Faculty Bibliography

BACKGROUND To minimize the potential for harmful inheritable conditions, donors are rigorously screened according to standard guidelines, yet such guidelines may not be sufficient to exclude egg donors with certain known inheritable conditions. We compared universal screening of oocyte donors with Tay-Sachs, Fragile X, karyotype and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) versus standard American Society of Reproductive Medicine (ASRM) guidelines that do not include such testing. METHODS In this 12 year retrospective cohort study, results of enhanced universal screening of all anonymous oocyte donor candidates from 1997 to 2008 at a university hospital oocyte donation program were reviewed. Primary outcomes were the frequency of oocyte donor candidates excluded as a result of enhanced universal screening (Tay-Sachs, Fragile X, karyotypic analysis and MMPI-2) versus basic screening according to ASRM guidelines. RESULTS Of 1303 candidates who underwent on-site evaluation, 47% passed the screening process, 23% were lost to follow-up and 31% were excluded. Genetic and psychological factors accounted for the most common reasons for candidate exclusion. Enhanced genetic screening excluded an additional 25 candidates (19% of all genetic exclusions) and enhanced psychological screening excluded an additional 15 candidates (12% of all psychological exclusions). Altogether enhanced screening accounted for 40 candidates (10%) of the total pool of excluded candidates. CONCLUSIONS Although our study is limited by its retrospective nature and center-specific conclusions, we show that enhanced comprehensive screening can exclude a significant number of candidates from an oocyte donor program and should be encouraged to assure optimal short-term and long-term outcomes for pregnancies achieved through oocyte donation

OBJECTIVE: To describe a case of chronic isolated fallopian tubal torsion in a woman without identifiable risk factors and discuss the difficulty of diagnosis. DESIGN: Case report. SETTING: University-based reproductive endocrinology and infertility center. PATIENT(S): Multiparous woman with no risk factors of torsion of the fallopian tube presenting with chronic right lower quadrant pain. INTERVENTION: Laparoscopy with subsequent salpingectomy. MAIN OUTCOME MEASURE(S): Resolution of symptoms. Preservation of ovary and future fertility. RESULT(S): Patient's symptoms resolved after salpingectomy. Information regarding future fertility is pending. CONCLUSION(S): Isolated fallopian tube torsion is rare and often difficult to diagnose. Despite ultrasonographic evidence of arterial and/or venous flow to the adnexa, adnexal torsion cannot be ruled out. If clinical suspicion for torsion is high, early diagnosis and treatment via laparoscopy is encouraged as a means of preserving fallopian tube integrity and maintaining fertility, especially in reproductive-age women

To assess whether the use of extended embryo culture can reduce the incidence of high-order multiple gestations, a retrospective analysis of 7,418 fresh ETs performed in a university-based IVF clinic from 1997-2003 was conducted, comparing program results before and after institution of a protocol to select patients for extended culture of in vitro fertilized embryos. The incidence of triplet pregnancies was significantly reduced in patients at highest risk for high-order multiple gestations, i.e., those at <35 years of age (16.8% versus 6.8%), those at 35-37 years of age (13.0% versus 5.6%), and recipients of donated oocytes (11.2% versus 4.5%)

BACKGROUND: We sought to determine to what extent intraoperative salvaged red blood cells (RBC) might theoretically reduce exposure to appropriately transfused allogenic erythrocytes in Cesarean delivery patients. METHODS: Medical records of Cesarean delivery patients requiring blood transfusions from January 1, 1992 to June 30, 1996 and June 1, 1998 to June 30, 2003 were reviewed. For each patient, we calculated the number of allogenic RBC units that could have theoretically been avoided had intraoperative autotransfusion been performed, based upon estimated blood loss, preoperative hematocrit, and the amount of retrieved blood needed to yield a single RBC unit. RBC transfusion appropriateness was determined using the recommended guideline of transfusing RBCs if the hemoglobin is <7 gm/dL in a patient with continuing bleeding. RESULTS: A small percentage of Cesarean delivery patients (1.8%) received blood product transfusions. Of 207 patients receiving blood transfusions, salvaged erythrocytes could have theoretically decreased exposure to allogenic RBCs in 115 (55.6%) patients. Only 75.7% of these 115 patients were appropriately transfused with erythrocytes. CONCLUSION: Theoretically, based on best, average, and worst RBC salvage recovery calculations, 25.1%, 21.2%, or 14.5% of the appropriately transfused patients, respectively, could have completely avoided allogenic RBC transfusion

OBJECTIVE: To determine the influence of body mass index (BMI) on in vitro fertilization (IVF) outcome by studying a large cohort of good-prognosis IVF patients. STUDY DESIGN: This was a retrospective study at a university-based IVF center evaluating 920 good-prognosis patients (< 40 years, all with normal ovarian reserve) undergoing luteal leuprolide down-regulation and gonadotropin stimulation for IVF and evaluating IVF outcome, including response to stimulation, cancellation rates and pregnancy outcome based on obesity status. RESULTS: One hundred forty-eight (16.09%) patients were classified as obese (BMI > 27). Obese patients were more likely to undergo cancellation (14.9% vs. 9.1%, p = 0.03) when compared to nonobese patients. There was no difference in the amount of gonadotropins required. Obese patients had fewer oocytes retrieved and lower peak estradiol levels than did nonobese patients. In spite of the lower response, the clinical pregnancy rates per retrieval were no different (56.4% for both groups). CONCLUSION: Obese patients undergoing IVF are more likely to undergo cancellation. If cancellation does not occur, obesity confers a risk of a lower stimulation response. Despite this, the clinical pregnancy rates (per retrieval) were no different in obese patients and nonobese patients

PURPOSE: In this study we review our experience with a day 2 start, 'Co-Flare' protocol analyzing the flare response as a predictor of outcome in patients with a history of a poor response. METHODS: This study was conducted at a university based IVF Center. A total of 564 patient cycles over a 2.5-year time frame in patients that had either elevated FSH levels or a previous poor response to conventional leuprolide acetate down-regulated stimulation were retrospectively analyzed. These patients were treated with our co-flare protocol (1.0 mg of leuprolide acetate administered on day 2 and decreased on day 5 to 0.5 mg; gonadotropins initiated on day 3). We analyzed the initial flare response and the outcome for these patients. RESULTS: A total of 564 patients attempted to initiate an IVF cycle. The patients mean age was 39.4+/-3.7 years. Of the 450 cycles that started, the outcomes were as follows: 24% (108/450) cancellation, 20.4% (92/450) clinical pregnancy per initiated cycle, and a 14.0% delivery rate per initiated cycle. Patients with an estradiol flare that doubled were less likely to have cycles cancelled (13.6% vs. 35.6%, P < 0.01), but no differences were noted in pregnancy outcome if the cycle was not cancelled once the patient made it to retrieval. CONCLUSIONS: We have demonstrated an overall 14.0% delivery rate per initiated cycle in these 'poor prognosis' patients. While the initial flare response (as indicated by a doubling of the estradiol by the second day of stimulation) was indicative of a better stimulation, no difference in pregnancy outcome was seen if the patient underwent retrieval