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Efforts are Preconception care that begins early on and continues now underway to develop guidelines for preconception care between pregnancies will help to ensure that women have and expand the package of interventions to include those a reproductive life plan and are able to decide when to have listed in Table 3. In some regions, cultural and other chronic diseases like diabetes and hypertension, norms promote early marriage, which is a factor in high preventing intimate partner violence and promoting cessa rates of adolescent pregnancy. Regulations to increase the tion of tobacco use and exposure to secondhand smoke in legal age at marriage and educating communities to change the home and workplace. It should be noted that because cultural norms that support early marriage may be ways preconception care is a relatively new concept, the evidence to prevent adolescent pregnancy in those countries. In an base for risks and interventions before conception is still effort to discover what interventions are most effective to being strengthened. Thus, broad consensus regarding a prevent adolescent pregnancy, a wide variety of programs package of evidence-based interventions for care in the carried out in low-, middle-, and high-income countries has preconception period has yet to be decided. It is important to note that programs with a lon personal development programs that incorporated skills ger duration were more effective since adolescents require building and include contraceptive provision were shown time to integrate new information, practice the skills that will 37 to women and couples Table 3. Appropriate birth spacing after a previous live Prevent unintended pregnancies and birth or pregnancy loss decreases the risk for prematurity promote optimal birth spacing in subsequent pregnancies (Shah and Zao, 2009; Conde One way to ensure that mothers and babies have good Agudelo et al. Women who have very closely spaced pregnancies (within 6 months of Although contraceptive use, particularly amongst ado a previous live birth or pregnancy) are more likely to have lescents, currently falls far short of the optimal with only preterm or low-birthweight babies (Conde-Agudelo et al. This may be because they have not had enough time the Countdown to 2015 priority countries (Requejo et al. Encouraging family planning and the use an unprecedented opportunity to scale up use of contra of contraceptive methods (hormonal and barrier methods) ception and allows for women and partners to plan their has other advantages including reductions in maternal and pregnancy. Breastfeeding promotion for 24 months can prevent closely spaced pregnancies, a method that continues to be underused despite strong evidence of its positive effect on maternal and newborn health. On its own, 12 months of contraception-only coverage in the preceding birth interval can reduce the mortality risk for the next newborn by 31. Programs to make effective contraception available Photo: Susan Warner/Save the Children 38 the Global Action Report on Preterm Birth in low-resource settings, are urgently needed and require Torloni et al. Given that maternal undernourishment is a risk fac the likelihood of developing weight-related complications tor for being underweight, improving food security could during gestation (Gavard and Artail, 2008). It is important, therefore, to evaluate whether local lifestyle, to build motivation and increase the chances of and national food programs largely targeted towards chil sustaining weight loss.

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Postmenopausal hyperthecosis: functional dysregulation of androgenesis in climacteric ovary. Familial hyperthecosis: comparison of endocrinologic and histologic findings with polycystic ovarian disease. Treatment of severe androgen excess due to ovarian hyperthecosis with a long-acting gonadotropin-releasing hormone agonist. Prenatal diagnosis of female pseudohermaphroditism associated with bilateral luteoma of pregnancy: case report. Heterogeneity of human growth hormone and prolactin secreted in vitro: immunoassay and radioreceptor assay correlations. Large molecular size prolactin with reduced receptor activity in human serum: high proportion in basal state and reduction after thyrotropin-releasing hormone. Circulating big human prolactin: conversion to small human prolactin by reduction of disulfide bonds. Characterization of a large molecular weight prolactin in women with idiopathic hyperprolactinemia and normal menses. Detailed assessment of big big prolactin in women with hyperprolactinemia and normal ovarian function. Heterogeneity of serum prolactin throughout the menstrual cycle and pregnancy in hyperprolactinemic women with normal ovarian function. Polymorphism of prolactin secreted by human prolactinoma cells: immunological, receptor binding, and biological properties of the glycosylated and nonglycosylated forms. Effects of a dopamine antagonist on the release of gonadotropin and prolactin in normal women and women with hyperprolactinemic anovulation. Functional studies of dopamine control of prolactin secretion in normal women and women with hyperprolactinemic pituitary microadenoma. Different dopaminergic control of plasma luteinizing hormone, follicle stimulating hormone and prolactin in ovulatory and postmenopausal women: effect of ovariectomy. Synchronous secretion of lutei-nizing hormone and prolactin in the human luteal phase: neuroendocrine mechanisms. Ethanolamine-O-sulfate enhances gamma-aminobutyric acid secretion into hypophysial portal blood and lowers serum prolactin concentrations. The effects of the gabaergic drug, sodium valproate, on prolactin secretion in normal and hyperprolactinemic subjects. Pharmacological activation of gamma-aminobutyric acid-system blunts prolactin response to mechanical breast stimulation in puerperal women. Blood prolactin levels: influence of age, menstrual cycle and oral contraceptives. Pulsatile gonadotrophin secretion in hyperprolactinaemic amenorrhoea an the response to bromocriptine therapy. Relationship between plasma prolactin and the endocrine microenvironment of the developing human antral follicle.

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Soft catheters such as those made by the Cook or Wallace companies are preferred to rigid catheters to minimize prostaglandin release after cervical and/or endometrial trauma (353). The utility of cervical mucus removal prior to embryo transfer in improving embryo delivery remains controversial (353, 372). Although intrauterine infections decrease pregnancy rates, the efficacy of antibiotic administration at the time of transfer is not clear. During a conventional embryo transfer, embryos are suspended in 20 L of media at the tip of a syringe with air on either side of the fluid. Abdominal ultrasound visualization during embryo transfer is useful to ensure deposit of the embryos 1. Once the embryos are deposited, the inner and outer sheath should be removed as a unit to avoid suction within the device (353). If present, retained embryos should be transferred because there is no detriment in pregnancy rates (353). Because transfer of cryopreserved embryos is less expensive than a second fresh cycle, overall fertility treatment costs can be optimized. Embryo cryopreservation can be considered as a means to prevent ovarian hyperstimulation syndrome. Techniques for embryo cryopreservation include slow freezing and rapid freezing or vitrification. Slow freezing protocols use lower concentrations of cryoprotectants but are more time-consuming when compared to vitrification, which uses high-concentration cryoprotectants for rapid cooling and is less expensive. Embryo thawing is accomplished by brief exposure to air and warm water followed by rehydration (373). Infant outcomes are reassuring for slow freezing but are more limited for the newer technique of vitrification (375). Overall, use of frozen embryos results in lower pregnancy rates when compared to fresh transfer cycles, but this may be a result of embryo selection (the best embryos are typically used for fresh transfer and lesser quality embryos are frozen) (373, 376). Frozen transfer outcomes are heavily dependent on the characteristics of the fresh cycle that generated the frozen embryos; excellent pregnancy rates are noted when the fresh cycle resulted in conception or when all the embryos were frozen from the fresh cycle (376). Transvaginal ultrasound is used to assess endometrial thickness during estrogen therapy, and estrogen administration continues until an optimal thickness of greater than 8 mm is reached (373). Progesterone supplementation begins 48 to 72 hours prior to transfer when cleavage-stage embryos are used and 6 to 7 days prior to transfer when blastocysts will be thawed (373, 377). Validation by an independent dataset and comparison with a control model that is based on chronological age alone showed that the boosted tree model was more than 1, 000 times better in fitting new data and improved discrimination. Approximately 60% of patients were found to have significantly different predicted live birth probabilities when compared to the use of age categories. Further testing across different clinics will be required to determine whether this approach may be generally valid and applicable. These findings may move prognostic counseling away from an age-centric paradigm and toward a more objective extraction of predictive value from simultaneous analysis of a wide array clinical factors. Patients with a very poor prognosis have a 2% to 5% chance of achieving a live birth with fertility therapy, and those with a futile prognosis have a 1% or less chance.

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This is an area in which (i) very few physicians received formal training, (ii) there is little (albeit increasing) research in the mainstream medical journals, and (iii) there is a tremendous amount of information, of variable quality, in the lay press. All of these factors contribute to a circumstance that often is uncomfortable for physicians. This discomfort is important to recognize because it can contribute to avoidance of the topic altogether. It is appropriate to begin the conversation with a patient by explaining that this is new territory in conventional medicine and that you are not an expert. Most patients have assumed this to be the case, appreciate the honesty, and value the opportunity to discuss these dilemmas. It is necessary to evaluate the potential to cause both direct harm and indirect harm. Potential for Direct Harm this should include any evidence regarding potential harm directly from the therapy or potential interactions. When lacking good evidence, assessment of the invasiveness of the therapy is a strong predictor of risk. Potential for Indirect Harm this should include an assessment of potential harm caused by postponing effective treatments, and by financial exploitation. Marketing can prey on vulnerable patients and result in significant and unnecessary expenditures. Step Two: Assess Potential Benefits the potential for any approach to be of benefit should be assessed on several levels. Scientific Evidence A review of the peer-reviewed literature should certainly be conducted for evidence of the effectiveness of the approach under consideration. Cultural Evidence Another form of useful information is the historic or cultural use of the approach. For example, it is valuable to consider whether a therapy has a long history of use within a given culture. If, on the other hand, the approach has no historic use, this is important to recognize. Examples include the use of black cohosh for menopausal symptoms, which was used for centuries with reported safety and effectiveness, compared with red clover, which has no historic use or track record. Another example would be acupuncture, with thousands of years of use, compared with chelation, which was in use for a relatively short time and is associated with considerable debate regarding its benefit. If the patient has a strong belief in the approach, and there is no evidence of potential harm, it is often reasonable to support its use. Product Assessing the history of the manufacturing company and understanding its process of quality assurance can be useful.