Assisted reproductive technology: an overview of Cochrane Reviews

Association between ambient air pollution exposure and pregnancy outcomes in women treated with assisted reproductive technology: an updated systematic review and meta-analysis

BACKGROUND

Ambient air pollution has been recognized as a potential threat to reproductive system function. However, studies investigating the relationship between air pollutants and pregnancy outcomes, particularly in the context of assisted reproductive technology (ART), has yielded inconsistent findings.

METHODS

This study conducted an updated comprehensive search to identify observational studies published before October 14, 2023, that examined the associations between air pollution exposure and pregnancy outcomes among women undergoing ART. Meta-analysis using random effects models were employed to calculate pooled risk estimates of clinical pregnancy, biochemical pregnancy, and live birth.

RESULTS

A total of 20 studies were included in the systematic review and meta-analysis, with 12 studies included in the quantitative synthesis. The results revealed that exposure to carbon monoxide (CO) (RR = 0.949, 95% CI: 0.900, 0.999; I2 = 73%) and nitrogen dioxide (NO2) (RR = 0.976, 95% CI: 0.961, 0.992; I2 = 10%) during the period from ovarian stimulation to oocyte retrieval was associated with lower clinical pregnancy rates. Similarly, exposure to CO (RR = 0.985, 95% CI: 0.975, 0.996; I2 = 0%) and NO2 (RR = 0.978, 95% CI: 0.961, 0.996; I2 = 27%) during this period reduced biochemical pregnancy rates.

CONCLUSIONS

Our study highlights the potential association between air quality and ART outcomes, underscoring the need for improvements in air quality to enhance reproductive success.

Evaluating the Effectiveness of Assisted Oocyte Activation in ICSI: Pairwise Meta-Analyses and Systematic Evidence Evaluation

BACKGROUND

Artificial oocyte activation (AOA) is used to improve fertilisation rates in intracytoplasmic sperm injection (ICSI) cycles.

OBJECTIVES

To assess the effectiveness of AOA on fertilisation, embryo development, and clinical outcomes, including live birth.

SEARCH STRATEGY

We searched PubMed, Cochrane, and Scopus from January 1990 to March 2024 using terms related to 'artificial oocyte activation' and 'ICSI.'

SELECTION CRITERIA

Study designs included randomised trials (RCTs), quasi-experimental, cohort, and case-control studies that evaluated AOA's effects on ICSI outcomes, provided quantitative data and were published in English.

DATA COLLECTION AND ANALYSIS

Reviewers independently performed data extraction using a standardised form. Study quality was appraised using Joanna Briggs Institute (JBI) Checklists. Meta-analyses employed a random-effects model, and evidence was classified using a comprehensive numerical framework.

MAIN RESULTS

We included 45 studies covering 56 787 mature oocytes, 7463 women for clinical pregnancies, and 7063 women for live births. AOA showed potential in increasing fertilisation rates in patients with a history of low or absent fertilisation but did not enhance embryo development or clinical outcomes. This effect diminished when excluding low-quality studies or focusing solely on RCTs. In other patient groups, AOA showed limited or nonsignificant benefits.

CONCLUSIONS

Applying comprehensive evidence assessment, AOA showed potential in improving fertilisation rates in patients with fertilisation problems but no benefits for embryo development or live birth rates. This underscores the critical importance of rigorous evidence credibility in informing clinical practice in assisted conception.

Identifying effective obesity prevention intervention components: An umbrella review mapping systematic review evidence

This overview of reviews synthesizes the effectiveness of obesity prevention interventions in children and adults on BMI/zBMI, following JBI and Cochrane Handbook guidelines. The protocol was prospectively registered in OSF in September 2020. Searches for eligible reviews were run in five databases and gray literature in May 2022. Systematic reviews published in 2010 and assessed BMI/zBMI outcomes of obesity prevention interventions were eligible. Screening, data extraction, and quality assessment were performed independently and in duplicate using standardized tools. For similar interventions, the more recent, higher-quality review was included. Thirty reviews reporting on 60 discrete interventions (i.e., a specific intervention component), mapped to 14 of 21 IOM sub-domains, were included. Nine interventions were classified as effective in improving BMI outcomes, including digital health or counseling interventions for adults in 'healthcare environments', behavioral interventions for children (broadly nutrition education), physical education curriculum modifications, and policies targeting food and beverages in 'School environments'. This review extends on previous reviews by consolidating evidence from high-quality, recent reviews to identify effective intervention components. Thus, this review provides direction for implementation efforts and highlights research gaps, where future research is warranted. However, as primary studies were not directly analyzed, gaps may reflect a lack of systematic reviews rather than primary research.

Multi-omics revealed that DCP1A and SPDL1 determine embryogenesis defects in postovulatory ageing oocytes

Growing evidence indicates that the deterioration of egg quality caused by postovulatory ageing significantly hampers embryonic development. However, the molecular mechanisms by which postovulatory ageing leads to a decline in oocyte quality have not been fully characterized. In this study, we observed an accelerated decay of maternal mRNAs through RNA-seq analyses in postovulatory-aged (PostOA) oocytes. We noted that these downregulated mRNAs should be degraded during the 2-cell stage. Proteomic analyses revealed that the degradation of maternal mRNAs is associated with the accumulation of DCP1A. The injection of exogenous Dcp1a mRNA or siRNA into MII stage oocytes proved that DCP1A could accelerate the degradation of maternal mRNAs. Additionally, we also found that SPDL1 is crucial for maintaining spindle/chromosome structure and chromosome euploidy in PostOA oocytes. Spdl1-mRNA injection remarkably recovered the meiotic defects in PostOA oocytes. Collectively, our findings provide valuable insights into the molecular mechanisms underlying postovulatory ageing.

A Nomogram Predicting Testicular Sperm Extraction Success in Men With Non-obstructive Azoospermia: A Multi-center Study

OBJECTIVE

To develop an efficient and easy-to-use nomogram that can predict testicular sperm extraction (TESE) success in men with non-obstructive azoospermia (NOA) by using pre-operative parameters.

MATERIALS AND METHODS

Data of 3093 men who underwent TESE for NOA were included in this study. Demographic data, testis volumes, presence of varicocele, length of infertility, history of previous surgeries, history of genitourinary infections, smoking status, chromosome abnormalities, presence of Y-chromosome microdeletion, family history of infertility, testis biopsy, surgical data, sperm retrieval rate, final pathology obtained at TESE, follicle-stimulating hormone, luteinizing hormone, and testosterone levels were recorded. The primary outcome was to develop an efficient nomogram that can predict the TESE success in men with NOA. The secondary outcomes were identifying the significant pre-operative parameters that are associated with success in TESE.

RESULTS

Sperm retrieval rate was 50.2%(1553/3093). Testis volume, history of varicocelectomy, chromosome abnormalities, and presence of Y-chromosome microdeletion were shown to affect sperm retrieval rate significantly (P <.05). Sperm retrieval success was higher in men with older age, higher testis volume (>10 mL), lower follicle-stimulating hormone level (≤12.92 mIU/mL), lower luteinizing hormone level, and higher testosterone level (P <.05). Only testis volume and patient's age were associated with successful sperm retrieval in multivariate logistic regression analysis.

CONCLUSION

In men with NOA, high testis volume, old age, low follicle-stimulating hormone level, low luteinizing hormone level, and high testosterone level are advantageous for successful sperm retrieval in TESE. Herein, we present a nomogram that can predict the outcome of TESE in men with NOA with adequate success.

Interacting and joint effects of assisted reproductive technology and gestational diabetes mellitus on preterm birth and the mediating role of gestational diabetes mellitus: a cohort study using a propensity score

OBJECTIVE

To investigate whether gestational diabetes mellitus (GDM) mediates the association between assisted reproductive technology (ART) and preterm birth (PTB), and to examine the interaction and joint effects of ART and GDM on PTB.

METHODS

This retrospective cohort study utilized data from 20,721 mothers with singleton live births at Sichuan Jinxin Xinan Women and Children's Hospital from January 2020 to December 2023. The exposures were ART and GDM, and the outcome was PTB. Multivariate logistic regression assessed the separate associations of ART and GDM with PTB. Mediation, interaction, and joint effects were analyzed using R software.

RESULTS

1,053 (5.08%) women experienced PTB. ART (OR 1.60; 95% CI 1.27-2.03) and GDM (OR 1.51; 95% CI 1.19-1.92) were both associated with increased PTB risk. GDM partially mediated the ART-PTB relationship (PM 2.72%; 95%CI 0.47%-8.86%). No additive interaction was found between GDM and ART for PTB in the general population. However, a significant additive interaction was observed in women aged ≥ 35 years (RERI 1.22; 95%CI 0.27-2.39). Compared to the spontaneous conception (SC)-non-GDM group, the SC-GDM (OR 1.56; 95%CI 1.07-2.29), ART-non-GDM (OR 1.63; 95%CI 1.22-2.18), and ART-GDM (OR 2.42; 95%CI 1.74-3.37) groups had higher PTB risk.

CONCLUSIONS

ART was associated with higher PTB risk, partially mediated by GDM. Women undergoing ART who develop GDM may face greater PTB risk than those exposed to only one factor, with a synergistic effect in older pregnancies.

Trial characteristics, geographic distribution, and selected methodological issues of 1425 infertility trials published from 2012 to 2023: a systematic review

STUDY QUESTION

What are the trial characteristics, geographic distribution, and selected methodological issues of randomized controlled trials (RCTs) in infertility published from 2012 to 2023?

SUMMARY ANSWER

Of the 1425 infertility RCTs, over two-thirds focused on IVF, nearly two-fifths did not use pregnancy or live birth as the primary outcome, a third lacked a primary outcome, a half were unregistered, and just over half were conducted in China (22%), Iran (20%), or Egypt (10%).

WHAT IS KNOWN ALREADY

RCTs are the main source of evidence on the effectiveness of interventions. Knowledge about RCTs in infertility from the recent past will help to pinpoint research gaps and prioritize the future research agenda. Here, we aim to present a descriptive analysis of trial characteristics, geographic distribution, and selected methodological issues in infertility trials published in the last decade.

STUDY DESIGN SIZE DURATION

This is a systematic review. We systematically searched Embase, Medline, and Cochrane Central for RCTs in infertility from January 2012 to August 2023. RCTs involving subfertile women and women who reported pregnancy endpoints were eligible, while conference abstracts or secondary analyses were not. We did not limit our search based on the language of the articles.

PARTICIPANTS/MATERIALS SETTING METHODS

The full articles were text-mined and manually extracted for the description of trials' characteristics (e.g. sample size, blinding method, types of intervention), the country where the patients were recruited, and methodological issues (trial registrations and specification of primary outcomes). We extracted funding statements from Dimensions, a literature database chosen for its comprehensive and robust metadata. Gross domestic product (GDP) data were obtained from the United Nations' official website. The accuracy of extracted data was validated in a random sample of 50 articles, and false positivity and false negativity were all at or below 8%. We used descriptive statistics, including frequencies and percentages to illustrate the overall and temporal trends.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 8757 records, we found 1425 eligible RCTs, with a median sample size of 140, and 33.3% had a sample size <100. Most (69.6%) of the trials focused on IVF, with the rest focusing on ovulation induction (12.4%), intrauterine insemination (10.6%), surgeries (4.8%), or other interventions (2.6%). Regarding the geographic distribution, China (n = 310), Iran (n = 284), and Egypt (n = 138) contributed to 51% of the RCTs, followed by Turkey (n = 82), India (n = 71), and the USA (n = 69); mainland Europe produced 343 trials. Ranked by publications of trials per trillion GDP, Greece had the most papers with 4.6, followed by Iraq at 3.9, and Iran at 2.5. Regarding trial registration, 47.8% of trials were unregistered, the proportion of studies that were unregistered halved from 70.0% in 2012 to 34.6% in 2022. Of all RCTs, 37.6% had primary outcomes unspecified; the proportion of trials specifying primary outcomes increased from 49.5% in 2012 to 61.4% in 2022. The proportion of trials which declared receiving no funding was 76.9%.

LIMITATIONS REASONS FOR CAUTION

We primarily used text mining for data extraction. Despite optimizing the algorithm to identify all outcome definitions and manually curating the extracted data, there were inaccuracies in data extraction; however, the false positivity and false negativity of data extraction were all at or below 8%. Also, we focused on trials reporting pregnancy outcomes, as these are of primary interest to patients and carry significant implications on clinical practice. However, we acknowledge that early-stage trials with only upstream endpoints also play an important role and should be considered when evaluating the full spectrum of infertility trials. Finally, we only included published RCTs and hence, our results cannot be extrapolated to unpublished RCTs.

WIDER IMPLICATIONS OF THE FINDINGS

The domination of RCTs on IVF calls for a reconsideration of other topics to be studied and a realignment of research priorities. The imbalanced geographic distribution of infertility trials raises questions about the generalizability of study results and equity in the distribution of healthcare resources. The prevalence of trials without registration or primary outcomes specified highlights the imperative to improve trial design and reporting quality. Encouragingly, the improving trial registrations suggest the enforcement of trial registrations from the journals is effective.

STUDY FUNDING/COMPETING INTERESTS

B.W.M. is supported by an NHMRC Investigator grant (GNT1176437). W.T.L. is supported by an NHMRC Investigator grant (GTN2016729). W.L.L. reports receiving a PhD scholarship from the China Scholarship Council. Q.F. reports receiving a PhD scholarship from Merck. B.W.M. reports receiving consultancy fees, travel support, and research funding from Merck; consultancy fees from Organon and Norgine; and stock ownership in ObsEva. T.D.H and S.L. are employees of Merck. W.T.L., W.L.L., and J.C. report no conflicts of interest.

REGISTRATION NUMBER

PROSPERO CRD42024498624.

Gonadotropin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotropin-releasing hormone agonists (GnRHa) are commonly used in assisted reproduction technology (ART) cycles to prevent a luteinising hormone (LH) surge during controlled ovarian hyperstimulation (COH) prior to planned oocyte retrieval, thus optimising the chances of live birth. We compared the benefits and risks of the different GnRHa protocols used.

OBJECTIVES

To evaluate the effectiveness and safety of different GnRHa protocols used as adjuncts to COH in women undergoing ART.

SEARCH METHODS

We searched the following databases in December 2022: the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, and registries of ongoing trials. We also searched the reference lists of relevant articles and contacted experts in the field for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any two protocols of GnRHa, or variations of the protocol in terms of different doses or duration, used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles in subfertile women.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Our primary outcome measures were number of live births or ongoing pregnancies and incidence of ovarian hyperstimulation syndrome (OHSS) per woman/couple randomised. Our secondary outcome measures included number of clinical pregnancies, pregnancy losses, number of oocytes retrieved, amount of gonadotropins used, and cost and acceptability of the treatment protocols.

MAIN RESULTS

We included 40 RCTs (4148 women). The trials evaluated 10 different comparisons between protocols. The evidence is current to December 2022. Only half of the studies reported the primary outcome of live birth or ongoing pregnancy rates. We restricted the primary analysis of live birth and ongoing pregnancy to trials with low risk of selection and reporting bias. Nineteen studies compared long and short protocols. The primary analysis restricted to trials with low risk of bias included five studies reporting on live birth or ongoing pregnancy rates. Results showed little or no difference when the long protocol was compared with a short protocol (odds ratio (OR) 1.45, 95% confidence interval (CI) 0.83 to 2.52; I² = 0%; 5 studies, 381 women; low-certainty evidence). For the same comparison, there was evidence that the long protocol may improve clinical pregnancy rates when compared to the short protocol (OR 1.56, 95% CI 1.01 to 2.40; I² = 23%; 8 studies, 552 women; low-certainty evidence). No study in this comparison reported on OHSS. We are uncertain if there is a difference between groups in terms of live birth and ongoing pregnancy rates when the following GnRHa protocols were compared: long versus ultrashort (OR 1.78, 95% CI 0.72 to 4.36; 1 study, 150 women; very low-certainty evidence); long luteal versus long follicular phase (OR 1.89, 95% CI 0.87 to 4.10; 1 study, 223 women; very low-certainty evidence); GnRHa reduced-dose versus GnRHa same-dose continued in the long protocol (OR 1.59, 95% CI 0.66 to 3.87; 1 study, 96 women; very low-certainty evidence); GnRHa administration for two versus three weeks before stimulation (OR 0.88, 95% CI 0.37 to 2.05; 1 study, 85 women; very low-certainty evidence); GnRHa continued versus discontinued after human chorionic gonadotropin (HCG) administration in the long protocol (OR 0.89, 95% CI 0.49 to 1.64; 1 study, 181 women; very low-certainty evidence); and 500 µg dose versus 80 µg dose in the short protocol (OR 0.31, 95% CI 0.10 to 0.98; 1 study, 200 women; very low-certainty evidence). Clinical pregnancy rates may improve with a 100 µg dose compared to a 25 µg dose in the short protocol (OR 2.30, 95% CI 1.06 to 5.00; 2 studies, 133 women; low-certainty evidence). Only four of the 40 included studies reported adverse events. We are uncertain of any difference in OHSS rate in the GnRHa reduced-dose versus GnRHa same-dose regimen in the long protocol (OR 0.47, 95% CI 0.04 to 5.35; 1 study, 96 women; very low-certainty evidence) or when administration of GnRHa lasted for two versus three weeks before stimulation (OR 0.93, 95% CI 0.06 to 15.37; 1 study, 85 women; very low-certainty evidence). Regarding miscarriage rates, we are uncertain of any difference when the GnRHa long protocol was administered for two versus three weeks before stimulation (OR 0.93, 95% CI 0.18 to 4.87; 1 study, 85 women; very low-certainty evidence) and when a 500 µg dose was compared with an 80 µg dose in the short protocol (OR 3.15, 95% CI 0.32 to 31.05; 1 study, 131 women; very low-certainty evidence). No studies reported on cost-effectiveness or acceptability of the different treatment protocols. The certainty of the evidence ranged from low to very low. The main limitations were failure to report live birth or ongoing pregnancy rates, poor reporting of methods in the primary studies, imprecise findings due to lack of data, and insufficient data regarding adverse events. Only eight of the 40 included studies were conducted within the last 10 years.

AUTHORS' CONCLUSIONS

When comparing long and short GnRHa protocols, we found little or no difference in live birth and ongoing pregnancy rates, but there was evidence that the long protocol may improve clinical pregnancy rates overall. We were uncertain of any difference in OHSS and miscarriage rates for all comparisons, which were reported by only two studies each. There was insufficient evidence to draw any conclusions regarding other adverse effects or the cost-effectiveness and acceptability of the different treatment protocols.

The impact of assisted reproductive technologies on ADHD: A systematic review and meta-analysis

BACKGROUND

The escalating utilization of assisted reproductive technology (ART) in response to global infertility rates has spurred research into its complications. Short-term and long-term outcomes have been extensively studied, particularly the neurological concerns surrounding attention-deficit/hyperactivity disorder (ADHD) among ART-conceived children. This study aims investigate the association between ART and ADHD.

METHODS

Medline, Embase, Scopus, and Web of Science databases were searched through April 4, 2023. Cohort, case-control, and cross-sectional studies were eligible for inclusion. primary summary measures included the unadjusted relative risk (RR) and adjusted hazard ratio (HR) with 95 % confidence intervals. Both fixed-effects and random-effects models were utilized for meta-analysis data pooling to determine the overall effect size. The onset of ADHD in children conceived through ART compared to those conceived naturally.

RESULTS

The systematic search yielded 8 studies with 10,176,148 individuals included in the meta-analysis. The meta-analysis revealed a pooled RR of 0.93 (0.68-1.26) for cohort studies and a pooled RR of 0.97 (0.41-2.29) for cross-sectional studies, along with a pooled HR of 1.08 (1.03-1.13) for ADHD in the ART group compared to the non-ART group.

CONCLUSION

While this study identifies some potential association between ART and ADHD, the limited effect size and inherent heterogeneity underscore the need for cautious interpretation.

Translational potential of mesenchymal stem cells in regenerative therapies for human diseases: challenges and opportunities

Advances in stem cell technology offer new possibilities for patients with untreated diseases and disorders. Stem cell-based therapy, which includes multipotent mesenchymal stem cells (MSCs), has recently become important in regenerative therapies. MSCs are multipotent progenitor cells that possess the ability to undergo in vitro self-renewal and differentiate into various mesenchymal lineages. MSCs have demonstrated promise in several areas, such as tissue regeneration, immunological modulation, anti-inflammatory qualities, and wound healing. Additionally, the development of specific guidelines and quality control methods that ultimately result in the therapeutic application of MSCs has been made easier by recent advancements in the study of MSC biology. This review discusses the latest clinical uses of MSCs obtained from the umbilical cord (UC), bone marrow (BM), or adipose tissue (AT) in treating various human diseases such as pulmonary dysfunctions, neurological disorders, endocrine/metabolic diseases, skin burns, cardiovascular conditions, and reproductive disorders. Additionally, this review offers comprehensive information regarding the clinical application of targeted therapies utilizing MSCs. It also presents and examines the concept of MSC tissue origin and its potential impact on the function of MSCs in downstream applications. The ultimate aim of this research is to facilitate translational research into clinical applications in regenerative therapies.

Effect of astaxanthin supplementation on female fertility and reproductive outcomes: a systematic review and meta-analysis of clinical and animal studies

CONTEXT

Oxidative stress (OS) plays a harmful role in female reproduction and fertility. Several studies explored various dietary interventions and antioxidant supplements, such as astaxanthin (AST), to mitigate the adverse effects of OS on female fertility. Ameliorative effects of AST on female fertility and the redox status of reproductive organs have been shown in several animal and clinical studies.

OBJECTIVES

The main objective of present systematic review and meta-analysis of both animal and clinical studies was to provide a comprehensive overview of the current evidence on the effects of AST on female fertility and reproductive outcomes. The effect of AST on redox status, inflammatory and apoptotic markers in reproductive organs were included as the secondary outcomes.

DATA SOURCES

We systematically searched electronic databases including PubMed, Scopus, and Web of Science, until January 1, 2024, using specified search terms related to AST, female reproductive performance, and infertility, considering the diverse synonyms found in the literature for interventional studies that compared oral AST supplementation with placebo or control in human or animal models.

DATA EXTRACTION

Two independent reviewers extracted data on study characteristics, outcomes, and risk of bias. We pooled the results using random-effects models and assessed the heterogeneity and quality of evidence. We descriptively reported the data from animal models, as meta-analysis was not possible.

DATA ANALYSIS

The meta-analysis of clinical trials showed that AST significantly increased the oocyte maturation rate (MD: 8.40, 95% CI: 4.57 to 12.23, I2: 0%) and the total antioxidant capacity levels in the follicular fluid (MD: 0.04, 95% CI: 0.02 to 0.06, I2: 0%). The other ART and pregnancy outcomes and redox status markers did not show statistically significant changes. The animal studies reported ameliorative effects of AST on redox status, inflammation, apoptosis, and ovarian tissue histomorphology.

CONCLUSION

This systematic review shows that AST supplementation may improve assisted reproductive technology outcomes by enhancing oocyte quality and reducing OS in the reproductive organs. However, the evidence is limited by the heterogeneity, risk of bias, and small sample size of the included studies.

Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews

Background

Caesarean section (CS) is the most performed major surgery worldwide. Surgical techniques used for CS vary widely and there is no internationally accepted standardization. We conducted an overview of systematic reviews (SR) of randomized controlled trials (RCT) to summarize the evidence on surgical techniques or procedures related to CS.

Methods

Searches were conducted from database inception to 31 January 2024 in Cochrane Database of Systematic Reviews, PubMed, EMBASE, Lilacs and CINAHL without date or language restrictions. AMSTAR 2 and GRADE were used to assess the methodological quality of the SRs and the certainty of evidence at outcome level, respectively. We classified each procedure-outcome pair into one of eight categories according to effect estimates and certainty of evidence. The overview was registered at PROSPERO (CRD 42023208306).

Findings

The analysis included 38 SRs (16 Cochrane and 22 non-Cochrane) published between 2004-2024 involving 628 RCT with a total of 190,349 participants. Most reviews were of low or critically low quality (AMSTAR 2). The SRs presented 345 procedure-outcome comparisons (237 procedure versus procedure, 108 procedure versus no treatment/placebo). There was insufficient or inconclusive evidence for 256 comparisons, clear evidence of benefit for 40, possible benefit for 17, no difference of effect for 13, clear evidence of harm for 14, and possible harm for 5. We found no SRs for 7 pre-defined procedures. Skin cleansing with chlorhexidine, Joel-Cohen-based abdominal incision, uterine incision with blunt dissection and cephalad-caudal expansion, cord traction for placental extraction, manual cervical dilatation in pre-labour CS, changing gloves, chromic catgut suture for uterine closure, non-closure of the peritoneum, closure of subcutaneous tissue, and negative pressure wound therapy are procedures associated with benefits for relevant outcomes.

Interpretation

Current evidence suggests that several CS surgical procedures improve outcomes but also reveals a lack of or inconclusive evidence for many commonly used procedures. There is an urgent need for evidence-based guidelines standardizing techniques for CS, and trials to fill existing knowledge gaps.

Funding

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).

Systematic review of the economic evaluation model of assisted reproductive technology

BACKGROUND

With the increasing demand for fertility services, it is urgent to select the most cost-effective assisted reproductive technology (ART) treatment plan and include it in medical insurance. Economic evaluation reports are an important reference for medical insurance negotiation. The aim of this study is to systematically evaluate the economic evaluation research of ART, analyze the existing shortcomings, and provide a reference for the economic evaluation of ART.

METHODS

PubMed, EMbase, Web of Science, Cochrane Library and ScienceDirect databases were searched for relevant articles on the economic evaluation of ART. These articles were screened, and their quality was evaluated based on the Comprehensive Health Economics Evaluation Report Standard (CHEERS 2022), and the data on the basic characteristics, model characteristics and other aspects of the included studies were summarized.

RESULTS

One hundred and two related articles were obtained in the preliminary search, but based on the inclusion criteria, 12 studies were used for the analysis, of which nine used the decision tree model. The model parameters were mainly derived from published literature and included retrospective clinical data of patients. Only two studies included direct non-medical and indirect costs in the cost measurement. Live birth rate was used as an outcome indicator in half of the studies.

CONCLUSION

Suggesting the setting of the threshold range in the field of fertility should be actively discussed, and the monetary value of each live birth is assumed to be in a certain range when the WTP threshold for fertility is uncertain. The range of the parameter sources should be expanded. Direct non-medical and indirect costs should be included in the calculation of costs, and the analysis should be carried out from the perspective of the whole society. In the evaluation of clinical effect, the effectiveness and safety indexes should be selected for a comprehensive evaluation, thereby making the evaluation more comprehensive and reliable. At least subgroup analysis based on age stratification should be considered in the relevant economic evaluation.

Autologous platelet-rich plasma for assisted reproduction

BACKGROUND

Autologous platelet-rich plasma (PRP) consists of plasma and a concentrate of platelets extracted from fresh whole blood of the person being treated. Research has suggested that intrauterine or intraovarian infusion/injection of PRP before embryo transfer may improve endometrial receptivity and response to ovarian stimulation in women undergoing assisted reproduction. We compared these interventions to standard treatment, placebo, or other interventions (mechanical or pharmacological).

OBJECTIVES

To assess the effectiveness and safety of intrauterine and intraovarian infusion/injection of platelet-rich plasma in infertile women undergoing assisted reproductive technology cycles.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, and the Epistemonikos database in January 2023. We also searched the reference lists of relevant articles and contacted the trial authors and experts in the field for any additional trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated the application of PRP in the uterine cavity, ovaries, or both versus no intervention, placebo, or any other intervention (either mechanical or pharmacological) in women undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane, including use of the updated risk of bias tool (RoB 2). The primary outcomes were live birth (or ongoing pregnancy) and miscarriage. The secondary outcomes were clinical pregnancy, complications of the procedure, multiple pregnancy, ectopic pregnancy, fetal growth restriction, preterm delivery, and fetal abnormality. We estimated the average effect of the interventions by fitting a Der Simonian-Laird's random-effects meta-analysis model. We reported pooled odds ratios (ORs) with 95% confidence intervals (CIs). We restricted the primary analyses to trials at low risk of bias for the outcomes and performed sensitivity analyses that included all studies.

MAIN RESULTS

We included 12 parallel-group RCTs that recruited a total of 1069 women. We identified three different comparison groups. Using GRADE, we assessed the certainty of evidence as very low for almost all outcomes. Intrauterine injection/infusion of platelet-rich plasma versus no intervention or placebo Nine studies evaluated intrauterine PRP versus no intervention or placebo. Eight included women with at least two or three previous implantation failures. Only one was assessed at low risk of bias for each outcome. This study provided very low-certainty evidence about the effect of intrauterine PRP injection versus no intervention on live birth (OR 1.10, 95% CI 0.38 to 3.14; 94 women) and miscarriage (OR 0.96, 95% CI 0.13 to 7.09; 94 women). If the likelihood of live birth following no intervention is assumed to be 17%, then the likelihood following intrauterine PRP would be 7% to 40%; and if the risk of miscarriage following no intervention is 4%, then the risk following intrauterine PRP would be 1% to 24%. When we analyzed all studies (regardless of risk of bias), we found very low-certainty evidence about the effect of intrauterine PRP compared with placebo or no intervention on live birth or ongoing pregnancy (OR 2.38, 95% CI 1.16 to 4.86; I² = 54%; 6 studies, 564 women) and miscarriage (OR 1.54, 95% CI 0.59 to 4.01; I² = 0%; 5 studies, 504 women). The study at low risk of bias provided very low-certainty evidence about the effect of intrauterine PRP compared with no intervention on clinical pregnancy (OR 1.55, 95% CI 0.64 to 3.76; 94 women) and ectopic pregnancy (OR 2.94, 95% CI 0.12 to 73.95; 94 women). The synthesis of all studies provided very low-certainty evidence about the effect of intrauterine PRP compared with placebo or no intervention on clinical pregnancy (OR 2.22, 95% CI 1.50 to 3.27; I² = 24%; 9 studies, 824 women), multiple pregnancy (OR 2.68, 95% CI 0.81 to 8.88; I² = 0%; 2 studies, 240 women), and ectopic pregnancy (OR 2.94, 95% CI 0.12 to 73.95; 1 study, 94 women; very low-certainty evidence). Intrauterine infusion of PRP may increase the risk of preterm delivery compared with no intervention (OR 8.02, 95% CI 1.72 to 37.33; 1 study, 120 women; low-certainty evidence). No studies reported pain, infection, allergic reaction, fetal growth restriction, or fetal abnormality. Intrauterine infusion of platelet-rich plasma versus intrauterine infusion of granulocyte colony-stimulating factor Two RCTs evaluated intrauterine PRP versus intrauterine granulocyte colony-stimulating factor (G-CSF); both included women with thin endometrium, and neither was judged at low risk of bias for any outcome. We are uncertain about the effect of intrauterine PRP compared with intrauterine G-CSF on live birth (OR 0.88, 95% CI 0.43 to 1.81; 1 study, 132 women; very low-certainty evidence), miscarriage (OR 1.94, 95% CI 0.63 to 5.96; 1 study, 132 women; very low-certainty evidence), and clinical pregnancy (OR 1.24, 95% CI 0.66 to 2.35; 2 studies, 172 women; very low-certainty evidence). Neither study reported adverse outcomes other than miscarriage. Intraovarian injection of platelet-rich plasma versus no intervention One RCT evaluated PRP injection into both ovaries versus no intervention; it was judged at high risk of bias for the two outcomes it reported. We are uncertain about the effect of intraovarian PRP injection compared with no intervention on ongoing pregnancy (OR 1.09, 95% CI 0.33 to 3.63; 73 women; very low-certainty evidence) and clinical pregnancy (OR 0.90, 95% CI 0.31 to 2.60; 73 women; very low-certainty evidence). The study examined no safety outcomes.

AUTHORS' CONCLUSIONS

We are uncertain about the effect of intrauterine or intraovarian administration of PRP on outcomes of assisted reproduction technology in infertile women. The pooled results should be interpreted with caution. Only one of the 12 included studies was judged at low risk of bias. Other limitations of the included trials were failure to report live birth, poor reporting of methods, lack of prospective protocol registration, low precision due to the small number of enrolled participants, indirectness due to the specific subpopulations and settings studied, and insufficient or absent safety data.

Corticosteroids for the prevention and treatment of bronchopulmonary dysplasia: an overview of systematic reviews

BACKGROUND

Bronchopulmonary dysplasia (BPD) remains an important complication of prematurity. Pulmonary inflammation plays a central role in the pathogenesis of BPD, explaining the rationale for investigating postnatal corticosteroids. Multiple systematic reviews (SRs) have summarised the evidence from numerous randomised controlled trials (RCTs) investigating different aspects of administrating postnatal corticosteroids. Besides beneficial effects on the outcome of death or BPD, potential short- and long-term harms have been reported.

OBJECTIVES

The primary objective of this overview was to summarise and appraise the evidence from SRs regarding the efficacy and safety of postnatal corticosteroids in preterm infants at risk of developing BPD.

METHODS

We searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase, CINAHL, and Epistemonikos for SRs in April 2023. We included all SRs assessing any form of postnatal corticosteroid administration in preterm populations with the objective of ameliorating pulmonary disease. All regimens and comparisons were included. Two review authors independently checked the eligibility of the SRs comparing corticosteroids with placebo, and corticosteroids with different routes of administration and regimens. The included outcomes, considered key drivers in the decision to administer postnatal corticosteroids, were the composite outcome of death or BPD at 36 weeks' postmenstrual age (PMA), its individual components, long-term neurodevelopmental sequelae, sepsis, and gastrointestinal tract perforation. We independently assessed the methodological quality of the included SRs by using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) and ROBIS (Risk Of Bias In Systematic reviews) tools. We assessed the certainty of the evidence using GRADE. We provided a narrative description of the characteristics, methodological quality, and results of the included SRs.

MAIN RESULTS

We included nine SRs (seven Cochrane, two non-Cochrane) containing 87 RCTs, 1 follow-up study, and 9419 preterm infants, investigating the effects of postnatal corticosteroids to prevent or treat BPD. The quality of the included SRs according to AMSTAR 2 varied from high to critically low. Risk of bias according to ROBIS was low. The certainty of the evidence according to GRADE ranged from very low to moderate. Early initiated systemic dexamethasone (< seven days after birth) likely has a beneficial effect on death or BPD at 36 weeks' PMA (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.81 to 0.95; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 10 to 41; I2 = 39%; 17 studies; 2791 infants; moderate-certainty evidence) and on BPD at 36 weeks' PMA (RR 0.72, 95% CI 0.63 to 0.82; NNTB 13, 95% CI 9 to 21; I2 = 39%; 17 studies; 2791 infants; moderate-certainty evidence). Early initiated systemic hydrocortisone may also have a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.90, 95% CI 0.82 to 0.99; NNTB 18, 95% CI 9 to 594; I2 = 43%; 9 studies; 1376 infants; low-certainty evidence). However, these benefits are likely accompanied by harmful effects like cerebral palsy or neurosensory disability (dexamethasone) or gastrointestinal perforation (both dexamethasone and hydrocortisone). Late initiated systemic dexamethasone (≥ seven days after birth) may have a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.75, 95% CI 0.67 to 0.84; NNTB 5, 95% CI 4 to 9; I2 = 61%; 12 studies; 553 infants; low-certainty evidence), mostly contributed to by a beneficial effect on BPD at 36 weeks' PMA (RR 0.76, 95% CI 0.66 to 0.87; NNTB 6, 95% CI 4 to 13; I2 = 14%; 12 studies; 553 infants; low-certainty evidence). No harmful side effects were shown in the outcomes chosen as key drivers to the decision to start or withhold late systemic dexamethasone. No effects, either beneficial or harmful, were found in the subgroup meta-analyses of late hydrocortisone studies. Early initiated inhaled corticosteroids probably have a beneficial effect on death and BPD at 36 weeks' PMA (RR 0.86, 95% CI 0.75 to 0.99; NNTB 19, 95% CI not applicable; I2 = 0%; 6 studies; 1285 infants; moderate-certainty evidence), with no apparent adverse effects shown in the SRs. In contrast, late initiated inhaled corticosteroids do not appear to have any benefits or harms. Endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier likely has a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.60, 95% CI 0.49 to 0.74; NNTB 4, 95% CI 3 to 6; I2 = 0%; 2 studies; 381 infants; moderate-certainty evidence) and on BPD at 36 weeks' PMA. No evidence of harmful effects was found. There was little evidence for effects of different starting doses or timing of systemic corticosteroids on death or BPD at 36 weeks' PMA, but potential adverse effects were observed for some comparisons. Lowering the dose might result in a more unfavourable balance of benefits and harms. Moderately early initiated systemic corticosteroids, compared with early systemic corticosteroids, may result in a higher incidence of BPD at 36 weeks' PMA. Pulse dosing instead of continuous dosing may have a negative effect on death and BPD at 36 weeks' PMA. We found no differences for the comparisons of inhaled versus systemic corticosteroids.

AUTHORS' CONCLUSIONS

This overview summarises the evidence of nine SRs investigating the effect of postnatal corticosteroids in preterm infants at risk for BPD. Late initiated (≥ seven days after birth) systemic administration of dexamethasone is considered an effective intervention to reduce the risk of BPD in infants with a high risk profile for BPD, based on a favourable balance between benefits and harms. Endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier is a promising intervention, based on the beneficial effect on desirable outcomes without (so far) negative side effects. Pending results of ongoing large, multicentre RCTs investigating both short- and long-term effects, endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier is not appropriate for clinical practice at present. Early initiated (< seven days after birth) systemic dexamethasone and hydrocortisone and late initiated (≥ seven days after birth) hydrocortisone are considered ineffective interventions, because of an unfavourable balance between benefits and harms. No conclusions are possible regarding early and late inhaled corticosteroids, as more research is needed.

Algorithm vs. clinical experience: controlled ovarian stimulations with follitropin-delta and individualised doses of follitropin-alpha/beta

In the registrational trials, follitropin delta was compared with a fixed dose of 150 UI of follitropin alpha/beta, finding higher chances to reach a target response of 8-14 oocytes compared to controls. For this reason, follitropin delta is marketed as particularly useful in expected hyper-responder patients. The main outcome of this study is to report if comparable results are reached in a real-life scenario with follitropin alpha/beta personalized doses, based on patients' characteristics. This is a retrospective study performed in two public fertility centres. All first cycles from January 2020 to June 2022 with either follitropin delta (cases) or alpha/beta (controls) in patients with antiMüllerian hormone >2.5 ng/ml were compared by an inverse probability weighting approach based on propensity score. The follitropin total dose was higher in controls (1179.06 ± 344.93 vs. 1668.67 ± 555.22 IU, p<0.001). The target response of 8-14 oocytes was reached by 40.2% of cases and 40.7% of controls (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.65-1.53, p=0.98). Fewer than 8 oocytes were collected in 24.1% of cases and 22% of controls (OR 1.10, 95% CI 0.71-1.69, p=0.67); more than 14 oocytes in 35.7% of cases and 37.3% of controls (OR 0.83, 95% CI 0.54-1.28, p=0.40). Our experience did not find worse results in term of proportion of patients who reached the target response with an algorithm-chosen dose of follitropin delta compared to a personalised starting dose of follitropin alpha/beta, with follitropin delta having the advantage of objectivity. Larger numbers are needed to confirm these results.

Efficacy and safety of follitropin delta versus follitropin alpha/beta in infertility treatment: A systematic review and meta-analysis

Background

Follitropin δ may be an alternative to conventional follitropin α/β for controlled ovarian stimulation (COS) within assisted reproductive treatment (ART), but its efficacy and safety remain unknown. We performed a random-effects meta-analysis to compare the efficacy and safety of follitropin δ and follitropin α/β.

Methods

We searched randomized controlled trials comparing follitropin δ and follitropin α/β using MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and WHO-ITCRP on December 14, 2022. The primary outcomes were the live birth rate and the incidence of moderate or severe ovarian hyperstimulation syndrome (OHSS). The certainty of the evidence was assessed using the grading of recommendations assessment, development, and evaluation approach. The protocol was registered on the Open Science Framework.

Results

Three studies involving 2682 participants were included in our meta-analysis. The results indicated that follitropin δ may result in little to no difference in live birth rates (risk ratio [RR], 1.12; 95% confidence interval [CI], 0.91-1.38; low certainty) and the incidence of moderate or severe OHSS (RR, 0.78; 95% CI, 0.48-1.26; low certainty) compared with follitropin α/β.

Conclusion

Follitropin δ may result in little to no difference in COS compared with follitropin α/β, especially in terms of live births and safety.

Assisted reproductive technology and imprinting errors: analyzing underlying mechanisms from epigenetic regulation

With the increasing maturity and widespread application of assisted reproductive technology (ART), more attention has been paid to the health outcomes of offspring following ART. It is well established that children born from ART treatment are at an increased risk of imprinting errors and imprinting disorders. The disturbances of genetic imprinting are attributed to the overlap of ART procedures and important epigenetic reprogramming events during the development of gametes and early embryos, but the detailed mechanisms are hitherto obscure. In this review, we summarized the DNA methylation-dependent and independent mechanisms that control the dynamic epigenetic regulation of imprinted genes throughout the life cycle of a mammal, including erasure, establishment, and maintenance. In addition, we systematically described the dysregulation of imprinted genes in embryos conceived through ART and discussed the corresponding underlying mechanisms according to findings in animal models. This work is conducive to evaluating and improving the safety of ART.

The status of surrogacy in China

China's birth rates hit a record low in 2021. The high demand for having children has spawned a massive market for surrogacy, which, however, is a dilemma in China involving a series of moral and legal issues under the current circumstances. First, special populations, including infertile patients, families who have lost their sole child, and homosexuals, wanted to have children, giving rise to surrogacy. Then, the development of and innovation in assisted reproductive technology allowed surrogacy to mature. A high return offsets a high risk, and consequently, an underground surrogacy market has emerged, causing various social issues for the Chinese Government, such as civil disputes, gender disproportion, crime, and the spread of disease. At the same time, surrogacy violates moral ethics, traditional Chinese culture, and the rights and interests of vulnerable groups.

Pregnancy outcome in long- versus short-acting gonadotropin-releasing hormone agonist cycles in participants with normal ovarian reserve: An RCT

Background

There is no agreement on which of the 2 gonadotropin-releasing hormone (GnRH) agonist protocols are the most efficient, neither there is any consensus on which one yields a better clinical pregnancy percentage.

Objective

The present study aims to compare the effectiveness of reduced dosages of long- and short-acting GnRH agonists on pregnancy outcomes.

Materials and Methods

In this randomized controlled clinical trial, 400 women were randomly assigned to 2 groups (n = 200/group): the reduced dosage of long-acting GnRH agonist group (group 1, 1.25 mg Decapeptyl) and the short-acting GnRH agonist group (group 2, 0.5 mg/day Buserelin Acetate). The study was conducted at Mehr Medical Institute, Rasht, Iran between July 2019 and July 2020. Biochemical and clinical pregnancy were compared between groups.

Results

No significant differences were observed in the endometrial lining, the total number of retrieved and metaphase-II oocytes, progesterone, and serum estradiol levels on human chorionic gonadotropin day, fertilization rate, and top-quality embryos between the groups. The duration of induction (10.8 ± 1.7 vs. 10 ± 2.1, p < 0.001) and the total dosage of gonadotropins (2939.4 ± 945.9 vs. 2441 ± 1247.1, p < 0.001) were significantly greater in group 2 than in group 1. No significant differences were observed between the 2 groups in terms of implantation rate, chemical pregnancy rate, and clinical pregnancy rate. A higher percentage of ovarian hyperstimulation syndrome was observed in group 2 (p = 0.005).

Conclusion

Due to a lower percentage of ovarian hyperstimulation syndrome in group 1 and similar assisted reproductive technology outcomes in both groups, the long protocol was found to be superior to the short protocol.

Going the Distance : Ethics of Space and Location on Accessing Reproductive Services in Australia

Qualitative studies on assisted reproductive technology commonly focus on the perspectives of participants living in major metropolises. In doing so, the experiences of those living outside major cities, and the unique way conditions of spatiality shape access to treatment, are elided. In this paper, we examine how location and regionality in Australia impact upon access and experience of reproductive services. We conducted twelve qualitative interviews with participants residing in regional areas across Australia. We asked participants to discuss their experience with assisted reproduction services and the impacts of location on access, service choice, and experience of care, and analysed the data using reflexive thematic analysis, as outlined by Braun and Clarke (2006, 2019). Participants in this study reported that their location impacted the services available to them, required considerable time in travel, and reduced continuity of care. We draw on these responses to examine the ethical implications of uneven distribution of reproductive services in commercial healthcare settings which rely on market-based mechanisms.

Maternidad subrogada a debate

La maternidad subrogada es una respuesta técnica ante una dificultad biológica que se puede dar en la reproducción humana. Luego de una introducción, que muestra la problemática que la guerra en Ucrania ha ocasionado en esta materia, se exponen algunas generalidades sobre la maternidad subrogada, su presencia en el mundo y sus costos; así mismo, se reflexiona sobre los problemas éticos, bioéticos y biojurídicos desde las perspectivas biológica, antropológica y jurídica en cada uno de los actores del proceso (madre sustituta, pareja o persona contratante, el embrión resultante y la sociedad). Se concluye que la maternidad subrogada, aunque sea técnicamente posible, no es una solución ética ni bioética para la esterilidad humana porque deja de lado el respeto a la dignidad; es un negocio que incluye explotación de mujeres; impone actuaciones jurídicas que fuerzan la realidad al declarar como derechos lo que no son más que deseos y es causa de varias formas de vulnerabilidad en las personas que intervienen en ella y en la sociedad en su conjunto.

Prediction model of gonadotropin starting dose and its clinical application in controlled ovarian stimulation

Background

Selecting an appropriate and personalized Gn starting dose (GSD) is an essential procedure for determining the quality and quantity of oocytes in the controlled ovarian stimulation (COS) process of the in-vitro fertilization (IVF) treatment cycle. The current approach for determining the GSD is mainly based on the experience of a clinician, lacking unified and scientific standards. This study aims to establish a prediction model of GSD, based on which good COS outcomes can be achieved with the influencing factors comprehensively evaluated quantitatively.

Material and methods

We collected a total of 1555 patients undergoing the first oocytes retrieving cycle and conducted correlation analysis to find the significant factors related to the GSD. Two GSD models are built based on two popular machine learning approaches, and the one with better model performance is selected as the final model. Finally, clinical application and validation were conducted to verify the effectiveness of the proposed model.

Results

(1) Age, duration of infertility, type of infertility, body mass index (BMI), antral follicle count (AFC), basal follicle stimulating hormone (bFSH), estradiol (E₂), luteinizing hormone (LH), anti-Müllerian hormone (AMH) and COS treatment regimen were closely related to the GSD (P < 0.05). (2) The selected model has good modeling performance in terms of both root mean square error (RMSE) (29.87 ~ 34.21) and regression coefficient R (0.947 ~ 0.953). (3) A comprehensive evaluation of influencing factors for GSD is conducted and shows that the top four most significant factors are age, AMH, AFC, and BMI. (4) The proposed GSD can approximate the actual value well in the clinical application, with the mean absolute error of only 11.26 units, and the recommended results can prompt the number of oocytes retrieved (NOR) close to the optimal number.

Conclusion

Modeling the GSD value with machine learning approaches is feasible and effective, and the proposed model has good clinical application for determining the GSD in the IVF treatment cycle.

Outcomes of frozen embryo transfer in patients with and without ovarian hyperstimulation syndrome

"Introduction: One of the methods utilized to treat infertility is the use of frozen embryos. This technique is particularly employed in patients with ovarian hyperstimulation syndrome (OHSS), which leads to heightened blood estrogen levels. The purpose of this study was to compare the percentage of pregnancy and abortion between patients who used the frozen embryo method due to OHSS and others who practiced the same method for other reasons. Materials and Methods: This retrospective, cohort study was conducted on a total of 338 patients who visited in vitro fertilization (IVF) section of Kowsar Hospital of Urmia-Iran to employ the frozen embryo method (May 2013 to December 2015). The patients were classified into two groups, i.e. the OHSS group (N=150) and the non-OHSS group (N=188). Data were obtained and examined by evaluating the files in a questionnaire. Results: The two groups did not differ significantly with regard to their mean age (p = 0.57). There was also no statistically significant difference between the OHSS and non-OHSS groups regarding the quality of frozen embryo transferred (P = 0.17). Also, there was also no statistically significant difference between the two groups in terms of their pregnancy rate (OHSS = 30.0% vs. non-OHSS = 25.0%) and miscarriage rate (OHSS = 31.11% vs. non-OHSS = 24.44%) (p = 0.32 and p = 0.31, respectively). Conclusion: Ovum exposure to high estrogen during ovulation stimulation does not affect embryo implantation and miscarriage in patients with OHSS."

Effect of a High Estrogen Level in Early Pregnancy on the Development and Behavior of Marmoset Offspring

The use of assisted reproductive technology (ART) has risen steadily worldwide over the past 3 decades and helps many infertile families. However, ART treatments lead to an abnormal internal environment in the uterus, which may increase the risks of health problems for the offspring. Higher maternal estradiol (E₂) is a notable feature in women who use ART treatments, and this has been suggested as a key factor for the risk of diseases in the offspring. In the current study, we have established a marmoset model with a high E₂ level in early pregnancy to examine its potential risk to the development and behavior of the offspring. In comparison with the normal group, babies of the high E₂ group exhibited lower average survival rates and birth weights. However, those who survived in the high E₂ group demonstrated normal vocal production with rich call repertoires, normal speed during locomotion, and normal behaviors in the home cage. In contrast to the normal group, surviving babies of the high E₂ group spent more time sleeping during development without signs of sleep disorders. In summary, our study revealed that high estrogen in early pregnancy may cause low survival rates and birth weights of the offspring, though the surviving infants did not show obvious behavioral deficiencies during development. The current study is a valuable and highly important non-human primate study for evaluating the safety of ART treatments. However, it is worth noting that some results did not reach the significant level, which may be due to the small sample size caused by animal shortage stemming from the COVID-19 epidemic.

Experiences of infertile women pursuing treatment in Kenya: a qualitative study

Background

The infertility treatment process is associated with various psychological, physical, social, moral, and financial challenges, especially for women. The women are likely to report low marital satisfaction and emotional distress due to fertility treatment demands. This study explored how infertile women described their treatment experience and how they coped with treatment demands as they underwent treatment at three gynecology outpatient clinics in Kenya.

Methods

A qualitative phenomenological research design was used to analyze and describe women’s fertility treatment experiences. The data were collected through semi-structured in-depth interviews with 33 infertile women selected purposively. Trustworthiness of the findings was ensured using Guba and Lincoln’s criteria. The recorded interviews were transcribed verbatim and then analyzed using reflective thematic analysis, developed by Braun and Clarkes.

Results

Three themes and 13 sub-themes related to women’s fertility treatment experiences and coping strategies were identified. The theme challenges encountered during fertility treatment have three sub-themes: emotional distressing, physical pain, and financial constraining. Theme impacts of fertility treatment on relationships have three sub-themes: relationship with their husband, relationship with their family, and relationship with their friends. Finally, coping with fertility treatment has six sub-themes: religious practices and personal faith, giving in to feelings, shifting focus, taking a break, staying with their relative’s children, and receiving support from others.

Conclusion

The experiences of women undergoing treatment are multi-dimensional. Therefore, incorporating psychosocial interventions or counseling into the fertility treatment routine with National Health Insurance Fund cards may reduce the treatment burden, improving women’s psychological well-being and relationships with their husbands, family, and friends.

Stem cell-based therapy for human diseases

Recent advancements in stem cell technology open a new door for patients suffering from diseases and disorders that have yet to be treated. Stem cell-based therapy, including human pluripotent stem cells (hPSCs) and multipotent mesenchymal stem cells (MSCs), has recently emerged as a key player in regenerative medicine. hPSCs are defined as self-renewable cell types conferring the ability to differentiate into various cellular phenotypes of the human body, including three germ layers. MSCs are multipotent progenitor cells possessing self-renewal ability (limited in vitro) and differentiation potential into mesenchymal lineages, according to the International Society for Cell and Gene Therapy (ISCT). This review provides an update on recent clinical applications using either hPSCs or MSCs derived from bone marrow (BM), adipose tissue (AT), or the umbilical cord (UC) for the treatment of human diseases, including neurological disorders, pulmonary dysfunctions, metabolic/endocrine-related diseases, reproductive disorders, skin burns, and cardiovascular conditions. Moreover, we discuss our own clinical trial experiences on targeted therapies using MSCs in a clinical setting, and we propose and discuss the MSC tissue origin concept and how MSC origin may contribute to the role of MSCs in downstream applications, with the ultimate objective of facilitating translational research in regenerative medicine into clinical applications. The mechanisms discussed here support the proposed hypothesis that BM-MSCs are potentially good candidates for brain and spinal cord injury treatment, AT-MSCs are potentially good candidates for reproductive disorder treatment and skin regeneration, and UC-MSCs are potentially good candidates for pulmonary disease and acute respiratory distress syndrome treatment.

The cumulative live birth rate of recombinant follicle-stimulating hormone alfa verse urinary human follicle-stimulating hormone for ovarian stimulation in assisted reproductive technology cycles

Background

Infertility remains a significant public health concern. An issue with controlled ovarian stimulation (COS) is the selection of an exogenous gonadotropin (Gn) regimen, which is mainly based on urinary follicle-stimulating hormone (uFSH), recombinant follicle-stimulating hormone alfa (rFSH-alfa), and human menopausal gonadotropin (HMG). In addition, most previous studies focused on the clinical pregnancy rates or live birth rates (LBR) per transfer cycle, but not on the cumulative live birth rate (CLBR) per started cycle. The CLBR, appears to be a more comprehensive and accurate universal measure of IVF treatment success. Therefore, this study aimed to compare the cumulative live birth rate (CLBR) between rFSH-alfa and uFSH regimens for ovarian stimulation.

Methods

This retrospective cohort study included patients who underwent assisted reproductive technology (ART) with gonadotropin-releasing hormone (GnRH) agonist long protocol between March 2009 and December 2018. Patients were grouped according to the Gn regimen received (rFSH-alfa or uFSH). The main outcome was CLBR, which defined as the first live birth following the use of all fresh and frozen embryos derived from a single COS cycle.

Results

A total of 1078 cycles were analyzed (314 with rFSH-alfa and 764 with uFSH). The rFSH-alfa group was characterized by a higher number of retrieved oocytes (13.3 vs. 11.0) and transferable embryos (5.0 vs. 4.0), a higher fresh embryo transfer rate (35.0% vs. 26.3%), and a higher multiple birth rate among the fresh embryo transfer cycles (8.2% vs. 2.5%) (P < 0.05). There were no differences in pregnancy rate (32.7% vs. 33.8%) and LBR (25.5% vs. 26.9%) per transfer cycle (P > 0.05). No significant difference was found in clinical outcomes among the frozen embryo transfer cycles (P > 0.05). The CLBR per started cycle in the rFSH-alfa group was higher than in the uFSH group (53.5% vs. 43.1%, P < 0.05). After adjustment, rFSH-alfa was independently associated with a higher CLBR (OR = 1.56; 95%CI = 1.18–2.05; P = 0.0018).

Conclusions

rFSH-alfa and uFSH have similar pregnancy rates and LBR per transfer cycle, rFSH-alfa might achieve more transferrable blastocysts and higher CLBR per started cycle compared to uFSH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-022-01009-w.

Effects of different sperm sources on clinical outcomes in intracytoplasmic sperm injection cycles

The aim was to investigate the influences of different sperm sources on clinical outcome and neonatal outcome of patients with intracytoplasmic sperm injection. We retrospectively analysed patients who underwent intracytoplasmic sperm injection in our reproductive centre from 2011 to 2020. We screened data on assisted reproductive outcomes from four groups of sources: testicular sperm, epididymal sperm, ejaculated sperm and donor sperm for analysis and divided the non-ejaculated group from the ejaculated group to explore their impact on clinical outcomes and neonatal outcomes. A total of 2139 cycles were involved in this study. There were significant differences in fertilisation rate (77.0% vs. 73.6%, p < .001), cleavage rate (97.4% vs. 94.4%, p < .001) and high-quality embryo rate (52.8% vs. 49.9%, p < .001) between the ejaculated and non-ejaculated sperm groups. There were no significant differences amongst the four groups in biochemical pregnancy rate, clinical pregnancy rate, abortion rate, live birth rate, male-female ratio and single-twin ratio. Different sperm sources did not affect the length, weight or physical defects of newborns amongst the groups. Sperm source did not affect pregnancy and neonatal outcomes of intracytoplasmic sperm injection in general.

The association of impaired semen quality and pregnancy rates in assisted reproduction technology cycles: Systematic review and meta-analysis

Some studies suggest a relationship between semen quality and pregnancy rates of assisted reproduction technologies (ART). Others have questioned the utility of semen quality as proxy for fertility in couples attempting to conceive with or without assistance. We aimed to investigate the current body of evidence which correlates semen parameters and clinical pregnancy among couples utilizing ART (i.e. in vitro fertilization [IVF], intracytoplasmic sperm injection [ICSI]) through a systematic review and meta‐analysis of cross‐sectional and retrospective cohort studies. Pooled Odd Ratio (OR) for oligo‐, astheno‐ and teratospermic compared to normospermic number of ART cycles were calculated among. Meta‐regression and sub‐group analysis were implemented to model the contribution of clinical/demographic and laboratory standards differences among the studies. Overall, 17 studies were analysed representing 17,348 cycles were analysed. Pooled OR for impaired sperm concentration, motility and morphology was 1 (95%Confidence Interval [CI]: 0.97–1.03), 0.88 (95%CI: 0.73–1.03) and 0.88 (95%CI: 0.75–1) respectively. Further analysis on sperm morphology showed no differences with regard of IVF versus ICSI (p = 0.14) nor a significant correlation with rising reference thresholds (Coeff: −0.02, p = 0.38). A temporal trend towards a null association between semen parameters and clinical pregnancy was observed over the 20‐year observation period (Coeff: 0.01, p = 0.014). The current analysis found no association between semen quality (as measured by concentration, motility or morphology) and clinical pregnancy rates utilizing ART. Future investigations are necessary to explore the association between semen parameters and other ART outcomes (e.g. fertilization, implantation, birth and perinatal health).

The novel oral gonadotropin-releasing hormone receptor antagonist relugolix is a new option for controlled ovarian stimulation cycles

Purpose

Relugolix is an oral gonadotropin-releasing hormone antagonist (GnRHant), which was first introduced in 2019. This study investigated the effects of the conventional injectable GnRHant formulation and this new oral GnRHant formulation on controlled ovarian stimulation (COS) cycles.

Methods

Relugolix was administered in 126 cycles and conventional GnRHant injection was administered in 658 cycles (controls). The follicle stimulation was performed by an antagonist method, and for final oocyte maturation, recombinant human chorionic gonadotropin (rHCG), or gonadotropin-releasing hormone agonist (GnRHa), or both (dual trigger) were selected. The number of retrieved oocytes was counted and then they were evaluated for subsequent development up to cleavage stage.

Results

The number of retrieved oocytes which was the primary outcome of this research was affected by the combination of GnRHant type and the final oocyte maturation agent. The combination of relugolix and a GnRHa trigger showed a significantly lower number of retrieved oocytes (p < 0.001) than the other combinations.

Conclusions

Relugolix is a new option for COS cycles, but should be carefully combined with the final maturation agent.

Clinical trial approval

This study was conducted after approval by the Medical Corporation Sankeikai Institutional Ethics Committee (approval number: 2019-34).

Live-Birth Prediction of Natural-Cycle In Vitro Fertilization Using 57,558 Linked Cycle Records: A Machine Learning Perspective

BACKGROUND

Natural-cycle in vitro fertilization (NC-IVF) is an in vitro fertilization (IVF) cycle without gonadotropins or any other stimulation of follicular growth. Previous studies on live-birth prediction of NC-IVF were very few; the sample size was very limited. This study aims to construct a machine learning model to predict live-birth occurrence of NC-IVF using 57,558 linked cycle records and help clinicians develop treatment strategies.

DESIGN AND METHODS

The dataset contained 57,558 anonymized register patient records undergoing NC-IVF cycles from 2005 to 2016 filtered from 7bsp;60,732 records in the Human Fertilisation and Embryology Authority (HFEA) data. We selected matching records and features through data filtering and feature selection methods. Two groups of twelve machine learning models were trained and tested. Eight metrics, e.g., F1 score, Matthews correlation coefficient (MCC), the area under the receiver operating characteristic curve (AUC), etc., were computed to evaluate the performance of each model.

RESULTS

Two groups of twelve models were trained and tested. The artificial neural network (ANN) model performed the best in the machine learning group (F1 score, 70.87%; MCC, 50.37%; and AUC score, 0.7939). The LogitBoost model obtained the best scores in the ensemble learning group (F1 score, 70.57%; MCC, 50.75%; and AUC score, 0.7907). After the comparison between the two models, the LogitBoost model was recognized as an optimal one.

CONCLUSION

In this study, NC-IVF-related datasets were extracted from the HFEA data, and a machine learning-based prediction model was successfully constructed through this largest NC-IVF dataset currently. This model is universal and stable, which can help clinicians predict the live-birth success rate of NC-IVF in advance before developing IVF treatment strategies and then choose the best benefit treatment strategy according to the patients' wishes. As "use less stimulation and back to natural condition" becomes more and more popular, this model is more meaningful in the decision-making assistance system for IVF.

25(OH)VitD and human endocrine and functional fertility parameters in women undergoing IVF/ICSI

BACKGROUND

Vitamin D plays an important role in reproduction. Evidence shown that free 25-hydroxyvitamin D (25(OH)VitD) was more accurate than total 25(OH)VitD in reflecting the status of 25(OH)VitD during pregnancy. However, the relationship between free 25(OH)VitD and female fertility parameters has not been reported yet. Therefore, this study aims to compare the correlation of free and total 25(OH)VitD with fertility parameters in infertility females undergoing in vitro fertilization and embryo transfer (IVF-ET) or intracytoplasmic sperm injection (ICSI).

METHODS

According to the inclusion and exclusion criteria, 2569 infertility patients who received IVF-ET or ICSI treatment for the first time participated in this study. Five milliliter peripheral blood samples of the patients were collected on the day before embryo transfer (ET). Enzyme linked immunosorbent assay (ELISA) kits was used to detect free 25(OH)VitD and total 25(OH)VitD, and clinical information was collected. Spearman's rho was used to evaluate the association between the variables.

RESULTS

The median (IQR) of free 25(OH)VitD was 4.71 (4.11-5.31) pg/mL and total 25(OH)VitD was 19.54 (16.52-22.83) ng/m. The correlation between them, however, was week (rho=0.311). Compared to total 25(OH)VitD, free 25(OH)VitD was slightly better correlated with basal follicle-stimulating hormone (FSH) (rho=0.041, P=0.036), basal estradiol (E₂) (rho=0.089, P<0.001), anti-Müllerian hormone (AMH) (rho=-0.057, P=0.004), antral follicle count (AFC) (rho=-0.053, P=0.007), E₂ (rho=-0.080, P<0.001), number of oocytes retrieval (rho=-0.079, P<0.001) and progesterone (P)/E₂ on hCG trigger day (rho=0.081, P<0.001).

CONCLUSIONS

Overall, there was only a rather weak correlation of free as well as total 25(OH)VitD with human endocrine and functional fertility parameters in women undergoing IVF/ICSI. Neither free nor total 25(OH)VitD seems to play a major role in human embryo implantation.

Epigenetics in the Uterine Environment: How Maternal Diet and ART May Influence the Epigenome in the Offspring with Long-Term Health Consequences

The societal burden of non-communicable disease is closely linked with environmental exposures and lifestyle behaviours, including the adherence to a poor maternal diet from the earliest preimplantation period of the life course onwards. Epigenetic variations caused by a compromised maternal nutritional status can affect embryonic development. This review summarises the main epigenetic modifications in mammals, especially DNA methylation, histone modifications, and ncRNA. These epigenetic changes can compromise the health of the offspring later in life. We discuss different types of nutritional stressors in human and animal models, such as maternal undernutrition, seasonal diets, low-protein diet, high-fat diet, and synthetic folic acid supplement use, and how these nutritional exposures epigenetically affect target genes and their outcomes. In addition, we review the concept of thrifty genes during the preimplantation period, and some examples that relate to epigenetic change and diet. Finally, we discuss different examples of maternal diets, their effect on outcomes, and their relationship with assisted reproductive technology (ART), including their implications on epigenetic modifications.

School-Based Nutrition Interventions in Children Aged 6 to 18 Years: An Umbrella Review of Systematic Reviews

Schools are identified as a key setting to influence children's and adolescents' healthy eating. This umbrella review synthesised evidence from systematic reviews of school-based nutrition interventions designed to improve dietary intake outcomes in children aged 6 to 18 years. We undertook a systematic search of six electronic databases and grey literature to identify relevant reviews of randomized controlled trials. The review findings were categorised for synthesis by intervention type according to the World Health Organisation Health Promoting Schools (HPS) framework domains: nutrition education; food environment; all three HPS framework domains; or other (not aligned to HPS framework domain). Thirteen systematic reviews were included. Overall, the findings suggest that school-based nutrition interventions, including nutrition education, food environment, those based on all three domains of the HPS framework, and eHealth interventions, can have a positive effect on some dietary outcomes, including fruit, fruit and vegetables combined, and fat intake. These results should be interpreted with caution, however, as the quality of the reviews was poor. Though these results support continued public health investment in school-based nutrition interventions to improve child dietary intake, the limitations of this umbrella review also highlight the need for a comprehensive and high quality systematic review of primary studies.

Endometrial polyps with increased plasma cells are associated with chronic endometritis in infertility patients: Hysteroscopic findings and post-polypectomy pregnancy rates

PURPOSE

The relationship between endometrial polyps (EPs), chronic endometritis (CE), hysteroscopic findings, and antimicrobial in infertility patients was determined.

METHODS

We retrospectively enrolled 115 infertility patients with suspected EPs who underwent office hysteroscopy. Patients were divided into 3 groups: 38 with increased plasma cells in EPs (group 1); 31 without increased plasma cells in EPs (group 2); and 46 without EPs (group 3). The 3 groups underwent hysteroscopy with or without polypectomies, and immediately thereafter, an endometrial aspiration biopsy (EAB) was performed. CE was diagnosed based on plasma cell infiltration in the non-polypoid endometrium obtained by EAB.

RESULTS

The percentage of CE was 68.4%, 32.2%, and 28.3% in groups 1, 2, and 3, respectively. CE was more frequent in group 1 than group 2 or 3 (P = .01 and P = .002, respectively). The number of polyps was higher in group 1 than group 2. After adjustment for age and assisted reproductive technology, antibiotic therapy was not associated with pregnancy (adjusted odds ratio, 0.44; 95% confidence interval, 0.05-3.57) in patients with EPs and CE.

CONCLUSIONS

Group 1 was associated with CE, and hysteroscopic findings were different from group 2. Antibiotic therapy after polypectomy for EPs with CE may not always be necessary.

Secular changes in human reproduction and assisted reproductive technologies

Since the middle to late 20th century the majority of children born in the developing world have been likely to enter into post-reproductive age. Currently, child mortality is at its lowest level in human history. While more children are living to post reproductive age, approximately 15% of couples are experiencing infecundity. This is either a result of one or both members of the couple being infecund, or, despite both being fecund, the interaction between them prevents fertility for some reason. Assisted reproductive technologies have provided many infertile couples an opportunity to have children. Assisted reproductive technologies operate by intervening and manipulating gametic and intrauterine natural selection. This paper discusses the possible influence of assisted reproductive technologies on child development. This paper outlines some of the reported changes in children resulting from assisted reproductive technologies. Although, few people are either aware or care about possible long term consequences of relaxed natural selection contributed by medical intervention (i.e. assisted reproductive technologies) we have little understanding to what extent such medical interference may affect long term fitness in humans.

Pharmaceutical industry payments and assisted reproduction in Australia: a retrospective observational study

OBJECTIVES

To investigate the extent and nature of pharmaceutical industry payments related to fertility and assisted reproduction in Australia.

DESIGN AND SETTING

This retrospective observational study employed four databases compiled from publicly available pharmaceutical industry transparency reports on educational event sponsorship (October 2011-April 2018), payments to healthcare professionals (October 2015-April 2018) and patient group support (January 2013-December 2017). Analyses were restricted to fertility-related payments by two major manufacturers of fertility medicines in Australia: Merck Serono and Merck, Sharp and Dohme (MSD).

PRIMARY AND SECONDARY OUTCOME MEASURES

Descriptive statistics on fertility-related payments and other transfers of value (counts, total and median costs in Australian dollars) for educational events and to healthcare professionals and patient groups.

RESULTS

Between October 2011 and April 2018, Merck Serono and MSD spent $A4 522 263 on 970 fertility-related events for healthcare professionals, including doctors, nurses and fertility scientists. 56.8% (551/970) events were held by fertility clinics and 29.3% (284/970) by professional medical associations. Between October 2015 and April 2018, Merck Serono spent $A403 800 across 177 payments to 118 fertility healthcare professionals, predominantly for educational event attendance. Recipients included obstetricians and gynaecologists (76.3% of payments, 135/177), nurses (11.3%, 20/177) and embryologists/fertility scientists (9.6%, 17/117). The highest paid healthcare professionals held leadership positions in major fertility clinics. Merck Serono provided $A662 850 to fertility-related patient groups for advocacy and education (January 2013-December 2017).

CONCLUSIONS

The pharmaceutical industry sponsored a broad range of fertility clinicians and organisations, including doctors, nurses, embryologists, professional medical organisations, fertility clinics and patient groups. This sponsorship may contribute to the overuse of fertility services.

Hysterolaparoscopy: A Gold Standard for Diagnosing and Treating Infertility and Benign Uterine Pathology

BACKGROUND

Combined hysteroscopy and laparoscopy is a valuable method for diagnosing and treating infertility and benign uterine pathology. Both procedures are minimally invasive, reliable, and safe, with a low complication rate.

AIM

In this review, we expose the efficiency and safety of hysterolaparoscopy in the management of infertility and other benign uterine pathologies.

METHOD

We performed a systematic literature review on several databases: PubMed®/MEDLINE, PMC, Crossref.org, and Web of Science in the last 10 years.

INCLUSION CRITERIA

Women of reproductive age with primary or secondary infertility and/or benign uterine pathology.

EXCLUSION CRITERIA

pre-puberty, menopause, couple with male infertility.

CONCLUSION

Hysterolaparoscopy is a useful tool to assess infertility and simultaneously diagnose and treat pelvic and uterine lesions.

Optimizing Fertility in Primary Ovarian Insufficiency: Case Report and Literature Review

Primary ovarian insufficiency (POI) is a clinical spectrum of ovarian dysfunction. Overt POI presents with oligo/amenorrhea and hypergonadotropic hypogonadism before age 40 years. Overt POI involves chronic health problems to include increased morbidity and mortality related to estradiol deficiency and the associated osteoporosis and cardiovascular disease as well as psychological and psychiatric disorders related to the loss of reproductive hormones and infertility. Presently, with standard clinical testing, a mechanism for Overt POI can only be identified in about 10% of cases. Now discovery of new mechanisms permits an etiology to be identified in a research setting in 25-30% of overt cases. The most common genetic cause of Overt POI is premutation in FMR1. The associated infertility is life altering. Oocyte donation is effective, although many women prefer to conceive with their own ova. Surprisingly, the majority who have Overt POI still have detectable ovarian follicles (70%). The major mechanism of follicle dysfunction in Overt POI has been histologically defined by a prospective NIH study: inappropriate follicle luteinization due to the tonically elevated serum LH levels. A trial of physiologic hormone replacement therapy, clinically proven to suppress the elevated LH levels in these women, may improve follicle function and increase the chance of ovulation. Here, we report the case of a woman with Overt POI diagnosed at age 35 years. To attempt pregnancy, she elected a trial of intrauterine insemination (IUI) in conjunction with follicle monitoring and physiologic hormone replacement therapy. She conceived on the eighth cycle of treatment and delivered a healthy baby. Our report calls for a concerted effort to define the best methods by which to optimize fertility for women who have POI.

One couple's experience with infertility: Nursing theory-based practice case study

Infertility can be devastating for some couples. The purpose of this paper is to demonstrate a translation of knowledge and nursing theory-based practice regarding nursing care of couples experiencing infertility through a case study approach. It is important to consider the translation of knowledge to probable scenarios so that we may have opportunities to be better prepared when addressing such situations in actual nursing practice. Data sources include current literature, theoretical perspectives on power as knowing participation in change and nursing classifications. Data synthesis is illustrated within the context of a simulated case study of a couple experiencing unexplained secondary infertility through the application of a theory-based practice methodology, health patterning. The authors conclude that the theoretical perspectives of unitary science and the theory of power as knowing participation in change can be applied in practice. Theory-based practice methodologies such as health patterning offer an opportunity to provide holistic care to couples experiencing infertility. Using these theoretical perspectives, nurses can engage with couples expressing a readiness for enhanced power for a desired change. Nursing implications include the value of theory-based practice and the essential view of couples as unique human beings. In addition, it demonstrates the ongoing usefulness of case study approaches for nursing education as vehicles to enhance awareness of unitary experiences, updates to clinical care, and demonstration of the application of theory to practice.

Predictive factors of ovarian response to GnRH antagonist stimulation protocol: AMH and age are potential candidates

Background

Prediction of ovarian response prior to the ovarian stimulation cycle is useful in determining the optimal starting dose of recombinant follicle-stimulating hormone (r-FSH). This study was designed to (I) evaluate which of the following parameters (age, AMH, and FSH) can be used as a predictor of ovarian response to GnRH antagonist stimulation protocol, (II) determine the cutoff value of AMH and age for predicting poor and high ovarian response, and (III) investigate the relationship between age, AMH level, and other clinical parameters. It is a retrospective study. A total of 318 women with a mean age of 28.2 ± 5.9 years old were included in this study. Hormone levels (FSH, LH, PRL, E2, and AMH) and the number of collected oocytes were determined. Based on the number of retrieved oocytes, the participants were divided into three groups: poor response (oocytes < 4, n= 51), normal response (oocytes 4–14, n= 192), and high response (oocytes > 14, n= 75).

Results

A significant increase has been found in AMH level and number of retrieved oocytes and mature oocytes from low to normal and high ovarian response group (P < 0.001). Also, the age in the poor ovarian response group was significantly greater than normal and high ovarian response groups (P < 0.001). A significant positive correlation has been found between the number of retrieved oocytes and mature oocytes and level of AMH (P < 0.001). The receiver operating characteristic (ROC) curves showed that both AMH and age had the highest accuracy in the prediction of poor ovarian response with a cutoff value < 1.45 and > 31.5 years, respectively. Additionally, the ROC analysis has shown that the AMH had the highest accuracy, followed by age in the prediction of high ovarian response with a cutoff value > 3.55 and < 27.5 years, respectively.

Conclusions

This study demonstrates that AMH level and women’s age may be used as potential predictors of ovarian response to GnRH antagonist stimulation protocol.

Novel nomogram-based integrated gonadotropin therapy individualization in in vitro fertilization/intracytoplasmic sperm injection: A modeling approach

OBJECTIVE

This study aimed to characterize a validated model for predicting oocyte retrieval in controlled ovarian stimulation (COS) and to construct model-based nomograms for assistance in clinical decision-making regarding the gonadotropin protocol and dose.

METHODS

This observational, retrospective, cohort study included 636 women with primary unexplained infertility and a normal menstrual cycle who were attempting assisted reproductive therapy for the first time. The enrolled women were split into an index group (n=497) for model building and a validation group (n=139). The primary outcome was absolute oocyte count. The dose-response relationship was tested using modified Poisson, negative binomial, hybrid Poisson-Emax, and linear models. The validation group was similarly analyzed, and its results were compared to that of the index group.

RESULTS

The Poisson model with the log-link function demonstrated superior predictive performance and precision (Akaike information criterion, 2,704; λ=8.27; relative standard error (λ)=2.02%). The covariate analysis included women's age (p<0.001), antral follicle count (p<0.001), basal follicle-stimulating hormone level (p<0.001), gonadotropin dose (p=0.042), and protocol type (p=0.002 and p<0.001 for short and antagonist protocols, respectively). The estimates from 500 bootstrap samples were close to those of the original model. The validation group showed model assessment metrics comparable to the index model. Based on the fitted model, a static nomogram was built to improve visualization. In addition, a dynamic electronic tool was created for convenience of use.

CONCLUSION

Based on our validated model, nomograms were constructed to help clinicians individualize the stimulation protocol and gonadotropin doses in COS cycles.

Thin endometrium is associated with the risk of hypertensive disorders of pregnancy in fresh IVF/ICSI embryo transfer cycles: a retrospective cohort study of 9,266 singleton births

BACKGROUND

Thin endometrial thickness (EMT) has been suggested to be associated with reduced incidence of pregnancy rate after in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment, but the effect of thin endometrium on obstetric outcome is less investigated. This study aims to determine whether EMT affects the incidence of obstetric complications in fresh IVF/ICSI-embryo transfer (ET) cycles.

METHODS

We conducted a retrospective cohort study collecting a total of 9266 women who had singleton livebirths after fresh IVF/ICSI-ET treatment cycles at the Center for Reproductive Medicine Affiliated to Shandong University between January 2014 and December 2018. The women were divided into three groups according to the EMT: 544 women with an EMT ≤8 mm, 6234 with an EMT > 8-12 mm, and 2488 with an EMT > 12 mm. The primary outcomes were the incidence of obstetric complications including hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), placental abruption, placenta previa, postpartum hemorrhage (PPH) and cesarean section. Multivariable logistic regression analysis was performed to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for associations between the EMT measured on the day of human chorionic gonadotropin (HCG) trigger and the risk of the outcomes of interest.

RESULTS

The HDP incidence rate of pregnant women was highest in EMT ≤ 8 mm group and significantly higher than those in EMT from > 8-12 mm and EMT > 12 mm group, respectively (6.8% versus 3.6 and 3.5%, respectively; P = 0.001). After adjustment for confounding variables by multivariate logistic regression analysis, a thin EMT was still statistically significant associated with an increased risk of HDP. Compared with women with an EMT > 8-12 mm, women with an EMT ≤8 mm had an increased risk of HDP (aOR = 1.853, 95% CI 1.281-2.679, P = 0.001).

CONCLUSION

A thin endometrium (≤8 mm) was found to be associated with an increased risk of HDP after adjustment for confounding variables, indicating that the thin endometrium itself is a risk factor for HDP. Obstetricians should remain aware of the possibility of HDP when women with a thin EMT achieve pregnancy through fresh IVF/ICSI-ET treatment cycles.

Controlled ovarian hyperstimulation for poor ovarian responders undergoing in vitro fertilisation/intracytoplasmic sperm injection: a protocol for systematic review and Bayesian network meta-analysis

INTRODUCTION

Controlled ovarian hyperstimulation (COH) is the routine regimen used to generate a sufficient number of follicles during in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Poor ovarian response is a challenge encountered by many clinicians during COH and poor ovarian responders (PORs) usually have higher follicle stimulating hormone levels, lower levels of anti-Mullerian hormone and few oocytes retrieved, which have been attributed mainly to advanced maternal age and poor follicle reserve or other reasons that could impair ovarian response during ovarian stimulation. Over the last few decades, researchers have proposed a series of strategies and ovarian stimulation protocols to improve pregnancy outcomes in patients with POR during their IVF/ICSI treatment. However, clinical decisions regarding COH protocols in PORs during IVF/ICSI treatment remain controversial. Traditional pairwise meta-analysis only allows the direct comparison of two protocols in COH for patients with POR. However, many of these COH protocols have not been compared directly in randomised controlled trials (RCTs). Thus, we aim to use network meta-analysis (NMA) to assess the clinical effectiveness and safety of COH protocols and to generate treatment rankings of these COH protocols for the most clinically important and commonly reported outcomes events.

METHODS AND ANALYSIS

The PubMed, Embase, Cochrane Library, Web of Science, SinoMed, CNKI, WanFang database and Chongqing VIP information databases will be searched for all RCTs of COH for POR women during IVF/ICSI from inception to 31 March 2020. Primary outcomes will include live birth rate and number of oocytes retrieved. Secondary outcomes will include ongoing pregnancy rate, clinical pregnancy rate, miscarriage rate, ovarian hyperstimulation syndrome rate, multiple pregnancy rate and cycle cancellation rate. Pairwise meta-analysis and Bayesian NMA will be conducted for each outcome. Subgroup analysis, meta-regression, and sensitivity analysis will be performed to assess the robustness of the findings. The generation of NMA plots and subsequent results will be performed by using R V.4.0.1. The assessment of confidence in network estimates will use the Confidence in Network Meta-Analysis)web application (see https://cinema.ispm.unibe.ch/).

ETHICS AND DISSEMINATION

This review does not require ethics approval and the results of the NMA will be submitted to a peer-review journal.

Association of single-nucleotide polymorphisms in the ESR2 and FSHR genes with poor ovarian response in infertile Jordanian women

Objective

Poor ovarian response (POR) refers to a subnormal follicular response that leads to a decrease in the quality and quantity of the eggs retrieved after ovarian stimulation during assisted reproductive treatment (ART). The present study investigated the associations of multiple variants of the estrogen receptor 2 (ESR2) and follicle-stimulating hormone receptor (FSHR) genes with POR in infertile Jordanian women undergoing ART.

Methods

Four polymorphisms, namely ESR2 rs1256049, ESR2 rs4986938, FSHR rs6165, and FSHR rs6166, were investigated in 60 infertile Jordanian women undergoing ART (the case group) and 60 age-matched fertile women (the control group), with a mean age of 33.60±6.34 years. Single-nucleotide polymorphisms (SNPs) were detected by restriction fragment length polymorphism and then validated using Sanger sequencing.

Results

The p-value of the difference between the case and control groups regarding FSHR rs6166 was very close to 0.05 (p=0.054). However, no significant differences were observed between the two groups in terms of the other three SNPs, namely ESR2 rs1256049, ESR2 rs4986938, and FSHR rs6165 (p=0.561, p=0.433, and p=0.696, respectively).

Conclusion

The association between FSHR rs6166 and POR was not statistically meaningful in the present study, but the near-significant result of this experiment suggests that statistical significance might be found in a future study with a larger number of patients.

Non-pharmacological strategies for self-directed and interpersonal violence in people with severe mental illness: a rapid overview of systematic reviews

INTRODUCTION

Self-directed and interpersonal violence among people with severe mental illness has become a health priority. Though non-pharmacological interventions have been investigated, to our knowledge, no summary of all systematic reviews on this topic has been reported. We will conduct a rapid overview of reviews to synthesise evidence available by identifying systematic reviews on non-pharmacological interventions for self-directed or interpersonal violence in people with severe mental illness.

METHODS AND ANALYSIS

This is a protocol for a rapid overview of reviews. The overview will include any systematic reviews (with or without meta-analyses) of randomised controlled trials (RCTs) or cluster RCTs that examine the effect of non-pharmacological interventions on self-directed or interpersonal violence in people with severe mental illness. This protocol applies the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, the criteria for conducting overviews of reviews in the Cochrane Handbook of Systematic Reviews of Interventions and the criteria for the Cochrane Rapid Reviews. To identify studies, a search will be performed in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, LILACS, SciELO, Web of Science, Scopus, ProQuest, the Cochrane Database of Systematic Reviews through the Cochrane Library and the Epistemonikos database of systematic reviews. The searches date from inception to September 2020. The study selection process will be described using a PRISMA flow diagram, we will assess the quality of evidence in systematic reviews included and the quality of the systematic reviews themselves and the main results will be summarised in categories to provide a map of the evidence available.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. The results will be presented at mental health conferences and for publication in a peer-reviewed journal.

REGISTRATION DETAILS

The protocol was registered on the Open Science Framework (https://osf.io/myzd9/).