• HIV and Syphilis Co-Infection in Maricopa County

      Thomas, Sarah; The University of Arizona College of Medicine - Phoenix; Khurana, Renuka; Campos-Outcalt, Douglas; Mickey, Tom (The University of Arizona., 2011-02)
      BACKGROUND: The past decade has seen a resurgence of Syphilis infections on the global, national and local levels, and Arizona has been no exception. After having fallen to record lows nationally in 1999, rates of Primary and Secondary (P&S) syphilis increased incrementally each year from 2001-2008 [5] [16]. Overall increases in rates between 2001 and 2008 were observed primarily among men [5]. Concurrently, the estimated proportion of all P&S syphilis cases occurring in men nationally who have sex with men (MSM) increased dramatically from 5% in 2000 to 62% in 2004 [15]. This trend has been described in epidemiologic research from coast to coast in Washington State’s King County, Southern California and New York City [9] [10] [11]. These national trends are mirrored locally in Arizona. In Arizona early syphilis (primary, secondary and early latent) has increased from 2004-2008 [19]. The majority of these cases have occurred in Maricopa County. Also noted has been an apparent increase in patients who are concurrently infected with HIV, by self report and testing. OBJECTIVES: This study aims to evaluate these trends in syphilis rates, HIV rates and co-infection rates in Maricopa County over an 11 year period. METHODS: The study enrolled all individuals diagnosed with of Primary, Secondary and Early Latent Syphilis identified in Maricopa County between the years 1998-2008. At time of diagnosis all individuals with a syphilis diagnosis were interviewed for demographic and risk factor variables by the Maricopa County Public Health Investigators. This data was then matched and merged with the Arizona State HIV database to identify individuals with confirmed HIV positive status and early syphilis diagnosis. All personal identifiers were removed once the data was merged. Co-morbidity was defined as any individual with any known diagnosis of HIV and early syphilis regardless of the order of the diagnoses. Co-infection was defined as individuals with a diagnosis of early syphilis 3 or more months after the diagnosis of HIV. This information was then analyzed using SAS statistical software. Logistic regression analysis evaluated for significant risk factors within individuals co-infected HIV and Syphilis, as compared to individuals with early Syphilis diagnosis without HIV positive status. The study examined demographics including gender, age, and race as well as behavioral risk factors; men 5 who have sex with men, meeting sex partners on the internet, having anonymous sex partners, number of sexual partners in the past year, citizenship status, drug use, receiving money or drugs for sex, giving money or drugs for sex, and incarceration within the past year. RESULTS: Initial evaluation using Chi Squared analysis revealed that among all factors examined, MSM behavior was most strongly associated with HIV co-infection (Chi Squared Odds Ratio 42.242, 95% CI 29.736 – 60.008). Subsequent analysis was stratified and Non-MSM and MSM populations were considered separately. Early syphilis and HIV co-infection in the non-MSM population (including men that do not have sex with men, women, and transgendered individuals) is associated with several expected STD risk factors; receiving money or drugs for sex (adjusted OR 2.714, 95% CI (1.229 – 5.992)), more than 5 sexual partners (adjusted OR 5.256, 95% CI (1.207 – 5.283)), more than 10 sexual partners (adjusted OR 2.784, 95% CI (1.201 – 6.451)), and having been in jail in the last 12 months (adjusted OR 3.096, 95% CI (1.260 – 7.608), while showing no differences among racial groups when using White/non-Hispanic as a reference group. However, among MSM individuals none of the behavioral risk factors examined were statistically associated with co-infection. The only factor with which an association was demonstrated was citizenship of the United States (adjusted OR 1.925, 95% CI (1.052 – 3.525)) while Hispanic race was negatively associated with co-infection risk among MSM (OR 0.400, 95% CI (0.288 – 0.555)). No other association with co-infection among racial groups was found when using White/non-Hispanic as a reference group. CONCLUSIONS: It is clear that in Maricopa County the population affected by syphilis from 1998-2008 is characterized by increased rates of HIV co-infection. The population affected by early syphilis and HIV co-infection is largely dimorphic between MSM and non-MSM affected, with distinct risk factors and demographic attributes. Clearly there is a need for public health interventions and awareness campaigns regarding the risk of HIV and syphilis co-infection and morbidity, as well as the increasing incidence of syphilis within the community of men who have sex with men, are needed in Maricopa County.
    • Hyperbilirubinemia and Gallbladder Complications in Pediatric Hematopoietic Stem Cell Transplant Patients

      Makinde, Ambimbolu S.; The University of Arizona College of Medicine - Phoenix; Notrica, David (The University of Arizona., 2011-03)
      3 Abstract Background: Hyperbilirubinemia in pediatric hematopoietic stem cell transplant (HSCT) patients presents a diagnostic and therapeutic dilemma. This study was designed to determine the frequency of known causes of hyperbilirubinemia, correlate its effect on survival, review the effects of gallbladder procedural interventions on outcomes, and to define parameters to guide patient care. Methods: 60 Pediatric HSCT patients transplanted between August 2003 and March 2010 were stratified according to bilirubin levels, presence of Veno-occlusive Disease (VOD), also known as Sinusoidal Occlusive Syndrome (SOS), gallbladder involvement, and surgical intervention. Subgroups were analyzed for peak liver enzyme levels, Intensive care unit (PICU)/hospital length of stay (LOS), and mortality. Results: Fifty-five per cent of patients developed hyperbilirubinemia. Survival was 55% in that group versus 85% in the normo-bilirubin patients. 79% of the hyperbilirubinemia patients exhibited gallbladder involvement and 31% of those underwent surgical intervention. Survival was 60% in the patients with gallbladder involvement without SOS who underwent surgery versus 50% in the non-surgical. In patients with both SOS and gallbladder involvement, survival was 33% in the intervention group versus 50% in the non-intervention group. Overall survival in the SOS alone, SOS with gallbladder involvement, and gallbladder involvement only patients was 50%, 4 44%, and 53% respectively. Hepatic enzymes were increased in patients who received intervention compared to the non-intervention groups, but no individual lab or combination of labs predicted intervention or mortality. Intervention patients spent more days in the hospital post bilirubin peak. Conclusions: Pediatric HSCT patients with elevated bilirubin levels and SOS are at increased risk for gallbladder complications and death. Patients receiving gallbladder procedures are more likely to require longer hospital stays than patients who do not. Surgical intervention may decrease mortality in patients with gallbladder involvement that do not have SOS, but no conclusion regarding a positive impact of gallbladder intervention on patients with coexisting SOS can be made on other patients based on this data set. Keywords: Bilirubin, Hyperbilirubinemia, Hematopoietic stem cell transplant, Cholecystectomy, Cholecystostomy, Veno-occlusive disease, Sinusoidal obstructive syndrome
    • Impact of the Integrative Medicine Elective on Medical Students

      Wright, Courtney A.; The University of Arizona College of Medicine - Phoenix; Maizes, Victoria (The University of Arizona., 2011-03)
      Background: Integrative Medicine offers an approach to medical practice which addresses the public’s increasing use of complementary and alternative medicine (CAM), personal, professional, and federal calls for more patient-centered care, and medical professionals’ deficiencies in self-care and reflection. Though the need for exposure to IM in medical school has been well articulated and many schools offer exposure to the field, the impact of such experiences is largely unknown. The University of Arizona’s Center for Integrative Medicine (AxCIM) re-designed its month-long elective in 2004 to better introduce students to the discipline. This paper reports the preliminary findings of a study examining changes in medical students’ attitudes about IM after participation in this elective. Methods: The Integrative Medicine Attitudes Questionnaire (IMAQ) was administered to medical students participating in the AzCIM’s bi-annual, month long IM elective at the beginning of the elective, at the end, 6 months after completion and 1 year after the elective. Results: 66 complete IMAQ scores were collected at baseline, 36 six months post-elective and 23 1 year after. Post-elective scores were significantly higher than at baseline. No difference from baseline was found in scores 6 months and 12 months post-elective. Conclusions: The preliminary results are encouraging regarding the elective’s improving attitudes toward IM immediately after its completion. This study serves as a resource and encouragement for IM education assessment and evaluation.
    • Informed Consent with Homeless Patients

      Whitley, Sarah Marie; The University of Arizona College of Medicine - Phoenix; Robert, Jason (The University of Arizona., 2011-03)
      Access to healthcare for homeless persons is a significant problem within the United States. However, as barriers are lessened through federally funded or philanthropic organizations, attention must be paid to ensuring quality healthcare. The homeless population has disproportionately high rates of substance abuse, mental health disorders, and traumatic brain injuries. This places these patients at greater risk for lacking capacity to consent. This study was designed to examine the informed consent practices of healthcare practitioners in the primary care setting of clinics having received the federal Healthcare for the Homeless grant. Due to the poor response rate, no data of statistical significance were obtained and the study was treated as a pilot study. Patient demographics closely mirrored national statistics of homelessness excepting ethnicity. Likewise, patients seen in these clinics experience high rates of substance abuse and mental health disease. Providers reported only low rates of traumatic brain injuries in their population, contrary to national statistics demonstrating high rates of this disorder. Despite the high prevalence of risk factors for incapacity to consent, providers rarely questioned their patients’ decisional capacity. Practices involving informed consent varied widely. Further studies need to be conducted to evaluate informed consent practices though it is apparent that studies of this nature may be impractical and unethical, if not impossible.
    • Meningiomas Assessed with In Vivo 3D 1H-Magnetic Resonance Spectroscopy Integrated Into a Standard Neurosurgical Image Guidance System: Determining Biochemical Markers of Clinically Aggressive Behavior and Providing a Resection Advantage

      Moore, Nina Zobenica; The University of Arizona College of Medicine - Phoenix; Preul, Mark (The University of Arizona., 2011-03)
      15 usable patients with recurrent or newly diagnosed meningiomas using a 3T GE Signa scanner. Quantified spectral metabolite peaks were used to select voxels that had high or low alanine for tissue sampling. 3D 1H-MRSI was integrated into a standard image guided surgery (IGS) system; a mask of the voxel was loaded onto the IGS system allowing surgeons to precisely extract tissue intraoperatively according to biochemical mapping. Ex vivo NMR and conventional histological grading were performed on the extracted tissue. Results: Tumor spectra showed biochemically heterogeneous regions, especially for choline, lactate and alanine. Mean alanine concentrations were lower in more aggressive--histologically and immunohistochemically--regions of the meningiomas in the study. In addition, lower grade meningiomas showed high alanine at the tumor periphery with decreased central alanine. Ex vivo NMR was well-correlated with in vivo 3D 1H-MRSI. Conclusions: Non-invasive detection of various intratumoral biochemical markers using 3D 1H-MRSI can distinguish areas within meningiomas that express more aggressive features. There is regional heterogeneity in the concentrations of these markers within individual tumors. Furthermore, 3D 1H-MRSI may be able to exploit these regional differences to separate more aggressive from less aggressive areas within a given meningioma. Such knowledge may be useful to 5 the neurosurgeon faced with the task of meningioma resection, and in the planning adjuvant therapy for residual meningioma
    • Nutrition in Phoenix Metropolitan Area Homeless Youth

      Burnett, Greg; The University of Arizona College of Medicine - Phoenix; Appelhans, Brad (The University of Arizona., 2011-03)
      Homeless youth are a large, poorly characterized population of the United States [1, 2]. Though over seven percent of American youth aged twelve to seventeen years experienced homelessness last year, there is a paucity of data regarding their general condition and health status. This study was undertaken to describe the adequacy of nutritional intake of homeless youth in the Phoenix metropolitan area. Interviews were conducted with 71 homeless youth aged 16 to 21 years (44 male, 27 female) who were recruited from homeless youth drop-in centers and outdoor public areas. A standardized 24 hour dietary recall was utilized during the interview to gather nutritional data, which was analyzed against Dietary Reference Intakes (DRI). Overall results demonstrated a slight excess of caloric and macronutrient intakes; though intakes of several micronutrients were deficient. Over one third of participants consumed less than 50% of the DRI for folate, calcium and zinc; 42% consumed under 50% of the DRI for vitamin C, and 63% consumed under 50% of the DRI for vitamin A. Upon further analysis, statistically significant difference in iron intake was found between male and female participants. Statistically significant difference in fat, iron, and zinc intake was also found between participants recruited from differing locations. In comparison to 2007-2008 data reported in the WWEIA/ NHANES study, participants in this study consumed more calories, protein, carbohydrates, and fat [3]. Participants from both studies consumed insufficient vitamin A quantities; female participants from both studies consumed insufficient calcium. Interstingly, mean iron intake was low for female WWEIA/ NHANES data, but at DRI for study participants. Further surveys of a larger number of participants may be warranted, especially considering the significant skew and non-normal distribution of the nutritional intake data from this study. This study does find inadequate micronutrient intake in homeless despite the fact that they are consuming more than enough macronutrients (calories, protein, carbohydrates, fat). These inadequacies could potentially contribute to poorer health in these youth.
    • An Objective Methodology to Quantify Motor Skills in Basic Orthopaedic and Gynecologic Surgical Tasks

      Sharer, Sarah Kennedy; The University of Arizona College of Medicine - Phoenix; Kahol, Kanav (The University of Arizona., 2011-02)
      This study is the initial step in the development of a basic skills simulator for surgical residents, intended to serve as a cross-platform objective motor skills training system. A robust system was developed to measure motor skills of orthopaedic surgeons and gynecologic surgeons. The orthopaedic study focused on three basic skills: drill, tap, and screw insertion. Each of the participants repeated the sequential task of drill, tap, screw insertion ten times in cadaveric femoral diaphyseal bone. The gynecologic study focused on placement of sutures across ten incisions in synthetic skin. Real time wrist, hand, and finger position was recorded bilaterally using Immersion CyberGloves® and the Ascension Liberty Tracker®. Four metrics were evaluated: task duration, gesture proficiency, hand movement smoothness (replaced by subjective rating in Gyn study), and number of errors, in order to differentiate between groups with different skill levels: No Skills, Limited Skills, Advanced Skills, and Expert Skills. The results demonstrated a significant difference between the Expert Skills group and the less skilled groups. In both studies the Expert Skills group completed the tasks the fastest, with the greatest proficiency, smoothness and accuracy. These results establish the 5 capability of our present skill quantification system and will assist in future improvement of the analysis algorithm.
    • Parental Attitudes Regarding HPV Vaccination of Pre-Adolescent and Adolescent Females in Arizona

      Morris, Stephanie M.; The University of Arizona College of Medicine - Phoenix; Taylor, Melanie (The University of Arizona., 2011-03)
      Background – HPV (human papillomavirus) is considered to be the most pervasive sexually transmitted disease among sexually active young adults in the U.S. and is responsible for approximately 90% of cervical cancers worldwide. In 2006, the FDA (Federal Drug Administration) licensed the first HPV vaccine for use in girls aged 9 to 26; however, evidence shows that vaccine uptake rates among adolescent females remains to be low throughout the country. Objective – To assess parental attitudes and beliefs regarding HPV and HPV vaccination of pre-adolescent and adolescent females in order to identify factors that affect intent to vaccinate. Methods – A questionnaire instrument was distributed to parent members of the AZPTA (Arizona Parent-Teacher Association) and the general internet population in Arizona from March 2010 to August 2010. Results – Of the eligible respondents, 61.1% expressed intent to vaccinate their daughter(s) with the HPV vaccine. Approximately 92% of parents who did not intend to vaccinate their daughter(s) had completed some or all of a post-secondary education. Parents who believed that the HPV vaccine promotes earlier sexual debut (33.3% vs. 68.8%), unsafe sexual behavior (40.0% vs. 73.5%) and sexual promiscuity (25.0% vs. 74.0%) showed significantly less intent to vaccinate with the HPV vaccine than parents who did not believe that the HPV vaccine promotes high-risk sexual activity. 75% of parents were aware that HPV causes cervical cancer and is transmitted by sexual contact; however, 75% of parents answered incorrectly to other HPV knowledge questions. Parents who believed that vaccinations, in general, are unsafe universally did not intend to vaccinate with the HPV vaccine. Conclusions – Barriers to HPV vaccination included parental aversion to vaccinations, miseducation or lack of education about human papillomavirus infection, belief that vaccination will encourage risky sexual behavior among teenagers and concerns regarding efficacy and safety of the HPV vaccine. Efforts to educate parents regarding
    • Personal Reflection: A Prescription for Medical Education

      Solem, Casey; The University of Arizona College of Medicine - Phoenix; Robert, Jason (The University of Arizona., 2011-03)
      Since the time of the Second World War, patients have taken a more active role in their medical decision-making processes (Thomasma 1983). This has led to an increased expectation of professionalism, empathy, and respect from their physicians. The act of personal reflection by physicians is proposed as a means to help physicians meet these growing expectations from patients. The study of literature throughout the process of medical education has been established as a means to promote this type of personal reflection (Charon 2006). An exploration of the historical elements of this process provides a framework for the role that personal reflection plays in the practice of medicine and in the process of medical education. An analysis of key components of educating future physicians is provided, with an emphasis placed on methodologies that have been previously implemented. A review of personal reflection seminars that have been available in various medical education settings provides an understanding of factors that lead to the success and failure of such curricula, and provides the framework for a set of recommendations, a prescription, which may assist additional medical educators as they produce similar programs. Examples of personal reflection by the author are provided in order to emphasize the salient themes identified by the literature.
    • Perspectives for the Primary-Care Physician on the Strengths and Shortcomings in the Healthcare-Oriented Research of Child and Adult Literacy

      Brimhall, Darrell M.; The University of Arizona College of Medicine - Phoenix; Brady, Sharon (The University of Arizona., 2011-03)
      The acquisition of literacy is a skill that cannot be understated. A wide variety of distinct academic fields have long studied this issue and have found strong evidence that proficiency in literacy affect many aspects of the individual including socioeconomic status, health, and behaviors. In the last two decades, literacy in healthcare has been intently investigated not only as it relates to the health status of the individual, but also how one functions in the health system. Health literacy is a subset of the much broader concept of general literacy and physicians will gain a greater ability to understand and assist patients by incorporating this paradigm into their practice. While the literature has made important headway in understanding the impact of literacy, gaps and inconsistencies appear frequently within the literature. The intent of this study was to examine the wide variety of literacy research and summarize the strengths and weaknesses through the perspective of primary-care clinicians.
    • Physician Personal Characteristics and Obesity Treatment Plan Study

      Schottelkorb, Marisa Jo; The University of Arizona College of Medicine - Phoenix; Appelhans, Brad (The University of Arizona., 2011-03)
      Obesity is a very common finding in the primary care physician's office; however, physicians do not always treat obese patients according to guidelines. This investigation examined the possible relationships between a physician's personal weight history, anti-obesity bias, and the proposed treatment plan for an obese, hypertensive patient. Fifty-five Family Medicine, twenty-one Internal Medicine, and five “Other” Family or Internal Medicine Subspecialty physician participants viewed a video featuring either a hypothetical female or male patient with stage I hypertension and obesity (with a BMI of 32.) Of the total 81 physician participants, only 33 completed the entire study. Of these, 79.4% had attempted weight loss in their lifetime, with 55.9% having attempted weight loss in the past year. Median physician BMI was 25, with a small standard deviation of 2.7. Mean obesity bias score was 50.6 (out of possible 117, the maximum value reflecting the most anti-obese attitudes,) with a standard deviation of 19.7. Among all 81 participants, weight loss was in the three highest-ranked treatment recommendations in 90.9% of physician participants. Only 21.2% recommended all four JNC- 6 recommended components of lifestyle change. 93.9% recommended the initiation of a drug during this diagnostic visit. Statistical significance was not achieved in relating physician personal characteristics such as weight history to treatment recommendations due to the low number of participants completing all study measures.
    • Security and Privacy in Radiology

      Workie, Betre; The University of Arizona College of Medicine - Phoenix; Krupinski, Elizabeth (The University of Arizona., 2011-10-28)
      Radiology is one of the most high-tech fields of medicine. The digitization of medical information including radiographic data has led to improved efficiency and productivity but it has also presented new challenges in the area of privacy and security. In this study we have tried to answer some questions regarding how secure the current electronic radiology systems are and what individual and systemic factors affect the security and privacy of confidential patient data. A total of 77 radiologists and radiology residents participated in an online survey which included questions on physical security, computer systems security, and training and prevention. Since there was no objective way to measure overall security, we have used the overall security grade given by survey takers as our outcome, the dependent variable. Multiple regression analysis and ANOVA (Analysis of Variance) analyses were conducted. The regression analysis, with few exceptions, showed that only two variables contributed significantly to the final security grade. One of them was about unauthorized persons gaining access to the radiology facility, and the second one was about locking computer screens when temporarily away from a work station. A separate analysis was done using data for physical security, 4 computer systems security, training and prevention, and other security/privacy questions. Security threat level to current radiology systems is very low; however, the preparedness of these facilities to protect their infrastructure from future attacks is not adequate and there is room for improvement. As far as keeping confidential patient information private, most institutions seem to be doing a good job.
    • Specificity of Enzyme Immunoassay for Serologic Coccidioidomycosis Diagnosis Compared to Immunodiffusion

      Petein, Nathalie; The University of Arizona College of Medicine - Phoenix (The University of Arizona., 2011-03)
      BACKGROUND: Serologic testing for coccidioidomycosis challenges clinicians due to conflicting small studies regarding the sensitivity and specificity of newer enzyme immunoassay (EIA) tests and the lack of a true gold standard diagnostic test for comparison. METHODS: We analyzed all Lab Corp coccidioidomycosis serological test results from February 2008 through February 2009 and calculated the sensitivity, specificity, and positive/negative predictive values of EIA immunoglobulin (Ig)M and IgG. Immunodiffusion IgM and IgG (ID), complement fixation titers (CF), and tissue/culture diagnosis were used as tests for comparison. The comparison test (CT) was considered positive if any comparison test was positive the day of EIA collection or if tissue/culture diagnosis occurred during the time period. Cases required EIA IgM and IgG and ≥ 2 comparison tests performed the same day for inclusion. Medical records associated with positive EIA and negative comparison test results were reviewed for coccidioidomycosis symptoms, physician diagnosis, and subsequent positive comparison test results. Sensitivity, specificity, and predictive values were calculated, including those with subsequent positive comparison test results. RESULTS: A total of 1445 laboratory test sets were identified. EIA sensitivity and specificity were 83.8% and 92.6%, respectively. Positive and negative predictive values were 61.5% and 97.6%, respectively. Of 94 “false positive” EIA results, 92 (97.9%) were associated with documented coccidioidomycosis symptoms and 81% with coccidioidomycosis physician diagnosis. CONCLUSION: Based on the largest study of sensitivity and specificity calculated from laboratory surveillance data, EIA sensitivity and specificity for coccidioidomycosis diagnosis are lower than previously reported using only coccidioidomycosis laboratory tests as a comparison. However, association of “false positive” EIA results with coccidioidomycosis symptoms and physician diagnosis suggests that ID and CF laboratory tests alone are not a sufficient confirmation test for diagnosis.
    • The Test Tube Baby: Out of Reach or Out of Luck? A Retrospective Look at the Impact of Basal FSH and Age on In Vitro Fertilization Success in a Clinic Operating Without Laboratory Value Thresholds or Age Limits?

      Padrnos, Leslie; The University of Arizona College of Medicine - Phoenix; McGaughey, Robert (The University of Arizona., 2011-03)
      Objective: To assess the impact of age and FSH on IVF outcomes in an assisted reproductive technology clinic that does not have treatment thresholds based on age or laboratory FSH values. Design: Retrospective cohort study Setting: The Arizona Center For Fertility Studies in Phoenix, AZ Patient(s): Women who sought fertility treatment (with the exclusion of patients using donor or frozen oocytes) ages 18-50, representing a total of 1388 IVF cycles Intervention(s): IVF using nondonor embryos Main Outcome Measure(s): Live-birth rate per cycle started Result(s): A total of 1388 IVF cycles with autologous oocytes were analyzed to determine the impact of basal FSH and age on therapy outcomes. The pregnancy rates for individuals 18-34 years old were not significantly different and ranged from 41.1% to 34%. Pregnancy rates for individuals aged 35-39 years old exhibited a reduced pregnancy rate that ranged from 24.7% to 19.8%. For the eldest patients, a significant reduction in pregnancy rates was demonstrated with patients over the age of 40 having a pregnancy rate of 14.3%, and for those 41 years old and 42 and older having pregnancy rates of 7% and 6% respectively. The live birth rate also mirrored this trend with the youngest age group having a live birth rate of 38.9% and the eldest group of individuals aged 42-50 years having a live birth rate of 3.4%. While increasing FSH levels were associated with reduced numbers of oocytes retrieved and transferred during the IVF procedures, there was no statistically significant reduction in pregnancy rate or live birth rate in those with elevated basal FSH levels. Conclusion: The data analysis revealed that increasing age in this population does correlate with decreasing successful outcomes in IVF. At ages 36 and 40 years, there are significant reductions in pregnancy rate. At ages 38 and 40, there are significant reductions in live birth rate. Interestingly, there were no significant differences in pregnancy rate or live birth rate based on basal FSH level.