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Home , Reproductive medicine

Gynecology Update Winter 2013

Dear Colleague, We would like to take this opportunity to update you on some of the exciting clinical and research endeavors of the past year within the and gynecology programs at NewYork-Presbyterian Hospital. The Hospital’s affiliations with Columbia University College of and Surgeons and Weill Cornell Medical College continue to provide our physicians and researchers with important opportunities for the development of technologies and that will produce new ways of preventing, diagnosing, and treating the health issues that face women throughout their lifetime.

Frank A. Chervenak, MD Mary E. D’Alton, MD Given Foundation Professor and Chairman Willard C. Rappleye Professor and Chair Obstetrician and Gynecologist-in-Chief Department of Obstetrics and Gynecology Weill Cornell Medical College and Columbia University Medical Center NewYork-Presbyterian Hospital Director of Services, Sloane Hospital for Women (212) 746-1729 Columbia University Medical Center and [email protected] New York-Presbyterian Hospital (212) 305-2377 [email protected]

Clinical and Research Highlights

Dr. Frank A. Chervenak, Chair The work of Dr. Mary E. D’Alton, of Obstetrics and Gynecology Chair, Obstetrics and Gynecology at NewYork-Presbyterian/Weill at NewYork-Presbyterian/ Cornell, is an international Columbia, to advance research, leader in obstetrics and gyne- policy development, and clinical cology. Dr. Chervenak is Vice practice has earned her national President of the International recognition, including the Life- Academy of Perinatal time Achievement Award by and has been elected to the the Society for Maternal Fetal Institute of Medicine. Medicine.

The Departments of Obstetrics and Gynecology at As the following initiatives and programs will illustrate, NewYork-Presbyterian are led by renowned maternal- the physicians and researchers in the Departments fetal medicine specialists – Dr. Frank A. Chervenak of Obstetrics and Gynecology are leaders in their and Dr. Mary E. D’Alton – who have established respective specialties. From adolescent gynecology premier centers for fetal evaluation and diagnosis at to issues and , and their respective campuses. The Departments provide concerns to gynecological malignancies, these a wide range of comprehensive services, from routine specialists continue to make important contributions well-woman care to the most advanced diagnostic to the field of women’s health as advocates and as and treatment programs for disorders of the cervix, health professionals. , vulva, ovaries, and fallopian tubes, as well Benign Gynecology. The Hospital’s gynecologists as urologic disorders. The Hospital’s gynecologists manage a range of benign gynecological conditions – offer nonsurgical and surgical expertise in areas that routine and complex. These include , include pelvic pain, endometriosis, and symptoms and fibroids, ovarian , pelvic pain, symptoms related conditions related to . Minimally invasive to menopause, bleeding disorders, fistulas, and approaches involve the use of robotics and performing conditions of the cervix, such as cervical dysplasia. either through the vagina or laparoscopically Over the past several years, the Hospital’s to achieve maximum success and minimal discomfort. in women with recurrent partially platinum sensitive Dr. Kevin Holcomb, newly named or resistant epithelial ovarian, primary peritoneal, or Director of Gynecologic in the Department of Obstetrics fallopian tube . Additionally a front-line trial is and Gynecology at NewYork-Pres- available that examines this novel targeted biologic in byterian/Weill Cornell, has contrib- conjunction with standard chemotherapy. uted significantly to research in the management of cervical Kevin Holcomb, MD, recently was named Director and the treatment of pre-invasive of and Director of Minimally cervical lesions in HIV-positive Invasive Surgery at NewYork-Presbyterian/Weill Cornell. women. Under his leadership, the gynecologic oncology program continues to develop more effective techniques in chemical, radiological, and surgical treatments for gynecologists have transitioned to an increased use challenging conditions. Dr. Holcomb and his colleagues of minimally invasive procedures and laparoscopic are also pursuing the development of robotic and for conditions that previously required open laparoscopic surgical techniques for gynecologic cancers. surgery. Today, robotics surgery is routinely used for most major gynecologic and urogynecological Researchers at Weill Cornell are investigating procedures, including hysterectomy and sacral various biomarkers as indicators for malignancies in colpopexy. “Our service continues to push the gynecology. Current translational research studies include examining whether the HE4 marker is envelope in minimally invasive approaches, removing a better indicator for recurrence larger masses and reducing the number of open than the current standard of care test, CA-125, and surgeries that were formerly the norm,” says Barry whether biomarkers in vaginal fluid can determine D. Shaktman, MD, who specializes in gynecological malignancy. There are also active collaborations surgery at NewYork-Presbyterian/Weill Cornell. underway with colleagues in basic science to study John C. Evanko, MD, MBA, Division Chief of the molecular characterizations of endometrial and ovarian . Gynecologic Surgery at NewYork-Presbyterian/ Columbia, agrees. Dr. Evanko and his colleagues are experts in the least invasive surgical options, including Dr. Jason D. Wright, an expert in gynecologic cancers and vaginal approaches and laparoscopic or robotic gynecologic surgery at NewYork- techniques. “We can provide patients with less invasive Presbyterian/Columbia, cares alternatives to hysterectomy and myomectomy,” for a large number of women says Dr. Evanko. “We also can perform hysteroscopy with hereditary cancer and procedures in the office setting. And syndromes, women who robotically, we cross over to OB. We are one of the require complex gynecologic procedures, as well as few places in the country doing robotic cerclages women with placenta accreta. followed by successful pregnancy outcomes.”

Gynecologic Oncology. NewYork-Presbyterian’s A study by researchers at the Herbert Irving gynecologic oncologists provide expertise in laparo- Comprehensive Cancer Center (HICCC) at NewYork- scopic and robotic surgery, advanced reconstructive Presbyterian/Columbia, published in the Journal of and complex pelvic surgery, intraoperative radiation Clinical Oncology, suggests that women who have , and chemotherapy – including clinical trials for surgery for ovarian cancer at high-volume hospitals promising chemotherapeutic treatments and targeted have superior outcomes than similar patients at biological therapies – to treat cancer of the reproduc- low-volume hospitals. The improved survival rate tive organs. This complements major programs in is not dependent on a lower rate of complications basic science and translational research also under- following surgery, but on the treatment of the way. The Divisions of Gynecologic Oncology at both complications. Under the direction of lead author NewYork-Presbyterian/Columbia and NewYork- Jason D. Wright, MD, a gynecologic oncologist at Presbyterian/Weill Cornell are participating in a number NewYork-Presbyterian/Columbia, and a member of of innovative national and international clinical trials, the HICCC, the researchers examined the influence including a Phase III trial of paclitaxel plus AMG 386 of hospital volume on complications, failure to

2 rescue from complications, and inpatient mortality . NewYork-Presbyterian/ in ovarian cancer patients aged 18 to 90 who Columbia and NewYork-Presbyterian/Weill Cornell underwent oophorectomy using National Inpatient offer comprehensive, hospital-based reproductive Sample data from 1998 to 2009 – a total of more medicine programs with the expertise required to than 36,000 patients treated at 1,166 hospitals. The treat medically complex patients and challenging study concluded that more effective treatment of cases where the prognosis for success is low. Both complications at high volume centers resulted in programs specialize in basic treatment methods, such superior outcomes. as Clomid cycles, intracytoplasmic injection, and artificial , as well as more advanced . The Departments offer expertise in approaches, including in vitro fertilization and frozen pelvic floor disorders, including urinary incontinence, . Physicians also care for newly stress incontinence, vaginal prolapse, uterine diagnosed cancer patients who are seeking to preserve prolapse, rectal prolapse, cystocele, rectocele, and potential prior to intervention and treatment. vesicovaginal and rectovaginal fistulas. At NewYork-Presbyterian/Columbia, the Department In 2012, NewYork-Presbyterian/Weill Cornell of Obstetrics and Gynecology works in close col- welcomed Tirsit S. Asfaw, MD, a urogynecologist laboration with the Department of Maternal-Fetal who specializes in pelvic floor therapy. Dr. Asfaw’s Medicine, the Carmen and John Thain Center for expertise includes robotic, abdominal, and vaginal Prenatal , and the Reproductive Medicine reconstructive surgery. She completed a residency Program at the Columbia Center for Women’s Repro- in obstetrics and gynecology at New York University ductive Care. Under the direction of Mark V. Sauer, and a fellowship in urogynecology and reconstructive MD, the Columbia Center for Women’s Reproduc- pelvic surgery at the University of Pennsylvania. tive Care provides patients with advanced infertility NewYork-Presbyterian/Columbia welcomed Cara L. care through an interdisciplinary team of physicians, Grimes, MD, a urogynecologist who manages the full nurses, assistants, social workers, and embry- spectrum of female pelvic floor disorders, including pelvic ologists. The Center’s team approach allows for con- organ prolapse, urinary incontinence, recurrent urinary sistent high quality care, as well as the benefits tract , and fistula and urethral diverticulum. of collaboration and shared research. Dr. Sauer, a specialist in reproductive medicine since 1986, is Dr. Grimes pursued residency training in obstetrics and known internationally for his innovative research in gynecology at Johns Hopkins Hospital, and a fellowship assisted and is recognized as one of the in female pelvic medicine and reconstructive surgery at pioneers of and embryo donation. the University of California, San Diego. Most recently, a joint team of scientists from The New Pediatric and Adolescent Gynecology. Gynecologic York Stem Cell Foundation (NYSCF) Laboratory and problems in children and adolescents can be Columbia University Medical Center has developed a hormonal, structural, or functional. “Children and technique that may prevent the inheritance of mito- adolescents with gynecologic problems have unique chondrial diseases in children. The study, published needs and benefit from specialized evaluation, treat- in the December 19, 2012 online edition of Nature ment, and follow-up by a gynecologist with expertise and led by Dr. Sauer and Michio Hirano, MD, at in these disorders,” notes Beth W. Rackow, MD, NewYork-Presbyterian/Columbia and their colleagues Director of the new Pediatric and Adolescent at NYSCF Laboratory, demonstrated how the nucleus Gynecology Service at NewYork-Presbyterian/Morgan of a cell can be transferred successfully between Stanley Children’s Hospital, established in 2012. The human egg cells. This landmark achievement Service provides evaluation and management of carries significant implications for those children who gynecologic disorders, often in consultation with have the potential to inherit mitochondrial disease. other pediatric specialists, with a focus on preserving “This technique may allow us to provide women normal reproductive function and fertility. Dr. Rackow with a therapeutic option that will prevent these dis- has a particular expertise in , orders,” says Dr. Sauer, The scientists plan to move including advanced laparoscopy and hysteroscopy, toward clinical application using this technique. Next management of congenital anomalies of the female steps include the production of more mitochondrial reproductive tract, and polycystic ovarian syndrome.

3 disease-free egg cells and the generation of healthy Montefiore Medical Center, and a fellowship in family progeny in an animal model. planning at Columbia University Medical Center. Her research addresses contraception and and The Ronald O. Perelman and Claudia Cohen Center for procedural pain control. Reproductive Medicine and Infertility (CRMI) at Weill Cornell Medical College and NewYork-Presbyterian Obstetrics. The Perinatal Center at Weill Cornell and Hospital, led by Zev Rosenwaks, MD, works closely the Carmen and John Thain Center for Prenatal with faculty in the Department of Obstetrics and Pediatrics at NewYork-Presbyterian/Morgan Stanley Gynecology and maternal-fetal medicine specialists, Children’s Hospital provide multidisciplinary care – providing patients with the most effective new from prenatal diagnostic testing and genetic counsel- procedures and technologies available in infertility ing to consultations, management, and follow-up of treatment. Dr. Rosenwaks and his colleagues from high risk by a team of maternal-fetal and CRMI were members of the medical team that pediatric experts. Both centers are designated sites of successfully used in vitro fertilization for the first time the North American Fetal Therapy Network, an asso- in the United States in 1981, and Dr. Rosenwaks was ciation of medical centers with established expertise also the first in this country to use donor in fetal surgery and care for complex disorders of the in the treatment of infertility. More recently, fetus. This network enables NewYork-Presbyterian to he and his colleagues have developed capabilities offer patients access to the latest clinical studies. in genetic testing that have made possible pre- “About a third of cases referred to the Carmen and implantation diagnosis to determine whether an John Thain Center for Prenatal Pediatrics involves embryo carries certain inherited traits. congenital heart disease, followed by chest issues, In a study published in the January 3, 2013 edition including diaphragmatic hernia and lung lesions, and of Fertility and Sterility, Dr. Rosenwaks and his co- multiple gestations,” says Lynn L. Simpson, MD, authors – Pak H. Chung, MD; Owen K. Davis, MD; Medical Director of the Carmen and John Thain Eleni Greenwood, MD, MSc; and David E. Reichman, Center for Prenatal Pediatrics. “As the number of MD – investigated whether patients who failed an women having twins has increased, so have the IVF cycle can proceed with a subsequent IVF cycle odds of developing a serious pregnancy complica- after waiting only one , or whether tion called twin-to-twin transfusion syndrome.” This there is a benefit to allowing two or more menstrual disorder affects as many as 15 percent of identical cycles to elapse before proceeding. IVF outcomes twin pregnancies and results from uneven blood flow were compared for 164 patients who waited only between the fetuses. Until recently the outcome was one menstrual cycle versus 557 patients who waited usually death or disabilities for the surviving babies. two or more menstrual cycles. The study revealed The Carmen and John Thain Center is the only pro- that delaying successive IVF cycle start for two or gram in New York to offer a new minimally invasive more menstrual cycles likely offers no advantage over laser treatment for this syndrome, which involves pursuing repeated IVF after one menstrual cycle. coagulating unnecessary and harmful blood connec- tions between the two fetuses. . For more than a decade, Columbia researchers have participated in the NIH Clinical Tri- At NewYork-Presbyterian/Columbia, the newly als Network on Phase I, II, and III trials of new contra- established innovative Mothers’ Center centralizes ceptive methods. Current research focuses on a dose services to give pregnant women with complications finding trial for a new vaginal ring with ethanediol a single point of access to any or rather than ethinyl estradiol and early phase trials to specialty for treatment, leveraging the breadth and discriminate women at high versus low risk of contra- depth of NewYork-Presbyterian/Columbia’s clinical ceptive-associated venous thromboembolism. faculty. NewYork-Presbyterian/Columbia is a major referral center in the country for placenta accreta In 2012, Kathleen Morrell, MD, MSc, a specialist in and is currently involved in a major research study services with expertise in contra- to determine how to prevent and treat this life- ception, joined NewYork-Presbyterian/Columbia. threatening complication involving an abnormally Dr. Morrell completed residency training in obstetrics deep attachment of the placenta. and gynecology at Albert Einstein College of Medicine/

4 A new genetic test has resulted in significantly more resource for perinatal healthcare providers. The book clinically relevant information than the current stan- provides guidelines on effectively diagnosing and dard method of prenatal testing – the result of a large, treating fetal patients, counseling parents faced with multicenter clinical trial led by Ronald J. Wapner, a diagnosis of a fetal abnormality, and providing MD, Vice Chairman for Research for the Department thorough information on managing antepartum, of Obstetrics and Gynecology and Director of Repro- peripartum, and postpartum care. ductive at NewYork-Presbyterian/Columbia. Shari Gelber, MD, PhD, Director of Perinatal Research The test uses microarray analysis to conduct a more at NewYork-Presbyterian/Weill Cornell, has a primary comprehensive examination of a fetus’s DNA than is research focus on innate immune system activation possible with the current standard method, karyotyping, at the maternal-fetal interface in animal models of which is a visual analysis of the fetus’s chromosomes. adverse pregnancy outcome. Dr. Gelber also pursues The first-of-its-kind study was published in the translational research to identify biomarkers of both December 6, 2012, issue of The New England infectious and immune mediated adverse pregnancy Journal of Medicine. “Based on our findings, we outcome. The goal is to identify at-risk populations believe that microarray will and should replace karyo- and design novel treatments. typing as the standard for evaluating chromosomal abnormalities in fetuses,” says Dr. Wapner. Stephen T. Chasen, MD, Director of High Risk Obstetrics at Weill Cornell, conducts research on the early detection The Division of Maternal Fetal Medicine at NewYork- of genetic anomalies. The research of Dr. Chasen and Presbyterian/Columbia participates in a number his colleagues has resulted in the decrease of invasive of nationally competitive studies sponsored by procedures for diagnosing anomalies and the ability to the National Institute of Child Health and Human offer patients more options during their pregnancy. Development (NICHD). Among these are: Amos Grunebaum, MD, Director of Obstetrics, and Maternal Fetal Medicine Unit Network – The Division his team launched a comprehensive obstetrics is one of only 14 centers in this leading collaborative safety program. In a landmark study published in group responsible for cutting-edge findings that change the February 2011 issue of the American Journal of the way obstetrics is practiced. A member for 20 years, Obstetrics & Gynecology, Dr. Grunebaum, who is the Division is among a select number of centers who also Director of Patient Safety for the Department, are leaders in conducting high quality perinatal research. reported that the obstetric safety initiatives begun The Nulliparous Pregnancy Outcomes Study: in 2003 reduced sentinel events, such as avoidable Monitoring Mothers-to-be (nuMoM2b) – The deaths and serious injuries, to zero in 2008-2009. Division is one of only eight sites across the Among the changes implemented were an online county selected competitively to participate in this status board to communicate patient progress; longitudinal first-time study of 10,000 patients who hiring a patient safety nurse to educate staff on will undergo evaluations to identify causes for a bad new emergency protocols, and training for fetal outcome during a first pregnancy. monitoring certification. National Standard for Fetal Growth: Fetal At NewYork-Presbyterian/Weill Cornell, the Obstetric Growth Study – As one of only five institutions Division is actively involved in quality chosen to participate in this study of more than improvement efforts, such as The Joint Commission’s 3,300 Caucasian, African-American, Hispanic, and Culture of Safety initiative, to encourage communica- Asian women, the Division will help to identify tion between team members, drive improvements longitudinally how fetuses grow through frequent in policies and procedures, and maximize behaviors serial ultrasounds and develop a reliable growth that improve patient safety. Obstetric anesthesiolo- standard to distinguish the difference between gists participate in team briefings at the start of shifts normal and abnormal growth in pregnancy. and team huddles throughout the day. The Division also pursues research aimed at improving patient Dr. Mary E. D’Alton is a co-author of Fetology: care and comfort, including a study examining means Diagnosis and Management of the Fetal Patient – for decreasing during elective Cesarean now in its second edition. The comprehensive, highly sections and examining temperature regulation regarded reference book has become an important

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Gynecology Update Winter 2013 during labor epidural analgesia to determine if low- Presbyterian’s Quality and Patient Safety Star Award, dose local anesthetic concentrations cause a rise in recognizing their role in improving patient outcomes. maternal temperature. At NewYork-Presbyterian/Weill Cornell, Dr. Chervenak At NewYork-Presbyterian/Columbia, Richard L. and his colleague, Laurence B. McCullough, PhD, Berkowitz, MD, an internationally recognized expert Baylor College of Medicine and Adjunct Professor of in invasive fetal therapy, and co-recipient of the King Ethics in Obstetrics and Gynecology at Weill Cornell, Faisal Award for Medicine in 2012, heads the Division have collaborated for 30 years – the longest association of Quality Assurance for Obstetrical and Gynecological of a physician and ethicist in the history of ethics in services. Dr. Berkowitz also co-chairs the Committee obstetrics and gynecology and bioethics. Drs. Chervenak for Patient Safety for the America Congress of Obstet- and McCullough published the first book on ethics in rics and Gynecology (ACOG) District II and is a found- obstetrics and gynecology (Ethics in Obstetrics and ing member of ACOG’s national Patient Safety Council. Gynecology, Oxford University Press, 1994). Their In addition to implementing departmental protocols, recent work, appearing in such journals as the American team training, and simulation training and testing, the Journal of Obstetrics and Gynecology and the QA Division has reorganized the triage operation on the American Journal of Bioethics, calls for a clinically com- obstetrical service and reviews every clinical case involv- prehensive, practical approach to ethics in obstetrics ing suboptimal outcomes or “near-misses” with a view and gynecology based on the Professional Responsibility to correcting any systems issues that are uncovered. Model. This model of obstetric ethics rejects simplistic, clinically inadequate approaches in favor of a more Anna Burgansky, MD, Chief of the Obstetrics and complex, clinically appropriate approach based on the Gynecology Division at NewYork-Presbyterian/The Allen physician’s ethical obligations to pregnant, fetal, Hospital, implemented a multidisciplinary simulation and neonatal patients and the professional integrity of training program for Labor and Delivery staff designed clinical practice, research, and education. Using the to improve team response in the diagnosis and treat- Professional Responsibility Model, Drs. Chervenak and ment of obstetrical complications. The simulation drills McCullough have provided practical, ethically justified enhanced teamwork, clinical assessment, and commu- guidance for controversial clinical topics, such as nication skills. In August 2012, Dr. Burgansky and the patient-choice cesarean delivery and home birth, and Labor and Delivery staff were presented with NewYork- for physician leadership of healthcare organizations.

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