Historically antenatal screening was offered primarily to women older than 35.
These mothers were offered amniocentesis, which at that time was the only available option.
Thirty-five was chosen, because at this age, the risk of a fetal congenital abnormality was equal
to the risk of a procedure-related complication due to the amniocentesis--in other words,
the risk/benefit ratio tipped at this age to favor testing.

In reality, because the total number of babies born to women younger than 35 years old is
so much greater than the number born to older women, most babies with congential anomalies are born to women younger than 35. Obviously, amniocentesis,  though it remains the gold-standard diagnostic test,
is not a desireable screening tool for all women.  The procedure, which requires insertion of a needle through
the maternal abdominal wall directly into the fluid surrounding the fetus, is uncomfortable, invasive and is best
delayed until the second trimester. For this reason, clinicians continue to search for reliable alternative methods of
screening for Down's syndrome and other fetal genetic abnormalities.

Presently, the most efficient and widely-used screening test is the "quad" screen.
Made up of a panel of four blood analytes (alpha-fetoprotein[afp], human chorionic gonadotropin[hCG], unconjugated estriol, and inhibin-a), it is accurate, reliable and non-invasive.  The chief disadvantage is that as with the amniocentesis, the "quad" screen must be delayed until the second trimester.  Additionally, results are difficult to interpret in multiple gestations (twins and higher).

Recently, interest has been directed toward  first-trimester screening.  A combination of ultrasound and serum analytes has been implemented as a tool  in some centers. Though the optimal sequence of reporting results to the expectant parents remains controversial, there are definite benefits to having reliable data as early as possible in pregnancy.  Early reassurance will reduce the number of pregnancies put at risk by invasive tests, and will permit maximum options for management in affected pregnancies.

The "nuchal translucency" is a normal fluid fillled space at the back of the fetal neck.  With proper use of ultrasound technique, this space and its overlying skin can be accurately measured in most pregnancies between 10 and 14 weeks gestational age.  Abnormalities in this measurement correlate well with fetal Down's syndrome, other fetal aneuploidies and fetal major cardiac anomalies. Additionally, it is known that pregnancies affected by fetal Down's syndrome are associated with higher levels of free beta-hCG and lower levels of pregnancy-associated plasma protein-a (PAPP-A).  For a given pregnancy with a  combination both of a normal ultrasound study and normal values of beta-hCG/PAPP-A, clinicians can feel comfortable recommending deferral of invasive testing. Alternatively, abnormal values alert clinicians to recommend confirmatory testing with chorionic villus sampling(CVS) or amniocentesis.

Major disadvantages of first-trimester screening include expense, the ultrasound component is technically difficult to perform and must be done by specially trained technicians, and the need for an additional blood test in the second trimester to complete the evaluation. The "nuchal translucency" and PAPP-A/beta-hCG combination does not screen for spina bifida or ventral wall defects, therefore most authorities continue to recommend an alpha-fetoprotein the second trimester. While no single option is ideal for every pregnancy, first-trimester screening with "nuchal translucency" and free beta-hCG/PAPP-A, has definite advantages when early results are desireable.

Urinary incontinence affects 10-70% of women. Including over 200,000 women world-wide. Prevalance increases gradually during young adult life, has a broad peak around middle age and then steadily increases in the elderly. Prevalance in the United States is increasing.  Women are often reticent to volunteer information about symptoms, so prevalance data may under-estimate the true extent of the problem.

Incontinence can be divided into three broad categories.  Urodynamic stress incontinence, (leaking with coughing, sneezing or positional changes) affects 29-75% of symptomatic women.  Urge incontinence, or detrussor instability accounts for 7-33% of patients.  The remainder have mixed incontinence with some component of both types.

Although the multiplicity of symptoms associated with urinary incontinence can severely erode the quality of life, historically, most women have not sought medical care. Possibly because sufferers are embarrassed to report symptoms to their physicians, or are unaware of other treatment options, absorbent products (eg. disposable pads or undergarments) are the most commonly used management method.

The first line of therapy for incontinence sufferers who do seek medical intervention is lifestyle modification.  Often physicians will ask patients to keep a "voiding diary".  Studies have shown that 3-7 days of recording paramenters (such as fluid intake, number and volumes of both voluntary voids and leaks) is sufficient. Recommendations can then be made. Usually recommendations  include reducing caffeine and alcohol, stopping smoking, weight loss, and therapy for chronic cough, timed or prompted voiding, "bladder training", bladder emptying prior to planned activity, etc. These simple changes can reduce or eliminate symptoms in some women. Pelvic muscle rehabilitation with targeted exercise (such as Kegel's) can play a role in improving all three types of incontinence.

For patients who have failed to improve dramatically with first line therapy there are few non-surgical options.  Most of these involve an effort to mechanically obstruct the urethral opening temporarily. Pessaries (vaginal inserts) or urethral bulking agents (collagen injections) are two options. Medications are sometimes helpful, particularly for sufferers of urge or mixed forms of incontinence.  Newer agents have fewer side-effects than older medications which may cause dry mouth, blurred vision, and other untoward effects.

Surgery for incontinence is probably best resevered for more severe cases. Surgery is typically more effective for correcting the pure urodynamic stress form of incontinence. Surgical modalities, similar to conservative therapies, attempt to obstruct the urethral orifice temporarily during episodes of increased intra-abdomnal pressure, by placing a "sling" or "tape" beneath the urethra near its exit point from the bladder. Success rates as well as complication rates vary with the type of procedure. The "gold standard" surgical procedure remains the Burch colposuspension. Pubo-vaginal sling procedures can be done in cases of treatment failure. Recently the transvaginal tape procedures have become increasingly popular. This type of procedure can be done in a day surgery type setting.  Unfortunately, long-term cure rates for any of the surgical procedures have been disappointing.

As the United States population ages, the number of sufferers of urinary incontinence is predicted to increase.  Disposable products are widely available, but most symptom sufferers would prefer another option if such were available. In 1988, our clinic developed a new option for treatment called Genityte. In the next segment of this blog article, I hope to introduce and describe this new non-invasive procedure as well as our experience with it to date.

At long last, it seems, it has become possible to successfully freeze (and thaw) human eggs. Vitrification, a process of freezing living tissue has been an elusive goal for researchers hoping to preserve human oocytes.  Recently however, the University of Connecticut Health Center has reported a series of 6 live births from eggs that have been frozen and thawed. They  join several other centers that are also reporting success. UCHC will begin an egg donation program this summer. Their technique is one of several new safe and effective options for oocyte cryo-preservation.  Egg freezing, which has previously been considered only experimental may soon become widespread.  

Until very recently, for women, the biological clock has continued relentlessly ticking. Despite significant advances in assisted reproductive technologies, women over 40 have a small chance and beyond age 45, women have almost no hope of achieving a successful live birth using their own eggs. New methods of oocyte cryopreservation, will very likely change this, however, allowing women to better correlate their fertility desires with the career and relationship demands of today. Women with cancer or other conditions necessitating chemo or radiation therapy, probably represent the most important group for whom this technology is being developed. These women may now choose to freeze and store eggs, circumventing infertility which commonly otherwise occurs as a consequence of treatment.

Assisted reproductive technology(ART) has a long and colorful history. The first successful pregnancy resulting from artificial insemination (AI) was described in 1790. The next significant advance was not reported until 1953 when a pregnancy resulting from a frozen sperm was achieved. sperm donation and banking has since become well accepted and widely practiced. In vitro (test tube) fertilization was originally developed as a solution for women with "tubal factor" infertility. When normally fertile couples conceive, egg and sperm meet in the fallopian tube, the fertilized egg or embryo subsequently navigates onward  through the tube and ultimately implants in the endometrium (uterine lining).  Endometriosis, sexually transmitted infections or surgical scarring can cause  tubal blockages which interrupt this sequence of events.

The very first successful in vitro fertilization (IVF) of a human ova in 1973 resulted in a chemical pregnancy.  The second, in 1976, an ectopic pregnancy.  Finally in  1978 Louise Brown was born.  Her successful conception was achieved through a process developed by Drs. Steptoe and Edwards. Because continued refinements in IVF technologies have now made it so successful, often more embryos than are needed result from a cycle; often as many as 20 eggs fertilize. Freezing the extra embryos was a logical next step. Interestingly, freezing and thawing embryos is much easier to do than vitrification.  Genetically more stable, than ova, embryos frozen for as long as 20 years have been thawed, transferred, and ultimately born.

For a woman without a male partner to fertilize her eggs however,"freezer burn" until now has forestalled further progress. As opposed to men who are continually manufacturing new sperm cells, women are born with their ovaries "preloaded" with eggs.  At birth, a woman's ovaries have about 2 million eggs.  At puberty only about 400,000 remain.  By the average age of menopause, 50, there will be only approximately 1000 remaining.  Not only are eggs lost to atresia, but as they age, they suffer wear and tear.  The delicate machinery that allows an egg to divide its chromosomes properly in half, breaks down over time.  Abnormal numbers of chromosomes in an egg result in embryos which may not implant, may miscarry, or may result in the birth of a child with problems such as Down's syndrome. By the time a woman is 45, her risk of having a child with Down's syndrome reaches 1/30 live births. Her risk of all types of chromosomally-mediated birth defects is approx 1/10.


It seems possible that at last persistent "tweaking" of the vitrification procedure has finally paid off. UConn's first successful live birth from an egg which was frozen, reported in 2002, has now been succeeded by 5 more babies.
Worldwide, over 900 babies have been born following oocyte cryopreservation. UConn will begin an egg freezing program this summer. Initially their goal is to permit women needing cancer treatment to store their eggs for the future when improved health may permit pregnancy.  Soon, many healthy women may have the opportunity to take advantage of this promising new technology. Already we are beginning to see egg and sperm banks side by side. For more information on UConn's program see:
http://www.dailycampus.com/news/uchc-to-begin-egg-freezing-program-1.2020449

Unfortunately, many women are unaware of the availability of emergency contraception.  Also known as the Morning After Pill or Post coital Contraception, emergency contraception is safe, effective and easy to obtain.  

Emergency contraception is a therapy used to prevent pregnancy after unprotected intercourse, or in cases of contraceptive failure such as a broken condom. It involves taking only two doses of medication which can be completed within a 24 hours period.

There are two different types of emergency contraception.  In the United States, Plan B is the most common preparation; its cost is between $10 and $50. It can be obtained without a prescription by women over 18 years of age, and with a prescription for those under 18.  With a doctor's instructions, emergency contraception can also be made up from standard oral contraceptive pills to create the second type of preparation.

Emergency contraception works by several possible methods, the most likely being by delaying or preventing ovulation. It has no effect at all on a fertilized embryo, and should not be confused with medical abortion. Most data indicate that it will not cause birth defects in the event that it is inadvertently taken during pregnancy, and it will not cause abortion of an established pregnancy.

Emergency contraception is most effective when used as soon as possible after unprotected sex, but may be effective up to 120 hours after the fact. Studies indicate that use of emergency contraception prevents up to 75% of expected pregnancies.  

There are very few people who cannot take emergency contraception.  Even women who are not normally candidates for oral contraceptives, such as those with migraines, liver disease, or heart disease can take emergency contraception.  Breastfeeding is not a contraindication.

Most women's health providers such as Planned Parenthood, primary care providers, and obstetrician/gynecologists
will prescribe emergency contraception to their established patients over the telephone without the need for an office visit or laboratory tests. Walk-in Clinics and Emergency rooms will prescribe emergency contraception to patients without an established physician.

Common side effects of emergency contraception are nausea/vomiting and irregular menstrual bleeding.  Many health care providers prescribe anti-nausea medications which may be taken one hour prior to the dosage, to help reduce the symptoms.  If vomiting occurs within 2 hours of the dose, the dose should be repeated. It is rare for the nausea to last more than 24-48 hours. Nausea is much less common with Plan B than with other preparations.

Irregular bleeding is very common.  The normal period can come early or be delayed, spotting may also occur.  Abnormal bleeding does not usually persist into the next menstrual cycle.

No follow up evaluation is needed after emergency contraception, unless the period is delayed by more than a week, irregular bleeding persists, or abdominal pain or other symptoms develop.  A barrier method of contraception (such as condom or diaphragm) should be used for the remainder of the cycle. Emergency contraception can be repeated within
the same cycle if necessary. Emergency contraception is not recommended as a regular form of birth control. On-going hormonal or other contraception may be started immediately after emergency contraception or with the next menstrual period.

To summarize:

Emergency contraception requires only two doses of medication, and can be finished with in 24 hours.

It is available to women over 18 without a prescription, or a prescription can often be obtained over the telephone.

It can be used safely by almost anyone.  

It can be used up to 120 hours after unprotected sex, although it is most effective if taken within the first 72 hours.

Side effects are minor and can be alleviated.

It is effective in preventing 75% or more of expected pregnancies, but will not cause abortion.

Plan B is the most common product in the United States; the cost of Plan B ranges from $10 to $50.

For more information go to:

http://www.go2planb.com
or
http://www.womenshealth.gov/faq/emergency-contraception.cfm