Prospective analysis of progesterone exposure in programmed single thawed euploid embryo transfer cycles and outcomes
Hirschberg, Carly I; Blakemore, Jennifer K; Fino, Elizabeth; Grifo, Jamie A
PURPOSE/OBJECTIVE:In the era of personalized medicine and the increased use of frozen embryo transfer (FET), assay of the endometrium's receptivity prior to transfer has gained popularity, especially among patients. However, the optimal timing for single thawed euploid embryo transfers (STEET) in a programmed FET has yet to be determined Mackens et al. (Hum Reprod. 32(11):2234-42, 2017). We sought to examine the outcomes of euploid FETs by length of progesterone (P4) exposure. METHODS:Prospective cohort study of programmed FETs of single euploid embryos between June 1, 2018, and December, 18, 2018, at our center. Subjects reported the exact start time for initiating progesterone. The transfer time was noted to calculate the primary independent variable, duration of progesterone exposure. Statistical analysis included ANOVA and Spearman's rho correlation, with pâ€‰<â€‰0.05 considered significant. RESULTS:Inclusion criteria were met for 253 programmed STEET cycles in the analysis. There was no significant difference in P4 duration when comparing outcome groups (112.8â€‰Â±â€‰3.1 ongoing pregnancy (OP), 112.4â€‰Â±â€‰4.4 spontaneous abortion (SAB), 111.6â€‰Â±â€‰1.7 biochemical pregnancy (BP), 113.9â€‰Â±â€‰5.7 no pregnancy (NP), F 1.76, df 3, pâ€‰=â€‰0.16). An ROC curve assessing the ability of P4 duration to predict ongoing pregnancy (OP) had an area under the curve of 0.467 (pâ€‰=â€‰0.38). CONCLUSION/CONCLUSIONS:Duration of P4 was not associated with outcome. Of the cycles, 65.6% resulted in ongoing pregnancy with our center's instructions resulting in an average progesterone exposure of 112.8Â h, with a range of 98.3-123.7Â h. With growing popularity for individualized testing, these results provide evidence for patient counseling of the high likelihood of ongoing pregnancy without personalized testing.
A Modern Measles Outbreak: Understanding maternal immunity and impact on postpartum vaccination uptake
Hirschberg, Carly I; Limaye, Meghana; Roman, Ashley; Friedman, Steven; Lighter, Jennifer L; Deeb, Jessica; Schweizer, William; Wei, Lili; Mehta-Lee, Shilpi S
OBJECTIVE:In October 2018, a measles (rubeola) outbreak was identified in New York City (NYC) & Rockland County (RC) and a public health campaign and hospital policy changes were made to increase awareness of the importance of vaccination and increase vaccination rates. We describe the prevalence of rubeola immunity in pregnant women and the change in uptake of postpartum MMR vaccination before and during the measles outbreak. METHODS:A multi-pronged intervention was developed by the health system with the intent of raising awareness of the outbreak, identifying patients at risk of contracting measles during pregnancy, and limiting exposure of inpatients to the disease. This was a quality improvement study to assess the impact of the intervention and public health policy on the rates of documentation of rubeola immunity and rubeola vaccination rates in non-immune women. Women who delivered at NYU Langone Health prior to the outbreak (7/1/2016 to 7/1/2017) were compared to women who delivered during the outbreak (7/1/18 to 7/1/19). The primary outcome was acceptance of MMR vaccination in non-immune women during the postpartum period. Analysis was conducted using logistic regression and chi-square tests, and alpha was set at 0.05. RESULTS:19585 patients were analyzed. 9,162 women delivered prior to outbreak and 10,423 delivered during the outbreak. Of these, 2589 (13.2%) were documented as living in a high-risk ZIP code, which were areas at the epicenter of the measles outbreak. 14,731 women (75.2%) were tested for rubeola immunity and 3270 (22.2%) of those tested were not immune. In the year of the outbreak, a higher proportion of women had rubeola immunity documented with serum titers than in the year prior to the outbreak (81% vs. 69%, p<0.001). Inpatient compliance with postpartum MMR administration was greater during the outbreak than prior to it (76% vs 59%, p <.001) for patients from both low risk and high-risk ZIP codes. CONCLUSION/CONCLUSIONS:The NYC & RC measles outbreak, together with implementation of a health system wide education program and a change in public health policy led to an increase in the proportion of pregnant women being screened for rubeola immunity. It also led to an increase in uptake of the immediate postpartum MMR vaccine.
Endothelial glycocalyx, apoptosis and inflammation in an atherosclerotic mouse model
Cancel, Limary M; Ebong, Eno E; Mensah, Solomon; Hirschberg, Carly; Tarbell, John M
BACKGROUND AND AIMS:Previous experiments suggest that both increased endothelial cell apoptosis and endothelial surface glycocalyx shedding could play a role in the endothelial dysfunction and inflammation of athero-prone regions of the vasculature. We sought to elucidate the possibly synergistic mechanisms by which endothelial cell apoptosis and glycocalyx shedding promote atherogenesis. METHODS:4- to 6-week old male C57Bl/6 apolipoprotein E knockout (ApoE(-/-)) mice were fed a Western diet for 10 weeks and developed plaques in their brachiocephalic arteries. RESULTS:Glycocalyx coverage and thickness were significantly reduced over the plaque region compared to the non-plaque region (coverage plaque: 71Â Â±Â 23%, non-plaque: 97Â Â±Â 3%, pÂ =Â 0.02; thickness plaque: 0.85Â Â±Â 0.15Â Î¼m, non-plaque: 1.2Â Â±Â 0.21Â Î¼m, pÂ =Â 0.006). Values in the non-plaque region were not different from those found in wild type mice fed a normal diet (coverage WT: 92Â Â±Â 3%, pÂ =Â 0.7 vs. non-plaque ApoE(-/-), thickness WT: 1.1Â Â±Â 0.06Â Î¼m, pÂ =Â 0.2 vs. non-plaque ApoE(-/-)). Endothelial cell apoptosis was significantly increased in ApoE(-/-) mice compared to wild type mice (ApoE(-/-):64.3Â Â±Â 33.0, WT: 1.1Â Â±Â 0.5 TUNEL-pos/cm, pÂ =Â 2Â Ã—Â 10(-7)). The number of apoptotic endothelial cells per unit length was 2 times higher in the plaque region than in the non-plaque region of the same vessel (pÂ =Â 3Â Ã—Â 10(-5)). Increased expression of matrix metalloproteinase 9 co-localized with glycocalyx shedding and plaque buildup. CONCLUSIONS:Our results suggest that, in concert with endothelial apoptosis that increases lipid permeability, glycocalyx shedding initiated by inflammation facilitates monocyte adhesion and macrophage infiltration that promote lipid retention and the development of atherosclerotic plaques.