Medicine and Health Sciences Commons^™

Obesity And Insulin Resistance But Not Hyperandrogenism Mediates Vascular Dysfunction In Women With Polycystic Ovary Syndrome., Anuja Dokras, Dinesh Jagasia, Michelle Maifeld, Christine Sinkey, Bradley Van Voorhis, William Haynes

Bradley J Van Voorhis

OBJECTIVE: Polycystic ovary syndrome (PCOS) is associated with biochemical evidence of early atherosclerosis; however, data regarding vascular function are controversial. We hypothesized that resistance vessel function (mediated by the endothelium or smooth muscle) would be impaired in women with PCOS and aimed to determine the contribution of hyperandrogenism, obesity, or insulin resistance to vascular dysfunction.

DESIGN: Prospective study.

SETTING: University practice.

PATIENT(S): Women with PCOS (n = 24) and age/weight-matched controls (n = 22).

INTERVENTION(S): Vascular function was assessed by measuring forearm vasodilatation in response to both endothelium-dependent (acetylcholine/bradykinin) and endothelium-independent dilators (nitroprusside/verapamil).

MAIN OUTCOME MEASURE(S): Resistance vessel function.

RESULT(S): …

Obstetric Outcomes After In Vitro Fertilization In Obese And Morbidly Obese Women., Anuja Dokras, Lindsey Baredziak, Jill Blaine, Craig Syrop, Bradley Van Voorhis, Amy Sparks

Bradley J Van Voorhis

OBJECTIVE: In addition to numerous health detriments caused by obesity, fertility and pregnancy success may also be compromised. The aims of this study were to compare the effects of obesity and morbid obesity on in vitro fertilization (IVF) outcomes. We also investigated the effects of obesity on obstetric outcomes after IVF treatment. METHODS: Retrospective study of women less than 38 years of age during their first fresh IVF cycle (January 1995 to April 2005). RESULTS: A total of 1,293 women were included in the study, with 236 obese women (body mass index [BMI] = 30-39.9) and 79 morbidly obese women …

The Cost Of Infertility Evaluation And Therapy: Findings Of A Self-Insured University Healthcare Plan., D. Stovall, B. Allen, Amy Sparks, Craig Syrop, R. Saunders, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To assess the total costs of infertility coverage, determine the proportion of healthcare costs related to infertility, compare infertility costs to those of other diseases, and calculate a per member per month cost of an infertility benefit. DESIGN: Historical prospective analysis. SETTING: A university-based, self-insured, fee-for-service healthcare plan. PATIENT(S): Healthcare policy members from January 1993 through December 1995. INTERVENTION(S): General and infertility-specific healthcare that included diagnostic tests for infertility, induction of ovulation, artificial insemination, donor gametes, in vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, microsurgical epididymal sperm aspiration, embryo cryopreservation, and frozen embryo transfer. MAIN OUTCOME MEASURE(S): Healthcare …

Ultrasound Is The Optimal Choice For Guidance In Difficult Hysteroscopy., J. Kresowik, Craig Syrop, Bradley Van Voorhis, Ginny Ryan

Bradley J Van Voorhis

OBJECTIVES: To compare costs and complications associated with ultrasound-guided hysteroscopy vs laparoscopy-guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae. METHODS: This was a retrospective cohort study. Charts of all patients undergoing reparative surgery for intrauterine synechiae or uterine septa at our academic institution between 2000 and 2008 were reviewed. A total of 159 procedures were included in the study, categorized into concurrent laparoscopic guidance (n = 69), ultrasound guidance (n = 52) or no guidance (n = 38). Data regarding billing, surgical case logs and complications were collected for these procedures. Using these data, …

A Mandatory Single Blastocyst Transfer Policy With Educational Campaign In A United States Ivf Program Reduces Multiple Gestation Rates Without Sacrificing Pregnancy Rates, Ginny Ryan, Amy Sparks, C. Sipe, Craig Syrop, A. Dokras, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To reduce the twin rate in our IVF program. DESIGN: A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING: University-based infertility center. PATIENT(S): One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S): A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S): Knowledge of twin risks and desired number of embryos …

Early Diagnosis Of Ovarian Torsion By Color Doppler Ultrasonography, Bradley Van Voorhis, J. Schwaiger, Craig Syrop, F. Chapler

Bradley J Van Voorhis

Ovarian torsion is often difficult to diagnose because of the nonspecific nature of the clinical findings. We report on the use of color Doppler ultrasonography in diagnosing early ovarian torsion. This technique provides a highly specific finding, the absence of blood flow to the ovary, that greatly facilitates the diagnosis of ovarian torsion.

In Vitro Fertilization Patients Support A Single Blastocyst Transfer Policy, S. Martini, Bradley Van Voorhis, B. Stegmann, Amy Sparks, T. Shochet, M. Zimmerman, Ginny Ryan

Bradley J Van Voorhis

OBJECTIVE: To determine whether patients support a mandatory single blastocyst transfer (mSBT) policy in IVF. DESIGN: Prospective survey study. SETTING: Academic hospital-based infertility center. PATIENT(S): Two hundred sixty-two female patients presenting for fresh or cryopreserved/thawed ET after IVF. INTERVENTION(S): Internet-based in-clinic survey after ET. Follow-up at-home survey after pregnancy test results. MAIN OUTCOME MEASURE(S): Patient support for an mSBT policy and attitudes regarding patient input into IVF treatment. Logistic regression analyses tested associations among main outcome measures, patient characteristics, and treatment results. RESULT(S): Ninety-four percent of patients endorsed support for our mSBT policy; 95% and 87% felt they had the …

The Desire Of Infertile Patients For Multiple Births, Ginny Ryan, S. Zhang, A. Dokras, Craig Syrop, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To determine the proportion of infertile women who prefer a multiple birth over a singleton, patient characteristics associated with this desire, and patient knowledge about the risks of multiple births. DESIGN: Prospective analysis. SETTING: Academic university hospital-based infertility center and private general gynecology clinic. PATIENT(S): Four hundred sixty-four female patients with infertility who presented for their initial visit. MAIN OUTCOME MEASURE(S): Demographic characteristics, infertility history, desire regarding multiple births, knowledge of the risks of multiple births, and goals of infertility evaluation and treatment were determined by using a 41-question survey. Univariate analysis was performed to assess patient characteristics associated …

Detection Of Enlarged Yolk Sac On Early Ultrasound Is Associated With Adverse Pregnancy Outcomes, D. Berdahl, J. Blaine, Bradley Van Voorhis, A. Dokras

Bradley J Van Voorhis

Pregnancies with mean yolk sac diameter>or=5 mm on early ultrasound require monitoring and counseling about a threefold increased risk for first-trimester loss independent of maternal risk factors such as age, body mass index, polycystic ovary syndrome, smoking, and diabetes. In addition, our study shows for the first time that enlarged yolk sac diameter may be associated with an increased risk of preterm delivery.

Oral Ovulation Induction Agents Combined With Low-Dose Gonadotropin Injections And Intrauterine Insemination: Cost- And Clinical Effectiveness, Ginny Ryan, V. Moss, W. Davis, Amy Sparks, A. Dokras, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To compare the efficacy and cost-effectiveness of different induction protocols involving gonadotropins with intrauterine insemination (IUI). STUDY DESIGN: We performed a retrospective chart review of 648 IUI cycles. Some patients had gonadotropin injections alone before human chorionic gonadotropin (hCG) and IUI (human menopausal gonadotropin protocol); others were given oral medications, then gonadotropins before hCG and IUI (combination protocol). Outcomes included pregnancy rates, multiple birth rates, endometrial thickness, number of ovarian follicles, injection days, ampules of gonadotropins and cost. RESULTS: The combination protocol was more cost-effective. In first cycles, pregnancy rates, multiple birth rates, number of large follicles produced and …

Computational Models For Prediction Of Ivf/Icsi Outcomes With Surgically Retrieved Spermatozoa, M. Wald, Amy Sparks, J. Sandlow, Bradley Van Voorhis, Craig Syrop, C. Niederberger

Bradley J Van Voorhis

IVF/intracytoplasmic sperm injection (ICSI) using surgically retrieved spermatozoa (SRS) is a key option in the treatment of severe male infertility. It was aimed to develop a computational model for the prediction of this modality's outcome. A dataset of 113 exemplars, derived from patients who underwent IVF/ICSI with SRS, was retrospectively analysed. The dataset, containing input features maternal age, sperm retrieval technique, type of spermatozoa used, type of male factor and output intrauterine pregnancy, was randomized into a modelling ('training') set of 83 and cross-validation ('test') set of 30. neUROn++, a set of C++ programs, was used to model the dataset …

Outcomes From Assisted Reproductive Technology, Bradley Van Voorhis

Bradley J Van Voorhis

The use of assisted reproductive technology (ART) for treating the infertile couple is increasing in the United States. The purpose of this paper is to review the short-term outcomes after ART. Pregnancy rates after ART have shown nearly continuous improvement in the years since its inception. A number of factors affect the pregnancy rate, with the most important being a woman's age. Certain clinical diagnoses are associated with a poorer outcome from ART, including the presence of hydrosalpinges, uterine leiomyomata that distort the endometrial cavity, and decreased ovarian reserve. Multiple gestations are the major complication after ART. New laboratory techniques, …

Colon Carcinoma Complicating Pregnancy. A Report Of Two Cases, Bradley Van Voorhis, D. Cruikshank

Bradley J Van Voorhis

Two cases occurred of colon carcinoma complicating pregnancy. Both patients presented with occult blood in the stool and iron deficiency anemia; that makes their cases different from the 20 previously reported ones of colon carcinoma above the peritoneal reflection associated with pregnancy. These cases illustrate the importance of a rectal examination and stool guiaic test in evaluating iron deficiency anemia in pregnancy.

Immunohistochemical Localization Of Prostaglandin H Synthase In The Female Reproductive Tract And Endometriosis, Bradley Van Voorhis, P. Huettner, M. Clark, J. Hill

Bradley J Van Voorhis

Prostaglandin H synthase, also known as cyclooxygenase, is an essential enzyme in prostaglandin synthesis. Using a monoclonal antibody and immunohistochemical techniques, we studied the localization of this enzyme in the female reproductive tract and in endometriosis. In the uterus, prostaglandin H synthase was primarily localized to endometrial epithelium with surface epithelium containing more immunoreactive prostaglandin H synthase than glandular epithelium. Fallopian tube secretory epithelial cells also contained prostaglandin H synthase while ciliated epithelial cells did not. Cervical epithelium and myometrial cells did not contain prostaglandin H synthase. A higher percentage of glands in endometriosis and adenomyosis, as compared with eutopic …

Clinical Predictors Of Human Blastocyst Formation And Pregnancy After Extended Embryo Culture And Transfer, M. Thomas, Amy Sparks, Ginny Ryan, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To determine the clinical factors associated with blastocyst development and pregnancy. DESIGN: Evaluation of a prospectively collected IVF database. SETTING: An academic IVF practice. PATIENT(S): Couples (n = 529) undergoing their first IVF cycle who qualified for extended embryo culture (more than six zygotes) over the past 5 years. INTERVENTION(S): Seven or eight zygotes were cultured for 5 days, assessed for quality, and then transferred with excess zygotes cryopreserved at the pronuclear stage. MAIN OUTCOME MEASURE(S): Clinical predictors of blastocyst development and pregnancy. RESULT(S): The mean blastocyst development rate was 49.8%, with a median number of total and good-quality …

Clinical Practice. In Vitro Fertilization, Bradley Van Voorhis

Bradley J Van Voorhis

No abstract provided.

The Effects Of Smoking On Ovarian Function And Fertility During Assisted Reproduction Cycles, Bradley Van Voorhis, J. Dawson, D. Stovall, Amy Sparks, Craig Syrop

Bradley J Van Voorhis

OBJECTIVE: To investigate the effects of cigarette smoking on ovarian function and fertility in women undergoing assisted reproduction cycles. METHODS: We assessed the effects of smoking on ovarian function and fertility in a cohort of 499 women. Questionnaires were designed to quantify past smoking exposure and to determine whether the woman was smoking during the treatment cycle. Ovarian function characteristics and pregnancy rates were compared among current smokers, past smokers, and nonsmokers. RESULTS: Compared with nonsmokers, both current and past smokers have reduced gonadotropin-stimulated ovarian function. A history of increasing tobacco exposure was associated with decreasing serum estradiol concentrations, numbers …

The Effects Of Ru 486 On Immune Function And Steroid-Induced Immunosuppression In Vitro, Bradley Van Voorhis, D. Anderson, J. Hill

Bradley J Van Voorhis

The effect of RU 486 [17 beta-hydroxy-11 beta-(4-dimethylamino-phenol)17 alpha-(prop-1-ynyl)estra- 4,9diene-3-one] on [3H]thymidine incorporation into Concanavalin-A-stimulated human peripheral blood mononuclear cells and its influence on the suppressive effects of cortisol and progesterone were investigated. Cortisol suppressed lymphocyte thymidine incorporation at 10(-5), 10(-6), and 10(-7) M (17.6%, 20%, and 38% of control, respectively; P less than 0.01). Cortisol-induced suppression was reversed when low concentrations of RU 486 (10(-7) and 10(-6) M) were added. RU 486 at 10(-5) M further suppressed lymphocyte thymidine incorporation when added to cultures with cortisol. Progesterone significantly inhibited lymphocyte thymidine incorporation at 10(-5) M (8.2% of control; P …

In Vitro Fertilization Is Associated With An Increase In Major Birth Defects, C. Olson, K. Keppler-Noreuil, P. Romitti, W. Budelier, Ginny Ryan, Amy Sparks, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To determine the risk of major birth defects in cohorts of children conceived through IVF or through IUI as compared with naturally conceived children. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): Children conceived by IVF or IUI at the University of Iowa from 1989 through 2002, compared with a matched cohort of naturally conceived children. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Outcome data were obtained from Iowa state birth and fetal death certificates and from the Iowa Birth Defects Registry. RESULT(S): Ninety of 1,462 IVF-conceived children (6.2%) and 17 of 343 IUI-conceived children (5.0%) had a major birth …

Sextuplets: An Unusual Complication Of Single Embryo Transfer, L. Mains, Ginny Ryan, Amy Sparks, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To describe an unusual case of a sextuplet gestation after IVF and transfer of a single blastocyst. DESIGN: Case report. SETTING: University-based IVF clinic. PATIENT(S): A 32-year-old female with secondary infertility undergoing IVF-ET. INTERVENTION(S): Transvaginal oocyte retrieval, transfer of a single blastocyst, and multifetal pregnancy reduction. MAIN OUTCOME MEASURE(S): Ultrasound determination of pregnancy viability. RESULT(S): Six intrauterine gestational sacs, each with a fetus having cardiac activity, reduced to a triplet gestation. CONCLUSION(S): Physicians should consider advising patients undergoing IVF-ET to abstain from unprotected intercourse at least 4 days before the anticipated oocyte retrieval. Incomplete aspiration of ovarian follicles is …

A 41-Year-Old Woman With Menorrhagia, Anemia, And Fibroids: Review Of Treatment Of Uterine Fibroids, Bradley Van Voorhis

Bradley J Van Voorhis

Uterine fibroids are common tumors that can cause heavy menstrual bleeding, pelvic pressure symptoms, and reproductive disorders. The incidence of fibroids peaks in the fifth decade of age and they are more common in African American women. Often, fibroids are asymptomatic and require no treatment. However, the case of Ms P, a 41-year-old woman with recurrent uterine fibroids, menorrhagia, anemia, and fatigue who wishes to retain fertility, illustrates the symptoms that require treatment. Evaluation usually begins with a pelvic examination and an ultrasound to determine both the size and location of the fibroids within the uterus. Standard treatment of symptomatic …

Effects Of Smoking On Ovulation Induction For Assisted Reproductive Techniques, Bradley Van Voorhis, Craig Syrop, D. Hammitt, M. Dunn, G. Snyder

Bradley J Van Voorhis

OBJECTIVE: To determine the effects of smoking on ovulation induction for assisted reproductive techniques. DESIGN: Matched, retrospective, cohort study. SETTING: Outpatient University endocrine/infertility program. PATIENTS: Eighteen smokers and 36 nonsmokers: 2 nonsmokers matched to each smoker for age, weight, and history of ovarian surgery. MAIN OUTCOME MEASURES: During a stimulation cycle, the serum estradiol (E2) level, number of follicles, number of oocytes, number of embryos, and ampules of gonadotropins used were compared in the smoking versus the nonsmoking groups by Wilcoxon's signed rank test for paired data. Follicular fluid (FF), testosterone (T), androstenedione (A), E2, A:E2 ratios, and T:E2 ratios …

Progression Of Atypical Endometrial Hyperplasia To Adenocarcinoma Despite Intrauterine Progesterone Treatment With The Levonorgestrel-Releasing Intrauterine System., J. Kresowik, Ginny Ryan, Bradley Van Voorhis

Bradley J Van Voorhis

BACKGROUND: Intrauterine progesterone therapy has been proposed as a potential uterine-sparing treatment for atypical endometrial hyperplasia and adenocarcinoma.

CASE: We present a case of an infertility patient with atypical endometrial hyperplasia who was treated with the levonorgestrel-releasing intrauterine system for 6 months. At follow-up, she was noted to have an increasing endometrial thickness on ultrasonography, and biopsy revealed progression of her lesion to adenocarcinoma.

CONCLUSION: Although there is a need for uterine-sparing treatment for atypical endometrial hyperplasia and early adenocarcinoma, especially in the setting of desired fertility, caution should be exercised. We do not recommend using the levonorgestrel-releasing intrauterine system …

Use Of Oocytes From Anonymous, Matched, Fertile Donors For Prevention Of Heritable Genetic Diseases, Bradley Van Voorhis, R. Williamson, J. Gerard, D. Hammitt, Craig Syrop

Bradley J Van Voorhis

Heritable genetic diseases can be prevented with the use of donor oocytes. We report our experience in using donor oocytes from anonymous, matched, fertile donors in four women with heritable genetic disorders. Our results show that use of donor oocytes is a practical, successful, and currently available technique for the prevention of genetic disorders.

Five-Years Of A Mandatory Single-Embryo Transfer (Mset) Policy Dramatically Reduces Twinning Rate Without Lowering Pregnancy Rates, J. Kresowik, B. Stegmann, Amy Sparks, Ginny Ryan, Bradley Van Voorhis

Bradley J Van Voorhis

OBJECTIVE: To report the outcomes of a program policy instituted in 2004 mandating single-embryo transfer (mSET) for all women aged <38 >years, with at least seven zygotes, no prior failed fresh cycle at our center, and at least one good-quality blastocyst. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): All women 1, 1999, to May 31, 2004 (before mSET) and from June 1, 2004, to May 31, 2009 (after mSET). INTERVENTION(S): mSET policy implementation. MAIN OUTCOME MEASURE(S): Live-birth rate, multiple pregnancy rate, clinical volume, and outcomes of all mSET fresh IVF transfers were analyzed. RESULT(S): Clinical volume was unchanged between …

Primary Hypothyroidism Associated With Multicystic Ovaries And Ovarian Torsion In An Adult, Bradley Van Voorhis, T. Neff, Craig Syrop, F. Chapler

Bradley J Van Voorhis

BACKGROUND: Primary hypothyroidism is known to be associated with multicystic ovaries in juvenile females, but this association has been reported only once previously in an adult. This report describes an unusual case of bilateral multicystic ovaries occurring in an adult patient with profound hypothyroidism. CASE: A 26-year-old woman presented with an acute abdomen and bilateral adnexal masses. An emergency exploratory laparotomy revealed bilateral enlarged multicystic ovaries with torsion of the right ovary. Because this ovary was necrotic, it was removed; pathology revealed multiple hemorrhagic follicular cysts. Laboratory studies to evaluate the cause of the multicystic ovaries revealed negative serum beta-hCG, …