KCl). MAIN OUTCOME MEASURE(S): Beta-human chorionic gonadotropin level, vaginal bleeding, length of hospital stay, and future fecundity. RESULT(S): A retrospective analysis of 15 patients with CEP treated conservatively using methotrexate with leucovorin rescue (MTx/Leu) alone (group 1, five cases), with UAE as an adjunctive therapy (group 2, six cases), or also having received intra-amniotic KCl before UAE (group 3, four cases) is reported. There was no significant difference in age, parity, or gestational age among treatment groups. The median ß-hCG level on presentation was 9,606 mIU/mL for group 1, 26,516 mIU/mL for group 2, and 130,464 mIU/mL for group 3. The difference was found to be statistically significant. No patients developed complications from UAE. Of the 10 patients who underwent UAE, 2 subsequently had confirmed viable pregnancies. CONCLUSION(S): Uterine artery embolization with methotrexate is an option for minimally invasive intervention in the treatment of CEP.

Trends in sterilization since the introduction of Essure hysteroscopic sterilization.

STUDY OBJECTIVE: To investigate trends in sterilization in women at the Detroit Medical Center, Michigan (DMC), since the introduction of Essure hysteroscopic sterilization. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Outpatient surgery center and university teaching hospitals. PATIENTS: Women who underwent interval sterilization procedures at the DMC (Hutzel Women's Hospital, Sinai-Grace Hospital, and the Berry Center) and postpartum sterilization procedures at Hutzel Women's Hospital between January 1, 2002, and December 31, 2007. INTERVENTIONS: Permanent sterilization procedures including minilaparotomy tubal ligation, laparoscopic sterilization, Essure hysteroscopic sterilization, and postpartum tubal ligation performed at the time of cesarean section or after vaginal delivery. MEASUREMENTS AND MAIN RESULTS: In all, 5509 permanent sterilization procedures were performed in the 6 years between January 1, 2002, and December 31, 2007, at the DMC facilities analyzed: 2484 interval sterilization procedures at Hutzel Women's Hospital, Sinai-Grace Hospital, and the Berry Center, and 3025 postpartum tubal ligations at Hutzel Women's Hospital. From 2002 through 2007, the decrease in laparoscopic sterilizations from 97.9% to 48.5% of all interval sterilization procedures corresponded significantly with the increase in Essure hysteroscopic sterilizations from 0.0% to 51.3% (p <.001). Postpartum tubal ligations performed after vaginal delivery also decreased significantly during the study period from 7.9% to 3.3% of all vaginal deliveries (p <.001) while the percentage of tubal ligations performed at the time of cesarean section remained constant (p =.051). CONCLUSION: At the DMC facilities analyzed from January 1, 2002, through December 31, 2007, a significant decrease occurred in the percentage of laparoscopic sterilizations and postpartum tubal ligations performed after vaginal delivery. Of the interval sterilizations performed, the percentage of Essure hysteroscopic sterilizations increased significantly from 0.0% to 51.3% of all procedures. Since the approval of Essure hysteroscopic sterilization in November 2002, this minimally invasive method of hysteroscopic sterilization has increased in popularity at the DMC.

Karyotyping twins in early pregnancy loss: a novel approach of obtaining specimens to avoid maternal contamination.

OBJECTIVE: To test for chromosomal abnormalities in a missed abortion involving a twin gestation. DESIGN: Case report. SETTING: University-based infertility practice. PATIENT(S): A 37-year-old G3P0030 with recurrent abortions presented with a fourth missed abortion involving a twin gestation in the first trimester. INTERVENTION(S): Under anesthesia, hysteroscopy was performed and specimens obtained for karyotyping from each twin. MAIN OUTCOME MEASURE(S): Karyotype of each twin. RESULT(S): The karyotype of the conceptus on the left was 46,XY and that on the right was 46,XX. CONCLUSION(S): Direct hysteroscopic biopsies can successfully differentiate the karyotypes of each twin of a missed abortion.

Post-Essure hysterosalpingography compliance in a clinic population.

STUDY OBJECTIVE: To determine the follow-up rate for post-Essure hysterosalpingography (HSG) in a non-study, general clinic population in an urban environment. DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Eighty-three University Health Center (UHC) patients who underwent attempted placement of the Essure permanent birth control device at the ambulatory surgery center at Hutzel Women's Hospital from January 2003 through June 2007. INTERVENTION: Hysteroscopic placement of the Essure permanent birth control device. MEASUREMENTS AND MAIN RESULTS: Placement of the Essure permanent birth control device was attempted in 83 patients, of which 79 were successfully completed (95.2%). Of the 79 patients, 10 underwent post-Essure HSG (12.7%). HSG was performed 3 to 6 months after placement of the Essure device. Bilateral tubal occlusion was documented in all 10 patients. CONCLUSION: Despite preoperative and postoperative counseling, the follow-up rate for post-Essure HSG for this clinic population was only 12.7%. For those in whom HSG was performed, bilateral tubal occlusion was confirmed in all. Steps or approaches to promote compliance with postprocedural confirmation of tubal occlusion should be utilized to improve future follow-up rates.

Sequential use of thrombolytic agents for thrombosed mitral valve prosthesis during pregnancy.

Thrombolytic therapy has gained popularity as an alternative to surgery in the treatment of prosthetic heart valve thrombosis. We report on the sequential use of streptokinase followed by recombinant tissue type plasminogen activator (rt-PA) for the treatment of a thrombosed prosthetic mitral valve in a pregnant woman at 26 weeks of gestation. Although thrombolysis was unsuccessful, the patient carried till 34 weeks of gestation and delivered by cesarean section a live newborn with an uneventful postpartum course. Based on our case and on what has been previously described in the literature, thrombolytic therapy should be considered as an option in the management of hemodynamically unstable pregnant patients with prosthetic valve thrombosis. When a single agent proves insufficient, combination therapy should be considered as it might provide hemodynamic stability and improvement in cardiac function that would allow patients at a high surgical risk to carry their pregnancy to viability.