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Ribeirão Preto, Brazil

Gleicher N.,Center for Human Reproduction | Gleicher N.,Foundation Medicine
Reproductive BioMedicine Online | Year: 2013

It has been known for decades that nulliparity is associated with an increased risk for certain reproductive malignancies, including breast, ovarian and uterine cancers. A recent commentary in The Lancet summarized the available evidence based on data in nulliparous women and concluded that the risk of nulliparity was related to the increased number of ovulatory cycles, and so might be preventable by utilization of oral contraceptives. That communication described significant differences in age-dependent cancer mortality in nulliparous nuns, as well as in parous controls, between breast, ovarian and uterine cancers. Moreover, the steep inclines in cancer mortality in nuns are only observed decades after the menopause. Taken together, these observations make it appear unlikely that the number of ovulations is associated aetiologically with increased cancer risks in nulliparous nuns. Here are postulated other possible primary mechanisms that could be responsible for the reported age-related increase in cancer risks in nulliparous women, such as nuns, and conclude that a better understanding of such mechanisms may offer important new insights into tumour initiation in general. © 2013, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Gleicher N.,Center for Human Reproduction | Gleicher N.,Foundation Medicine | Elkayam U.,University of Southern California
Autoimmunity Reviews | Year: 2013

Offspring of women with anti-SSA/Ro-SSB/La antibodies are believed to be at risk for congenital heart block (CHB). Whether this risk can be reduced, and what constitutes standard of care treatment is, however, unclear. The objective of this review therefore was to determine whether currently proposed standard of care treatments to avoid CHB in offspring of mothers at risk are evidence-based. To do so, we conducted a review of the literature under appropriate keywords and phrases in Medline/PubMed and Google Scholar for the years 2000-2013. Reference lists were further reviewed, and relevant manuscripts were pulled. We also reviewed www.clinicaltrials.gov for registered studies. In the absence of randomized prospective clinical trials, a meta-analysis was not feasible. We, therefore, reviewed lower evidence level studies individually. Risk of CHB actually appears more closely associated with general autoimmunity than, specifically, with SSA/Ro-SSB/La antibodies. This and other observations raise questions whether CHB is caused by passively transferred maternal autoimmunity, as is currently widely believed. Observational studies suggest the possible effectiveness of intravenous gamma globulin (IV-Ig) and hydroxychloroquine (Plaquenil) in reducing CHB-risk. Evidence for both is, however, inconclusive, and studies are biased in favor of hydroxychloroquine and against IV-Ig. Based on the review of the literature, current evidence of effectiveness for any treatment has to be judged as insufficient. Among the available treatment options, some considerations favor IV-Ig over hydroxychloroquine or, alternatively, suggest treatment with IV-Ig periconceptionally and into early gestation, with hydroxychloroquine added or replacing IV-Ig at approximately 10. weeks gestational age. Benefits for the utilization of steroid drugs are unclear. Since no treatment can be considered as established, prevention of CHB in offspring should be considered experimental, and performed under appropriate study conditions. © 2013 Elsevier B.V.

After appropriate counseling and absent medical contraindications, if a patient desires twins, they should be welcomed. What is surprising to this author is the uncritical acceptance by so many colleagues of the notion that twins are "bad." How far some colleagues are willing to take this concept is best demonstrated by a recent paper from the same Finnish group that initially introduced eSET to the world.21 In this paper the authors, who themselves initially proposed eSET only for favorable patients, now propose eSET for women up to age 44. Can one responsibly suggest to a patient to have an eSET at age 44 because she always can have another child 12 to 18 months later? I don't think so.

Gleicher N.,Center for Human Reproduction | Gleicher N.,Foundation Medicine | Gleicher N.,Yale University
Reproductive BioMedicine Online | Year: 2011

The manuscript in this issue of the journal by Bissonette et al. reports on a new government-sponsored intervention into the practice of IVF within the province of Quebec, Canada, which in the authors' opinion highly successfully reduced twinning rates, while maintaining overall acceptable pregnancy rates. Given the opportunity to comment, their manuscript, in my opinion, only reemphasizes why, despite wide professional support, the concept of single embryo transfer (SET) is: (i) damaging to most infertility patients by reducing pregnancy chances; (ii) does so without compensatory benefits; (iii) impinges on patients' rights to self-determination; (iv) has significant negative impact on IVF-generated birth rates; and (v) thus, demonstrating, once more, that governments should not interfere with the patient-physician relationships. © 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Hershlag A.,Center for Human Reproduction
Journal of pediatric and adolescent gynecology | Year: 2011

Teenage girls who have survived childhood and adolescent cancer are at risk of losing ovarian function as a result of treatment. This iatrogenic complication may compromise their ability to conceive in the future. In addition, the more immediate consequence is interference in the physical, sexual, and psychosocial development of the female adolescent and her ability to "graduate" into young adulthood. This paper lends strong support to meticulous, graduated hormone replacement, mimicking Tanner's stages of pubertal development, to allow smooth transition of adolescent cancer survivors into adulthood.

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