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ObjectiveTo assess attitudes and factors that influence public opinion in the general US population toward insurance coverage and provision of infertility care to lower income patients.DesignCross-sectional survey.SettingOnline.PatientsA nationally representative sample of US residents.InterventionsQuestionnaire with multiple choice and open response questions.Main outcome measuresPublic attitudes toward in vitro fertilization and infertility care coverage for lower income patients.ResultsA total of 1,027 (90.2%) participants completed the survey, among whom 620 (60.4%) had private insurance, 275 (26.8%) had Medicare/Medicaid, and 56 (5.5%) were uninsured. The majority (916, 89.2%) did not consider infertility a disease. Over half of the respondents (568, 55.3%) supported private insurance coverage of infertility services, including for in vitro fertilization. Most respondents, 735 (71.6%) believed that the prevalence and psychosocial impact of infertility were equal among the lower and higher income people. The majority of respondents with an opinion (512, 67.6%) believed that doctors should provide infertility treatments regardless of the income level of the patients. Of supporters, 40.1% believed in the right to have a family regardless of income, and 38.2% believed that doctors had a social responsibility to provide infertility services. After adjusting for covariates, age

BackgroundFew studies have examined health literacy and fertility knowledge among women from low income, socio-culturally diverse communities presenting for fertility care in the United States. Our study sought to examine demographic predictors of fertility-related knowledge among infertile women from low and high-resource communities in two major metropolitan centers in the United States.MethodsFertility Knowledge Assessments were administered to women presenting for fertility care at county medical centers serving low-resource, largely immigrant patients and to women from largely affluent populations presenting to comprehensive fertility centers in two cities. The influence of demographic predictors on fertility knowledge was examined through regression analysis.ResultsA total of 143 women were included in our analysis. In the county hospital/low resource clinic (LR, n = 70), the mean age was 32.8 ± 6.1 years vs 35.0 ± 5.0 years in the fee-for-service/high resource clinic (HR, n = 73). Among the LR patients, 74% were immigrants, 71% had an annual income $100,000, and 95% had some college or above. On average, women from HR settings scored 3.0 points higher on the Fertility Knowledge Assessment than their LR counterparts (p

BackgroundInfertility is a prevalent disease of reproductive health that exerts an impact on an estimated 80 million people worldwide. For many, involuntary childlessness becomes a central and preoccupying issue in their lives, the impact of which is exacerbated by lack of access to basic care and treatment. These effects maybe further magnified among immigrant communities, a growing but highly marginalized population that has been shown in other areas of reproductive health to experience worse health outcomes and delays in access to care. To date, few studies have examined the unique medical and sociocultural considerations of infertility among immigrant populations in the United States.MethodsOur study is a cross-sectional analysis of women presenting for infertility evaluation at a county hospital serving a low resource, socioculturally diverse largely immigrant communities in comparison to infertile women from a largely affluent population presenting to a high resource, comprehensive fertility center. We employed surveys to evaluate demographics and socioeconomic parameters as well as abstracted data from medical records to obtain infertility diagnoses. Multivariate regression analysis was applied to examine impact of sociocultural factors as predictors of duration of untreated infertility disease burden experienced by patients.ResultsEighty-seven women were included in our analysis. In the county hospital/low resource clinic (LR), the mean age was 32.9 ± 4.9 vs 36.4 ± 6.3 years in the fee-for-service/high resource clinic (HR). The mean reported duration of infertility in LR and HR patients was 3.4 ± 3.0 vs 2.3 ± 1.5 years. 70% of LR patients were monolingual non-English speakers vs 5.4% of HR patients. 59% of LR patients reported an annual household income of less than $25,000 and 70% did not have a college degree. 81.1% of HR patients reported an income of higher than $100,000, and 81.1% had completed college or graduate school. The most common infertility diagnosis in the LR was anovulation (38%) and tubal factor (28%) compared to diminished ovarian reserve (37.8%) and male factor (51.4%) in the HR. After controlling for age at the initiation of pregnancy attempt, lower education level, lower income, and immigrant status were significantly correlated with a longer duration of infertility.ConclusionsWomen presenting for infertility care to a low resource county medical center represent immigrant communities and are generally of younger age, but with a longer duration of infertility. This study identifies lower educational level, income, and immigrant status as barriers in access to care.

ObjectiveAdenomyosis is a clinical disorder defined by the presence of endometrial glands and stroma within the myometrium, the pathogenesis of which is poorly understood. We postulate that dysregulation of genes and pathways in eutopic endometrium may predispose to ectopic implantation. No study, to our knowledge, has examined the global transcriptome of isolated eutopic endometrium from women with clinically significant adenomyosis.DesignLaboratory-based study with full institutional review board approval and consents.Material and methodsEndometrial sampling was performed on hysterectomy specimens (proliferative phase) from symptomatic women with pathologically confirmed diffuse adenomyosis (n = 3). Controls (n = 5) were normo-ovulatory patients without adenomyosis. All patients were free from leiomyoma, endometriosis, and hormonal exposures. Isolated purified total RNA was subjected to microarray analysis using the Gene 1.0 ST Affymetrix platform. Data were analyzed with GeneSpring and Ingenuity Pathway analysis. Validation of several genes was undertaken by quantitative real-time reverse transcriptase polymerase chain reaction.ResultsComparison of transcriptomes of proliferative endometrium from women with and without adenomyosis revealed 140 upregulated and 884 downregulated genes in samples from women with adenomyosis compared to controls. Highly differentially expressed genes include those involved in regulation of apoptosis, steroid hormone responsiveness, and proteins involved in extracellular matrix remodeling as well as microRNAs of unknown significance. Affected canonical pathways included eukaryotic initiation factor 2 signaling, oxidative phosphorylation, mitochondrial dysfunction, estrogen receptor signaling, and mammalian target of rapamycin signaling.ConclusionThe eutopic endometrium in patients with adenomyosis has fundamental abnormalities that may predispose to invasion and survival beyond the myometrial interface.

Abstract Background The extensive medicinal plant knowledge of Amazonian tribal peoples is widely recognized in the scientific literature and celebrated in popular lore. Despite this broad interest, the ethnomedical systems and knowledge of disease which guide indigenous utilization of botanical diversity for healing remain poorly characterized and understood. No study, to our knowledge, has attempted to directly examine patterns of actual disease recognition and treatment by healers of an Amazonian indigenous culture. Methods The establishment of traditional medicine clinics, operated and directed by elder tribal shamans in two remote Trio villages of the Suriname rainforest, presented a unique investigational opportunity. Quantitative analysis of clinic records from both villages permitted examination of diseases treated over a continuous period of four years. Cross-cultural comparative translations were articulated of recorded disease conditions through ethnographic interviews of elder Trio shamans and a comprehensive atlas of indigenous anatomical nomenclature was developed. Results 20,337 patient visits within the period 2000 to 2004 were analyzed. 75 disease conditions and 127 anatomical terms are presented. Trio concepts of disease and medical practices are broadly examined within the present and historical state of their culture. Conclusion The findings of this investigation support the presence of a comprehensive and highly formalized ethnomedical institution within Trio culture with attendant health policy and conservation implications.

Objective To report on outcomes from a university-based low-cost and low-complexity IVF program using mild stimulation approaches and simplified protocols to provide basic access to ART to a socioculturally diverse low-income urban population. Design Retrospective cohort study. Setting Academic infertility center. Patient(s) Sixty-five infertile couples were enrolled from a county hospital serving a low-resource largely immigrant population. Interventions(s) Patients were nonrandomly allocated to one of four mild stimulation protocols: clomiphene/letrozole alone, two clomiphene/letrozole–based protocols involving sequential or flare addition of low-dose gonadotropins, and low-dose gonadotropins alone. Clinical fellows managed all aspects of cycle preparation, monitoring, oocyte retrieval, and embryo transfer under an attending preceptor. Retrieval was undertaken without administration of deep anesthesia, and laboratory interventions were minimized. All embryo transfers were performed at the cleavage stage. Main Outcome Measure(s) Sociomedical demographics, treatment response, and pregnancy outcomes were recorded. Result(s) From August 2010 to June 2016, 65 patients initiated 161 stimulation IVF cycles, which resulted in 107 retrievals, 91 fresh embryo transfers, and 40 frozen embryo transfer cycles. The mean age of patients was 33.3 years, and mean reported duration of infertility was 5.3 years; 33.5% (54/161) of cycles were cancelled before oocyte retrieval, with 13% due to premature ovulation. Overall, cumulative live birth rates per retrieval including subsequent use of frozen embryos was 29.0%; 44.6% (29/65) of patients enrolled in the program achieved pregnancy. Conclusion(s) Use of mild stimulation protocols, simplified monitoring, and minimized laboratory handling procedures enabled access to care in a low-resource socioculturally diverse infertile population. [ABSTRACT FROM AUTHOR]

Objective: To report 2 cases of adverse pregnancy outcomes due to delayed diagnosis of urogenital tuberculosis and propose a screening algorithm for patients from tuberculosis-endemic countries., Design: Case report., Setting: Academic medical center., Patients: Two patients with delayed diagnosis of urogenital tuberculosis leading to a fetal loss and a preterm delivery of an infant with congenital tuberculosis., Interventions: Endometrial biopsy, acid-fast bacilli culture of urine, and endometrium., Main Outcome Measures: Pregnancy outcomes., Results: Fetal loss at 19 weeks and preterm delivery of an infant with congenital tuberculosis before urogenital tuberculosis treatment., Conclusions: Patients who are at risk of urogenital tuberculosis should be screened in advance of infertility treatment to potentially prevent adverse pregnancy outcomes., (© 2022 The Author(s).)

Background: Given the concurrence of medical residency and fellowship training with typical childbearing years, trainees often must make difficult decisions regarding family planning, requiring the support of their residency and fellowship program directors (PDs) to guide them. Objective: Our hypothesis was that PDs have knowledge gaps and varying levels of support in terms of their trainees' fertility, and the goal of our study was to assess the knowledge and support of residency and fellowship PDs in the United States toward trainees' reproductive needs. Methods: Cross-sectional survey distributed to all residency and fellowship PDs providing contact information through the Accreditation Council for Graduate Medical Education website in August 2019. Results: Of 299 respondents, the most common lengths of leave reported were 6-8 weeks of maternity leave and under 2 weeks of paternity leave. A total of 57.2% did not know their program's insurance for infertility treatment, and 68.6% did not know fertility preservation coverage. A total of 52.2% of PDs were unaware of if their trainees faced infertility. PDs supported residents' needs through moral support (68.2%) and time off for appointments (65.2%). Similarly, most PDs (66.2%) never had a trainee express interest in fertility preservation to them but offered moral support (59.2%) and time off (48.5%). Respondents felt it was important to increase resources for trainees by increasing their awareness of needs (47.5%) and establishing reproduction-related policies (34.1%). Conclusion: The study found variations regarding PDs' knowledge and support levels for trainees' fertility needs. Most were unaware of their trainees' fertility needs, and many PDs felt it would be important to improve resources by increasing personal awareness and creating policies for support to promote reproductive health equity for trainees., Competing Interests: No competing financial interests exist., (© Megan Huynh et al., 2021; Published by Mary Ann Liebert, Inc.)

Objective: To survey practice patterns designed to increase access to infertility care and evaluate the exposure of obstetrics and gynecology residents to infertility care for the underserved., Design: Cross-sectional., Setting: Reproductive endocrinology and infertility (REI) practices associated with Accreditation Council for Graduate Medical Education-accredited obstetrics and gynecology residency training programs., Patients: None., Interventions: Questionnaire survey., Main Outcome Measures: Presence of clinical programs designed to improve access to REI care, resident involvement in such programs, and perceived barriers to expanding access to care., Results: Clinical initiatives to expand access included discounted infertility services (38%, n = 30), utilization of a low-cost in vitro fertilization (IVF) program (28%, n = 22), and utilization of a resident- and/or fellow-staffed clinic to provide infertility care (39%, n = 31). The most commonly discounted infertility services were IVF (73%, n = 22), clinical consultation (70%, n = 21), and intrauterine insemination (53%, n = 16). The provision of discounted prices was correlated with the increasing practice size (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.23-4.24) and number of assisted reproductive technology cycles performed annually (OR, 3.65; 95% CI, 1.48-9.02). Academic REI practices (OR, 3.6; 95% CI, 0.98-13.25) were more likely to have a low-cost IVF program. Less than half of obstetrics and gynecology residency programs (39%, n = 31) had an associated REI clinic in which obstetrics and gynecology residents provide direct infertility care to the medically underserved. Frequency and services offered in trainee clinics varied. Multiple barriers to expanding access to care were reported., Conclusions: Reproductive endocrinology and infertility practices associated with obstetrics and gynecology residency programs utilize a diverse range of approaches to provide infertility care to the underserved in the backdrop of considerable challenges and barriers, but significant gaps persist., (© 2021 The Author(s).)

Objective: To provide a review of the current literature surrounding barriers to reproductive medicine and present examples of how resident and fellow education can be used to overcome these barriers., Design: A review of the relevant literature addressing barriers to reproductive medicine, resident and fellow education, and related materials was completed., Setting: Academic medical institutions., Patients: None., Interventions: None., Main Outcome Measures: Health disparities and barriers in access to care., Results: Of barriers in access to care, 3 were reviewed in detail: cost of health care, racial inequities, and marginalization of immigrant communities. The suggested strategies to mitigate these barriers include the following: reducing racial inequities through improved diversity within reproductive medicine and through antiracism training, developing opportunities for trainees to engage in advocacy, strengthening reproductive endocrinology and infertility clinical exposure and educational curricula in training programs, inclusion of residents and fellows in clinical care, and improving the accessibility of fertility care through implementing approaches to optimize the management of infertility in challenging, resource-constrained settings., Conclusions: Infertility is one of the most prevalent reproductive health diseases, yet profound disparities and inequities in access to care exist today in the United States. Lower-income, minority, and immigrant communities are among those most marginalized. Improved access to care begins with broadened obstetrics and gynecology and reproductive endocrinology and infertility trainee education, which acknowledges the barriers these communities face and provides strategies to help overcome these obstacles to care., (© 2021 The Author(s).)

Objective: To assess attitudes and factors that influence public opinion in the general US population toward insurance coverage and provision of infertility care to lower income patients., Design: Cross-sectional survey., Setting: Online., Patients: A nationally representative sample of US residents., Interventions: Questionnaire with multiple choice and open response questions., Main Outcome Measures: Public attitudes toward in vitro fertilization and infertility care coverage for lower income patients., Results: A total of 1,027 (90.2%) participants completed the survey, among whom 620 (60.4%) had private insurance, 275 (26.8%) had Medicare/Medicaid, and 56 (5.5%) were uninsured. The majority (916, 89.2%) did not consider infertility a disease. Over half of the respondents (568, 55.3%) supported private insurance coverage of infertility services, including for in vitro fertilization. Most respondents, 735 (71.6%) believed that the prevalence and psychosocial impact of infertility were equal among the lower and higher income people. The majority of respondents with an opinion (512, 67.6%) believed that doctors should provide infertility treatments regardless of the income level of the patients. Of supporters, 40.1% believed in the right to have a family regardless of income, and 38.2% believed that doctors had a social responsibility to provide infertility services. After adjusting for covariates, age <45 years, noncollege graduates, desiring more children, believing that infertility was a disease, and residence in the Northeast region remained significant predictors for support of private insurance coverage., Conclusions: Public perception of infertility as a disease is one of the strongest predictors of support for insurance coverage for infertility services, underscoring the need for enhanced advocacy and education in the general public., (© 2021 The Authors.)

Background: Gynecomastia is a disorder of the endocrine system characterized by an abnormal presence of a palpable unilateral or bilateral enlargement and proliferation of glandular ductal benign breast tissue in male individuals. This case discusses the medical implications of an unregulated, indirect exposure to nonformulary, bioidentical hormone replacement therapy in male children., Case: An 8-year-old boy presented with prepubertal gynecomastia secondary to estrogen exposure from maternal use of bioidentical hormonal replacement therapy (the Wiley protocol). We review the literature on prepubertal gynecomastia secondary to exogenous estrogen exposure, evaluation, clinical surveillance of the pubertal development, and relevant short- and long-term implications., Conclusion: Indirect exposure to nonformulary hormonal replacement in our case report was an etiologic factor in the development of prepubertal gynecomastia. This novel estrogen exposure source has important implications in the differential diagnosis of prepubertal gynecomastia and potential adverse effects secondary to precocious hormonal exposure.

Unlabelled: The diagnostic criteria and clinical relevance of the arcuate uterine anomaly have long been debated. Our review critically examines the contemporary and past literature regarding the definition, prevalence, and clinical impact of the arcuate uterine anomaly on reproductive outcomes. To bring a novel perspective to the debate, we examined studies evaluating the clinical significance of the presence of a residual septal stump following surgical resection, which has morphology comparable to that of the arcuate anomaly. The balance of the existing literature does not support an association of the arcuate anomaly to adverse reproductive outcomes. Hysteroscopic resection of arcuate anomaly does not appear to be universally indicated. Treatment decisions should be individualized at clinician discretion for symptomatic patients without otherwise identifiable etiology., Target Audience: General Obstetricians & gynecologists, Reproductive Endocrinology & Infertility Specialists and Radiologists., Learning Objectives: After completion of this article, the reader should be able to distinguish the arcuate uterine anomaly and its diagnosis, demonstrate its clinical significance, and what impact, if any, it may have on reproductive potential. Furthermore, the reader should be able to assess which patient population, if any, might benefit from surgical management of the arcuate anomaly.

Background: The extensive medicinal plant knowledge of Amazonian tribal peoples is widely recognized in the scientific literature and celebrated in popular lore. Despite this broad interest, the ethnomedical systems and knowledge of disease which guide indigenous utilization of botanical diversity for healing remain poorly characterized and understood. No study, to our knowledge, has attempted to directly examine patterns of actual disease recognition and treatment by healers of an Amazonian indigenous culture., Methods: The establishment of traditional medicine clinics, operated and directed by elder tribal shamans in two remote Trio villages of the Suriname rainforest, presented a unique investigational opportunity. Quantitative analysis of clinic records from both villages permitted examination of diseases treated over a continuous period of four years. Cross-cultural comparative translations were articulated of recorded disease conditions through ethnographic interviews of elder Trio shamans and a comprehensive atlas of indigenous anatomical nomenclature was developed., Results: 20,337 patient visits within the period 2000 to 2004 were analyzed. 75 disease conditions and 127 anatomical terms are presented. Trio concepts of disease and medical practices are broadly examined within the present and historical state of their culture., Conclusion: The findings of this investigation support the presence of a comprehensive and highly formalized ethnomedical institution within Trio culture with attendant health policy and conservation implications.

Although intravenous immunoglobulin (IVIg) generally is considered a safe treatment for various autoimmune and inflammatory disorders, rare cases of thrombosis may occur. We describe two patients who experienced thrombotic complications associated with IVIg therapy. A 54-year-old woman with idiopathic thrombocytopenia received IVIg 1 g/kg/day for 2 days. While receiving her infusion on day 2, she had an ischemic stroke with hemiparesis; 3 days later she developed deep vein thrombosis. A 33-year-old woman with Evans' syndrome received IVIg 400 mg/kg/day for 5 days and developed deep vein thrombosis 1 week after therapy was completed; she then received warfarin. Six months later, she received an additional course of IVIg for recurrent hemolytic anemia; 1 day later she died of pulmonary thromboembolism. We suggest that IVIg may promote thrombosis by increasing blood viscosity, activating platelets, or causing vasospasm and should be administered with caution.