Publications by authors named "Paula C Brady"

34 Publications

Outcomes of the First Pregnancy After Fertility-Sparing Surgery for Early-Stage Ovarian Cancer.

Obstet Gynecol 2021 06;137(6):1109-1118

Department of Gynecologic Oncology and Reproductive Medicine, the Department of Health Services Research, Division of Cancer Prevention and Population Sciences, and the Department of Breast Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, Texas; the Department of Obstetrics and Gynecology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; the Department of Obstetrics and Gynecology, the University of Texas Medical Branch at Galveston, Galveston, Texas; and the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, and the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York.

Objective: To evaluate the outcomes of the first pregnancy after fertility-sparing surgery in patients treated for early-stage ovarian cancer.

Methods: We performed a retrospective study of women aged 18-45 years with a history of stage IA or IC ovarian cancer reported to the California Cancer Registry for the years 2000-2012. These data were linked to the 2000-2012 California Office of Statewide Health Planning and Development birth and discharge data sets to ascertain oncologic characteristics and obstetric outcomes. We included in the case group ovarian cancer patients who conceived at least 3 months after fertility-sparing surgery. The primary outcome was preterm birth, and only the first pregnancy after cancer diagnosis was considered. Secondary outcomes included small-for-gestational-age (SGA) neonates, neonatal morbidity (respiratory support within 72 hours after birth, hypoxic-ischemic encephalopathy, seizures, infection, meconium aspiration syndrome, birth trauma, and intracranial or subgaleal hemorrhage), and severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Propensity scores were used to match women in a 1:2 ratio for the case group and the control group. Wald statistics and logistic regressions were used to evaluate outcomes.

Results: A total of 153 patients who conceived after fertility-sparing surgery were matched to 306 women in a control group. Histologic types included epithelial (55%), germ-cell (37%), and sex-cord stromal (7%). Treatment for ovarian cancer was not associated with preterm birth before 37 weeks of gestation (13.7% vs 11.4%; odds ratio [OR] 1.23, 95% CI 0.69-2.20), SGA neonates (birth weight less than the 10th percentile: 11.8% vs 12.7%; OR 0.91, 95% CI 0.50-1.66), severe maternal morbidity (2.6% vs 1.3%; OR 2.03, 95% CI 0.50-8.25), or neonatal morbidity (both 5.9% OR 1.00, 95% CI 0.44-2.28).

Conclusion: Patients who conceived at least 3 months after surgery for early-stage ovarian cancer did not have an increased risk of adverse obstetric outcomes.
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http://dx.doi.org/10.1097/AOG.0000000000004394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141030PMC
June 2021

Use of fertility preservation services in male reproductive-aged cancer patients.

Gynecol Oncol Rep 2021 May 10;36:100716. Epub 2021 Feb 10.

Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, United States.

While fertility preservation is a major concern among reproductive age cancer patients, little is known about access and use of fertility preserving services. We examined use of fertility preserving services among men with common solid tumors. A total of 3648 men age 18-40 including 2610 (71.6%) with testicular cancer, 939 (25.7%) with colorectal and 99 (2.7%) with prostate cancer were identified. Fertility preservation services were utilized in 9.3% of men overall including 4.1% who underwent fertility evaluation only and 7.8% who had a fertility preservation procedure. The rate of fertility preservation services rose from 6.6% (95%CI, 3.2-10.0) in 2008 to 12.4% (95%CI, 7.3-17.5) in 2017 (P = 0.04). Use of fertility preservation service was more common in patients with testicular (11.6%, aRR = 3.31; 95% CI 2.22-4.92) and prostate cancer (6.1%, aRR = 3.14; 95% CI 1.28-7.70) compared to those with colon cancer (3.4%). Younger men were more likely to utilize fertility preservation services. 11.5% of men age ≤ 35 years vs. 5.2% of men 36-40 used these services (P < 0.0001). Fertility preservation services were used in 10.8% of those who received chemotherapy (aRR = 1.81; 95% CI, 1.45-2.27) and in 8.1% of those who received radiation (aRR = 1.30 95% CI, 0.98-1.73). Medicaid patients were less likely to receive fertility preservation services than those with commercial insurance (0.7% vs. 10.1%; aRR = 11.58, 95%CI 2.10-63.69). These data indicate that while use of fertility preserving services is increasing, overall use of services is low among reproductive age males with cancer.
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http://dx.doi.org/10.1016/j.gore.2021.100716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907757PMC
May 2021

An oncofertility prediction tool? Forecasting fertility after cancer.

Fertil Steril 2021 Feb 29;115(2):323-324. Epub 2020 Dec 29.

Columbia University Fertility Center, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York.

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http://dx.doi.org/10.1016/j.fertnstert.2020.10.032DOI Listing
February 2021

Triple stimulation (TriStim) before bilateral oophorectomy in a young woman with ovarian cancer: a case report and review of the literature.

Fertil Res Pract 2020 26;6:17. Epub 2020 Oct 26.

Department of Obstetrics and Gynecology, Columbia University Fertility Center, Columbia University Irving Medical Center, New York, USA.

Background: Double ovarian stimulation (DuoStim) involves two rounds of controlled ovarian stimulation (COS) and oocyte retrieval in immediate succession. It represents a promising approach to increase oocyte yield for patients with diminished ovarian reserve or those with limited time before fertility-threatening oncologic treatment. We report the case of a 31-year-old woman with Stage IC endometrioid ovarian cancer who underwent a triple stimulation or "TriStim," completing three rounds of COS and oocyte retrieval within 42 days prior to bilateral salpingo-oophorectomy.

Case Presentation: A 31 year old nulligravid woman presented for fertility preservation counseling following a bilateral ovarian cystectomy that revealed Stage IC endometroid adenocarcinoma arising within endometrioid borderline tumors. The patient was counseled for bilateral salpingo-oophorectomy, lymph node dissection, and omentectomy followed by three cycles of carboplatin/paclitaxel. Prior to this, all within six weeks, the patient underwent three rounds of controlled ovarian stimulation using an antagonist protocol and human chorionic gonadotropin (hCG) trigger, resulting in vitrification of nine two-pronuclear zygotes (2PN), after which definitive surgery was performed.

Conclusions: Advantages of DuoStim procedures are increasingly recognized, especially for oncology patients with limited time before potentially sterilizing cancer treatment. To our knowledge, this is the first report of a triple stimulation ("TriStim"). Our case highlights that triple stimulation is a viable option for patients needing urgent fertility preservation in order to maximize egg and embryo yield within a limited time period.
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http://dx.doi.org/10.1186/s40738-020-00087-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586661PMC
October 2020

Outcomes after Fertility-sparing Surgery for Women with Ovarian Cancer: A Systematic Review of the Literature.

J Minim Invasive Gynecol 2021 03 26;28(3):527-536.e1. Epub 2020 Aug 26.

Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center (Drs. Nitecki and Rauh-Hain), Houston, Texas. Electronic address:

Objective: To compare reproductive and oncologic outcomes of patients diagnosed with early-stage epithelial ovarian carcinoma, borderline ovarian tumors, or nonepithelial ovarian carcinoma according to receipt of fertility-sparing surgery or conventional surgery.

Data Sources: PubMed was searched from January 1, 1995, to May 29, 2020.

Methods Of Study Selection: Studies were included if they (1) enrolled women of childbearing age diagnosed with ovarian cancer between the ages of 18 years and 50 years, (2) reported on oncologic and/or reproductive outcomes after fertility-sparing surgery for ovarian cancer, and (3) included at least 20 patients.

Tabulation, Integration, And Results: The initial search identified 995 studies. After duplicates were removed, we abstracted 980 unique citations. Of those screened, 167 publications were identified as potentially relevant, and evaluated for inclusion and exclusion criteria. The final review included 44 studies in epithelial ovarian cancer, 42 in borderline ovarian tumors, and 31 in nonepithelial ovarian carcinoma. The narrative synthesis demonstrated that overall survival does not seem to be compromised in patients undergoing fertility-sparing surgery compared with those undergoing conventional surgery, although long-term data are limited. Areas of controversy include safety of fertility-sparing surgery in the setting of high-risk factors (stage IC, grade 3, and clear cell histology), as well as type of surgery (salpingo-oophorectomy vs cystectomy). It seems that although there may be some fertility compromise after surgery, pregnancy and live-birth rates are encouraging.

Conclusion: Fertility-sparing surgery is safe and feasible in women with early-stage low-risk ovarian cancer. Pregnancy outcomes for these patients also seem to be similar to those of the general population.
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http://dx.doi.org/10.1016/j.jmig.2020.08.018DOI Listing
March 2021

Gender inequality in leadership and academic rank in academic reproductive endocrinology programs.

J Assist Reprod Genet 2020 Aug 21;37(8):1959-1962. Epub 2020 Jun 21.

Department of Obstetrics and Gynecology, Columbia University Fertility Center, Columbia University Irving Medical Center, 5 Columbus Circle, Penthouse, New York, NY, 10019, USA.

Purpose: To identify gender differences in leadership and academic rank within academic reproductive endocrinology (REI) programs with fellowships in the USA.

Methods: Official institutional websites of the 2017-2018 American Board of Obstetrics and Gynecology (ABOG)-accredited reproductive endocrinology fellowship programs were reviewed, and gender representation at each leadership position and academic rank (Division and Fellowship Director and Full, Associate, and Assistant Professor) was recorded. Univariate comparisons were performed using Chi-square tests, with significance at p < 0.05.

Results: Among 49 ABOG-accredited reproductive endocrinology programs, 263 faculty were identified, 129 (49.0%) male and 134 (51.0%) female. Division directors were 69.3% male and 30.7% female (p = 0.006). Similarly, fellowship directors were 65.3% male and 34.6% female (p = 0.03). Full professors (n = 101) were more frequently male (70.3% vs. 29.7%, p < 0.001). There was no difference in gender among associate professors (n = 60, 51.7% male vs. 48.3% female, p = 0.79), while significantly more assistant professors were female than male (n = 102, 73.6% vs. 26.4%, p < 0.001).

Conclusion: While a majority of residents in obstetrics and gynecology and half of reproductive endocrinology academic faculty are female, women are still underrepresented among leadership positions and full professors in academic reproductive endocrinology programs with fellowship programs.
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http://dx.doi.org/10.1007/s10815-020-01866-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468001PMC
August 2020

Restoring fertility in women aged 40 years and older after tubal ligation: tubal anastomosis versus in vitro fertilization.

Fertil Steril 2020 04;113(4):735-742

Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.fertnstert.2020.01.041DOI Listing
April 2020

Research priorities for endometriosis differ among patients, clinicians, and researchers.

Am J Obstet Gynecol 2020 06 3;222(6):630-632. Epub 2020 Mar 3.

Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ.

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http://dx.doi.org/10.1016/j.ajog.2020.02.047DOI Listing
June 2020

Hyperglycosylated human chorionic gonadotropin as a predictor of ongoing pregnancy.

Am J Obstet Gynecol 2020 01 8;222(1):68.e1-68.e12. Epub 2019 Aug 8.

Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.

Background: Hyperglycosylated human chorionic gonadotropin, the predominant human chorionic gonadotropin variant secreted following implantation, is associated with trophoblast invasion.

Objective: To determine whether the initial serum hyperglycosylated human chorionic gonadotropin differs between ongoing and failed pregnancies, and to compare it to total serum human chorionic gonadotropin as a predictor of ongoing pregnancy.

Materials And Methods: Women undergoing fresh/frozen in vitro fertilization cycles at a university-based infertility clinic with an autologous day 5 single embryo transfer resulting in serum human chorionic gonadotropin >3 mIU/mL (n = 115) were included. Human chorionic gonadotropin was measured 11 days after embryo transfer in a single laboratory (coefficient of variation <6%). Surplus frozen serum (-80C) was shipped to Quest Laboratories for measurement of hyperglycosylated human chorionic gonadotropin (coefficient of variation <9.1%). Linear regression analyses adjusted for oocyte age a priori were used to compare human chorionic gonadotropin and hyperglycosylated human chorionic gonadotropin in ongoing pregnancies (>8 weeks of gestation) and failed pregnancies (clinical pregnancy loss, biochemical and ectopic pregnancies).

Results: A total of 85 pregnancies (73.9%) were ongoing. Hyperglycosylated human chorionic gonadotropin and human chorionic gonadotropin values were highly correlated (Pearson correlation coefficient 92.14, P < .0001), and mean values of both were positively correlated with blastocyst expansion score (P value test for trend < .0004). Mean human chorionic gonadotropin and hyperglycosylated human chorionic gonadotropin were significantly higher in ongoing vs failed pregnancies. Among ongoing pregnancies vs clinical losses, mean hyperglycosylated human chorionic gonadotropin, but not human chorionic gonadotropin, was significantly higher (19.0 vs 12.2 ng/mL, β -8.1, 95% confidence interval -13.0 to -3.2), and hyperglycosylated human chorionic gonadotropin comprised a higher proportion of total human chorionic gonadotropin (4.6% vs 4.1%; risk ratio, 0.79; 95% confidence interval, 0.66-0.94).

Conclusion: Measured 11 days after single blastocyst transfer, hyperglycosylated human chorionic gonadotropin and human chorionic gonadotropin values were highly correlated, but only mean hyperglycosylated human chorionic gonadotropin and its ratio to total human chorionic gonadotropin were significantly higher in ongoing pregnancies vs clinical pregnancy losses. Further evaluation of hyperglycosylated human chorionic gonadotropin, including in multiple embryo transfers and multiple pregnancy, and using serial measurements, is required.
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http://dx.doi.org/10.1016/j.ajog.2019.08.004DOI Listing
January 2020

The effect of endometriosis on the antimüllerian hormone level in the infertile population.

J Assist Reprod Genet 2019 Jun 16;36(6):1179-1184. Epub 2019 Apr 16.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.

Purpose: To determine whether the presence of endometriosis in infertile women without prior ovarian surgery influences markers of ovarian reserve, AMH and FSH.

Methods: A retrospective cohort study included three groups of women who presented for IVF treatment at our tertiary care center from 04/27/2015 to 05/31/2017: women with endometriosis and prior ovarian surgery (EnSx), women with endometriosis without prior ovarian surgery (En), and women with a primary diagnosis of male factor infertility (MF; reference group).

Results: There were 671 patients that met inclusion criteria (78 EnSx, 60 En, and 533 MF). Compared to the MF group (3.6 ± 3.0), a lower mean AMH level (ng/mL) was observed in the EnSx group (2.5 ± 2.5; aβ - 1.21; 95% CI [- 1.79, -0.62]) and in the En group (2.5 ± 2.2; aβ - 1.11; 95% CI [- 1.68, - 0.54]). Both endometriosis groups had a statistically significantly higher proportion of patients with an AMH < 1 (EnSx, 24.4%; OR, 2.39 [95% CI, 1.31, 4.36]; En, 28.3%; OR, 2.67 [95% CI, 1.41, 5.08]) compared to the MF group (13.9%). The mean baseline FSH level (lU/L) was statistically significantly higher in both endometriosis groups (EnSx, 8.6 ± 4.3; β, 1.37 [95% CI, 0.39, 2.34]; En, 8.4 ± 3.7; β, 0.96 [95% CI, 0.04, 1.87]) compared to the MF group (7.3 ± 2.2).

Conclusions: Among infertility patients with endometriosis, with and without a history of ovarian surgery, ovarian reserve markers were worse (lower AMH and higher FSH) and a higher proportion had decreased ovarian reserve as measured by AMH compared to women with MF.
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http://dx.doi.org/10.1007/s10815-019-01450-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603105PMC
June 2019

Diagnosis and management of a heterotopic pregnancy and ruptured rudimentary uterine horn.

Fertil Res Pract 2018 29;4. Epub 2018 Sep 29.

1Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115 USA.

Background: Heterotopic pregnancies implanted in a rudimentary uterine horn account for 1 in 2-3 million gestations, and confer significant risk of morbidity due to uterine rupture and hemorrhage.

Case Presentation: A 34-year-old nullipara presented with acute pelvic pain at 17 weeks of gestation with dichorionic-diamniotic twins, one in each horn of an anomalous uterus first diagnosed in pregnancy as bicornuate. Three-dimensional ultrasound and MRI revealed myometrial disruption in the left rudimentary uterine horn, and the patient underwent an uncomplicated abdominal hemi-hysterectomy. Fourteen days later, an uncomplicated dilation and curettage was performed for a fetal anomaly in the remaining twin in the right unicornuate uterus.

Conclusion: This case demonstrates the utility of magnetic resonance imaging and three-dimensional ultrasound in the assessment of myometrial integrity in a gravid patient with a heterotopic pregnancy and ruptured rudimentary uterine horn. This case demonstrates the importance of pre-pregnancy diagnosis and management of mullerian anomalies.
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http://dx.doi.org/10.1186/s40738-018-0051-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162954PMC
September 2018

Serum Human Chorionic Gonadotropin Among Women With and Without Obesity After Single Embryo Transfers.

J Clin Endocrinol Metab 2018 11;103(11):4209-4215

Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Context: Serum human chorionic gonadotropin (hCG) levels are essential for diagnosing and monitoring early pregnancy. Obesity is a health care epidemic; however, the performance of this vital serum hormone in women with an elevated body mass index (BMI) is unknown.

Objective: To investigate the association of BMI with serum hCG values and rate of hCG increase.

Design: Retrospective cohort study.

Setting: University-based infertility clinic.

Patients: Women undergoing fresh vs frozen in vitro fertilization cycles with single-day three or five embryo transfers resulting in singleton live births (≥24 weeks' gestational age) from 2008 to 2015.

Intervention(s): None.

Main Outcome Measure(s): The initial hCG (mIU/mL, 16 days after oocyte retrieval) and 2-day percentage of hCG increases among BMI categories were compared using multivariable linear and logistic regression, adjusted a priori for the day of embryo transfer.

Results: The initial serum hCG values correlated inversely with the BMI (P < 0.0001, test for trend). Low initial hCG values (<100 mIU/mL) were significantly more common across increasing BMI classes, from 1.4% of normal weight patients to 15.6% of those with a BMI ≥40 kg/m2 (P = 0.001, test for trend). The mean 2-day hCG increases were similar and normal (≥53%) across the BMI groups.

Conclusions: Patients with obesity achieving live births had statistically significantly lower initial serum hCG values compared with patients who were nonobese. However, the mean 2-day percentage of increases in hCG were similar across BMI categories. The initial hCG values might lack sensitivity for live births in patients with obesity. The rate of hCG increase remains the mainstay of monitoring very early pregnancies after in vitro fertilization. Future studies should investigate whether serum analyte ranges should be adjusted according to the BMI.
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http://dx.doi.org/10.1210/jc.2018-01057DOI Listing
November 2018

Antimüllerian hormone: Don't put all the eggs in one basket.

Fertil Steril 2018 08 28;110(3):412. Epub 2018 Jun 28.

Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.fertnstert.2018.04.001DOI Listing
August 2018

Fertility preservation in women with marrow failure syndromes prior to allogeneic stem cell transplantation.

Am J Hematol 2018 May 13. Epub 2018 May 13.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1002/ajh.25130DOI Listing
May 2018

Perinatal and Peripartum Outcomes in Vanishing Twin Pregnancies Achieved by In Vitro Fertilization.

Obstet Gynecol 2018 06;131(6):1011-1020

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, and the Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; the Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan; and Reproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey.

Objective: To compare perinatal and peripartum outcomes of vanishing twin gestations with singleton and dichorionic twin gestations in pregnancies conceived by in vitro fertilization.

Methods: We conducted a retrospective cohort study of vanishing twin pregnancies after fresh and cryopreserved autologous in vitro fertilization cycles performed at our institution from 2007 to 2015. Singleton, dichorionic twin, and dichorionic twin pregnancies with spontaneous reduction to one by 14 weeks of gestation (vanishing twins) were included. Analysis was restricted to patients with a live birth delivery at our institution at or beyond 24 weeks of gestation. The primary outcomes were gestational age and birth weight at delivery; secondary outcomes included peripartum morbidities. A subanalysis further differentiated the vanishing twin pregnancies between those in which demise of the twin occurred before compared with after identification of fetal cardiac activity. Logistic regression models were used to estimate the adjusted odds ratio (OR) with a 95% CI of outcomes.

Results: There were 1,189 pregnancies that met inclusion criteria (798 singleton, 291 twin, and 100 vanishing twin). The mean gestational age at birth and birth weights were 38.6±2.3 weeks of gestation and 3,207±644 g in singleton pregnancies, 35.5±2.7 weeks of gestation and 2,539±610 g in twin pregnancies, and 38.5±1.8 weeks of gestation and 3,175±599 g in vanishing twin pregnancies. When compared with twins, those with a vanishing twin had lower odds of preterm delivery (OR 0.13, 95% CI 0.07-0.23; adjusted OR 0.12, 95% CI 0.07-0.22) and small-for-gestational-age birth weight (OR 0.24, 95% CI 0.13-0.45; adjusted OR 0.14, 95% CI 0.07-0.28).

Conclusion: In pregnancies conceived by in vitro fertilization that progress to at least 24 weeks of gestation, vanishing twin and singleton pregnancies had similar perinatal and peripartum outcomes. Both were significantly better than twin pregnancies.
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http://dx.doi.org/10.1097/AOG.0000000000002595DOI Listing
June 2018

Combined Oocyte Retrieval and Robot-assisted Hysterectomy in a Super Morbidly Obese Patient with Endometrial Carcinoma.

Anticancer Res 2018 03;38(3):1467-1470

Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A.

Aim: To report on the unique, innovative management of a super morbidly obese patient presenting for fertility preservation in the setting of Grade 2 endometrioid endometrial adenocarcinoma.

Case Report: A back-to-back oocyte retrieval and robot-assisted total laparoscopic hysterectomy (RA-TLH) with bilateral salpingo-oophorectomy (BSO) was performed in a 37-year-old nulligravid woman with super morbid obesity (BMI 63 kg/m) with endometrial cancer.

Main Outcome Measure: the successful retrieval of oocytes for fertility preservation and oncologic intervention via RA-TLH with BSO in the same operative and anesthetic episode.

Results: This combined procedure strategy was successful in our case and is a feasible option for similar high-risk patients in the future.

Conclusion: Identifying safe and effective approaches for oocyte retrieval in morbidly obese patients represents a pressing need as obesity rates rise among reproductive-aged women. Back-to-back oocyte retrieval and RA-TLH with BSO are not only feasible, but could also decrease significant anesthetic risks for morbidly obese patients.
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http://dx.doi.org/10.21873/anticanres.12372DOI Listing
March 2018

Abnormal human chorionic gonadotropin (hCG) trends after transfer of multiple embryos resulting in viable singleton pregnancies.

J Assist Reprod Genet 2018 Mar 19;35(3):483-489. Epub 2017 Dec 19.

Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St., ASBI-3, Boston, MA, 02115, USA.

Purpose: The purpose of this study is to investigate whether abnormal hCG trends occur at a higher incidence among women conceiving singleton pregnancies following transfer of multiple (two or more) embryos (MET), as compared to those having a single embryo transfer (SET).

Methods: Retrospective cohort study was performed of women who conceived singleton pregnancies following fresh or frozen autologous IVF/ICSI cycles with day 3 or day 5 embryo transfers between 2007 and 2014 at a single academic medical center. Cycles resulting in one gestational sac on ultrasound followed by singleton live birth beyond 24 weeks of gestation were included. Logistic regression models adjusted a priori for patient age at oocyte retrieval and day of embryo transfer were used to estimate the Odds Ratio of having an abnormal hCG rise (defined as a rise or < 66% in 2 days) following SET as compared to MET.

Results: Among patients receiving two or more embryos, 6.1% (n = 84) had abnormal hCG rises between the first and second measurements, compared to 2.7% (n = 17) of patients undergoing SET (OR 2.16, 95% CI 1.26-3.71). Among patients with initially abnormal hCG rises who had a third level checked (89%), three-quarters had normal hCG rises between the second and third measurements.

Conclusions: Patients who deliver singletons following MET were more likely to have suboptimal initial hCG rises, potentially due to transient implantation of other non-viable embryo(s). While useful for counseling, these findings should not change standard management of abnormal hCG rises following IVF. The third hCG measurements may clarify pregnancy prognosis.
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http://dx.doi.org/10.1007/s10815-017-1102-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5904070PMC
March 2018

New Evidence to Guide Ectopic Pregnancy Diagnosis and Management.

Authors:
Paula C Brady

Obstet Gynecol Surv 2017 Oct;72(10):618-625

Fellow in Reproductive Endocrinology and Infertility, Brigham and Women's Hospital Center for Infertility and Reproductive Surgery, Boston, MA.

Importance: Ectopic pregnancy is a leading source of morbidity and mortality in pregnancy, accounting for 1% to 2% of all pregnancies. Timely diagnosis and management of these abnormal gestations are vital to patient safety.

Objective: The objective of this study was to describe recent evidence in the risk factors, diagnosis, and management of ectopic pregnancy.

Evidence Acquisition: Comprehensive review of the published literature.

Results: Recent literature describes newly identified risk factors for ectopic pregnancy, particularly those specific to assisted reproduction. Furthermore, evidence mounts for the utility of endometrial sampling for the diagnosis of pregnancy location, allowing a significant proportion of women to avoid methotrexate by diagnosing failing intrauterine pregnancies instead. Finally, recent, high-level evidence supports (in women with normal contralateral fallopian tubes) the equivalence of salpingectomy and salpingostomy regarding rates of subsequent intrauterine pregnancy and recurrent ectopic pregnancy.

Conclusions And Relevance: While serial serum human chorionic gonadotropin levels and transvaginal ultrasound are the mainstays of ectopic pregnancy diagnosis, recent publications revisit the utility of endometrial sampling in diagnosing pregnancy location, using manual vacuum aspiration instead of the criterion-standard dilation and curettage. Expectant management of ectopic pregnancies is the subject of ongoing research, and in the meantime, treatment remains medical or surgical (dependent on clinical parameters and patient preference); salpingostomy and salpingectomy provide equivalent subsequent pregnancy outcomes in women with contralateral fallopian tubes in place.
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http://dx.doi.org/10.1097/OGX.0000000000000492DOI Listing
October 2017

Outpatient endometrial aspiration: an alternative to methotrexate for pregnancy of unknown location.

Am J Obstet Gynecol 2017 08 19;217(2):185.e1-185.e9. Epub 2017 Apr 19.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.

Background: Pregnancies of unknown location with abnormal beta-human chorionic gonadotropin trends are frequently treated as presumed ectopic pregnancies with methotrexate. Preliminary data suggest that outpatient endometrial aspiration may be an effective tool to diagnose pregnancy location, while also sparing women exposure to methotrexate.

Objective: The purpose of this study was to evaluate the utility of an endometrial sampling protocol for the diagnosis of pregnancies of unknown location after in vitro fertilization.

Study Design: A retrospective cohort study of 14,505 autologous fresh and frozen in vitro fertilization cycles from October 2007 to September 2015 was performed; 110 patients were diagnosed with pregnancy of unknown location, defined as a positive beta-human chorionic gonadotropin without ultrasound evidence of intrauterine or ectopic pregnancy and an abnormal beta-human chorionic gonadotropin trend (<53% rise or <15% fall in 2 days). These patients underwent outpatient endometrial sampling with Karman cannula aspiration. Patients with a beta-human chorionic gonadotropin decline ≥15% within 24 hours of sampling and/or villi detected on pathologic analysis were diagnosed with failing intrauterine pregnancy and had weekly beta-human chorionic gonadotropin measurements thereafter. Those patients with beta-human chorionic gonadotropin declines <15% and no villi identified were diagnosed with ectopic pregnancy and treated with intramuscular methotrexate (50 mg/m) or laparoscopy.

Results: Across 8 years of follow up, among women with pregnancy of unknown location, failed intrauterine pregnancy was diagnosed in 46 patients (42%), and ectopic pregnancy was diagnosed in 64 patients (58%). Clinical variables that included fresh or frozen embryo transfer, day of embryo transfer, serum beta-human chorionic gonadotropin at the time of sampling, endometrial thickness, and presence of an adnexal mass were not significantly different between patients with failed intrauterine pregnancy or ectopic pregnancy. In patients with failed intrauterine pregnancy, 100% demonstrated adequate postsampling beta-human chorionic gonadotropin declines; villi were identified in just 46% (n=21 patients). Patients with failed intrauterine pregnancy had significantly shorter time to resolution (negative serum beta-human chorionic gonadotropin) after sampling compared with patients with ectopic pregnancy (12.6 vs 26.3 days; P<.001).

Conclusion: With the use of this safe and effective protocol of endometrial aspiration with Karman cannula, a large proportion of women with pregnancy of unknown location are spared methotrexate, with a shorter time to pregnancy resolution than those who receive methotrexate.
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http://dx.doi.org/10.1016/j.ajog.2017.04.023DOI Listing
August 2017

Bladder Involvement in Stage I Endometriosis.

J Pediatr Adolesc Gynecol 2017 Aug 8;30(4):503-504. Epub 2017 Apr 8.

Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gynecology, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts; Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts.

Background: Endometriosis-the ectopic implantation of endometrial-like tissue-affects 10% of adolescent females and adults. Bladder involvement, causing dysuria and hematuria, occurs in a very small number of endometriosis patients.

Case: The patient presented at age 12 years with dysuria and pelvic pain. Laparoscopy revealed stage I endometriosis. Postoperatively, she reported persistent dysuria and passage of tissue in her urine. Cystoscopy showed diffuse erythema; urine cytology revealed glandular and spindle cells suggestive of endometriosis. She was transitioned from oral contraceptives to an intranasal gonadotropin-releasing hormone agonist, with symptom resolution.

Summary And Conclusion: Intravesicular endometriosis coinciding with stage I disease supports a mechanism of endometriosis dissemination other than direct bladder infiltration. Patients with endometriosis who complain of urinary symptoms warrant assessment, because intravesicular bladder involvement cannot be excluded using pelviscopy.
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http://dx.doi.org/10.1016/j.jpag.2017.03.143DOI Listing
August 2017

Continuation of a Levonorgestrel Intrauterine Device During Hematopoietic Stem Cell Transplant: A Case Report.

Anticancer Res 2017 04;37(4):1985-1987

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, U.S.A.

Background: During treatment of hematologic malignancies in premenopausal women, both menstrual suppression and contraception are crucial. Continuation of hormonal intrauterine devices (IUDs) - widely used and highly effective contraceptives that also decrease menstrual flow - is controversial during hematopoietic stem cell transplants (SCTs) due to infectious and vaginal bleeding concerns.

Case Report: A 23-year-old nulligravid female was diagnosed with acute myeloid leukemia (AML, positive for FLT3-ITD, DNMT3A and RUNX1, with normal cytogenetics). She elected to retain her existing levonorgestrel-containing IUD during chemotherapy and SCT. During and following treatment, she remained amenorrheic without infection, despite severe neutropenia and thrombocytopenia. Eight months later, she remains in remission without IUD-related complications.

Discussion: This is the first report of levonorgestrel IUD retention during hematopoietic SCT. Despite severe neutropenia and thrombocytopenia, the patient developed neither pelvic infection by retaining her IUD nor significant vaginal bleeding. Future studies are needed to confirm the safety of levonorgestrel IUDs in women undergoing SCT.
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http://dx.doi.org/10.21873/anticanres.11541DOI Listing
April 2017

Clinical predictors of failing one dose of methotrexate for ectopic pregnancy after in vitro fertilization.

J Assist Reprod Genet 2017 Mar 5;34(3):349-356. Epub 2017 Jan 5.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.

Purpose: The aim of this study is to investigate the clinical predictors of failure of a single dose of methotrexate (MTX) for management of ectopic pregnancy after in vitro fertilization (IVF).

Methods: A retrospective cohort study was performed of women who conceived ectopic pregnancies following fresh or frozen IVF cycles at an academic infertility clinic between 2007 and 2014, and received intramuscular MTX (50 mg/m). Successful single-dose MTX treatment was defined as a serum beta-human chorionic gonadotropin (hCG) decline ≥15% between days 4 and 7 post-treatment. Logistic regression models adjusted for oocyte age, number of embryos transferred, and prior ectopic pregnancy were used to estimate the adjusted odds ratio (OR) (95% confidence interval [CI]) of failing one dose of MTX.

Results: Sixty-four patients with ectopic pregnancies after IVF were included. Forty required only one dose of MTX (62.5%), while 15 required additional MTX alone (up to four total doses, 23.4%), and 9 required surgery (14.1%). By multivariable logistic regression, the highest tertiles of serum hCG at peak (≥499 IU/L, OR = 9.73, CI 1.88-50.25) and at first MTX administration (≥342 IU/L, OR = 4.74, CI 1.11-20.26), fewer embryos transferred (OR = 0.37 per each additional embryo transferred, CI 0.19-0.74), and adnexal mass by ultrasound (OR = 3.65, CI 1.10-12.11) were each correlated with greater odds of requiring additional MTX and/or surgery.

Conclusion: This is the first study to report that in women with ectopic pregnancies after IVF, higher hCG-though well below treatment failure thresholds previously described in spontaneous pregnancies-fewer embryos transferred, and adnexal masses are associated with greater odds of failing one dose of MTX. These findings can be used to counsel IVF patients regarding the likelihood of success with single-dose MTX.
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http://dx.doi.org/10.1007/s10815-016-0861-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360686PMC
March 2017

Hepatic Adenomas in Adolescents and Young Women with Endometriosis Treated with Norethindrone Acetate.

J Pediatr Adolesc Gynecol 2017 Jun 23;30(3):422-424. Epub 2016 Dec 23.

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gynecology, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts; Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts.

Background: Endometriosis-ectopic implantation of endometrial-like tissue-affects 10% of female adolescents and adults. First-line treatment includes progesterone only (such as norethindrone acetate [NET-A]) or combined estrogen/progestin oral contraceptive pills. Estrogen-containing contraceptives confer increased risk of hepatic adenomas, whereas the association with NET-A is very rarely reported.

Case: Three adolescents with stage I to II endometriosis managed with NET-A (up to 15 mg/d for 28-78 months) were diagnosed with hepatic adenomas at ages 17-22 years. They previously received estrogen-containing medications, which were stopped 24 months or longer before diagnosis of hepatic adenoma.

Summary And Conclusion: NET-A in a dose greater than 10 mg/d might be associated with increased risk for hepatic adenomas, likely due to peripheral conversion to ethinyl estradiol. Use of NET-A might not be advisable in patients with known hepatic adenomas.
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http://dx.doi.org/10.1016/j.jpag.2016.12.002DOI Listing
June 2017

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review.

Fertil Res Pract 2015 15;1:15. Epub 2015 Oct 15.

Department of Obstcpetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA.

Background: Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.

Findings: Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.

Conclusion: This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.
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http://dx.doi.org/10.1186/s40738-015-0008-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5424401PMC
October 2015

Dynamic antimüllerian hormone levels during controlled ovarian hyperstimulation predict in vitro fertilization response and pregnancy outcomes.

Fertil Steril 2015 Nov 24;104(5):1153-61.e1-7. Epub 2015 Aug 24.

Vincent Department of Obstetrics and Gynecology, Vincent Reproductive Medicine and IVF, Massachusetts General Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Medical School, Harvard University, Boston, Massachusetts.

Objective: To evaluate the patterns of change in serum antimüllerian hormone (AMH) during controlled ovarian hyperstimulation (COH) and their relation to concurrent response and in vitro fertilization (IVF) pregnancy outcomes.

Design: Prospective cohort study.

Setting: Academic medical center.

Patient(s): A total of 113 consecutive fresh IVF embryo transfer cycles from September 1, 2012 through January 1, 2013.

Intervention(s): Serial serum AMH measurements were analyzed on each day that serum estradiol (E2) was drawn during COH.

Main Outcome Measure(s): Relationship between the rate of COH AMH change [Δ ng/mL per day] (stratified into tertiles), and ovarian response, and pregnancy outcomes.

Result(s): During COH, AMH declined. Age and ovarian reserve testing were associated with the rate of AMH decline (RAD). Women with intermediate and minimal RAD had statistically significantly fewer follicles ≥ 12 mm, lower peak serum E2, fewer oocytes, and inferior early embryo development compared with women with the greatest RAD. Compared with patients with the lowest RAD, clinical pregnancy was more likely in patients with the greatest RAD in the total population (adjusted odds ratio 3.51; 95% confidence interval, 1.03, 11.94) and among patients older than 35 years (adjusted odds ratio 6.95; 95% confidence interval, 1.09, 44.1).

Conclusion(s): The rate of COH AMH decline was associated with ovarian reserve testing, oocyte yield, embryo progression, and clinical pregnancy rates, particularly in women older than 35 years. These results suggest that dynamic AMH levels may provide a novel intracycle approach to predict response and treatment outcomes after IVF.
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http://dx.doi.org/10.1016/j.fertnstert.2015.07.1161DOI Listing
November 2015

Laparoscopic uteroovarian ligament truncation and uterosacral oophoropexy for idiopathic recurrent ovarian torsion: case report and review of literature.

Fertil Res Pract 2015 21;1. Epub 2015 Apr 21.

Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114 USA.

Background: Unilateral recurrent ovarian torsion in adults is unusual following treatment of common underlying risk factors (e.g. benign cysts). Subtle anatomic etiologies, such as an elongated uteroovarian ligament and robust ovarian volume, are commonly underappreciated and may contribute to idiopathic recurrent unilateral torsion in adults. As seen in this case, combined surgical procedures may be required to prevent recurrence.

Case: 28 year old nulligravid woman with seven episodes of right ovarian torsion (without adnexal pathology)-six of those within 18 months-refractory to a series of previous surgical interventions. Laparoscopic uteroovarian ligament truncation with interval uterosacral ligament oophoropexy was employed. Ovarian torsion has not occurred in 45 months.

Conclusion: Uteroovarian ligament truncation and uterosacral ligament oophoropexy is a feasible and effective combined surgical approach for the prevention of recurrent idiopathic ovarian torsion in adults without obvious risk factors.
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http://dx.doi.org/10.1186/2054-7099-1-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5415195PMC
April 2015

Serum progesterone concentration on day of embryo transfer in donor oocyte cycles.

J Assist Reprod Genet 2014 May 12;31(5):569-75. Epub 2014 Mar 12.

Department of Obstetrics, Gynecology and Reproductive Biology, Division of Reproductive Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

Purpose: To evaluate the association between serum progesterone (P) levels on the day of embryo transfer (ET) and pregnancy rates in fresh donor IVF/ICSI cycles.

Methods: Fresh donor cycles with day 3 ET from 10/2007 to 8/2012 were included (n = 229). Most cycles (93 %) were programmed with a gonadotropin releasing hormone (GnRH) agonist; oral, vaginal or transdermal estradiol was used for endometrial priming, and intramuscular P was used for luteal support (50-100 mg/day). Recipient P levels were measured at ET, and P dose was increased by 50-100 % if <20 ng/mL per clinic practice. The main outcome measure was rate of live birth (> = 24 weeks gestational age). Generalized estimating equations were used to account for multiple cycles from the same recipient, adjusted a priori for recipient and donor age.

Results: Mean recipient serum P at ET was 25.5 ± 10.1 ng/mL. Recipients with P < 20 ng/mL at ET, despite P dose increases after ET, were less likely to achieve clinical pregnancy (RR = 0.75, 95 % CI = 0.60-0.94, p = 0.01) and live birth (RR = 0.77, 95 % CI = 0.60-0.98, p = 0.04), as compared to those with P ≥ 20 ng/mL. P dose increases were more often required in overweight and obese recipients.

Conclusions: Serum P levels on the day of ET in fresh donor IVF/ICSI cycles were positively correlated with clinical pregnancy and live birth rates. An increase in P dose after ET was insufficient to rescue pregnancy rates. Overweight and obese recipients may require higher initial doses of P supplementation. Future research is needed to define optimal serum P at ET and the interventions to achieve this target.
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http://dx.doi.org/10.1007/s10815-014-0199-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4016380PMC
May 2014

Safety of conservative management of ovarian masses during pregnancy.

J Reprod Med 2013 Sep-Oct;58(9-10):377-82

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 8th Floor, New York, NY 10032, USA.

Objective: To determine the clinical outcomes and risk factors for persistence of ovarian cysts in pregnant women. With the increased use of ultrasound in pregnancy, the identification of incidental ovarian masses is becoming more common.

Study Design: An observational study of women with ovarian masses identified before 24 weeks of pregnancy was performed. Only women who underwent follow-up imaging or surgery were included. Factors associated with persistence and outcomes of women who underwent surgery were analyzed.

Results: Of the 803 women with available follow-up, the cysts resolved in 707 (88.1%) patients. Fifty (6.2%) women underwent surgical intervention. Women with persistent cysts were younger, more often Hispanic, detected at a later gestational age, had larger cysts, and more often had complex or solid components (p < 0.05 for all). Overall, 1 (0.1%) malignancy was diagnosed (a patient with a B-cell lymphoma), while 3 (0.4%) women had borderline epithelial ovarian tumors.

Conclusion: Ovarian masses identified during pregnancy have a low risk of malignancy. The majority of women can be serially monitored without intervention.
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October 2013

Uterine fibroids and subfertility: an update on the role of myomectomy.

Curr Opin Obstet Gynecol 2013 Jun;25(3):255-9

Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.

Purpose Of Review: Uterine fibroids, the most common neoplasm of reproductive-aged women, can have a significant impact on quality of life, and may affect fertility and pregnancy outcomes. Although it is generally accepted that submucosal fibroids are of clinical significance, the effect of intramural and subserosal fibroids, and the benefit of surgical removal remains an area of active debate. Because of this controversy, this article will review current evidence for an association of fibroids and subfertility, and assess the impact of surgical management on fertility outcomes.

Recent Findings: Recent analyses of patients with intramural fibroids have reported an increase in pregnancy loss and reduction in pregnancy and live birth rates. However, when analyzing studies with high quality diagnostic methods for assessing the endometrial cavity, no significant impact on reproductive outcomes was observed, and no benefit of myomectomy was consistently demonstrated. Myomectomy for submucosal fibroids greater than 2 cm and for intramural fibroids distorting the endometrial contour likely confers improvement of fertility outcome.

Summary: Submucosal fibroid location and distortion of the endometrial cavity (either submucosal or deeply infiltrating intramural fibroids) are most predictive of impaired fertility and probable benefit of surgical removal, and warrant consideration of myomectomy in the subfertile patient.
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http://dx.doi.org/10.1097/GCO.0b013e3283612188DOI Listing
June 2013

Early β-human chorionic gonadotropin trends in vanishing twin pregnancies.

Fertil Steril 2013 Jul 29;100(1):116-21. Epub 2013 Mar 29.

Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.

Objective: To describe the early β-hCG trends in vanishing twins compared with normally progressing singleton and twin pregnancies.

Design: Retrospective cohort study.

Setting: University-based infertility clinic.

Patient(s): Women undergoing fresh IVF/intracytoplasmic sperm injection (ICSI) cycles between 1998 and 2010.

Intervention(s): Early β-hCG level increase in vanished twin pregnancies was compared with the level increase in normally progressing singleton and twin pregnancies.

Main Outcome Measure(s): Two-day percent increase in β-hCG level.

Result(s): Pregnancies with vanishing twins demonstrated a significantly lower mean 2-day percent increase in β-hCG level than singletons and twins (114.3% vs. 128.8% and 125.4%, respectively). Vanishing twins arresting at earlier developmental stages demonstrated significantly further reduced β-hCG level increases. Infrequently, all groups had β-hCG level increases less than previously established clinical thresholds that led to a live birth.

Conclusion(s): Early β-hCG level increases are slower in vanishing twins than in singleton and twin pregnancies, with the slowest increases seen when the spontaneous fetal losses occur at earlier developmental stages. All increases, however, are within clinically accepted normal limits. Therefore, abnormal β-hCG level increases should not be attributed to a vanishing twin. Of note, an abnormal β-hCG level trend--even an initial decrease--does not preclude live birth, even in a singleton pregnancy.
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http://dx.doi.org/10.1016/j.fertnstert.2013.02.057DOI Listing
July 2013