bluuebunny/crossref_metadata_2025_split huggingface dataset:
Twin Anemia Polycythemia Sequence: A Complication of Monochorionic Diamniotic Twin Gestation [16P]
Authors: Savasan Zeynep Alpay , Zeb Amna , Scott Lauren 
Published: May 2017

INTRODUCTION:
Twin anemia polycythemia sequence (TAPS) is an important prenatal complication of monochorionic twin gestations due to abnormal placental vascular anastomosis. Prenatal ultrasound is the only screening modality. Our objective was to evaluate the prediction potential of current prenatal ultrasound screening in diagnosing TAPS in monochorionic diamniotic twin gestations.

METHODS:
Maternal and neonatal medical records were reviewed for women with monochorionic diamniotic twins who delivered at Beaumont Hospital System (Royal Oak and Troy) from 2009-2014. Available prenatal ultrasound findings were compared with the neonatal outcomes. Postnatal TAPS diagnosis was confirmed with neonatal peripheral blood hemoglobin values.

RESULTS:
A total of 132 maternal charts were reviewed and 102 were used in data collection. The median maternal age was 31 years (19-45) with a median parity of 1 (0-3). Among these women 10% (n=10) had assisted reproductive technology. Median gestational age at time of delivery was 35.4 weeks (20.7-39). Median NICU stay for twin A and twin B were 9 (0-264) and 8.5 days, (0-103), respectively. Among 132 prenatal ultrasound screenings, 26% (n=32) were reported as abnormal. Thirty-three percent (n=34) of the neonates were diagnosed with anemia and polycythemia; of these neonates 29% (n=30) had anemia, 4% (n=4) had polycythemia. The sensitivity and specificity of prenatal ultrasound in the prediction of TAPS was 26% (95% CI: 13-44) and 77% (95% CI: 65-87), respectively.

CONCLUSION:
Current prenatal ultrasound screening guidelines have low sensitivity and specificity in predicting TAPS in monochorionic diamniotic twin gestations. New and updated prenatal screening methods may improve TAPS prediction.
Is Advance Maternal Age an Indication for Fetal Echocardiogram? [18P]
Authors: Patel Krunal , Parikh Bijal , Guirguis George , Williams Shauna , Apuzzio Joseph 
Published: May 2017

INTRODUCTION:
Pregnancies in women of advanced maternal age (AMA) are at increased risk for aneuploidy and therefore could be at increased risk for congenital heart disease (CHD). Our objective was to assess whether AMA without another risk factor for CHD is associated with abnormal fetal echocardiogram.

METHODS:
This is a retrospective cohort study of all patients who were referred for specialized sonogram and fetal echocardiogram January 1, 2015 through December 31, 2015 at a single academic institution. Data was collected on demographics, indications for specialized sonogram and fetal echocardiogram, aneuploidy screening, amniocentesis results and obstetric outcomes. Patients were grouped by age (< 35 or > 35 at delivery) and rate of abnormal fetal echocardiograms were compared by Fisher's exact test.

RESULTS:
483 patients underwent specialized sonogram, 189 (39%) were AMA patients. Fetal echocardiogram was performed in 87 (46%) patients in the AMA group versus 134 (45.4%) patients in the non-AMA group. Abnormal fetal echocardiograms were found in 2 (2.2%) of the AMA group compared to 8 (6%) of the non-AMA group (p=0.32). Of the 65 AMA patients who did not have another indication for fetal echocardiogram, 2 (3%) had abnormal results (mild cardiomyopathy, VSD) whereas there were no abnormal echocardiograms in AMA patients with another indication (0/22). One of the two patients had an abnormal quad screen for increased risk for trisomy 21.

CONCLUSION:
In this cohort, AMA without another indication for fetal echocardiogram had a 3% rate of abnormal fetal echocardiogram. This suggests that a fetal echocardiogram should be considered in patients who are AMA.
Cost-effectiveness of Preimplantation Genetic Screening for Women Older than 37 Years Undergoing IVF [19P]
Authors: Collins Stephen C. , Xu Xiao , Mak Winifred 
Published: May 2017

INTRODUCTION:
Adding preimplantation genetic screening (PGS) to in-vitro fertilization (IVF) has been shown to increase live birth rates (LBR) in women older than 37. However, PGS is an expensive procedure. It is important to evaluate the cost-effectiveness of IVF-PGS versus IVF alone in improving LBR.

METHODS:
We constructed a decision analytic model for a hypothetical fresh, autologous IVF cycle (with versus without PGS) for women older than age 37 who had a successful oocyte retrieval. The model incorporated probability and cost estimates of main clinical events including PGS, blastocyst transfer, clinical pregnancy, miscarriage, pregnancy termination, and live birth based on data from published literature.

RESULTS:
In base-case analysis, IVF-PGS offered a 4.2 percentage point increase in LBR for an additional cost of $4,287, yielding an incremental cost-effectiveness ratio (ICER) of $100,290 for one additional live birth. This ICER was less than the expected cost of $122,581 for achieving one live birth with IVF (assuming an average LBR of 15.3% and $18,707 per cycle for this patient population). Furthermore, sensitivity analysis suggested that ICER improved substantially with decreases in PGS cost and increases in PGS effectiveness. Monte Carlo simulation showed PGS to be cost-effective in 89.1% of iterations at an acceptability cutoff of $122,581.

CONCLUSION:
Considering the expected cost of achieving one live birth with IVF, PGS appears to be a cost-effective strategy for women older than 37 undergoing IVF. Additional research on patients' willingness-to-pay for an additional live birth would further inform our understanding regarding the cost-effectiveness of PGS.
Voicing Needs: The Experience of Fertility Care in the United States [21P]
Authors: Kudesia Rashmi , Bhasin Deepika , Lee Joseph A. , Daneyko Margaret , Collura Barb , Copperman Alan B. 
Published: May 2017

INTRODUCTION:
To learn how reproductive medicine practices in the United States can improve patient care.

METHODS:
A 52-item survey that included six domains of structured and open-ended questions. Open-ended responses were evaluated by the grounded theory method.

RESULTS:
Patients stated a desire for personalized care, including being treated “like a person” and not “feeling like a number”. Many participants described feeling “herded” during morning hormone monitoring. Occasionally, they felt they might be receiving a “one-size-fits-all” treatment, and that diagnostic testing had been insufficient and could have led towards invasive treatment. Respondents voiced trust in their physician and that regular visitation helped their treatment experience. Twenty-eight respondents mentioned sensitivity as a center attribute. An absence in sensitive was perceived to be caused by provider burnout and the concept that “they know you don't really have a choice”. A desire to be treated with patience, educated and offered in-house ancillary care services were observed. Triggers viewed as unnecessary provocations during an already-stressful time included the presence of children in the waiting room, visibly pregnant patients or staff, particularly when there was a perception that someone “showed off her pregnant belly”, care costs, insurance coverage, inconvenient calls, center preference to email, and concern over a lack in regulation.

CONCLUSION:
While satisfied with overall care, some issues, such as lack of uniform insurance coverage, are out of our direct center control. Moreover, vigilance in office workflow, staff education, and forming partnerships with financial, emotional and complementary medical support services could improve the patient experience.
Cabergoline Preserves Implantation and Ongoing Pregnancy Rates in High Responders to Gonadotropin [22P]
Authors: Wilson Alexandra , Shu Yimin , Patel Bansari , Berga Sarah , Prokai David , Johnston-MacAnanny Erika 
Published: May 2017

INTRODUCTION:
While infrequent, excessive response to gonadotropin occurs in spite of careful pre-cycle planning. We sought to determine the impact of cabergoline administration on implantation, clinical and ongoing pregnancy rates in patients with excessive response to gonadotropins without other features of ovarian hyperstimulation syndrome (OHSS) during fresh embryo transfer.

METHODS:
All fresh IVF cycles undergoing embryo transfer from 2013-2016 in an academic center were reviewed to identify cycles with excessive response to gonadotropin. Patients were excluded if their embryos underwent preimplantation genetic screening or if early OHSS was diagnosed necessitating cryopreservation. All patients were triggered with urinary hCG and oocyte collection occurred 36 hours after trigger. Administration of cabergoline at the time of hCG trigger stratified the two groups. Choice to administer cabergoline was based on provider discretion. Differences between groups were obtained through chi-squared analysis.

RESULTS:
Sixteen patients (N=16) met inclusion criteria for study. Subjects were equally divided into cabergoline exposure (N=8) and absence of cabergoline exposure (N=8). The implantation rates were 28.5% (4/14) and 63.3% (7/11), in the non-exposure and exposure groups respectively. 50% (4/8) of the non-exposure group versus 75% (6/8) exposure group achieved clinical pregnancy. Ongoing pregnancy rates were identical with 75% rate (6/8) in both groups.

CONCLUSION:
In high responders, those who had co-administration of cabergoline maintain outstanding implantation rates and clinical and ongoing pregnancy rates. In patients exposed to cabergoline without other features of OHSS, embryo transfer may be carefully considered without compromise of implantation rates, particularly in those with high response.
New FIGO Guidelines on Gestational Diabetes [24P]
Authors: Dahiya Krishna 
Published: May 2017

INTRODUCTION:
Gestational diabetes mellitus is one of the most common medical disorders found in pregnancy. Clinical recognition of GDM is important because timely intervention by dietary measures or insulin and fetal surveillance can reduce the well described associated maternal and fetal complications.

METHODS:
This observational study was done over a period of one year. Single step test using 75 gms oral glucose was used as screening and diagnostic test for GDM. A total of 500 pregnant women attending antenatal clinic were selected randomly for the study at less than 16 weeks POG. All the selected women were given a 75 gm anhydrous glucose powder dissolved in a glass of water, to be consumed over 5 minutes, irrespective to the time of last meal. A venous blood sample was collected at 2 hours for estimating plasma glucose by the glucose oxidase peroxidase (GOD-POD) method. GDM was diagnosed if 2 hrs plasma glucose is >140 mg/dl.

RESULTS:
Prevalence of GDM was found to be 7% in present study. Age ≥25 years, obesity, multigravidity and family history of diabetes mellitus were major risk factors for developing GDM. Maternal and fetal outcomes were poor in GDM group as compared to the control group. In GDM group common maternal complications were polyhydramnios and recurrent vaginal infections.

CONCLUSION:
Present study concurs with the WHO recommendation of 2-hr 75 gms OGTT as single step procedure for both screening as well as diagnosis of GDM. Hence we suggest the adaptation of 75 gms glucose single step test for screening and diagnosis of GDM.
Does Laterality of the Dominant Follicle Matter Under Ovulation Induction? [26P]
Authors: Gentry Adrienne , Theisen John G. , Norwick Holly , Pagidas Kelly 
Published: May 2017

INTRODUCTION:
Evidence suggests that ovulation from the right ovary has a higher chance of pregnancy. Alternating ovulation from cycle to cycle also favors pregnancy, rather than when a woman ovulates from the same ovary cycle to cycle. There is minimal literature regarding laterality of dominant follicle with ovulation induction with clomiphene citrate and/or letrozole. The study objective was to evaluate laterality of dominant follicles and associated outcomes in ovulation induction or superovulation with letrozole or clomiphene citrate.

METHODS:
This retrospective chart review of patients who underwent ovulation induction with Letrozole or Clomiphene Citrate at the University of Louisville Fertility Center included women (age 18 or older) that had a monitored ovulation ultrasound. Exclusion criteria were any factors that excluded them from ovulation induction. Cycle differences analyzed via logistic regression to get odds ratio, CI, and p values.

RESULTS:
Overall, 171/188 cycles had a dominant follicle (91%). Pregnancy rate was 14.4% when a lead follicle was present. There was no difference in laterality of dominant follicle (left 53.2%, right 46.7%, P=0.44), no difference in pregnancy rate regarding laterality of dominant follicle (left 12.5%, right 14.1%, OR (R vs L) =1.15 (0.45-2.94), P= 0.94). Pregnancy rate was increased when more than one dominant follicle was noted (OR (2+ vs 1)=3.79 (1.31-10.95) P=0.01).

CONCLUSION:
The laterality of the dominant follicle does not seem to be influenced by ovulation induction with clomiphene citrate or letrozole and does not seem to influence a successful outcome. This study confirms that more than one dominant follicle increases your chance of pregnancy.
Rural, Resident Fertility Clinic Patients Have Little Insight Into Their BMI or Implications of Obesity on Fertility [27P]
Authors: Ulrich Nicole , Straney Jennifer , Luo Qingyang , Wells Lindsay 
Published: May 2017

INTRODUCTION:
Abnormal weight and its effects on health and fertility are poorly understood by patients. We aimed to evaluate differences in knowledge of abnormal weight and its effect on fertility between patients seen for infertility and general gynecology (GYN) at a rural, resident-run clinic.

METHODS:
Participation in this 12-question survey-based analysis of weight/fertility knowledge was offered to patients seen in our rural, resident-run clinic. Survey assessed knowledge of abnormal weight and its effect on fertility, yielding a “Fertility Knowledge Score” and “Physician Education Score.” Visit number, age, visit type, and body mass index (BMI) were collected via chart review. The mean correct scores of both groups of patients (infertility and GYN) were compared using 2 sample T-test and Chi-squared test.

RESULTS:
Surveys for 44 infertility patients and 51 GYN patients were included. Infertility patients had higher mean BMI (37.5) than gynecology patients (32.9), (p=0.0263); 91% of fertility patients and 80% of GYN patients were overweight/obese. Infertility patients (p=0.0239) and patients with higher BMI (p=0.0112) reported discussing weight/BMI with a physician more often. There was no difference in survey scores between new and established patients overall or when these scores were analyzed by patient weight.

CONCLUSION:
Both infertility and GYN patients have little insight into their own BMI, with no change over visits. BMI is higher among infertility patients. Though, infertility patients have high general knowledge of effects of abnormal weight on fertility. This suggests we are not effectively discussing individual implications of weight/BMI despite large numbers of overweight/obese patients under our care.
Reproductive Uterine Transplantation: Ethical Considerations [30P]
Authors: Allyse Megan 
Published: May 2017

INTRODUCTION:
The recent live births of five babies after elective uterine transplantation from a live donor has demonstrated one possible mechanism to address absolute uterine factor infertility. However, national and cultural factors contributed to the ethical and medical permissibility of uterine transplant in the Swedish context. These factors may be different in other socio-national contexts. We sought to understand the potential permissibility of the procedure in the US context.

METHODS:
We conducted an ethical analysis of the potential practice of elective reproductive uterine transplantation in the US from a perspective of women's health and rights.

RESULTS:
Relevant vectors of analysis include alternative paths to parenthood, considerations of baseline status versus enhancement, reproductive rights, feminist critiques, allocation of healthcare resources, and the balance of risk and benefit. Compelling arguments are made on both sides of the deliberation under all vectors.

CONCLUSION:
On balance, arguments for or against elective uterine transplant in the US context appeared to balance. However, the most compelling factors that must be addressed in order to justify the procedure include the absence of alternatives, the risk to donors and recipients, and the healthcare opportunity costs.
Hysterosalpingogram (HSG) vs Mid-Cycle Ultrasound (MCUS) in Anatomic Assessment of Infertile Women [32P]
Authors: Durowade Taiwo , Ayers Jonathan 
Published: May 2017

INTRODUCTION:
Utero-tubal anatomic abnormalities represent a very important etiology for primary infertility, and proper evaluation is critical for directed therapy. The most common methods used for evaluation of patients presenting with infertility are: transcervical injection of contrast media with radiography; Hysterosalpingogram (HSG) or transcervical injection of saline with ultrasound; Saline infusion sonography (SIS). However, these methods are painful, costly and can be “non-diagnostic.” Studies show that there is a ten-fold increase in estradiol levels during the mid-cycle. This increases fallopian tube fluid production and endometrial gland thickness, thereby providing a “natural contrast” vs iodinated contrast of HSG. This study proposes that a mid-cycle 2D ultrasound (MCUS) can provide the same accuracy of information as HSG without the pain, cost and potential false findings.

METHODS:
In the year prior to this study, 153 women with primary infertility underwent both HSG and MCUS during their evaluation at IVF Michigan. The HSG and the dynamic MCUS were performed by a reproductive endocrinologist. The findings of tubal and uterine abnormalities identified with HSG were compared with those identified with MCUS.

RESULTS:
MCUS identified all distal tubal occlusions with sensitivity and specificity of 100% compared to HSG, and it identified uterine abnormalities with 76% sensitivity and 96% specificity.

CONCLUSION:
Physician performed dynamic MCUS provides an excellent screening alternative for anatomic assessment of women with infertility and may eliminate the need for invasive testing in this population.
Management of Ectopic Ovary in the Setting of Mullerian Agenesis [35P]
Authors: Kanter Jessica , Jarrard Merry , Gavrilova-Jordan Larisa 
Published: May 2017

INTRODUCTION:
Mullerian agenesis can be associated with a complex array of other congenital anomalies, including ectopic ovaries. As a rare finding, clinical recommendations are not clear cut, therefore we present a case report and literature review to develop recommendations for clinical management of an ectopic ovary in the setting of complete Mullerian agenesis.

METHODS:
An adolescent female with primary amenorrhea underwent complete evaluation at an academic reproductive endocrinology clinic. Clinical management recommendations were developed based on literature review.

RESULTS:
Physical examination of the 16-year-old amenorrheic female revealed a short blind vagina, fullness of the left inguinal canal, normal sexual hair distribution and breast development. Further evaluation with pelvic MRI demonstrated absence of the uterus, normal right ovary, and ectopic ovarian gonad located in the left inguinal canal. She was additionally found to have absence of the left kidney and a hypertrophic right kidney with a single ureter. We performed extensive literature review to develop clinical recommendation on ectopic ovary in patients with complete Mullerian agenesis, also known as Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. The considerations of gonadal conservation, risk of malignancy, and indications of ovarian transposition were evaluated in preparation of management recommendations.

CONCLUSION:
Ovarian conservation without ovarian transposition is an optimal clinical management in the case of unilateral ectopic ovary in patients with Mullerian agenesis. Absence of significant increase of malignant transformation should be discussed with these patients. A review of possible oocyte recovery from an ectopic ovary and role of assisted reproductive technology is highly recommended to diminish patient anxiety about future fertility.
Reproductive Options for Transgender Patients [36P]
Authors: Luikenaar Rixt 
Published: May 2017

INTRODUCTION:
The Affordable Health care Act 1557 in May 2016 forbids discrimination on the basis of gender by physicians. Obstetricians and gynecologists continue to see an increase in the number of transgender patients desiring to reproduce and have children. They have questions about surrogacy, egg freezing and are looking for nonjudging obstetricians to deliver their babies. There are few to none data showing effect of cross hormone therapy on fertility. Barriers to access of care have been lack of education of physicians and the lack of insurance companies offering transgender inclusive health plans.

METHODS:
Since 2011 I have treated over 2,000 transgender and gender nonconforming patients. Besides hormone therapy, pre- and postoperative care, primary and preventive care I also heard many reproductive questions, either about sperm and egg banking, surrogacy or pregnancies. I performed a literature review study which revealed very few articles. From my own patient histories I continue to hear about being mis-gendered or doctors not paying attention to preferred pronouns or assuming they want their reproductive organs removed.

RESULTS:
There are no evidence based studies that tell us how to counsel our transgender patients about future fertility, however many transgender men and women desire pregnancy.

CONCLUSION:
This is pioneer work. There are few data and still many physicians have issues with trans men and trans women's reproductive rights. We need to support and advocate for this minority that needs us to help them make healthy decisions for themselves and their families, however different they may be from yours.
Inpatient Prenatal Yoga for Hospitalized High-Risk Antepartum Patients: A Feasibility Study [1Q]
Authors: Demtchouk Veronica , Kelly Jeannie , Prigo Corinne , Dangel Alissa 
Published: May 2017

INTRODUCTION:
Prenatal yoga has been shown to be a safe and effective treatment for depression and pain, while improving high-risk pregnancy outcomes. This study investigated the feasibility of establishing a prenatal yoga program for hospitalized high-risk antepartum patients.

METHODS:
Patients admitted for at least 72 hours to the antepartum service at a tertiary care center were screened for eligibility and consented. Additional medical clearance was obtained from their primary obstetrician. A 30-minute prenatal yoga session was held once a week by a certified prenatal yoga instructor. Physical activity level was adapted to accommodate patients on modified bed rest. Participants completed a questionnaire following the conclusion of each session addressing class timing, length, and frequency. Antepartum nurses were also surveyed to evaluate their perspective.

RESULTS:
The majority of antepartum patients hospitalized for pregnancy-related complications were offered participation. Of these, 34 women consented and were eligible to participate; 13 attended at least one session during their hospitalization. Others did not participate due to scheduling conflicts with fetal testing, change in clinical status, lack of interest the day of, and delivery or discharge. Post session patient surveys revealed that all patients enjoyed class length and frequency and viewed them as beneficial for managing stress, musculoskeletal discomfort, and sleep quality. Nursing surveys revealed the class did not affect their ability to provide medical care for the patients.

CONCLUSION:
Inpatient prenatal yoga is a feasible and acceptable intervention for high risk women admitted for antepartum management. Future study of the effect on maternal and fetal outcomes should be strongly considered.