OCP Use Research Articles

Antral follicle count (AFC) predicts natural menopause in a population based cohort: the coronary artery risk development in young adults (CARDIA) and cardia women's study (CWS)

Tools to predict future fertility are needed for contraceptive decision-making as large numbers of women are approaching perimenopause. We evaluated the ability of AFC and other ovarian reserve markers to predict natural menopause (NatMen) in US women ages 34-49. CARDIA is a multicenter (Chicago, IL; Birmingham, AL; Minneapolis, MN; Oakland, CA) observational cohort study begun in 1985-86. In 2002-04, CWS evaluated 1163 women with ≥1 ovary with transvaginal ultrasound and FSH levels. The exam was targeted to the follicular phase unless irregular cycles or OCP use was present. Subjects were re-examined in 2005-06 and followed-up annually by phone through 2009-10. AFC (total # of 2-10mm follicles on 2 visualized ovaries) was assessed in 498 CWS subjects with follow-up data and no history of ovarian/uterine surgeries or menopause. We used C-statistics to determine optimal age, FSH, and AFC cutpoints for NatMen. Cox regression was used to predict NatMen hazard over 7 years' follow up adjusting for race, smoking, OCP use and menstrual history.Tabled 1Risk for NatMen over 7 Years of Follow-upVariableHazard Ratio95% CIAFC £4 vs. >41.72(1.10-2.68)Age >45 vs. £ 454.91(3.13-7.69)Black vs. White0.63(0.42-0.95)Current Smoker vs. Not1.68(1.09-2.59)FSH >13 vs. £132.39(1.56-3.65)Regular vs. Irregular Menses0.59(0.38-0.85)OCP use P>0.05 Open table in a new tab OCP use P>0.05 Median(Q1-Q3) AFC and FSH were 5(2-9) and 8(6-11) at a mean age of 42 (range 34-49). 107 women reported NatMen by 2009-10. Cutpoints at Age>45, FSH>13, and AFC≤4 yielded the highest c-statistic for NatMen with a PPV = 63% (29/47) and a NPV = 83% (373/451) through 2010. In Cox models, age, race, AFC, and FSH were independent predictors of NatMen. AFC is an independent predictor of natural menopause over 7 years of follow-up after controlling for the more established markers of age, race, and FSH in our community-based sample.

Celiac Disease and Type 1 Diabetes Mellitus Association: A Retrospective Analysis of Pediatric Cases in ROME

sumption (>4 cups per day) and current illicit drug use. RESULTS: Of 656 responses, 202 patients with biopsy proven CD (79% female, avg age 45.6), 83 IBD (53% female, avg age 38.6), 198 C (63% female, avg age 49.5) were analyzed. The 3 groups differed significantly in age and sex (p<0.0001). 47 (23%) Chronic headaches were reported by 64 (32%) of CD, 14 (17%) of IBD and 59 (30%) of C. The CD group had significantly higher prevalence of migraine (22%) compared to controls (11%), p= 0.0040, while the prevalence of migraine in IBD patients (14%) was comparable to that of controls (p=0.1574). On multivariate logistic regression, female sex was an independent predictor of migraine (OR 3.69 95%CI 1.66-8.17). Daily opioid, NSAID or Trazodone use showed a trend towards an independent predictor ( OR 4.26 95% CI 0.98-8.57), as did OCP or HRT use (OR 2.16 95%CI 0.974.82). Age and depression were not independent predictors of migraine. After correcting for age, sex, HRT/OCP use, Opioids/NSAIDs/Trazodone use and depression/anxiety the CD group still had significantly higher prevalence of migraine headaches compared to C (OR 1.83, 95% CI 1.02-3.28), whereas the IBD group had similar incidence of migraine to C (OR 1.42, 95% CI 0.61-3.28). There was no correlation between years on gluten-free diet and severity of migraine as assessed by the HIT-6. CONCLUSIONS: Our finding of significantly higher rates of migraine in patients with CD suggests that migraine is a common neurologic manifestation of CD. Screening with CD serologies among migraine patients and studying the effect of gluten-free diet in migraine patients with CD is needed.

What Is the Best Time to Initiate Peri-Operative Heparin Therapy In General Surgery Patients? A Risk-Benefit Dilemma.

AbstractAbstract 1088 Background:While many studies support the use of prophylactic heparin therapy around the time of operation in cancer patients, little data shows the optimal timing of such therapy in general surgery (GS) patients. Methods:From 2001–2008, 95 patients identified with thromboembolism reported in our GI/General Surgery Division and were compared with a matched control group for: age, gender, type of operation, date of operation, diagnosis of malignancy, and BMI. Timing of heparin therapy, characteristics of TE or bleeding events, driving distance from our institution, history of smoking or OCP use, anticoagulation use after operation, length of hospital stay, and mortality were collected. Peri-operative heparin therapy was defined as heparin given within a 24 hr window of incision. The McNemar's test for proportions was performed. Conditional logistic regression was used for the analysis of risk factors and survival curves were implemented for mortality comparisons. Results:mean age and BMI were similar (57 yrs, 33 kgM-2), 45% were female and 53% had malignancy in both groups. Duration of operation was similar (204 vs. 191 minutes, P=NS). peri-operative heparin administration was similar in the two groups (56%, 64%, p=0.05). But, pre-operative therapy was seen more in the control group (77% vs. 51%, p=0.01). Regression model showed a protective effect for heparin if it was given pre-operatively (OR=0.37, p=0.047) with no effect if it was given beyond 10 hours. Mean blood transfusion units (97 and 106 mL) and hemorrhagic events (4.5% and 5%) were similar (p=NS). Median (range) length of hospital stay was longer (19 days (0-201) vs. 6 (0-66), p=0.001) and two-year survival lower in the TE group (p=0.03). Conclusions:data from our institutional case-control study shows that heparin administration before GS is associated with more than 2-fold reduction in the risk of thromboembolism. The optimal period appears to be between 1–10 hours prior to the time of incision. Large prospective trials need to be desgined to more accurately determine the time of heparin therapy. Disclosures:No relevant conflicts of interest to declare.

Cycle scheduling with oral contraceptive pills in GnRH antagonist protocol vs long protocol: a randomized, controlled trial

OBJECTIVE: Recently, controversy has arisen regarding the use of oral contraceptive pill and the impact on implantation rates in patients undergoing IVF/ICSI. This debate is still open as cycle scheduling is a common practice in most units. Thus, we decided to compare cycle outome after scheduling with the standard long protocol versus the use of OCPs in patients undergoing GnRH antagonist cycles.

A study on knowledge, attitude and practice of contraception among college students in Sikkim, India

To assess the knowledge, attitude and practice of contraception among the college students. A cross sectional study was conducted in the Government College, Gangtok, Sikkim, during the month of April 2009 to evaluate the knowledge, attitude and practice of contraception among 156 students enrolled in the first year bachelor course. Descriptive statistics was used for data analysis. 98% (153/156) of the students had knowledge about family planning and 86% (134/156) of them had heard about contraceptives. Most of them knew about condoms (85%) and contraceptive pills (40%) but knowledge about permanent methods and Cu-T was poor (average 12%). Most students thought contraceptives were to be used to prevent unwanted pregnancy (35%) and for birth spacing (30%). 11% of students had used some form of contraceptive in the past and 7% were currently users. The most commonly used contraceptives were condoms, followed by combined use of OCP and condom. The study highlights the need to motivate the youth for effective and appropriate use of contraceptives when required and arrest the trend towards unwanted pregnancy.

Investigating the levels and trends of organochlorine pesticides and polychlorinated biphenyl in sewage sludge

A study was completed to investigate temporal trends of organochlorine pesticides (OCPs; aldrin, chlordane, dieldrin, heptachlor, hexachlorbenzene, and DDT) and polychlorinated biphenyls (PCBs) in sewage sludge. Between 2004 and 2006 the concentration of OCPs and PCBs in Australian sewage sludge (n=829) was consistently <1000μgkg−1 dry solids DS. Dieldrin, chlordane and DDE were detected in 68%, 27% and 13% at maximum concentrations of 770, 290 and 270 µgkg−1 DS, respectively.Time series analysis (1995–2006) of OCPs and PCBs sewage sludge concentrations (n=2266) taken from six wastewater treatment plants (WWTPs) of the same geographic region found that lindane, aldrin HCB, heptachlor, DDT, DDD and PCBs were infrequently detected (<8%). A correlation between dieldrin and chlordane levels was found (P<0.05) which provides evidence of similar environmental mechanisms facilitating movement of dieldrin and chlordane through environment compartments. It has taken more than 10years for dieldrin and chlordane to reduce to less than detectable concentrations in freshly generated sewage sludge in Australia following government restrictions.Internationally, reported sewage sludge OCP concentrations were consistently low and often less than detection limits. Therefore, OCPs are not considered to be a contaminant of regulatory concern for countries that phased out OCP use several decades ago. Concentrations of PCBs in sewage sludge were also consistently low and rarely exceeded European contaminant limits and therefore, regulatory limits may warrant review. The authors recommend that Australian authorities revise regulatory requirements for OCP and PCBs contaminant levels in sewage sludge destined for beneficial reuse as biosolids.

Organochlorine pesticides in soils from south-western Uganda

Organochlorine (OC) residues were analysed in soil samples collected from Kihiihi sub-county, Kanungu District, which is located in south-western Uganda. Mabira Central Forest Reserve which is located in central Uganda was used as a reference site in this study. The samples were collected at 15–20 cm depths below the soil surface and extracted with organic solvents. The extracts were cleaned using florisil, and were analysed using a gas chromatograph (GC) equipped with an electron capture detector (ECD). The results were confirmed using a GC equipped with a mass spectrometer (MS). The levels of the OC residues in soil from Kihiihi sub-county varied from non-detectable (ND) to 59 μg kg −1 dry weight. The frequencies of detection for p, p′ -DDT, p, p′ -DDE and p, p′ -DDD in the total soil samples were 47%, 24% and 11%, respectively. The o, p′compounds were detected in the following frequencies: o, p′ -DDT (23%), o, p′ -DDE (19%) and o, p′ -DDD (8%). The low p, p′-DDE/ p, p′-DDT residue ratios (0.2–0.9) in Kihiihi samples suggest recent inputs of DDT in Kihiihi sub-county. The detection frequencies for dieldrin, endosulfan- α, - β and -sulphate in the soil samples were 21%, 26%, 31% and 19%, respectively. Mabira Forest Reserve soils showed detection frequencies of p, p′-DDT (5%) and p, p′-DDE (9% of the soil samples), varying from ND to 9 μg kg −1. Although the use of OCPs has been banned, our results show that they can still be detected in the environment. Their presence may be attributed to adulteration of pesticides which are not banned and also atmospheric deposition.

The epidemiology of ovarian granulosa cell tumors: A case-control study

Objective This study identified risk factors for ovarian granulosa cell tumors (GCT) through a case-control study comparing women with GCT to women with epithelial ovarian cancers (OC) and general population (GP) controls. Methods Women with GCT and OC were identified from our hospital tumor board and the Massachusetts and New Hampshire Statewide Cancer Registries between January, 1988 and November, 2008. Age, gender and county matched GP controls were identified through town books in Massachusetts and drivers' license lists in New Hampshire. Epidemiologic factors including age, race, obesity, pregnancy history, smoking, and family history were evaluated. Odds ratio (OR) was calculated and adjusted for race and age. Results Seventy-two women with GCT, 1578 GP controls, and 1511 OC controls were identified. Patients with GCT were significantly more likely to be non-white (OR 8.49; 4.07, 17.7), obese with a BMI > 30 (OR 5.80; 3.01, 11.2), and have a family history of breast (OR 2.13; 1.19, 3.80) or ovarian cancer (OR 2.89; 1.08, 7.72) than GP controls. The risk of developing GCT was significantly decreased in women who smoked (OR 0.46; 0.27, 0.78), used oral contraceptive pills (OR 0.32; 0.17, 0.63) or were parous with 1–2 (OR 0.30; 0.16–0.56) or greater than 2 births (OR 0.50; 0.27, 0.94) when compared to GP controls. Conclusion These findings suggest an independent association between non-white race and obesity as a hyperestrogenic state in the development of GCT while parity and OCP use may be protective. An unknown familial predisposition for GCT may exist.

Changes in Components of the Natural Coagulation Inhibitor System, in Patients with Antiphospholipid Antibodies and/or the Lupus Inhibitor.

The cell surface glycoproteins thrombomodulin (TM) and endothelial protein C receptor (EPCR) are major intermediaries in the down-regulation of thrombin and are noted to be shed from endothelial cells (ECs) due to the actions of proinflammatory cytokines, thrombin and other agents. Antiphospholipid antibodies (APLA) have been described as perturbing ECs. The level of protein S (PS) and protein Z (PZ) have been reported to inconsistently relate to the presence of antibodies and clinical outcomes. We previously reported using a coagulation assay system to demonstrate that adverse pregnancy outcomes (APO) are associated with a greater incidence of resistance to the anticoagulant effects of TM. In the current study we measured the plasma levels of soluble TM (sTM), soluble EPCR (sEPCR) as a possible indicator of APLA-EC interaction. We measured levels of free PS, PZ, sTM and sEPCR in patients (pts) with APLA and/or lupus inhibitor (LI), and correlated the findings with a positive or negative history for thrombosis [THRM(+) or (−)]. APO were not assessed at this time. The study group consisted of 26 males and 60 females, ages ranging from 25 to 90 years; mean of 56. GROUP 1: 33 pts with increased (inc) APLA and 24 of them THRM(+), GROUP 2: 16 pts positive for LI and 7 of them THRM(+), GROUP 3: 37 pts positive for both APLA & LI and 21 of them THRM(+). The pts were compared to 49 normal APLA negative donors (CTR). Pts who have moderate to high levels of anticardiolipin and/or anti-β2 glycoprotein I are APLA positive. LI positive pts have prolonged LI sensitive PTT, and are positive for at least two of the confirmatory tests (Hexagonal phase assay, platelet neutralization procedure, and diluted Russel Viper Venom Time Ratio). GROUP 1 has statistically significant (SS) (p<0.05) decreased (dec) sTM, sEPCR, and free PS when compared to CTR (sTM 1.0+/−1.4 vs 5.1+/−3.3ng/ml, sEPCR 43+/−53 vs 145+/−140ng/ml, free PS 63+/−25 vs 76+/−14%). Free PS is SS lower in the THRM(−) vs. THRM(+). PZ levels do not demonstrate SS differences in the subset comparisons. 8% of THRM(+) pts have PZ deficiency (PZ <1.0ug/ml) with none noted in the THRM(−) pts. Free PS is dec in a majority of the THRM(−). This might be related to the much higher % of females in the THRM(−). Therefore issues such as use of OCP, estrogens, current or recent pregnancy might influence PS. The incidents of dec sTM levels (<2.0ng/ml) are surprisingly higher in this group of patients (82%). This is strikingly higher than the CTR (4%). There is no apparent difference in the THRM(+) to THRM(−). The number of patients with dec sEPCR (<5ng/ml) is much lower however; none of the THRM(−) has dec levels. Inc sTM (>8.0ng/ml) nor inc sEPCR (>284ng/ml) is noted in any of the Pts. In GROUP 2, there is SS dec sTM & sEPCR (sTM 1.6+/−1.8ng/ml, sEPCR 42+/−32ng/ml) vs. CTR with no SS difference in the THRM(+) vs. THRM(−). In GROUP 3, sEPCR is SS dec in pts (sEPCR 68+/−100ng/ml) vs. CTR and CTR vs THRM(+) (sEPCR 29+/−25ng/ml). sTM is SS dec in the CTR vs. THRM(+) (sTM 1.3+/11.4ng/ml). Our data shows low levels of sTM and sEPCR in the APLA patients. This might indicate that the levels are consumed by antibody interactions and could indicate that the APLA and associated other antibodies might interfere with their functions. Previous reports indicating a resistance to TM in a coagulation assay method in patients with THRM and APO raises the possibility of an inhibiting substance present in the APLA. Further work in larger patient groups is necessary to clarify these issues.

3: Sexual behaviors following universal screening and diagnosis of sexually transmitted infections in a non-clinic sample of young healthy women

with statistical significance declared at p 0.05. Results: 1122 diary periods were evaluated, and 353 diary periods (31.5%) exhibited the presence of CT, GC, or TV infection. Multivariable logistic models for CT infections showed that OCP use was a predictor for infection ( 0.5; p .06) compared to no hormonal contraception. The other predictor for CT was 1 sexual partner (compared to no partners) [ 1.2; p 0.003]. DMPA usage was a significant predictor for GC infection ( 0.63; p 0.01) compared to no hormonal contraception. Exposed coital event rate ( 2.51; p 0.02) and 1 sexual partner ( 1.62; p 0.01) compared to no sexual partners were also significant predictors for GC infection. The single significant predictor for TV infection was 1 sexual partner ( 1.77; p 0.004) compared to no partners. Conclusion: OCP and DMPA increase the risk of infection with CT and GC respectively. Contraceptive care for adolescents is an ongoing process to provide both pregnancy and STI prevention services. With increased risk of STI associated with hormonal methods, clinicians should maintain high emphasis on the use of barrier methods in conjunction with hormonal methods. Physiologic causation for STI risk with hormonal contraception remains unclear; future research should be pursued for possible explanations. Support: AAMC #MM-0467; HRSA T71M8; T32HD42990; HD042404.

Occurrence and distribution of organochlorine pesticides (HCH and DDT) in sediments collected from East China Sea

Sediments used in this study were collected from different depths of eight sites in East China Sea in November 2002. The levels and distribution patterns of the selected organochlorine pesticides (OCPs = p,p′-DDT, o,p′-DDT, p,p′-DDE, p,p′-DDD, α-, β-, γ- and δ-HCH) in samples were investigated by the technique of sonication extraction followed by the analysis of gas chromatography (GC) coupled with a micro-electron capture detector (μECD). The concentrations of ΣHCH and ΣDDT in the surface sediments were in the range of < 0.05–1.45 ng/g (mean 0.76 ng/g), < 0.06–6.04 ng/g (mean 3.05 ng/g) based on dry weight (dw), respectively. In the vertical distributions, the ΣHCH and ΣDDT were in the range of < 0.05–2.52 ng/g, < 0.06–10.94 ng/g dw, respectively. Residues of OCPs varied significantly with different sampling sites. ΣDDT in the surface sediments was correlated well with total organic carbon (TOC) content ( r 2 = 0.71), while ΣHCH showed no obvious correlation. The distribution showed that the sediments from the vicinity estuary or near shore had higher TOC contents, and higher OCPs concentrations. The contamination record indicated an extensive use of OCPs in the catchments from Yangtze River in the past might greatly affect the OCP residues.

Status and fuzzy comprehensive assessment of combined heavy metal and organo-chlorine pesticide pollution in the Taihu Lake region of China

The status of combined heavy metal and organo-chlorine pesticide (OCPs; i.e. HCH and DDT) pollution was investigated and the soil environmental quality of the Taihu Lake watershed, one of the most developed regions in China, was evaluated using a fuzzy comprehensive assessment. Statistical analyses showed the presence of combined pollution in the soil. At many sampling sites, heavy metal concentrations were above corresponding background values, indicating the effects of extraneous pollutants. It has been over 20 years since China banned the use of OCPs, but they can still be found in soil samples of this region. HCH levels at all investigated sites were below the Chinese Environmental Quality Standard for Soils. Fuzzy comprehensive assessment showed that the overall soil quality in this region could be categorized as class I. Nevertheless, the high coefficients of variation for levels of DDT, Cd and Hg indicated the existence of some point-source pollution. Continuous monitoring and further studies of the region are recommended to prevent pollution of farmland from these sources.

Appendectomy, tonsillectomy, and risk of inflammatory bowel disease: a case control study in Iran

There is some controversy about the prevalence of appendectomy and tonsillectomy among patients with Crohn's disease and a lower rate of appendectomy among patients with ulcerative colitis (UC). The objective of this study was to elucidate the role of appendectomy and tonsillectomy in Iranian patients with inflammatory bowel disease (IBD). Three hundred and eighty-two consecutive cases of UC and 46 cases of CD were included. Age and sex-matched controls were randomly selected. A total of 382 controls for UC and 184 controls for CD were enrolled. A standard record concerning smoking habit, history of appendectomy and tonsillectomy, OCP, and NSAID use was completed. Logistic regression analysis was used to evaluate potential confounding variables. Twelve patients (3.1%) with UC reported a previous history of appendectomy compared with 30 controls (7.9%) (OR=0.38, 95%CI=0.19-0.76, P<0.004). Appendectomy was reported by five patients (10.9%) with CD compared with four controls (2.2%) (OR=5.49, 95%CI=1.41-21.34, P<0.02). The logistic regression analysis showed that appendectomy is a risk factor in CD but has a modest protective effect for development of UC. No association with tonsillectomy was found for either disease. A statistically significant protective effect for smoking in UC was found (OR=0.2, 95%CI=0.13-0.32, P<0.0001). We have found an inverse association between OCP and NSAID use with UC, but not CD (P<0.0001 and P<0.001, respectively). Appendectomy is protective in UC, but a risk factor in CD among Iranian population. Tonsillectomy was not associated with either UC or CD disease. UC, but not CD, is a disease of non-smokers. The inverse association between ulcerative colitis and OCP or NSAID in the Iranian population is noted.

Defining ?ovarian age? and its impact on the selection of a stimulation protocol

Female fertility declines with advancing maternal age and leads to decreased fecundity. The concept of ovarian reserve is hardly novel, but its application by physicians is, for the most part, kept for the unmistakably sub-fertile patient who has failed previous ovulation induction. An increased basal FSH or an inadequate response to gonadotrophin stimulation may recognize diminished ovarian function. Unlike early concepts that suggested maternal age in combination with basal FSH concentrations had predictive values for ART outcome, the goal of this study is to develop the concept of “ovarian age” as an extrapolative tool to help physicians define an appropriate stimulation protocol for all IVF patient populations. We tested the hypothesis that unlike chronological age, a progressive definition of ovarian age (i.e., function or reserve) which takes into account various clinically relevant factors can serve as a dynamic measure for the clinician for all IVF candidates. This report describes the initial 13 normal women who were randomized to either a “low” rFSH (150IU/150IU rFSH; Follistim®, Organon Pharmaceuticals USA,) or a “high” rFSH protocol (300 IU/300IU rFSH). The high-dosage group had a slightly elevated BMI compared to the low-dosage group (26 vs. 21) and median day3 FSH levels were elevated (12IU/ml vs. 5.3IU/ml). Similar total ovarian volumes were measured (580mm2 vs. 669mm2). Day 3 mean E2 levels were higher in the low dosage group (42.3pg/ml.vs. 28.3pg/ml) as was the mean follicle number (11 vs. 8.5) and the historical use of OCP (85 % vs 50%). Correspondingly the total number of oocytes recovered, number of mature oocytes, number of oocytes fertilized, total embryo number, and number of embryos transferred were all elevated in the “low-dosage” group. More pregnancies were seen in the “low-dosage” group as well (4/7 vs 2/6). These data are preliminary and the differences noted between the group’s BMI and d3FSH cannot be overlooked, but should normalize themselves by study completion. Data appear to support the hypothesis that chronological age does not predicate the responsiveness to rFSH therapy. Thus far, the low-dosage group has achieved superior clinical results. Ultimately, a dynamic approach of analysis and synthesis of these data is expected to yield a clinically effective tool (equation or schema) for the development of tailored stimulation regimens for women undergoing IVF. Female fertility declines with advancing maternal age and leads to decreased fecundity. The concept of ovarian reserve is hardly novel, but its application by physicians is, for the most part, kept for the unmistakably sub-fertile patient who has failed previous ovulation induction. An increased basal FSH or an inadequate response to gonadotrophin stimulation may recognize diminished ovarian function. Unlike early concepts that suggested maternal age in combination with basal FSH concentrations had predictive values for ART outcome, the goal of this study is to develop the concept of “ovarian age” as an extrapolative tool to help physicians define an appropriate stimulation protocol for all IVF patient populations. We tested the hypothesis that unlike chronological age, a progressive definition of ovarian age (i.e., function or reserve) which takes into account various clinically relevant factors can serve as a dynamic measure for the clinician for all IVF candidates. This report describes the initial 13 normal women who were randomized to either a “low” rFSH (150IU/150IU rFSH; Follistim®, Organon Pharmaceuticals USA,) or a “high” rFSH protocol (300 IU/300IU rFSH). The high-dosage group had a slightly elevated BMI compared to the low-dosage group (26 vs. 21) and median day3 FSH levels were elevated (12IU/ml vs. 5.3IU/ml). Similar total ovarian volumes were measured (580mm2 vs. 669mm2). Day 3 mean E2 levels were higher in the low dosage group (42.3pg/ml.vs. 28.3pg/ml) as was the mean follicle number (11 vs. 8.5) and the historical use of OCP (85 % vs 50%). Correspondingly the total number of oocytes recovered, number of mature oocytes, number of oocytes fertilized, total embryo number, and number of embryos transferred were all elevated in the “low-dosage” group. More pregnancies were seen in the “low-dosage” group as well (4/7 vs 2/6). These data are preliminary and the differences noted between the group’s BMI and d3FSH cannot be overlooked, but should normalize themselves by study completion. Data appear to support the hypothesis that chronological age does not predicate the responsiveness to rFSH therapy. Thus far, the low-dosage group has achieved superior clinical results. Ultimately, a dynamic approach of analysis and synthesis of these data is expected to yield a clinically effective tool (equation or schema) for the development of tailored stimulation regimens for women undergoing IVF.

Defining “ovarian age” and its impact on the selection of a stimulation protocol

Female fertility declines with advancing maternal age and leads to decreased fecundity. The concept of ovarian reserve is hardly novel, but its application by physicians is, for the most part, kept for the unmistakably sub-fertile patient who has failed previous ovulation induction. An increased basal FSH or an inadequate response to gonadotrophin stimulation may recognize diminished ovarian function. Unlike early concepts that suggested maternal age in combination with basal FSH concentrations had predictive values for ART outcome, the goal of this study is to develop the concept of “ovarian age” as an extrapolative tool to help physicians define an appropriate stimulation protocol for all IVF patient populations. We tested the hypothesis that unlike chronological age, a progressive definition of ovarian age (i.e., function or reserve) which takes into account various clinically relevant factors can serve as a dynamic measure for the clinician for all IVF candidates. This report describes the initial 13 normal women who were randomized to either a “low” rFSH (150IU/150IU rFSH; Follistim®, Organon Pharmaceuticals USA,) or a “high” rFSH protocol (300 IU/300IU rFSH). The high-dosage group had a slightly elevated BMI compared to the low-dosage group (26 vs. 21) and median day3 FSH levels were elevated (12IU/ml vs. 5.3IU/ml). Similar total ovarian volumes were measured (580mm2 vs. 669mm2). Day 3 mean E2 levels were higher in the low dosage group (42.3pg/ml.vs. 28.3pg/ml) as was the mean follicle number (11 vs. 8.5) and the historical use of OCP (85 % vs 50%). Correspondingly the total number of oocytes recovered, number of mature oocytes, number of oocytes fertilized, total embryo number, and number of embryos transferred were all elevated in the “low-dosage” group. More pregnancies were seen in the “low-dosage” group as well (4/7 vs 2/6). These data are preliminary and the differences noted between the group’s BMI and d3FSH cannot be overlooked, but should normalize themselves by study completion. Data appear to support the hypothesis that chronological age does not predicate the responsiveness to rFSH therapy. Thus far, the low-dosage group has achieved superior clinical results. Ultimately, a dynamic approach of analysis and synthesis of these data is expected to yield a clinically effective tool (equation or schema) for the development of tailored stimulation regimens for women undergoing IVF.

Pre-treatment with oral contraceptive pill improves outcome in IVF cycles of poor-responders using the GNRH antagonist

Objective: The use of OCP in antagonist cycles for the poor-responding patients warrants careful consideration since their ovarian reserves may be especially sensitive to suppression of endogenous gonadotropins. We compared ovarian response and clinical pregnancy rates in low responders who underwent GnRH antagonist supplemented controlled ovarian hyperstimulation and in vitro fertilization with and withour pretreatment with oral contraceptives. Design: Non-Randomized comparison. Materials and Methods: One thousand three hundred sixty-five women undergoing IVF at Reproductive Medicine Associates of New York and New Jersey were prospectively identified as “low-responders” and therefore were each treated with a starting dose of 450 ampules of gonadotropins based on one or more of the following criteria: basal antral follicle count < 6, patients aged 40 or older, patients with a peak E2 < 500 pg/mL. Controlled ovarian hyperstimulation using a combination of recombinant follicle stimulating hormone (rFSH) and human Menopausal Gonadotropin (hMG) were initiated in split doses beginning on the third day of the menstrual cycle for patients whether or not they were pretreated with oral contraceptive. Ganirelix acetate (250 g/day) was started when the lead follicle reached 14mm. As these patients were known to have decreased ovarian reserve, standard protocol was to perform an “add-back” of 75 IU of hMG beginning the first day of antagonist. Human chorionic gonadotropin (hCG) was administered on the first day that 3 follicles with a diameter of greater than 18 mm were observed by ultrasonography. Results: In patients who were prospectively predicted to be low responders and therefore given a starting dose of 6 amps of gonadotropins, the pregnancy rate was significantly higher in patients pretreated with OCP (423/875 = 48%) than patients not pretreated with OCP (177/468 = 37%) (p < .05). For patients who were not deemed low responders, and therefore treated with <450 IU of gonadotropins per day, there was no difference in pregnancy rate (OCP: 117/193 = 62% vs. no OCP: 26/46 = 65%). The percentage of patients receiving 450 IU who made >8 eggs was significantly higher (566/799 = 71% vs 216/366 = 59%) (p < .05) when pre-treated with OCP. The percentage of patients receiving 450 IU cancelled was significantly lower (25/875 = 2.9% vs 47/468 = 10%) (p < .05) when pre-treated with OCP. Conclusion: These results provide strong evidence that OCP pretreatment in antagonist supplemented cycles of controlled ovarian hyperstimulation can be of benefit to poor-responding patients. In addition to having assisting IVF patient scheduling, there appears to be value in follicular recruitment and synchronization, and therefore in IVF outcome. Based on this data, it is now our policy to routinely administer OCP prior to initiating GnRH Antagonist cycles.

Assessment of fetal weight based on ultrasonic femur length after the second trimester

Objective: The ultrasonic measurement of the fetal femur length is a sensitive and precise variable for estimation of fetal growth and development. The objective of this study is to predict fetal weight in fetuses of more than 24 weeks gestation by ultrasound measurement of the femur length. Method: In this study, pregnant mothers were identified by the criteria of normalities, such as: well-known LMP, regular menstrual cycles, no use of OCP for the last 3 months, no use of alcohol or cigarettes, no drug abuse, no history of diabetes or chronic HTN. Multiple gestations, congenital anomalies and still-births were excluded. Birth-weight measurements (adjusted for maternal age, baby's sex, parity and week of gestation) were taken immediately after birth. Result: The relation between fetal weight and fetal femur length has been determined by cross-sectional analysis of 900 normal fetuses (≥25 weeks gestation) using real time ultrasonography. Mathematical modeling of the data has demonstrated that the femur growth curve is non-linear beyond 24 weeks gestation. With the aid of a scientific calculator the data were analyzed and a simple second-grade equation has been derived: EFW (kg)=0.042FL 2 (cm)+0.32FL−1.36, S.D.∼±235 g (Honarvar's Formula 2). With the use of this data, the error in estimation of EFW given FL is ±235 g. Conclusion: This simple, new and accurate equation appears to be clinically reliable and easy to use and suggests that previous normal ultrasonic fetal femur length curves for another population may underestimate or overestimate normal fetal weight for the Iranian population. Thus, our formula is an excellent means to estimate true fetal weight.

Surgical management of benign tumors of the liver.

Benign tumors of the liver are increasingly being diagnosed and continue to represent a management challenge. These lesions constitute a substantial component of hepatic neoplasms evaluated and resected at a tertiary referral center. We reviewed our experience with resection of benign liver lesions to clarify the safety and effectiveness of this treatment. Between January 1996 and January 2000, 28 patients with benign hepatic lesions were identified from a cohort of 140 hepatic resection patients. Demographic characteristics, operative management, morbidity, mortality and follow-up were retrospectively analyzed. The mean age in our patients was 35 +/- 14, with 24/28 (86%) patients being female. Seven of the 24 woman (29%) at presentation were either pregnant or immediate postpartum. A history of OCP use was noted in 14/24 (58%) female patients. The most common presenting symptom was abdominal pain in 12/28 (43%). Resection for an undiagnosed mass occurred in 11/28 (39%) patients. The distribution of pathology was hemangioma 10/28 (35.7%), adenoma 8/28 (28.6%), hepatic cyst 5/28 (17.9%), hamartoma 2/28 (7.1%), and FNH 3/28 (10.7%). Average size of the tumor was 7.4 +/- 3.9 (range 2.5-15 cm) with a mean of 1.4 +/- 0.8 lesions (range 1-3) per patient. Tumors were evenly distributed between the right and left side while eight patients (29%) had bilobar tumors. Enucleation rather than anatomic resection was performed in 18/28 (64%) patients, with a mean blood loss of 457 +/- 532 cc (range 50-2200 cc). Blood transfusion was required in only 3/28 (10%) patients, while total vascular isolation was used in only a single patient undergoing an extended left hepatectomy. Mean length of stay was 6.8 +/- 3.2 d (range 3-14 d). Three complications (10.7%) were encountered: pulmonary embolus, ileus and non-operative bile leak. There were no mortalities in this series. Recurrence of tumor occurred in only one patient with a giant hepatic cyst managed laparoscopically. In our institution, the management of clinically relevant benign tumors of the liver comprises a significant proportion of our resectional practice (20%). Our data suggests that both enucleation and anatomically based resections can be performed safely with minimal blood loss and transfusion requirements. Resection of symptomatic lesions was highly effective in treating abdominal pain due to these benign tumors. We advocate resection of non-resolving hepatic adenomas, symptomatic lesions, or when malignancy cannot be excluded.

Assessment of gestational age based on ultrasonic femur length after the first trimester: a simple mathematical correlation between gestational age (GA) and femur length (FL)

Objective: The ultrasonic measurement of the fetal femur length is a sensitive and precise variable for estimation of fetal growth and development. The objective of this study was to predict gestational age in fetuses more than 13 weeks of gestation by ultrasound measurement of the femur length. Method: In this study, pregnant mothers were identified by the criteria of normalities such as: well-known LMP, regular menstrual cycles, no use of OCP for the last 3 months, no smoking, no history of diabetes, etc. Result: The relation between gestational age and fetal femur length has been determined by cross-sectional analysis of 900 normal fetuses (≥14 weeks of gestation) using real time ultrasonography. Mathematical modeling of the data has demonstrated that the femur growth curve is non-linear beyond 13 weeks of gestation. With the aid of a scientific calculator the data were analyzed and a simple second grade equation has been derived: GA (weeks)=0.262 2 FL (cm)+2 FL+11.5, S.D.∼±5 days (Honarvar’s Formula 3). With the use of this data, the error in the estimation of GA given as FL is ±5days. Conclusion: This simple, new and accurate equation appears to be clinically reliable and easy to use and suggests that previous normal ultrasonic fetal femur length curves for another population may under- or overestimate normal fetal age for the Iranian population. Thus, our formula is an excellent means of estimating true gestational age.

Teen compliance with contraception: Analysis of the ohio medicaid claims data

Background: Teen pregnancy is an important and costly issue for society and often commits the mother to a life of poverty. Physicians play an important role in preventing teen pregnancy by identifying teens at risk for pregnancy and prescribing contraception. This study examines for the first time, whether pharmacy data can be used to evaluate teens' compliance with contraception. Such a method may be useful to physician groups, health plans or state agencies to identify teens at risk for unwanted pregnancy and target interventions.Methods: Secondary analysis of the Ohio Medicaid Claims Data from 1998 was done identifying continuously enrolled young women ages 12–19 years, at high risk for pregnancy defined by ICD 9 codes for an STD, an abnormal pap smear, contraception, or a CPT code for a pregnancy test.Results: Between 1/1/98–3/31/98 we identified 4009 females, ages 12–19 years at high risk for pregnancy. During the study interval, 1084 (27%) became pregnant. 1732 (43%) used no prescription contraception and 1190 (30%) used a method at some time. Depo only (551) and OCP only (552) use was equal. Eighty-three combined the use of Depo and OCP. Compliance was poor. Only 20% of the contracepting group had coverage for the full year and approximately 30% used a method for 3 months or less. There was little difference in age or concurrent chronic physical or mental illness between the contracepting and non-contracepting groups. General practice physicians provided 40% of the OCP prescriptions to teens compared with 36% Ob/Gyn, 10% Pediatrics, and 6% Internal Medicine.Conclusions: Analysis of pharmacy data to evaluate the contraceptive compliance of teens at high risk for pregnancy demonstrated poor compliance. This may be a useful tool for identifying teens at risk for unwanted pregnancy and targeting interventions.