UCSF Obstetrics, Gynecology & Reproductive Sciences 2016 Department Report

UCSF Obstetrics, Gynecology and Reproductive Sciences Department Report 2016

Contents 1 Overview Promoting Our Vision of Excellence Department Strategic Plan Department Leadership Department Faculty Department Financial Sources

5 Our Clinical Divisions: Giving Patients Excellent Care Destinations of Choice Obstetrics, Gynecology and Gynecologic Subspecialties Gynecologic Oncology Maternal-Fetal Medicine (MFM) Division Reproductive Endocrinology and Infertility (REI) and Center for Reproductive Health (CRH) Zuckerberg San Francisco General Obstetrics and Gynecology

13 Education: Training the Next Generation Graduate Medical Education/Continuing Medical Education Medical Student Education Program UCSF/Kaiser Permanente Northern California Undergraduate Research Internship (URI) Educational Programs Supported Through Our ZSFG Division

17 Research: Facilitating Discovery, Broadening Understanding Center for Reproductive Sciences UCSF NIH National Center for Translational Research in Reproduction and Infertility (NCTRI) Research within the Obstetrics, Gynecology, and Gynecologic Subspecialties Division Research Within the Gynecologic Oncology Division Research Groups Within the MFM Division Research Projects Within the REI Division Research Within ZSFG Community COORDINATING EDITOR: BRIAN AUERBACH DESIGN: LAURA MYERS DESIGN PHOTOGRAPHY: BRIAN AUERBACH, STEVE BABULJAK, CINDY CHEW, ELISABETH FALL, AUDREY FEELEY, SUSAN MERRELL © 2016 THE REGENTS OF THE UNIVERSITY OF CALIFORNIA

Overview Welcome to the Department of Obstetrics, Gynecology and Reproductive Sciences (ObGyn & RS) at UCSF. Our Department provides outstanding patient care, promotes cutting-edge basic and clinical reproductive science research, educates the next generation of health care providers, and is a leader in women’s health policy research.

This report is designed to give you insight into our achievements and goals, and an introduction to the many people who make our Department so renowned. ObGyn & RS is a preeminent clinical, educational, and academic research Department within the School of Medicine. Our Department’s outstanding team of physicians, scientists, students, residents, fellows, and staff take great pride in our promise to improve the quality of life for all women. We are home to internationally recognized physicians and scientists whose work in the areas of patient care, basic science, clinical investigation, and public health policy research has led to significant advancements in women’s health.

We also promote new technological development and clinical trials in women’s health. Furthermore, our education and training programs attract the highest qualified applicants, ensuring future generations of exceptional healthcare providers and researchers. Our research and educational programs translate the latest in research and training into comprehensive, compassionate care.

I am confident that the mission, vision and values of our Department will be the guiding principles of our thoughtful, collaborative and flexible strategic plan as we advance women’s health worldwide.

Linda C. Giudice, MD, PhD, MSc, Distinguished Professor and Chair, The Robert B. Jaffe MD Endowed Professor in the Reproductive Sciences

In pursuit of excellence, innovation, and leadership, we strive to touch the lives of women in as many ways as possible. To promote and protect women’s health and well being, we provide a wide range of women’s health services, including holistic approaches to wellness through our clinical practices and our scientific endeavors.

Department Report 2015–2016 | 1

OVERVIEW

Promoting Our Vision of Excellence The UCSF Department of Obstetrics, Gynecology and Reproductive Sciences is devoted to improving the lives and health of our patients through excellence, innovation and leadership in patient care, scientific discovery, education, and advocacy. We accomplish this mission by supporting the programmatic initiatives of our outstanding faculty and staff. We are committed to providing quality health care services to all women and their families; educating health care providers and investigators; and conducting research to advance knowledge in our field.

Our Department has received more than $15 million in NIH funding for 2015, ranking first in the United States for ObGyn departments and fourth as a Department within the UCSF School of Medicine.

Our work is spread across five Divisions—Obstetrics, Gynecology and Gynecologic Subspecialites; Gynecologic Oncology (GYN Onc); Maternal-Fetal Medicine (MFM); Reproductive Endocrinology and Infertility (REI); and Obstetrics/Gynecology at Zuckerberg San Francisco General. Our organized research unit, the Center for Reproductive Sciences, conducts cutting edge research in the basic and translational sciences, and programs such as the Bixby Center for Global Reproductive Health, Advancing New Standards In Reproductive Health (ANSIRH) and our Program on Reproductive Health and the Environment (PRHE) work to convert groundbreaking research into women’s health policy, while also conducting independent scientific and policy initiatives.

US News & World Report ranks our services at the UCSF Medical Center as seventh nationally. We continue to be leaders in innovation with our Center for Reproductive Health programs for women and men, our obstetrics and genetics programs, and our gynecologic cancer care.

Our thriving midwifery program at the UCSF Medical Center and Zuckerberg San Francisco General provides expert care and classes such as CenteringPregnancy®, a prenatal care model. In addition to their excellent care for routine pregnancy, our midwives engage as fully integrated clinical partners with our MFM/Obstetrics clinicians caring for the full range of obstetrical patients.

We have a strong and diverse medical education program with our residency program, medical student programs, and fellowships in four areas: Gynecologic Oncology, Reproductive Endocrinology and Infertility, Maternal-Fetal Medicine, which also has a medical genetics component, and Family Planning.

We also have a Women’s Health Clinical Research Fellowship through the US Department of Veterans’ Affairs at the San Francisco VA Hospital.

2 | UCSF Obstetrics Gynecology and Reproductive Sciences

OVERVIEW

Department Strategic Plan In 2012, our Department embarked on a five-year strategic plan to implement our vision to advance and transform women’s health through innovation and discovery.

With a mission to improve the lives and health of all women through excellence, innovation, and leadership in patient care, scientific discovery, education, and advocacy, we agreed on six priorities that continue to drive our strategic planning process: ■■ Shared ■■ Foster

Departmental identity

an environment in which all thrive

■■ Sustainable ■■ Innovative ■■ Become ■■ Attain

financial model

and sustainable education model

the destinations of choice for clinical services

a comprehensive research enterprise

Current initiatives for our Strategic Plan include continuing the collaborative process between Division faculty and investigators and extending into areas such as staff engagement, staff appreciation, assuring Diversity of our Department members, and recruitment. Mechanisms are in place now to share staff and budgetary resources.

Some of our initiatives for 2015–2016 include: ■■ New

staff appreciation initiatives, including combined All-Hands and Staff Appreciation events, August 2015 and May 2016

■■ New

Departmental website launched summer 2015 and continued expansion of web services in 2016

■■ Unconscious ■■ Residency

Bias Workshops

support events

■■ Incentivizing

faculty activity in clinical and academic work, including educational programs

■■ Annual

inventory assessment of educational activities

■■ Grand

Rounds speakers on Diversity, Education, and Engagement

■■ Retreats

Department Leadership Council ■■ Linda

C. Giudice, MD, PhD, MSc, Chair

■■ Amy

(Meg) Autry, MD, Director, Graduate Medical Education

■■ Marcelle

Cedars, MD, Division Chief, REI, Vice Chair for Clinical Operations

■■ Lee-may

Chen, MD, Division Chief, Gynecologic Oncology

■■ Marco

Conti, MD, Director, Center for Reproductive Sciences, Vice Chair for Basic Research

■■ Dana

Gossett, MD, MSCI, Division Chief, Obstetrics, Gynecology, and Gynecologic Subspecialties, and Vice Chair for UCSF Health Regional Women’s Health Strategy

■■ Rachel

Galgoul, Interim Chief Financial Officer

■■ Dixie

Horning, Associate Chair for Administration and Finance

■■ Rebecca

Jackson, MD, Division Chief and Vice Chair

for ZSFG ■■ Miriam

Kuppermann, PhD, MPH, Vice Chair for Clinical & Translational Research

■■ Jeannette

Lager, MD, MPH, Director of Medical Student

Education ■■ Nancy

Milliken, MD, Director, National Center of Excellence in Women’s Health

■■ Mary

Norton, MD, Interim Chief, Maternal Fetal Medicine and Vice Chair for Clinical & Translational Genetics

■■ Jody

Steinauer, MD, Vice Chair for Education

■■ Mari-Paule

Thiet, MD, Vice Chair for Patient Safety and Quality Assurance

Three rotating faculty representatives round out the leadership council.

Department Report 2015–2016 | 3

OVERVIEW

Department Faculty Gynecologic Oncology Edwin Alvarez, MD Jocelyn Chapman, MD Lee-may Chen, MD Yvonne Lin-Liu, MD, MS Karen Smith-McCune, MD, PhD Stephanie Ueda, MD

Maternal-Fetal Medicine (MFM) Judith Bishop, CNM, MPH Tammy Brunk, CNM Shilpa Chetty, MD Jackie Chyu, MD Melinda Fowler, CNM, MSN Kate Frometa, CNM Joanne Gras, DO Juan M. Gonzalez Velez, MD, MS, PhD Thoa Ha, MD Linda Hopkins, MD Lena Kim, MD Miriam Kuppermann, PhD, MPH Ben Li, MD Mary Norton, MD Larry Rand, MD Patricia Robertson, MD Melissa Rosenstein, MD, MAS Kirsten Salmeen, MD Mari-Paule Thiet, MD Vanessa Tilp, CNM Mai-Anh Tran, CNM Stephanie Valderramos, MD, PHD Laura Weil, CNM, NP Sharon Weiner, CNM, MPH Tracey Woodruff, PhD, MPH Sasha Yamnik, CNM Marya Zlatnik, MD, MMS

Obstetrics, Gynecology, and Gynecologic Subspecialties Meg Autry, MD Erin Dainty, MD, MS Elena Gates, MD Mindy Goldman, MD

Dana Gossett, MD, MSCI Tushani Illangasekare, MD Andrea Jackson, MD, MAS Alison Jacoby, MD Vanessa Jacoby, MD, MAS Deborah Kamali, MD Jeannette Lager, MD, MPH Robyn Lamar, MD, MPH Felicia Lester, MD, MPH Nancy Milliken, MD Kavita Mishra, MD Jessica Opoku-Anane, MD, MS Gaetan Pettigrew, MD Tami Rowen, MD, MS George Sawaya, MD Leslee Subak, MD Sara Whetstone, MD, MHS

Reproductive Endocrinology and Infertility (REI) Hakan Cakam, MD, PhD Marcelle Cedars, MD Victor Fujimoto, MD Linda C. Giudice, MD, PhD, MSc Heather Huddleston, MD Evelyn Mok-Lin, MD Martha Noel, MD Paolo Rinaudo, MD, PhD Mitchell Rosen, MD, HCLD

Zuckerberg San Francisco General Obstetrics and Gynecology Deborah Anderson, CNM, MSN Carol Camlin, PhD, MPH* Deborah Cohan, MD, MPH Craig Cohen, MD, MPH* Holly Cost, CNM, MSN Phil Darney, MD, MSc* Ana Delgado, CNM, MS Julio Diaz-Abarca, CNM, MSN Eleanor Drey, MD, EdM* Linda Ennis, CNM, MS Lori Freedman, PhD* Diana Greene Foster, PhD* Daniel Grossman, MD, FACOG*

4 | UCSF Obstetrics Gynecology and Reproductive Sciences

Cynthia Harper, PhD* Margy Hutchison, CNM, MS Rebecca Jackson, MD* Carole Joffe, PhD* J. Joseph Speidel, MD, MPH* Laurie Jurkiewicz, CNM, MS Rachel Kaplan, PhD, MPH* Rebekah Kaplan, CNM, MSN Jennifer Kerns, MD, MS, MPH* Katrina Kimport, PhD, MA* Abner Korn, MD Karen Meckstroth, MD, MPH* Suellen Miller, PhD, RN, CNM, MHA* Kara Myers, CNM, MS Sara Newmann, MD, MPH* Misa Perron-Burdick, MD, MAS Andrea Pfeffer, CNM, MSN Michael Policar, MD, MPH* Carmen Rivera, CNM, MS Sarah Roberts, DrPH* Corinne Rocca, PhD, MPH* Jody Steinauer, MD, MAS* Naomi Stotland, MD Heike Thiel de Bocanegra, PhD, MPH* Juan Vargas, MD Dilys Walker, MD* Ushma Upadhyay, PhD, MPH* *Bixby Center for Global Reproductive Health faculty

OVERVIEW

Department Financial Sources Our Department is a multi-disciplinary organization that encompasses patient care, education, scientific discovery, and public advocacy. We are broadening how we position the Department’s clinical programs in the context of women’s health services at UCSF Medical Center and ZSFG, locally, and in the changing environment of the UCSF Health System. We continue to exceed expectations in Obstetrical services and Prenatal Diagnostic Services at the new UCSF Medical Center at Mission Bay. Our programs at ZSFG continue to lead in women’s healthcare in their new facilities, including a state-of-the-art birth center. We also continue to explore opportunities for services, collaborations, and research between ZSFG & the UCSF Medical Center at Mission Bay.

Total Revenue – UCSF ObGyn & RS Percent of all funding sources – FY17 Plan

Indirect Cost Recovery & Other 2.45%

ZSFG Affiliation Agreement 3.03%

State Funds 1.72%

Clinical Revenue 31.10%

Our overall research enterprise continues to be robust and faculty continue to diversify their funding models to obtain support for new and innovative approaches in their portfolios.

The Center for Reproductive Sciences (CRS) continues to move in a more translational direction to include mechanisms underlying pregnancy disorders, immune tolerance during pregnancy, and the role of inflammation and environment in reproductive disorders.

Looking ahead, we are well-positioned to lay the foundation for a UC-wide program for women’s precision medicine (WPM) that we define in the context of women’s health and diseases that occur only or more commonly in women or have different outcomes or therapies in women. We will draw upon the combined strength of the University of California campuses in women’s health clinically and in research to reach diverse patient populations, advanced our methods with computational tools and biomedical technologies.

Research Revenue 50.70%

Endowment & Gift Revenue 7.00%

Department Report 2015–2016 | 5

Our Clinical Divisions

Giving Patients Excellent Care Our mission is to provide all women who come to us with the highest quality care and with the information needed to make knowledgeable decisions about their health and wellness. Our medical care teams include physicians, nutritionists, nurse specialists, genetic counselors, and health educators, who work together to diagnose, treat, educate and support women in all phases of life. Our renowned physician leaders, our state-of-the-art technology, our pioneering research activities, and our commitment to providing compassionate care place UCSF on the leading edge of women health.

Our Department offers several world-class Divisions devoted to giving our patients the newest and best methods of care known to medical science.

These are: ■■ Obstetrics,

Gynecology and Gynecologic Subspecialities

■■ Gynecologic

Oncology

■■ Maternal-Fetal ■■ Reproductive ■■ Zuckerberg

Medicine

Endocrinology and Infertility

San Francisco General Obstetrics and Gynecology

At every step of the way, we stress the importance of collaborative decision-making, so that patients know they are in control of their care.

Our clinical enterprise also serves an important role in educating students and in conducting research.

6 | UCSF Obstetrics Gynecology and Reproductive Sciences

OUR CLINICAL DIVISIONS

Destinations of Choice Our practice locations throughout San Francisco and beyond

Obstetrics, Gynecology and Gynecologic Subspecialties

Mission Bay Campus

The Division offers comprehensive obstetrical and gynecology services provided by faculty physicians and nurse practitioners across all of our practice sites. Faculty lead specialized programs for the care of women with fibroids and endometriosis. Inpatient and outpatient surgical procedures are performed in the operating rooms at the UCSF Medical Center at Mission Bay and UCSF Medical Center at Mount Zion. Comprehensive inpatient obstetric services in the Mission Bay Labor and Delivery Unit are provided by our faculty, in partnership with midwives and maternal-fetal medicine faculty.

■■ Center

for Reproductive Health 499 Illinois Street, Suite 600 Fertility Practice Fertility Preservation

■■ Betty

Irene Moore Women’s Hospital 1855 Fourth Street Labor & Delivery Prenatal Diagnostic Center Gynecologic Surgeries Gynecologic Oncology Surgeries

■■ Ron

Conway Family Gateway Medical Building 1825 Fourth Street Third Floor: Obstetrics Practice, Gynecology Practice Fourth Floor: Gynecologic Oncology Practice

■■ Bakar

Cancer Hospital 1855 Fourth Street Gynecologic Oncology Practice

■■ Owens

Street ObGyn Practice 1500 Owens Street, Suite 380

Mt. Zion Campus ■■ Women’s

Health Building 2356 Sutter Street Gynecology Practice General Obstetrics Practice Dysplasia Clinic Center for Reproductive Health

Zuckerberg San Francisco General 1001 Potrero Avenue Obstetrics/Gynecology Gynecologic Oncology

Serramonte ObGyn Practice 333 Gellert Blvd., Suite 120, Daly City, CA

Satellite Practices ■■ Gynecologic

Oncology: Greenbrae, Santa Rosa

■■ Prenatal

Diagnostic Center: Fremont, Greenbrae, Monterey, Santa Rosa

US News and World Report ranks our care seventh in the country. We provide routine and specialized care aimed at maintaining health and treating disease.

As part of our well-women gynecology care, we provide consultation and continuing care for a wide spectrum of conditions. All of our practitioners value collaborative decision-making as the most effective way to provide each woman with the care most appropriate for her.

Obstetrics, Gynecology and Gynecologic Subspecialties Leadership ■■ Dana

Gossett, MD, MSCI, Division Chief, Grace Marie Waldrop Chair in Obstetrics and Gynecology

■■ Alison

Jacoby, MD, Director, Comprehensive Fibroid Center and Director, Gynecologic Surgery

■■ Division

faculty who have leadership roles in our Department include: ■■ Amy

(Meg) Autry, MD, Director of Graduate Medical Education and Residency Program Director

■■ Andrea

Jackson, MD, Director of Undergraduate Research Internship

■■ Jeannette

Lager, MD, MPH, Director of Medical Student Education

■■ Jessica

Opoku-Anane, MD, MS, Director of the UCSF Center for Endometriosis

■■ Leslee

Subak, MD, Director, Women’s Health Clinical Research Center

■■ Sara

Whetstone, MD, MHS, Assistant Residency Program Director

Number of faculty: 18 full-time; 2 part-time Number of staff: 30 Number of patients: More than 20,000 per year Department Report 2015–2016 | 7

OUR CLINICAL DIVISIONS

Gynecologic Oncology This Division provides services in our Department and also the NIH National Cancer Institute-designated Helen Diller Family Comprehensive Cancer Center. Aligning the mission of our Department and the Cancer Center, our Division turns the Department’s mission into action through patient care, scientific discovery, education, and advocacy.

We are dedicated to providing high quality and personalized cancer treatment to women with gynecologic malignancies.

This work includes shaping evidence-based clinical practice guidelines; pioneering cancer genetic services, improving patient safety practices for better outcomes; supporting cutting edge and innovative cancer research; and educating the leaders for tomorrow in the Gynecologic Oncology field.

With the continued trend of strong leadership and support within the Department and the Cancer Center, our Division is working diligently to be the number one regional referral center in the San Francisco Bay Area for gynecologic cancer. With cutting-edge technology and personalized medicine for our patients, our faculty are committed to delivering the best, most compassionate and comprehensive care possible.

Patient Care

Gynecologic Oncology Division Leadership

The UCSF Gynecologic Oncology and Surgical Practice is based in the new state-of-the-art UCSF Bakar Cancer Hospital at the UCSF Medical Center on the UCSF Mission Bay campus.

■■ Lee-may

Our practice provides comprehensive gynecologic cancer treatments for cervical, ovarian, fallopian tube, peritoneal, uterine, endometrial, vulva, vaginal, and trophoblastic cancer patients. Procedures include open, laparoscopic and robotic-assisted surgery, chemotherapy and adjuvant therapy. We host a weekly tumor board to discuss patients’ treatment options and symptom management with our multidisciplinary team of colleagues who are radiologists, pathologists, radiation oncologists, nurses, and genetic counselors. In addition, our Gynecologic Cancer Risk Program provides personal genetic counseling for patients who have a familial/genetic predisposition. Preventive measures such as risk-reducing surgery may be offered.

8 | UCSF Obstetrics Gynecology and Reproductive Sciences

Chen, MD, FACS, Division Director; John A. Kerner, MD Distinguished Professorship in Gynecologic Oncology

■■ Karen

Smith-McCune, MD, PhD, Director of Dysplasia Clinic; John A. Kerner, MD Endowed Professorship of Gynecologic Oncology

Number of faculty: 6 full-time; 3 fellows Number of staff: 16 Number of patients: More than 5,000 per year

OUR CLINICAL DIVISIONS

MFM Division Leadership ■■ Mary

Norton, MD, Interim Director, MFM Division; Vice Chair of Clinical and Translational Genetics; and David E. Thorburn, MD, and Kate McKee Thorburn Endowed Chair in Perinatal Medicine and Genetics

■■ Mari-Paule

Thiet, MD, Vice Chair of Patient Safety and Quality Assurance, Chief of Obstetrics, Medical Director of Labor and Delivery

■■ Ben

Li, MD, Associate Chief of Obstetrics, Associate Medical Director of Labor & Delivery

■■ Kirsten

Salmeen, MD, Director of Outpatient Services

■■ Miriam

Kuppermann, PhD, MPH, Vice Chair for Clinical Research, Director of CTSI Resident Research Training Program, Director of Program in Clinical Perinatal and Comparative Effectiveness Research, Deputy Director of Preterm Birth Initiative

Maternal-Fetal Medicine (MFM)

■■ Larry

Rand, MD, Director of Preterm Birth Initiative-CA, Director of Perinatal Services at UCSF Fetal Treatment Center, Lynne and Marc Benioff Endowed Chair in Maternal and Fetal Medicine

The MFM Division provides clinical care and expertise in routine and high-risk obstetrics, labor and delivery, antepartum care, prenatal diagnosis, obstetrical ultrasound and fetal treatment, and is a key stakeholder of the Department’s and UCSF Health’s obstetrical strategy.

■■ Juan

The new Betty Irene Moore Women’s Hospital and the Benioff Children Hospital at Mission Bay enable our obstetrics and MFM specialist teams to utilize the latest technology and expanded capabilities to continue providing family-centered obstetric care.

Number of faculty: 23 MFM division faculty members

The Division has strong clinical/translational and basic research programs in pregnancy outcomes, decisionmaking, placental biology, and environmental reproductive health. In addition, it has a fully accredited fellowship in Maternal Fetal Medicine and Genetics and the National Institutes of Health have honored several junior faculty with Career Development (K) Awards.

When it comes to high-risk obstetrics, the UCSF Medical Center at Mission Bay boasts best-in-class service, including highly experienced clinical faculty, including MFM specialists, obstetricians, Certified Nurse Midwives (CNM), genetic counselors; perinatal research; and our focus on quality throughout the entire patient experience. With the transition from the Parnassus campus to the Mission Bay in February 2015, we have expanded our patient rooms and clinical capacity with the latest design, supporting a comfortable and patient- and family-friendly atmosphere.

Gonzalez, MD, MS, PhD, MFM Fellowship Program Director

■■ Marya

Zlatnik, MD, Associate MFM Fellowship Program Director, Associate Director of Maternal Fetal Health and Environment Program

Over 2,500 deliveries at our new Mission Bay facility Over 22,000 prenatal care visits at our four locations Number of fellows and areas of fellowship: Five fellows in MFM with two as MFM/Genetics fellows (one year with Pediatrics; two years in MFM). The fellowship program provides outstanding clinical training in the areas of obstetrical, medical, and surgical complications of pregnancy. In the Educational Program, inpatient and outpatient teaching of maternal fetal medicine occurs at both the main UCSF campus and at Zuckerberg San Francisco General (ZSFG). Inpatient high-risk obstetrics rotations occur at both hospitals.

Department Report 2015–2016 | 9

OUR CLINICAL DIVISIONS

Reproductive Endocrinology and Infertility (REI) and Center for Reproductive Health (CRH) The REI division is housed in a new home with 30,000 square feet of clinical, lab and procedural space on the Mission Bay campus. To complete our vision to build a world-class Center for the Study of Reproduction, we have proposed an additional 11,000 square feet for clinical expansion, collaborative translational research, and a wellness center.

The clinical program has continued to grow. The Center for Reproductive Health sees patients largely at the Mission Bay Campus, with a smaller presence remaining at Mt. Zion.

CRH provides a broad range of services across the reproductive lifespan from childhood through menopause.

Increasingly we are seeing adolescents and teens with hormonal or anatomic abnormalities, and we are growing our collaborations with the gynecology division and pediatric urology.

We continue to grow our multidisciplinary practice of infertility with collaborations between urology, genetics, and psychology to complement internal expertise in endocrinology, andrology, and embryology. We have expanded fertility preservation (elective egg freezing) to non-cancer patients and have a growing practice in pre-implantation genetic testing. Additionally, we offer services to help grow families across gender and sexual orientation groups.

The UCSF Multidisciplinary Clinic for Women with Polycystic Ovarian Syndrome (PCOS) was established in 2006. The first of its kind, the clinic offers comprehensive care to women with PCOS through a set of two visits. Patients meet with providers from Reproductive Endocrine, Dermatology, Psychology, Nutrition and Genetic Counseling over the course of two visits and receive an in-depth, multidisciplinary diagnostic evaluation and treatment plan as well as counseling about strategies for achieving lifestyle change.

The Fertility Preservation Program is the largest in the country and continues to grow. This program has a commitment to see patients newly diagnosed with cancer within 48 hours and receives one such “urgent” referral on average every other day. This program collaborates closely with multiple disciplines from the UCSF Helen Diller Family Comprehensive Cancer Center and throughout Northern California.

In addition to our thriving REI fellowship program, we are developing plans to add a combined REI/genetics fellowship to the program.

REI and CRH Division Leadership ■■ Marcelle

Cedars, MD, Division Chief; Director, IVF Program; Fellowship Director

■■ Victor

Fujimoto, MD, Director, FDA Compliance; Director, REI Medical Student Education

■■ Evelyn

Mok-Lin, MD, CRH Medical Director; Director, REI Residency Education

■■ Heather

Huddleston, MD, Director, Oocyte Donor Program; Director of the PCOS Clinic

■■ Mitchell

Rosen, MD, HCLD, Director, Embryology Lab; Director, Fertility Preservation Program

REI division faculty: 9 full-time faculty; 6 fellows Number of patients: More than 22,000 annually with 2,360 new patients in fiscal year 2016

10 | UCSF Obstetrics Gynecology and Reproductive Sciences

OUR CLINICAL DIVISIONS

Zuckerberg San Francisco General Obstetrics and Gynecology ZSFG Leadership ■■ Rebecca

Jackson, MD, Chief of Service and Vice Chair

for ZSFG ■■ Abner ■■ Juan ■■ Ana

Korn, MD, Director of Gynecology

Vargas, MD, Director of Obstetrics

Delgado, CNM, Assistant Director of Obstetrics

■■ Margy

Hutchison, CNM, Director of Midwifery

■■ Eleanor

Drey, MD, Medical Director, Women’s Options Center

■■ Misa

Perron-Burdick, MD, MAS, Medical Director, Women’s Health Center

■■ Jody

Steinauer, MD, MAS, Director of Clinical Research, Vice Chair for Education after Director of Clinical Research

■■ Philip

Darney, MD, MSc, Co-Director, Bixby Center for Global Reproductive Health

Number of faculty: 24 clinical faculty 12 PhD faculty in the Bixby Center for Global Reproductive Health 4 Family Planning Fellows

ZSFG Clinical Practice UCSF has partnered with the City since 1873 to provide medical care for San Francisco’s uninsured and underinsured at Zuckerberg San Francisco General and Trauma Center.

The physicians at ZSFG are all UCSF faculty members.

The Department of Obstetrics and Gynecology at ZSFG provides comprehensive obstetric and gynecologic services to the City’s vulnerable and uninsured patients. Our mission is to promote justice, quality, and equity in women’s health care. We do this by: providing exemplary patient care to all women, especially those who are poor and vulnerable; training and inspiring the next generation of reproductive health leaders; and improving policy and practice through research and scholarship. At ZSFG, we teach our resident physicians, medical and nurse midwifery students how to provide high-quality, evidence-based, and culturally humble care. Our certified nurse midwifery faculty are national experts in achieving normal birth and brought CenteringPregnancy®, a popular and effective group prenatal care model, to San Francisco. Our family planning specialists are world leaders in the field offering high quality clinical care combined with policy-changing research.

Number of patients: 25,000 per year

Department Report 2015–2016 | 11

OUR CLINICAL DIVISIONS

Our new hospital, Zuckerberg San Francisco General and Trauma Center, opened May 22, 2016, and features a state-of-the-art Family Birth Center with spacious, private rooms. We offer the choice of delivery by midwives or doctors, labor support by trained doulas, and nurses who are specially trained to support our culturally diverse and socially complex patients. As a certified Baby Friendly Hospital, we are a recognized leader in breastfeeding support. Our Cesarean birth rates are consistently one of the lowest in the Bay Area and our vaginal birth after Cesarean rate is the highest in the state.

ZSFG Fellowships: The Fellowship in Family Planning is a two-year fellowship that focuses on creating leaders in research, teaching and clinical skills in abortion and contraceptive care. All fellows also complete of a Master’s degree in clinical research.

12 | UCSF Obstetrics Gynecology and Reproductive Sciences

The Bixby Center for Global Reproductive Health is a multi-disciplinary group of social scientists and clinicians working on the most pressing reproductive health problems in the U.S. and abroad. We conduct research, training, evaluation, and policy analysis in the areas of family planning, abortion, adolescent reproductive health, sexually transmitted infections (STIs) including HIV, and maternal health. Programs in the Bixby Center are highlighted in the Research section of this report.

Education

Training the Next Generation UCSF prides itself on providing the highest quality education available in any academic health center in the world. Within this rich environment, our Department offers a wide variety of educational programs for students at many different levels of their professional development, including medical, nurse-midwife, nurse practitioner and graduate students, as well as residents, clinical fellows and postdoctoral scholars. We also provide ongoing opportunities for health care practitioners to continue to develop their fund of knowledge in women’s health, integrating the most recent evidence-based medicine with continuing medical education and career development support. The scope of our mission is broad, but a spirit of collaboration and emphasis on individual growth permeate the whole.

Department Report 2015–2016 | 13

EDUCATION

Graduate Medical Education/ Continuing Medical Education We have one of the premier residency programs in the country. Every year we receive more than 500 applications and choose 100 applicants to interview for only nine spots.

We have 36 residents from 24 different medical schools across the country. Forty-seven percent of our residents are underrepresented in medicine. The residents spend approximately one-third of their time in training at the Zuckerberg San Francisco General and half at the Benioff Children’s Hospital and Betty Irene Moore Women’s Hospital. In their third year, our residents can do a four-week rotation at Makerere University and Mulago Hospital in Kampala Uganda.

More than half of our graduates every year pursue additional subspecialty training or enter academic medicine.

Our residents publish in all of the major specialty journals and present at a myriad of meetings, including the annual meetings of the American College of Obstetricians and Gynecologists, the Association of Professors of Gynecology and Obstetrics, the American Urogynecologic Society, the Society of Maternal Fetal Medicine, the Society of Gynecologic Oncologists, and the American Society of Reproductive Medicine.

In 2015, our residency received Song-Brown funding from the State of California to recruit minorities in medicine and train and place them in underserved areas. We have established a new rotation for second-year residents to rotate in federally qualified health centers in the San Francisco Bay Area. We have arranged for speakers who work with marginalized communities to spend time with the residents, and we have facilitated resident attendance at disparity conferences. We have established EMPOWUR (Educating, Mentoring, and Preparing ObGyns to Care for Women in Under-Resourced Communities), a didactic and experiential curriculum to enhance care for marginalized women and prepare learners for careers in low resource settings. We developed an online curriculum for learners in low resource settings and we participate in the STEP-UP program, an interdisciplinary and interprofessional program based at the Zuckerberg San Francisco General designed for residents interested in the care of marginalized populations.

Our Department has traditional fellowships in maternal fetal medicine, family planning, and reproductive endocrinology.

We have had a joint gynecologic oncology fellowship with Stanford and a joint maternal fetal medicine/genetics fellowship with the Department of Pediatrics. Along with

14 | UCSF Obstetrics Gynecology and Reproductive Sciences

the Departments of Internal Medicine, Pediatrics, Psychiatry, and Anesthesia, we participate in the HEAL fellowship program, which works with the domestic Indian Health Service to enable trainees to conduct their clinical work in a global setting. As part of the Preterm Birth Initiative, we sponsor Preterm Birth Fellows. The majority of our fellowship graduates pursue academic careers. We also train and mentor ObGyn-trained physicians in clinical and/or translational research, including a UCSF Master’s Degree in Clinical Research as part of the San Francisco VA Advanced Fellowship in Women’s Health Research.

Our Department sponsors three continuing medical education (CME) courses. The “Antepartum and Intrapartum Management” course serves a multidisciplinary audience of primarily obstetrician/gynecologists and midwives. The “ObGyn: What Does the Evidence Tell Us” course serves obstetrician/gynecologists mainly from the western part of the United States. We also co-sponsor a course with the Department of Medicine titled “Essentials of Women’s Health.” Attendance at these courses averages 200–250 and has been stable or increasing over time.

During the academic year (September–June), our Department hosts weekly Grand Rounds presentations on a variety of topics, including research, clinical activities, and policy initiatives in women’s health. Faculty from other institutions also present at these Grand Rounds.

GME/CME Leadership ■■ Amy

(Meg) Autry, MD, Director, GME and Residency Program

■■ Rebecca

Jackson, MD, Associate Director, Residency

Program ■■ Laura

Pliska, Administrative Manager

EDUCATION

Medical Student Education Program We encourage medical students to become involved with women’s health from the moment they step on campus until the moment they graduate. Our program offers introductory electives; second-year formal ObGyn curriculum and pelvic exam practice; clerkships at 10 sites; research opportunities; fourth-year sub-internships in advanced ObGyn topics; an ObGyn special interest group, and extensive mentoring by residents and faculty.

Highlights by the Numbers ■■ 600

students annually in ObGyn courses (245 in our clinical and research settings)

■■ 10

clerkship sites (Mission Bay/Mount Zion, ZSFG, Kaiser SF, Kaiser Oakland, Kaiser Daly City/Redwood City, CPMC, Highland Alameda County Hospital, UCSF/Fresno, St. Luke’s, and Marin General Hospital)

■■ 335

instructors (125 UCSF faculty, fellows, and residents, and 135 Volunteer Clinical Faculty [VCF], and 75 instructors and residents at other sites)

■■ 25

students in 2015 and successfully matched into ObGyn residencies

■■ 17

students in 2015 and 2016 worked on research projects in ObGyn at UCSF, the NIH, or another academic institution

■■ VCF

provided approximately 18,500 hours of teaching

■■ 25

percent of VCF received student teaching scores at or above 4.5 (5 is highest)

■■ 25

percent of UCSF faculty received student teaching scores at or above 4.5 (5 is highest)

■■ 7

teaching awards were given to our residents and fellows with top teaching scores

Innovations ■■ Collaborated

with our Program on Reproductive Health and the Environment (PRHE) to develop the new “Women’s Health, The Environment, and Physician Activist” elective.

■■ Collaborated

with Ovarian Cancer National Alliance Survivors, Teaching Students Program.

■■ Added

“Minimally Invasive Gynecologic Surgery” elective with Dr. Camran Nezhat.

■■ Developed

a well-received brochure for all instructors, “How to Create an Inclusive and Collaborative Learning Environment.”

■■ Added

Diversity Corner with current articles on diversity in medical education settings to our Student Newsletter, sent out eight times per year to 335 instructors.

■■ Expanded

Evidence-Based Medicine presentation training to Mission Bay site student curriculum.

Department Report 2015–2016 | 15

EDUCATION

UCSF/Kaiser Permanente Northern California Undergraduate Research Internship (URI) To build a more supportive pathway for underrepresented University of California, Berkeley undergraduate students interested in a career in medicine, we continue to develop our Undergraduate Research Internship program (URI).

URI engages 16 interns each year in a meaningful research project, clinical shadowing at UCSF and Kaiser Oakland, didactics, leadership training, and extensive mentoring during the eight-week program, as well as through the medical school application process. The program directors also support the growing network of URI graduates who contribute back through peer-to-peer support and by mentoring new URI interns.

Major achievements of our 106 URI graduates to date include: ■■ 28

graduates have matriculated into medical school, three are currently in residencies, and two are in a Nursing Master’s Program leading to a nurse practitioner certificate.

■■ 30

percent of graduates are earning additional degrees besides the MD/DO degree (MPH, MPP, Master’s in Epidemiology).

■■ 70

percent are involved in research projects while in medical school.

■■ Medical

School admission offers to our URI grads this past year included: UCSF, UCLA, UCSD, UCD, UCI, USC, Stanford, Northwestern, Harvard, Washington University, Columbia, Mount Sinai, and the University of Washington.

■■ Dr.

Patricia Robertson, Co-founder URI Program

■■ Dr.

Andrea Jackson, Co-Director URI

■■ Dr.

Juan Guerra, Co-founder and Co-Director URI

Medical Education Leadership ■■ Jeannette

Lager, MD, MPH, Director of Medical Student Education

■■ Naomi

Stotland, MD, Associate Director of Medical Student Education

16 | UCSF Obstetrics Gynecology and Reproductive Sciences

Educational Programs Supported Through Our ZSFG Division Bridging Interdisciplinary Research Careers in Women’s Health (BIRCWH) program is an NIH-funded career training grant that aims to foster the next generation of women’s health scholars. A joint initiative of UCSF Bixby and the Kaiser Permanente Division of Research, BIRCWH emphasizes novel, interdisciplinary approaches to a wide range of women’s health issues, with a particular focus on translation into policy impact.

The Fellowship in Family Planning is a post-residency clinical training program that delivers advanced research and clinical skills in abortion and contraception. There are 31 programs in the US and Canada. Graduates go on to conduct research and initiate family planning programs in academic medical centers, teaching hospitals, NGOs and research institutions globally.

Innovating Education in Reproductive Health is a digital hub for sharing cutting-edge curricula to teach abortion and family planning to health professionals at all levels. The goal is to support reproductive healthcare clinicians through eLearning, mobile technology and hands-on support. The group produced the first-ever online course about abortion which reached almost 7,000 students from 155 countries.

The Kenneth J. Ryan Residency Program is a national initiative based at the Bixby Center that integrates and enhances family planning training for ObGyn residents in the United States and Canada. The program helps medical school departments ensure that all ObGyn residents are comprehensively trained in evidence-based abortion care and contraception. There are 85 Ryan programs in the U.S. and Canada and more than 4,300 resident physicians have received training.

TEACH, Training in Early Abortion for Comprehensive Healthcare, is an academic-community partnership that has provided training and networking for a number of Northern California Family Medicine residency programs and innovative curricula for primary care providers.

Research

Facilitating Discovery, Broadening Understanding One of the goals of caring for our patients is discovering and developing the latest treatments and technologies. Our research activities span from basic, translational and clinical investigation to patient-centered outcome, epidemiological inquiry, population studies and the development of public health policy. Our interdisciplinary approach brings together our clinical faculty, clinical and postdoctoral fellows, residents and members of our various research units. The spirit of cooperation and innovation, coupled with an unswerving standard of excellence, rank us first in the United States for ObGyn departments.

Department Report 2015–2016 | 17

RESEARCH

Center for Reproductive Sciences Marco Conti, MD, Fred Gellert Endowed Professor and Director Aditi Bhargava, PhD, Professor Susan Fisher, PhD, Professor Jennifer Fung, PhD, Associate Professor Linda C. Giudice, MD, PhD, MSc, Professor, The Robert B. Jaffe, MD Endowed Professor in the Reproductive Sciences Steven Hall, PhD, Professor Diana Laird, PhD, Associate Professor Syndy Mellon, PhD, Professor Miguel Ramalho-Santos, PhD, Associate Professor Joshua Robinson, PhD, Assistant Professor Fred Schaufele, PhD, Professor Stephanie Valderamos, MD, PhD, Assistant Professor Katy Williams, PhD, Associate Professor The Center for Reproductive Sciences (CRS), founded in 1977, is an Organized Research Unit within our Department.

The mission of the CRS is threefold: ■■ Promote

high quality, cutting edge research in the field of reproductive sciences

■■ Facilitate

the transfer of concepts developed in the laboratory to clinical applications

■■ Provide

an integrated interdisciplinary training program for future leaders in the field of reproductive sciences.

The CRS faculty crosses Departments, and currently comprises 12 basic science researchers and 18 physician scientists drawn from the Departments of ObGyn/RS, Pediatrics, Urology, Anatomy and Physiology, Biochemistry, Surgery, Epidemiology and Biostatistics, the General Clinical Research Center, the Cancer Center, and the Center for Regeneration Medicine and Stem Cell Research. The CRS faculty members use state of the art techniques to expand our knowledge of reproductive processes. Molecular, cellular and genetic approaches are used to address fundamental aspects of reproductive sciences, and results are translated to our understanding, diagnosis, and treatment of reproductive disorders. With its research programs, the CRS interfaces with other divisions in the department

18 | UCSF Obstetrics Gynecology and Reproductive Sciences

including the REI, MFM and the Program in Reproductive Health and the Environment.

Principal investigators (PIs) within the CRS act as mentors for scholars in several University-based training activities including the Developmental and Stem Cell Biology Program (DSCB), Programs in Biological Sciences (PIBS) and Biomedical Sciences (BMS), the Molecular Medicine Program, and two national NIH training programs—the Medical Scientist Training Program and the Women’s Reproductive Health Research Career Development Center.

At present, twenty-three postdoctoral fellows, twenty-three graduate students and nine clinical fellows are being trained in CRS laboratories. Those who have graduated recently have gone on to academic positions or are employed in industry or clinics throughout the country in approximately equal number. In addition to the day-to-day training in the laboratories, the CRS provides trainees with several opportunities to present their research at the biweekly CRS workshop and an annual CRS retreat attended by more than 100 scientists.

Areas of focus for CRS investigators include gametogenesis, primordial germ cell development and migration, early embryo development including cell fate decisions and stem cell biology, endometrial development and regeneration, placentation, and immunology of pregnancy.

The CRS houses two Tissue Banks (Placenta and Endometrial) that are National Resources and funded by the NIH for all investigators.

The CRS has a tradition of almost forty years of accomplishments in the field of reproduction. The most recent research breakthroughs of CRS laboratories include the development of new imaging tools to evaluate the ovarian reserve, the discovery of a role for vitamins in epigenetic inheritance, and the elucidation of the biochemical mechanisms triggering ovulation. These discoveries have paved the way for improvements in the outcome of in vitro maturation (IVM), and improved embryo culture in the IVF clinics. Moreover, laboratories in the CRS have developed a high-fidelity molecular classifier to diagnose end stage endometriosis as well as the presence of uterine/ pelvic pathology. This classifier is now being tested at the national level.

RESEARCH

UCSF NIH National Center for Translational Research in Reproduction and Infertility (NCTRI) Linda C. Giudice, MD, PhD, MSc, Principal Investigator and Center Director Co-investigators Marco Conti, MD; Susan Fisher, PhD; Robert Blelloch, MD, PhD; Paolo Rinaudo, MD, PhD; Nadia Roan, PhD; Jennifer Fung, PhD, Core B Director Sindy Mellon, PhD, Core C Director Linda Giudice, MD, PhD, Director, Human Endometrial & DNA Bank Susan Fisher, PhD, Director, Human Placenta Bank Central Theme: Early human development and the origins and biological consequences of human infertility The major goal of our NCTRI Center at UCSF is to translate findings from basic studies to improve the reproductive health of women and men and fertility and outcomes of pregnancies and children conceived by couples with infertility. Our long-term goals are to devise novel strategies for the prevention of infertility and to develop novel fertility diagnostics and targeted therapeutics. To this end our Center integrates the complementary investigative disciplines of molecular, cellular, and stem cell biology and genetics with

clinical investigation to facilitate bench-to-bedside transfer of fundamental knowledge. Project 1 and Core A Pilot are providing novel insights into the molecular basis and molecular markers of oocyte developmental competence and early embryo development in the mouse, critical to improve current assisted reproductive technologies in humans. Understanding mechanisms underlying trophoblast differentiation from progenitors (Project 2) and posttranscriptionally (Project 3) in the human and mouse, respectively, have direct relevance to normal and abnormal placental development and understanding the human pregnancy disorder preeclampsia. Project 4 focuses on human endometrium, the “soil” in which an embryo implants and is directly relevant to infertility (e.g., endometriosis) and implantation disorders with poor pregnancy outcomes (e.g., preeclampsia, fetal growth restriction, miscarriage).

The Pilot project is translational, as it studies mechanisms underlying effects of seminal plasma on endometrial function.

Thus, all of the projects have studies that investigate basic physiology or pathophysiology in humans or are translatable to humans.

The Center for Reproductive Sciences has awarded funding for three Pilot Project Proposals from the UCSF NIH National Center for Translational Research in Reproduction and Infertility (NCTRI). These Pilot projects are related to the Center’s central theme of early human development and the origins and biological consequences of human infertility.

Department Report 2015–2016 | 19

RESEARCH

Research within the Obstetrics, Gynecology, and Gynecologic Subspecialties Division Uterine Fibroids Vanessa Jacoby, MD, MAS; Alison Jacoby, MD — Uterine fibroids are a very common non-cancerous (benign) tumors of the uterus that are present in up to 70% of women before menopause. Fibroids are 3 times as common among African-American women than white women. Fibroids can cause very heavy menstrual cycles, pelvic pressure and discomfort, urinary frequency, and pregnancy complications.

Our research focuses on improving care for women with fibroids by studying new, innovative, safe and effective treatments. For women who prefer to avoid major surgery, we have studied several new treatments to shrink fibroids and alleviate symptoms including MR guided focused ultrasound, radiofrequency ablation, and nonhormonal medications. We also participate in a UC-wide collaboration to conduct studies of new fibroid treatments (UC Fibroid Network) and a nationwide study of 10,000 women to compare the long-term effectiveness of surgical and nonsurgical fibroid treatments.

Surgery to Prevent Cancer in Women with BRCA 1 and 2 Gene Mutations Vanessa Jacoby, MD, MAS; Alison Jacoby, MD — Women with these gene mutations have a high risk of being diagnosed with breast and/or ovarian cancer. These women are often counseled to have their ovaries surgical removed at age <40 years to prevent these familial cancers. However, removing the ovaries induces a premature menopause that may have significant adverse consequences to women.

Our studies evaluate the impact of this premature surgical menopause on cardiovascular health, bone density, sexual function, and overall quality of life. Our aim is to help women keep healthy and feeling well if they decide to remove the ovaries to prevent familiar cancer.

Urinary Incontinence and Lower Urinary Tract Function Leslee Subak, MD — Urinary incontinence affects almost 25% of reproductive age and 50% of post-menopausal women, causing substantial negative impact on quality of life. We are investigating treatments for urinary incontinence and overactive bladder, including randomized clinical trials of a group-based yoga program and paced respiration.

20 | UCSF Obstetrics Gynecology and Reproductive Sciences

We are also evaluating the efficacy and cognitive effects of pharmacological treatment of these conditions in older women. Obesity is one of the strongest risk factors for incontinence and we have conducted a series of studies of diet and surgical weight loss, showing that these are effective treatments for incontinence that also have a cascade of additional health benefits.

Peripartum Mental Health Disorders Dana Gossett, MD, MSCI — Pregnancy and the postpartum period are vulnerable times for the development or worsening of depression, postpartum depression, and other mental health conditions including anxiety disorders, obsessive-compulsive disorders, and post-traumatic stress disorder. This work has focused on better understanding the prevalence of these disorders and their interactions with depression, as well as effects on other obstetric outcomes.

Obstetric Perineal Lacerations Dana Gossett, MD, MSCI — Most women having a first vaginal delivery will experience some degree of tearing of the vagina. For most women, this heals without significant consequences. However, a minority of women have a more serious tear involving the anal sphincter, which can have long-term consequences including anal incontinence. We study modifiable predictors of severe obstetric lacerations and efforts to reduce their occurrence, as well as optimal care when they do occur.

Sexual and Gender Minority (SGM) Health Juno Obedin-Maliver, MD, MPH — Between 2–6% of the U.S. population are lesbian, gay, bisexual, transgender or another sexual and/or gender minority (SGM). Secondary to long-standing stigma and discrimination sexual and gender minority individuals are underserved, understudied, and vulnerable to poor health. Our research includes refining metrics for assessing sexual orientation and gender identity in research studies comprehensive epidemiological studies on SGM health. The PRIDE Study (pridestudy.org) is a community-engaged national prospective longitudinal cohort of SGM people to understand the compressive health implications of being a sexual and or gender minority. We are also investigating sexual and reproductive health of transgender people including the perinatal health and health care needs of transgender men.

RESEARCH

Research Within the Gynecologic Oncology Division Karen Smith-McCune, MD, PhD Pathogenesis of cervical cancer Cervical cancer represents a good example of the failure of the immune system to recognize a tumor antigen, given that human papillomavirus (HPV) is present in >95% of tumors. Our work found that HPV-associated lesions are associated with a robust local immune response including the development of germinal centers in the cervical stroma underlying precancers. This work was the first to show that the cervix is a site of mucosal-associated lymphoid tissue (MALT). Functional analysis of the infiltrating immune cells demonstrated that their properties shifted from being cytotoxic (favoring elimination of HPV) to being immunetolerant in neoplastic HPV infections (favoring immune escape), underscoring the potential to target immune checkpoints for treatment of cervical cancer. The finding that cervical HPV infection results in robust recruitment of HIV target cells led to the hypothesis that HPV might result in increased risk of HIV acquisition, which was validated this hypothesis in a large cohort study in Zimbabwe (co-PI with George Sawaya). The results demonstrated that transient, but not persistent, HPV infection was associated with increased risk of HIV acquisition. These results have implications for the public health benefits of HPV vaccination cancer in areas of high HIV prevalence, beyond the prevention of cervical cancer. In addition, these findings have led to a new focus on the cervix as a potential portal for HIV acquisition. Ongoing research continues to focus on the effects of HPV infection and commonly used contraceptives on the local immune microenvironment of the cervix, to better understand their effects on HIV susceptibility in areas of high prevalence of HPV and cervical cancer.

Jocelyn S. Chapman, MD ■■ Early

detection of ovarian cancer using cell-free DNA

■■ Genomic

characterization of early ovarian cancer and serous tubal intraepithelual carcinoma (STIC)

■■ Immunoprofiling

advanced ovarian cancer

Next-generation sequencing technologies developed in the last ten years have dramatically widened our view into the many kinds of events that are driving tumor biology. Gene fusions, copy number alterations, mutations, epigenetic changes, stromal microenvironment, immunogenicity and transcript level alterations can all be ascertained via the knife of DNA and RNA sequencing. Statistical methods, factor analysis, insights from evolutionary biology and immunology

as well as an understanding of mutation processes at work in tumors can help us distill out the important driver events from the background of non-functional passenger mutations, and give us useful insights into the multiple systemic processes driving tumor progression.

Our team is specifically interested in using these integrated approaches to help understand and improve treatments for gynecologic cancers. However, the “organ of origin” approach has narrowed our view and exploring carcinogenesis pan-cancer will allow for novel insights into uncommon or difficult to treat gynecologic cancers. To this end, we collaborate with clinicians and scientists across oncology with a goal to further a model of cancer medicine in which genetic data is incorporated with immunologic insights and computational and analytical expertise to improve patient care.

Research Groups Within the MFM Division Program in Clinical Perinatal and Comparative Effectiveness Research (PCPCER) Miriam Kuppermann, PhD, MPH, Director. PCPCER is composed of several main parts: ■■ Perinatal

Database Committee improves the quality, accessibility and usability of the perinatal database. We aim to develop and implement a system for requesting access to data or data analysis. From 2001 to 2011, we cleaned up the existing database, starting with the “smart clean” list. Now we are working on creating and implementing new maternal abstraction forms and identifying NICU data we also need. In the future, we plan to insure that APeX will process the data that the new abstract forms are going to collect.

■■ Participant

Recruitment Program implements systems so that investigators inside and outside of the department can obtain specimens from patients on L&D. Some main principles include: Each patient on L&D should be approached once: and only once: to solicit their interest in participating in studies; interested patients should be triaged to studies in a fair way; disruption to clinical care should be minimized; investigators and division should contribute to the support of this program.

■■ MFM

Research Oversight Committee develops recruitment algorithms, reviews, and recruitment numbers and discusses new studies.

Department Report 2015–2016 | 21

RESEARCH

■■ Labor

and Delivery (L&D) Participant Recruitment and Biospecimen Collection Program recruits L&D patients to be study participants.

■■ Outpatient

Recruitment Program recruits outpatients to be study participants.

■■ Seminars

and Works in Progress (WIP) provide venues for MFM fellows and faculty to present work, obtain feedback, and enhance collaborations.

■■ Research

design, statistical, and programming support creates an infrastructure for MFM fellows and faculty to conduct clinical research efficiently.

Center for Maternal-Fetal Precision Medicine Mary E. Norton, MD, Co-Director Tippi MacKenzie, MD, Co-Director (Department of Pediatric Surgery) The UCSF Center for Maternal-Fetal Precision Medicine seeks to translate scientific discoveries into tailored treatments for fetuses, newborns, and pregnant women.

We collect, connect, and apply vast amounts of scientific research data and information about maternal and fetal health to understand why individuals respond differently to treatments and therapies, and which course is best for a specific patient.

Because many illnesses have their origin in the very earliest stages of life, the Center has catalyzed interest from researchers in fields as diverse as blood disorders, autism, and preterm labor. The UCSF Center for Maternal-Fetal Medicine synergizes the many threads of research and clinical care underway at UCSF, accelerating breakthrough discoveries that will fundamentally change our understanding of health and disease.

The Center is co-directed by Tippi MacKenzie, MD, a fetal and pediatric surgeon, immunologist, and stem cell researcher; and Mary E. Norton, MD, a maternal-fetal medicine specialist and clinical geneticist. In collaboration with a broad spectrum of researchers, clinicians, and community partners, the Center applies 21st century tools to improve the care of fetuses and expectant mothers.

22 | UCSF Obstetrics Gynecology and Reproductive Sciences

Program on Reproductive Health and the Environment (PRHE) Tracey Woodruff, PhD, MPH, Director PRHE works at the intersection of science, medicine, policy, and community. We conduct targeted research and translate scientific findings in order to expand clinical practice and to advance science-based policy solutions. Drawing from PRHE’s multidisciplinary approach, our clinical research focus is on expanding our understanding of sources and exposures to environmental chemicals during development and effects on health. We prioritize filling gaps in knowledge that support clinical decision-making and public policy.

PRHE’s research strategy is to expand knowledge of prenatal exposures to chemicals, focusing on: ■■ Identifying

the major sources of exposure to chemicals that are ubiquitous in our environment in order to support effective strategies for reducing and preventing harmful exposures.

■■ Increasing

our understanding of fetal exposures to chemicals during key periods of prenatal development in order to improve the accuracy of health-based decision and policy-making as well as epidemiologic and clinical research.

■■ Illuminating

the potential impacts of prenatal exposures on health throughout life in order to expand our understanding of many common chronic childhood and adult diseases and disabilities.

Pre-Term Birth Initiative (PTBi-CA) Larry Rand, MD, Director Across the globe, one in 10 babies are born preterm. More than 1 million children die each year from the complications of preterm birth. Many survivors face lifelong disability.

Progress to understand the causes of prematurity and to reduce its incidence has been slow. While some effective interventions do exist, failure to implement them at scale hampers preterm birth prevention and efforts to improve outcomes of babies born preterm. In 2014, philanthropists Marc and Lynne Benioff envisioned a game-changing initiative at UCSF that could achieve real breakthroughs in this space.

RESEARCH

The California Preterm Birth Initiative (PTBi-CA) is especially dedicated to reducing disparities in preterm birth experienced by women of color and in low income women through a “place-based” research approach in three geographic demonstration sites (San Francisco, Oakland and Fresno) that engages and partners directly with highly impacted communities and related stakeholders.

Susan Fisher Group Susan Fisher, PhD, Principal Investigator The Fisher Group works in three areas. The first is reproductive biology, focusing on the human placenta. We study the mechanisms that human cytotrophoblasts use to invade the uterus and the resident arterioles in normal pregnancy and the defects in this process that are associated with preeclampsia. We also study the initial steps of human embryonic and extraembryonic development using human embryos and human embryonic stem cell models. In addition, a portion of the Fisher Group uses mass spectrometry tools and functional glycomics and proteomics approaches to investigate many normal vs. disease states including endometriosis, cystic fibrosis, Sjögren’s syndrome and breast cancer.

Research Projects Within the REI Division Ovarian Aging Marcelle Cedars, MD; Mitchell Rosen, MD; Charles McCulloch, PhD (Epidemiology/Biostatistics), Rita Redberg, MD (cardiology); Elizabeth Blackburn, PhD; Elissa Epel, PhD Women are a special group where microvascular disease is more common and traditional risk factors may not fully identify risk. Women’s reproductive history (e.g. menarcheal age, menstrual cycles, infertility, pregnancy, menopause) may pose unique risk and suggests an opportunity for new approaches. We propose a women-centered approach for early identification of women at cardiovascular disease (CVD) risk that investigates the unique loss of reproductive function at an age long before other vital systems fail.

Not only does the loss of ovarian function have a profound impact of reproduction, especially as more women enter the workforce and delay childbearing, but if accelerated ovarian aging is associated with long-term CVD risk, this knowledge would allow a unique opportunity to identify young at-risk women. Our studies seek to provide data on

Department Report 2015–2016 | 23

RESEARCH

the normal trajectory of ovarian aging in a young, longitudinal, community-based, multi-ethnic cohort (OVA) and insight into the association of ovarian age with long-term health risks such as CVD. We propose this risk is independent of the well-known impact of early menopause and estrogen deficiency. Rather, we hypothesize common cellular mechanisms underlie both ovarian aging and CVD risk, but are first evident in the ovary due to its sensitivity and earlier demise, making the ovary a window on underlying somatic health. Our novel longitudinal approach to evaluating markers of ovarian and cellular aging as predictors of CVD could lead to a new way to identify women at earlier and/or increased CVD risk and be used to develop new riskreduction strategies.

Long-term Outcome of Assisted Reproduction (newly funded) Marcelle Cedars, MD; Paolo Rinaudo, MD, PhD; Mary Norton, MD; Susan Fisher, PhD; Lydia Zablotsky, PhD (Epidemiology/Biostatistics); Robert Lustig, MD (Pediatric Endocrinology) The number of pregnancies conceived with assisted reproductive technology (ART) has dramatically increased over the last 30 years. Additionally, techniques developed for in vitro fertilization (IVF) are now utilized without in vitro

24 | UCSF Obstetrics Gynecology and Reproductive Sciences

culture. These widely-used non-IVF fertility treatments (NIFT) have increased the number of children potentially at risk for adverse health effects. Increased short-term risks for perinatal complications and birth defects, following ART, are well-known. However, the risk of these adverse outcomes has been difficult to characterize as studies used different methodologies, varied age of detection, and did not have appropriate comparison groups. For example, when underlying parental factors and infertility are included in the analyses of birth defects, the association is substantially weakened or disappears completely. More importantly, while the long-term health of children born through these technologies is of critical public health interest, and of personal interest to families, only limited data exist. In order to evaluate the potential risk for long-term health of children conceived through ART and NIFT, rigorous epidemiological methods, appropriate characterization of the exposure, standardized collection of outcome data, and appropriate comparison groups are required. We propose to establish a Developmental Epidemiological Study of Children born through Reproductive Technology (DESCRT) by linking the electronic medical records (EMR) of patients treated at UCSF with birth outcomes and health data. Our studies focus on potential metabolic risk for children given the strong preliminary data in an animal model from the lab of Paolo Rinaudo.

RESEARCH

Study of Metals/Chemicals in Assisted Reproductive Technology Victor Fujimoto, MD, Principal Investigator Exposure to chemical pollutants is widespread and can affect reproduction. Prior research strongly suggests that environmental contaminants may directly alter various aspects of human reproduction. We need further research to pinpoint what chemical pollutants affect the reproductive system and what levels of exposure are safe. The overarching aim of the SMART study is to assess the impact of toxic trace element and chemical exposures on IVF outcomes. We are studying infertility couples to understand the impact. The study includes an online dietary and cigarette smoking questionnaires while at the Center.

Follicular and seminal fluid metals, organic chemical concentrations and anti-oxidant enzyme activities will be measured and associated with a spectrum of IVF outcomes from response to stimulation through live birth. With these data, we can develop recommendations that will help people improve their chances of having a baby from IVF.

Investigating the Long Term Effects of in vitro Fertilization Paolo Rinaudo, MD, PhD, Principal Investigator The focus of our research is to understand how in vitro fertilization and in vitro culture during the pre-implantation period affect fetal and adult development. This has particular relevance in light of the widespread use of artificial reproductive techniques (ART). In fact, fetal adaptations in utero to adverse conditions can lead to specific diseases in the adult, including diabetes, high blood pressure and coronary heart disease. This phenomenon, termed the developmental origin of adult health and disease or the Barker hypothesis, has been extrapolated back to preimplantation development. http://rinaudolab.ucsf.edu/rinaudolab/

Study of Metals/Chemicals in Assisted Reproductive Technology Victor Fujimoto, MD, Principal Investigator Exposure to chemical pollutants is widespread and can affect reproduction. Prior research strongly suggests that environmental contaminants may directly alter various aspects of human reproduction. We need further research to pinpoint what chemical pollutants affect the reproductive

system and what levels of exposure are safe. The overarching aim of the SMART study is to assess the impact of toxic trace element and chemical exposures on IVF outcomes. We are studying infertility couples to understand the impact. The study includes an online dietary and cigarette smoking questionnaires while at the Center.

Follicular and seminal fluid metals, organic chemical concentrations and anti-oxidant enzyme activities will be measured and associated with a spectrum of IVF outcomes from response to stimulation through live birth. With these data, we can develop recommendations that will help people improve their chances of having a baby from IVF.

Fertility Preservation Program Mitchell Rosen, MD; Emily Mok-Lin, MD; Hakan Cakmak, MD The Fertility Preservation Program research focus is to personalize how cancer treatments influence reproductive potential and to develop alternative ways to stimulate ovaries when undergoing ART for fertility preservation that minimizes any potential delays for cancer treatment and maximizes success. Several manuscripts have been published that have had a key impact in this field. One study in particular, focused on new estimates for how treatments influence reproductive capacity. A second study, focused on an alternative way to stimulate ovaries when undergoing fertility preservation that minimizes any potential delays for cancer treatment. The alternative method of stimulation is a random start at any point in the cycle. These studies have been referenced numerous times and are now practiced nationally and internationally.

UCSF PCOS Cohort Study and Clinical Research Program Heather Huddleston, MD; Marcelle Cedars, MD; Lauri Pasch, PhD (Psychiatry); Kinade Shinkai, MD (Dermatology) The cohort study has been enrolling patients since 2007 and now represents the largest cohort of women with PCOS in North America (n=575). Enrollment is on-going, with approximately 6-8 subjects per month consenting to participate. This cohort is also well-characterized: clinical symptoms, trans-vaginal ultrasound, physical and dermatologic exam, laboratory data (hormonal and metabolic findings), detailed family history and validated questionnaire data are systematically maintained in a database. Our team has been highly productive in publishing findings using

Department Report 2015â&#x20AC;&#x201C;2016 | 25

RESEARCH

cross-sectional, longitudinal and biobank data, including investigations of exercise, aging, depression and ethnicity.

We have recently expanded the cohort to include a longitudinal component that involves subject re-evaluation (mean follow-up time of 2-3 years). In addition we currently have several small randomized controlled trials currently enrolling subjects from the clinic. The cohort has also been used in collaborations with both basic scientists (Giudice Lab) and clinicians from other disciplines (Gastroenterology) and we are currently building additional collaborations with Neuroscience.

Research Within ZSFG Bixby Center for Global Reproductive Health The Bixby Center for Global Reproductive Health merges social science with clinical science to improve reproductive and sexual health for women around the world. Founded in 1999, the Bixby Center includes more than 150 talented faculty, fellows, and staff representing a range of disciplines, including nursing, medicine, sociology, anthropology, demography, epidemiology, law, and public health, and hailing from numerous UCSF departments and institutes, such as the Departments of Obstetrics, Gynecology & Reproductive Sciences, Pediatrics, and Family and Community Medicine; and the Philip R. Lee Institute for Health Policy Studies and Global Health Sciences. Over the years, Bixby’s work has changed policy, clinical care, medical education and laws. For example, Bixby researchers have: ■■ Played

a part in testing every contraceptive method currently approved by the US Food and Drug Administration

■■ Provided

the evidence that advanced practice clinicians (e.g., nurse practitioners) can safely perform early abortions which led to one of the few recent state laws expanding access to abortion care

■■ Showed

that every dollar spent on family planning services saves over $9 in public sector expenditures and that providing a year’s supply of birth control pills results in more women sticking with the method over time

Bixby’s education programs have reached thousands of medical and nursing students, resident physicians and family planning fellows to improve their knowledge and skills related

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to abortion and contraception. Bixby’s global health researchers have developed a model for understanding how migration contributes to HIV risks in women in Africa, examined HIV/AIDS among transgender populations in the Middle East and demonstrated the benefits of integrating family planning services with HIV care. Bixby includes a number of specific programs including:

ANSIRH, Advancing New Standards in Reproductive Health ANSIRH, Advancing New Standards in Reproductive Health, conducts rigorous and innovative social science research on complex and controversial issues related to reproduction and abortion. ANSIRH’s Turnaway Study is an innovative longitudinal study examining the mental, emotional, physical and socioeconomic in those receiving or not being able to receive an abortion. Additional ANSIRH research is focused on integrating abortion into primary care, the effects of state abortion restrictions, provider experiences of abortion, abortion safety and cultural narratives about abortion in film and television.

Beyond the Pill Beyond the Pill works to improve women’s access to effective contraception and reproductive health care.

Research focuses on improving access to contraception and care, understanding contraceptive decision-making, and implementation of IUD and contraceptive implants into routine clinical practice. In a landmark national study, Beyond the Pill researchers showed that training family planning clinic staff in the use of IUDs and implants reduced unintended pregnancies by half. They have trained thousands of health care providers, including community clinics, school health centers, hospitals, agencies with multiple clinics, and peer education groups.

Family AIDS Care and Education Services FACES, the Family AIDS Care and Education Services program is a family-focused, comprehensive HIV prevention, care and treatment program in collaboration with the Kenyan Ministry of Health. FACES research has provided evidence on how to effectively build sustainable HIV/AIDS care systems for women, men, children and families. FACES education programs have reached more than 200 health professions students who have completed elective rotations

RESEARCH

at clinics within the FACES network. The GloCal Health Fellowship is a mentored research fellowship that trains the next generation of leaders in global health in partnership with 27 international institutions.

Safe Motherhood Program The Safe Motherhood Program aims to reduce maternal morbidity and mortality throughout the world through evidence-based training and intervention appropriate to lower-resource settings. For instance, the Safe Motherhood Program pioneered use of the non-pneumatic anti-shock garment (NASG) or “Life-Wrap” as a first-aid device to stabilize women who are suffering from obstetric hemorrhage and shock. Together with collaborators at the University of Utah and PRONTO International, Bixby researchers are evaluating the impact of an innovative simulation-based training model for provider teams in Mexico, Guatemala, India and Kenya.

UCSF-University of Zimbabwe Collaborative Research Programme (UZ-UCSF) The UCSF-University of Zimbabwe Collaborative Research Programme (UZ-UCSF) is an NIH-sponsored Clinical Trials Unit that conducts clinical research on HIV prevention

strategies such as female-controlled methods, prevention of mother to child transmission and pre-exposure prophylaxis.

UCSF provides scientific leadership and administrative support for the program, while UZ conducts research in centers throughout Zimbabwe.

Clinical Trials We also have active Clinical Trials programs in each of our clinical divisions.

Women’s Health Clinical Research Center (WHCRC) Leslee Subak, MD; Vanessa Jacoby, MD, MAS; Juno Obedin-Maliver, MD, MPH; Tami Rowen, MD, MS Our multidisciplinary team includes clinician researchers in ObGyn&RS, urology, medicine, neurology, psychiatry, physical therapy, surgery, nursing, and geriatrics and we investigate lower urinary tract symptoms, sexual function, pelvic pain, and menopause. The WHCRC provides the research infrastructure to perform Clinical Trials and coordinate multi-center studies.

Department Report 2015–2016 | 27

RESEARCH

Community Our Department engages the Bay Area community in a variety of ways.

National Center of Excellence in Women’s Health The National Center of Excellence in Women’s Health trains interns and produces programming specific to women’s health. They sponsor and support the annual Young Women’s Health Leadership Summit, now in its twelfth year.

Women’s Health Resource Center The Women’s Health Resource Center, with locations at the Women’s Health Building on the UCSF Mount Zion campus and at the Betty Irene Moore Women’s Hospital on the UCSF Mission Bay campus, supports a range of health and wellness educational programs, in particular the Great Expectations health classes, and also provides consultation and literature concerning women’s health.

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Linda C. Giudice, MD, PhD, MSc (above) is stepping down as chair after eleven years. During this time she guided our department through significant growth and development.

Dr. Giudice led the shaping of an extraordinary team of faculty and staff in reproductive medicine and science. The department has achieved national ratings as the premier ObGyn Department in the U.S. in education (#2 residency), comprehensive clinical care (#2 by US News & World Report), and research (#1 in NIH funding for the past decade).

In addition, thanks to her vision, we contribute consistently to the excellence of our School and University, providing leadership in local, national and global women’s health across all missions.

We are enormously grateful for Linda’s leadership and look forward to her continued participation within our Center for Reproductive Sciences.

Thank You & How to Give Thanks for taking the time to learn about the outstanding patient care, education, and research that are all part of our amazing Department of Obstetrics, Gynecology, and Reproductive Sciences. If you’d like to learn more, please visit us online at obgyn.ucsf.edu, or give us a call at 415-476-2564 If you would like to support our mission, please go to our website home page, obgyn.ucsf.edu, and scroll down to the Make A Gift button.

Thanks!

Department of Obstetrics, Gynecology and Reproductive Sciences

Giving Patients Excellent Care Training the Next Generation Facilitating Discovery, Broadening Understanding

obgyn.ucsf.edu