Richard S Legro

Heilongjiang University of Chinese Medicine, Charbin, Heilongjiang Sheng, China

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Publications (244)1140.72 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Clinical trials testing infertility treatments often do not report on the major outcomes of interest to patients and clinicians and the public (such as live birth) nor on the harms, including maternal risks during pregnancy and fetal anomalies. This is complicated by the multiple participants in infertility trials which may include a woman (mother), a man (father), and result in a third individual if successful, their offspring (child), who is also the desired outcome of treatment. The primary outcome of interest and many adverse events occur after cessation of infertility treatment and during pregnancy and the puerperium, which create a unique burden of follow-up for clinical trial investigators and participants. In 2013, because of the inconsistencies in trial reporting and the unique aspects of infertility trials not adequately addressed by existing Consolidated Standards of Reporting Trials (CONSORT) statements, we convened a consensus conference in Harbin, China, with the aim of planning modifications to the CONSORT checklist to improve the quality of reporting of clinical trials testing infertility treatment. The consensus group recommended that the preferred primary outcome of all infertility trials is live birth (defined as any delivery of a live infant ≥20 weeks gestations) or cumulative live birth, defined as the live birth per women over a defined time period (or number of treatment cycles). In addition, harms to all participants should be systematically collected and reported, including during the intervention, any resulting pregnancy, and during the neonatal period. Routine information should be collected and reported on both male and female participants in the trial. We propose to track the change in quality that these guidelines may produce in published trials testing infertility treatments. Our ultimate goal is to increase the transparency of benefits and risks of infertility treatments to provide better medical care to affected individuals and couples.
    Human reproduction (Oxford, England). 09/2014;
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    ABSTRACT: Background Clomiphene is the current first-line infertility treatment in women with the polycystic ovary syndrome, but aromatase inhibitors, including letrozole, might result in better pregnancy outcomes. Methods In this double-blind, multicenter trial, we randomly assigned 750 women, in a 1:1 ratio, to receive letrozole or clomiphene for up to five treatment cycles, with visits to determine ovulation and pregnancy, followed by tracking of pregnancies. The polycystic ovary syndrome was defined according to modified Rotterdam criteria (anovulation with either hyperandrogenism or polycystic ovaries). Participants were 18 to 40 years of age, had at least one patent fallopian tube and a normal uterine cavity, and had a male partner with a sperm concentration of at least 14 million per milliliter; the women and their partners agreed to have regular intercourse with the intent of conception during the study. The primary outcome was live birth during the treatment period. Results Women who received letrozole had more cumulative live births than those who received clomiphene (103 of 374 [27.5%] vs. 72 of 376 [19.1%], P=0.007; rate ratio for live birth, 1.44; 95% confidence interval, 1.10 to 1.87) without significant differences in overall congenital anomalies, though there were four major congenital anomalies in the letrozole group versus one in the clomiphene group (P=0.65). The cumulative ovulation rate was higher with letrozole than with clomiphene (834 of 1352 treatment cycles [61.7%] vs. 688 of 1425 treatment cycles [48.3%], P<0.001). There were no significant between-group differences in pregnancy loss (49 of 154 pregnancies in the letrozole group [31.8%] and 30 of 103 pregnancies in the clomiphene group [29.1%]) or twin pregnancy (3.4% and 7.4%, respectively). Clomiphene was associated with a higher incidence of hot flushes, and letrozole was associated with higher incidences of fatigue and dizziness. Rates of other adverse events were similar in the two treatment groups. Conclusions As compared with clomiphene, letrozole was associated with higher live-birth and ovulation rates among infertile women with the polycystic ovary syndrome. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT00719186 .).
    New England Journal of Medicine 07/2014; 371(2):119-129. · 51.66 Impact Factor
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    ABSTRACT: Context: Polycystic ovary syndrome (PCOS) is a highly heritable complex trait. Parents of affected women have reproductive and metabolic phenotypes. Objective: We tested the hypothesis that there are parental effects on the heritability of fasting dysglycemia in women with PCOS. Design and Setting: This was a cross-sectional study at an academic medical center. Participants: Participants included 367 women with PCOS and their parents (1101 total subjects). Main Outcome Measures: We compared maternal and paternal contributions to heritability of fasting dysglycemia and to transmission of the PCOS susceptibility allele of D19S884 within the fibrillin-3 gene (D19S884-A8) on fasting dysglycemia. Results: Fathers had higher fasting glucose levels, prevalence of fasting dysglycemia and proinsulin to insulin molar ratios (P < .0001), a marker of defective insulin processing, compared with mothers. Heritability of fasting dysglycemia was significant in PCOS families (h(2) = 37%, SE = 10%, P = .001). Maternal heritability (h(2) = 51%, SE = 15%, P = .0009) was higher than paternal heritability (h(2) = 23 %, SE = 23%, P = .186) of fasting dysglycemia after adjustment for age and body mass index. Within dysglycemic probands, there was increased maternal compared with paternal transmission of D19S884-A8 (maternal 84% vs paternal 45%, χ(2) = 6.51, P = .011). Conclusions: There was a sex difference in the parental metabolic phenotype with fathers having an increased risk of fasting dysglycemia and evidence for pancreatic β-cell dysfunction compared with mothers. However, only maternal heritability had significant effects on the prevalence of fasting dysglycemia in women with PCOS. Furthermore, there were maternal parent-of-origin effects on transmission of D19S884-A8 probands with fasting dysglycemia. These findings suggest that maternal factors, genetic and perhaps epigenetic, contribute to the metabolic phenotype in affected women.
    The Journal of clinical endocrinology and metabolism. 05/2014;
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    ABSTRACT: Polycystic ovary syndrome (PCOS) patients are at increased risk of pregnancy complications, which may impair pregnancy outcome. Transfer of fresh embryos after superovulation may lead to abnormal implantation and placentation and further increase risk for pregnancy loss and complications. Some preliminary data suggest that elective embryo cryopreservation followed by frozen-thawed embryo transfer into a hormonally primed endometrium could result in a higher clinical pregnancy rate than that achieved by fresh embryo transfer.
    Trials. 05/2014; 15(1):154.
  • Richard S Legro, Xiaoke Wu
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    ABSTRACT: Clinical trials in infertility choose from a variety of outcomes including change in some surrogate marker of gamete quality to healthy live birth. Incomplete reporting of outcomes makes it difficult to compare studies and to determine the clinical impact of infertility treatments. In this Views and Reviews, we explore the merits of collecting various outcomes of interest in infertility trials from the vantage point of infertility specialists, an obstetrician, and a pediatrician. These articles support more complete reporting of maternal, paternal, fetal, and infant outcomes from infertility trials to improve patient care and ultimately public health.
    Fertility and sterility 05/2014; 101(5):1201-1202. · 3.97 Impact Factor
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    ABSTRACT: English is increasingly the medical lingua franca. We hypothesized that an intensive journal club model based on articles and questions from obstetrics and gynecology could improve written and spoken comprehension of medical English in a population of Chinese medical professionals. Participants took a three-part baseline examination (multiple choice, 15 questions), written (10-point scale) and oral (12-point scale), to assess medical English comprehension that was repeated at study conclusion. After baseline, students were randomized to either 1) an intensive treatment arm with 24 journal club sessions led by a U.S. medical student over the course of 8 weeks; or 2) a self-study group. Primary outcome measured was the change in score from baseline on the multiple choice examination, adapted from APGO uWISE examinations. Secondary outcomes included change in written and oral scores with grading scales used for respective TOEFL tests. The agreement between the two evaluators had weighted κ scores ranging from 0.57 to 0.71 that are comparable to TOEFL κ scores. Both groups improved the mean number of correct multiple choice responses, but there was no statistically significant difference between groups (P=.16). Compared with self-study, however, an intensive journal club significantly improved written scores (mean change 3.1, 95% confidence interval [CI] 1.1-5.0, P=.003) and oral scores (mean change 1.9, 95% CI 0.1-3.8, P=.04). Although reading journal articles improved the mean medical comprehension of both groups (13% and 7%, respectively), interacting with colleagues and an English-speaking facilitator in an intensive journal club environment may selectively improve both written and speaking capabilities.
    Obstetrics and Gynecology 05/2014; 123 Suppl 1:23S. · 4.80 Impact Factor
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    ABSTRACT: Polycystic ovary syndrome (PCOS), characterized by increased ovarian androgen biosynthesis, anovulation, and infertility, affects 5-7% of reproductive-age women. Genome-wide association studies identified PCOS candidate loci that were replicated in subsequent reports, including DENND1A, which encodes a protein associated with clathrin-coated pits where cell-surface receptors reside. However, these studies provided no information about functional roles for DENND1A in the pathogenesis of PCOS. DENND1A protein was located in the cytoplasm as well as nuclei of theca cells, suggesting a possible role in gene regulation. DENND1A immunostaining was more intense in the theca of PCOS ovaries. Using theca cells isolated and propagated from normal cycling and PCOS women, we found that DENND1A variant 2 (DENND1A.V2) protein and mRNA levels are increased in PCOS theca cells. Exosomal DENND1A.V2 RNA was significantly elevated in urine from PCOS women compared with normal cycling women. Forced overexpression of DENND1A.V2 in normal theca cells resulted in a PCOS phenotype of augmented CYP17A1 and CYP11A1 gene transcription, mRNA abundance, and androgen biosynthesis. Knock-down of DENND1A.V2 in PCOS theca cells reduced androgen biosynthesis and CYP17A1 and CYP11A1 gene transcription. An IgG specific to DENND1A.V2 also reduced androgen biosynthesis and CYP17 and CYP11A1 mRNA when added to the medium of cultured PCOS theca cells. We conclude that the PCOS candidate gene, DENND1A, plays a key role in the hyperandrogenemia associated with PCOS. These observations have both diagnostic and therapeutic implications for this common disorder.
    Proceedings of the National Academy of Sciences 03/2014; · 9.81 Impact Factor
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    ABSTRACT: Although there is evidence of metabolic risks in young women with irregular menses and androgen excess, persistence of risks after menopause is unclear. To determine the impact of menopause on the cardiometabolic profile in women with high androgens and a history of menstrual irregularity. Study of Women's Health across the Nation is a longitudinal cohort study. Data from 1929 women without metabolic syndrome (MetS) at baseline were analyzed for incidence of MetS, self-reported stroke and myocardial infarction (MI). Cox Hazard Ratios (HR) were estimated, adjusting for age, ethnicity, body mass, smoking, menopausal status and study site. Among MetS-free women at baseline, 497 new cases were identified during 20,249 woman-years of follow-up over 12 years. Women with hyperandrogenemia (HA) and oligomenorrhea (Oligo) developed incident cases of MetS at a comparable rate compared to their counterparts: eumenorrheic, normoandrogenic women (HR 1.4 [0.9-2.2]), oligomenorrheic, normoandrogenic women (HR 1.3 [0.8-2.2]), and eumenorrheic hyperandrogenic women (HR 1.2 [0.7-1.8]). Smoking and obesity were the strongest predictors of incident MetS. There was no significant difference in incidence of self-reported stroke or MI by HA/Oligo status. Longitudinal evidence suggests that a history of androgen excess and menstrual irregularity is not associated with worsening of metabolic health after menopause. Our findings challenge the notion that a history of concurrent HA and Oligo reflects ongoing cardiometabolic risk in postmenopausal women.
    The Journal of clinical endocrinology and metabolism 02/2014; · 6.50 Impact Factor
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    ABSTRACT: Context: Although inflammation is clearly associated with obesity, diabetes, and insulin resistance, the role of chronic inflammation in the etiology of PCOS is unclear. Objective: To determine whether chronic inflammation plays a causal role in the etiology of PCOS, we tested for association between PCOS and genetic markers mapping to 80 members of the inflammatory pathway. Design: Case-control association study. Setting: Academic medical center. Patients or Participants: 905 index cases with PCOS and 955 control women (108 intensively-phenotyped subjects with normal androgen levels and regular menses and 847 minimally-phenotyped subjects with regular menses and no history of PCOS). Interventions: Subjects were genotyped at SNPs mapping to 80 inflammatory genes. Logistic regression was used to test for association between 822 SNPs and PCOS after adjusting for population stratification, BMI and/or age. In the index cases, we also tested for association with 11 quantitative traits (BMI, testosterone, fasting insulin, fasting glucose, 2-hour post-challenge glucose, LH, FSH, total cholesterol, HDL, LDL and triglyceride levels). Main Outcome Measures: Evidence for association with PCOS and with 11 quantitative traits. Results: Nominally significant evidence for association was observed with MAP3K7, IKBKG, TNFRS11A, AKT2, IL6R and IRF1, but none remained statistically significant after adjustment for multiple testing. Conclusions: Genetic variation in the inflammatory pathway is not a major contributor to the etiology of PCOS or related quantitative traits in women with PCOS.
    The Journal of clinical endocrinology and metabolism 01/2014; · 6.50 Impact Factor
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    ABSTRACT: Objective To summarize baseline characteristics from a large multicenter infertility clinical trial. Design Cross-sectional baseline data from a double-blind randomized trial of two treatment regimens (letrozole vs. clomiphene). Setting Academic Health Centers throughout the United States. Patient(s) Seven hundred fifty women with polycystic ovary syndrome (PCOS) and their male partners took part in the study. Intervention(s) None. Main Outcome Measure(s) Historic, biometric, biochemical, and questionnaire parameters. Result(s) Females averaged 30 years and were obese (body mass index [BMI] 35) with ∼20% from a racial/ethnic minority. Most (87%) were hirsute and nulligravid (63%). Most of the women had an elevated antral follicle count and enlarged ovarian volume on ultrasound. Women had elevated mean circulating androgens, LH-to-FSH ratio (∼2), and antimüllerian hormone levels (8.0 ng/mL). In addition, women had evidence for metabolic dysfunction with elevated mean fasting insulin and dyslipidemia. Increasing obesity was associated with decreased LH-to-FSH levels, antimüllerian hormone levels, and antral follicle counts but increasing cardiovascular risk factors, including prevalence of the metabolic syndrome. Men were obese (BMI 30) and had normal mean semen parameters. Conclusion(s) The treatment groups were well matched at baseline. Obesity exacerbates select female reproductive and most metabolic parameters. We have also established a database and sample repository that will eventually be accessible to investigators. Clinical Trial Registration Number NCT00719186.
    Fertility and Sterility. 01/2014; 101(1):258–269.e8.
  • Kathleen M Hoeger, Richard S Legro, Corrine K Welt
    The Journal of clinical endocrinology and metabolism 01/2014; 99(1):35A-36A. · 6.50 Impact Factor
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    ABSTRACT: Objective To determine the effects of high-dose vitamin D on insulin sensitivity in polycystic ovary syndrome (PCOS). Design Randomized, placebo-controlled trial. Setting Academic medical center. Patient(s) Twenty-eight women with PCOS. Intervention(s) Vitamin D3, 12,000 IU, or placebo daily for 12 weeks. Main Outcome Measure(s) The primary outcome was quantitative insulin sensitivity check index. Secondary outcomes included glucose and insulin levels during a 75-g oral glucose tolerance test and blood pressure. Result(s) Twenty-two women completed the study. Compared with placebo, vitamin D significantly increased 25-hydroxyvitamin D (mean [95% confidence interval] in vitamin D group 20.1 [15.7 to 24.5] ng/mL at baseline and 65.7 [52.3 to 79.2] ng/mL at 12 weeks; placebo 22.5 [18.1 to 26.8] ng/mL at baseline and 23.8 [10.4 to 37.2] ng/mL at 12 weeks). There were no significant differences in quantitative insulin sensitivity check index and other measures of insulin sensitivity; however, we observed trends toward lower 2-hour insulin and lower 2-hour glucose. We also observed a protective effect of vitamin D on blood pressure. Conclusion(s) In women with PCOS, insulin sensitivity was unchanged with high-dose vitamin D, but there was a trend toward decreased 2-hour insulin and a protective effect on blood pressure. Clinical Trial Registration Number NCT00907153.
    Fertility and sterility 01/2014; · 3.97 Impact Factor
  • Fertility and Sterility. 01/2014; 102(3):e2.
  • Richard S Legro, Eli Y Adashi
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    ABSTRACT: In this Views and Reviews section the authors review male and female germline stem cell research, including the potential for translation to the clinic. Larger and more complex teams, beyond basic and clinical science expertise, will be necessary to achieve this goal.
    Fertility and sterility 01/2014; 101(1):1-2. · 3.97 Impact Factor
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    Evidence-based complementary and alternative medicine : eCAM. 01/2014; 2014:698921.
  • Richard S Legro
    Seminars in Reproductive Medicine 11/2013; 31(6):389-390. · 3.21 Impact Factor
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    ABSTRACT: Objective:The aim was to formulate practice guidelines for the diagnosis and treatment of polycystic ovary syndrome (PCOS).Participants:An Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer developed the guideline.Evidence:This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.Consensus Process:One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize supporting evidence.Conclusions:We suggest using the Rotterdam criteria for diagnosing PCOS (presence of two of the following criteria: androgen excess, ovulatory dysfunction, or polycystic ovaries). Establishing a diagnosis of PCOS is problematic in adolescents and menopausal women. Hyperandrogenism is central to the presentation in adolescents, whereas there is no consistent phenotype in postmenopausal women. Evaluation of women with PCOS should exclude alternate androgen-excess disorders and risk factors for endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease. Hormonal contraceptives are the first-line management for menstrual abnormalities and hirsutism/acne in PCOS. Clomiphene is currently the first-line therapy for infertility; metformin is beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but it has limited or no benefit in treating hirsutism, acne, or infertility. Hormonal contraceptives and metformin are the treatment options in adolescents with PCOS. The role of weight loss in improving PCOS status per se is uncertain, but lifestyle intervention is beneficial in overweight/obese patients for other health benefits. Thiazolidinediones have an unfavorable risk-benefit ratio overall, and statins require further study.
    The Journal of clinical endocrinology and metabolism 10/2013; · 6.50 Impact Factor
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    ABSTRACT: Is a vaginal preparation of sildenafil citrate capable of alleviating acute menstrual pain in patients with primary dysmenorrhea (PD)? A vaginal preparation of sildenafil citrate is capable of alleviating acute menstrual pain in patients with PD with no observed adverse effects. Oral preparations of nitric oxide (NO) donor drugs augment relaxant effects of NO on myometrial cells, reverse the vasoconstriction caused by prostaglandins and successfully alleviate pain, but the incidence of side effects is too high for routine clinical use. Sildenafil citrate inhibits type 5-specific phosphodiesterase (PDE5), thus preventing the degradation of cyclic guanosine monophosphate (cGMP) in the muscle and augmenting the vasodilatory effects of NO. Therefore, by inhibiting PDE5, the tissue remains relaxed and more blood can circulate through. It has been used previously in a vaginal form with no observed side effects, and it enhances endometrial blood flow. A double-blind, randomized, controlled trial comparing vaginal preparation of sildenafil citrate (100 mg single dose) to a placebo in 62 PD patients at the time of painful menstruation was conducted. The primary outcome was total pain relief over 4 consecutive hours (TOPAR4) comparing sildenafil citrate to placebo, where higher TOPAR4 scores represent better pain relief. Secondary outcomes were pain relief as measured by the visual analog scale (VAS) and uterine artery pulsatility index (PI). Subjects were recruited from December 2007 to January 2011. The trial was stopped due to closeout of the funding for the study. Participants were women in good health, were aged 18-35 years and suffered from moderate to severe PD. They were randomized to either vaginal placebo or 100 mg vaginal sildenafil citrate in a 1:1 ratio using random permuted blocks having a block size of 4. At baseline and 1, 2, 3, and 4 h post-treatment, patients were asked to provide assessment of their degree of pain using two scales: (i) pain on the 5-level ordinal scale used for TOPAR4 calculation and (ii) pain level on the VAS. The study ended 4 h after treatment initiation. Twenty-five subjects completed the study. Using the TOPAR4 score, the sildenafil citrate group had significantly better pain relief compared with the placebo group [mean (SD): 11.9 (3.2) versus 6.4 (2.1), respectively; difference in means = 5.3; 95% CI: (2.9,7.6); P < 0.001)]. On the VAS, sildenafil citrate provided better pain relief than placebo at each time point. At the 2-h time point, the PI was significantly lower in the sildenafil citrate group compared with the placebo group [mean (SD): 1.6 (0.6) versus 2.3 (0.5), respectively; difference in means = -0.7; 95% CI: (-1.2, -0.1); P = 0.01)]. Since we did not meet our sample size due to the loss of funding and could not confirm our primary hypothesis, larger studies of longer duration, likely multi-center, are needed to confirm the findings from this study. A number of medications have been investigated to improve the treatment options for PD, but most have proven unsuccessful or to have an unfavorable risk/benefit ratio. Since PD is a condition that most women suffer from and seek treatment for at some point in their lives, our study offers hope that vaginal sildenafil citrate is a safe and effective option for patients who do not desire or are unresponsive to treatments now available on the market. Funding for this study was provided by National Institutes of Health (NIH) grants RO3 TW007438 and K24 HD01476. The authors report no relevant conflicts of interest. NCT00123162 (Clinical trials.gov).
    Human Reproduction 08/2013; · 4.67 Impact Factor
  • Richard S Legro
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    ABSTRACT: In this Views and Reviews section we explore the ontogeny of polycystic ovary syndrome (PCOS) from in utero through puberty linking together, where possible, basic and clinical scientists to explore the implications of basic research for our clinical understanding of the syndrome.
    Fertility and sterility 07/2013; 100(1):1. · 3.97 Impact Factor
  • Richard S Legro
    Seminars in Reproductive Medicine 07/2013; 31(4):233-4. · 3.21 Impact Factor

Publication Stats

8k Citations
1,140.72 Total Impact Points

Institutions

  • 2013–2014
    • Heilongjiang University of Chinese Medicine
      Charbin, Heilongjiang Sheng, China
  • 1998–2014
    • Pennsylvania State University
      University Park, Maryland, United States
  • 1997–2014
    • Penn State Hershey Medical Center and Penn State College of Medicine
      • • Obstetrics and Gynecology
      • • Urology
      • • Cellular and Molecular Physiology
      • • Department of Health Evaluation Sciences
      Hershey, Pennsylvania, United States
  • 2012
    • Carolinas Medical Center University
      Charlotte, North Carolina, United States
  • 2011–2012
    • Wayne State University
      • Department of Obstetrics and Gynecology
      Detroit, MI, United States
    • University of Colorado
      • Department of Obstetrics and Gynecology
      Denver, CO, United States
    • State University of New York Upstate Medical University
      • Department of Urology
      Syracuse, NY, United States
    • University of Missouri
      • Department of Obstetrics, Gynecology and Women's Health
      Columbia, MO, United States
    • University of North Carolina at Chapel Hill
      • Department of Obstetrics and Gynecology
      Chapel Hill, NC, United States
    • University of Vermont
      Burlington, Vermont, United States
    • Lehigh Valley Health Network
      Allentown, Pennsylvania, United States
  • 2008–2012
    • Meharry Medical College
      • Department of Obstetrics and Gynecology
      Nashville, TN, United States
    • Stanford Medicine
      Stanford, California, United States
  • 2003–2012
    • University of Alabama at Birmingham
      • Department of Obstetrics and Gynecology
      Birmingham, Alabama, United States
  • 2009–2011
    • Virginia Commonwealth University
      • • Division of Endocrinology and Metabolism
      • • Department of Obstetrics and Gynecology
      Richmond, VA, United States
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
    • Alpert Medical School - Brown University
      • Department of Obstetrics and Gynecology
      Providence, RI, United States
    • Cedars-Sinai Medical Center
      Los Angeles, California, United States
  • 1999–2011
    • Hospital of the University of Pennsylvania
      • Department of Genetics
      Philadelphia, Pennsylvania, United States
  • 2010
    • University of Bologna
      • Division of Endocrinology
      Bologna, Emilia-Romagna, Italy
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 2002–2009
    • Northwestern University
      • • Division of Endocrinology, Metabolism and Molecular Medicine
      • • Feinberg School of Medicine
      • • Department of Medicine
      Evanston, IL, United States
    • Boston Children's Hospital
      • Division of Endocrinology
      Boston, MA, United States
    • Brigham and Women's Hospital
      • Division of Women’s Health
      Boston, MA, United States
  • 2007–2008
    • Rutgers New Jersey Medical School
      • Department of Obstetrics, Gynecology and Women's Health
      Newark, NJ, United States
  • 2000–2008
    • University of California, Los Angeles
      • Department of Obstetrics and Gynecology
      Los Angeles, California, United States
    • University of Pennsylvania
      • Department of Genetics
      Philadelphia, PA, United States
  • 2006
    • National and Kapodistrian University of Athens
      • Department of Medicine
      Athens, Attiki, Greece
    • University of Chicago
      • Department of Medicine
      Chicago, IL, United States
    • University of Pittsburgh
      • Department of Obstetrics, Gynecology and Reproductive Sciences
      Pittsburgh, PA, United States
  • 2005
    • Duke University Medical Center
      • Department of Obstetrics and Gynecology
      Durham, NC, United States
    • The University of Chicago Medical Center
      • Department of Medicine
      Chicago, IL, United States
  • 2000–2002
    • West Georgia Obstetrics and Gynecology
      Georgetown, Georgia, United States
  • 1992–2000
    • University of Southern California
      • Department of Obstetrics and Gynecology
      Los Angeles, CA, United States