Ovarian sensitivity index can be used as a more sensitive indicator than follicular output rate to predict IVF/ICSI outcomes in patients of normal expected ovarian response stimulated with GnRH antagonist protocol

This retrospective study was performed to investigate the predictive power of the Ovarian Sensitivity Index (OSI) for IVF/ICSI outcomes in infertile patients who were of normal expected ovarian response. A total of 912 infertile patients who underwent GnRH antagonist protocol between January 2017 to August 2019 at the Medical Center for Human Reproduction, Beijing Chao-Yang Hospital were included. All patients completed the full oocyte retrieval cycle and either had a live birth or had no embryos left. OSI was significantly lower in patients with a live birth (196.0 ± 120.4 in the live birth group vs 276.4 ± 235.7 in the non-live birth group, p < 0.001) while follicular output rate (FORT, defined as the ratio of pre-ovulatory follicle count on hCG day x 100/small antral follicle count at baseline) showed no significant difference. Patients were divided into low, average and high OSI groups and analysed in tertiles. From the low to the high OSI group, the cumulative live birth rate (CLBR) decreased dramatically (72.7 vs 67.2 vs 54.8%, p < 0.001). Multivariate regression analysis showed that OSI was an independent factor affecting CLBR (OR: 0.996, 95%CI: 0.995-0.998, p < 0.001) in our study population. In conclusion, OSI can be used as an independent indicator to distinguish fecundity in infertile patients with normal expected ovarian response and is probably more sensitive than FORT.

The effects of chromosome polymorphism on the clinical outcomes of in vitro fertilization/embryo transfer-assisted reproduction

OBJECTIVE

To investigate the effects of chromosome polymorphism on the clinical outcomes of in vitro fertilization/embryo transfer (IVF/ET)-assisted reproductive technology.

METHODS

The case data of 2740 patients treated between January 2018 and January 2019 were retrospectively analyzed. The patients were organized into two groups: a case group and a control group. In the case group (n = 81), one or both parents were characterized by chromosomal polymorphism; in the control group (n = 2659), both parents had normal chromosome karyotyping. The primary outcomes included clinical pregnancy rate (clinical pregnancy rate of fresh transfer cycles = number of clinical pregnancy cycles/number of fresh embryo transfer cycles × 100%) and live birth rate (live birth rate per fresh transfer cycles = number of live births/numbers of fresh embryo transfer cycles × 100%). The propensity score matching (PSM) method was used for statistical analysis.

RESULTS

After PSM 1:2 matching for the patients in the two groups, 72 patients were successfully matched. The clinical pregnancy rate and live birth rate in the case group were lower than in the control group before PSM (clinical pregnancy rate: 33.30% case group vs. 46.60% control group, p = .020; live birth rate: 30.90% case group vs. 47.90% control group, p = .03). The differences were statistically significant (p < .05). The live birth rate in the case group was also significantly lower than in the control group after PSM (34.98% case group vs. 74.52% control group; p = .028). The correlation coefficient between clinical pregnancy and grouping (i.e. if there was a characteristic chromosome polymorphism) was -.045 (p = .02), while the correlation coefficient between live birth and grouping was -.046.

CONCLUSION

Chromosome polymorphism is weakly negatively correlated with live birth in IVF/ET-assisted reproduction and can significantly reduce the live birth rate of patients.

Alteration of relative telomere length and telomerase reverse transcriptase expression in the granulosa cells of women during aging and assessment of in vitro fertilization outcomes

Telomere attrition plays a critical role in the reproductive aging process in humans. Telomere length (TL) is typically regulated by telomerase, the main component of which is telomerase reverse transcriptase (TERT). The aim of the present study was to investigate the changes of relative TL (RTL) and TERT expression in granulosa cells (GCs) during aging and its association with reproduction. Clinical data on the frozen‑thawed embryo transfer cycles of older (>35 year old) and younger (≤35 year old) women from a single center over a 3‑year period were retrospectively analyzed. Preimplantation genetic testing for chromosome aneuploidies in older women during the same period was also analyzed. Following the analysis of the data, several biological characteristics of senescent GCs were explored. In addition, a total of 160 women who were undergoing their first fresh cycle of in vitro fertilization (IVF) or intracytoplasmic sperm injection were included in the study. GCs were collected from all participants. The changes of RTL and TERT expression in GCs during aging were investigated using quantitative PCR and western blotting. The associations of RTL and TERT with IVF outcomes were also assessed. The clinical data demonstrated that the pregnancy and live birth rates of women aged >35 years were ~20% lower than those of women aged ≤35 years, and the number of embryos with aneuploidy was 7‑fold of that without euploidy in the older age group. An aging‑induced change in follicle stimulating hormone receptor expression was observed. A shorter TL and increased TERT expression were detected in the older women. A significant inverse correlation between the expression levels of TERT and oocyte yield was identified. However, no association of RTL and TERT with blastocyst formation rate and the probability of clinical pregnancy was detected. It may be concluded that RTL and TERT alterations in GCs are potential determinants of ovarian aging. TERT expression in GCs appears to be a potential biomarker for the prediction of ovarian response, which provides a novel strategy for the assessment of female fertility.

Elevated antimüllerian hormone levels are not associated with preterm delivery after in vitro fertilization or ovulation induction

OBJECTIVE

To investigate the association between antimüllerian hormone (AMH) and preterm birth risk in a larger cohort of patients who underwent either in vitro fertilization or ovulation induction with intrauterine insemination at a US academic fertility center.

DESIGN

Retrospective cohort study.

SETTING

Single academic fertility center.

PATIENT(S)

Live singleton births from patients who underwent in vitro fertilization or ovulation induction between 2016 and 2020 at a single academic fertility center were included in this study. Patients were excluded if they had a missing prepregnancy AMH level, a pregnancy using donor oocytes or a gestational carrier, multiple gestations, a delivery before 20 weeks gestation, or a cerclage in place.

INTERVENTION(S)

AMH level.

MAIN OUTCOME MEASURE(S)

The primary outcome was the proportion of preterm delivery. Secondary outcomes included the rate of pregnancy-induced hypertension, gestational diabetes, and small for gestational age.

RESULT(S)

In the entire cohort (n = 875), 8.4% of deliveries were preterm. The mean AMH values were similar between those with term and preterm births (3.9 vs. 4.2 ng/mL). Similar proportions of patients with term and preterm deliveries had AMH levels greater than the 75th percentile (25% vs. 21%). The odds of preterm birth were similar by AMH quartile after adjusting for the history of preterm birth. Similarly, in the polycystic ovary syndrome (PCOS) cohort, there was no difference between mean AMH values of term and preterm births (n = 139, 9.6 vs. 10.0 ng/mL). The proportions of patients with PCOS with AMH levels greater than the 75th percentile were similar between those with term and preterm deliveries (25% vs. 22%). The odds of preterm birth were similar by the AMH quartile after adjusting for the history of preterm birth.

CONCLUSION(S)

Elevated AMH levels were not associated with an increased risk of preterm birth in patients who conceived after in vitro fertilization and ovulation induction, including patients with PCOS. Although studies suggest that AMH levels may help stratify the risk of preterm birth in this population, our findings indicate that further studies are needed before clinical application.

Race, ovarian responsiveness, and live birth after in vitro fertilization

OBJECTIVE

To determine if ovarian responsiveness to gonadotropin stimulation differs by race/ethnicity and whether this predicts live birth rates (LBRs) in non-White patients undergoing in vitro fertilization (IVF).

DESIGN

Retrospective cohort study.

SETTING

Academic infertility center.

PATIENT(S)

White, Asian, Black, and Hispanic patients undergoing ovarian stimulation for IVF.

INTERVENTION(S)

Self-reported race and ethnicity.

MAIN OUTCOME MEASURE(S)

The primary outcome was ovarian sensitivity index (OSI), defined as (the number of oocytes retrieved ÷ total gonadotropin dose) × 1,000 as a measure of ovarian responsiveness, adjusting for age, body mass index, infertility diagnosis, and cycle number. Secondary outcomes included live birth and clinical pregnancy after first retrievals, adjusting for age, infertility diagnosis, and history of fibroids, as well as miscarriage rate per clinical pregnancy, adjusting for age, body mass index, infertility diagnosis, duration of infertility, history of fibroids, and use of preimplantation genetic testing for aneuploidy.

RESULT(S)

The primary analysis of OSI included 3,360 (70.2%) retrievals from White patients, 704 (14.7%) retrievals from Asian patients, 553 (11.6%) retrievals from Black patients, and 168 (3.5%) retrievals from Hispanic patients. Black and Hispanic patients had higher OSIs than White patients after accounting for those with multiple retrievals and adjusting for confounders (6.08 in Black and 6.27 in Hispanic, compared with 5.25 in White). There was no difference in OSI between Asian and White patients. The pregnancy outcomes analyses included 2,299 retrievals. Despite greater ovarian responsiveness, Black and Hispanic patients had lower LBRs compared with White patients, although these differences were not statistically significant after adjusting for confounders (adjusted odds ratio, 0.83; 95% confidence interval [CI], 0.63-1.09, for Black; adjusted odds ratio, 0.93; 95% CI, 0.61-1.43, for Hispanic). Ovarian sensitivity index was modestly predictive of live birth in White and Asian patients but not in Black (area under the curve, 0.51; 95% CI, 0.38-0.64) and Hispanic (area under the curve, 0.50; 95% CI, 0.37-0.63) patients.

CONCLUSION(S)

Black and Hispanic patients have higher ovarian responsiveness to stimulation during IVF but do not experience a consequent increase in LBR. Factors beyond differences in responsiveness to ovarian stimulation need to be explored to address the racial/ethnic disparity established in prior literature.

Recommendations for reducing the risk of viral transmission during fertility treatment with the use of autologous gametes: a committee opinion

Sexually transmitted infections are of major concern to reproductive specialists. Heading the list are human immunodeficiency virus types 1 and 2 and hepatitis B and C viruses. These pathogens, which may cause incurable chronic infections, can be transmitted through assisted reproductive technologies and from infected mothers to the fetus or newborn. This document replaces the document of the same name, last published in 2020.

Methotrexate use among men-association with fertility and the perinatal health of their children: a Swedish nationwide register study

OBJECTIVE

To study the effect of methotrexate on male fertility and subsequent effects on their children, for which data are scarce and contradictory.

DESIGN

Nationwide multiregister cohort study.

SETTING

Not applicable.

SUBJECT(S)

All children born alive in Sweden between 2006 and 2014 and their fathers. Three cohorts were defined: children to fathers with periconceptional methotrexate exposure (exposed cohort), children whose fathers stopped methotrexate intake ≥2 years before conception (previously exposed cohort), and children to fathers with no methotrexate exposure (control cohort).

EXPOSURE(S)

The father having at least one dispensed methotrexate prescription from pharmacies 0-3 months before conception, along with at least one more dispensed methotrexate prescription 0-12 months before conception (periconceptional exposure). Previously exposed cohort: the father having no dispensed methotrexate prescriptions in the 2 years before conception, but having at least two dispensed prescriptions before that.

MAIN OUTCOME MEASURES

Congenital anomalies (major and any; primary outcomes), preterm birth (PTB) and being small for gestational age (SGA; secondary outcomes), as well as need of intracytoplasmic sperm injection (ICSI) to achieve pregnancy (primary outcome in exposed cohort vs. controls, exploratory outcome in previously exposed cohort vs. controls). Outcomes were analyzed using logistic regression.

RESULTS

A total of 223 children to fathers with periconceptional methotrexate exposure were identified, along with 356 children whose fathers stopped methotrexate intake ≥2 years before conception and 809,706 not methotrexate-treated controls. In children with fathers periconceptionally exposed to methotrexate, the adjusted and unadjusted odds ratios (95% confidence intervals) for major congenital anomalies were 1.1 (0.4-2.6) and 1.1 (0.4-2.4), any congenital anomalies 1.3 (0.7-2.4) and 1.4 (0.7-2.3), PTB 1.0 (0.5-1.8) and 1.0 (0.5-1.8), SGA 1.1 (0.4-2.6) and 1.0 (0.4-2.2), and conception by use of ICSI 3.9 (2.2-7.1) and 4.6 (2.5-7.7). Use of ICSI was not increased among fathers who stopped methotrexate intake ≥2 years before conception, having adjusted and unadjusted odds ratios 0.9 (0.4-1.9) and 1.5 (0.6-2.9).

CONCLUSION

This study suggests that paternal periconceptional methotrexate use does not increase risk of congenital anomalies, PTB, or SGA in the offspring but may temporarily reduce fertility.

Endometrial compaction is associated with the increased live birth rate in artificial frozen-thawed embryo transfer cycles

We aimed to assess the effect of endometrial compaction on the live birth rate in frozen-thawed embryo transfer (FET) cycles and to investigate the parameters associated with compaction. FET cycles performed in a tertiary care infertility centre between May 2013 and October 2019 were reviewed retrospectively. The decremental change of endometrial thickness between the end of oestrogen phase and ET day was defined as endometrial compaction. The primary outcome measure was endometrial compaction, and the secondary outcome was the live birth rate. Among all, 89 had endometrial compaction and 194 did not. The live birth rate was significantly higher in the compaction group (23.6 vs. 13.4%, respectively; p = 0.039). Multivariate logistic regression analysis revealed that in FET cycles with artificial endometrial preparation, the chance for live birth was significantly higher in cycles with endometrial compaction [OR: 3.133, 95% confidence interval (CI) 1.104-8.892; p = 0.032] when adjusted for age, stage of the embryo, and endometrial thickness at the end of the oestrogen phase. According to receiver operating characteristic (ROC) curve analysis the sensitivity and specificity of 9.25 mm endometrial thickness at the end of oestrogen phase were 76.4 and 58.8%, respectively (area under the curve: 0.701, 95% CI 0.640-0.763; p < 0.001) to predict endometrial compaction.

Oviduct epithelial cell‑derived extracellular vesicles promote the developmental competence of IVF porcine embryos

Assisted reproductive technology has increased the efficiency of animal reproduction. However, polyspermy is a significant limitation of porcine in vitro fertilization (IVF). Therefore, reducing the polyspermy rate and improving monospermic embryos is crucial. Recent studies have reported that oviductal fluid, along with its contents of extracellular vesicles (EVs), enhanced the fertilization process and supported embryo development. Consequently, the present study investigated the effects of porcine oviduct epithelial cells (OEC‑EVs) on sperm‑oocyte interactions during porcine IVF and evaluated in vitro embryo developmental competence outcomes. During IVF embryo development, the cleavage rate was significantly higher in the group treated with 50 ng/ml OEC‑EVs compared with the control group (67.6±2.5 vs. 57.3±1.9; P<0.05). Furthermore, the OEC‑EV group had significantly more embryos (16.4±1.2 vs. 10.2±0.8; P<0.05), and the polyspermy rate significantly decreased (32.9±2.5 vs. 43.8±3.1; P<0.05) compared with that of the control group. Additionally, the fluorescence intensities of cortical granules (3.56±0.47 vs. 2.15±0.24; P<0.05) and active mitochondria (8.14±0.34 vs. 5.96±0.38; P<0.05) were significantly higher in the OEC‑EV group compared with those in the control group. In conclusion, OEC‑EV adsorption and penetration crosstalk between sperm and oocytes was observed. OEC‑EV treatment was demonstrated to significantly improve the concentration and distribution of cortical granules in oocytes. Furthermore, OEC‑EVs also increased oocyte mitochondrial activity, reduced polyspermy and increased the IVF success rate.

Predicted probabilities of live birth following assisted reproductive technology using United States national surveillance data from 2016 to 2018

BACKGROUND

As the use of in vitro fertilization continues to increase in the United States, up-to-date models that estimate cumulative live birth rates after multiple oocyte retrievals and embryo transfers (fresh and frozen) are valuable for patients and clinicians weighing treatment options.

OBJECTIVE

This study aimed to develop models that generate predicted probabilities of live birth in individuals considering in vitro fertilization based on demographic and reproductive characteristics.

STUDY DESIGN

Our population-based cohort study used data from the National Assisted Reproductive Technology Surveillance System 2016 to 2018, including 196,916 women who underwent 207,766 autologous embryo transfer cycles and 25,831 women who underwent 36,909 donor oocyte transfer cycles. We used data on autologous in vitro fertilization cycles to develop models that estimate a patient's cumulative live birth rate after all embryo transfers (fresh and frozen) within 12 months after 1, 2, and 3 oocyte retrievals in new and returning patients. Among patients using donor oocytes, we estimated the cumulative live birth rate after their first, second, and third embryo transfers. Multinomial logistic regression models adjusted for age, prepregnancy body mass index (imputed for 18% of missing values), parity, gravidity, and infertility diagnoses were used to estimate the cumulative live birth rate.

RESULTS

Among new and returning patients undergoing autologous in vitro fertilization, female age had the strongest association with cumulative live birth rate. Other factors associated with higher cumulative live birth rates were lower body mass index and parity or gravidity ≥1, although results were inconsistent. Infertility diagnoses of diminished ovarian reserve, uterine factor, and other reasons were associated with a lower cumulative live birth rate, whereas male factor, tubal factor, ovulatory disorders, and unexplained infertility were associated with a higher cumulative live birth rate. Based on our models, a new patient who is 35 years old, with a body mass index of 25 kg/m2, no previous pregnancy, and unexplained infertility diagnoses, has a 48%, 69%, and 80% cumulative live birth rate after the first, second, and third oocyte retrieval, respectively. Cumulative live birth rates are 29%, 48%, and 62%, respectively, if the patient had diminished ovarian reserve, and 25%, 41%, and 52%, respectively, if the patient was 40 years old (with unexplained infertility). Very few recipient characteristics were associated with cumulative live birth rate in donor oocyte patients.

CONCLUSION

Our models provided estimates of cumulative live birth rate based on demographic and reproductive characteristics to help inform patients and providers of a woman's probability of success after in vitro fertilization.

Malpractice litigation surrounding in vitro fertilization in the United States: a legal literature review

IMPORTANCE

Analysis of malpractice lawsuits that involve in vitro fertilization (IVF) can provide insight into the breadth of legal challenges faced by IVF clinics and the patient harms and financial consequences that can result from alleged errors in practice.

OBJECTIVE

We aimed to review malpractice litigations involving IVF and identify common themes in plaintiff allegations and defense arguments.

EVIDENCE REVIEW

We queried Nexis Uni, Westlaw, and CourtListener legal databases to collect records from malpractice litigations involving IVF. The nature of the cases, allegations, and outcomes were abstracted from court documents.

FINDINGS

Of the 447 cases identified in the query, 53 involved both malpractice and IVF, occurring between 1993 and 2022. Defendants included a reproductive endocrinologist in 19 (35.8%) cases, an academic institution in 17 (32.1%) cases, embryology personnel in 9 (17.0%) cases, and nursing staff in 2 (3.8%) cases. Twenty-four (45.3%) cases involved embryology errors (e.g., lost specimens and incorrect sperm donor), 11 (20.8%) preimplantation genetic testing errors (e.g., child born with genetic illness despite testing), 6 (11.3%) medical or surgical complications (e.g., ovarian hyperstimulation syndrome), 4 (7.5%) misdiagnoses (e.g., malignancy before cycle start), 3 (5.6%) misrepresentations of IVF outcomes, 2 (3.8%) medical eligibility screening issues (e.g., medical comorbidities in a gestational carrier), 2 (3.8%) confidentiality breaches, and 1 (1.9%) case of discrimination. The most common secondary claims were negligence (23 cases, 16.4% of all claims), breach of contract (13, 9.3%), lack of informed consent (11, 7.9%), and negligent infliction of emotional distress (11, 7.9%). Twenty-nine (54.7%) cases were decided in favor of the defending IVF clinic or provider, 13 (24.5%) cases were decided in favor of the plaintiff, and 11 (20.8%) involved ongoing proceedings. Financial awards ranged from $4171 to $14,975,000, with the largest monetary award resulting from a cryostorage accident class action lawsuit.

CONCLUSION

In vitro fertilization malpractice claims are varied, with the most common issues involving embryology laboratory processes and genetic testing errors. Some errors may be avoidable with increased vigilance and implementation of stringent laboratory and clinical guidelines. Understanding jurisdiction-specific legislation and court processes may also assist IVF providers in navigating the malpractice litigation process.

RELEVANCE

This comprehensive review of IVF litigation may have the potential to promote practices that protect both providers and patients.

Reproductive outcomes after surgical sperm retrieval in couples with male factor subfertility: a 10-year retrospective national cohort

OBJECTIVE

To determine any significant differences in the reproductive outcome from intracytoplasmic sperm injection (ICSI) with surgical sperm retrieval (SSR) between cycles using fresh and cryopreserved sperm and between cycles using epididymal and testicular sperm.

DESIGN

A retrospective national cohort study using data from the UK Human Fertilisation and Embryology Authority, including all ICSI cycles performed in the United Kingdom over a 10-year period.

SETTING

Hospital.

PATIENT(S)

All nondonor ICSI cycles from 2008 to 2017 categorized by sperm source and cryopreservation status.

INTERVENTION(S)

Intracytoplasmic sperm injection with SSR using fresh or cryopreserved sperm and using ejaculated, testicular, and epididymal sperm.

MAIN OUTCOME MEASURE(S)

Live birth rate, pregnancy rate, and implantation rate.

RESULT(S)

We analyzed data from 214,649 ICSI cycles, including 199,818 cycles of ejaculated sperm, 5,646 cycles of epididymal sperm, and 9,185 cycles of testicular sperm. Live births rates per ICSI cycle were 28.5%, 30.6%, and 28.7% for ejaculated, epididymal, and testicular sperm cycles, respectively. Epididymal sperm cycles had a higher live birth rate than that of testicular sperm cycles (odds ratio [OR], 1.067; 95% confidence interval [CI], 1.014-1.123). This was despite a higher mean male age (42.5 vs. 40.6 years; 95% CI of difference, 1.81-1.85 years) and female age (34.3 vs. 34.0 years; 95% CI of difference, 0.32-0.34 years) in epididymal cycles than in testicular cycles. Implantation (61.2% vs. 58.0%; OR, 1.086; 95% CI, 1.041-1.133) and clinical pregnancy rates (34.3% vs. 31.3%; OR, 1.085; 95% CI, 1.039-1.132) were also higher in epididymal cycles than in testicular cycles. There were no statistically significant differences in outcomes between cycles using fresh sperm and those using cryopreserved sperm for SSR-ICSI.

CONCLUSION(S)

Our study indicates that reproductive outcomes of SSR-ICSI are at least comparable with those of ICSI using ejaculated sperm and does not support the preferential use of fresh sperm over cryopreserved sperm in SSR-ICSI. Births per SSR-ICSI cycle were higher for cycles using epididymal sperm than for cycles using testicular sperm; however, the differences were small, which may provide reassurance to patients undergoing these procedures. The results must be interpreted with caution because multivariable analysis was not possible because of aggregation of data.

Uterine niche is associated with adverse in vitro fertilization and intracytoplasmic sperm injection outcomes: a retrospective cohort study

OBJECTIVE

To investigate the relationship between uterine niche and reproductive outcomes of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

DESIGN

A retrospective cohort study.

SETTING

A reproductive medicine center.

PATIENT(S)

A total of 2,449 women with cesarean section history who underwent 2,874 IVF/ICSI cycles between January 2015 and December 2019.

INTERVENTION(S)

A defect deeper than 2 mm visible under three-dimensional transvaginal sonography or hysteroscopy was defined as uterine niche. The IVF/ICSI outcomes of the first embryo transfer were obtained by telephone interview 1 year after embryo transfer regardless of fresh embryos or frozen-thawed embryos. Generalized estimating equations, logistic regression analyses, and propensity score matching were applied to clarify the relationship between uterine niche and IVF/ICSI outcomes.

MAIN OUTCOME MEASURE(S)

Primary outcome was live birth rate. Secondary outcomes were positive human chorionic gonadotropin test results, clinical pregnancy rate, implantation rate, miscarriage rate, and ectopic pregnancy rate.

RESULTS

After excluding 48 cycles for uterine malformation; 18 cycles for chromosome abnormality; 281 cycles for no available embryo or no embryo transfer; 5 cycles for oocyte donation; and 7 cycles for loss of follow-up, we finally included 2,231 women with 2,515 cycles in our study. Compared with women without niche, women with niche had reduced live birth rate (18.99% vs. 31.51%, : 0.51, 95% CI: 0.34-0.77), positive human chorionic gonadotropin test rate (34.08% vs. 46.40%, adjusted odds ratio [aOR]: 0.61, 95% confidence interval [CI]: 0.43-0.87), clinical pregnancy rate (29.05% vs. 42.25%, aOR: 0.57, 95% CI: 0.39-0.82) and implantation rate (25.87% vs. 36.95%, aOR: 0.53, 95% CI: 0.38-0.76). In all the sensitivity analyses, the niche group had a 7.28% to 18.22% increase in miscarriage rate even not all of them were statistically significant.

CONCLUSION(S)

Uterine niche may have a detrimental effect on subsequent fertility of women with cesarean section history undergoing IVF/ICSI treatment. Practitioners should be noted that women with uterine niches may be associated with adverse IVF/ICSI outcomes.

Racial and ethnic disparities in assisted reproductive technology: a systematic review

There is emergent scientific literature examining the disparities in reproductive care of women in the United States. Reproduction is a basic human right and there are unique challenges that racial and ethnic minorities face in accessing fertility care and assisted reproductive technology. The identification of these disparities can aid in identifying areas for interventions to improve and resolve, the inequities that exist in providing care for minority populations. A literature search was performed using PubMed to identify articles with data specific to racial and ethnic differences in study populations as it related to infertility, access to care, and treatment outcomes. The following review and collection of articles provide a comprehensive overview of the disparities that exist, the factors that contribute to these disparities, and recommendations for how providers and health care systems may begin to resolve the gaps in equitable care.

A case series of adrenoleukodystrophy in children conceived through in vitro fertilization with an egg donor

Objective

To report 3 cases of adrenoleukodystrophy (ALD) in children conceived by in vitro fertilization (IVF) and egg donation.

Design

A case report.

Patients

Patients aged 4-5 years old, evaluated by the University of Minnesota Leukodystrophy Center, who were diagnosed with ALD after being conceived by IVF with oocytes provided by the same donor.

Interventions

One patient received a hematopoietic stem cell transplant from a human leukocyte antigen-matched donor, and 1 patient received autologous lentiviral corrected hematopoietic cells. The disease state in 1 patient was unfortunately too advanced for effective treatment to be administered.

Main Outcome Measures

Progression of disease after diagnosis or treatment was observed by cerebral magnetic resonance imaging and monitoring the development or advancement of any cognitive, adaptive, and motor deficits.

Results

Patients who received a transplant for ALD successfully experienced little to no disease progression at least 6 months to 1 year after treatment.

Conclusions

These 3 cases of transmission of ALD through oocyte donation and IVF highlight the potential need to implement more comprehensive genetic screening of gamete donors to prevent the transfer of rare but severe genetic diseases through IVF. Further, these cases highlight limitations in carrier screening guidelines that limit reportable variants to pathogenic and likely pathogenic variants.

Mifepristone-misoprostol combination treatment for early pregnancy loss after embryo transfer: a case series

Objective

Evidence strongly supports the use of mifepristone-misoprostol combination treatment for early pregnancy loss (EPL) among pregnancies conceived without assisted reproductive technologies. No literature exists, however, regarding the efficacy of this treatment in the medical management of EPL among pregnancies after in vitro fertilization and embryo transfer (IVF-ET). These patients differ as some use exogenous hormonal supplementation to provide pregnancy support. Thus, the management for EPL may differ between unassisted conceptions and those after ET. Mifepristone, a progesterone receptor antagonist, may demonstrate an altered treatment effect when used with misoprostol to manage EPL in assisted reproductive technologie-conceived pregnancies.

Objective

To describe our institution's experience using mifepristone-misoprostol to manage EPL after in vitro fertilization with embryo transfer IVF-ET.

Design

Retrospective case series.

Setting

Single academic institution from 2020 to 2022.

Patientss

Nine patients with ultrasound confirmed EPL after IVF-ET.

Interventions

All 9 patients underwent in vitro fertilization followed by fresh or frozen embryo transfer. All 9 received 200 mg of mifepristone 24 hours before 800 μg of misoprostol.

Main Outcome Measurements

Incomplete abortion, need for surgical management, number of days to negative serum human chorionic gonadotropin (hCG).

Results

Of the 9 subjects included, one had a programmed frozen embryo transfer cycle, 6 had modified natural frozen embryo transfer cycles, and 2 underwent fresh ET. Eight subjects had successful expulsion of tissue with one dose of treatment, and one required uterine aspiration. No subjects required additional dosing of misoprostol. The mean number of days elapsed from mifepristone treatment to tissue expulsion was 4.89 ± 11.30 days and the mean days to negative-range serum hCG was 36.89 ± 18.59 days. At the initial ultrasound, all pregnancies had one gestational sac seen; 5/9 had a yolk sac; only 3 had fetal cardiac activity. The mean gestational age at the time of EPL diagnosis was 55.22 ± 8.77 days, with the majority (8/9) having completed 7 weeks gestation.

Conclusions

Mifepristone-misoprostol combination treatment appears to be a reasonable option for those with EPL after IVF-ET. Future, larger-scale studies are needed comparing combination treatment with misoprostol only among various ET protocols.

Laparoscopic management of second trimester ruptured cornual heterotopic pregnancy with subsequent live birth delivery: A case report and literature review

OBJECTIVE

Heterotopic pregnancy (HP) is the coexistence of extra- and intrauterine gestation implantation sites. A rare case of a second-trimester ruptured cornual HP (CHP) treated with laparoscopic cornual resection with the primary repair is presented. Risk factors, clinical presentations, treatments, and outcomes of CHPs are also reviewed.

CASE REPORT

A 35-year-old pregnant woman with CHP presented with lower abdominal pain with hemoperitoneum and her hemoglobin level dropped. Laparoscopic management of a ruptured HP was performed, leaving the surplus intrauterine fetus intact. She delivered a 2360 g male infant via cesarean section at 34 weeks' gestation due to preterm premature rupture of membranes. We found a well-healed wound over the left uterine cornua during the cesarean section.

CONCLUSION

Ruptured CHP is a rare but life-threatening complication of an obstetric emergency. Although the pregnant uterus becomes congested and fragile, using reliable laparoscopic energy devices and barbed sutures, successful treatment is feasible.

Embryo donation: national trends and outcomes, 2004-2019

BACKGROUND

In 2016, the US Food and Drug Administration amended existing regulations to increase access to donated embryos for reproductive use. Current information regarding the characteristics and outcomes of embryo donation cycles could benefit patients and providers during counseling and decision making.

OBJECTIVE

This study aimed to examine the trends in the utilization of embryo donation, pregnancy rates, and live birth rates per transfer between 2004 and 2019 and to describe the recipients of donated embryos and outcomes of frozen donated embryo transfer cycles during the most recent time period, that is, 2016 to 2019.

STUDY DESIGN

We conducted a retrospective, population-based cohort study of frozen donated embryo transfer cycles in United States fertility clinics reporting to the National Assisted Reproductive Technology Surveillance System during 2004 to 2019. The trends in the annual number and proportion of frozen donated embryo transfers, pregnancy rates, and live birth rates from 2004 to 2019 were described. During 2016 to 2019, the rates of cycle cancellation, pregnancy, miscarriage, live birth, singleton birth, and good perinatal outcome (delivery ≥37 weeks, birthweight ≥2500 g) of frozen donated embryo transfers were also calculated. Transfer and pregnancy outcomes stratified by oocyte source age at the time of oocyte retrieval were also described.

RESULTS

From 2004 to 2019, there were 21,060 frozen donated embryo transfers in the United States, resulting in 8457 live births. During this period, the annual number and proportion of frozen donated embryo transfers with respect to all transfers increased, as did the pregnancy rate and live birth rate. Among all initiated cycles during 2016 to 2019, the cancellation rate was 8.2%. Among 8773 transfers with known outcomes, 4685 (53.4%) resulted in pregnancy and 3820 (43.5%) in live birth. Among all pregnancies, 814 (17.4%) resulted in miscarriage. Among all live births, 3223 (84.4%) delivered a singleton, of which 2474 (76.8%) had a good perinatal outcome. The clinical pregnancy rate and live birth rate per frozen donated embryo transfer decreased with increasing age of oocyte source.

CONCLUSION

The outcomes of embryo donation cycles reported in this national cohort may aid patients and providers when considering the use of donated embryos.

State insurance mandates for in vitro fertilization are not associated with improving racial and ethnic disparities in utilization and treatment outcomes

BACKGROUND

Racial and ethnic disparities in utilization and clinical outcomes following fertility care with in vitro fertilization in the United States are well-documented. Given the cost of fertility care, lack of insurance is a barrier to access across all races and ethnicities.

OBJECTIVE

This study aimed to determine how state insurance mandates are associated with racial and ethnic disparities in in vitro fertilization utilization and clinical outcomes.

STUDY DESIGN

This was a cohort study using data from the Society for Assisted Reproductive Technology Clinical Outcome Reporting System from 2014 to 2019 for autologous in vitro fertilization cycles. The primary outcomes were utilization-defined as the number of in vitro fertilization cycles per 10,000 reproductive-aged women-and cumulative live birth-defined as the delivery of at least 1 liveborn neonate resulting from a single stimulation cycle and its corresponding fresh or thawed transfers.

RESULTS

Most (72.9%) of the 1,096,539 cycles from 487,191 women occurred in states without an insurance mandate. Although utilization was higher across all racial and ethnic groups in mandated states, the increase in utilization was greatest for non-Hispanic Asian and non-Hispanic White women. For instance, in the most recent study year (2019), the utilization rates for non-Hispanic White women compared with non-Hispanic Black/African American women were 23.5 cycles per 10,000 women higher in nonmandated states and 56.2 cycles per 10,000 women higher in mandated states. There was no significant interaction between race and ethnicity and insurance mandate status on any of the clinical outcomes (all P-values for interaction terms > .05).

CONCLUSION

Racial and ethnic disparities in utilization of in vitro fertilization and clinical outcomes for autologous cycles persist regardless of state health insurance mandates.

Association of state insurance coverage mandates with assisted reproductive technology care discontinuation

BACKGROUND

Insurance coverage for fertility services may reduce the financial burden of high-cost fertility care such as assisted reproductive technology and improve its utilization. Patients who exit care after failing to reach their reproductive goals report higher rates of mental health problems and a lower sense of well-being. It is important to understand the relationship between state-mandated insurance coverage for fertility services and assisted reproductive technology care discontinuation.

OBJECTIVE

This study aimed to assess whether state-mandated insurance coverage for fertility services is associated with lower rates of care discontinuation after an initial assisted reproductive technology cycle that did not result in a live birth.

STUDY DESIGN

This is a retrospective, population-based cohort study using data from United States fertility clinics reporting to the National Assisted Reproductive Technology Surveillance System during 2016 and 2018. Patients who began their first autologous assisted reproductive technology cycle during 2016 and 2017 and did not have a live birth were included. We describe the rate of assisted reproductive technology care discontinuation (no additional cycle within 12 months of the previous cycle's date of failure). Multivariable analyses were conducted to evaluate factors independently associated with care discontinuation, including the scope of fertility services included in state coverage mandate at assisted reproductive technology cycle initiation that were as follows: comprehensive (≥3 assisted reproductive technology cycles), limited (1, 2, or an unspecified number of assisted reproductive technology cycles), mandate not including assisted reproductive technology, and no mandate.

RESULTS

Among 91,324 patients who underwent their first autologous assisted reproductive technology cycle that did not result in live birth, 24,072 (26.4%) discontinued care. Compared with patients who lived in states with mandates for comprehensive assisted reproductive technology coverage, those in states with mandates for fertility services coverage that did not include assisted reproductive technology or states with no mandate were 46% (adjusted relative risk, 1.46; 95% confidence interval, 1.31-1.63) and 26% (adjusted relative risk, 1.26; 95% confidence interval, 1.15-1.39) more likely to discontinue care, respectively, after controlling for patient and cycle characteristics. Increasing patient age, distance from clinic ≥50 miles, previous live birth, fewer oocytes retrieved, and not having embryos cryopreserved were also associated with higher rates of discontinuation. Non-Hispanic Black, non-Hispanic Asian, and Hispanic patients had higher rates of care discontinuation than non-Hispanic White patients regardless of the existence or scope of state-mandated assisted reproductive technology coverage.

CONCLUSION

Comprehensive state-mandated insurance coverage for assisted reproductive technology is associated with lower rates of assisted reproductive technology care discontinuation.

Endometrial receptivity array before frozen embryo transfer cycles: a systematic review and meta-analysis

OBJECTIVE

To investigate the impact of endometrial receptivity array (ERA) before frozen embryo transfer in patients undergoing in vitro fertilization (IVF). There is a lack of consensus regarding the use of ERA for increasing the success rate of IVF cycles, mainly in terms of the live birth rate.

DESIGN

PubMed, Web of Science and Embase were searched from inception up to February 15, 2022.

SETTING

Not applicable.

PATIENT(S)

Patients undergoing ERA vs no ERA before frozen embryo transfer.

INTERVENTION(S)

Only comparative studies evaluating pregnancy rates of patients undergoing frozen embryo transfer cycles with or without prior ERA were included. Inter-study heterogeneity was also assessed using Cochrane's Q test and the I² statistic. The random-effects model was used to pool the odds ratio (OR) with the corresponding 95% confidence intervals (CIs). Subgroup analyses were performed to investigate the impact of ERA on pregnancy rates according to the number of previous embryo transfer (ET) failures (≤ 2 previous failed ETs vs. > 2 failed ETs, defined as recurrent implantation failure). Separate analyses were performed according to the study design and adjustment for confounders.

MAIN OUTCOME MEASURES(S)

The primary outcomes of the study were live birth rate and/or ongoing pregnancy rate. Implantation rate, biochemical pregnancy rate, clinical pregnancy rate, and miscarriage rate were considered secondary outcomes.

RESULT(S)

Eight studies (representing data on n = 2,784 patients; n = 831 had undergone ERA and n = 1,953 without ERA) were found to be eligible for this meta-analysis. The live birth or ongoing pregnancy rate for the ERA group was not significantly different compared with the non-ERA group (OR, 1.38; 95% CI, 0.79-2.41; I² 83.0%), nor was a difference seen in subgroup analyses based on the number of previous failed ETs. The rates of implantation, biochemical pregnancy, clinical pregnancy, and miscarriage were also comparable between the ERA and the non-ERA groups. After separate analyses according to the study design and adjustment for confounding factors, overall pooled estimates remained statistically nonsignificant.

CONCLUSION(S)

The findings of the current meta-analysis did not reveal a significant change in the rate of pregnancy after IVF cycles using ERA, and it is not clear whether ERA can increase the pregnancy rate or not.

SYSTEMATIC REVIEW REGISTRATION

Prospectively registered in PROSPERO (CRD42022310862).

More follicle-stimulating hormone may not improve outcomes, but can it be counterproductive?

Many studies have sought to explore the impact of high-dose gonadotropin on stimulation outcomes based on a hypothesis that higher doses of follicle-stimulating hormone may harm the quantity or quality of oocytes and, therefore, be counterproductive. Herein, we describe the results of a narrative review aimed at elucidating any harm associated with "excess" follicle-stimulating hormone dosing in poor-to-moderate responders. Additionally, we sought to describe the outcomes associated with mild ovarian stimulation, with an eye toward determining whether this approach is superior. We concluded that there is no apparent harm to higher-dose gonadotropin stimulation for poor-to-moderate responders. Simultaneously, we did not find compelling data to suggest that mild stimulation is superior. Finally, we close by presenting data that suggest that more gonadotropin may be beneficial in specific clinical scenarios.

Infertility and treatments used have minimal effects on first-trimester placental DNA methylation and gene expression

OBJECTIVE

To determine whether deoxyribonucleic acid (DNA) methylation alterations exist in the first-trimester human placenta between conceptions using fertility treatments and those that do not and, if so, whether they are the result of underlying infertility or fertility treatments. We also assessed whether significant alterations led to changes in gene expression.

DESIGN

We compared DNA methylation of the first-trimester placenta from singleton pregnancies that resulted in live births from unassisted, in vitro fertilization (IVF), and non-IVF fertility treatment (NIFT) conceptions using the Infinium MethylationEPIC BeadChip array. Significant CpG sites were compared with corresponding ribonucleic acid sequencing analysis in similar cohorts to determine whether methylation alterations lead to differences in gene expression.

SETTING

Academic medical center.

PATIENT(S)

A total of 138 singleton pregnancies undergoing chorionic villus sampling resulting in a live birth were recruited for methylation analysis (56 unassisted, 38 NIFT, and 44 IVF conceptions). Ribonucleic acid-sequencing data consisted of 141 subjects (74 unassisted, 33 NIFT, and 34 IVF conceptions) of which 116 overlapped with the methylation cohort.

INTERVENTION(S)

In vitro fertilization-conceived pregnancy or pregnancy conceived via NIFT, such as ovulation induction and intrauterine insemination.

MAIN OUTCOME MEASURE(S)

Significant methylation changes at CpG sites after adjustment for multiple comparisons. The secondary outcome was gene expression changes of significant CpG sites.

RESULT(S)

Of the 741,145 probes analyzed in the placenta, few were significant at Bonferroni <0.05: 185 CpG sites (0.025%) significant in pregnancies conceived with the fertility treatments (NIFT + IVF) vs. unassisted conceptions; 28 in NIFT vs. unassisted; 195 in IVF vs. unassisted; and only 13 (0.0018%) in IVF vs. NIFT conceptions. Of all significant CpG sites combined, 10% (35) were located in genes with suggestive gene expression changes, but none were significant after adjustment for multiple comparisons (ribonucleic acid sequencing false discovery rate <0.05). None of the 13 differentially methylated probes in the IVF vs. NIFT placenta were located in genes with suggestive IVF vs. NIFT gene expression differences.

CONCLUSION(S)

Underlying infertility is the most significant contributor to the minimal differences in first-trimester placental methylation, and not the specific fertility treatment used, such as IVF.

Assisted reproductive technology treatment and risk of multiple sclerosis - a Danish cohort study

OBJECTIVE

To compare the incidence of multiple sclerosis (MS) among women who had undergone assisted reproductive technology (ART) treatment with the women who had conceived a child without previous ART treatment.

DESIGN

A register-based nationwide cohort study.

PATIENT(S)

Women with a first ovarian stimulation cycle before in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) (i.e., ART treatment) recorded in the Danish IVF register between 1996 and 2018; and women recorded in the Danish Medical Birth Register with the birth of their first child where date of conception is between 1996 and 2018. The cohort was observed until March 10, 2021.

INTERVENTION(S)

Mainly included IVF, ICSI, and fresh embryo transfer with hormone stimulation.

MAIN OUTCOME MEASURES

A diagnosis of MS recorded in the Danish Multiple Sclerosis Registry. Crude and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 585,716 women were included in the cohort of which 63,791 (11%) were exposed to at least one initiated IVF or ICSI cycle during the study period. Cycles with oocyte donation were excluded. The median follow-up time for the entire cohort was 12.4 years (Q1-Q3= 6.6-18.1). Compared with women conceiving without previous ART, ART treated women were older (31.8 years vs. 27.5 years), more often had a university degree (45% vs. 36%), and more often had received other fertility treatments than IVF or ICSI before cohort entry (26% vs. 3%). We found no association between incident MS and exposure to ART compared with non-ART pregnancy (aHR=1.08; 95 % CI, 0.93-1.25). An analysis following intention-to-treat principle on a propensity score matched sub cohort confirmed our results. In subgroup analysis including all ART cycles among the ART treated women, we found no increased risk of MS within 2 years of ART cycle start for successful ART cycles (pregnancy) compared with failed ART cycles (no pregnancy) (aHR=1.01; 95% CI, 0.58-1.76). We found a non-significant trend toward increased risk of MS with increasing numbers of ART cycles although based on small numbers.

CONCLUSION(S)

Women treated with ART do not seem to be at increased risk of developing MS compared with the women not exposed to ART.