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Agrawal K, Gainder S, Dhaliwal LK, Suri V. Ovulation Induction Using Clomiphene Citrate Using Stair - Step Regimen versus Traditional Regimen in Polycystic Ovary Syndrome Women - A Randomized Control Trial. J Hum Reprod Sci 2018; 10:261-264. [PMID: 29430152 PMCID: PMC5799929 DOI: 10.4103/jhrs.jhrs_15_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: To determine the efficacy of the stair-step protocol (SSP) using clomiphene citrate (CC) in patients with polycystic ovary syndrome (PCOS) and compare it with traditional regimen. Design: This was randomized control trial. Setting: Infertility Clinic. Patient(s): Sixty infertile PCOS women. Intervention(s): Patients were randomized into the study (SSP – 30 patients) and control group (traditional protocol – 30 patients). In the SSP, patients were treated with CC 50 mg/day for 5 days and in nonresponsive patients, the dosage was increased to 100 mg/day for 5 days in the same cycle. Maximum dose of 150 mg was given until the dominant follicle was generated. In control group, the dose increment in nonovulatory cases was done in subsequent cycle. Ultrasonography follow-up was done to detect ovulation. Main Outcome Measure(s): Ovulation rate and duration of treatment. Results: Ovulation (66.7% vs. 50% respectively) and pregnancy rates (26.7% vs. 15.7%) were similar between the stair step and the control group. The duration of treatment was significantly shorter in stair step compared to traditional protocol (17.23 vs. 53 days). CC 100 mg was the most effective dose for ovulation in either group. There were no significant differences in the systemic side effect. Conclusions: By using SSP, effective treatment is provided in significantly shorter time period without any detrimental effect on the ovulation and pregnancy rates.
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Affiliation(s)
- K Agrawal
- Department of Obstetrics and Gynecology, PGIMER, Chandigarh, India
| | - Shalini Gainder
- Department of Obstetrics and Gynecology, PGIMER, Chandigarh, India
| | | | - Vanita Suri
- Department of Obstetrics and Gynecology, PGIMER, Chandigarh, India
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Tumor necrosis factor alpha versus LH and androstendione as a reliable predictor of spontaneous ovulation after laparoscopic ovarian drilling for women with clomiphene citrate resistance polycystic ovarian disease. Eur J Obstet Gynecol Reprod Biol 2018; 222:126-133. [PMID: 29408743 DOI: 10.1016/j.ejogrb.2018.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 11/05/2017] [Accepted: 01/10/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Laparoscopic ovarian drilling (LOD) is still a controversial decision; due to the long term hazards; so short and long term predictors after the procedure should be taken in consideration. The aim of this work was to investigate the role of the serum level of tumor necrosis factor alpha (TNF-α) and other polycystic ovarian disease (PCOD) relevant clinical and biochemical factors as a predictor of spontaneous ovulation after laparoscopic ovarian drilling (LOD) in women with clomiphene citrate resistant polycystic ovarian disease (CCR-PCOD). METHODS It was a prospective research work, where 150 infertile women with CCR-PCOD had been recruited. TNF-α serum level, which is an inflammatory biomarker, was investigated in addition to other PCOD relevant clinical and biochemical parameters as possible predictors of successful spontaneous ovulation and subsequent pregnancy after LOD. RESULTS Recruited women with higher preoperative levels of TNF-α, LH, and androstenedione had significantly higher rates of spontaneous ovulation within the first three months follow up after LOD, in contrast to obese women with BMI ≥ 25 kg/m2, long duration of infertility ≥3 years, marked biochemical hyperandrogenism (testosterone levels ≥4.5 nmol/L, free androgen index ≥15), and high insulin resistance (IR). Ninty five (95 = 63.3%) women in between women regularly menstruated (105 = 70%) had spontaneous ovulation, and of those spontaneously ovulated, 35(36.8%) women got pregnant spontaneously during the first 3 months follow up. Extended follow up for 12 months period revealed that 61 women got pregnant, with cumulative pregnancy rate of 58%. Logistic regression showed that the best cut-off values for spontaneous ovulation after LOD were 65.1 pg/ml, 11.5 IU/l, and 3.1 ng/ml and with a sensitivity of 91%, 88%, 55%, and with a specificity of 85%, 79%, 78%, for TNF-α, LH, androstenedione serum level respectively. CONCLUSION TNF-α, LH, and Androstenedione could be considered as reliable predictors to depend on for recruiting the ideal women candidates with CCR-PCOD; to have the maximum benefits after LOD treatment option.
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Ismail Madkour WA, Noah B, Abdel Hamid AMS, Zaheer H, Al-Bahr A, Shaeer M, Moawad A. Luteal phase support with estradiol and progesterone versus progesterone alone in GnRH antagonist ICSI cycles: a randomized controlled study. HUM FERTIL 2018; 19:142-9. [PMID: 27434094 DOI: 10.1080/14647273.2016.1200145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In vitro fertilization (IVF) cycles are associated with a defective luteal phase. Although progesterone supplementation to treat this problem is standard practice, estrogen addition is debatable. Our aim was to compare pregnancy outcomes in 220 patients undergoing antagonist intracytoplasmic sperm injection (ICSI) cycles protocol. The patients were randomly assigned into two equal groups to receive either vaginal progesterone alone (90 mg once daily) starting on the day of oocyte retrieval for up to 12 weeks if pregnancy occurred or estradiol addition (2 mg twice daily) starting on the same day and continuing up to seven weeks (foetal viability scan). Primary outcomes were pregnancy and ongoing pregnancy rates per embryo transfer. Secondary outcomes were implantation and early pregnancy loss rates. Pregnancy rates showed no significant difference between group 1 (39.09%) and 2 (43.63%) (p value = 0.3). Similarly, both groups were comparable regarding ongoing pregnancy rate (32.7% group 1 and 36.3% group 2, p value = 0.1). Implantation rates showed no difference between group 1 (19.25%) and group 2 (23.44%) (p value = 0.2). Early pregnancy loss rates were comparable, with 6.3% and 7.2% in groups 1 and 2, respectively, (p value = 0.4). In conclusion, the addition of 4 mg estrogen daily to progesterone for luteal support in antagonist ICSI cycles is not beneficial for pregnancy outcome.
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Affiliation(s)
- Wael A Ismail Madkour
- a Obstetrics and Gynecology Department , Ain-Shams University , Cairo , Egypt ;,b Dubai Gynecology and Fertility Centre , Dubai , UAE
| | - Bassel Noah
- b Dubai Gynecology and Fertility Centre , Dubai , UAE
| | - Amr M S Abdel Hamid
- a Obstetrics and Gynecology Department , Ain-Shams University , Cairo , Egypt ;,c IVF Unit , Enjab Hospital , Sharjah , UAE
| | - Hena Zaheer
- b Dubai Gynecology and Fertility Centre , Dubai , UAE
| | | | | | - Ashraf Moawad
- c IVF Unit , Enjab Hospital , Sharjah , UAE ;,d Obstetrics and Gynecology Department, Al-Azhar University , Cairo , Egypt
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154
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Abu Hashim H, Foda O, El Rakhawy M. Unilateral or bilateral laparoscopic ovarian drilling in polycystic ovary syndrome: a meta-analysis of randomized trials. Arch Gynecol Obstet 2018; 297:859-870. [PMID: 29374790 DOI: 10.1007/s00404-018-4680-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/17/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE This systematic review and meta-analysis aimed to compare the effectiveness of unilateral vs. bilateral laparoscopic ovarian drilling (ULOD vs. BLOD) for improving fertility outcomes in infertile women with clomiphene-resistant polycystic ovary syndrome (PCOS) as well as its effect on ovarian reserve. METHODS Searches were conducted on PubMed, ScienceDirect, ClinicalTrials.gov, and CENTRAL databases from January 1984 to January 2017. Only randomized trials comparing ULOD with BLOD were included. The PRISMA Statement was followed. Main outcomes were ovulation and clinical pregnancy rates per woman randomized. Secondary outcomes were; live birth and miscarriage rates as well as postoperative serum anti-mullerian hormone (AMH) concentration and antral follicle count (AFC). Quality assessment was performed by the Cochrane Collaboration risk of bias tool. RESULTS Eight eligible trials (484 women) were analyzed. No significant difference was found in rates of ovulation (OR 0.73; 95% CI 0.47-1.11), clinical pregnancy (OR 0.56; 95% CI 0.22-1.41), live birth (OR 0.77; 95% CI 0.28-2.10), or miscarriage (OR 0.90; 95% CI 0.33-2.84) when ULOD was compared with BLOD. The reduction in AMH was comparable between the two procedures (MD 0.64 ng/ml; 95% CI - 0.08 to 1.36). A significantly higher AFC at 6-month follow-up was found with dose-adjusted ULOD (MD 2.20; 95% CI 1.01-3.39). CONCLUSIONS After carefully weighing up the well-known benefits of BLOD against a potential risk to ovarian reserve, clinicians could be advised to offer the fixed-dose ULOD to their infertile patients with clomiphene-resistant PCOS. This is concordant with the "primum non nocere" principal if LOD will be envisaged.
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Affiliation(s)
- Hatem Abu Hashim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Osama Foda
- Endocrinology Unit, Department of Internal Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed El Rakhawy
- Department of Diagnostic Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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155
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Abushama M, Rawhani R, Abdellatif A. Antenatal Diagnosis of Fetal Skeletal Malformation. ACTA ACUST UNITED AC 2018. [DOI: 10.5005/jp-journals-10009-1561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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156
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Singh K, Mutreja A, Bhattacharyya M, Dangda S, Jaisingh K. Bilateral Phacomatosis Pigmentovascularis in a Young Male with Developmental Glaucoma and Varicose Veins. J Curr Glaucoma Pract 2018. [DOI: 10.5005/jp-journals-10028-1251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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157
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Kristensen SG, Andersen CY. Cryopreservation of Ovarian Tissue: Opportunities Beyond Fertility Preservation and a Positive View Into the Future. Front Endocrinol (Lausanne) 2018; 9:347. [PMID: 30002647 PMCID: PMC6031740 DOI: 10.3389/fendo.2018.00347] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/11/2018] [Indexed: 12/18/2022] Open
Abstract
In current years, ovarian tissue cryopreservation (OTC) and transplantation is gaining ground as a successful method of preserving fertility in young women with primarily cancer diseases, hereby giving them a chance of becoming biological mothers later on. However, OTC preserves more than just the reproductive potential; it restores the ovarian endocrine function and thus the entire female reproductive cycle with natural levels of essential hormones. In a female population with an increased prevalence in the loss of ovarian function due to induced primary ovarian insufficiency (POI) and aging, there is now, a need to develop new treatments and provide new opportunities to utilize the enormous surplus of follicles that most females are born with and overcome major health issues associated with the lack of ovarian hormones. Cell/tissue-based hormone replacement therapy (cHRT) by the use of stored ovarian tissue could be one such option comprising both induction of puberty in prepubertal POI girls, treatment of POI and premature menopause, and as primary prevention at the onset of menopause. In the current review, we explore known and entirely new applications for the potential utilization of OTC including cHRT, social freezing, culture of immature oocytes, and a modern ovarian resection for women with polycystic ovaries, and discuss the indications hereof.
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158
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Baatarkhuu O, Gerelchimeg T, Munkh-Orshikh D, Batsukh B, Sarangua G, Amarsanaa J. Epidemiology, Genotype Distribution, Prognosis, Control, and Management of Viral Hepatitis B, C, D, and Hepatocellular Carcinoma in Mongolia. Euroasian J Hepatogastroenterol 2018; 8:57-62. [PMID: 29963464 PMCID: PMC6024043 DOI: 10.5005/jp-journals-10018-1260] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/15/2018] [Indexed: 01/31/2023] Open
Abstract
Mongolia is located between Russia and China. The total population of Mongolia as of December 2017 is estimated to be 3.2 million people. According to our previous study results, the prevalence of HBV was 11.8%, and anti-HDV was detected in 4.8% among the HBsAg-positive subjects. Interestingly, most HCV infection is caused by genotype 1b. Among all HBV DNA-positive samples, 98.5% were classified into genotype D, and regarding HDV genotypes, all HDV RNA-positive samples, 100%, were classified into genotype I. The second study is the baseline survey of a Nationwide Cancer Cohort Study. Prevalence of HBsAg was 10.6%. Additionally, HCV infection was observed in 9.9%, and 0.8% were coinfected with HBV and HCV among the general population aged from 10 to 64 years. The third study investigated the population-based prevalence of hepatitis B and C virus in apparently healthy population of Ulaanbaatar city, Mongolia. The anti-HCV prevalence was 9.0%. In addition, the prevalence of HBV was 8.0%. The fourth study is on the prevalence of HCV and coinfections among nurses in a tertiary hospital in Mongolia. The prevalence of HCV was 18.9%. Additionally, HBV infection was observed in 23.1%, and 1.2% were coinfected with HCV and HBV. Mongolia has the highest HCC incidence in the world (78.1/100,000, 3.5* higher than China). As a result, the Mongolia government has launched The National Viral Hepatitis Program, which is a comprehensive program that involves all aspects from prevention to care and disease control to meet a reduction goal for morbidity and mortality due to HBV, HCV, and HDV. Consequently, access to antiviral therapies is now improving in Mongolia. How to cite this article: Baatarkhuu O, Gerelchimeg T, Munkh-Orshikh D, Batsukh B, Sarangua G, Amarsanaa J. Epidemiology, Genotype Distribution, Prognosis, Control, and Management of Viral Hepatitis B, C, D, and Hepatocellular Carcinoma in Mongolia. Euroasian J Hepato-Gastroenterol 2018;8(1):57-62.
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Affiliation(s)
- Oidov Baatarkhuu
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Tsagaantsooj Gerelchimeg
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Dashchirev Munkh-Orshikh
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Badamnachin Batsukh
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia; Happy Veritas Clinic and Diagnostic Center, Ulaanbaatar, Mongolia
| | - Ganbold Sarangua
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; National Center for Communicable Diseases, Ulaanbaatar, Mongolia
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia; Happy Veritas Clinic and Diagnostic Center, Ulaanbaatar, Mongolia
| | - Jazag Amarsanaa
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; National Center for Communicable Diseases, Ulaanbaatar, Mongolia
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
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159
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Sabel BA, Cárdenas-Morales L, Gao Y. Vision Restoration in Glaucoma by Activating Residual Vision with a Holistic, Clinical Approach: A Review. J Curr Glaucoma Pract 2018; 12:1-9. [PMID: 29861576 PMCID: PMC5981087 DOI: 10.5005/jp-journals-10028-1237] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 11/22/2017] [Indexed: 01/07/2023] Open
Abstract
How to cite this article: Sabel BA, Cárdenas-Morales L, Gao Y. Vision Restoration in Glaucoma by activating Residual Vision with a Holistic, Clinical Approach: A Review. J Curr Glaucoma Pract 2018;12(1):1-9.
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Affiliation(s)
- Bernhard A Sabel
- Professor, SAVIR Center, Magdeburg, Germany; Institute for Medical Psychology, Otto von Guericke University of Magdeburg Magdeburg, Germany
| | - Lizbeth Cárdenas-Morales
- Lecturer, Institute for Medical Psychology, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Ying Gao
- Researcher, SAVIR Center, Magdeburg, Germany; Institute for Medical Psychology, Otto von Guericke University of Magdeburg Magdeburg, Germany
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160
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Rajput S, Jain S. Is Autoverification of Reports the Need of the Hour in Clinical Chemistry Laboratory? ACTA ACUST UNITED AC 2018. [DOI: 10.5005/jp-journals-10054-0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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161
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Popovic M, Campos-Möller X, Saheb H, Ahmed IIK. Efficacy and Adverse Event Profile of the iStent and iStent Inject Trabecular Micro-bypass for Open-angle Glaucoma: A Meta-analysis. J Curr Glaucoma Pract 2018. [DOI: 10.5005/jp-journals-10028-1248] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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162
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Thangamathesvaran L, Crane E, Modi K, Khouri AS. Outcomes of Resident-versus attending-performed Tube Shunt Surgeries in a United States Residency Program. J Curr Glaucoma Pract 2018. [DOI: 10.5005/jp-journals-10028-1245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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163
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Ohara T, Suzutani T. Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis. Euroasian J Hepatogastroenterol 2018; 8:11-17. [PMID: 29963455 PMCID: PMC6024036 DOI: 10.5005/jp-journals-10018-1251] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/22/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION We aimed to investigate the effects of intake of yogurt containing Bifidobacterium longum (BB536-y) and fructo-oligosaccharides (FOS) in preventing colorectal carcinogenesis in healthy subjects, and the preventive effects of short-chain fatty acids (SCFA), whose production was enhanced by the intake of BB536-y and FOS, in human colon cancer cell lines. MATERIALS AND METHODS The subjects were 27 healthy persons who were divided into a group taking yogurt containing BB536 (BB536-y group; n = 14) and a group taking yogurt containing BB536 and FOS (BB536-y with FOS group; n = 13) once a day for 5 weeks. The feces were sampled before and after the intake to analyze the amount of SCFA in the feces and the profile of intestinal flora, such as putrefactive bacteria and Bacteroides fragilis enterotoxin (ETBF). Subsequently, human colon cancer cell lines (DLD-1 cells, WirDr cells) were cultured in the presence of SCFA (butyric acid, isobutyric acid, acetic acid) in order to evaluate the cell growth-inhibitory activity of SCFA (WST-8 assay) by calculating the IC50 value from the dose-response curve. RESULTS Intake of BB536-y increased the total amount of SCFA in the feces and significantly suppressed the detection rate of ETBF and growth of putrefactive bacteria. Intake of BB536-y with FOS was associated with a higher Bifidobacterium detection rate than that of BB536-y alone. The contents of butyric acid, isobutyric acid, and acetic acid, namely, of SCFA, were also decreased. Analysis of the results of culture of DLD-1 cells and WirDr cells in the presence of butyric acid, isobutyric acid, and acetic acid revealed that each of the substances showed significant cell growth-inhibitory activity, with the activity being the highest for butyric acid, followed by that for isobutyric acid and acetic acid. CONCLUSION These findings suggest that intake of both BB536-y and BB536-y with FOS prevents colorectal carcinogenesis.How to cite this article: Ohara T, Suzutani T. Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis. Euroasian J Hepato-Gastroenterol 2018;8(1):11-17.
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Affiliation(s)
- Tadashi Ohara
- Department of Intestinal Bioscience and Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Tatsuo Suzutani
- Department of Microbiology, Fukushima Medical University, Fukushima City, Fukushima, Japan
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164
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Arora V, Arora P, Soliman M. Evaluation of Coronal Leakage of Preheated Nanohybrid and Bulk Fill Composites in Endodontically Treated Teeth: An in vitro Study. ACTA ACUST UNITED AC 2018. [DOI: 10.5005/jp-journals-10015-1534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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165
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166
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J Lu L, Hall L, Liu J. Improving Glaucoma Surgical Outcomes with Adjunct Tools. J Curr Glaucoma Pract 2018; 12:19-28. [PMID: 29861578 PMCID: PMC5981089 DOI: 10.5005/jp-journals-10028-1239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/09/2017] [Indexed: 11/23/2022] Open
Abstract
Conventional glaucoma surgeries, such as trabeculectomy and glaucoma drainage device (GDD) surgery, have been enhanced by surgeons to improve outcome and decrease complications. Over the last two decades, adjuncts, such as collagen matrix implants, fibrin adhesives, and amniotic membrane transplantation (AMT) have been found to be effective in modulating fibrosis and scarring during the wound-healing process, reducing postoperative inflammation, and repairing bleb leakage or conjunctival erosion. The use of these tools provides several advantages when used in trabeculectomy, GDD surgery, and surface reconstruction associated with glaucoma surgery complications. Their use will be discussed in this review. How to cite this article: Lu LJ, Hall L, Liu J. Improving Glaucoma Surgical Outcomes with Adjunct Tools. J Curr Glaucoma Pract 2018;12(1):19-28.
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Affiliation(s)
- Louise J Lu
- Medical Student, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, United States
| | - Laura Hall
- Ophthalmologist, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, United States
| | - Ji Liu
- Ophthalmologist, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, United States
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167
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Shiralkar VV, Jagtap PE, Belwalkar GJ, Nagane NS, Dhonde SP. Effect of Steam Sauna Bath on Fasting Blood Glucose Level in Healthy Adults. ACTA ACUST UNITED AC 2018. [DOI: 10.5005/jp-journals-10054-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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168
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Dong J, Syed ZA, Fan K, Yahya AF, Melki SA. Potential Savings from Visit Reduction of Continuous Intraocular Pressure Monitoring. J Curr Glaucoma Pract 2018. [DOI: 10.5005/jp-journals-10028-1246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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169
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Hossain E, Ahammed F, K Saha S, A Foez S, A Rahim M, M Noor-E-Alam S, S Abdullah A. Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease. Euroasian J Hepatogastroenterol 2018; 8:18-22. [PMID: 29963456 PMCID: PMC6024039 DOI: 10.5005/jp-journals-10018-1252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/22/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Noninvasive assessment of esophageal varices (EV) decreases the medical and financial burden related to screening and helps in the management of patients with chronic liver diseases (CLDs). In this study, our aim was to assess the utility of the platelet count/spleen diameter index for the noninvasive evaluation of EV. Materials and methods In this cross-sectional observational study, a total of 100 CLD patients underwent screening endoscopy for EV in Medicine and Gastroenterology Department, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh. Platelet count/spleen diameter ratio was assessed in all patients and its diagnostic implication was calculated. Results Upper gastrointestinal endoscopy revealed that 45 (45.0%) patients had medium EV followed by 27 (27.0%) that had small EV and 19 (19.0%) patients had large EV. Receiver operator characteristic (ROC) curve was constructed using platelet count/spleen index, which gave a cut-off value of >905. The validity of platelet count/spleen index evaluation of CLD was: Sensitivity 92.3%, specificity 66.7%, accuracy 90.0%, positive predictive value (PPV) and negative predictive value (NPV) were 96.6 and 46.2% respectively. True positive was 84 cases, false positive 3 cases, false negative 7 cases, and true negative 6 cases. If we consider cut-off value as 909 in the evaluation of EV in CLD, then true positive was 85 cases, false positive 3 cases, false negative 6 cases, and true negative 6 cases. From this, by calculation, sensitivity was 93.4%, specificity 66.7%, accuracy 91%, PPV 96.6%, and NPV 50%. Conclusion The platelet count/spleen index may be proposed to be a safe and reliable mean of screening of EV in CLD patients; however, case-control study would be required to validate this. How to cite this article: Hossain E, Ahammed F, Saha SK, Foez SA, Rahim MA, Noor-e-Alam SM, Abdullah AS. Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease. Euroasian J Hepato-Gastroenterol 2018;8(1):18-22.
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Affiliation(s)
- Enayet Hossain
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Ferdaus Ahammed
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Satyajit K Saha
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Syed A Foez
- Department of Hepatology, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Mohammad A Rahim
- Department of Hepatology, Abdul Malek Ukil Medical College, Noakhali, Bangladesh
| | - Sheikh M Noor-E-Alam
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Abu S Abdullah
- Department of Medicine, Moulvibazar District Sadar Hospital, Moulvibazar, Bangladesh
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Ali A, Almaroof A, Festy F, Banerjee A, Mannocci F. In vitro Remineralization of Caries-affected Dentin after Selective Carious Tissue Removal. ACTA ACUST UNITED AC 2018. [DOI: 10.5005/jp-journals-10015-1529] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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171
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Muthiah M, H Chong C, G Lim S. Liver Disease in Singapore. Euroasian J Hepatogastroenterol 2018; 8:66-68. [PMID: 29963466 PMCID: PMC6024054 DOI: 10.5005/jp-journals-10018-1262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/27/2018] [Indexed: 11/28/2022] Open
Abstract
Liver disease is a significant health issue in Singapore. In the Singapore Burden of Disease Survey, liver cancer and liver cirrhosis contributed 3.2 and 0.9% of years of life lost (YLL) out of 182,753 YLL respectively. Liver cancer was ranked 8th and liver cirrhosis was ranked 20th in YLL. Liver cancer is the 5th most common cancer in males, and has an age-adjusted rate of 17.6 per 100,000 population. The underlying etiology of liver cirrhosis is chronic hepatitis B (CHB) in 63.3%, alcohol in 11.2%, cryptogenic in 9%, and chronic hepatitis C (CHC) in 6.9%. The overall seroprevalence rate of CHB is 3.6%, while CHC is approximately 0.1%. The trend in prevalence of liver cancer is gradually reducing as is CHB. However, less is known about alcoholic liver disease and fatty liver disease and there is some evidence that the latter is increasing. Singapore has a multilayered health care system designed to provide basic health care needs to the population. There are various schemes available that provide subsidized and assisted health care for treatment of hepatitis B and C as well as liver transplantation. Health policy with regard to a national action plan has not yet been developed and there is room for health care specialists, government and nongovernment agencies to work together to tackle liver disease in Singapore. How to cite this article: Muthiah M, Chong CH, Lim SG. Liver Disease in Singapore. Euroasian J Hepato-Gastroenterol 2018;8(1):66-68.
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Affiliation(s)
- Mark Muthiah
- Division of Gastroenterology and Hepatology, National University Health System, Singapore and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chern H Chong
- Division of Gastroenterology and Hepatology, National University Health System, Singapore; Division of General Medicine, Woodlands Health Campus, Singapore
| | - Seng G Lim
- Division of Gastroenterology and Hepatology, National University Health System, Singapore and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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172
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Tannus S, Tan J, Son WY, Dahan MH. Prevalence, clinical characteristics, and reproductive outcomes of polycystic ovary syndrome in older women referred for tertiary fertility care. Arch Gynecol Obstet 2017; 297:1037-1042. [PMID: 29289990 DOI: 10.1007/s00404-017-4642-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/22/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive age women. The clinical symptoms of PCOS vary with female age, as older women tend to have lower hyperandrogenic symptoms and many regain regular cycles. In this study, we aimed to estimate the prevalence of PCOS among older women referred for fertility care, describe their clinical characteristics, and compare their reproductive outcomes to those of matched control group. METHODS A retrospective study conducted at a single reproductive center. All women aged ≥ 40, who were referred for in-vitro fertilization (IVF), between the years 2011-2015 were screened for possible inclusion. The PCOS diagnosis (was) made based on the Rotterdam criteria. The reproductive outcomes of the PCOS group were compared to those of matched control with tubal infertility. RESULTS During the study period, 1427 women, aged 40 years and over, underwent a total of 2124 IVF cycles. Of these, 72 (5%) women were diagnosed with PCOS. In 69 (95.6%), the PCOS diagnosis was made by a combination of polycystic ovary morphology (PCOM) and anovulation. Compared to women with tubal factor infertility, women with PCOS needed lower doses of gonadotropins, had higher number of retrieved oocytes (16.6 vs. 10.4) and higher number of cycles with embryo cryopreservation (47 vs. 22.9%). This resulted in higher cumulative live birth in the PCOS group (26.3 vs. 15.2%, p = 0.04). CONCLUSION PCOS comprised 5% of the infertility diagnosis in women aged ≥ 40; PCOM and anovulation were the most prominent features. The higher oocyte number resulted in improved cumulative live birth rate.
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Affiliation(s)
- Samer Tannus
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University Health Centre (MUHC) Reproductive Centre, 888, Blvd. de Maisonneuve East, suite 200, Montreal, QC, H2L 4S8, Canada.
| | - Justin Tan
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Weon-Young Son
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University Health Centre (MUHC) Reproductive Centre, 888, Blvd. de Maisonneuve East, suite 200, Montreal, QC, H2L 4S8, Canada
| | - Michael-Haim Dahan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University Health Centre (MUHC) Reproductive Centre, 888, Blvd. de Maisonneuve East, suite 200, Montreal, QC, H2L 4S8, Canada
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173
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Letrozole versus laparoscopic ovarian drilling in infertile women with PCOS resistant to clomiphene citrate. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2017. [DOI: 10.1016/j.mefs.2017.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lepine S, Jo J, Metwally M, Cheong YC. Ovarian surgery for symptom relief in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2017; 11:CD009526. [PMID: 29125183 PMCID: PMC6486107 DOI: 10.1002/14651858.cd009526.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is a common endocrine condition, affecting approximately one in 10 women. PCOS is defined by two of three features: oligo- or anovulation, clinical or biochemical hyperandrogenism or both, or polycystic ovaries.Women with PCOS can have a wide range of health problems, including infrequent and irregular periods, unwanted hair growth and acne, and subnormal fertility. Long-term health concerns include an increased risk of heart disease, diabetes and the development of precancerous disease of the womb. OBJECTIVES To assess the effectiveness and harms of ovarian surgery as a treatment for symptomatic relief of hirsutism, acne and menstrual irregularity in PCOS. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Group specialized register, CENTRAL, MEDLINE, Embase and PsycINFO (from inception to 17 October 2016). We handsearched citation lists, registers of ongoing trials and conference proceedings. SELECTION CRITERIA We included randomized controlled trials (RCTs) of women undergoing ovarian drilling in comparison to no treatment, medical treatment, or other forms of surgical treatment for the symptoms of PCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary outcome measures were improvement in menstrual regularity and androgenic symptoms of PCOS (hirsutism, acne); the secondary outcome measures included harms, change of body mass index (BMI), waist circumference, androgen levels, metabolic measures and quality of life. We assessed the quality of the evidence using GRADE methods. MAIN RESULTS We included 22 RCTs (2278 women analyzed) of participants with PCOS and symptoms of acne, hirsutism or irregular menstrual cycles, all of which included laparoscopic ovarian drilling (LOD) as an intervention.Two studies reported their funding source (Farquhar 2002 - supported in part by the Auckland Medical Research Foundation; Sarouri 2015 - the authors thank the Vice Chancellor for Research of Guilan University of Medical Sciences for funding this project).The quality of the evidence ranged from very low to moderate quality. The main limitations were imprecision associated with the low number of studies, inconsistency and risk of bias associated with the inability to blind participants. There were too few studies to assess risk of publication bias. Menstrual RegularityTwo studies compared LOD versus metformin (n=226) but no conclusions could be drawn with regard to menstrual regularity, as their findings were inconsistent and they were unsuitable for pooling. There appeared to be little or no difference in the rate of women reporting improvement in menstrual regularity when LOD was compared with medical treatment including metformin + clomiphene (OR 1.02, 95% CI 0.64 to 1.64, 2 studies, 332 women, I2 = 13%, low-quality evidence), letrozole (OR 1.08, 95% CI 0.64 to 1.84, 1 study, 260 women, low-quality evidence), or metformin + letrozole (OR 0.95, 95% CI 0.49 to 1.81, 1 study, 146 women, low-quality evidence). However, one study reported that LOD was superior to gonadotrophin (OR 19.2, 95% CI 3.17 to 116.45, 1 study, 35 women, very low-quality evidence).There appeared to be little or no difference in the rate of women reporting improvement in menstrual regularity when bilateral unipolar LOD was compared to unilateral LOD (OR 1.51, 95% CI 0.62 to 3.71, 2 studies, 104 women, I2 = 0%, moderate-quality evidence), transvaginal ultrasound-guided LOD (OR 1.23, 95% CI 0.64 to 2.37, 1 study, 147 women, low-quality evidence), LOD using adjusted thermal dose in accordance with the ovarian volume (OR 0.42, 95% CI 0.16 to 1.14, 1 study, 115 women, low-quality evidence) or bipolar LOD (OR 1.00, 95% CI 0.05 to 18.57, 1 study, 18 women, low-quality evidence).Four to five punctures per ovary may improve the rate of women reporting menstrual regularity compared with two or fewer (OR 16.04, 95% CI 4.19 to 61.34, 2 studies, 73 women, I2 = 0%, low-quality evidence). Androgenic SymptomsThere was probably little or no difference in improvement in androgenic symptoms when LOD was compared to metformin (OR 1.00, 95% CI 0.42 to 2.37, 1 study, 126 women, moderate-quality evidence) or gonadotrophins; acne (OR 3.20, 95% CI 0.33 to 30.94, 1 study, 25 women, low-quality evidence), hirsutism (OR 2.31, 95% CI 0.22 to 23.89, 1 study, 25 women, low-quality evidence).There appeared to be little or no difference in improvement of androgenic symptoms when LOD was compared to transvaginal ultrasound-guided LOD, with respect to hirsutism (OR 1.09, 95% CI 0.30 to 3.91, 1 study, 39 women, low-quality evidence) or acne (OR 0.84, 95% CI 0.20 to 3.50, 1 study, 31 women, low-quality evidence). HarmsLOD was associated with fewer gastrointestinal side effects than metformin plus clomiphene (OR 0.05, 95% CI 0.01 to 0.36, 2 studies, 332 women, I2 = 0%, moderate-quality evidence). One study suggested little or no difference in rates of ovarian hyperstimulation syndrome between LOD and gonadotrophins (OR 0.08, 95% CI 0.00 to 1.61, 1 study, 33 women, low-quality evidence).There were fewer adhesions with transvaginal hydrolaparoscopy compared to LOD (OR 0.10, 95% CI 0.05 to 0.18, 1 study, 246 women, moderate-quality evidence). There appeared to be little or no difference in adhesions when variable energy LOD was compared with standard LOD (OR 0.96, 95% CI 0.32 to 2.88, 1 study, 64 women, low-quality evidence). Another study (44 women) reported that none of the women who returned for surgery following either traditional or unilateral LOD were found to have adhesions. AUTHORS' CONCLUSIONS There was no clear evidence that LOD improves menstrual regularity or the androgenic symptoms of PCOS, compared to most of the medical treatments used in the included studies. LOD was associated with fewer gastrointestinal side effects compared to metformin and clomiphene.There was also no clear evidence of different effectiveness between types of LOD, except that LOD with four to five punctures per ovary may be more effective than two or fewer punctures. There was little evidence comparing LOD with different types of surgery, although one study concluded that transvaginal hydrolaparoscopy had a lower risk of adhesions than LOD.There was evidence from one small study of benefit from LOD compared to gonadotrophins for menstrual regulation. However, gonadotrophins are seldom used for this indication.
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Affiliation(s)
- Sam Lepine
- Capital and Coast District Health BoardDepartment of Obstetrics and GynaecologyWellingtonNew Zealand
| | - Junyoung Jo
- Conmaul Hospital of Korean MedicineDepartment of Korean Obstetrics and GynecologyFl. 5, Lotte Castle Medici, 1656‐4, Seocho‐dong, Seocho‐guSeoulKorea, South
| | - Mostafa Metwally
- Sheffield Teaching HospitalsThe Jessop Wing and Royal Hallamshire HospitalSheffieldUKS10 2JF
| | - Ying C Cheong
- University of SouthamptonDepartment of Obstetrics and GynaecologyLevel F, Princess Anne HospitalCoxford RoadSouthamptonUKSO16 5YA
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Arya S, Kupesic-Plavsic S, Mulla ZD, Dwivedi AK, Crisp Z, Jose J, Noble LS. Ovulation induction and controlled ovarian stimulation using letrozole gonadotropin combination: A single center retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 218:123-128. [PMID: 28985546 DOI: 10.1016/j.ejogrb.2017.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/12/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess the effect of letrozole in combination with low dose gonadotropins for ovulation induction in anovulatory infertility from polycystic ovary syndrome (PCOS) and controlled ovarian stimulation for endometriosis, and unexplained infertility patients. STUDY DESIGN Retrospective cohort study in a setting of private Reproductive Endocrinology and Infertility Clinic affiliated with the University. Three hundred couples (650 cycles) requiring OI/COS for PCOS (92 patients, 195 cycles), endometriosis (89 patients, 217 cycles), and unexplained infertility (119 patients, 238 cycles). Patients received 2.5mg or 5mg letrozole for 5days (D3-D7) and recombinant follicle-stimulating hormone on alternating D3-D7 and human menopausal gonadotropin-highly purified alternating D5-D10 until growth of ideally 2 mature follicles. Ovulation was triggered with 10,000 IU of HCG. Maximum number of cycles per patient was four. RESULTS Main outcome measures were clinical pregnancy rates, multiple order pregnancy rates, miscarriage rates, number of follicles and endometrial thickness on the day of HCG administration. The cumulative incidence of pregnancy was estimated as 35% (95%CI: 29%-41%) overall and was highest in patients with PCOS (36.6%), followed by unexplained infertility (34.6%) and endometriosis (32.5%). The pregnancy rates per cycle in PCOS, endometriosis and unexplained infertility patients were 17%, 13.2% and 17.2% respectively, no statistically significant difference between the groups. There were three twin pregnancies in PCOS, and one in unexplained infertility group. Monofolliculogenesis was noted in 48% of patients. CONCLUSION(S) Letrozole-low dose gonadotropins combination appears to be effective across different causes of infertility for superovulation. The letrozole-low dose gonadotropin combination resulted in high rate of monofolliculogenesis, low occurrence of multiple gestations and no case of OHSS or cycle cancellation.
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Affiliation(s)
- Sushila Arya
- Department of Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4801 Alberta Ave, El Paso, TX, 79905, USA.
| | - Sanja Kupesic-Plavsic
- Department of Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA.
| | - Zuber D Mulla
- Department of Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA.
| | - Alok K Dwivedi
- Department of Biomedical Sciences, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA.
| | - Zeni Crisp
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA
| | - Jisha Jose
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA
| | - Luis S Noble
- Reproductive Endocrinology and Infertility, Southwest Center for Reproductive Health, 700 S Mesa Hills Dr., El Paso, TX, 79912, USA.
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Giampaolino P, Morra I, De Rosa N, Cagnacci A, Pellicano M, Di Carlo C, Nappi C, Bifulco G. Impact of transvaginal hydrolaparoscopy ovarian drilling on ovarian stromal blood flow and ovarian volume in clomiphene citrate-resistant PCOS patients: a case-control study. Gynecol Endocrinol 2017; 33:690-693. [PMID: 28412862 DOI: 10.1080/09513590.2017.1310837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in gynecology. In PCOS patients vascularization parameters are altered. Transvaginal hydrolaparoscopy (THL) is a mini-invasive approach for ovarian drilling in PCOS patients. In this study, we assessed the effect of ovarian drilling using THL on ovarian volume (OV) and vascularization index (VI) using 3D power Doppler ultrasonography in CC-resistant PCOS patients. A case-control study on 123 CC-resistant PCOS women who underwent THL ovarian drilling was performed. Patients underwent 3D ultrasound and power Doppler to measure VI, flow index (FI), vascularization flow index (VFI) and to evaluate OV before and after the procedure, at six months, and on the early follicular phase of the menstrual cycle. After THL ovarian drilling, OV and power Doppler flow indices were significantly reduced compared to pre-operative values (OV: 7.85 versus 11.72 cm3, p < 0.01; VI: 2.50 versus 4.81, p < 0.01; VFI: 1.10 versus 2.16, p < 0.01; FI: 32.05 versus 35.37, p < 0.01). In conclusion, THL ovarian drilling seems to reduce OV and 3D power Doppler indices, and could therefore be a viable alternative to LOD in PCOS patients resistant to medical therapy.
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Affiliation(s)
| | - Ilaria Morra
- b Department of Obstetrics, Gynecology, and Urology , University of Naples "Federico II" , Naples , Italy , and
| | - Nicoletta De Rosa
- b Department of Obstetrics, Gynecology, and Urology , University of Naples "Federico II" , Naples , Italy , and
| | - Angelo Cagnacci
- c Department of Obstetrics and Gynecology , University of Udine , Udine , Italy
| | - Massimiliano Pellicano
- b Department of Obstetrics, Gynecology, and Urology , University of Naples "Federico II" , Naples , Italy , and
| | - Costantino Di Carlo
- b Department of Obstetrics, Gynecology, and Urology , University of Naples "Federico II" , Naples , Italy , and
| | - Carmine Nappi
- a Department of Public Health , University of Naples "Federico II" , Naples , Italy
| | - Giuseppe Bifulco
- b Department of Obstetrics, Gynecology, and Urology , University of Naples "Federico II" , Naples , Italy , and
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Penzias A, Bendikson K, Butts S, Coutifaris C, Falcone T, Fossum G, Gitlin S, Gracia C, Hansen K, La Barbera A, Mersereau J, Odem R, Paulson R, Pfeifer S, Pisarska M, Rebar R, Reindollar R, Rosen M, Sandlow J, Vernon M. Role of metformin for ovulation induction in infertile patients with polycystic ovary syndrome (PCOS): a guideline. Fertil Steril 2017; 108:426-441. [DOI: 10.1016/j.fertnstert.2017.06.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/20/2017] [Indexed: 01/07/2023]
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Kalem MN, Kalem Z, Gurgan T. Effect of metformin and oral contraceptives on polycystic ovary syndrome and IVF cycles. J Endocrinol Invest 2017; 40:745-752. [PMID: 28244019 DOI: 10.1007/s40618-017-0634-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/01/2017] [Indexed: 12/30/2022]
Abstract
AIM The aim of this study is to investigate the effect of metformin and/or OC added to the treatment of PCOS patients at our clinic on IVF outcome. MATERIALS AND METHODS This study is a retrospective study that assesses the data of PCOS patients who received IVF between 2005 and 2015 at a private IVF center. The study included 496 PCOS cases aged between 24 and 40. Participants diagnosed with PCOS were divided into 4 groups according to the use of metformin and OC prior to the IVF cycle: 11.1% were in the metformin group, 31.3% in the OC group, 14.9% in the Metformin + OC group, and 42.7% in the control group. RESULTS No difference was found in the total gonadotropin dose and duration of stimulation between the groups. Clinical pregnancy rates and implantation rates were similar in all groups, although the numbers of oocytes, mature oocytes, fertilized oocytes, and transferred embryos were lower in the treatment groups received metformin compared to the OC group and control group. There was no significant difference in the presence of OHSS and the singleton and multiple pregnancies between the four groups. CONCLUSION The present study established no positive role of metformin and OC use in increasing the treatment success in IVF/ICSI cycles in PCOS patients. It would be appropriate to limit the use of these agents with special indications such as decreasing insulin resistance or synchronizing follicular cohort.
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Affiliation(s)
- M N Kalem
- Department of Obstetrics and Gynecology, Liv Hospital, Ankara, Turkey.
| | - Z Kalem
- IVF Department, Gurgan Clinic, Ankara, Turkey
| | - T Gurgan
- IVF Department, Gurgan Clinic, Ankara, Turkey
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179
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Wu XK, Stener-Victorin E, Kuang HY, Ma HL, Gao JS, Xie LZ, Hou LH, Hu ZX, Shao XG, Ge J, Zhang JF, Xue HY, Xu XF, Liang RN, Ma HX, Yang HW, Li WL, Huang DM, Sun Y, Hao CF, Du SM, Yang ZW, Wang X, Yan Y, Chen XH, Fu P, Ding CF, Gao YQ, Zhou ZM, Wang CC, Wu TX, Liu JP, Ng EHY, Legro RS, Zhang H. Effect of Acupuncture and Clomiphene in Chinese Women With Polycystic Ovary Syndrome: A Randomized Clinical Trial. JAMA 2017; 317:2502-2514. [PMID: 28655015 PMCID: PMC5815063 DOI: 10.1001/jama.2017.7217] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Acupuncture is used to induce ovulation in some women with polycystic ovary syndrome, without supporting clinical evidence. OBJECTIVE To assess whether active acupuncture, either alone or combined with clomiphene, increases the likelihood of live births among women with polycystic ovary syndrome. DESIGN, SETTING, AND PARTICIPANTS A double-blind (clomiphene vs placebo), single-blind (active vs control acupuncture) factorial trial was conducted at 21 sites (27 hospitals) in mainland China between July 6, 2012, and November 18, 2014, with 10 months of pregnancy follow-up until October 7, 2015. Chinese women with polycystic ovary syndrome were randomized in a 1:1:1:1 ratio to 4 groups. INTERVENTIONS Active or control acupuncture administered twice a week for 30 minutes per treatment and clomiphene or placebo administered for 5 days per cycle, for up to 4 cycles. The active acupuncture group received deep needle insertion with combined manual and low-frequency electrical stimulation; the control acupuncture group received superficial needle insertion, no manual stimulation, and mock electricity. MAIN OUTCOMES AND MEASURES The primary outcome was live birth. Secondary outcomes included adverse events. RESULTS Among the 1000 randomized women (mean [SD] age, 27.9 [3.3] years; mean [SD] body mass index, 24.2 [4.3]), 250 were randomized to each group; a total of 926 women (92.6%) completed the trial. Live births occurred in 69 of 235 women (29.4%) in the active acupuncture plus clomiphene group, 66 of 236 (28.0%) in the control acupuncture plus clomiphene group, 31 of 223 (13.9%) in the active acupuncture plus placebo group, and 39 of 232 (16.8%) in the control acupuncture plus placebo group. There was no significant interaction between active acupuncture and clomiphene (P = .39), so main effects were evaluated. The live birth rate was significantly higher in the women treated with clomiphene than with placebo (135 of 471 [28.7%] vs 70 of 455 [15.4%], respectively; difference, 13.3%; 95% CI, 8.0% to 18.5%) and not significantly different between women treated with active vs control acupuncture (100 of 458 [21.8%] vs 105 of 468 [22.4%], respectively; difference, -0.6%; 95% CI, -5.9% to 4.7%). Diarrhea and bruising were more common in patients receiving active acupuncture than control acupuncture (diarrhea: 25 of 500 [5.0%] vs 8 of 500 [1.6%], respectively; difference, 3.4%; 95% CI, 1.2% to 5.6%; bruising: 37 of 500 [7.4%] vs 9 of 500 [1.8%], respectively; difference, 5.6%; 95% CI, 3.0% to 8.2%). CONCLUSIONS AND RELEVANCE Among Chinese women with polycystic ovary syndrome, the use of acupuncture with or without clomiphene, compared with control acupuncture and placebo, did not increase live births. This finding does not support acupuncture as an infertility treatment in such women. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01573858.
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Affiliation(s)
- Xiao-Ke Wu
- Committee of Reproductive Medicine, World Federation of Chinese Medicine Societies, Beijing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Elisabet Stener-Victorin
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Hong-Ying Kuang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Hong-Li Ma
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Jing-Shu Gao
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Liang-Zhen Xie
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Li-Hui Hou
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Zhen-Xing Hu
- Outpatient Department, Xuzhou Maternal and Children’s Hospital, Xuzhou, China
| | - Xiao-Guang Shao
- Centre for Reproductive Medicine, Dalian Maternal and Children’s Centre, Dalian, China
| | - Jun Ge
- Department of Infertility, Tanggu District Maternal and Children’s Hospital, Tianjin, China
| | - Jin-Feng Zhang
- Department of Obstetrics and Gynecology, Shanxi Province Hospital of Chinese Medicine, Taiyuan, China
| | - Hui-Ying Xue
- Centre for Reproductive Medicine, Huaian Maternal and Children’s Hospital, Huaian, China
| | - Xiao-Feng Xu
- Department of Gynecology, Suzhou City Hospital of Chinese Medicine, Suzhou, China
| | - Rui-Ning Liang
- Department of Gynecology, Second Hospital, Jiangxi University of Chinese Medicine, Nanchang, China
| | - Hong-Xia Ma
- Department of Chinese Medicine, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Hong-Wei Yang
- Department of Infertility, Liwan District Hospital of Chinese Medicine, Guangzhou, China
| | - Wei-Li Li
- Department of Obstetrics and Gynecology, Affiliated Hospital, Anhui University of Chinese Medicine, Hefei, China
| | - Dong-Mei Huang
- Institute of Integrated Traditional and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Sun
- Department of Gynecology, Wenzhou City Hospital of Chinese Medicine, Wenzhou, China
| | - Cui-Fang Hao
- Centre for Reproductive Medicine, Yuhuangding Hospital, Yantai, China
| | - Shao-Min Du
- Department of Obstetrics and Gynecology, Daqing Longnan Hospital, Daqing, China
| | - Zheng-Wang Yang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Hunan University of Chinese Medicine, Changsha, China
| | - Xin Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Liaoning University of Chinese Medicine, Shenyang, China
| | - Ying Yan
- Department of Gynecology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiu-Hua Chen
- Department of Traditional Technology, Guangdong Province Hospital of Chinese Medicine, Guangzhou, China
| | - Ping Fu
- Department of Gynecology, Hangzhou City Hospital of Chinese Medicine, Hangzhou, China
| | - Cai-Fei Ding
- Centre for Reproductive Medicine, Zhejiang Province Hospital of Integrative Medicine, Hangzhou, China
| | - Ya-Qin Gao
- Centre for Reproductive Medicine, Daqing Oilfield General Hospital, Daqing, China
| | - Zhong-Ming Zhou
- Department of Obstetrics and Gynecology, Hubei Province Hospital of Chinese Medicine, Wuhan, China
| | - Chi Chiu Wang
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Tai-Xiang Wu
- Chinese Clinical Trial Registry, Shenzhen, China
| | - Jian-Ping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Ernest H. Y. Ng
- Department of Obstetrics and Gynecology, The University of Hong Kong, Hong Kong, China
| | - Richard S. Legro
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
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Use of clomiphene or letrozole for treating women with polycystic ovary syndrome related subfertility in Hilla city. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2017. [DOI: 10.1016/j.mefs.2016.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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181
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Broskey NT, Klempel MC, Gilmore LA, Sutton EF, Altazan AD, Burton JH, Ravussin E, Redman LM. Assessing Energy Requirements in Women With Polycystic Ovary Syndrome: A Comparison Against Doubly Labeled Water. J Clin Endocrinol Metab 2017; 102:1951-1959. [PMID: 28323951 PMCID: PMC5470767 DOI: 10.1210/jc.2017-00459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/01/2017] [Indexed: 12/15/2022]
Abstract
CONTEXT Weight loss is prescribed to offset the deleterious consequences of polycystic ovary syndrome (PCOS), but a successful intervention requires an accurate assessment of energy requirements. OBJECTIVE Describe energy requirements in women with PCOS and evaluate common prediction equations compared with doubly labeled water (DLW). DESIGN Cross-sectional study. SETTING Academic research center. PARTICIPANTS Twenty-eight weight-stable women with PCOS completed a 14-day DLW study along with measures of body composition and resting metabolic rate and assessment of physical activity by accelerometry. MAIN OUTCOME Total daily energy expenditure (TDEE) determined by DLW. RESULTS TDEE was 2661 ± 373 kcal/d. TDEE estimated from four commonly used equations was within 4% to 6% of the TDEE measured by DLW. Hyperinsulinemia (fasting insulin and homeostatic model assessment of insulin resistance) was associated with TDEE estimates from all prediction equations (both r = 0.45; P = 0.02) but was not a significant covariate in a model that predicts TDEE. Similarly, hyperandrogenemia (total testosterone, free androgen index, and dehydroepiandrosterone sulfate) was not associated with TDEE. In weight-stable women with PCOS, the following equation derived from DLW can be used to determine energy requirements: TDEE (kcal/d) = 438 - [1.6 * Fat Mass (kg)] + [35.1 * Fat-Free Mass (kg)] + [16.2 * Age (y)]; R2 = 0.41; P = 0.005. CONCLUSIONS Established equations using weight, height, and age performed well for predicting energy requirements in weight-stable women with PCOS, but more precise estimates require an accurate assessment of physical activity. Our equation derived from DLW data, which incorporates habitual physical activity, can also be used in women with PCOS; however, additional studies are needed for model validation.
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Affiliation(s)
| | | | - L. Anne Gilmore
- Pennington Biomedical Research Center, Baton Rouge, Louisiana 70808
| | | | - Abby D. Altazan
- Pennington Biomedical Research Center, Baton Rouge, Louisiana 70808
| | | | - Eric Ravussin
- Pennington Biomedical Research Center, Baton Rouge, Louisiana 70808
| | - Leanne M. Redman
- Pennington Biomedical Research Center, Baton Rouge, Louisiana 70808
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182
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Elkhateeb RR, Mahran AE, Kamel HH. Long-term use of clomiphene citrate in induction of ovulation in PCO patients with clomiphene citrate resistance. J Gynecol Obstet Hum Reprod 2017; 46:575-577. [PMID: 28549986 DOI: 10.1016/j.jogoh.2017.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of our study to evaluate the effect of extended clomiphene citrate treatment on the ovulation rate, pregnancy rate, and hormonal profile of clomiphene resistant PCOS. METHODOLOGY This a prospective study conducted in Maternity Hospital Minia University, 200 patients with PCOS recruited in the study during the period from September 2015 till February 2016 (6 months was duration of the study), they were diagnosed as PCO with clomiphene resistance before being recruited in the study. They received 150mg clomiphene citrate for 10 days start in 2nd day of cycle for three consecutive cycles, and followed up for another three months without treatment, last follow-up cycle was on February. We studied the effect of extended treatment with CC in ovulation rate, pregnancy rate and hormonal profile in patients before and after treatment. RESULTS There was significant improvement in ovulation rate in the patients after extended CC treatment for 3 months and 3 months follow-up (as 12 cases in the first cycle and 32 cases in the second cycle and increased to 76 cases in the third cycle) while no ovulation documented before treatment pregnancy rate was 17% itis generally low but it highly significant when compared with was zero preceding treatment. CONCLUSION Extended CC treatment is good method to improve ovulation and pregnancy rate in CC resistant PCOS but further multi-center studies are needed to provide more powerful evidence.
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Affiliation(s)
- R R Elkhateeb
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia 61111, Egypt.
| | - A E Mahran
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia 61111, Egypt
| | - H H Kamel
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia 61111, Egypt
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Amer SA, Shamy TTE, James C, Yosef AH, Mohamed AA. The impact of laparoscopic ovarian drilling on AMH and ovarian reserve: a meta-analysis. Reproduction 2017; 154:R13-R21. [PMID: 28420801 DOI: 10.1530/rep-17-0063] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/07/2017] [Accepted: 04/18/2017] [Indexed: 01/27/2023]
Abstract
Laparoscopic ovarian drilling (LOD) has been widely used as an effective treatment of anovulatory women with polycystic ovarian syndrome (PCOS). However, there has been a growing concern over a possible damaging effect of this procedure on ovarian reserve. The objective of this study was to investigate the hypothesis that LOD compromises ovarian reserve as measured by post-operative changes in circulating anti-Müllerian hormone (AMH). This meta-analysis included all cohort studies as well as randomised controlled trials (RCTs) investigating serum AMH concentrations and other ovarian reserve markers in women with PCOS undergoing LOD. Various databases were searched including MEDLINE, EMBASE, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and Cochrane Library from January 2000 to December 2016. Sixty studies were identified, of which seven were deemed eligible for this review. AMH data were extracted from each study and entered into the RevMan software to calculate the weighted mean difference (WMD) between pre- and post-operative values. Pooled analysis of all studies (n = 442) revealed a statistically significant decline in serum AMH concentration after LOD (WMD -2.13 ng/mL; 95% confidence interval (CI) -2.97 to -1.30). Subgroup analysis based on duration of follow-up, AMH kit, laterality of surgery and amount of energy applied during LOD consistently showed a statistically significant fall in serum AMH concentration. In conclusion, although LOD seems to markedly reduce circulating AMH, it remains uncertain whether this reflects a real damage to ovarian reserve or normalisation of the high pre-operative serum AMH levels. Further long-term studies on ovarian reserve after LOD are required to address this uncertainty.
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Affiliation(s)
- Saad A Amer
- Department of Obstetrics and GynaecologyUniversity of Nottingham, Royal Derby Hospital, Derby, UK
| | - Tarek T El Shamy
- Derby Teaching Hospitals NHS Foundation TrustRoyal Derby Hospital, Derby, UK
| | - Cathryn James
- Derby Teaching Hospitals NHS Foundation TrustRoyal Derby Hospital, Derby, UK
| | - Ali H Yosef
- Department of Obstetrics and GynaecologyThe University of British Columbia, Vancouver, British Columbia, Canada
| | - Ahmed A Mohamed
- Department of Obstetrics and GynaecologyUniversity of Nottingham, Royal Derby Hospital, Derby, UK
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184
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Palomba S, Daolio J, La Sala GB. Oocyte Competence in Women with Polycystic Ovary Syndrome. Trends Endocrinol Metab 2017; 28:186-198. [PMID: 27988256 DOI: 10.1016/j.tem.2016.11.008] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/17/2016] [Accepted: 11/23/2016] [Indexed: 02/06/2023]
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age and affects fertility and pregnancy in cases of oligoanovulation. Ovulation induction is often used to treat anovulatory patients with PCOS, but many of these women fail to conceive and resort to assisted reproductive technologies. Alterations in oocyte competence (OC) are considered potential causative factors for subfertility in women with PCOS. In this review we present and critically assess all recent clinical and experimental data regarding OC in women with PCOS. Our analysis demonstrates that the contribution of OC to reproductive potential in women with PCOS varies and largely depends on the PCOS phenotype and comorbidities associated with PCOS.
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Affiliation(s)
- Stefano Palomba
- Unit of Gynecology and Obstetrics, IRCCS - Arcispedale Santa Maria Nuova, Viale Risorgimento 80, Reggio Emilia 42123, Italy.
| | - Jessica Daolio
- Unit of Gynecology and Obstetrics, IRCCS - Arcispedale Santa Maria Nuova, Viale Risorgimento 80, Reggio Emilia 42123, Italy
| | - Giovanni Battista La Sala
- Unit of Gynecology and Obstetrics, IRCCS - Arcispedale Santa Maria Nuova, Viale Risorgimento 80, Reggio Emilia 42123, Italy; University of Modena and Reggio Emilia, Via Università 4, Modena 41100, Italy
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185
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Kudesia R, Talib HJ, Pollack SE. Fertility Awareness Counseling for Adolescent Girls; Guiding Conception: The Right Time, Right Weight, and Right Way. J Pediatr Adolesc Gynecol 2017; 30:9-17. [PMID: 27486027 DOI: 10.1016/j.jpag.2016.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To provide a detailed summary of fertility awareness counseling pearls for healthy teens and those with fertility-relevant comorbidities, and to assist providers in offering such counseling to adolescents and young adult women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Comprehensive literature review of English-language studies relating to fertility in pediatric and adolescent female patients (ages 13-21 years), and evidence-based dialogue guide. RESULTS The literature indicates that although adolescents are interested in discussing sexuality and reproduction, this is commonly overlooked during the standard office medical visit. As a result, adolescents often turn to less reliable sources and hold a variety of reproductive misconceptions and a sense of lack of control over future fertility. We found no studies that examined the routine provision of fertility awareness counseling with healthy adolescents. There are a multitude of specific gynecologic and medical conditions that have ramifications for fertility. We detail these comprehensively, and provide a dialogue guide to assist with fertility awareness counseling for the female adolescent, containing specific information and indications for referral. CONCLUSION Providers caring for adolescent girls have the opportunity to enhance fertility awareness as part of a larger reproductive health conversation that adolescents desire, and from which they might benefit. Identifying potential future fertility issues, understanding age-related fertility decline, and aiding in health optimization before future conception might empower the adolescent to make informed reproductive decisions. We provide an algorithm to use with adolescents to discuss the "right time, right weight, right way" to pursue childbearing.
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Affiliation(s)
- Rashmi Kudesia
- Division of Reproductive Endocrinology and Infertility, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Hina J Talib
- Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Staci E Pollack
- Division of Reproductive Endocrinology and Infertility, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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186
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Romanski P, Stanic AK. Practical Approach to the PCOS Patient. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0190-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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187
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Wang R, Kim BV, van Wely M, Johnson NP, Costello MF, Zhang H, Ng EHY, Legro RS, Bhattacharya S, Norman RJ, Mol BWJ. Treatment strategies for women with WHO group II anovulation: systematic review and network meta-analysis. BMJ 2017; 356:j138. [PMID: 28143834 PMCID: PMC5421445 DOI: 10.1136/bmj.j138] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare the effectiveness of alternative first line treatment options for women with WHO group II anovulation wishing to conceive. DESIGN Systematic review and network meta-analysis. DATA SOURCES Cochrane Central Register of Controlled Trials, Medline, and Embase, up to 11 April 2016. STUDY SELECTION Randomised controlled trials comparing eight ovulation induction treatments in women with WHO group II anovulation: clomiphene, letrozole, metformin, clomiphene and metformin combined, tamoxifen, gonadotropins, laparoscopic ovarian drilling, and placebo or no treatment. Study quality was measured on the basis of the methodology and categories described in the Cochrane Collaboration Handbook. Pregnancy, defined preferably as clinical pregnancy, was the primary outcome; live birth, ovulation, miscarriage, and multiple pregnancy were secondary outcomes. RESULTS Of 2631 titles and abstracts initially identified, 54 trials reporting on 7173 women were included. All pharmacological treatments were superior to placebo or no intervention in terms of pregnancy and ovulation. Compared with clomiphene alone, both letrozole and the combination of clomiphene and metformin showed higher pregnancy rates (odds ratio 1.69, 95% confidence interval 1.33 to 2.14; 1.71, 1.28 to 2.27; respectively). Letrozole led to higher live birth rates when compared with clomiphene alone (1.67, 1.11 to 2.49). Metformin led to lower multiple pregnancy rates compared with clomiphene alone (0.22, 0.05 to 0.93). CONCLUSIONS In women with WHO group II anovulation, letrozole and the combination of clomiphene and metformin are superior to clomiphene alone in terms of pregnancy. Compared with clomiphene alone, letrozole is the only treatment showing a significantly higher rate of live birth. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015027579. READERS' NOTE This is the second version of this paper. The original version was corrected following the retraction of two studies and removal of another which were ineligible (references 40, 41, and 75 of the original paper). These studies are not shown in this version. A tracked changes version of the original version is attached as a supplementary file to the correction notice, which explains the issue further.
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Affiliation(s)
- Rui Wang
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- Reproductive Medicine Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bobae V Kim
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
| | - Madelon van Wely
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Neil P Johnson
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Michael F Costello
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Hanwang Zhang
- Reproductive Medicine Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ernest Hung Yu Ng
- Department of Obstetrics and Gynaecology, University of Hong Kong, Hong Kong, China
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, USA
| | | | - Robert J Norman
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- FertilitySA, Adelaide, Australia
- NHMRC (National Health and Medical Research Council) Centre for Research Excellence in Polycystic Ovary Syndrome, Adelaide, Australia
| | - Ben Willem J Mol
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
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Alviggi C, Conforti A, De Rosa P, Strina I, Palomba S, Vallone R, Gizzo S, Borrelli R, Andersen CY, De Placido G, Guerriero S. The Distribution of Stroma and Antral Follicles Differs between Insulin-Resistance and Hyperandrogenism-Related Polycystic Ovarian Syndrome. Front Endocrinol (Lausanne) 2017; 8:117. [PMID: 28620353 PMCID: PMC5449504 DOI: 10.3389/fendo.2017.00117] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/12/2017] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Although insulin resistance plays an important pathogenetic role in polycystic ovary syndrome (PCOS), no correlation between ultrasound PCOS pattern and insulin resistance has yet been reported. The aim of this retrospective observational study was to assess whether the ovarian ultrasonographic parameter differed between PCOS women with insulin resistance and those with a hyperandrogenic profile. MATERIALS AND METHODS Women who fulfilled the Rotterdam criteria for PCOS were retrospectively studied. Anthropometric, biochemical, and clinical data were recorded. Women were divided into two groups based on specific transvaginal ultrasound parameters: subjects with more than half of the follicles measuring between 5 and 9 mm in diameter, an ultrasonographic determined stroma/total area (S/A) > 0.34 and a "necklace" sign of antral follicles (Group A); and subjects with more than half of the antral follicles measuring between 2 and 4 mm in diameter, an S/A ≤ 0.34; no "necklace" sign but ubiquitously distributed follicles determined by ultrasound (Group B). The association between these ultrasound patterns and the presence of insulin resistance was also evaluated. RESULTS Seventy-eight patients were enrolled: 33 with ultrasound sound pattern A and 45 with pattern B. The latter pattern had a sensitivity of 88% and a specificity of 78% in predicting PCOS women with insulin resistance. There were no differences in age, Ferriman-Gallwey score, and serum gonadotropin or androgen levels between the two groups. Body mass index, the waist-to-hip ratio, and homeostasis model assessment were significantly higher in group B than in group A (p < 0.05). Conversely, sex hormone binding globulin levels and ovarian volume were significantly higher in group A (p < 0.05). Insulin resistance was more frequent in group B than in group A (36/41, 87.8% versus 7/32, 21.8%; p < 0.05). CONCLUSION These results suggest that insulin resistance could be associated with a specific ultrasound pattern in PCOS patients.
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Affiliation(s)
- Carlo Alviggi
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
- *Correspondence: Carlo Alviggi,
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Pasquale De Rosa
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Ida Strina
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Stefano Palomba
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Roberta Vallone
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Salvatore Gizzo
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Rosaria Borrelli
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, Faculty of Health and Medical Sciences, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Giuseppe De Placido
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Stefano Guerriero
- Department of Obstetrics and Gynecology, Policlinico Universitario Duilio Casula, University of Cagliari, Cagliari, Italy
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189
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Goyal M, Dawood AS. Debates Regarding Lean Patients with Polycystic Ovary Syndrome: A Narrative Review. J Hum Reprod Sci 2017; 10:154-161. [PMID: 29142442 PMCID: PMC5672719 DOI: 10.4103/jhrs.jhrs_77_17] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is a complex syndrome showing the clinical features of an endocrine/metabolic disorder, including hyperinsulinemia and hyperandrogenism. Two phenotypes are present, either lean or obese, with different biochemical, hormonal, and metabolic profiles. Evidence suggests many treatment modalities that can be applied. However, many of these modalities were found to be not suitable for the lean phenotype of PCOS. Much contradictory research was found regarding lean patients with PCOS. The aim of this narrative review is to shed light on the debate prevailing regarding characteristics, as well as metabolic, hematological, and potential management modalities. Literature review was performed from January 1, 2000 to March 31, 2017 with specific word search such as lean PCOS, hormonal abnormalities in lean PCOS, and the management of lean PCOS. All retrieved articles were carefully assessed, and data were obtained. We could conclude that the debate is still prevailing regarding this specific lean population with PCOS, especially with regard to their characteristics and management modalities. Further studies are still required to resolve this debate on the presence of PCOS in lean women.
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Affiliation(s)
- Manu Goyal
- Department of Obstetrics and Gynecology, AIIMS, New Delhi, India
| | - Ayman S Dawood
- Department of Obstetrics and Gynecology, Tanta University, Tanta, Egypt
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190
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Giampaolino P, Morra I, Della Corte L, Sparice S, Di Carlo C, Nappi C, Bifulco G. Serum anti-Mullerian hormone levels after ovarian drilling for the second-line treatment of polycystic ovary syndrome: a pilot-randomized study comparing laparoscopy and transvaginal hydrolaparoscopy. Gynecol Endocrinol 2017; 33:26-29. [PMID: 27228002 DOI: 10.1080/09513590.2016.1188280] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Aim of the study was to asses and compare serum anti-Mullerian harmone (AMH) levels after laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL) ovarian drilling in clomifene citrate (CC)-resistant polycystic ovary syndrome (PCOS) patients; secondary outcome was to evaluate postoperative pain to estimate the acceptability of procedures. A total of 246 patients with CC-resistant PCOS were randomized into two groups: 123 underwent LOD and 123 underwent THL ovarian drilling. AMH serum levels were evaluated before and after the procedure; moreover, women were asked to rate pain on a visual analog scale (VAS) from 0 (no pain, perfectly acceptable) to 10 (unbearable pain, completely unacceptable). In both groups, postoperative serum AMH levels were significantly reduced compared to preoperative levels (6.06 ± 1.18 and 5.84 ± 1.16 versus 5.00 ± 1.29 and 4.83 ± 1.10; p < 0.0001). Comparing postoperative serum AMH levels, no statistically significant difference was observed between the two surgical technique. After the procedure, mean pain VAS score was significantly higher for women who underwent LOD ovarian drilling in comparison to THL (3.26 ± 1.1 versus 1.11 ± 0.5; p < 0.0001). In conclusion, THL ovarian drilling is comparable to the LOD in terms of reduction in AMH, but it is preferred by patients in terms of acceptability. These results could support to use of THL ovarian drilling in the treatment of patients with CC- resistant PCOS.
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Affiliation(s)
| | - Ilaria Morra
- a Department of Obstetrics , Gynecology, and Urology and
| | | | | | | | - Carmine Nappi
- b Department of Public Health , University of Naples "Federico II" , Naples , Italy
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191
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The role of steroid hormone supplementation in non–assisted reproductive technology treatments for unexplained infertility. Fertil Steril 2016; 106:1600-1607. [DOI: 10.1016/j.fertnstert.2016.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/18/2016] [Accepted: 09/07/2016] [Indexed: 11/23/2022]
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192
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Tan MH, Alquraini H, Mizokami-Stout K, MacEachern M. Metformin: From Research to Clinical Practice. Endocrinol Metab Clin North Am 2016; 45:819-843. [PMID: 27823607 DOI: 10.1016/j.ecl.2016.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Metformin is the recommended first-line oral glucose-lowering drug initiated to control hyperglycemia in type 2 diabetes mellitus. It acts in the liver, small intestines, and skeletal muscles with its major effect on decreasing hepatic gluconeogenesis. It is safe, inexpensive, and weight neutral and can be associated with weight loss. It can reduce microvascular complication risk and its use is associated with a lower cardiovascular mortality compared with sulfonylurea therapy. It is also used to delay the onset of type 2 diabetes mellitus, in treating gestational diabetes, and in women with polycystic ovary syndrome.
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Affiliation(s)
- Meng H Tan
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Hussain Alquraini
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
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Melo ASD, Kliemchen J, Junior AAJ, Ferriani RA, Navarro PA. Oxidative stress and polycystic ovary syndrome: evaluation during ovarian stimulation for ICSI. Reproduction 2016; 153:REP-16-0084. [PMID: 27799629 DOI: 10.1530/rep-16-0084] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 10/26/2016] [Indexed: 01/24/2023]
Abstract
Oxidative stress (OS) may affect natural fertility and the results of assisted reproduction techniques (ARTs). Subfertility associated with polycystic ovary syndrome (PCOS) may be related to OS. This process may intensify during controlled ovarian stimulation (COS) for ARTs because of increased ovarian metabolic activity and hypoestrogenism with the use of gonadotropin-releasing hormone agonists (GnRHas). The objective of this study was to investigate the presence of systemic OS in non-stimulated cycles and to determine OS markers (malondialdehyde [MDA], advanced oxidation protein products [AOPP], hydroperoxides [FOX], glutathione [GSH], and vitamin E) during COS in non-obese infertile women with and without PCOS who were subjected to ARTs. A prospective cohort study was conducted on non-obese women (16 with PCOS, and 60 ovulatory patients with infertility due to male and/or tubal factors). The OS markers were determined during the following time-points: the follicular phase of the natural cycle (D1), after pituitary downregulation with GnRHa and before the use of gonadotropins (D2), on the day of administration of human chorionic gonadotropin (D3), and at oocyte retrieval (D4). Intergroup analysis showed that serum MDA concentrations were higher in the PCOS group at D3 (P=0.048) and D4 (P=0.002). On an intragroup analysis, the control group had higher MDA concentrations at D2 than at D1 (P=0.01) or D4 (P=0.004). The AOPP concentrations were higher at D2 (P<0.0001), D3 (P<0.001) and D4 (P<0.0001) compared to D1. The FOX concentrations were lower at D2 (P<0.0001), D3 (P<0.0001), and D4 (P<0.001) than at D1. Serum GSH concentrations were significantly higher at D4 than at D1 (P=0.02). An intragroup analysis of the PCOS subjects showed that the five OS markers did not differ significantly among the four time-points when they were analyzed (D1, D2, D3 and D4). In conclusion, non-obese infertile women with PCOS showed evidence of systemic OS after COS with gonadotropins for ICSI. On the other hand, non-obese ovulatory infertile women, and women with infertility due to male and/or tubal factors showed a possible systemic oxidative balance until the final of COS.
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Affiliation(s)
- Anderson Sanches de Melo
- A Melo, Unit of Human Reproduction and Gynaecological Endocrinology, Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo (Universidade de São Paulo - USP), Brazil., Ribeirão Preto, 14049-900 , Brazil
| | - Jhenifer Kliemchen
- J Kliemchen, Obstetrics and Gynecology, Medical School of Ribeirão Preto, University of SãoPaulo, Ribeirão Preto, Brazil
| | - Alceu Afonso Jordão Junior
- A Junior, Nutrition and Metabolism Laboratory, Medical School of Ribeirão Preto, University of Sao Paulo, Ribeirão Preto, Brazil
| | - Rui A Ferriani
- R Ferriani, Gynecology and Obstetrics, University of Sao Paulo, Ribeirao preto, 14049900, Brazil
| | - Paula Andrea Navarro
- P Navarro, Obstetrics and Gynecology, Medical School of Ribeirão Preto, University of SãoPaulo, Ribeirão Preto, Brazil
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Hormonal Changes After Laparoscopic Ovarian Diathermy in Patients with Polycystic Ovarian Syndrome. J Obstet Gynaecol India 2016; 66:528-33. [PMID: 27651657 DOI: 10.1007/s13224-016-0882-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/19/2016] [Indexed: 12/30/2022] Open
Abstract
AIM OF THE PRESENT STUDY To assess the changes in hormonal profile (serum FSH, LH, prolactin and total testosterone) following laparoscopic ovarian drilling (LOD) in patients with polycystic ovarian syndrome. MATERIALS AND METHODS Fifty patients with PCOS have been included in this study. Serum prolactin, total testosterone, follicular-stimulating hormone (FSH) and luteinizing hormone (LH) levels have been used as biochemical markers, before and after procedures. RESULTS Laparoscopic ovarian drilling was successfully employed without any surgical complications and on an average follow-up time of 24 weeks after the procedure. During the follow-up serum values for prolactin, total testosterone and LH have decreased significantly and FSH levels remained unchanged after the procedure. CONCLUSIONS The LOD in patients with PCOS may avoid or reduce the risk of OHSS and the multiple pregnancy rate induced by gonadotropin therapy. The high pregnancy rate and the economic aspect of the procedure offer an attractive management for patients with PCOS. However, LOD can be considered as second-line treatment after clomiphene citrate treatment failure and/or resistance.
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Is there a role for diet in ameliorating the reproductive sequelae associated with chronic low-grade inflammation in polycystic ovary syndrome and obesity? Fertil Steril 2016; 106:520-7. [DOI: 10.1016/j.fertnstert.2016.07.1069] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/11/2016] [Accepted: 07/12/2016] [Indexed: 02/06/2023]
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Nagelberg J, Burks H, Mucowski S, Shoupe D. The effect of home exercise on ovulation induction using clomiphene citrate in overweight underserved women with polycystic ovarian syndrome. Contracept Reprod Med 2016; 1:14. [PMID: 29201403 PMCID: PMC5693512 DOI: 10.1186/s40834-016-0025-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 01/26/2016] [Indexed: 01/07/2023] Open
Abstract
Background Age-adjusted rates of obesity are reported to be 35.8 % among US adult women and 49 % in some race/ethnicity, underserved populations. (1). Underserved populations often have less access to weight-loss intervention options and are at high risk for obesity related problems including anovulation, infertility, pregnancy-related complications and adverse long-term health outcomes. (2). The purpose of this study was to evaluate a home exercise plan using a pedometer on weight loss, ovulation induction and pregnancy rates in our overweight and obese underserved clinic population. Methods Twenty one overweight (BMI ≥ 25–29.9) and obese I-II (BMI ≥ 30–39.9) 18–42 years old were recruited. Participants received an exercise/nutrition questionnaire at the initiation and completion and called weekly for 4 weeks. Ten participants were randomly assigned to the home exercise program (PedGp). PedGp received a pedometer, daily step-count goal, and were called to increase goal by 50 % weekly. All participants then underwent clomiphene stair-step ovulation induction. All study participants were referred to the University Wellness Clinic for diet and exercise counseling. Results There were high percentages of women with co-morbidities in both groups including fatty liver, low vitamin D, hyperlipidemia, hypothyroidism, prediabetes and diabetes. 1. Those completing the 4-week home program increased baseline steps by 21.2 % weekly. Only 3/10 women reached at least one weekly goal of 50 % increase. Although the goal was rarely met, participants who completed study had increased number of daily steps. 2. Greater number in PedGp lost weight or stayed the same (5/10 vs. 2/11). 3. Greater number in PedGp spontaneously ovulated (4/10 vs. 1/11) or became pregnant (4/10 vs. 3/11). (not statistically significant due to small sample size). Conclusion There are high percentages of comorbidities in this population. Although the goal was rarely met, participants who completed study had increased number of daily steps. A greater number in PedGp lost weight or stayed the same. A greater number in PedGp spontaneously ovulated or became pregnant (not statistically significant due to small sample size). Importantly, 40 % of women who lost weight became pregnant. This is highly encouraging and suggests that the development of pedometer interventions may prove a cost effective option. Weight loss programs for this population hold promise and efficient hospital or community-based programs may prove beneficial.
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Affiliation(s)
- Jodi Nagelberg
- Keck School of Medicine, Los Angeles, CA 90033 USA.,University of Southern California, Los Angeles, CA 90033 USA
| | - Heather Burks
- Department of Obstetrics and Gynecology, Los Angeles, CA 90033 USA.,Keck School of Medicine, Los Angeles, CA 90033 USA.,University of Southern California, Los Angeles, CA 90033 USA
| | - Sara Mucowski
- Department of Obstetrics and Gynecology, Los Angeles, CA 90033 USA.,Keck School of Medicine, Los Angeles, CA 90033 USA.,University of Southern California, Los Angeles, CA 90033 USA
| | - Donna Shoupe
- Department of Obstetrics and Gynecology, Los Angeles, CA 90033 USA.,Keck School of Medicine, Los Angeles, CA 90033 USA.,University of Southern California, Los Angeles, CA 90033 USA.,Department of Obstetrics and Gynecology, Keck School of Medicine, Health Sciences Campus, IRD 530, Los Angeles, CA 90089 USA
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Abstract
Polycystic ovary syndrome (PCOS) affects 5-20% of women of reproductive age worldwide. The condition is characterized by hyperandrogenism, ovulatory dysfunction and polycystic ovarian morphology (PCOM) - with excessive androgen production by the ovaries being a key feature of PCOS. Metabolic dysfunction characterized by insulin resistance and compensatory hyperinsulinaemia is evident in the vast majority of affected individuals. PCOS increases the risk for type 2 diabetes mellitus, gestational diabetes and other pregnancy-related complications, venous thromboembolism, cerebrovascular and cardiovascular events and endometrial cancer. PCOS is a diagnosis of exclusion, based primarily on the presence of hyperandrogenism, ovulatory dysfunction and PCOM. Treatment should be tailored to the complaints and needs of the patient and involves targeting metabolic abnormalities through lifestyle changes, medication and potentially surgery for the prevention and management of excess weight, androgen suppression and/or blockade, endometrial protection, reproductive therapy and the detection and treatment of psychological features. This Primer summarizes the current state of knowledge regarding the epidemiology, mechanisms and pathophysiology, diagnosis, screening and prevention, management and future investigational directions of the disorder.
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Goodman NF, Cobin RH, Futterweit W, Glueck JS, Legro RS, Carmina E. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE EVALUATION AND TREATMENT OF POLYCYSTIC OVARY SYNDROME - PART 2. Endocr Pract 2016; 21:1415-26. [PMID: 26642102 DOI: 10.4158/ep15748.dscpt2] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Polycystic ovary syndrome (PCOS) is recognized as the most common endocrine disorder of reproductive-aged women around the world. This document, produced by the collaboration of the American Association of Clinical Endocrinologists and the Androgen Excess Society aims to highlight the most important clinical issues confronting physicians and their patients with PCOS. It is a summary of current best practices in 2014. Insulin resistance is believed to play an intrinsic role in the pathogenesis of PCOS. The mechanism by which insulin resistance or insulin give rise to oligomenorrhea and hyperandrogenemia, however, is unclear. Hyperinsulinemic-euglycemic clamp studies have shown that both obese and lean women with PCOS have some degree of insulin resistance. Insulin resistance is implicated in the ovulatory dysfunction of PCOS by disrupting the hypothalamic-pituitary-ovarian axis. Given the association with insulin resistance, all women with PCOS require evaluation for the risk of metabolic syndrome (MetS) and its components, including type 2 diabetes, hypertension, hyperlipidemia, and the possible risk of clinical events, including acute myocardial infarction and stroke. Obese women with PCOS are at increased risk for MetS with impaired glucose tolerance (IGT; 31 to 35%) and type 2 diabetes mellitus (T2DM; 7.5 to 10%). Rates of progression from normal glucose tolerance to IGT, and in turn to T2DM, may be as high as 5 to 15% within 3 years. Data suggest the need for baseline oral glucose tolerance test every 1 to 2 years based on family history of T2DM as well as body mass index (BMI) and yearly in women with IGT. Compared with BMI- and age-matched controls, young, lean PCOS women have lower high-density lipoprotein (HDL) size, higher very-low-density lipoprotein particle number, higher low-density lipoprotein (LDL) particle number, and borderline lower LDL size. Statins have been shown to lower testosterone levels either alone or in combination with oral contraceptives (OCPs) but have not shown improvement in menses, spontaneous ovulation, hirsutism, or acne. Statins reduce total and LDL cholesterol but have no effect on HDL, C-reactive protein, fasting insulin, or homeostasis model assessment of insulin resistance in PCOS women, in contrast to the general population. There have been no long-term studies of statins on clinical cardiac outcomes in women with PCOS. Coronary calcification is more prevalent and more severe in PCOS than in controls. In women under 60 years of age undergoing coronary angiography, the presence of polycystic ovaries on sonography has been associated with more arterial segments with >50% stenosis, but the relationship between PCOS and actual cardiovascular events remains unclear. Therapies for PCOS are varied in their effects and targets and include both nonpharmacologic as well as pharmacologic approaches. Weight loss is the primary therapy in PCOS--reduction in weight of as little as 5% can restore regular menses and improve response to ovulation- inducing and fertility medications. Metformin in premenopausal PCOS women has been associated with a reduction in features of MetS. Clamp studies using ethinyl estradiol/drosperinone combination failed to reveal evidence of an increase in either peripheral or hepatic insulin resistance. Subjects with PCOS have a 1.5-times higher baseline risk of venous thromboembolic disease and a 3.7-fold greater effect with OCP use compared with non-PCOS subjects. There is currently no genetic test to screen for or diagnose PCOS, and there is no test to assist in the choice of treatment strategies. Persistent bleeding should always be investigated for pregnancy and/or uterine pathology--including transvaginal ultrasound exam and endometrial biopsy--in women with PCOS. PCOS women can have difficulty conceiving. Those who become pregnant are at risk for gestational diabetes (which should be evaluated and managed appropriately) and the microvascular complications of diabetes. Assessment of a woman with PCOS for infertility involves evaluating for preconceptional issues that may affect response to therapy or lead to adverse pregnancy outcomes and evaluating the couple for other common infertility issues that may affect the choice of therapy, such as a semen analysis. Women with PCOS have multiple factors that may lead to an elevated risk of pregnancy, including a high prevalence of IGT--a clear risk factor for gestational diabetes--and MetS with hypertension, which increases the risk for pre-eclampsia and placental abruption. Women should be screened and treated for hypertension and diabetes prior to attempting conception. Women should be counseled about weight loss prior to attempting conception, although there are limited clinical trial data demonstrating a benefit to this recommendation. Treatment for women with PCOS and anovulatory infertility should begin with an oral agent such as clomiphene citrate or letrozole, an aromatase inhibitor.
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Giampaolino P, Morra I, Tommaselli GA, Di Carlo C, Nappi C, Bifulco G. Post-operative ovarian adhesion formation after ovarian drilling: a randomized study comparing conventional laparoscopy and transvaginal hydrolaparoscopy. Arch Gynecol Obstet 2016; 294:791-6. [DOI: 10.1007/s00404-016-4146-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/30/2016] [Indexed: 12/31/2022]
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Legro RS, Dodson WC, Kunselman AR, Stetter CM, Kris-Etherton PM, Williams NI, Gnatuk CL, Estes SJ, Allison KC, Sarwer DB, Diamond MP, Schlaff WD, Casson PR, Christman GM, Barnhart KT, Bates GW, Usadi R, Lucidi S, Baker V, Zhang H, Eisenberg E, Coutifaris C, Dokras A. Benefit of Delayed Fertility Therapy With Preconception Weight Loss Over Immediate Therapy in Obese Women With PCOS. J Clin Endocrinol Metab 2016; 101:2658-66. [PMID: 27172435 PMCID: PMC4929837 DOI: 10.1210/jc.2016-1659] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
CONTEXT In overweight/obese women with polycystic ovary syndrome (PCOS), the relative benefit of delaying infertility treatment to lose weight vs seeking immediate treatment is unknown. OBJECTIVE We compared the results of two, multicenter, concurrent clinical trials treating infertility in women with PCOS. DESIGN, SETTING, AND PARTICIPANTS This was a secondary analysis of two randomized trials conducted at academic health centers studying women 18-40 years of age who were overweight/obese and infertile with PCOS. INTERVENTION We compared immediate treatment with clomiphene from the Pregnancy in Polycystic Ovary Syndrome II (PPCOS II) trial (N = 187) to delayed treatment with clomiphene after preconception treatment with continuous oral contraceptives, lifestyle modification (Lifestyle: including caloric restriction, antiobesity medication, behavioral modification, and exercise) or the combination of both (combined) from the Treatment of Hyperandrogenism Versus Insulin Resistance in Infertile Polycystic Ovary Syndrome (OWL PCOS) trial (N = 142). MAIN OUTCOME MEASURES Live birth, pregnancy loss, and ovulation were measured. RESULTS In PPCOS II, after four cycles of clomiphene, the cumulative per-cycle ovulation rate was 44.7% (277/619) and the cumulative live birth rate was 10.2% (19/187), nearly identical to that after oral contraceptive pretreatment in the OWL PCOS trial (ovulation 45% [67/149] and live birth: 8.5% [4/47]). In comparison, deferred clomiphene treatment preceded by lifestyle and combined treatment in OWL PCOS offered a significantly better cumulative ovulation rate compared to immediate treatment with clomiphene. (Lifestyle: 62.0% [80/129]; risk ratio compared to PPCOS II = 1.4; 95% confidence interval [CI], 1.1-1.7; P = .003; combined: 64.3% [83/129]; risk ratio compared to PPCOS II = 1.4; 95% CI, 1.2-1.8; P < .001 and a significantly better live birth rate lifestyle: 25.0% [12/48]; risk ratio compared to PPCOS II = 2.5; 95% CI, 1.3-4.7; P = .01 and combined: 25.5% [12/47]; risk ratio compared to PPCOS II = 2.5; 95% CI, 1.3-4.8; P = .01). CONCLUSIONS These data show the benefit of improved ovulation and live birth with delayed infertility treatment with clomiphene citrate when preceded by lifestyle modification with weight loss compared with immediate treatment. Pretreatment with oral contraceptives likely has little effect on the ovulation and live birth rate compared with immediate treatment.
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Affiliation(s)
- Richard S Legro
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - William C Dodson
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Allen R Kunselman
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Christy M Stetter
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Penny M Kris-Etherton
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Nancy I Williams
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Carol L Gnatuk
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Stephanie J Estes
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Kelly C Allison
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - David B Sarwer
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Michael P Diamond
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - William D Schlaff
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Peter R Casson
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Gregory M Christman
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - G Wright Bates
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Scott Lucidi
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Valerie Baker
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Heping Zhang
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Esther Eisenberg
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
| | - Anuja Dokras
- Department of Obstetrics and Gynecology (R.S.L., W.C.D., C.L.G., S.J.E.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences (R.S.L., A.R.K., C.M.S.), Penn State College of Medicine, Hershey, Pennsylvania; Department of Nutritional Sciences (P.M.K.-E.), Penn State College of Health and Human Development, University Park, Pennsylvania; Department of Kinesiology (N.W.), Penn State College of Health and Human Development, University Park, Pennsylvania; Departments of Psychiatry (K.C.A., D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.B.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (M.P.D.), Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology (W.D.S.), University of Colorado, Denver, Colorado; Department of Obstetrics and Gynecology (P.R.C.), University of Vermont, Burlington, Vermont; Department of Obstetrics and Gynecology (G.M.C.), University of Michigan, Ann Arbor, Michigan; Department of Obstetrics and Gynecology (K.T.B., C.C., A.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology (W.B.), University of Alabama Birmingham, Birmingham, Alabama; Carolinas Medical Center (R.U.), Charlotte, North Carolina; Department of Obstetrics and Gynecology (S.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Obstetrics and Gynecology (V.B.), Stanford University Medical Center, Stanford, California; Department of Biostatistics (H.H.), Yale University School of Public Health, New Haven, Connecticut; Fertility and Infertility Branch (E.E.), Eunice Kennedy Shriver NICHD, Rockville, Maryland
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