Betsy Bates

CHICAGO — Few symptoms or clinical examination findings distinguished severely anemic patients from other women who presented for urgent evaluation of abnormal uterine bleeding, a retrospective cohort study showed.

Of 350 patients who presented to the emergency department for heavy menstrual bleeding, 122 (35%) were anemic, defined as having a hemoglobin concentration of less than 12 g/dL, while 48 (14%) were moderately to severely anemic, defined as having a hemoglobin concentration of less than 10 g/dL.

Only increasing age (relative risk, 1.04) and the presence of both tachycardia and hypotension (RR, 3.11) were associated with severe anemia, reported Dr. Kristen A. Matteson at the annual meeting of the American College of Obstetricians and Gynecologists.

“Our take-home message is that clinical symptoms and bleeding history are poorly predictive for moderate to severe anemia,” said Dr. Matteson of the department of obstetrics and gynecology at Brown University, Providence, R.I.

Because no presenting symptom or physical finding can rule out clinically important anemia, she suggested that “a low threshold should be maintained for performing a hemoglobin concentration.”

The median age of women in the study was 32 years. Nearly 70% were non-Hispanic white, and 20% were non-Hispanic black. Almost one in four had received outpatient care for abnormal uterine bleeding (AUB) in the prior 3 months, but, 49% had a concurrent medical condition that could affect treatment options for the condition, Dr. Matteson pointed out. These concurrent diagnoses included breast, endometrial, or ovarian cancer; cardiovascular disease; depression; diabetes; gastrointestinal diseases; migraine; seizure disorders; and thromboembolic disorders.

The duration of the current bleeding episode was more than 7 days in 55% of the study population. A combination of heavy and irregular bleeding was reported by 65%, and more than half reported passing clots or flooding. Neither the amount of bleeding recorded on examination nor bleeding patterns described by the patients were associated with moderate to severe anemia.

“We were not surprised that the amount of bleeding actually seen by the provider was scant in the majority of patients because abnormal uterine bleeding can be very unpredictable and episodic,” noted Dr. Matteson. “Diagnosis and management of heavy menstrual bleeding are dependent on what a woman says about her blood loss because clinically we do not have practical means to 'measure' bleeding.”

When a woman reports extremely heavy bleeding that affects her life at home and work, but has little bleeding during a 30-minute medical appointment, the disparity can lead to frustration on the part of both the physician and patient, she said. Studies have shown that such patients “often report dissatisfaction with their interactions with health care providers.”

Dr. Matteson said mild anemia is generally asymptomatic in patients who do not have cardiovascular disease. Severe anemia, on the other hand, can lead to cardiac events in some patients and may require blood transfusions. Anemia that is moderate to severe can cause extreme fatigue, reducing productivity and quality of life.

Dr. Matteson reported no financial conflicts of interest.

CHICAGO — Few symptoms or clinical examination findings distinguished severely anemic patients from other women who presented for urgent evaluation of abnormal uterine bleeding, a retrospective cohort study showed.

Of 350 patients who presented to the emergency department for heavy menstrual bleeding, 122 (35%) were anemic, defined as having a hemoglobin concentration of less than 12 g/dL, while 48 (14%) were moderately to severely anemic, defined as having a hemoglobin concentration of less than 10 g/dL.

Only increasing age (relative risk, 1.04) and the presence of both tachycardia and hypotension (RR, 3.11) were associated with severe anemia, reported Dr. Kristen A. Matteson at the annual meeting of the American College of Obstetricians and Gynecologists.

“Our take-home message is that clinical symptoms and bleeding history are poorly predictive for moderate to severe anemia,” said Dr. Matteson of the department of obstetrics and gynecology at Brown University, Providence, R.I.

Because no presenting symptom or physical finding can rule out clinically important anemia, she suggested that “a low threshold should be maintained for performing a hemoglobin concentration.”

The median age of women in the study was 32 years. Nearly 70% were non-Hispanic white, and 20% were non-Hispanic black. Almost one in four had received outpatient care for abnormal uterine bleeding (AUB) in the prior 3 months, but, 49% had a concurrent medical condition that could affect treatment options for the condition, Dr. Matteson pointed out. These concurrent diagnoses included breast, endometrial, or ovarian cancer; cardiovascular disease; depression; diabetes; gastrointestinal diseases; migraine; seizure disorders; and thromboembolic disorders.

The duration of the current bleeding episode was more than 7 days in 55% of the study population. A combination of heavy and irregular bleeding was reported by 65%, and more than half reported passing clots or flooding. Neither the amount of bleeding recorded on examination nor bleeding patterns described by the patients were associated with moderate to severe anemia.

“We were not surprised that the amount of bleeding actually seen by the provider was scant in the majority of patients because abnormal uterine bleeding can be very unpredictable and episodic,” noted Dr. Matteson. “Diagnosis and management of heavy menstrual bleeding are dependent on what a woman says about her blood loss because clinically we do not have practical means to 'measure' bleeding.”

When a woman reports extremely heavy bleeding that affects her life at home and work, but has little bleeding during a 30-minute medical appointment, the disparity can lead to frustration on the part of both the physician and patient, she said. Studies have shown that such patients “often report dissatisfaction with their interactions with health care providers.”

Dr. Matteson said mild anemia is generally asymptomatic in patients who do not have cardiovascular disease. Severe anemia, on the other hand, can lead to cardiac events in some patients and may require blood transfusions. Anemia that is moderate to severe can cause extreme fatigue, reducing productivity and quality of life.

Dr. Matteson reported no financial conflicts of interest.

CHICAGO — Few symptoms or clinical examination findings distinguished severely anemic patients from other women who presented for urgent evaluation of abnormal uterine bleeding, a retrospective cohort study showed.

Of 350 patients who presented to the emergency department for heavy menstrual bleeding, 122 (35%) were anemic, defined as having a hemoglobin concentration of less than 12 g/dL, while 48 (14%) were moderately to severely anemic, defined as having a hemoglobin concentration of less than 10 g/dL.

Only increasing age (relative risk, 1.04) and the presence of both tachycardia and hypotension (RR, 3.11) were associated with severe anemia, reported Dr. Kristen A. Matteson at the annual meeting of the American College of Obstetricians and Gynecologists.

“Our take-home message is that clinical symptoms and bleeding history are poorly predictive for moderate to severe anemia,” said Dr. Matteson of the department of obstetrics and gynecology at Brown University, Providence, R.I.

Because no presenting symptom or physical finding can rule out clinically important anemia, she suggested that “a low threshold should be maintained for performing a hemoglobin concentration.”

The median age of women in the study was 32 years. Nearly 70% were non-Hispanic white, and 20% were non-Hispanic black. Almost one in four had received outpatient care for abnormal uterine bleeding (AUB) in the prior 3 months, but, 49% had a concurrent medical condition that could affect treatment options for the condition, Dr. Matteson pointed out. These concurrent diagnoses included breast, endometrial, or ovarian cancer; cardiovascular disease; depression; diabetes; gastrointestinal diseases; migraine; seizure disorders; and thromboembolic disorders.

The duration of the current bleeding episode was more than 7 days in 55% of the study population. A combination of heavy and irregular bleeding was reported by 65%, and more than half reported passing clots or flooding. Neither the amount of bleeding recorded on examination nor bleeding patterns described by the patients were associated with moderate to severe anemia.

“We were not surprised that the amount of bleeding actually seen by the provider was scant in the majority of patients because abnormal uterine bleeding can be very unpredictable and episodic,” noted Dr. Matteson. “Diagnosis and management of heavy menstrual bleeding are dependent on what a woman says about her blood loss because clinically we do not have practical means to 'measure' bleeding.”

When a woman reports extremely heavy bleeding that affects her life at home and work, but has little bleeding during a 30-minute medical appointment, the disparity can lead to frustration on the part of both the physician and patient, she said. Studies have shown that such patients “often report dissatisfaction with their interactions with health care providers.”

Dr. Matteson said mild anemia is generally asymptomatic in patients who do not have cardiovascular disease. Severe anemia, on the other hand, can lead to cardiac events in some patients and may require blood transfusions. Anemia that is moderate to severe can cause extreme fatigue, reducing productivity and quality of life.

Dr. Matteson reported no financial conflicts of interest.

LOS ANGELES – Sixth graders who showed an aggressive temperament and/or symptoms of depression were more likely than their peers to begin using alcohol and other drugs by eighth grade, according to study findings presented as a poster at the annual meeting of the Society for Adolescent Medicine.

It was the third independent risk factor researchers detected–an early onset of puberty–that was less predictable, and it might be an early red flag for physicians.

Dr. Carolyn A. McCarty and associates from the University of Washington, Seattle, departments of pediatrics and psychology recruited 521 sixth graders from public schools in the Seattle area, interviewing them every 6 months for 2.5 years, until they entered the eighth grade.

Children with conduct problems and/or depressive symptoms on a psychological instrument were oversampled in the survey.

At the study's onset, 5.4% of sixth graders were using any substance, with alcohol the most common (4.2%).

By the study's conclusion, 16.7% of the eighth grade subjects reported using alcohol (13.2%), marijuana (6.8%), tobacco (4.2%), and/or other illicit substances (1.5%).

Sex, race, frustrated temperament, and externalizing symptoms were not significantly, independently associated with initiation of substance, but several factors were, after adjustment for other variables. Most pronounced were aggressive temperament, pubertal status, and depressive symptoms, Dr. McCarty and her colleagues found.

The link to early puberty (by sixth grade) found by the investagators is consistent with previous research that examined initiation of alcohol use.

However, the reason for this association remains unclear, according to Dr. McCarty, who is a psychologist who with a dual appointment in pediatrics and psychology at the university.

She suggested that providers take note when a girl or boy enters puberty early (by sixth grade), or shows signs of aggression and/or depression and do a more thorough risk assessment of behavior.

The research was supported by grants from the National Institute of Mental Health.

LOS ANGELES – Sixth graders who showed an aggressive temperament and/or symptoms of depression were more likely than their peers to begin using alcohol and other drugs by eighth grade, according to study findings presented as a poster at the annual meeting of the Society for Adolescent Medicine.

It was the third independent risk factor researchers detected–an early onset of puberty–that was less predictable, and it might be an early red flag for physicians.

Dr. Carolyn A. McCarty and associates from the University of Washington, Seattle, departments of pediatrics and psychology recruited 521 sixth graders from public schools in the Seattle area, interviewing them every 6 months for 2.5 years, until they entered the eighth grade.

Children with conduct problems and/or depressive symptoms on a psychological instrument were oversampled in the survey.

At the study's onset, 5.4% of sixth graders were using any substance, with alcohol the most common (4.2%).

By the study's conclusion, 16.7% of the eighth grade subjects reported using alcohol (13.2%), marijuana (6.8%), tobacco (4.2%), and/or other illicit substances (1.5%).

Sex, race, frustrated temperament, and externalizing symptoms were not significantly, independently associated with initiation of substance, but several factors were, after adjustment for other variables. Most pronounced were aggressive temperament, pubertal status, and depressive symptoms, Dr. McCarty and her colleagues found.

The link to early puberty (by sixth grade) found by the investagators is consistent with previous research that examined initiation of alcohol use.

However, the reason for this association remains unclear, according to Dr. McCarty, who is a psychologist who with a dual appointment in pediatrics and psychology at the university.

She suggested that providers take note when a girl or boy enters puberty early (by sixth grade), or shows signs of aggression and/or depression and do a more thorough risk assessment of behavior.

The research was supported by grants from the National Institute of Mental Health.

LOS ANGELES – Sixth graders who showed an aggressive temperament and/or symptoms of depression were more likely than their peers to begin using alcohol and other drugs by eighth grade, according to study findings presented as a poster at the annual meeting of the Society for Adolescent Medicine.

It was the third independent risk factor researchers detected–an early onset of puberty–that was less predictable, and it might be an early red flag for physicians.

Dr. Carolyn A. McCarty and associates from the University of Washington, Seattle, departments of pediatrics and psychology recruited 521 sixth graders from public schools in the Seattle area, interviewing them every 6 months for 2.5 years, until they entered the eighth grade.

Children with conduct problems and/or depressive symptoms on a psychological instrument were oversampled in the survey.

At the study's onset, 5.4% of sixth graders were using any substance, with alcohol the most common (4.2%).

By the study's conclusion, 16.7% of the eighth grade subjects reported using alcohol (13.2%), marijuana (6.8%), tobacco (4.2%), and/or other illicit substances (1.5%).

Sex, race, frustrated temperament, and externalizing symptoms were not significantly, independently associated with initiation of substance, but several factors were, after adjustment for other variables. Most pronounced were aggressive temperament, pubertal status, and depressive symptoms, Dr. McCarty and her colleagues found.

The link to early puberty (by sixth grade) found by the investagators is consistent with previous research that examined initiation of alcohol use.

However, the reason for this association remains unclear, according to Dr. McCarty, who is a psychologist who with a dual appointment in pediatrics and psychology at the university.

She suggested that providers take note when a girl or boy enters puberty early (by sixth grade), or shows signs of aggression and/or depression and do a more thorough risk assessment of behavior.

The research was supported by grants from the National Institute of Mental Health.

CHICAGO — Ultra-low-cost pregnancy tests seem able to detect human chorionic gonadotropin (HCG) at the same low levels as tests costing many times the price.

What's more, their results may be easier to read, according to a sampling of pregnancy test kits purchased from dollar stores throughout the Lehigh Valley, Pa., region by Dr. Sunaina Sehwani and associates at St. Luke's Hospital and Health Network in Bethlehem, Pa.

When 27 dollar store tests were compared with 27 QuickVue pregnancy tests (Quidel Corp.) using urine-purified HCG, all were positive at levels of 25 mIU/mL and above, the standard sensitivity for pregnancy tests used in physicians' offices and clinics, Dr. Sehwani reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Introduced to the commercial market in 1976, home pregnancy kits have declined in price, from an average of $15-$20 in 1999 to $6-$10 now for standard kits.

Earlier-response kits such as First Response or Walgreens' Early Result cost a bit more ($13-$20) and are advertised as sensitive at 6 days post ovulation and 99% accurate at the day after a missed period or 2 weeks post ovulation.

Dr. Sehwani and associates found that dollar pregnancy tests were 100% accurate at 25 mIU/mL of HCG and above, identical to the QuickVue pregnancy test. In fact, two of five that were tested at a lower level of HCG (20 mIU/mL) also were positive.

The dollar kits included in the study were marketed as New Choice, U-Check, and MD Quality, all manufactured by SCI International Inc.

Both the QuickVue and dollar store tests were read for accuracy by two independent observers at 3 and 10 minutes, as directed. They were also assessed for ease of interpretation by five independent observers, four of whom selected the dollar store tests as more visually interpretable.

“The dollar store pregnancy tests appeared able to detect HCG at the same low levels as the QuickVue urine pregnancy test, and also to be easier to read than the more expensive test,” Dr. Sehwani said.

The QuickVue pregnancy tests were donated by the women's health center of St. Luke's Hospital and Health Network for the study. The research team made no other relevant financial disclosures.

CHICAGO — Ultra-low-cost pregnancy tests seem able to detect human chorionic gonadotropin (HCG) at the same low levels as tests costing many times the price.

What's more, their results may be easier to read, according to a sampling of pregnancy test kits purchased from dollar stores throughout the Lehigh Valley, Pa., region by Dr. Sunaina Sehwani and associates at St. Luke's Hospital and Health Network in Bethlehem, Pa.

When 27 dollar store tests were compared with 27 QuickVue pregnancy tests (Quidel Corp.) using urine-purified HCG, all were positive at levels of 25 mIU/mL and above, the standard sensitivity for pregnancy tests used in physicians' offices and clinics, Dr. Sehwani reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Introduced to the commercial market in 1976, home pregnancy kits have declined in price, from an average of $15-$20 in 1999 to $6-$10 now for standard kits.

Earlier-response kits such as First Response or Walgreens' Early Result cost a bit more ($13-$20) and are advertised as sensitive at 6 days post ovulation and 99% accurate at the day after a missed period or 2 weeks post ovulation.

Dr. Sehwani and associates found that dollar pregnancy tests were 100% accurate at 25 mIU/mL of HCG and above, identical to the QuickVue pregnancy test. In fact, two of five that were tested at a lower level of HCG (20 mIU/mL) also were positive.

The dollar kits included in the study were marketed as New Choice, U-Check, and MD Quality, all manufactured by SCI International Inc.

Both the QuickVue and dollar store tests were read for accuracy by two independent observers at 3 and 10 minutes, as directed. They were also assessed for ease of interpretation by five independent observers, four of whom selected the dollar store tests as more visually interpretable.

“The dollar store pregnancy tests appeared able to detect HCG at the same low levels as the QuickVue urine pregnancy test, and also to be easier to read than the more expensive test,” Dr. Sehwani said.

The QuickVue pregnancy tests were donated by the women's health center of St. Luke's Hospital and Health Network for the study. The research team made no other relevant financial disclosures.

CHICAGO — Ultra-low-cost pregnancy tests seem able to detect human chorionic gonadotropin (HCG) at the same low levels as tests costing many times the price.

What's more, their results may be easier to read, according to a sampling of pregnancy test kits purchased from dollar stores throughout the Lehigh Valley, Pa., region by Dr. Sunaina Sehwani and associates at St. Luke's Hospital and Health Network in Bethlehem, Pa.

When 27 dollar store tests were compared with 27 QuickVue pregnancy tests (Quidel Corp.) using urine-purified HCG, all were positive at levels of 25 mIU/mL and above, the standard sensitivity for pregnancy tests used in physicians' offices and clinics, Dr. Sehwani reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Introduced to the commercial market in 1976, home pregnancy kits have declined in price, from an average of $15-$20 in 1999 to $6-$10 now for standard kits.

Earlier-response kits such as First Response or Walgreens' Early Result cost a bit more ($13-$20) and are advertised as sensitive at 6 days post ovulation and 99% accurate at the day after a missed period or 2 weeks post ovulation.

Dr. Sehwani and associates found that dollar pregnancy tests were 100% accurate at 25 mIU/mL of HCG and above, identical to the QuickVue pregnancy test. In fact, two of five that were tested at a lower level of HCG (20 mIU/mL) also were positive.

The dollar kits included in the study were marketed as New Choice, U-Check, and MD Quality, all manufactured by SCI International Inc.

Both the QuickVue and dollar store tests were read for accuracy by two independent observers at 3 and 10 minutes, as directed. They were also assessed for ease of interpretation by five independent observers, four of whom selected the dollar store tests as more visually interpretable.

“The dollar store pregnancy tests appeared able to detect HCG at the same low levels as the QuickVue urine pregnancy test, and also to be easier to read than the more expensive test,” Dr. Sehwani said.

The QuickVue pregnancy tests were donated by the women's health center of St. Luke's Hospital and Health Network for the study. The research team made no other relevant financial disclosures.

Anthropologist Margaret Mead once said, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

A living embodiment of that sentiment, the Foundation for International Dermatologic Education (FIDE), has been quietly lending a hand to colleagues in developing countries while fostering a rich exchange of dermatologic ideas across borders for 37 years.

A nonprofit organization, FIDE was founded in 1972 by 10 dermatologists from various countries (including 5 from the United States: Dr. Harvey Blank, Dr. Coleman Jacobson, Dr. Eugene Farber, Dr. Morris Samitz, and Dr. Orlando Cañizares (the principal founder and first director general).

In the 1970s, the group attempted to set up a dermatologic training and research center in Addis Ababa, Ethiopia, but was thwarted by political upheaval. The next attempt, a dermatologic clinic at Kamuzu Central Hospital in Malawi, soon became a reality as the only dermatologic teaching center in Southeastern Africa at the time.

From those humble roots, FIDE has greatly expanded both its mission and its membership, and today is at the forefront of a renaissance of global dermatology, both because of expanded technological outreach and the pressing medical needs that come with globalization, said Dr. Sigfrid A. Muller, president of FIDE for the past 10 years and an ardent supporter of international dermatology.

"I've been interested always in international cooperative studies and interchange," said Dr. Muller, recalling early efforts to unite dermatologists through both FIDE and the International Society of Dermatology, an organization with many shared members and ideals.

Through the years, Dr. Muller, retired chair of dermatology at the Mayo Clinic in Rochester, Minn., encountered both apathy and resistance to the notion of bridging cultural differences while assisting developing countries with basic training and clinical dermatologic needs.

A growing band of believers held to the task, however, and international dermatology organizations have flourished. Global dermatology has been embraced as a priority by every major dermatologic organization.

"The science of dermatology has improved tremendously worldwide," he said in an interview in Las Vegas, where he has practiced since his retirement from Mayo in 1995.

Early FIDE efforts, assisted by the International Foundation for Dermatology and the Tanzanian government, established the Regional Dermatology Training Centre in that country, which, under the direction of Dr. Henning Grossman, has trained 63 local non-MD dermatology officers in the diagnosis and treatment of skin diseases.

Further cooperation between FIDE and the Noah Worcester Dermatological Society has extended training to dermatologists; 16 Tanzanian community dermatologists and a Kenyan candidate were trained from 2001 to 2008.

These dermatologists now practice throughout rural Tanzania, profoundly improving the level of care throughout the country, said Dr. Muller.

In addition, FIDE (www.fide-derm.org

Candidates are selected—often by major departments of dermatology or societies in their native countries—on the basis of youth, leadership qualities, clinical skills, investigative and research abilities, and acumen in political outreach, said Dr. Muller.

In some cases, grants are underwritten by pharmaceutical companies such as Galderma, Neutrogena, and Stiefel. Other physicians are sponsored by dermatologists. "We can spend small amounts of money and take someone who's struggling and say to them, 'We believe in you. We're going to give you a scholarship to come to the academy. We believe you will make a difference in your country,'" said Dr. Muller.

Anthropologist Margaret Mead once said, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

A living embodiment of that sentiment, the Foundation for International Dermatologic Education (FIDE), has been quietly lending a hand to colleagues in developing countries while fostering a rich exchange of dermatologic ideas across borders for 37 years.

A nonprofit organization, FIDE was founded in 1972 by 10 dermatologists from various countries (including 5 from the United States: Dr. Harvey Blank, Dr. Coleman Jacobson, Dr. Eugene Farber, Dr. Morris Samitz, and Dr. Orlando Cañizares (the principal founder and first director general).

In the 1970s, the group attempted to set up a dermatologic training and research center in Addis Ababa, Ethiopia, but was thwarted by political upheaval. The next attempt, a dermatologic clinic at Kamuzu Central Hospital in Malawi, soon became a reality as the only dermatologic teaching center in Southeastern Africa at the time.

From those humble roots, FIDE has greatly expanded both its mission and its membership, and today is at the forefront of a renaissance of global dermatology, both because of expanded technological outreach and the pressing medical needs that come with globalization, said Dr. Sigfrid A. Muller, president of FIDE for the past 10 years and an ardent supporter of international dermatology.

"I've been interested always in international cooperative studies and interchange," said Dr. Muller, recalling early efforts to unite dermatologists through both FIDE and the International Society of Dermatology, an organization with many shared members and ideals.

Through the years, Dr. Muller, retired chair of dermatology at the Mayo Clinic in Rochester, Minn., encountered both apathy and resistance to the notion of bridging cultural differences while assisting developing countries with basic training and clinical dermatologic needs.

A growing band of believers held to the task, however, and international dermatology organizations have flourished. Global dermatology has been embraced as a priority by every major dermatologic organization.

"The science of dermatology has improved tremendously worldwide," he said in an interview in Las Vegas, where he has practiced since his retirement from Mayo in 1995.

Early FIDE efforts, assisted by the International Foundation for Dermatology and the Tanzanian government, established the Regional Dermatology Training Centre in that country, which, under the direction of Dr. Henning Grossman, has trained 63 local non-MD dermatology officers in the diagnosis and treatment of skin diseases.

Further cooperation between FIDE and the Noah Worcester Dermatological Society has extended training to dermatologists; 16 Tanzanian community dermatologists and a Kenyan candidate were trained from 2001 to 2008.

These dermatologists now practice throughout rural Tanzania, profoundly improving the level of care throughout the country, said Dr. Muller.

In addition, FIDE (www.fide-derm.org

Candidates are selected—often by major departments of dermatology or societies in their native countries—on the basis of youth, leadership qualities, clinical skills, investigative and research abilities, and acumen in political outreach, said Dr. Muller.

In some cases, grants are underwritten by pharmaceutical companies such as Galderma, Neutrogena, and Stiefel. Other physicians are sponsored by dermatologists. "We can spend small amounts of money and take someone who's struggling and say to them, 'We believe in you. We're going to give you a scholarship to come to the academy. We believe you will make a difference in your country,'" said Dr. Muller.

Anthropologist Margaret Mead once said, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

A living embodiment of that sentiment, the Foundation for International Dermatologic Education (FIDE), has been quietly lending a hand to colleagues in developing countries while fostering a rich exchange of dermatologic ideas across borders for 37 years.

A nonprofit organization, FIDE was founded in 1972 by 10 dermatologists from various countries (including 5 from the United States: Dr. Harvey Blank, Dr. Coleman Jacobson, Dr. Eugene Farber, Dr. Morris Samitz, and Dr. Orlando Cañizares (the principal founder and first director general).

In the 1970s, the group attempted to set up a dermatologic training and research center in Addis Ababa, Ethiopia, but was thwarted by political upheaval. The next attempt, a dermatologic clinic at Kamuzu Central Hospital in Malawi, soon became a reality as the only dermatologic teaching center in Southeastern Africa at the time.

From those humble roots, FIDE has greatly expanded both its mission and its membership, and today is at the forefront of a renaissance of global dermatology, both because of expanded technological outreach and the pressing medical needs that come with globalization, said Dr. Sigfrid A. Muller, president of FIDE for the past 10 years and an ardent supporter of international dermatology.

"I've been interested always in international cooperative studies and interchange," said Dr. Muller, recalling early efforts to unite dermatologists through both FIDE and the International Society of Dermatology, an organization with many shared members and ideals.

Through the years, Dr. Muller, retired chair of dermatology at the Mayo Clinic in Rochester, Minn., encountered both apathy and resistance to the notion of bridging cultural differences while assisting developing countries with basic training and clinical dermatologic needs.

A growing band of believers held to the task, however, and international dermatology organizations have flourished. Global dermatology has been embraced as a priority by every major dermatologic organization.

"The science of dermatology has improved tremendously worldwide," he said in an interview in Las Vegas, where he has practiced since his retirement from Mayo in 1995.

Early FIDE efforts, assisted by the International Foundation for Dermatology and the Tanzanian government, established the Regional Dermatology Training Centre in that country, which, under the direction of Dr. Henning Grossman, has trained 63 local non-MD dermatology officers in the diagnosis and treatment of skin diseases.

Further cooperation between FIDE and the Noah Worcester Dermatological Society has extended training to dermatologists; 16 Tanzanian community dermatologists and a Kenyan candidate were trained from 2001 to 2008.

These dermatologists now practice throughout rural Tanzania, profoundly improving the level of care throughout the country, said Dr. Muller.

In addition, FIDE (www.fide-derm.org

Candidates are selected—often by major departments of dermatology or societies in their native countries—on the basis of youth, leadership qualities, clinical skills, investigative and research abilities, and acumen in political outreach, said Dr. Muller.

In some cases, grants are underwritten by pharmaceutical companies such as Galderma, Neutrogena, and Stiefel. Other physicians are sponsored by dermatologists. "We can spend small amounts of money and take someone who's struggling and say to them, 'We believe in you. We're going to give you a scholarship to come to the academy. We believe you will make a difference in your country,'" said Dr. Muller.

INDIAN WELLS, CALIF. — Insulin resistance precedes and may set the stage for hyperandrogenism in peripubertal girls at risk for polycystic ovary syndrome, researchers concluded in what is believed to be the first prospective, longitudinal study of PCOS development.

Dr. Marc J. Kalan and his associates at the University of Southern California, Los Angeles, enrolled 57 prepubescent Hispanic girls aged 8–13 years who were at high risk for PCOS because they were obese (with a body mass index greater than or equal to the 85th percentile for age and sex), and had a first-degree family member with diabetes.

At yearly intervals for a mean of 4 years, the girls underwent interviews, physical examinations, dual-energy x-ray absorptiometry, and MRI to assess body composition and visceral fat accumulation, fasting serum hormone measurements, and oral and intravenous glucose tolerance testing. Dr. Kalan reported the results at the annual meeting of the Pacific Coast Reproductive Society.

Of the 57 girls, 15 (26%) developed a “PCOS-like” condition: Their menses became irregular at least 2 years after menarche and they had clinical evidence of androgen excess.

No differences were seen between these girls and those who did not develop PCOS-like findings in terms of adiposity, prepubertal insulin and sex hormone levels, or age at menarche (average, 12 years). However, within a year of menarche, they were significantly more insulin resistant than were their peers, reported Dr. Kalan of the division of reproductive endocrinology and infertility at USC.

The girls' testosterone levels were similar to those of girls who did not develop PCOS-like findings at 1 year post menarche, but at 2 years post menarche, they had significantly higher mean testosterone levels. The insulin resistance disparity widened during the second year post menarche.

All differences in study parameters persisted after statistical adjustment for adiposity.

Assessment of insulin values, specifically, insulin resistance, “may be clinically useful to predict PCOS in an overweight, high-risk [Hispanic] population,” the authors concluded.

Dr. Kalan's research was supported by the National Institutes of Health.

INDIAN WELLS, CALIF. — Insulin resistance precedes and may set the stage for hyperandrogenism in peripubertal girls at risk for polycystic ovary syndrome, researchers concluded in what is believed to be the first prospective, longitudinal study of PCOS development.

Dr. Marc J. Kalan and his associates at the University of Southern California, Los Angeles, enrolled 57 prepubescent Hispanic girls aged 8–13 years who were at high risk for PCOS because they were obese (with a body mass index greater than or equal to the 85th percentile for age and sex), and had a first-degree family member with diabetes.

At yearly intervals for a mean of 4 years, the girls underwent interviews, physical examinations, dual-energy x-ray absorptiometry, and MRI to assess body composition and visceral fat accumulation, fasting serum hormone measurements, and oral and intravenous glucose tolerance testing. Dr. Kalan reported the results at the annual meeting of the Pacific Coast Reproductive Society.

Of the 57 girls, 15 (26%) developed a “PCOS-like” condition: Their menses became irregular at least 2 years after menarche and they had clinical evidence of androgen excess.

No differences were seen between these girls and those who did not develop PCOS-like findings in terms of adiposity, prepubertal insulin and sex hormone levels, or age at menarche (average, 12 years). However, within a year of menarche, they were significantly more insulin resistant than were their peers, reported Dr. Kalan of the division of reproductive endocrinology and infertility at USC.

The girls' testosterone levels were similar to those of girls who did not develop PCOS-like findings at 1 year post menarche, but at 2 years post menarche, they had significantly higher mean testosterone levels. The insulin resistance disparity widened during the second year post menarche.

All differences in study parameters persisted after statistical adjustment for adiposity.

Assessment of insulin values, specifically, insulin resistance, “may be clinically useful to predict PCOS in an overweight, high-risk [Hispanic] population,” the authors concluded.

Dr. Kalan's research was supported by the National Institutes of Health.

INDIAN WELLS, CALIF. — Insulin resistance precedes and may set the stage for hyperandrogenism in peripubertal girls at risk for polycystic ovary syndrome, researchers concluded in what is believed to be the first prospective, longitudinal study of PCOS development.

Dr. Marc J. Kalan and his associates at the University of Southern California, Los Angeles, enrolled 57 prepubescent Hispanic girls aged 8–13 years who were at high risk for PCOS because they were obese (with a body mass index greater than or equal to the 85th percentile for age and sex), and had a first-degree family member with diabetes.

At yearly intervals for a mean of 4 years, the girls underwent interviews, physical examinations, dual-energy x-ray absorptiometry, and MRI to assess body composition and visceral fat accumulation, fasting serum hormone measurements, and oral and intravenous glucose tolerance testing. Dr. Kalan reported the results at the annual meeting of the Pacific Coast Reproductive Society.

Of the 57 girls, 15 (26%) developed a “PCOS-like” condition: Their menses became irregular at least 2 years after menarche and they had clinical evidence of androgen excess.

No differences were seen between these girls and those who did not develop PCOS-like findings in terms of adiposity, prepubertal insulin and sex hormone levels, or age at menarche (average, 12 years). However, within a year of menarche, they were significantly more insulin resistant than were their peers, reported Dr. Kalan of the division of reproductive endocrinology and infertility at USC.

The girls' testosterone levels were similar to those of girls who did not develop PCOS-like findings at 1 year post menarche, but at 2 years post menarche, they had significantly higher mean testosterone levels. The insulin resistance disparity widened during the second year post menarche.

All differences in study parameters persisted after statistical adjustment for adiposity.

Assessment of insulin values, specifically, insulin resistance, “may be clinically useful to predict PCOS in an overweight, high-risk [Hispanic] population,” the authors concluded.

Dr. Kalan's research was supported by the National Institutes of Health.

CHICAGO — Cesarean section rates were significantly higher in states with an impending or current medical liability crisis in 2004, a year after 76% of U.S. obstetricians had experienced a litigious event.

This finding from a cross-sectional observational study “may reflect a pattern of 'defensive' medicine in response to liability concerns,” Dr. Elizabeth A. Platz said at the annual meeting of the American College of Obstetricians and Gynecologists.

She and her colleagues investigated whether a correlation existed between C-section rates in individual states in 2004 and the medical liability climates in those same states at that time.

The year 2004 was chosen, because that was the year ACOG issued a state-by-state alert on the status of medical liability coverage availability and costs, said Dr. Platz of the Medical University of South Carolina, Charleston.

The previous year, 76% of all U.S. obstetricians had experienced a litigious event, and the median award for “negligence in birth care” was $2.3 million.

Ob.gyns. were reported to be retiring early, moving to less litigious states, dropping obstetrics, or as the study hypothesized, “turning to C-section deliveries at any sign” of trouble, Dr. Platz said.

Individual states were categorized in that report as “in crisis” (14 states), having a “crisis brewing” (8 states), or “not in crisis” (28 states).

For purposes of statistical adjustment, state demographic and population data were collected from the U.S. Census Bureau and the National Center for Health Statistics.

The mean state C-section rate for the nation in 2004 was 28.1%, ranging from 20.4% to 34.9%, Dr. Platz reported.

In states on ACOG's in-crisis list, the C-section rate was 29.9%, followed by 28.1% in states with a crisis brewing, versus 27.2% in states not considered crisis malpractice states, with significantly higher rates found in the crisis states even after confounding variables, such as other known risks for C-section delivery, were controlled for.

This may lend credence to the theory that pressured physicians practice defensive medicine, said Dr. Platz. She added that the findings highlighted an association, not a causal relationship, which would require more study.

Dr. Platz and her coinvestigators reported no financial conflicts of interest relative to their study.

CHICAGO — Cesarean section rates were significantly higher in states with an impending or current medical liability crisis in 2004, a year after 76% of U.S. obstetricians had experienced a litigious event.

This finding from a cross-sectional observational study “may reflect a pattern of 'defensive' medicine in response to liability concerns,” Dr. Elizabeth A. Platz said at the annual meeting of the American College of Obstetricians and Gynecologists.

She and her colleagues investigated whether a correlation existed between C-section rates in individual states in 2004 and the medical liability climates in those same states at that time.

The year 2004 was chosen, because that was the year ACOG issued a state-by-state alert on the status of medical liability coverage availability and costs, said Dr. Platz of the Medical University of South Carolina, Charleston.

The previous year, 76% of all U.S. obstetricians had experienced a litigious event, and the median award for “negligence in birth care” was $2.3 million.

Ob.gyns. were reported to be retiring early, moving to less litigious states, dropping obstetrics, or as the study hypothesized, “turning to C-section deliveries at any sign” of trouble, Dr. Platz said.

Individual states were categorized in that report as “in crisis” (14 states), having a “crisis brewing” (8 states), or “not in crisis” (28 states).

For purposes of statistical adjustment, state demographic and population data were collected from the U.S. Census Bureau and the National Center for Health Statistics.

The mean state C-section rate for the nation in 2004 was 28.1%, ranging from 20.4% to 34.9%, Dr. Platz reported.

In states on ACOG's in-crisis list, the C-section rate was 29.9%, followed by 28.1% in states with a crisis brewing, versus 27.2% in states not considered crisis malpractice states, with significantly higher rates found in the crisis states even after confounding variables, such as other known risks for C-section delivery, were controlled for.

This may lend credence to the theory that pressured physicians practice defensive medicine, said Dr. Platz. She added that the findings highlighted an association, not a causal relationship, which would require more study.

Dr. Platz and her coinvestigators reported no financial conflicts of interest relative to their study.

CHICAGO — Cesarean section rates were significantly higher in states with an impending or current medical liability crisis in 2004, a year after 76% of U.S. obstetricians had experienced a litigious event.

This finding from a cross-sectional observational study “may reflect a pattern of 'defensive' medicine in response to liability concerns,” Dr. Elizabeth A. Platz said at the annual meeting of the American College of Obstetricians and Gynecologists.

She and her colleagues investigated whether a correlation existed between C-section rates in individual states in 2004 and the medical liability climates in those same states at that time.

The year 2004 was chosen, because that was the year ACOG issued a state-by-state alert on the status of medical liability coverage availability and costs, said Dr. Platz of the Medical University of South Carolina, Charleston.

The previous year, 76% of all U.S. obstetricians had experienced a litigious event, and the median award for “negligence in birth care” was $2.3 million.

Ob.gyns. were reported to be retiring early, moving to less litigious states, dropping obstetrics, or as the study hypothesized, “turning to C-section deliveries at any sign” of trouble, Dr. Platz said.

Individual states were categorized in that report as “in crisis” (14 states), having a “crisis brewing” (8 states), or “not in crisis” (28 states).

For purposes of statistical adjustment, state demographic and population data were collected from the U.S. Census Bureau and the National Center for Health Statistics.

The mean state C-section rate for the nation in 2004 was 28.1%, ranging from 20.4% to 34.9%, Dr. Platz reported.

In states on ACOG's in-crisis list, the C-section rate was 29.9%, followed by 28.1% in states with a crisis brewing, versus 27.2% in states not considered crisis malpractice states, with significantly higher rates found in the crisis states even after confounding variables, such as other known risks for C-section delivery, were controlled for.

This may lend credence to the theory that pressured physicians practice defensive medicine, said Dr. Platz. She added that the findings highlighted an association, not a causal relationship, which would require more study.

Dr. Platz and her coinvestigators reported no financial conflicts of interest relative to their study.

The murder of Dr. George Tiller, a family physician and one of the nation's only providers of late-term abortions, has deepened the anxiety and apprehension of physicians who provide family planning services, especially abortion, according to providers and physicians' organizations.

There is nothing new about the fear that pervades abortion services in the United States, with Dr. Tiller's murder only the latest in a long string of murders, attempted murders, and bombings. Dr. Tiller himself had been shot in both arms in 1993, and his clinic in Wichita, Kan., had been bombed in 1985.

But “when there is a pro-choice [presidential] administration, the fringe violence movement becomes more desperate and acts out,” Dr. Nancy L. Stanwood, a board member of Physicians for Reproductive Choice and Health, said in an interview.

“We knew violence would probably go up. Of course, we are horrified that a murderous act happened so quickly,” said Dr. Stanwood of the department of obstetrics and gynecology at the University of Rochester (N.Y.).

The loss of Dr. Tiller, who Dr. Stanwood described as a careful, compassionate physician, poses a real blow to providers of prenatal care who depended on him for referral of difficult and tragic cases, she said.

“We've all had that dreadful ultrasound result. We all do screening amniocentesis, [chorionic villus sampling], and anatomic ultrasounds, and we know we're going to find terrible things now and then. We could refer patients to him and know he was a colleague with the medical skill and compassion to help these patients at a time of desperate need,” she said.

Dr. Stanwood added that an increase in the number of residency programs and fellowships that train physicians in safe abortion procedures gives her hope that intimidation will not further undermine the availability of family planning services to American women.

But a study by the National Abortion Federation and the American College of Obstetricians and Gynecologists found that antiabortion harassment and violence has been a top contributor to a precipitous decline in the number of abortion providers over the years.

Social stigma and marginalization, professional isolation, and peer pressure also factor into the decline, the study found.

Echoing Dr. Stanwood's predictions, many observers believe that extremist antiabortion rhetoric, as well as more mainstream protests, have escalated in the past few months, following the election of President Obama, who advocated abortion rights during his campaign.

Abortion clinics reported a sharp increase in the number of harassing telephone calls they received during the first 4 months of Mr. Obama's presidency, 1,401, compared with 396 during the last full year of George W. Bush's presidency.

Just weeks before the murder, buses carrying physicians to ACOG's annual meeting in Chicago negotiated a daily gauntlet of protesters lining the route, each displaying oversized, gruesome photographs of purported aborted fetuses. Billboard trucks circled the convention hotels. “Why do you hate babies, doctor?” one sign read.

At the ACOG meeting, researchers from the University of California, San Francisco, reported on findings from interviews with 30 ob.gyns. who had received abortion training at four residency programs 5-10 years previously.

The surveyed physicians detailed a highly adversarial culture surrounding abortion services, identifying professional barriers that included threats from other physicians and administrative hurdles, reported Dr. Jody Steinauer, Lori R. Freedman, Ph.D., and researcher Mitchel Hawkins.

Providing such services “is a great way to make no friends amongst the ob.gyns. and to have no family practice docs refer to you,” said one physician interviewed during the study.

One ob.gyn. recalled a partner asking him to sign a contract with a group that said, “I would not do terminations on certain genetic problems, like trisomy 21.”

Several others received direct intimidation. One potential employer told a candidate for an ob.gyn. position, “If I ever find out you did elective abortions … you'll never practice in [this state] again.”

Against this backdrop of nonviolent pressure, Dr. Tiller's murder may be an anomaly or may signal a return to violence that reached new heights during the 1990s, when President Clinton, another pro-choice advocate, was in office.

In all, there have been 8 murders and 17 attempted murders of physicians and allied health care workers involved in abortion services since 1977, according to statistics from the National Abortion Federation, a membership organization of abortion providers.

Professional organizations reacted swiftly to the murder in Kansas.

“There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it,” ACOG said in a statement. The statement called the killing “chilling and deeply disturbing,” noting that it occurred as the nation's leaders are searching for a “middle ground” on the topic of abortion. “There is no middle ground when it comes to violence of this nature.”

A Kansas man with ties to antigovernment groups and antiabortion protests, Scott Roeder, 51, has been charged with murder and aggravated assault in Dr. Tiller's slaying.

Following the shooting, U.S. Attorney Eric Holder activated the U.S. Marshals Service to increase security for “clinics and individuals” providing abortion services.

The number of U.S. abortion providers has been declining for many years, resulting in a situation in which 87% of U.S. counties (97% of nonmetropolitan counties) had no abortion provider as of 2005, reported the Alan Guttmacher Institute, a policy and research organization.

More than half of abortion providers (82% of large providers) experienced harassment in 2000, with abortion care depending on individuals like Dr. Tiller, who “risked his life on a daily basis,” said Guttmacher president Sharon Camp, Ph.D. “For the women he helped over the years, as well as those who will now have nowhere else to turn, this is an incalculable loss.” The majority of recognized antiabortion groups immediately condemned the killing as incompatible with their antiabortion stance.

“We denounce vigilantism and the cowardly act that took place this morning,” said Troy Newman, director of Operation Rescue, a Kansas-based activist antiabortion group. The group also distanced itself from former Operation Rescue leader Randall Terry, who said that Dr. Tiller was a “mass murderer [who] reaped what he sowed.”

Other individuals, many in anonymous Web postings, expressed satisfaction following the murder, equating it with abortion.

Kansas community activist Regina Dinwiddie, who had protested at Dr. Tiller's clinic, told the Los Angeles Times, “If anybody needed killing, George Tiller needed killing. The gut reaction from everybody who doesn't have their thoughts filtered by fear is 'Yahoo!'”

The National Task Force on Violence Against Health Care Providers, formed by then-Attorney General Janet Reno following the 1998 murder of abortion provider Dr. Barnett A. Slepian, lists nearly 60 safety tips for providers, including, “Do not allow your vehicle to be boxed in. Maintain at least 8 feet between you and the vehicle in front, and avoid the inner lanes.”

Dr. Stanwood said that several physicians had vowed to reopen and staff Dr. Tiller's clinic in Wichita. However, at press time, Dr. Tiller's family announced in a statement that the clinic would be closed permanently.

The murder of Dr. George Tiller, a family physician and one of the nation's only providers of late-term abortions, has deepened the anxiety and apprehension of physicians who provide family planning services, especially abortion, according to providers and physicians' organizations.

There is nothing new about the fear that pervades abortion services in the United States, with Dr. Tiller's murder only the latest in a long string of murders, attempted murders, and bombings. Dr. Tiller himself had been shot in both arms in 1993, and his clinic in Wichita, Kan., had been bombed in 1985.

But “when there is a pro-choice [presidential] administration, the fringe violence movement becomes more desperate and acts out,” Dr. Nancy L. Stanwood, a board member of Physicians for Reproductive Choice and Health, said in an interview.

“We knew violence would probably go up. Of course, we are horrified that a murderous act happened so quickly,” said Dr. Stanwood of the department of obstetrics and gynecology at the University of Rochester (N.Y.).

The loss of Dr. Tiller, who Dr. Stanwood described as a careful, compassionate physician, poses a real blow to providers of prenatal care who depended on him for referral of difficult and tragic cases, she said.

“We've all had that dreadful ultrasound result. We all do screening amniocentesis, [chorionic villus sampling], and anatomic ultrasounds, and we know we're going to find terrible things now and then. We could refer patients to him and know he was a colleague with the medical skill and compassion to help these patients at a time of desperate need,” she said.

Dr. Stanwood added that an increase in the number of residency programs and fellowships that train physicians in safe abortion procedures gives her hope that intimidation will not further undermine the availability of family planning services to American women.

But a study by the National Abortion Federation and the American College of Obstetricians and Gynecologists found that antiabortion harassment and violence has been a top contributor to a precipitous decline in the number of abortion providers over the years.

Social stigma and marginalization, professional isolation, and peer pressure also factor into the decline, the study found.

Echoing Dr. Stanwood's predictions, many observers believe that extremist antiabortion rhetoric, as well as more mainstream protests, have escalated in the past few months, following the election of President Obama, who advocated abortion rights during his campaign.

Abortion clinics reported a sharp increase in the number of harassing telephone calls they received during the first 4 months of Mr. Obama's presidency, 1,401, compared with 396 during the last full year of George W. Bush's presidency.

Just weeks before the murder, buses carrying physicians to ACOG's annual meeting in Chicago negotiated a daily gauntlet of protesters lining the route, each displaying oversized, gruesome photographs of purported aborted fetuses. Billboard trucks circled the convention hotels. “Why do you hate babies, doctor?” one sign read.

At the ACOG meeting, researchers from the University of California, San Francisco, reported on findings from interviews with 30 ob.gyns. who had received abortion training at four residency programs 5-10 years previously.

The surveyed physicians detailed a highly adversarial culture surrounding abortion services, identifying professional barriers that included threats from other physicians and administrative hurdles, reported Dr. Jody Steinauer, Lori R. Freedman, Ph.D., and researcher Mitchel Hawkins.

Providing such services “is a great way to make no friends amongst the ob.gyns. and to have no family practice docs refer to you,” said one physician interviewed during the study.

One ob.gyn. recalled a partner asking him to sign a contract with a group that said, “I would not do terminations on certain genetic problems, like trisomy 21.”

Several others received direct intimidation. One potential employer told a candidate for an ob.gyn. position, “If I ever find out you did elective abortions … you'll never practice in [this state] again.”

Against this backdrop of nonviolent pressure, Dr. Tiller's murder may be an anomaly or may signal a return to violence that reached new heights during the 1990s, when President Clinton, another pro-choice advocate, was in office.

In all, there have been 8 murders and 17 attempted murders of physicians and allied health care workers involved in abortion services since 1977, according to statistics from the National Abortion Federation, a membership organization of abortion providers.

Professional organizations reacted swiftly to the murder in Kansas.

“There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it,” ACOG said in a statement. The statement called the killing “chilling and deeply disturbing,” noting that it occurred as the nation's leaders are searching for a “middle ground” on the topic of abortion. “There is no middle ground when it comes to violence of this nature.”

A Kansas man with ties to antigovernment groups and antiabortion protests, Scott Roeder, 51, has been charged with murder and aggravated assault in Dr. Tiller's slaying.

Following the shooting, U.S. Attorney Eric Holder activated the U.S. Marshals Service to increase security for “clinics and individuals” providing abortion services.

The number of U.S. abortion providers has been declining for many years, resulting in a situation in which 87% of U.S. counties (97% of nonmetropolitan counties) had no abortion provider as of 2005, reported the Alan Guttmacher Institute, a policy and research organization.

More than half of abortion providers (82% of large providers) experienced harassment in 2000, with abortion care depending on individuals like Dr. Tiller, who “risked his life on a daily basis,” said Guttmacher president Sharon Camp, Ph.D. “For the women he helped over the years, as well as those who will now have nowhere else to turn, this is an incalculable loss.” The majority of recognized antiabortion groups immediately condemned the killing as incompatible with their antiabortion stance.

“We denounce vigilantism and the cowardly act that took place this morning,” said Troy Newman, director of Operation Rescue, a Kansas-based activist antiabortion group. The group also distanced itself from former Operation Rescue leader Randall Terry, who said that Dr. Tiller was a “mass murderer [who] reaped what he sowed.”

Other individuals, many in anonymous Web postings, expressed satisfaction following the murder, equating it with abortion.

Kansas community activist Regina Dinwiddie, who had protested at Dr. Tiller's clinic, told the Los Angeles Times, “If anybody needed killing, George Tiller needed killing. The gut reaction from everybody who doesn't have their thoughts filtered by fear is 'Yahoo!'”

The National Task Force on Violence Against Health Care Providers, formed by then-Attorney General Janet Reno following the 1998 murder of abortion provider Dr. Barnett A. Slepian, lists nearly 60 safety tips for providers, including, “Do not allow your vehicle to be boxed in. Maintain at least 8 feet between you and the vehicle in front, and avoid the inner lanes.”

Dr. Stanwood said that several physicians had vowed to reopen and staff Dr. Tiller's clinic in Wichita. However, at press time, Dr. Tiller's family announced in a statement that the clinic would be closed permanently.

The murder of Dr. George Tiller, a family physician and one of the nation's only providers of late-term abortions, has deepened the anxiety and apprehension of physicians who provide family planning services, especially abortion, according to providers and physicians' organizations.

There is nothing new about the fear that pervades abortion services in the United States, with Dr. Tiller's murder only the latest in a long string of murders, attempted murders, and bombings. Dr. Tiller himself had been shot in both arms in 1993, and his clinic in Wichita, Kan., had been bombed in 1985.

But “when there is a pro-choice [presidential] administration, the fringe violence movement becomes more desperate and acts out,” Dr. Nancy L. Stanwood, a board member of Physicians for Reproductive Choice and Health, said in an interview.

“We knew violence would probably go up. Of course, we are horrified that a murderous act happened so quickly,” said Dr. Stanwood of the department of obstetrics and gynecology at the University of Rochester (N.Y.).

The loss of Dr. Tiller, who Dr. Stanwood described as a careful, compassionate physician, poses a real blow to providers of prenatal care who depended on him for referral of difficult and tragic cases, she said.

“We've all had that dreadful ultrasound result. We all do screening amniocentesis, [chorionic villus sampling], and anatomic ultrasounds, and we know we're going to find terrible things now and then. We could refer patients to him and know he was a colleague with the medical skill and compassion to help these patients at a time of desperate need,” she said.

Dr. Stanwood added that an increase in the number of residency programs and fellowships that train physicians in safe abortion procedures gives her hope that intimidation will not further undermine the availability of family planning services to American women.

But a study by the National Abortion Federation and the American College of Obstetricians and Gynecologists found that antiabortion harassment and violence has been a top contributor to a precipitous decline in the number of abortion providers over the years.

Social stigma and marginalization, professional isolation, and peer pressure also factor into the decline, the study found.

Echoing Dr. Stanwood's predictions, many observers believe that extremist antiabortion rhetoric, as well as more mainstream protests, have escalated in the past few months, following the election of President Obama, who advocated abortion rights during his campaign.

Abortion clinics reported a sharp increase in the number of harassing telephone calls they received during the first 4 months of Mr. Obama's presidency, 1,401, compared with 396 during the last full year of George W. Bush's presidency.

Just weeks before the murder, buses carrying physicians to ACOG's annual meeting in Chicago negotiated a daily gauntlet of protesters lining the route, each displaying oversized, gruesome photographs of purported aborted fetuses. Billboard trucks circled the convention hotels. “Why do you hate babies, doctor?” one sign read.

At the ACOG meeting, researchers from the University of California, San Francisco, reported on findings from interviews with 30 ob.gyns. who had received abortion training at four residency programs 5-10 years previously.

The surveyed physicians detailed a highly adversarial culture surrounding abortion services, identifying professional barriers that included threats from other physicians and administrative hurdles, reported Dr. Jody Steinauer, Lori R. Freedman, Ph.D., and researcher Mitchel Hawkins.

Providing such services “is a great way to make no friends amongst the ob.gyns. and to have no family practice docs refer to you,” said one physician interviewed during the study.

One ob.gyn. recalled a partner asking him to sign a contract with a group that said, “I would not do terminations on certain genetic problems, like trisomy 21.”

Several others received direct intimidation. One potential employer told a candidate for an ob.gyn. position, “If I ever find out you did elective abortions … you'll never practice in [this state] again.”

Against this backdrop of nonviolent pressure, Dr. Tiller's murder may be an anomaly or may signal a return to violence that reached new heights during the 1990s, when President Clinton, another pro-choice advocate, was in office.

In all, there have been 8 murders and 17 attempted murders of physicians and allied health care workers involved in abortion services since 1977, according to statistics from the National Abortion Federation, a membership organization of abortion providers.

Professional organizations reacted swiftly to the murder in Kansas.

“There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it,” ACOG said in a statement. The statement called the killing “chilling and deeply disturbing,” noting that it occurred as the nation's leaders are searching for a “middle ground” on the topic of abortion. “There is no middle ground when it comes to violence of this nature.”

A Kansas man with ties to antigovernment groups and antiabortion protests, Scott Roeder, 51, has been charged with murder and aggravated assault in Dr. Tiller's slaying.

Following the shooting, U.S. Attorney Eric Holder activated the U.S. Marshals Service to increase security for “clinics and individuals” providing abortion services.

The number of U.S. abortion providers has been declining for many years, resulting in a situation in which 87% of U.S. counties (97% of nonmetropolitan counties) had no abortion provider as of 2005, reported the Alan Guttmacher Institute, a policy and research organization.

More than half of abortion providers (82% of large providers) experienced harassment in 2000, with abortion care depending on individuals like Dr. Tiller, who “risked his life on a daily basis,” said Guttmacher president Sharon Camp, Ph.D. “For the women he helped over the years, as well as those who will now have nowhere else to turn, this is an incalculable loss.” The majority of recognized antiabortion groups immediately condemned the killing as incompatible with their antiabortion stance.

“We denounce vigilantism and the cowardly act that took place this morning,” said Troy Newman, director of Operation Rescue, a Kansas-based activist antiabortion group. The group also distanced itself from former Operation Rescue leader Randall Terry, who said that Dr. Tiller was a “mass murderer [who] reaped what he sowed.”

Other individuals, many in anonymous Web postings, expressed satisfaction following the murder, equating it with abortion.

Kansas community activist Regina Dinwiddie, who had protested at Dr. Tiller's clinic, told the Los Angeles Times, “If anybody needed killing, George Tiller needed killing. The gut reaction from everybody who doesn't have their thoughts filtered by fear is 'Yahoo!'”

The National Task Force on Violence Against Health Care Providers, formed by then-Attorney General Janet Reno following the 1998 murder of abortion provider Dr. Barnett A. Slepian, lists nearly 60 safety tips for providers, including, “Do not allow your vehicle to be boxed in. Maintain at least 8 feet between you and the vehicle in front, and avoid the inner lanes.”

Dr. Stanwood said that several physicians had vowed to reopen and staff Dr. Tiller's clinic in Wichita. However, at press time, Dr. Tiller's family announced in a statement that the clinic would be closed permanently.

CHICAGO — The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists. Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all 3 calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

CHICAGO — The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists. Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all 3 calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

CHICAGO — The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists. Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all 3 calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

Positive ultrasound markers are highly predictive of a successful pregnancy outcome very early in pregnancy, providing reassurance to patients who have suffered from infertility or recurrent pregnancy losses, researchers reported in two studies.

Fetal cardiac activity, gestational sac diameter, and yolk sac diameter on postconception days 33-36 were all significantly associated with a viable pregnancy beyond 20 weeks' gestation, reported Dr. Soyoung Bae of the University of Toledo (Ohio) Medical Center.

Dr. Bae and Dr. Joseph V. Karnitis of the Fertility Center of Northwest Ohio, also in Toledo, retrospectively evaluated ultrasound results of 1,092 early pregnancies, tracking findings present in those that resulted in a successful pregnancy at 20 weeks' gestation and beyond.

“The majority of these pregnancies were conceived using infertility treatments, and the date of conception was clearly known,” said Dr. Bae during an award-winning paper presentation at the annual meeting of the American College of Obstetricians and Gynecologists.

The presence of cardiac activity during early pregnancy was associated with a 90.4% ongoing pregnancy rate at 20 weeks. Gestational sac diameter of 12 mm and above was a similarly reassuring finding, associated with an ongoing pregnancy rate of 91.9% at 20 weeks. A small gestational sac, less than 8 mm in diameter, was conversely associated with a miscarriage rate of 86.1%.

A yolk sac diameter between 2 mm and 6 mm was most predictive of a successful pregnancy, associated with an ongoing pregnancy rate of 89.2% at 20 weeks. Yolk sacs less than 2 mm in diameter or larger than 6 mm in diameter were associated with poor ongoing success rates of 20.5% and 20%.

An embryo's crown-rump length and fetal heart rate greater than 100 beats per minute predicted viability at 5-6 weeks post conception in a separate study presented at the annual meeting of the Pacific Coast Reproductive Society in Indian Wells, Calif.

Despite positive results on home pregnancy tests, anxiety runs high in couples who have struggled to become pregnant, said Dr. Charles C. Coddington, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

During ultrasounds at 5-6 weeks to establish the intrauterine location of the pregnancy, many patients want an estimate ofthe chances the pregnancy will progress, he said.

While conventional wisdom traditionally held that a fetal heart rate greater than 100 beats per minute was reassuring, there were few data to back that up. In cases where the heart rate was less than 100, “we didn't know whether to be reassuring or concerned,” he explained in an interview.

Dr. Coddington and his associates conducted a retrospective analysis of infertility patients who had undergone early first-trimester ultrasounds with duplex color Doppler imaging.

Viability was 100% in 38 pregnancies in which fetal heart rates exceeded 100 beats per minute and embryos were determined to be growing appropriately at 5-6 weeks based on crown-rump length on ultrasound, explained Dr. Coddington. Among pregnancies with a fetal heart rate less than 100 beats per minute at the first scan, just 5 of 11 progressed.

Fetal heart rate and crown-rump length were strongly correlated, with an R value coefficient of 0.736 and a P value of less than .0001.

When the 5- to 6-week ultrasound shows a reassuring crown-rump length and a fetal heart rate over 100, “we can give very positive reinforcement to couples, which is a wonderful thing you can do for them,” Dr. Coddington said.

Positive ultrasound markers are highly predictive of a successful pregnancy outcome very early in pregnancy, providing reassurance to patients who have suffered from infertility or recurrent pregnancy losses, researchers reported in two studies.

Fetal cardiac activity, gestational sac diameter, and yolk sac diameter on postconception days 33-36 were all significantly associated with a viable pregnancy beyond 20 weeks' gestation, reported Dr. Soyoung Bae of the University of Toledo (Ohio) Medical Center.

Dr. Bae and Dr. Joseph V. Karnitis of the Fertility Center of Northwest Ohio, also in Toledo, retrospectively evaluated ultrasound results of 1,092 early pregnancies, tracking findings present in those that resulted in a successful pregnancy at 20 weeks' gestation and beyond.

“The majority of these pregnancies were conceived using infertility treatments, and the date of conception was clearly known,” said Dr. Bae during an award-winning paper presentation at the annual meeting of the American College of Obstetricians and Gynecologists.

The presence of cardiac activity during early pregnancy was associated with a 90.4% ongoing pregnancy rate at 20 weeks. Gestational sac diameter of 12 mm and above was a similarly reassuring finding, associated with an ongoing pregnancy rate of 91.9% at 20 weeks. A small gestational sac, less than 8 mm in diameter, was conversely associated with a miscarriage rate of 86.1%.

A yolk sac diameter between 2 mm and 6 mm was most predictive of a successful pregnancy, associated with an ongoing pregnancy rate of 89.2% at 20 weeks. Yolk sacs less than 2 mm in diameter or larger than 6 mm in diameter were associated with poor ongoing success rates of 20.5% and 20%.

An embryo's crown-rump length and fetal heart rate greater than 100 beats per minute predicted viability at 5-6 weeks post conception in a separate study presented at the annual meeting of the Pacific Coast Reproductive Society in Indian Wells, Calif.

Despite positive results on home pregnancy tests, anxiety runs high in couples who have struggled to become pregnant, said Dr. Charles C. Coddington, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

During ultrasounds at 5-6 weeks to establish the intrauterine location of the pregnancy, many patients want an estimate ofthe chances the pregnancy will progress, he said.

While conventional wisdom traditionally held that a fetal heart rate greater than 100 beats per minute was reassuring, there were few data to back that up. In cases where the heart rate was less than 100, “we didn't know whether to be reassuring or concerned,” he explained in an interview.

Dr. Coddington and his associates conducted a retrospective analysis of infertility patients who had undergone early first-trimester ultrasounds with duplex color Doppler imaging.

Viability was 100% in 38 pregnancies in which fetal heart rates exceeded 100 beats per minute and embryos were determined to be growing appropriately at 5-6 weeks based on crown-rump length on ultrasound, explained Dr. Coddington. Among pregnancies with a fetal heart rate less than 100 beats per minute at the first scan, just 5 of 11 progressed.

Fetal heart rate and crown-rump length were strongly correlated, with an R value coefficient of 0.736 and a P value of less than .0001.

When the 5- to 6-week ultrasound shows a reassuring crown-rump length and a fetal heart rate over 100, “we can give very positive reinforcement to couples, which is a wonderful thing you can do for them,” Dr. Coddington said.

Positive ultrasound markers are highly predictive of a successful pregnancy outcome very early in pregnancy, providing reassurance to patients who have suffered from infertility or recurrent pregnancy losses, researchers reported in two studies.

Fetal cardiac activity, gestational sac diameter, and yolk sac diameter on postconception days 33-36 were all significantly associated with a viable pregnancy beyond 20 weeks' gestation, reported Dr. Soyoung Bae of the University of Toledo (Ohio) Medical Center.

Dr. Bae and Dr. Joseph V. Karnitis of the Fertility Center of Northwest Ohio, also in Toledo, retrospectively evaluated ultrasound results of 1,092 early pregnancies, tracking findings present in those that resulted in a successful pregnancy at 20 weeks' gestation and beyond.

“The majority of these pregnancies were conceived using infertility treatments, and the date of conception was clearly known,” said Dr. Bae during an award-winning paper presentation at the annual meeting of the American College of Obstetricians and Gynecologists.

The presence of cardiac activity during early pregnancy was associated with a 90.4% ongoing pregnancy rate at 20 weeks. Gestational sac diameter of 12 mm and above was a similarly reassuring finding, associated with an ongoing pregnancy rate of 91.9% at 20 weeks. A small gestational sac, less than 8 mm in diameter, was conversely associated with a miscarriage rate of 86.1%.

A yolk sac diameter between 2 mm and 6 mm was most predictive of a successful pregnancy, associated with an ongoing pregnancy rate of 89.2% at 20 weeks. Yolk sacs less than 2 mm in diameter or larger than 6 mm in diameter were associated with poor ongoing success rates of 20.5% and 20%.

An embryo's crown-rump length and fetal heart rate greater than 100 beats per minute predicted viability at 5-6 weeks post conception in a separate study presented at the annual meeting of the Pacific Coast Reproductive Society in Indian Wells, Calif.

Despite positive results on home pregnancy tests, anxiety runs high in couples who have struggled to become pregnant, said Dr. Charles C. Coddington, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

During ultrasounds at 5-6 weeks to establish the intrauterine location of the pregnancy, many patients want an estimate ofthe chances the pregnancy will progress, he said.

While conventional wisdom traditionally held that a fetal heart rate greater than 100 beats per minute was reassuring, there were few data to back that up. In cases where the heart rate was less than 100, “we didn't know whether to be reassuring or concerned,” he explained in an interview.

Dr. Coddington and his associates conducted a retrospective analysis of infertility patients who had undergone early first-trimester ultrasounds with duplex color Doppler imaging.

Viability was 100% in 38 pregnancies in which fetal heart rates exceeded 100 beats per minute and embryos were determined to be growing appropriately at 5-6 weeks based on crown-rump length on ultrasound, explained Dr. Coddington. Among pregnancies with a fetal heart rate less than 100 beats per minute at the first scan, just 5 of 11 progressed.

Fetal heart rate and crown-rump length were strongly correlated, with an R value coefficient of 0.736 and a P value of less than .0001.

When the 5- to 6-week ultrasound shows a reassuring crown-rump length and a fetal heart rate over 100, “we can give very positive reinforcement to couples, which is a wonderful thing you can do for them,” Dr. Coddington said.

INDIAN WELLS, CALIF. — Infertility specialists at the annual meeting of the Pacific Coast Reproductive Society expressed dismay and frustration at the circumstances surrounding the in vitro fertilization procedure that led to the birth in January of octuplets to a single, unemployed, 33-year-old California woman who already had six children.

“This is unethical. It violates everything we've worked for for 20 years,” said Dr. Robert K. Matteri, a reproductive endocrinologist and infertility specialist in Portland, Ore., during an emotional town hall session during the meeting.

Concerns extended beyond the question of whether six embryos should have been implanted in a woman under the age of 35 years who evidently was not infertile. Reportedly, two of the embryos divided to form homozygous twins, for a total of eight births.

Guidelines of the Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) call for consideration of transfer of a single embryo in women under 35 with a favorable prognosis. “All others in this age group should have no more than two embryos … transferred, in the absence of extraordinary circumstances.”

“There are a lot of reasons this does not reach the standards of care,” said Dr. Paul Magarelli, a reproductive endocrinologist and infertility specialist in private practice in Colorado Springs.

“Who is looking out for the rights of these children?” agreed Dr. William G. Kearns, director of a preimplantation genetic testing laboratory in Rockville, Md.

“What society is really mad at us for is not the “octo,” it's the “Mom,” said Dr. Karen Purcell, a reproductive endocrinologist and infertility specialist in San Jose, Calif.

Despite the violation of voluntary guidelines, the transfer of six embryos “is not really the huge harm,” and would have been viewed as a simple error in judgment if a normally conscientious infertility specialist had been desperate to help a woman who had “been trying to get pregnant for years and years and years,” Dr. Purcell argued. More salient, she said, is the legal, moral, and ethical question, “Who should not be a mom?”

“Actually, I think the bar should be fairly high,” said Dr. Lori Marshall, president of the Pacific Coast Reproductive Society (PCRS) and an infertility specialist in private practice in Seattle.

Some of these quandaries are societal, rather than medical, she stressed.

Indeed, much discussion at the meeting focused on news reports indicating Nadya Suleman had undergone repeated in vitro fertilization (IVF) procedures to have more children despite having no current source of financial support and living in her parents' house, which was in foreclosure. She has indicated in news interviews that three of her older children are disabled.

Some of the ethical issues raised by the Suleman case reminded fertility specialists of dilemmas in their own practices.

Audience members reported struggling with the decision to perform IVF on prospective parents after learning that their previous children had been removed from their homes by Child Protective Services, that prospective parents had criminal records of domestic violence, or that they demonstrated they were not able to reliably keep appointments and follow basic medical advice.

In a newspaper column distributed by the American Forum following the Suleman births, Dr. Marshall wrote that she and her colleagues “cringe” at the glowing publicity given to higher-order multiple births on reality television shows and through “Mother of the Year” contests.

The profound costs and medical risks associated with such gestations deserve a “public outcry,” she wrote.

On the other hand, Dr. Marshall cautioned against an overreaction that could lead to hasty, far-reaching legislation that could supplant well-constructed professional guidelines. Instead, consequences should focus on violations of current standards, she argued.

“In response to the birth of the octuplets, we should punish the rogue physician who completely ignored established standards of care in the field of reproductive medicine,” she wrote.

At the meeting, many members expressed support for issuing a strong, PCRS-endorsed statement of condemnation if future well-publicized cases imply professional irresponsibility or ethical laxity.

In the immediate aftermath of the octuplet case, that proved to be a tricky task, explained Dr. Richard Paulson, who sits on the board of the ASRM, which issued a statement that many PCRS members found too mild.

A statement on Feb. 9 by ASRM President R. Dale McClure expressed “heightened … concerns” following news reports about the IVF role in the births of Ms. Suleman's previous six children and noted that the organization was seeking details from her and her physician.

“We are pleased that the California Medical Board has announced they will be investigating this matter, and we are prepared to assist them in any way we can,” the statement continued.

Without the power to request medical records, the ASRM and other societies had no facts to go on other than what was being broadcast on often-sensational news shows. The physician's name, the number of embryos transferred, and even details about Ms. Suleman's family and financial circumstances were all purely speculative, Dr. Paulson argued.

“What on earth are you going to say? Whatever it was that they did, we strongly condemn it?” he asked rhetorically.

“Everyone was hoping that the California Medical Board would have some sanctions,” said Dr. Russell Foulk, a reproductive endocrinologist and infertility specialist in private practice in Reno, Nev.

However, no specific statutes may have been violated. The Medical Board of California's investigation into the circumstances of the Suleman case is ongoing, according to a spokeswoman at the board's headquarters in Sacramento. The board has not linked a physician's name with the case, although Ms. Suleman has identified Dr. Michael Kamrava of Beverly Hills, Calif. as her infertility specialist for all seven pregnancies.

The presumed facts of the case suggest that Dr. Kamrava, who is not board certified, acted “grossly below the standard of care,” but that may not be enough to justify discipline by the board, said Dr. Paulson, chief of the division of reproductive endocrinology and infertility at the University of Southern California in Los Angeles.

The Centers for Disease Control and Prevention's Fertility Clinic Reports Web site for 2006 includes statistics from Dr. Kamrava's clinic and indicates that the average number of embryos transferred in women under 35 was 3.5. Of a total of 52 cycles in women of all ages, two live births resulted, both in women under 35 and one, a twin gestation.

A spokeswoman at Dr. Kamrava's office, the West Coast IVF Clinic Inc., said he would not be interested in doing an interview for this story.

INDIAN WELLS, CALIF. — Infertility specialists at the annual meeting of the Pacific Coast Reproductive Society expressed dismay and frustration at the circumstances surrounding the in vitro fertilization procedure that led to the birth in January of octuplets to a single, unemployed, 33-year-old California woman who already had six children.

“This is unethical. It violates everything we've worked for for 20 years,” said Dr. Robert K. Matteri, a reproductive endocrinologist and infertility specialist in Portland, Ore., during an emotional town hall session during the meeting.

Concerns extended beyond the question of whether six embryos should have been implanted in a woman under the age of 35 years who evidently was not infertile. Reportedly, two of the embryos divided to form homozygous twins, for a total of eight births.

Guidelines of the Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) call for consideration of transfer of a single embryo in women under 35 with a favorable prognosis. “All others in this age group should have no more than two embryos … transferred, in the absence of extraordinary circumstances.”

“There are a lot of reasons this does not reach the standards of care,” said Dr. Paul Magarelli, a reproductive endocrinologist and infertility specialist in private practice in Colorado Springs.

“Who is looking out for the rights of these children?” agreed Dr. William G. Kearns, director of a preimplantation genetic testing laboratory in Rockville, Md.

“What society is really mad at us for is not the “octo,” it's the “Mom,” said Dr. Karen Purcell, a reproductive endocrinologist and infertility specialist in San Jose, Calif.

Despite the violation of voluntary guidelines, the transfer of six embryos “is not really the huge harm,” and would have been viewed as a simple error in judgment if a normally conscientious infertility specialist had been desperate to help a woman who had “been trying to get pregnant for years and years and years,” Dr. Purcell argued. More salient, she said, is the legal, moral, and ethical question, “Who should not be a mom?”

“Actually, I think the bar should be fairly high,” said Dr. Lori Marshall, president of the Pacific Coast Reproductive Society (PCRS) and an infertility specialist in private practice in Seattle.

Some of these quandaries are societal, rather than medical, she stressed.

Indeed, much discussion at the meeting focused on news reports indicating Nadya Suleman had undergone repeated in vitro fertilization (IVF) procedures to have more children despite having no current source of financial support and living in her parents' house, which was in foreclosure. She has indicated in news interviews that three of her older children are disabled.

Some of the ethical issues raised by the Suleman case reminded fertility specialists of dilemmas in their own practices.

Audience members reported struggling with the decision to perform IVF on prospective parents after learning that their previous children had been removed from their homes by Child Protective Services, that prospective parents had criminal records of domestic violence, or that they demonstrated they were not able to reliably keep appointments and follow basic medical advice.

In a newspaper column distributed by the American Forum following the Suleman births, Dr. Marshall wrote that she and her colleagues “cringe” at the glowing publicity given to higher-order multiple births on reality television shows and through “Mother of the Year” contests.

The profound costs and medical risks associated with such gestations deserve a “public outcry,” she wrote.

On the other hand, Dr. Marshall cautioned against an overreaction that could lead to hasty, far-reaching legislation that could supplant well-constructed professional guidelines. Instead, consequences should focus on violations of current standards, she argued.

“In response to the birth of the octuplets, we should punish the rogue physician who completely ignored established standards of care in the field of reproductive medicine,” she wrote.

At the meeting, many members expressed support for issuing a strong, PCRS-endorsed statement of condemnation if future well-publicized cases imply professional irresponsibility or ethical laxity.

In the immediate aftermath of the octuplet case, that proved to be a tricky task, explained Dr. Richard Paulson, who sits on the board of the ASRM, which issued a statement that many PCRS members found too mild.

A statement on Feb. 9 by ASRM President R. Dale McClure expressed “heightened … concerns” following news reports about the IVF role in the births of Ms. Suleman's previous six children and noted that the organization was seeking details from her and her physician.

“We are pleased that the California Medical Board has announced they will be investigating this matter, and we are prepared to assist them in any way we can,” the statement continued.

Without the power to request medical records, the ASRM and other societies had no facts to go on other than what was being broadcast on often-sensational news shows. The physician's name, the number of embryos transferred, and even details about Ms. Suleman's family and financial circumstances were all purely speculative, Dr. Paulson argued.

“What on earth are you going to say? Whatever it was that they did, we strongly condemn it?” he asked rhetorically.

“Everyone was hoping that the California Medical Board would have some sanctions,” said Dr. Russell Foulk, a reproductive endocrinologist and infertility specialist in private practice in Reno, Nev.

However, no specific statutes may have been violated. The Medical Board of California's investigation into the circumstances of the Suleman case is ongoing, according to a spokeswoman at the board's headquarters in Sacramento. The board has not linked a physician's name with the case, although Ms. Suleman has identified Dr. Michael Kamrava of Beverly Hills, Calif. as her infertility specialist for all seven pregnancies.

The presumed facts of the case suggest that Dr. Kamrava, who is not board certified, acted “grossly below the standard of care,” but that may not be enough to justify discipline by the board, said Dr. Paulson, chief of the division of reproductive endocrinology and infertility at the University of Southern California in Los Angeles.

The Centers for Disease Control and Prevention's Fertility Clinic Reports Web site for 2006 includes statistics from Dr. Kamrava's clinic and indicates that the average number of embryos transferred in women under 35 was 3.5. Of a total of 52 cycles in women of all ages, two live births resulted, both in women under 35 and one, a twin gestation.

A spokeswoman at Dr. Kamrava's office, the West Coast IVF Clinic Inc., said he would not be interested in doing an interview for this story.

INDIAN WELLS, CALIF. — Infertility specialists at the annual meeting of the Pacific Coast Reproductive Society expressed dismay and frustration at the circumstances surrounding the in vitro fertilization procedure that led to the birth in January of octuplets to a single, unemployed, 33-year-old California woman who already had six children.

“This is unethical. It violates everything we've worked for for 20 years,” said Dr. Robert K. Matteri, a reproductive endocrinologist and infertility specialist in Portland, Ore., during an emotional town hall session during the meeting.

Concerns extended beyond the question of whether six embryos should have been implanted in a woman under the age of 35 years who evidently was not infertile. Reportedly, two of the embryos divided to form homozygous twins, for a total of eight births.

Guidelines of the Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) call for consideration of transfer of a single embryo in women under 35 with a favorable prognosis. “All others in this age group should have no more than two embryos … transferred, in the absence of extraordinary circumstances.”

“There are a lot of reasons this does not reach the standards of care,” said Dr. Paul Magarelli, a reproductive endocrinologist and infertility specialist in private practice in Colorado Springs.

“Who is looking out for the rights of these children?” agreed Dr. William G. Kearns, director of a preimplantation genetic testing laboratory in Rockville, Md.

“What society is really mad at us for is not the “octo,” it's the “Mom,” said Dr. Karen Purcell, a reproductive endocrinologist and infertility specialist in San Jose, Calif.

Despite the violation of voluntary guidelines, the transfer of six embryos “is not really the huge harm,” and would have been viewed as a simple error in judgment if a normally conscientious infertility specialist had been desperate to help a woman who had “been trying to get pregnant for years and years and years,” Dr. Purcell argued. More salient, she said, is the legal, moral, and ethical question, “Who should not be a mom?”

“Actually, I think the bar should be fairly high,” said Dr. Lori Marshall, president of the Pacific Coast Reproductive Society (PCRS) and an infertility specialist in private practice in Seattle.

Some of these quandaries are societal, rather than medical, she stressed.

Indeed, much discussion at the meeting focused on news reports indicating Nadya Suleman had undergone repeated in vitro fertilization (IVF) procedures to have more children despite having no current source of financial support and living in her parents' house, which was in foreclosure. She has indicated in news interviews that three of her older children are disabled.

Some of the ethical issues raised by the Suleman case reminded fertility specialists of dilemmas in their own practices.

Audience members reported struggling with the decision to perform IVF on prospective parents after learning that their previous children had been removed from their homes by Child Protective Services, that prospective parents had criminal records of domestic violence, or that they demonstrated they were not able to reliably keep appointments and follow basic medical advice.

In a newspaper column distributed by the American Forum following the Suleman births, Dr. Marshall wrote that she and her colleagues “cringe” at the glowing publicity given to higher-order multiple births on reality television shows and through “Mother of the Year” contests.

The profound costs and medical risks associated with such gestations deserve a “public outcry,” she wrote.

On the other hand, Dr. Marshall cautioned against an overreaction that could lead to hasty, far-reaching legislation that could supplant well-constructed professional guidelines. Instead, consequences should focus on violations of current standards, she argued.

“In response to the birth of the octuplets, we should punish the rogue physician who completely ignored established standards of care in the field of reproductive medicine,” she wrote.

At the meeting, many members expressed support for issuing a strong, PCRS-endorsed statement of condemnation if future well-publicized cases imply professional irresponsibility or ethical laxity.

In the immediate aftermath of the octuplet case, that proved to be a tricky task, explained Dr. Richard Paulson, who sits on the board of the ASRM, which issued a statement that many PCRS members found too mild.

A statement on Feb. 9 by ASRM President R. Dale McClure expressed “heightened … concerns” following news reports about the IVF role in the births of Ms. Suleman's previous six children and noted that the organization was seeking details from her and her physician.

“We are pleased that the California Medical Board has announced they will be investigating this matter, and we are prepared to assist them in any way we can,” the statement continued.

Without the power to request medical records, the ASRM and other societies had no facts to go on other than what was being broadcast on often-sensational news shows. The physician's name, the number of embryos transferred, and even details about Ms. Suleman's family and financial circumstances were all purely speculative, Dr. Paulson argued.

“What on earth are you going to say? Whatever it was that they did, we strongly condemn it?” he asked rhetorically.

“Everyone was hoping that the California Medical Board would have some sanctions,” said Dr. Russell Foulk, a reproductive endocrinologist and infertility specialist in private practice in Reno, Nev.

However, no specific statutes may have been violated. The Medical Board of California's investigation into the circumstances of the Suleman case is ongoing, according to a spokeswoman at the board's headquarters in Sacramento. The board has not linked a physician's name with the case, although Ms. Suleman has identified Dr. Michael Kamrava of Beverly Hills, Calif. as her infertility specialist for all seven pregnancies.

The presumed facts of the case suggest that Dr. Kamrava, who is not board certified, acted “grossly below the standard of care,” but that may not be enough to justify discipline by the board, said Dr. Paulson, chief of the division of reproductive endocrinology and infertility at the University of Southern California in Los Angeles.

The Centers for Disease Control and Prevention's Fertility Clinic Reports Web site for 2006 includes statistics from Dr. Kamrava's clinic and indicates that the average number of embryos transferred in women under 35 was 3.5. Of a total of 52 cycles in women of all ages, two live births resulted, both in women under 35 and one, a twin gestation.

A spokeswoman at Dr. Kamrava's office, the West Coast IVF Clinic Inc., said he would not be interested in doing an interview for this story.