Faculty Bibliography

OBJECTIVE: To analyze the effect of a previous donor oocyte cycle on the outcome of subsequent attempts. DESIGN: Retrospective study. SETTING: Oocyte donation program at The New York Hospital/Cornell Medical Center. PATIENT(S): Two hundred sixty-seven patients undergoing 354 fresh cycles of oocyte donation. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical outcomes were divided into groups based on the attempt number of each cycle for each patient. Results were calculated for each recipient cycle. RESULT(S): A clinical pregnancy rate of 56.2% and ongoing pregnancy/delivery rate per retrieval of 50.3% were noted. No statistically significant differences in clinical outcomes were found between the first, second, and third attempts. A significant increase was noted in the ongoing pregnancy/delivery rate per recipient cycle for the second attempt in those patients who had a delivery after the first attempt compared with those who did not. CONCLUSION(S): We demonstrated an overall clinical pregnancy rate of 56.2% and an ongoing pregnancy/delivery rate of 50.3% per retrieval. Outcome for the second attempt was associated with success or failure during an initial attempt at oocyte donation

OBJECTIVE: To promote an even temporal distribution of patients starting IVF cycles at our center, patients undergoing GnRH agonist (GnRH-a) suppression frequently delay the start of gonadotropin stimulation. Our objective was to analyze the effect that the delay of initiation of gonadotropin stimulation has on outcome parameters in this population. DESIGN: Retrospective analysis. SETTING: A tertiary referral reproductive medicine unit. PATIENT(S): Patients undergoing IVF cycles on long GnRH-a protocols. INTERVENTION(S): Patients were treated with either a 'standard-dose' or 'low-dose' leuprolide acetate protocol initiated in the mid-luteal phase. MAIN OUTCOME MEASURE(S): Delay time, clinical pregnancy rate, ongoing pregnancy rate, cancellation rate. RESULT(S): Analysis of the overall group revealed associations between stimulation delay and decreases in stimulation duration and the number of gonadotropin ampules administered. Weighted linear regression analyzes revealed statistically positive relationships between delay time and both clinical pregnancy rates and ongoing pregnancy rates, despite a positive relationship between delay time and cancellation rates. Analysis of the standard-dose and low-dose subgroups revealed that the enhancement of pregnancy rates was attributable primarily to patients in the standard-dose protocol. CONCLUSION(S): Delay of gonadotropin stimulation while patients are receiving GnRH-a therapy allows for increased clinic efficiency. There appears to be an enhancement of clinical and ongoing pregnancy rates for the standard-dose leuprolide acetate protocol that is associated with stimulation delay

OBJECTIVE: To evaluate the outcomes of IVF and the incidence of ovarian hyperstimulation syndrome (OHSS) after discontinuing gonadotropin therapy in patients at risk of developing OHSS by delaying hCG administration until a drop in serum E2 levels was observed. DESIGN: Retrospective study. SETTING: IVF program at a university center. INTERVENTIONS: Gonadotropin administration was withheld in 22 patients (group 1) when their serum E2 level was > or = 3,000 pg/mL (conversion factor to SI unit, 3.671). Patients continued GnRH analogue injections daily, and hCG was administered when serum E2 levels dropped to < or = 3,000 pg/mL. Outcomes were compared with 26 patients (group 2) in whom embryo transfer was canceled and all embryos cryopreserved for transfer during a subsequent unstimulated cycle. MAIN OUTCOME MEASURES: Outcomes of IVF and incidence of OHSS were compared in both groups of patients. In group 1, follicular and hormonal parameters before and after the coasting interval were compared in pregnant versus nonpregnant patients. In addition, serum hormonal profiles were evaluated daily during the coasting period to determine the effects of gonadotropin withdrawal. RESULTS: Although the mean number of oocytes retrieved was significantly higher in group 2, fertilization rates, miscarriage rates, delivery rates/stimulation cycle, and the incidence of OHSS did not differ significantly between the two groups. CONCLUSION: Withholding gonadotropin administration is an effective alternative to prevent the development of severe OHSS in a high-risk population. Although the risk of cancellation cannot be completely eliminated, this strategy can provide a high pregnancy rate without the need to repeat multiple frozen-thawed cycles

Melanoma of the vulva is uncommon, and melanoma of the vagina is rare. The overall prognosis is poor and worse than for cutaneous melanomas. This appears to relate to diagnosis of genital lesions at an advanced stage. In a 28-year, retrospective analysis at Columbia Presbyterian Medical Center, there were 10 cases of primary melanoma of the lower genital tract. Seven cases of vulvar melanoma and three cases of vaginal melanoma were reviewed. All cases were in elderly women, and all were diagnosed at an advanced stage. The outcome in general was poor, regardless of therapy. This condition must be recognized earlier to afford an optimal patient outcome. Elderly women must undergo regular gynecologic care, and suspicious pigmented lesions must be biopsied

The purpose of this study was two-fold. The first was to extend the previously developed and published nomograms of the fetal lateral ventricles from 18 weeks back to 14 weeks of gestation using transvaginal sonography, and, second, to test the performance of the nomograms by plotting the measurements of 36 fetuses whose transabdominal and/or qualitative transvaginal scans were suspicious for ventriculomegaly. In all the cases in which postnatal confirmation of the diagnosis was possible, prenatal ultrasound correctly identified the lesion. Although a total of nine nomograms was created, the clinically meaningful measurements were: the height of the occipital horn on the parasagittal plane, and the two ratios derived from the measurements performed on the parasagittal plane. In conclusion, the transvaginally generated nomograms were useful for the correct identification of fetuses with ventriculomegaly

Nomograms of the fetal lateral ventricles were obtained by the transvaginal approach. Three hundred low-risk women with no sonographically apparent fetal anomalies were scanned prospectively in a cross-sectional study. Three measurements in the parasagittal plane, three in the midline coronal plane, and two in the posterior coronal plane were used to generate seven nomograms. Two additional nomograms reflecting two calculated ratios also were created. A mean regression line and the 5th and 95th confidence intervals were determined. We concluded that transvaginal sonography of the fetal brain generates images of both hemispheres of good enough resolution to allow several precise and reproducible measurements

Increasing use of cocaine among pregnant women has been reported. This study was conducted to determine the prevalence of positive urine toxicologic screens for cocaine and other substances of patients admitted to the Sloane Hospital for Women. Urine samples were obtained from 509 women admitted to the delivery suite. The overall prevalence of cocaine was 10% (n = 51). Cocaine use was 10 times more prevalent in the clinic population (14%) than in the private population, (1.4%). In addition, women whose urine samples were positive for cocaine were more likely to have no prenatal care, previous induced abortions, to be human immunodeficiency virus-positive, and admitted previous use of cigarettes, alcohol, cocaine, and other drugs. Amphetamines were detected in 13% (n = 65) of patients. However, the screens did not distinguish between metabolites of amphetamines and other drugs such as cold medications. The medical history alone predicted only 37% (n = 19) of the cocaine-positive screens and none of the amphetamine-positive screens

Anti-idiotypic antibodies are antibodies against the antigenic determinants (idiotypes) of an antibody's antigen-binding region. Anti-idiotypes can bind near (Ab2 gamma) or away (Ab2 alpha) from the antigen-combining site or can carry the internal image of the antigen (Ab2 beta). Idiotypes and anti-idiotypes have been described in T- and B-cell systems. They have been used in basic research to purify and characterize receptors and ligands against receptors, to treat tumors, to make vaccines and to diagnose and suppress the immune response. In experimental myasthenia gravis anti-idiotypes protect animals against the disease, block idiotype binding and share idiotypic specificities