In vitro fertilization: investigating the risk of ischemic placental disease and novel methods for quantifying success

The use of in vitro fertilization (IVF) has increased over the last several decades in the United States. The influence of IVF on pregnancy complications is not well understood and current methods for quantifying overall success of IVF procedures may be flawed. The aims of this dissertation were to evaluate the extent to which various aspects of IVF treatment are associated with the risk of ischemic placental disease (IPD, defined as preeclampsia, placental abruption, or small for gestational age infant) and to apply novel methods for measuring live birth after IVF success. We used data from a large tertiary care center and an affiliated infertility treatment center. In Study 1, we found an increased risk of IPD in pregnancies conceived by donor and autologous IVF compared with non-IVF pregnancies (risk ratio (RR): 2.5, 95% confidence interval (CI): 2.1-3.1 and RR 1.8, 95% CI: 1.7-2.0, respectively), and the risks were consistently higher for donor IVF pregnancies than autologous IVF pregnancies. In Study 2, we found an increased risk of IPD in pregnancies in the highest and middle tertiles of serum progesterone levels among autologous IVF cycles compared with the lowest tertile (RR 2.0, 95% CI 1.3-3.3 and RR 1.6, 95% CI 0.6-2.6, respectively), although the results were not imprecise. In study 3, we used inverse probability-of-censoring weighting (IPCW) to address a potential violation of the uninformative censoring assumption of the Kaplan-Meier (KM) survival analysis to calculate the cumulative incidence of live birth after multiple cycles of IVF. The two approaches were similar (cumulative incidence of live birth 69.1% using IPCW and 73.9% using KM). However, additional information is needed to calculate better IPCW weights, which may be more important when investigating exposure/outcome relationships. Our results suggest that women undergoing IVF, particularly donor IVF, might benefit from counseling about the increased risk of IPD. Our results also suggest that IPCW methods offer an improvement over other methods for validly estimating cumulative incidence of live birth across multiple IVF cycles. The routine application of IPCW methods to estimating incidence of live birth in epidemiologic studies will allow patients to make better-informed decisions about whether to pursue treatment

An assessment of attitudes toward gender inequitable sexual and reproductive health norms in South Sudan: a community-based participatory research approach

Background: Communities in South Sudan have endured decades of conflict. Protracted conflict exacerbated reproductive health disparities and gender inequities. This study, conducted prior to the country’s 2011 independence, aimed to assess attitudes toward gender inequitable norms related to sexual relationships and reproductive health and the effects of sex, age, and education on these attitudes. Methods: Applying a community-based participatory research approach and quota sampling, 680 adult male and female respondents were interviewed in seven sites within South Sudan in 2009–2011. The verbally administered survey assessed attitudes using the Gender Equitable Men scale. Data were stratified by sex, age (≤35 years and >35 years), and education. Results: Of 680 respondents, 352 were female, 326 were male, and 2 did not indicate their sex. The majority of women (77%) and men (74%) agreed “a man needs other women, even if things with his wife are fine”. Respondents who reported no education (60%) were more likely than those who reported any education (45%) to agree “if a woman is married, she should have sex with her husband whenever he wants to, even if she doesn’t want to” (p = 0.002). The majority of women (74%) and men (73%) agreed “it is a woman’s responsibility to avoid getting pregnant”. Respondents who reported no education (81%) were more likely than those who reported any education (72%) to agree with this statement (p = 0.04). When asked about condom use, the majority of respondents, across both sexes and both age groups, agreed “it would be outrageous for a wife to ask her husband to use a condom” and “women who carry condoms are easy”. There were no statistically significant differences between the two age groups for any of the assessed gender inequitable norms. Conclusion: The study reveals differences in attitudes toward gender inequitable sexual and reproductive health norms among those surveyed in South Sudan when stratified by sex and education. As a new nation seeks to strengthen its health system, these data can inform sexual and reproductive health policies and programming in South Sudan

Do Symptoms of Voiding Dysfunction Predict Urinary Retention?

OBJECTIVES: We assessed the relationship between symptoms of voiding dysfunction and elevated post void urinary residual (PVR). METHODS: Cross-sectional study of women presenting for initial evaluation from February through July 2011. Charts were reviewed for demographics, voiding dysfunction symptoms, and examination findings. Urinary retention was defined as PVR ≥100cc. Data are presented as median (interquartile range) or proportion; test characteristics are reported with 95% confidence intervals. RESULTS: Of 641 eligible women, 57 (8.9%) had urinary retention. Of these, 32 (56.1%) had at least one symptom of voiding dysfunction, most commonly sensation of incomplete emptying (30.1%). Sensitivity and positive predictive values of voiding dysfunction symptoms were low. Of 254 women reporting voiding symptoms, most (87.5%) had PVR<100 and were significantly more likely to have other pelvic floor symptoms and findings. CONCLUSIONS: Patient symptoms do not predict urinary retention. PVR should be measured and other causes of voiding dysfunction symptoms should be considered

Screening for Pain in Pediatric Brain Tumor Survivors Using the Pain Thermometer

Numerous instruments have been developed to measure pain within various populations; however, there remains limited understanding of how these tools are applicable to childhood cancer survivors. This study compared a single-item screening measure, the Pain Thermometer (PT), with a more in-depth measure, the Brief Pain Survey (BPS), in a cohort of childhood brain tumor survivors. Ninety-nine survivors (aged 13-32 years) with a median time from diagnosis of 9.9 years (range = 2-18 years) completed the 2 instruments. Thirty-seven survivors (37.4%) were identified on the BPS as having clinically significant pain, but the PT was not found to be an accurate tool for identifying these pain cases. Application of receiver operating characteristic curve analysis of PT ratings against BPS criterion indicated overall concordance between measures. No cutoff score on the PT were identified that resulted in acceptable sensitivity, meaning pain cases identified on the BPS would be missed on the PT. Findings suggest that a multi-item screening measure may better identify clinically significant pain in childhood brain tumor survivors compared with a 1-item screening measure alone. </jats:p

Characterization of Pain After Inside-Out Transobturator Midurethral Sling

OBJECTIVES: This study aimed to evaluate the prevalence, severity, duration, and location of pain after transobturator midurethral sling. METHODS: We evaluated patients who underwent inside-out transobturator sling from March 2011 through February 2013. Presence of pelvic girdle pain, its severity, and location were documented preoperatively and at 2- and 6-week postoperative visits. Pain severity was measured on a scale of 1 to 10, with 10 being the “worst imaginable” pain. RESULTS: Of the 130 women analyzed, the median age was 50.0 years (interquartile range, 44.0–62.0). Thirty-nine percent of women reported preoperative pain, mostly mild with a median score of 1.0 (1.0–5.0). The most common sites of postoperative-onset pain were the lateral leg, medial leg, groin, and low back. Women reporting preoperative pain were not more likely to report postoperative-onset pain than women without preoperative pain (P = 0.42). Twelve percent of women at 2 weeks and 0.8% at 6 weeks reported severe postoperative-onset pain. Women reporting postoperative-onset pain were equally likely to be satisfied with the procedure as those without pain at 2 (P = 0.76) and 6 (P = 0.74) weeks. CONCLUSIONS: Women undergoing transobturator sling commonly report preoperative pain. An expected postoperative increase in pain generally resolved by the sixth postoperative week. The lateral leg was the most common site of pain. Postoperative-onset pain was not associated with decreased patient satisfaction