OBJECTIVE To describe a computer algorithm designed for in vitro fertilization (IVF) management and to assess the algorithm's accuracy in the day-to-day decision making during ovarian stimulation for IVF when compared to... more
OBJECTIVE To describe a computer algorithm designed for in vitro fertilization (IVF) management and to assess the algorithm's accuracy in the day-to-day decision making during ovarian stimulation for IVF when compared to evidence-based decisions by the clinical team. DESIGN Descriptive and comparative study of new technology. SETTING Private fertility practice. INTERVENTION(S) None. PATIENT(S) Data were derived from monitoring during ovarian stimulation from IVF cycles. The database consisted of 2,603 cycles (1,853 autologous and 750 donor cycles) incorporating 7,376 visits for training. An additional 556 unique cycles were used for challenge and to calculate accuracy. There were 59,706 data points. Input variables included estradiol concentrations in picograms per milliliter; ultrasound measurements of follicle diameters in two dimensions in millimeters; cycle day during stimulation and dose of recombinant follicle-stimulating hormone during ovarian stimulation for IVF. MAIN OUTCOME MEASURE(S) Accuracy of the algorithm to predict four critical clinical decisions during ovarian stimulation for IVF: [1] stop stimulation or continue stimulation. If the decision was to stop, then the next automated decision was to [2] trigger or cancel. If the decision was to return, then the next key decisions were [3] number of days to follow-up and [4] whether any dosage adjustment was needed. RESULT(S) Algorithm accuracies for these four decisions are as follows: continue or stop treatment: 0.92; trigger and schedule oocyte retrieval or cancel cycle: 0.96; dose of medication adjustment: 0.82; and number of days to follow-up: 0.87. These accuracies are for first iteration of the algorithm. CONCLUSION(S) We describe a first iteration of a predictive analytic algorithm that is highly accurate and in agreement with evidence-based decisions by expert teams during ovarian stimulation during IVF. These tools offer a potential platform to optimize clinical decision making during IVF.
Research Interests:
Research Interests:
Research Interests:
Serum hCG and free beta hCG subunit were measured in intrauterine pregnancies (n = 21), ectopic pregnancies (n = 20) and spontaneous abortions (n = 19) matched for gestational age. Significantly higher concentrations of both dimer and... more
Serum hCG and free beta hCG subunit were measured in intrauterine pregnancies (n = 21), ectopic pregnancies (n = 20) and spontaneous abortions (n = 19) matched for gestational age. Significantly higher concentrations of both dimer and free beta subunit hCG were detected in normal pregnancies (86,336 IU/L) and 21.02 IU/L respectively) compared to abortions (10,460 IU/L and 3.73 IU/L) and ectopic pregnancies (3,900 IU/L and 3.73 IU/L) (p less than .05). When the ratio of free beta hCG/intact hCG (%) was studied, however, EP had significantly higher ratios (0.09 +/- 0.09) than IUP (p less than .05). Assessment of the relative distributions of these ratios revealed that 100% of IUP and AB and 65% of EP had ratios less than 0.10. Most notably, 35% of EP were uniquely characterized by ratios greater than 0.10. This ratio was sufficiently higher in 35% of EP to define a profile completely unique to EP. These data suggest that an increased free beta to dimer hCG ratio of greater than 0.10 may assist in the differentiation of ectopic from intrauterine pregnancies of spontaneous abortions and provide insight into a possible trophoblastic mechanics in these clinical events.
Research Interests:
Research Interests:
Obstetricians have increasingly petitioned courts for orders sanctioning treatment refused by pregnant patients. To speculate on the potential role of forced detention, we reviewed the clinical records of 39 obstetric patients who were... more
Obstetricians have increasingly petitioned courts for orders sanctioning treatment refused by pregnant patients. To speculate on the potential role of forced detention, we reviewed the clinical records of 39 obstetric patients who were discharged against medical advice (AMA) with several diagnoses: preterm labor (27), medical complications of pregnancy (9) and trauma (3). These patients were matched for chronologic age, gestational age and clinical examination at the time of admission and compared to a group of compliant patients who accepted and followed the treatment plan for hospitalization. No perinatal morbidity and/or mortality or other adverse outcome could be documented in the AMA group despite their refusal to continue undergoing admission and therapy. No difference could be demonstrated between the AMA group and the compliant group for obstetric complications, gestational age at delivery, newborn weight and percentage of appropriate-weight-for-gestational-age infants. These data suggest that failure to comply with major obstetric recommendations and hospitalization in these clinical settings might not adversely influence perinatal outcome.
Research Interests:
Research Interests:
Fifteen women with müllerian defects and a control population of 15 with normal müllerian systems underwent dynamic audiometric testing. The rate of auditory defects in women with müllerian abnormalities (33%) was significantly higher (P... more
Fifteen women with müllerian defects and a control population of 15 with normal müllerian systems underwent dynamic audiometric testing. The rate of auditory defects in women with müllerian abnormalities (33%) was significantly higher (P less than .05) than in the control population (0%). Those patients manifested mild, moderate and severe sensorineural defects in the high-frequency range. The defects were not accounted for by age or occupation and were associated with renal agenesis in 60% of the cases. One patient with normal audiometric testing and a septate uterus had a family history significant for an identical twin sister with unilateral renal agenesis, ipsilateral congenital deafness and an unevaluated müllerian tract. The results of the study suggest that a spectrum of auditory changes may exist in association with müllerian defects, ranging from previously described congenital deafness to more subtle hearing defects not clinically evident.
Research Interests:
Objective: The purpose of the present study was to compare prospectively the accuracy of pelvic US examination and MR imaging in the assessment of müllerian tract abnormalities. Patients and methods: Sixteen patients with congenital... more
Objective: The purpose of the present study was to compare prospectively the accuracy of pelvic US examination and MR imaging in the assessment of müllerian tract abnormalities. Patients and methods: Sixteen patients with congenital müllerian defects underwent US examination, MR imaging, diagnostic laparoscopy, and hysteroscopy. Abnormalities included unicornuate (n = 2), bicornuate (n = 6), and septate (n = 6) uteri, and normal uteri with septate vagina (n = 2). Patients with müllerian abnormalities were referred after hysterosalpingogram or clinical examination revealed uterine, cervical, and/or vaginal congenital abnormalities. Laparoscopic and hysteroscopic confirmation of these radiologic impressions was made in all patients. Results: Pelvic US examination and MR imaging for all abnormalities had an overall sensitivity of 57% and 77%, specificity of 50% and 33%, a positive predictive value of 89% and 83%, and a negative predictive value of 14% and 25%, respectively. Pelvic US examination and MR imaging correctly diagnosed septate uterus in 2/6 cases (33%) and 3/6 cases (50%), respectively. This abnormality was most commonly misdiagnosed as a normal or bicornuate uterine cavity. For bicornuate uterus, pelvic US and MR, however, correctly diagnosed 6/6 cases (100%) and 5/6 cases (83%), respectively. Accurate diagnoses were made for bicornuate uteri using either modality owing mainly to the presence of a characteristic fundal notch. US examination was nonspecific for unicornuate uterus (0/2 cases diagnosed), defining only a single cavity, but without sufficient details of adnexal regions. MR imaging of unicornuate uteri, however, provided detailed images of both uterine cavity configuration (2/2 cases diagnosed) and adnexal anatomy. Conclusions: Our data suggest that pelvic US examination and MR imaging are not sufficiently accurate to qualify as sole diagnostic studies for septate uteri. Though less expensive and less invasive than diagnostic laparoscopy, they do not provide a sufficiently sensitive and specific method to differentiate septate from bicornuate uteri, a critical aspect for surgical planning. Though more costly, diagnostic laparoscopy appears to be the most accurate diagnostic study for the assessment of uterine anatomy and definition of müllerian abnormalities.
Research Interests:
Objective: The purpose of this study was to determine whether missing pills in an oral contraceptive (OC) cycle resulted in folliculogenesis and eventual ovulation. Methods: Fifteen women selected from a population requesting tubal... more
Objective: The purpose of this study was to determine whether missing pills in an oral contraceptive (OC) cycle resulted in folliculogenesis and eventual ovulation. Methods: Fifteen women selected from a population requesting tubal reanastomosis were randomized into three groups and issued pill packs missing four consecutive pills in specific sequences, as follows: group I, days 1-4; group II, days 3-6; and group III, days 6-9. Serum was drawn for assay of LH, FSH, estradiol (E2), and progesterone, and serial ovarian ultrasound examinations were done to study follicular development throughout the cycle at 4-day intervals. Results: No subject ovulated, as suggested by serum progesterone concentrations (not exceeding 0.63 ng/mL for any woman) and ultrasound assessment of follicular development (no follicular diameter exceeding 13 mm). The highest (mean +/- standard deviation) serum concentrations of LH and FSH in any group (13.25 +/- 18.71 and 14.40 +/- 7.71 mIU/mL, respectively) and of E2 (44.35 +/- 26.79 pg/mL) were observed during or immediately after the pill-free interval. Ovarian ultrasound examinations suggested suppressed folliculogenesis in all groups. No functional ovarian cysts were detected. Conclusions: Oral contraceptives exerted a similar degree of pituitary and ovarian suppression even when the subjects missed four pills at varying times in a cycle. The anovulatory effect persisted when the OC pills were reinstituted and taken reliably after an interval of noncompliance.
Research Interests:
Research Interests:
To explore the role of an electronic bulletin board as a means of computer-based learning in reproductive endocrinology for residents in obstetrics and gynecology. An electronic bulletin board was networked to all residents to present a... more
To explore the role of an electronic bulletin board as a means of computer-based learning in reproductive endocrinology for residents in obstetrics and gynecology. An electronic bulletin board was networked to all residents to present a formal lecture series in reproductive endocrinology and an informal question, answer, and discussion session after each lecture. Ten lectures were presented, one each month, throughout the academic year followed by question, answer, and discussion sessions. All lectures could be stored in an electronic file folder or printed as hard copy for review. A questionnaire was distributed at the conclusion of the project to assess previous resident experience with computers, resident response to, and utilization of the bulletin board. A residency program in obstetrics and gynecology in a major medical center. Twenty-four residents in a 4-year program. Previous computer experience, ease of use, resident participation, and satisfaction with the bulletin board. Sixty-five percent of the residents considered themselves computer literate and 33 percent previously had taken a course in computer technology. Computer experience in word processing, spreadsheet, and database management was related by 55 percent, 40 percent, and 25 percent of the residents, respectively. Ninety-five percent of the residents accessed the bulletin board for the lectures and found this system a convenient means of review. Sixty percent reviewed the lectures and stored them in an electronic file folder for later review. Forty percent printed the lecture on hard copy. On a scale of 1 to 5 (1 = lowest; 5 = highest), overall resident satisfaction was high at 4.5. Our data suggest a potential role for electronic bulletin boards as a complement to standard teaching protocols in resident education. The relative ease of use and satisfaction suggest that these techniques are feasible and offer an effective method of on-line instruction.
Research Interests:
Endocrinology, Obstetrics, Medical Education, Reproductive endocrinology, Medicine, and 14 moreComputer Assisted Instruction, Fertility and Sterility, Obstetrics and Gynaecology, Graduate medical education, Residency training, Reproductive medicine, Clinical Sciences, Questionnaires, Gynecology, Public health systems and services research, Computer communication networks, Reproductive Endocrinology and Infertility, internship and residency, and Paediatrics and reproductive medicine
The widespread use of serum human chorionic gonadotropin (hCG) monitoring has enabled earlier diagnosis of ectopic pregnancy and increasingly conservative methods of management including operative laparoscopy, medical therapy with... more
The widespread use of serum human chorionic gonadotropin (hCG) monitoring has enabled earlier diagnosis of ectopic pregnancy and increasingly conservative methods of management including operative laparoscopy, medical therapy with methotrexate, and expectant management. We investigated the use of a combined laparoscopic and minilaparotomy approach as an operative management of ectopic pregnancy. Fifteen of 16 patients presenting to the Reproductive Endocrinology Service were managed using either operative laparoscopy or minilaparotomy. Serum hCG values at the time of diagnosis ranged from 239 to 8060 mIU/ml. Nine patients were managed by operative laparoscopy and six by minilaparotomy. All patients were ambulatory and tolerating oral intake within 8 hours of surgery. The average hospitalization was 31 hours from the time of surgery. Thirty-five percent of the patients were discharged within 24 hours and an additional 40% within 36 hours. This approach was applicable to all patients regardless of body habitus, degree of hemoperitoneum, or status of the ectopic pregnancy. Such a combined approach permitted minimal tissue manipulation and shortened hospitalization. Data of the present study suggest that such an approach may be applicable to most clinical circumstances, performed without undue morbidity and potentially avoid a standard laparotomy and its attendant risks and hospitalization.
Research Interests:
Research Interests:
Gentamicin in combination with other antibiotics is frequently used in the treatment of postpartum endomyometritis. The need to monitor and maintain therapeutic concentrations, however, is controversial. To assess the role of monitoring,... more
Gentamicin in combination with other antibiotics is frequently used in the treatment of postpartum endomyometritis. The need to monitor and maintain therapeutic concentrations, however, is controversial. To assess the role of monitoring, serum gentamicin concentrations were prospectively studied in an obstetric population treated for postpartum endomyometritis. Clinical course was correlated to serum gentamicin levels obtained using a 1 mg/kg/dose regimen. No patient demonstrated therapeutic concentrations. Sixteen of 18 obstetric patients (88%) exhibited a clinical response despite subtherapeutic serum gentamicin concentrations. The two failures included one case of septicemia and one wound seroma. Serum gentamicin levels of this obstetric population when compared to those from a gynecologic population treated for benign disease demonstrated no statistical difference. These data suggest that clinical response provides an accurate indication of the efficacy of therapy and that gentamicin doses of 1 mg/kg/dose provide sufficient antibiotic coverage in most cases. These results do not support the use of increased gentamicin dosages and the need to attain therapeutic levels in the obstetric patient, as previously suggested.
Research Interests:
Research Interests:
To determine possible etiologies of unsuccessful fluoroscopically guided tubal canalization, we studied the histology of tubal segments in cases of failed canalization for proximal tubal obstruction. Factors contributing to cases of... more
To determine possible etiologies of unsuccessful fluoroscopically guided tubal canalization, we studied the histology of tubal segments in cases of failed canalization for proximal tubal obstruction. Factors contributing to cases of unsuccessful fluoroscopically guided tubal canalization remain unclear. Prospective. Reproductive Endocrinology Clinic. Twenty-seven cornual and/or isthmic tubal segments from 15 patients who underwent proximal tubal surgery after fluoroscopically guided tubal canalization were studied. Specimens were prepared with hemotoxylin-eosin and Masson trichrome stains. Histologic examination of excised cornual and isthmic tubal segments revealed abnormalities in 93% of specimens. Obliterative fibrosis (61%), chronic salpingitis (57%), and salpingitis isthmica nodosa (42%) were the most commonly found histologic tubal abnormalities. One case of complete tubal occlusion and tubal schistosomiasis was also detected. These data suggest that cases of failed fluoroscopically guided tubal canalization may be secondary to severe intrinsic tubal disease and tubal occlusion and not to the technique. Fluoroscopically guided tubal canalization may provide a means of differentiating a functional obstruction amenable to conservative management from true occlusion requiring management by microsurgical techniques or in vitro fertilization.
Research Interests:
Research Interests:
Hysterosalpingography (HSG) to assess tubal patency in the postoperative evaluation of the infertile patient has been well described. However, the sensitivity and specificity of HSG after tubal surgery has not been reported. We correlated... more
Hysterosalpingography (HSG) to assess tubal patency in the postoperative evaluation of the infertile patient has been well described. However, the sensitivity and specificity of HSG after tubal surgery has not been reported. We correlated HSG and laparoscopic findings in 25 patients who had tubal surgery (microsurgical tubal reanastomoses [11] and distal salpingostomies [14]). HSG provided a more reliable means of assessing tubal patency (sensitivity and specificity of 96% and 61% respectively) than in detecting pelvic adhesive disease (PAD) (sensitivity and specificity of 12% and 75% respectively) regardless of tubal surgical procedure. HSG was associated with a high false negative rate (60%) due primarily to the inability to detect PAD. Complete agreement between HSG and laparoscopy was noted in only 15% of cases. These data suggest that HSG is a sensitive means to determine tubal patency, but was not sufficiently sensitive or specific to detect PAD after tubal surgery. These limitations should be noted in the interpretation of HSG in any infertile patient with a history of tubal surgery, and severely limits the application of HSG to the management of the post-operative infertile patient.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Law, Informed Consent, Risk assessment, Medicine, Humans, and 11 moreFertility and Sterility, Clinical Sciences, Public health systems and services research, Risk Assessment, Minors, Statutory law, Statute, Supreme Court Decisions, judicial role, parental consent, and Paediatrics and reproductive medicine
In two patients with apparent PTO, as diagnosed by HSG and laparoscopy, tubal patency was restored by hysteroscopic cannulation of the tubal ostia, followed by direct lavage. Tubal resection and reanastomosis/reimplantation may not be... more
In two patients with apparent PTO, as diagnosed by HSG and laparoscopy, tubal patency was restored by hysteroscopic cannulation of the tubal ostia, followed by direct lavage. Tubal resection and reanastomosis/reimplantation may not be necessary for all patients with apparent PTO.
Research Interests:
Surgery, Medicine, Endoscopy, Catheterization, Humans, and 13 moreFertility and Sterility, Female, Pubmed, Hysteroscopy, Clinical Sciences, Adult, Public health systems and services research, Occlusion, Female Infertility, Laparoscopy, Therapeutic Irrigation, Hysterosalpingography, and Paediatrics and reproductive medicine
Research Interests:
Premature ovarian failure, diagnosed from elevated serum gonadotropin concentrations, is generally considered irreversible. That there have been isolated cases of pregnancy, however, suggests that ovarian function may persist in these... more
Premature ovarian failure, diagnosed from elevated serum gonadotropin concentrations, is generally considered irreversible. That there have been isolated cases of pregnancy, however, suggests that ovarian function may persist in these patients. We recently studied the longitudinal progress of two patients with intermittent ovarian failure who manifested a spontaneous return of ovarian function and, in one patient, pregnancy.
Research Interests:
Research Interests:
Research Interests:
The demise of Roe v. Wade has prompted some state lawmakers to try to redefine legal personhood to begin before birth and even before pregnancy. The sweeping abortion bans passed and pending in the wake of Dobbs pose a threat to... more
The demise of Roe v. Wade has prompted some state lawmakers to try to redefine legal personhood to begin before birth and even before pregnancy. The sweeping abortion bans passed and pending in the wake of Dobbs pose a threat to reproductive rights that extends beyond abortion. That threat spills over into in vitro fertilization (IVF) and other assisted reproductive technologies (ART). If legislatures designate embryos as legal persons, fertility clinics will be forced to change how they manage embryos, including current standard practices such as pre-implantation genetic testing, storage of unused embryos, and the disposal of those unlikely to have reproductive potential. This essay examines the many ways in which conferring the status of persons under private and public law is likely to impact patients pursuing IVF and clinics practicing ART.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Debates regarding reproductive rights have waxed and waned since the early twentieth century. The current front-and-center debate draws this discussion into tighter focus. Challenges to reproductive rights, changes in definitions of... more
Debates regarding reproductive rights have waxed and waned since the early twentieth century. The current front-and-center debate draws this discussion into tighter focus. Challenges to reproductive rights, changes in definitions of personhood and a pending decision regarding Roe v Wade could change the management and options regarding the disposition of frozen embryos. This commentary outlines how changes in abortion law and reproductive rights could potentially impact the options available to both patients and clinics.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Endocrinology, Medicine, Humans, Internal Medicine, Female, and 13 moreOvulation, Ovulation Induction, Adult, Public health systems and services research, Gonadotropin Releasing Hormone, Combination drug therapy, Female Infertility, Luteinizing Hormone, Delayed-Action Preparations, Estradiol, Follicle stimulating hormone, Paediatrics and reproductive medicine, and primary ovarian insufficiency
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Hyperandrogenism and abnormal levels of other sex hormones prevent normal release of egg cells from the ovaries (ovulation) and regular menstrual periods, leading to difficulty conceiving a child (subfertility) or a complete inability to... more
Hyperandrogenism and abnormal levels of other sex hormones prevent normal release of egg cells from the ovaries (ovulation) and regular menstrual periods, leading to difficulty conceiving a child (subfertility) or a complete inability to conceive (infertility). For those who achieve pregnancy, there is an increased risk of complications and pregnancy loss. Due to irregular and infrequent menstruation and hormone abnormalities, affected women have an increased risk of cancer of the uterine lining (endometrial cancer).