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ABSTRACT: Physicians are involved in negotiations on a daily basis. Interactions with patients, support staff, nurses, fellow physicians, administrators, lawyers, and third parties all can occur within the context of negotiation. This article reviews the basic principles of negotiation and negotiation styles, models, and practical tools.
Seminars in Reproductive Medicine 05/2013; 31(3):215-8. · 3.80 Impact Factor
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Alan H Decherney
Seminars in Reproductive Medicine 05/2013; 31(3):187-8. · 3.80 Impact Factor
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ABSTRACT: For many years, health care delivery in the United States was accomplished through a complicated and evolving series of publicly and privately available insurance programs. In recent years, the increasing cost of health care as well as the relatively large number of individuals without any health care insurance coverage has prompted repeated attempts to modify or overhaul the current health care delivery paradigm. The largest legislative change to this system occurred on March 23, 2010, when President Barack Obama signed into law the Patient Protection and Affordable Care Act (PPACA).The PPACA is a multifaceted and sweeping piece of legislation. The law introduces a myriad number of changes into both public and private health insurance. Understanding the law, its implications, and how to navigate through these changes is essential to provide high-quality health care to patients. Although the law or parts of it are still at risk of being modified either through judicial or political action, it is important to recognize the current aspects of the law to understand any future modifications. Providing health care coverage in the United States is sure to be as it has always been: a constantly changing and evolving set of private and public policies that carry with them significant complexities and challenges. Health care providers must constantly strive to maximize access to and quality of medical care in whatever paradigm evolves in the future.
Seminars in Reproductive Medicine 05/2013; 31(3):189-97. · 3.80 Impact Factor
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ABSTRACT: OBJECTIVE: To estimate whether live birth in single-blastocyst transfers is correlated with the number of sibling supernumerary vitrified blastocysts (embryos not transferred) generated from that same cycle. DESIGN: Retrospective cohort study. SETTING: A large academic assisted reproduction clinic. PATIENT(S): All single-blastocyst transfers in 2010 graded as "good" embryos by Society for Assisted Reproductive Technologies (SART) criteria. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Implantation and live birth. RESULT(S): Of the 655 single-blastocyst transfers that met inclusion criteria, implantation occurred in 65% and live birth in 54% of cycles. In chi-square analysis, patients with supernumerary vitrified blastocysts had a statistically higher implantation rate (65% versus 50%) and live-birth rate (56% versus 41%) when compared with patients without supernumerary blastocysts. Univariate logistic regression demonstrated an increase in implantation (OR 1.09; 95% CI, 1.03-1.15) and live birth (OR 1.06; 95% CI, 1.02-1.09) with increasing number of supernumerary blastocysts. Multivariate logistic regression analysis demonstrated that patient age and the number of supernumerary blastocysts were statistically significantly associated with implantation and live birth. CONCLUSION(S): The number of supernumerary vitrified blastocysts correlated positively with the odds of implantation and live birth in good quality single-blastocyst transfers. Patients with supernumerary blastocysts are good candidates for single-embryo transfer.
Fertility and sterility 02/2013; · 3.97 Impact Factor
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ABSTRACT: OBJECTIVE: Prior studies have validated the ability of the SART embryo scoring system to correlate with outcomes in cleavage stage embryo transfers. However, this scoring system has not been evaluated in blastocyst transfers. The objective of this study was to estimate the correlation between the simplified SART embryo scoring system and ART cycle outcomes in single blastocyst transfers. MATERIALS AND METHODS: All fresh, autologous single blastocyst transfers cycles from a large ART center from 2010 were analyzed. Blastocysts were given a single grade of good, fair, or poor based upon SART criteria which combines the grading of the inner cell mass and trophectoderm. Multiple logistic regression assessed the predictive value of the SART grade on embryo implantation and live birth. RESULTS: Seven hundred seventeen fresh, autologous single blastocyst transfers cycles were included in the analysis. The live birth rate was 52 % and included both elective and non-elective SBT. Chi square analysis showed higher live birth in good grade embryos as compared to fair (p = 0.03) and poor (p = 0.02). Univariate binary logistic regression analysis demonstrated SART embryo grading to be significantly correlated with both implantation and live birth (p < 0.01). This significance persisted when patient age, BMI, and the stage of the blastocyst were controlled for with multiple logistic regression. In five patients with a poor blastocyst score, there were no live births. CONCLUSION: These data demonstrate that the SART embryo scoring system is highly correlated to implantation and live birth in single blastocyst transfers. Patients with a good grade embryo are excellent candidates for a single blastocyst transfer.
Journal of Assisted Reproduction and Genetics 02/2013; · 1.84 Impact Factor
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ABSTRACT: OBJECTIVE: To estimate the effect of the embryo stage, trophectoderm (TE) morphology grade, and inner cell mass (ICM) morphology grade on live birth in single-blastocyst transfers. DESIGN: Retrospective cohort study. SETTING: Large private assisted reproductive technologies (ART) practice. PATIENT(S): Fresh autologous ART cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Live birth. RESULT(S): A total of 694 single-blastocyst transfers met the inclusion criteria. Univariate regression analysis showed embryo stage and TE score to be correlated with implantation and live birth. Live birth rates were 57%, 40%, and 25% for TE grades A, B, and C, respectively. There was no significant association between ICM grade and implantation or live birth. Live birth rates were 53%, 52%, and 0% for ICM grades A, B, and C respectively. Multiple logistic regression analysis showed that only patient age and TE grade were significantly associated with implantation and live birth, whereas ICM grade was not significantly associated with outcome. The TE score had the strongest correlation with live birth. CONCLUSION(S): TE grading, but not ICM grading, significantly correlated with implantation and live birth for single-blastocyst transfers.
Fertility and sterility 01/2013; · 3.97 Impact Factor
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ABSTRACT: STUDY QUESTION: Does follicular flushing during assisted reproductive technologies (ART) improve the number of oocytes retrieved? SUMMARY ANSWER: Follicular flushing during ART does not result in a greater number of oocytes in normal responders. WHAT IS KNOWN ALREADY: Despite limited evidence supporting the use of follicular flushing, it continues to be a common procedure in many ART clinics. Prior studies have provided conflicting results regarding the routine use of flushing during oocyte retrieval. STUDY DESIGN, SIZE, DURATION: Systematic review and meta-analysis of 518 patients who participated in 6 randomized trials over 20 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: Literature searches were conducted to retrieve randomized controlled trials on follicle or ovarian flushing in ART. Databases searched included PubMed, EMBASE, Web of Science and the Cochrane Database of Clinical Trials (CENTRAL). Six trials that included 518 subjects matched the inclusion criteria. Studies included were limited to trials that were published, randomized trials comparing oocyte retrieval with a single-lumen pick-up needle versus follicle flushing after direct aspiration with a multi-channel oocyte pick-up needle in ART patients. MAIN RESULTS AND THE ROLE OF CHANCE: In each of the trials, measures of the oocyte yield (oocytes retrieved divided by follicles aspirated), total oocytes retrieved, fertilization or pregnancy were not different when comparing direct aspiration with follicle flushing. Four trials reported a higher operative time with follicle flushing. Results of the meta-analysis indicated no significant differences in the oocytes retrieved [weighted mean difference: 0.07, 95% confidence interval (CI): -0.13 to 0.29] or the oocyte yield (odds ratio: 1.06, 95% CI: 0.95-1.18) between the non-flushing and flushing groups. LIMITATIONS, REASONS FOR CAUTION: All trials featured an open label design and the majority of patients in this meta-analysis were normal responders. The applications of these results to poor responders, patients undergoing natural cycle ART or minimal stimulation ART should be made with caution. WIDER IMPLICATIONS OF THE FINDINGS: Follicle flushing does not improve ART outcomes in normal-responding patients and should not be performed. This meta-analysis should solidify this recommendation as it includes the largest trial published on the subject and is consistent with a recently published Cochrane review. STUDY FUNDING/COMPETING INTEREST(S): This work was supported, in part, by the Program in Reproductive and Adult Endocrinology, NICHD, NIH, Bethesda, MD. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER: N/A.
Human Reproduction 05/2012; 27(8):2373-9. · 4.47 Impact Factor
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ABSTRACT: To evaluate the effect of recombinant LH in assisted reproduction technology (ART) cycles in patients of advanced reproductive age.
A systematic review and meta-analysis.
Published randomized controlled clinical trials comparing recombinant LH plus recombinant FSH versus recombinant FSH only in patients of advanced reproductive age.
Patients 35 years and older undergoing assisted reproduction.
Recombinant LH plus recombinant FSH controlled ovarian hyperstimulation (COH) versus recombinant FSH stimulation only in assisted reproduction cycles.
Implantation and clinical pregnancy.
Seven trials were identified that met inclusion criteria and comprised 902 assisted reproduction technology cycles. No differences in serum E(2) on the day of hCG administration were reported in any trials. Two trials reported lower oocyte yield and one trial reported lower metaphase II oocyte yield in the recombinant LH-supplemented group. One trial reported higher fertilization rates in the recombinant LH-supplemented group. In a fixed effect model, implantation was higher in the recombinant LH-supplemented group (odds ratio 1.36, 95% confidence interval 1.05-1.78). Similarly, clinical pregnancy was increased in the recombinant LH-supplemented group (odds ratio 1.37, 95% confidence interval 1.03-1.83).
The addition of recombinant LH to ART cycles may improve implantation and clinical pregnancy in patients of advanced reproductive age.
Fertility and sterility 02/2012; 97(5):1108-14.e1. · 3.97 Impact Factor
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01/2012: pages 574-581; , ISBN: 978-0071439008
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Obstetrics and Gynecology 01/2012; 120(1):197-206. · 4.73 Impact Factor
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ABSTRACT: To describe the prevalence of "genuine" empty follicle syndrome (EFS) and "false" EFS at assisted reproductive technology (ART).
Retrospective cohort.
Large private fertility center.
A total of 12,359 patients who underwent ART between 2004 and 2009.
None.
The failure to recover an oocyte during oocyte retrieval at ART, with and without a detectable serum β-hCG on the day of retrieval.
Two cases of genuine EFS and nine cases of false EFS were identified in the cohort examined. The prevalence of genuine EFS was 0.016%, and the prevalence of false EFS was 0.072%. Only two out of 11 cases of EFS were considered genuine.
Genuine EFS is a rare occurrence. Because this syndrome tends to recur with dismal pregnancy rates at ART, continued identification and further investigation of the syndrome are needed.
Fertility and sterility 12/2011; 96(6):1375-7. · 3.97 Impact Factor
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ABSTRACT: To review recent data regarding subtle, but widespread, epigenetic alterations in phenotypically normal offspring conceived by assisted reproductive technologies (ART) compared with offspring conceived in vivo.
A PubMed computer search was performed to identify relevant articles.
Research institution.
Not applicable.
None.
Not applicable.
Studies in animals indicate that in vitro culture may be associated with widespread alterations in imprinted genes compared with in vivo-conceived offspring. Recently, studies in humans have likewise demonstrated widespread changes in DNA methylation, including genes linked to adipocyte development, insulin signaling, and obesity in offspring conceived by ART compared with in vivo-conceived children. Changes in multiple imprinted genes after ART also were noted in additional studies, which suggested that the diagnosis of infertility may explain the differences between in vivo-conceived and ART offspring.
These data suggest that ART is associated with widespread epigenetic modifications in phenotypically normal children, and that these modifications may increase the risk of adverse cardiometabolic outcomes. Further research is needed to elucidate the possible relationship between ART, genome-wide alterations in imprinted genes, and their potential relevance to subtle cardiometabolic consequences reported in ART offspring.
Fertility and sterility 12/2011; 96(6):1306-11. · 3.97 Impact Factor
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ABSTRACT: To determine whether a mandatory single-blastocyst transfer (mSBT) algorithm reduced multiple gestation rates without sacrificing clinical pregnancy rates.
Retrospective review.
U.S. university-based assisted reproductive technology (ART) program.
All women younger than 38 years undergoing their first ART cycle from 2009 to 2010 with ≥4 high-grade embryos on day 3 after oocyte retrieval (patients from 2009 were the "before" group, and patients completing ART under the mSBT policy in 2010 were the "after" group).
mSBT algorithm.
Multiple gestation and clinical pregnancy rates.
Of the qualified patients, 136 women met inclusion criteria (62 from 2009, 74 from 2010). The baseline demographics were similar between the groups. Statistically significantly fewer blastocysts were transferred per patient in 2010 compared with 2009 (1.5 vs. 1.9). The clinical pregnancy rates before (67.7%) or after (63.5%) the mSBT policy were not statistically significantly different. Multiple gestation rates were statistically significantly reduced, from 43.8% (2009) to 14.6% (2010) after the mSBT policy was instituted. More patients from 2010 had ≥1 blastocyst cryopreserved compared with 2009 (52.9% vs. 30.6%).
A novel single-blastocyst transfer algorithm reduced multiple gestation rates and improved cryopreservation rates without compromising clinical pregnancy rates in good-prognosis patients.
Fertility and sterility 07/2011; 96(3):580-4. · 3.97 Impact Factor
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ABSTRACT: In vitro fertilization has provided a unique window into the metabolic processes that drive embryonic growth and development from a fertilized ovum to a competent blastocyst. Post-fertilization development is dependent upon a dramatic reshuffling of the parental genomes during meiosis, as well as epigenetic changes that provide a new and autonomous set of instructions to guide cellular differentiation both in the embryo and beyond. Although early literature focused simply on the substrates and culture conditions required for progress through embryonic development, more recent insights lead us to suggest that the surrounding environment can alter the epigenome, which can, in turn, impact upon embryonic metabolism and developmental competence.
Trends in Endocrinology and Metabolism 07/2011; 22(10):412-20. · 8.11 Impact Factor
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Alan H DeCherney
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ABSTRACT: As I slowly close the door on this part of my career--but keeping the peephole open--I feel that the timing is perfect, that it's time for a new generation to have their influence.
Fertility and sterility 06/2011; 95(7):2180-1. · 3.97 Impact Factor
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ABSTRACT: To define whether anti-Müllerian hormone (AMH) may be a marker of acute cyclophosphamide (CTX)-induced germ cell destruction in mice pretreated with the GnRH antagonist, cetrorelix.
Controlled, experimental study.
Research laboratory in a federal research facility.
Balb/c female mice (6 weeks old).
Mice were treated with GnRH antagonist (cetrorelix) or saline for 15 days followed by 75 mg/kg or 100 mg/kg of CTX or saline control on day 9.
Number of primordial follicles (PMF), DNA damage, AMH protein expression, and AMH serum levels.
Ovaries in mice pretreated with cetrorelix had significantly more PMFs and reduced DNA damage compared with those exposed to CTX alone. Immunohistochemical staining for AMH expression and serum AMH levels did not differ significantly between treatment groups.
Cetrorelix protected PMFs and reduced DNA damage in follicles of mice treated with CTX, but AMH levels in tissue and serum did not correlate with germ cell destruction. Further research is needed to determine the mechanism responsible for the protective effects on PMF counts observed with cetrorelix.
Fertility and sterility 05/2011; 96(1):180-186.e2. · 3.97 Impact Factor
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The Journal of clinical endocrinology and metabolism 05/2010; 95(5):2058-60. · 6.50 Impact Factor
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ABSTRACT: To review published methods for transcervical collection of fetal cells and to assess the potential of this approach for application in prenatal diagnosis.
Retrospective analysis of efforts at prenatal diagnosis with trophoblast cells shed into the lower uterine pole that accumulate within the cervical mucus at the level of the internal os.
Minimally invasive techniques that include cervical mucus aspiration, cervical swabbing, and cervical or intrauterine lavage can be used to retrieve trophoblast cells during the first trimester for diagnostic purposes, including for prenatal genetic analysis. Fetal cells have been identified in these specimens with success rates that vary from 40% to 90%. The disparity in reported success rates can be a function of gestational age, collection method, operator variability, detection sensitivity, or pregnancy status. Molecular approaches have been devised to determine fetal sex and identify aneuploidies. Antibody markers have proven useful to select trophoblast cells for genetic analysis and to demonstrate that the abundance of recoverable fetal cells diminishes in abnormal gestations, such as in ectopic pregnancy or blighted ovum.
Transcervical collection of fetal cells offers several avenues for prenatal diagnosis that with further refinement could one day provide valuable information for the management of ongoing pregnancies.
Fertility and sterility 04/2010; 93(6):1725-30. · 3.97 Impact Factor
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01/2010: pages 1-10; , ISBN: 0521509769
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ABSTRACT: Extracellular hyperosmolarity, or osmotic stress, generally caused by differences in salt and macromolecule concentrations across the plasma membrane, occurs in lymphoid organs and at inflammatory sites. The response of immune cells to osmotic stress is regulated by nuclear factor of activated T cells 5 (NFAT5), a transcription factor that induces the expression of hyperosmolarity-responsive genes and stimulates cytokine production. We report that the guanine nucleotide exchange factor (GEF) Brx [also known as protein kinase A-anchoring protein 13 (AKAP13)] is essential for the expression of nfat5 in response to osmotic stress, thus transmitting the extracellular hyperosmolarity signal and enabling differentiation of splenic B cells and production of immunoglobulin. This process required the activity of p38 mitogen-activated protein kinase (MAPK) and NFAT5 and involved a physical interaction between Brx and c-Jun N-terminal kinase (JNK)-interacting protein 4 (JIP4), a scaffold molecule specific to activation of the p38 MAPK cascade. Our results indicate that Brx integrates the responses of immune cells to osmotic stress and inflammation by elevating intracellular osmolarity and stimulating the production of cytokines.
Science Signaling 02/2009; 2(57):ra5. · 7.50 Impact Factor
