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Ibrahim S, Mehra R, Tantibhedhyangkul J, Bena J, Flyckt RL. Sleep and obstructive sleep apnea in women with infertility. Sleep Breath 2023; 27:1733-1742. [PMID: 36609819 DOI: 10.1007/s11325-022-02770-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 01/08/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is associated with polycystic ovarian syndrome (PCOS), a common cause of infertility. Understanding predictors and outcomes of OSA in women with infertility may guide treatment. METHODS A descriptive cross-sectional survey was performed to assess OSA in women presenting to an infertility clinic using validated sleep questionnaires to assess sleep and fertility outcomes. An Infertile-C group (controls with male or tubal factors) and an Infertile-S group (unknown/other infertile causes) were analyzed to assess OSA risk and other sleep disorders (e.g., restless legs syndrome (RLS) and insomnia) with fertility outcomes (time to pregnancy, PCOS, irregular menstruation, and miscarriage). RESULTS In 258 women, occurrences of OSA diagnosis (6%) and RLS (10%) were reported similar to women of child-bearing age in the general population. PCOS was unassociated with OSA risk. Predictors of OSA risk were BMI, insomnia symptoms, and sleep aid use. Obese women with high OSA risk were more likely to have other comorbidities (e.g., depression). In adjusted models, prior clinical OSA diagnosis was associated with miscarriage (odds ratio: 6.17 (1.24, 30.62), p = 0.026). RLS was associated with irregular menstruation (odds ratio: 3.73 (1.21, 11.53), p = 0.022). CONCLUSIONS Similar to other populations, women with infertility and OSA risk have more health comorbidities and higher BMI and may present with insomnia symptoms. While the data are limited, this study supports the potential associations of OSA and miscarriage. Further work is needed to evaluate OSA in female infertility.
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Affiliation(s)
- Sally Ibrahim
- Division of Pediatric Pulmonary and Sleep Medicine, Rainbow Babies and Children's Hospital of University Hospitals, Cleveland, OH, USA.
| | - Reena Mehra
- Neurological Institute, Cleveland Clinic Sleep Disorders Center, Cleveland, OH, USA
| | - Julierut Tantibhedhyangkul
- Division of Reproductive Endocrinology and Infertility, Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - James Bena
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca L Flyckt
- Division of Reproductive Endocrinology and Infertility, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Kim AE, Nelson A, Stimpert K, Flyckt RL, Thirumavalavan N, Baker KC, Weinmann SC, Hoimes CJ. Minding the Bathwater: Fertility and Reproductive Toxicity in the Age of Immuno-Oncology. JCO Oncol Pract 2022; 18:815-822. [PMID: 36174117 PMCID: PMC10166412 DOI: 10.1200/op.22.00469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/29/2022] [Indexed: 01/05/2023] Open
Abstract
Immune checkpoint inhibition has resulted in significant efficacy across many cancer types, including melanoma. Melanoma is the second most common cancer among those of reproductive age, yet the reproductive toxicities of adjuvant and first-line immunotherapy are largely unknown.The normal innate and adaptive immune systems play a vital role in reproductive organ homeostasis of men and women and are essential for implantation, fertility, and a successful pregnancy. The programmed cell death-1 receptor/programmed cell death receptor ligand-1 (PD-1/PD-L1) pathway is essential in several aspects of fertility and pregnancy. Recent studies have largely focused on the role of the PD-1/PD-L1 pathway in fetomaternal tolerance, highlighting the importance of intact immune regulation in promoting a successful pregnancy.In this review, we describe a case of a reproductive-aged female with stage IIIC melanoma who sought guidance on family planning after pembrolizumab therapy. We discuss the known fertility-related toxicities of immune checkpoint inhibitors, the potential targets for reproductive toxicity in males and nonpregnant females, and the implications of anti-PD-1 therapy in relation to fetomaternal tolerance. Informed decision making will benefit from data and consensus.
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Affiliation(s)
- Anne E. Kim
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Ariel Nelson
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
- Department of Medicine, Division of Hematology and Oncology, The Medical College of Wisconsin, Milwaukee, WI
| | - Kyle Stimpert
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
- VA Northeast Ohio Healthcare System, Cleveland, OH
| | | | - Nannan Thirumavalavan
- Department of Urology, University Hospitals, Case Western Reserve University, Cleveland, OH
| | | | - Sophia C. Weinmann
- Division of Rheumatology and Immunology, Duke University, Durham, NC
- Center for Cancer Immunotherapy, Duke University, Durham, NC
| | - Christopher J. Hoimes
- Center for Cancer Immunotherapy, Duke University, Durham, NC
- Duke Cancer Institute, Duke University, Durham, NC
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Chung RK, Richards EG, Farrell R, Flyckt RL. Ascending toward a 30,000 foot view of uterus transplant. Fertil Steril 2022; 118:586-587. [PMID: 36116804 DOI: 10.1016/j.fertnstert.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Rebecca K Chung
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood, Ohio
| | - Elliott G Richards
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ruth Farrell
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rebecca L Flyckt
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood, Ohio
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Batra S, Coyne KD, Flyckt RL. Good intentions: the overprescription of opioids for analgesia with oocyte retrievals. Fertil Steril 2021; 117:142-143. [PMID: 34863520 DOI: 10.1016/j.fertnstert.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Sadhvi Batra
- University Hospitals, Cleveland Medical Center, Cleveland, Ohio
| | - Kathryn D Coyne
- University Hospitals, Cleveland Medical Center, Cleveland, Ohio
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Llarena NC, Richards EG, Priyadarshini A, Fletcher D, Bonfield T, Flyckt RL. Characterizing the endometrial fluid cytokine profile in women with endometriosis. J Assist Reprod Genet 2020; 37:2999-3006. [PMID: 33128115 PMCID: PMC7714820 DOI: 10.1007/s10815-020-01989-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To compare growth factor and cytokine profiles in the endometrial secretions of patients with and without endometriosis to determine whether a particular protein profile is predictive of the disease. METHODS Patients undergoing laparoscopic gynecologic surgery for benign indications were recruited for this prospective cohort study. Prior to surgery, endometrial fluid was aspirated and multiplex immunoassay was used to quantify 7 cytokines and growth factors. During surgery, each patient was staged according to the ASRM staging system for endometriosis. Cytokines and growth factors were evaluated using the Mann-Whitney and Kruskal-Wallis tests. Combinations of cytokines were evaluated using logistic regression analysis, and ROC curves were generated to evaluate the predictive capacity of the assay. RESULTS Endometrial secretions were analyzed from 60 patients. Nineteen had stage 3-4 endometriosis, 19 had stage 1-2 disease, and 22 had no endometriosis. There were no significant differences between controls and stage 1-2 endometriosis; however, levels of IL-1α and IL-6 were significantly increased in women with moderate-to-severe disease. A combination of IL-1α, IL-1β, and IL-6 in endometrial secretions predicts stage 3-4 endometriosis with an AUC of 0.78. A threshold value of 118 pg/mL yields a sensitivity of 75% and specificity of 70%. CONCLUSION Aspiration of endometrial fluid is a safe and effective approach for evaluating the endometrial profile of women with endometriosis. Women with moderate-to-severe endometriosis demonstrate a distinct cytokine profile compared to controls. A combination of IL-1α, IL-1β, and IL-6 in the endometrial secretions is predictive of stage 3-4 endometriosis, but is not predictive of minimal-to-mild disease.
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Affiliation(s)
- Natalia C. Llarena
- Division of Reproductive Endocrinology and Infertility, Women’s Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Elliott G. Richards
- Division of Reproductive Endocrinology and Infertility, Women’s Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Anju Priyadarshini
- Division of Reproductive Endocrinology and Infertility, Women’s Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - David Fletcher
- Department of Genetics and Genome Sciences, Department of Pediatrics and National Center of Regenerative Medicine, Case Western Reserve University, Biomedical Research Building #822, 10900 Euclid Ave, Cleveland, OH 44106 USA
| | - Tracey Bonfield
- Department of Genetics and Genome Sciences, Department of Pediatrics and National Center of Regenerative Medicine, Case Western Reserve University, Biomedical Research Building #822, 10900 Euclid Ave, Cleveland, OH 44106 USA
| | - Rebecca L. Flyckt
- Division of Reproductive Endocrinology and Infertility, Women’s Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195 USA
- Present Address: Division of Reproductive Endocrinology and Infertility, University Hospitals, Cleveland Medical Center, 1000 Auburn Drive, Suite 310, Beachwood, OH 44122 USA
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Llarena NC, Falcone T, Flyckt RL. Fertility Preservation in Women With Endometriosis. Clin Med Insights Reprod Health 2019; 13:1179558119873386. [PMID: 31516316 PMCID: PMC6724494 DOI: 10.1177/1179558119873386] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/12/2019] [Indexed: 12/11/2022]
Abstract
Infertility affects 30% to 50% of women with endometriosis. Women with endometriosis are at risk of decreased ovarian reserve, both because of the pathophysiology of the disease and iatrogenic injury resulting from surgical intervention. Fertility preservation must occur at multiple levels, including careful selection of surgical candidates, avoidance of repeat procedures, and meticulous surgical technique. Fertility preservation with oocyte or ovarian tissue cryopreservation may be considered on an individual basis for women with endometriosis, particularly those at risk of bilateral ovarian injury, such as women with bilateral endometriomas.
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Flyckt RL. Setting the focus on patient selection for minimally invasive myomectomy: operating times and surgical morbidity in a large database study. Fertil Steril 2019; 111:1127-1128. [PMID: 31043231 DOI: 10.1016/j.fertnstert.2019.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/27/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Rebecca L Flyckt
- Cleveland Clinic Lerner College of Medicine Obstetrics, Gynecology and Women's Health Institute, Cleveland, Ohio
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Arian SE, Flyckt RL, Herman R, Erfani H, Falcone T. Fertility preservation in pediatric female cancer patients. Fertil Steril 2018; 109:941. [PMID: 29778393 DOI: 10.1016/j.fertnstert.2018.02.112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/06/2018] [Accepted: 02/09/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe and demonstrate ovarian tissue cryopreservation (OTC) as an emerging fertility preservation technique DESIGN: Video presentation. SETTING University hospital. PATIENT(S) A 6 year-old female patient diagnosed with aplastic anemia with plan for bone marrow transplantation underwent laparoscopic unilateral oophorectomy in conjunction with surgical procedure for port placement by the pediatric surgeon, followed by cryopreservation of ovarian tissue. INTERVENTION(S) Laparoscopic unilateral oophorectomy followed by ovarian decortication in the operating room, and ovarian tissue freezing prior to undergoing bone marrow transplantation. MAIN OUTCOME MEASURE(S) To present principle surgical techniques of ovarian tissue harvesting prior to OTC in pediatric patients, and different surgical techniques for ovarian auto-transplantation of cryobanked ovarian tissue after completion of gonadotoxic treatment and when the patient is ready to conceive. RESULT(S) This video demonstrates the detailed surgical technique for ovarian tissue harvesting. This harvesting can be performed laparoscopically or via mini-laparotomy and can involve a complete oophorectomy versus removing a portion of the ovary (a procedure also known as ovarian decortication). CONCLUSION(S) In the prepubertal child, due to the small size of the ovaries, we recommend oophorectomy rather than decortication owing to the small size of prepubertal gonadal tissue. Many young cancer patients can be offered the option of ovarian tissue freezing. This tissue contains immature primordial follicles that can be stored. OTC requires surgical ovarian harvesting followed by cryopreservation of strips of ovarian tissue. The increased number of eggs in prepubertal children underscores the fact that smaller ovarian size in this population does not preclude OTC. At this time, ovarian auto-transplantation is the only option to utilize this stored tissue for fertility preservation. OTC is a relatively new procedure within the area of ART. The overall data from OTC is reassuring and further suggests that cryopreservation of ovarian tissue has the potential to become an established fertility preservation method in the near future.
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Affiliation(s)
- Sara E Arian
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio; Obstetrics, Gynecology, and Reproductive Sciences, Baylor College of Medicine, Houston, Texas.
| | - Rebecca L Flyckt
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard Herman
- Department of Pediatric Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Hadi Erfani
- Obstetrics, Gynecology, and Reproductive Sciences, Baylor College of Medicine, Houston, Texas
| | - Tommaso Falcone
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
This commentary endeavors to share our practical experience in developing and implementing the first uterine transplant clinical trial in the United States. Uterine transplant is a promising novel treatment for uterine factor infertility. After reported successful live births after uterine transplant in Sweden, research teams around the world are either embarking on or are considering the development of uterine transplant protocols. Our observations on the applied rather than theoretical aspects of uterine transplantation research in human subjects are detailed in this article. Important among these considerations are composing a broad and experienced multidisciplinary team as well as performing adequate preclinical preparations, including ideally animal studies and practice organ procurements. Ethical preparation is tantamount to clinical preparation for the complexities inherent in uterine transplant, and our suggestions for updating the current ethical criteria for uterine transplant are outlined here. We also describe our perspectives on the strengths and weaknesses of living compared with deceased donor models. Finally, we describe how a strong program can recover and adapt in the face of setbacks to continue a path toward innovation.
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Arian SE, Goodman L, Flyckt RL, Falcone T. Ovarian transposition: a surgical option for fertility preservation. Fertil Steril 2017; 107:e15. [DOI: 10.1016/j.fertnstert.2017.01.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 11/30/2022]
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Goodman LR, Goldberg JM, Flyckt RL, Gupta M, Harwalker J, Falcone T. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol 2016; 215:589.e1-589.e6. [PMID: 27242204 DOI: 10.1016/j.ajog.2016.05.029] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 05/14/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many women who experience endometriosis and endometriomas also encounter problems with fertility. OBJECTIVE The purpose of this study was to determine the impact of surgical excision of endometriosis and endometriomas compared with control subjects on ovarian reserve. STUDY DESIGN This was a prospective cohort study of 116 women aged 18-43 years with pelvic pain and/or infertility who underwent surgical treatment of suspected endometriosis (n=58) or endometriomas (n=58). Based on surgical findings, the suspected endometriosis group was further separated into those with evidence of peritoneal disease (n=29) and those with no evidence of endometriosis (n=29). Ovarian reserve was measured by anti-Müllerian hormone and compared before surgery and at 1 month and 6 months after surgery. RESULTS Baseline anti-Müllerian hormone values were significantly lower in the endometrioma vs negative laparoscopy group (1.8 ng/mL [95% confidence interval, 1.2-2.4 ng/mL] vs 3.2 ng/mL [95% confidence interval, 2.0-4.4 ng/mL]; P<.02), but the peritoneal endometriosis group was not significantly different than either of these groups. Only patients with endometriomas had a significant decline in ovarian reserve at 1 month (-48%; 95% confidence interval, -54 to -18%; P<.01; mean anti-Müllerian hormone baseline value, 1.77-1.12 ng/mL at 1 month). Six months after surgery, anti-Müllerian hormone values continued to be depressed from baseline but were no longer significantly different. The rate of anti-Müllerian hormone decline was correlated positively with baseline preoperative anti-Müllerian hormone values and the size of endometrioma that was removed. Those with bilateral endometriomas (n=19) had a significantly greater rate of decline (53.0% [95% confidence interval, 35.4-70.5%] vs 17.5% [95% confidence interval, 3.2-31.8%]; P=.002). CONCLUSION At baseline, patients with endometriomas had significantly lower anti-Müllerian hormone values compared with women without endometriosis. Surgical excision of endometriomas appears to have temporary detrimental effects on ovarian reserve.
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Giannios NM, Gulani V, Rohlck K, Flyckt RL, Weil SJ, Hurd WW. Left upper quadrant laparoscopic placement: effects of insertion angle and body mass index on distance to posterior peritoneum by magnetic resonance imaging. Am J Obstet Gynecol 2009; 201:522.e1-5. [PMID: 19761999 DOI: 10.1016/j.ajog.2009.07.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 05/15/2009] [Accepted: 07/08/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the ideal angle for insertion of laparoscopic instruments at Palmer's point. STUDY DESIGN Abdominal magnetic resonance images were reviewed for 75 women between ages 18 and 50 years old. The distance from the skin to the retroperitoneal structures were determined perpendicular to the spine and angled 45 degrees caudally. RESULTS When instruments are inserted perpendicular to the skin in the axial plane and peritoneum perpendicular to the spine, the distance from skin to posterior was 10.0 +/- 0.2 cm and to the aorta was 11.3 +/- 0.2 cm. If instruments are inserted at an angle 45 degrees caudally, this distance increased to 16.6 +/- 0.2 cm. CONCLUSION When inserting laparoscopic instruments at Palmer's point, insertion perpendicular to the skin in the axial plane and angled 45 degrees caudally in relation to the spine offers an increased margin of safety compared with insertion perpendicular to the spine, particularly in thin women.
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