Predictors of pregnancy in women with polycystic ovary syndrome

CONTEXT

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. The selection of first-line therapies for ovulation induction is empiric.

OBJECTIVE

The aim of the study was to develop a clinically useful predictive model of live birth with varying ovulation induction methods.

DESIGN, SETTING, AND PARTICIPANTS

We built four prognostic models from a large multicenter randomized controlled infertility trial of 626 women with PCOS performed at academic health centers in the United States to predict success of ovulation, conception, pregnancy, and live birth, evaluating the influence of patients' baseline characteristics.

INTERVENTIONS

Ovulation was induced with clomiphene, metformin, or the combination of both for up to six cycles or conception.

MAIN OUTCOME MEASURE

The primary outcome of the trial was the rate of live births.

RESULTS

Baseline free androgen index, baseline proinsulin level, interaction of treatment arm with body mass index, and duration of attempting conception were significant predictors in all four models. History of a prior loss predicted ovulation and conception, but not pregnancy or live birth. A modified Ferriman Gallwey hirsutism score of less than 8 was predictive of conception, pregnancy, and live birth (although it did not predict ovulation success). Age was a divergent predictor based on outcome; age greater than 34 predicted ovulation, whereas age less than 35 was a predictive factor for a successful pregnancy and live birth. Smoking history had no predictive value.

CONCLUSIONS

A live birth prediction chart developed from basic clinical parameters (body mass index, age, hirsutism score, and duration of attempting conception) may help physicians counsel and select infertility treatments for women with PCOS.

Transforming growth factor beta3 regulates the versican variants in the extracellular matrix-rich uterine leiomyomas

Uterine leiomyoma are common, benign tumors that are enriched in extracellular matrix. The tumors are characterized by a disoriented and loosely packed collagen fibril structure similar to other diseases with disrupted Transforming growth factor beta (TGF-beta) signaling. Here we characterized TGF-beta3 signaling and the expression patterns of the critical extracellular matrix component versican in leiomyoma and myometrial tissue and cell culture. We also demonstrate the regulation of the versican variants by TGF-beta3. Using leiomyoma and matched myometrium from 15 patients, messenger RNA (mRNA) from leiomyoma and myometrium was analyzed by semiquantitative real time reverse transcription-polymerase chain reaction (RT-PCR), while protein analysis was done by western blot. Transforming growth factor beta3 transcripts were increased 4-fold in leiomyoma versus matched myometrium. Phosphorylated-TGF-beta RII and phosphorylated-Smad 2/3 complex were greater in leiomyoma as documented by Western blot. The inhibitor Smad7 transcripts were decreased 0.44-fold. The glycosaminoglycan (GAG)-rich versican variants were elevated in leiomyoma versus myometrial tissue: specifically V0 (4.27 +/- 1.12) and V1 (2.01 +/- 0.27). Treatment of leiomyoma and myometrial cells with TGF-beta3 increased GAG-rich versican variant expression 7 to 12 fold. Neutralizing TGF-beta3 antibody decreased the expression of the GAG-rich versican variants 2 to 8 fold in leiomyoma cells. Taken together, the aberrant production of excessive and disorganized extracellular matrix that defines the leiomyoma phenotype involves the activation of the TGF-beta signaling pathway and excessive production of GAG-rich versican variants.

Ovarian preservation by GnRH agonists during chemotherapy: a meta-analysis

PURPOSE

Treatment with cyclophosphamide (CYC) confers up to a 40% risk of ovarian failure in women of reproductive age. The use of GnRH agonists (GnRHa) to preserve ovarian function has been investigated in several small studies. We performed a systematic review of studies examining whether a GnRHa administered during chemotherapy is protective of ovarian function and fertility.

METHODS

We searched the English-language literature (1966-April 2007) using MEDLINE and meeting abstracts and included studies that reported an association between GnRHa and ovarian preservation in women receiving chemotherapy. Studies without a control group were excluded. Ovarian preservation was defined as the resumption of menstrual cycles and a premenopausal follicle-stimulating hormone (FSH) after chemotherapy. Fertility was determined by a woman's ability to become pregnant. We estimated the summary relative risk (RR) and associated 95% confidence intervals (95% CI) using a random-effects model.

RESULTS

Nine studies included 366 women. Three studies included women with autoimmune disease receiving CYC; six included women with hematologic malignancy receiving combination chemotherapy. In total, 178 women were treated with GnRHa during chemotherapy, 93% of whom maintained ovarian function. Of the 188 women not treated with GnRHa, 48% maintained ovarian function. The use of a GnRHa during chemotherapy was associated with a 68% increase in the rate of preserved ovarian function compared with women not receiving a GnRHa (summary RR = 1.68, 95% CI 1.34-2.1). Among the GnRHa-treated women, 22% achieved pregnancy following treatment compared with 14% of women without GnRHa therapy (summary RR = 1.65, CI 1.03-2.6).

CONCLUSIONS

Based on the available studies, GnRHa appear to improve ovarian function and the ability to achieve pregnancy following chemotherapy. Several randomized trials are underway to define the role and mechanism of GnRHa in ovarian function preservation. In the meantime, premenopausal women facing chemotherapy should be counseled about ovarian preservation options, including the use of GnRHa therapy.

Ovulatory response to treatment of polycystic ovary syndrome is associated with a polymorphism in the STK11 gene

CONTEXT

Clomiphene and insulin sensitizers such as metformin are used to induce ovulation in polycystic ovary syndrome (PCOS), but the ovulatory response is variable, and the causes of this variation are poorly understood.

OBJECTIVE

Our objective was to identify predictive genetic polymorphisms and other determinants of ovulatory response.

DESIGN

This was a substudy of a multicenter randomized clinical trial.

SETTING

This study was performed at academic medical centers and their affiliates.

PARTICIPANTS

A total of 312 women with PCOS were included in the study.

MAIN OUTCOME MEASURES

Historical, biometric, biochemical, and genetic parameters were performed.

RESULTS

We found that the C allele of a single nucleotide polymorphism in the STK11 gene (expressed in liver; also known as LKB1) was associated with a significantly decreased chance of ovulation in PCOS women treated with metformin. In an analysis of ovulation per cycle, the adjusted odds ratio (OR) comparing the C/C genotype to the G/G genotype was 0.30 [95% confidence interval (CI) 0.14, 0.66], and the OR for the C/G genotype vs. the G/G genotype was also 0.30 (95% CI 0.14, 0.66). In an analysis of metformin-treated subjects, we found that the percentage of women who ovulated increased with the number of G alleles present: 48% (10 of 21) of C/C women, 67% (32 of 48) of C/G women, and 79% (15 of 19) of G/G women ovulated. We also found that increased frequency of ovulation was associated with lower body mass index (BMI) [adjusted OR of 2.36 (95% CI 1.65, 3.36) and 2.05 (95% CI 1.46, 2.88), respectively, for comparisons of BMI less than 30 vs. BMI equal to or more than 35, BMI 30-34 vs. BMI equal to or more than 35, in the analysis of ovulation per cycle], a lower free androgen index (FAI) [adjusted OR of 1.59 (95% CI 1.17, 2.18) for FAI<10 vs. FAI>or=10], and a shorter duration of attempting conception [adjusted OR of 1.63 (95% CI 1.20, 2.21) for<1.5 vs.>or=1.5 yr].

CONCLUSIONS

We have demonstrated that a polymorphism in STK11, a kinase gene expressed in liver and implicated in metformin action, is associated with ovulatory response to treatment with metformin alone in a prospective randomized trial. The interaction with the effects of changes in modifiable factors (e.g. BMI or FAI) requires further study.

Medication adherence and treatment success in the National Institute of Child Health and Human Development-Reproductive Medicine Network's Pregnancy in Polycystic Ovary Syndrome Trial

We investigated whether poor adherence with metformin tablets may have contributed to the poor success rates seen in the metformin-containing arms of the Pregnancy in Polycystic Ovary Syndrome (PPCOS) Trial. Median adherence for both metformin and clomiphene citrate tablets was within acceptable limits and unrelated to ovulation: thus, failure to comply with physician recommendations for metformin dosing was not the reason for low ovulation and pregnancy rates in the PPCOS Trial.

Hysterectomy and loss of fertility: implications for women's mental health

OBJECTIVE

The objective of this study was to assess the percentage of women scheduled for hysterectomy who would have liked to have had a child or more children and associated factors.

METHODS

The study sample included 1140 premenopausal women having hysterectomy for benign indications who were interviewed before and after their surgery over the course of a 2-year follow-up period. The main outcome measures for this study were desire for a (or another) child measured preoperatively; concurrent measures of psychological distress, including anxiety, depression, anger, and confusion, and seeking of professional help for emotional problems; and psychological distress measured 12 and 24 months postoperatively.

RESULTS

Of the sample, 10.5% (n=120) answered yes to the question, "Before you were told you needed a hysterectomy, would you have wanted a (or another) child?" As compared with those who did not, those who desired a (another) child were younger; more likely to be nulliparous; waited longer before having surgery; were more likely to have an indication of endometriosis; had higher levels of depression, anxiety, anger, and confusion; and were more than twice as likely to have seen a mental health professional for anxiety or depression in the 3 months before their surgery. These differences in psychological distress persisted over the course of the 2-year follow-up period.

CONCLUSIONS

The issue of loss of fertility should be discussed candidly with women considering hysterectomy, and those who express ambivalence, sadness, or regret at the loss of future childbearing options may benefit from further exploration of fertility-sparing treatments.

Progesterone protects fetal chorion and maternal decidua cells from calcium-induced death

OBJECTIVE

The purpose of this study was to determine whether progesterone exerts a protective effect in chorion and decidua cells when exposed to calcimycin.

STUDY DESIGN

Fetal membrane samples were collected from term elective repeat cesarean deliveries and chorion and decidua cells that are separated and cultured. Cells were pretreated with progesterone and exposed to calcimycin. Cell viability was determined, and percent cell viability was calculated.

RESULTS

Exposure to calcimycin resulted in a reduction of cell viability in both chorion and decidua cells in a dose-dependent fashion. In chorion and decidua cells, progesterone pretreatment followed by calcimycin increased cell viability compared with calcimycin treatment alone (chorion, 67%, vs controls, 24%; P < .001; decidua, 58%, vs controls, 35%; P < .001). The progesterone receptor antagonist, RTI 6413-49a, blocked the protective effect of progesterone in both chorion and decidua cells.

CONCLUSION

These preliminary results suggest that progesterone may provide a protective effect in fetal membrane cells and that this effect may be mediated through the progesterone receptor.

Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome

BACKGROUND

The polycystic ovary syndrome is a common cause of infertility. Clomiphene and insulin sensitizers are used alone and in combination to induce ovulation, but it is unknown whether one approach is superior.

METHODS

We randomly assigned 626 infertile women with the polycystic ovary syndrome to receive clomiphene citrate plus placebo, extended-release metformin plus placebo, or a combination of metformin and clomiphene for up to 6 months. Medication was discontinued when pregnancy was confirmed, and subjects were followed until delivery.

RESULTS

The live-birth rate was 22.5% (47 of 209 subjects) in the clomiphene group, 7.2% (15 of 208) in the metformin group, and 26.8% (56 of 209) in the combination-therapy group (P<0.001 for metformin vs. both clomiphene and combination therapy; P=0.31 for clomiphene vs. combination therapy). Among pregnancies, the rate of multiple pregnancy was 6.0% in the clomiphene group, 0% in the metformin group, and 3.1% in the combination-therapy group. The rates of first-trimester pregnancy loss did not differ significantly among the groups. However, the conception rate among subjects who ovulated was significantly lower in the metformin group (21.7%) than in either the clomiphene group (39.5%, P=0.002) or the combination-therapy group (46.0%, P<0.001). With the exception of pregnancy complications, adverse-event rates were similar in all groups, though gastrointestinal side effects were more frequent, and vasomotor and ovulatory symptoms less frequent, in the metformin group than in the clomiphene group.

CONCLUSIONS

Clomiphene is superior to metformin in achieving live birth in infertile women with the polycystic ovary syndrome, although multiple birth is a complication. (ClinicalTrials.gov number, NCT00068861 [ClinicalTrials.gov].).

Utility of screening for other causes of infertility in women with "known" polycystic ovary syndrome

We investigated the prevalence of abnormal screening results (questionnaire and testing for other causes of oligo-ovulation, male or tubal factor infertility) in a group of 1,313 oligo-ovulatory women (included and excluded subjects) whose condition was screened for inclusion in the Pregnancy in Polycystic Ovary Syndrome trial, a multicenter clinical trial that was conducted at 13 sites in the United States. Other than failure to demonstrate laboratory evidence of hyperandrogenemia, the most common reasons for subject exclusion were persistent oligospermia and tubal factor infertility.

The Pregnancy in Polycystic Ovary Syndrome study: baseline characteristics of the randomized cohort including racial effects

OBJECTIVE

To report the baseline characteristics and racial differences in the polycystic ovary syndrome (PCOS) phenotype from a large multicenter clinical trial (PPCOS).

DESIGN

Double-blind, randomized trial of three treatment regimens (with extended release metformin or clomiphene citrate).

SETTING

Academic medical centers.

PATIENT(S)

Six hundred twenty-six infertile women with PCOS, aged 18-39 years, with elevated T levels and oligomenorrhea (exclusion of secondary causes), seeking pregnancy, with > or = 1 patent fallopian tube, normal uterine cavity, and a partner with sperm concentration > or = 20 x 10(6)/mL in > or = 1 ejaculate.

INTERVENTION(S)

Baseline characterization.

MAIN OUTCOME MEASURE(S)

Historical, biometric, and biochemical measures of PCOS.

RESULT(S)

There were no significant differences in baseline variables between treatment groups. The overall mean (+/-SD) age of the subjects was 28.1 +/- 4.0 years, and the mean body mass index was 35.2 kg/m2 (+/-8.7). Polycystic ovaries (PCOs) were present in 90.3% of the subjects, and the mean volume of each ovary was 10 cm3 or more. Of the subjects, 7% had ovaries that were discordant for PCO morphology. At baseline, 18.3% of the subjects had an abnormal fasting glucose level (> 100 mg/dL). Asians tended to have a milder phenotype, and whites and African Americans were similar in these measures.

CONCLUSION(S)

The treatment groups were well matched for baseline parameters, and we have added further information to the PCOS phenotype.

The promise and perils of microarray analysis

Microarray analysis has provided a novel means of identifying clues into the mechanisms of disease development. As a methodology, microarray analysis holds the promise for genome-wide screening in which 2 tissues (diseased and normal) are compared, and molecular pathways that defined the phenotype of the disease could be precisely defined. Alternatively, microarray experiments can be used to differentially compare pathologically similar diseased tissues to predict response to chemotherapy and risk of recurrence. However, the clinician should be aware that various sources of error can influence microarray analysis results. Sources of error can be minimized but not eliminated, explaining why meticulously conducted experiments in different laboratories or using different platforms result in different lists of genes. Confirmation and validation of genome-wide microarray results using ancillary methods remains a critical step. With proper confirmatory studies and cautious interpretation, microarray analysis represents a powerful tool for molecular discovery.

A new hypothesis about the origin of uterine fibroids based on gene expression profiling with microarrays

This article will discuss some recent insights based on our microarray studies that have emphasized the role the extracellular matrix, transforming growth factor beta, and collagen structure in fibroid formation. These studies led to appreciation of molecular similarities between fibroids and keloids. Collectively, these observations suggest a model of fibroid development based on an abnormal response to tissue repair, resulting in disordered healing and formation of an altered extracellular matrix.

Comparative ultrastructure of collagen fibrils in uterine leiomyomas and normal myometrium

OBJECTIVE

To examine the ultrastructural characteristics of extracellular matrix and mature collagen fibrils in uterine leiomyomas and compare them with those in adjacent normal myometrium.

DESIGN

Analysis of paired leiomyoma-myometrium in surgical specimens.

SETTING

Research center and tertiary care center.

SUBJECT(S)

Women undergoing medically indicated hysterectomy for symptomatic uterine leiomyomas.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Appearance and spatial orientation of the collagen fibrils in leiomyomas compared with myometrium.

RESULT(S)

Observation of specimens at x 12,500 magnification indicated that collagen fibrils were more abundant, loosely packed, and arrayed in a nonparallel manner in leiomyomas compared with myometrium. Random areas were examined at x 6,500 to x 64,000 magnification and revealed collagen fibrils of equal diameter in both leiomyomas and myometrium. However, an ordered and regular barbed appearance was present in collagen fibrils from myometrium but was lacking in leiomyomas.

CONCLUSION(S)

Leiomyomas contain an abnormal collagen fibril structure and orientation, which suggests that the well-regulated fibril formation in myometrium is altered in leiomyomas. Alterations in collagen genes may play a role in the pathogenesis of leiomyomas.

Histological dating of timed endometrial biopsy tissue is not related to fertility status

OBJECTIVE

To assess the ability of histological dating to discriminate between women of fertile and infertile couples. The utility of histological dating of endometrium in the evaluation of infertile couples is uncertain.

DESIGN

Prospective multicenter study, with subjects randomly assigned to biopsy timing. Criterion standard for infertility was 12 months of unprotected, regular intercourse without conception and for fertility at least one live birth within 2 years.

SETTING

University-based infertility practices.

PATIENT(S)

Volunteer subjects (847) recruited at 12 clinical sites participating in the National Institutes of Health-funded Reproductive Medicine Network. Inclusion criteria included ages 20-39 years, regular menstrual cycles, and no hormonal treatment or contraceptive use for 1 month before the study. Fertile controls were excluded if they had a history of infertility, recurrent pregnancy loss, or recent breastfeeding.

INTERVENTION(S)

Subjects underwent daily urinary LH testing. After detection of the LH surge, subjects were randomized to biopsy in the mid (days 21-22) or the late (days 26-27) luteal phase. Pathologists at each site estimated the cycle day based on standard criteria. For the primary analysis, an out-of-phase biopsy was defined as a greater than 2-day delay in the histological maturation of the endometrium.

MAIN OUTCOME MEASURE(S)

The proportion of out-of-phase biopsies in fertile and infertile women was compared using logistic regression models with age at randomization as a covariate. Comparisons were also made between fertile vs. infertile at the midluteal or late luteal phase time points.

RESULT(S)

Biopsies were evaluated (301 mid and 318 late; N = 619). Out-of-phase biopsy results poorly discriminated between women from fertile and infertile couples in either the midluteal (fertile: 49.4%, infertile: 43.2%) or late luteal phase (fertile: 35.3%, infertile 23.0%). Results did not substantially differ using alternative definitions of "out-of-phase" or standardized cycle day.

CONCLUSION(S)

Histological dating of the endometrium does not discriminate between women of fertile and infertile couples and should not be used in the routine evaluation of infertility.

Absence of secretory endometrium after false-positive home urine luteinizing hormone testing

OBJECTIVE

To examine the proportion of cases with proliferative endometrium on biopsies performed after positive home urine LH testing.

DESIGN

Multicenter clinical trial of the usefulness of endometrial biopsy in the evaluation of infertility, with women from fertile and infertile couples randomly assigned to midluteal vs. late luteal phase endometrial sampling.

SETTING

Twelve clinical sites of the National Institutes of Health/National Institute of Child Health and Human Development-sponsored Reproductive Medicine Network.

PATIENT(S)

All women in the study had regular menstrual cycles. Fertile volunteers who had delivered a live born infant within the past 2 years without medical intervention were recruited through advertisements at participating sites. Infertile women with regular cycles were recruited from the clinical practices of the sites' physicians.

INTERVENTION(S)

Interview, informed consent, subject-interpreted home urine LH testing, and endometrial biopsy in either the midluteal or late luteal phase.

MAIN OUTCOME MEASURE(S)

Proportion of cases with proliferative endometrium on biopsy.

RESULT(S)

In both fertile and infertile women, more than 7% of endometrial biopsies performed 7-13 days after a positive home urine LH test revealed proliferative endometrium.

CONCLUSION(S)

Patient interpretation of home urine LH test kits not uncommonly results in false-positive tests. Women planning menstrual cycle testing or procedures related to ovulation may benefit from additional confirmatory testing.

Reduced dermatopontin expression is a molecular link between uterine leiomyomas and keloids

Uterine leiomyomas are prevalent estrogen-responsive clonal tumors, but the specific genetic alterations that contribute to their development have not been elucidated. To identify genes involved in the formation of leiomyomas, we used global expression profiling to compare clonal tumors with normal myometrium. Contrary to expectation, genes involved in estrogen action were not differentially expressed between leiomyoma and normal myometrium. Genes encoding extracellular-matrix proteins were prominently featured, suggesting their involvement in formation of a myofibroblast phenotype. Analysis of the extracellular matrix in the leiomyomas revealed a disordered collagen fibril orientation. Expression of the collagen-binding protein dermatopontin was found to be consistently decreased in leiomyoma by both reverse transcriptase-polymerase chain reaction (RT-PCR) and real-time RT-PCR (mean underexpression = 9.41-fold) regardless of leiomyoma size, leiomyoma location, patient race, and patient age. This expression pattern was observed in 11 subjects and a total of 23 leiomyoma:myometrium pairs. Decreased expression of dermatopontin was also associated with keloid formation, a fibrotic disease that shares epidemiologic similarities with leiomyoma. Immunohistochemical studies of leiomyomas and keloids demonstrated reduced levels of dermatopontin in both tissues. In addition, ultrastructural analysis revealed that the orientation of the collagen fibrils in the keloid tissues strongly resembled that in the leiomyomas. Reduction in dermatopontin was associated with an increase in transforming growth factor-beta3 (TGFB3) mRNA levels in leiomyomas, whereas other genes involved in dermatopontin signaling were not differentially expressed. These findings suggest that leiomyoma development involves a myofibroblast cell phenotype characterized by dysregulation of genes encoding extracellular-matrix proteins. In particular, decreased expression of dermatopontin represents a molecular link between the leiomyoma and keloid phenotypes.

The changing face of peer review at the National Institutes of Health

OBJECTIVE

To discuss the new peer review system at the National Institutes of Health (NIH) and to present the process undertaken to accomplish these changes, with an emphasis on the reproductive sciences.

DESIGN

A discussion of the many NIH committees and their composition and reports leading to the changes in peer review affecting the reproductive sciences.

RESULT(S) AND CONCLUSION(S)

The Center for Scientific Review (CSR), which reviews grants for all NIH Institutes, will initiate the Cellular, Molecular, and Integrative Reproduction, the Integrative and Clinical Endocrinology and Reproduction, and the Pregnancy and Neonatology study sections in February 2004. The National Institute of Child Health and Human Development (NICHD)'s Division of Scientific Review has the following subcommittees, which started review in July 2003: Pediatrics; Developmental Biology; Biobehavior and Behavior Sciences; Population Science; Obstetrics and Maternal-Fetal Biology; Reproduction, Andrology, and Gynecology; and Function, Integration, and Rehabilitation Science.

Strategy for elucidating differentially expressed genes in leiomyomata identified by microarray technology

OBJECTIVE

cDNA microarray technology identifies genes that are differentially expressed between tissues. Our previous study identified several genes that might contribute to the fibroid phenotype. We therefore sought to confirm genes involved in three distinct signal transduction pathways.

DESIGN

Evaluation of differential mRNA and protein expression of Dlk, Frizzled-2, and CD-24 in fibroids compared with adjacent myometrium. University hospital.

PATIENT(S)

Five women undergoing medically indicated hysterectomy for symptomatic fibroids.

INTERVENTION(S)

Microarray analysis of up to 33000 genes, reverse transcriptase-polymerase chain reaction (RT-PCR), real-time RT-PCR, Western blot, and immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Expression of mRNA transcripts and protein in fibroid compared with myometrium.A more extensive microarray confirmed differential expression of Frizzled-2 and CD-24 but did not confirm Dlk overexpression. RT-PCR and real-time PCR demonstrated equivalent Dlk mRNA expression between fibroid and myometrium (ratio, 1.02), a slight Frizzled-2 overexpression (ratio, 2.09), and robust CD-24 overexpression in fibroids (ratio, 12.35). Western blot and immunohistochemistry confirmed Frizzled-2 overexpression, but did not confirm Dlk overexpression.

CONCLUSION(S)

Microarray technology is the first phase of tissue evaluation, but changes in gene expression must be confirmed. Confirmed genes can then be used to generate hypotheses testing their involvement in fibroid development.

A survey of past obstetrics and gynecology research fellows

OBJECTIVE

To survey obstetrician-gynecologist-scientists to determine factors that enhanced or hindered research careers.

METHODS

A pretested mail survey was sent to 107 obstetrician-gynecologists who had received research fellowship awards from professional organizations during the years 1971-1999. Demographic information along with face-value, forced-choice and yes-no questions as well as those asking for a single response using a Likert-type scale were requested. Two open-ended questions were also asked. The questionnaire was designed to obtain at least a 60% return.

RESULTS

A 62.2% return demonstrated that 92% of this group of former fellows holds academic positions. Twenty-four percent of respondents had no research mentors in the first 5 years after fellowship, and 58% had or have National Institutes of Health grant awards, with an average of two grants. The majority believed they did not have adequate time to conduct research, stating that 80% or more time was necessary for a successful research career.

CONCLUSION

Career success of the respondents is variable and is related to mentors, time allocated to research, and funding. The obstetrics and gynecology specialty must find ways to provide increased mentoring and time allocation to encourage funding opportunities.

Providing research and research training infrastructures for clinical research in the reproductive sciences

The Reproductive Sciences Branch of the National Institutes of Child Health and Human Development has created pioneering new research and research training programs that address the impending shortage of physician-scientists in obstetrics, gynecology, and women's health and the need to bolster translational and clinical research. This article provides a brief overview of the Specialized Cooperative Centers Program in Reproduction Research, the National Cooperative Program for Infertility Research, the Reproductive Medicine Network, the Reproductive Scientist Development Program, the Women's Reproductive Health Research Career Development Program, and the Contraception and Infertility Research Loan Repayment Program and describes how these programs collectively create an infrastructure to promote the next generation of physician-scientists and to provide an information exchange between basic and clinical investigators. A key component in increasing the number of clinical investigators is the Contraception and Infertility Research Loan Repayment Program. This program has enabled clinicians to be involved in research without having to be concerned about educational loan debt. Other component programs provide basic/translational, clinical hypothesis-oriented research and clinical trials research infrastructure. The programs created are individually strong and collectively poised to support translational and clinical research efforts and to build a well-trained cadre of physician-scientists. The collective use of these types of programs is proposed as a model for the National Institutes of Health.

Ascorbic acid status in postmenopausal women with hormone replacement therapy

OBJECTIVES

Hormone oral contraceptives affected ascorbic acid status adversely in young women. In vitro, estrogens and progesterone inhibited ascorbic acid accumulation in intestinal cells. This is a pilot study to examine the relation between hormone replacement therapy (HRT) and plasma ascorbic acid levels among a group of healthy non-smoking postmenopausal women.

METHODS

Healthy non-smoking postmenopausal women aged 48-72 years, 34 with HRT and 21 without HRT, were recruited in summer, 1997. Their fasting plasma ascorbic acid levels were measured and information on ascorbic acid intakes (diet and supplements) was collected through questionnaires.

RESULTS

Women taking HRT in this study did not have significantly lower plasma ascorbic acid levels compared with non-HRT users. When subjects were further divided into groups based on ascorbic acid supplementation, HRT users without supplement had a lower mean plasma ascorbic acid level (54+/-16 microM, n=10) compared with non-HRT users (66+/-14 microM, n=12) (P=0.08 for the effect of therapy). HRT users and non-users taking ascorbic acid supplement had similar plasma levels (66+/-10 microM, n=24; 66+/-12 microM, n=9, respectively).

CONCLUSION

HRT does not affect ascorbic acid status of healthy well-nourished non-smoking postmenopausal women that are using ascorbic acid supplement. Future larger case-control or supplement intervention study is needed.