A persistent misperception: assisted reproductive technology can reverse the “aged biological clock”

Obstetric and perinatal outcomes of singleton pregnancy from donated frozen versus fresh oocytes

To evaluate whether oocyte cryopreservation affects obstetric and perinatal outcomes, 350 donor oocyte recipients with live-born singletons were divided into three groups: frozen embryo transfer (FET) with fresh oocytes (n = 101), fresh embryo transfer (ET) with frozen oocytes (n = 190), FET with frozen oocytes (n = 59). Gestational age differed significantly (P = 0.025), with the FET with frozen oocytes group showing longer gestational age than FET with fresh oocytes group (276 days vs. 272 days, P = 0.04). Other outcomes were comparable among groups. Subgroup analysis of FET pregnancies revealed no significant differences between frozen and fresh oocyte groups in gestational age (B 1.38, P = 0.749), birth weight (B -0.11, P = 0.530), premature birth rates (6.8% vs. 11.9%, P = 0.746), low birth weight (LBW) (5.1% vs. 12.9%, P = 0.865), macrosomia (5.1% vs. 4.0%, P = 0.976), small for gestational age (SGA) (6.8% vs. 11.9%, P = 0.599), large for gestational age (LGA) (22.0% vs. 18.8%, P = 0.943), gestational diabetes mellitus (GDM) (10.2% vs. 11.9%, P = 0.343), hypertensive disorders of pregnancy (HDP) (8.5% vs. 17.8%, P = 0.143) or placental abnormalities (8.5% vs. 19.8%, P = 0.133). The study confirmed oocyte cryopreservation did not affect birth weight or obstetrical complications in donor oocyte recipients.

The Effect of Endometrial Polyp and Myoma Uteri on Fertility-Related Genes in the Endometrium

Endometrial polyps are hyperplastic overgrowths of the endometrium that contain both glands and stroma. Myoma uteri is the most common benign tumor of the female pelvis and uterus. HOXA10, which is involved during the organogenesis of the uterus in the embryonic period. The aim of this study was to compare the expression levels of infertility-related genes in endometrial tissue obtained from patients with endometrial polyp and myoma uteri and from healthy controls. A total of 36 patients, including 15 women with endometrial polyp and 21 women with myoma uteri, and 23 healthy controls were enrolled in the study. All patients were evaluated using transvaginal ultrasonography. Endometrial tissue samples were collected from the patient and control groups between the 19th and 21st days of the menstrual cycle. Expression levels of the receptivity markers PROK1, PROKR1, PROK2, PROKR2 and HOXA10 genes were determined by RT- PCR. When the patients diagnosed with endometrial polyp and the healthy controls were compared, it was observed statistically significantly that the expression of PROKR1 increased in endometrium tissue of patients with endometrial polyp (p < 0.05). In patients diagnosed with myoma uteri, gene expression levels of endometrial PROKR1 was statistically significant increased and gene expression levels of PROK1, PROKR2, HOXA10 were found to be statistically significantly decreased compared to the controls (p < 0.05). Changes in the endometrial expression of the HOXA10 and prokineticin gene family in patients with myoma uteri and endometrial polyps may explain certain aspects of infertility in these patients.

Outcomes of female fertility preservation with cryopreservation of oocytes or embryos in the Netherlands: a population-based study

STUDY QUESTION

What are the reproductive outcomes of patients who cryopreserved oocytes or embryos in the context of fertility preservation in the Netherlands?

SUMMARY ANSWER

This study shows that after a 10-year follow-up period, the utilization rate to attempt pregnancy using cryopreserved oocytes or embryos was 25.5% and the cumulative live birth rate after embryo transfer was 34.6% per patient.

WHAT IS KNOWN ALREADY

Fertility preservation by freezing oocytes or embryos is an established treatment for women with a risk of premature ovarian failure (caused by a benign or oncological disease) or physiological age-related fertility decline. Little is known about the success of cryopreservation, the utilization rate of oocytes or embryos, or the live birth rates.

STUDY DESIGN, SIZE, DURATION

A retrospective observational study was performed in the Netherlands. Data were collected between 2017 and 2019 from 1112 women who cryopreserved oocytes or embryos more than 2 years ago in the context of fertility preservation in 10 IVF centers in the Netherlands.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1112 women were included in this study. Medical files and patient databases were used to extract data. Women were categorized based on indication of fertility preservation: oncological, benign, or non-medical. To indicate statistical differences the t-test or Mann-Whitney U test was used. Kaplan-Meier analyses were used for time endpoints, and log-rank analyses were used to assess statistical differences. The study protocol was approved by the medical ethics committee.

MAIN RESULTS AND THE ROLE OF CHANCE

Fertility preservation cycles have been performed increasingly over the years in the Netherlands. In the first years, less than 10 cycles per year were performed, increasing to more than 300 cycles per year 10 years later. Initially, embryos were frozen in the context of fertility preservation. In later years, cryopreservation of oocytes became the standard approach. Cryopreservation of oocytes versus embryos resulted in comparable numbers of used embryos (median of 2) for transfer and comparable live birth rates (33.9% and 34.6%, respectively). The 5-year utilization rate was 12.3% and the 10-year utilization rate was 25.5%. The cumulative clinical pregnancy rate was 35.6% and the cumulative live birth rate was 34.6% per patient. Those who had fertility preservation due to benign diseases returned earlier to use their cryopreserved embryos or oocytes.

LIMITATIONS, REASONS FOR CAUTION

The follow-up period after the fertility preservation procedure varied between patients in this study and not all frozen oocytes or embryos had been used at the end of this study. This might have led to underestimated outcomes reported in this study. Furthermore, intention to treat cannot be fully determined since women who started the fertility preservation procedure without success (cancellation due to low response) were not included in this study.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides data on the reproductive outcomes after various indications of fertility preservation. This knowledge can be informative for professionals and future patients to improve counseling and informed decision making regarding ovarian stimulation in the context of fertility preservation.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was obtained for this study. The authors have no conflicts of interest to declare related to this study. V.T.H. received grants paid to the institute for studies outside the present work from AstraZeneca, Gilead, Novartis, Eli Lily, Pfizer, and Daiichi Sankyo. V.T.H. received consulting fees from Eli Lily outside the present work. M.G. received grants paid to the institute for studies outside the present work from Guerbet and Ferring. E.M.E.B. received a grant from The Dutch Network of Fertility Preservation for a study outside the present work.

TRIAL REGISTRATION NUMBER

N/A.

Assessing Student and Physician Fertility Awareness Utilizing the Fertility and Infertility Treatment Knowledge Score (FIT-KS)

INTRODUCTION

Medical trainees are delaying childbearing due to competing demands of career, financial constraints, and limited parental leave. Delaying childbearing increases the risk of obstetric complications, with up to one-quarter of female physicians facing infertility. Education on family planning and fertility is rarely discussed among medical trainees, and research on medical trainees' knowledge of fertility and infertility is minimal.

METHODS

Subjects included medical students, residents, fellows, and attendings assigned female at birth. The distributed survey included the Fertility and Infertility Treatment Knowledge Score (FIT-KS) instrument to assess for fertility and infertility knowledge. Outcome measures include participant age, stage of training, parity, specialty, and FIT-KS.

RESULTS

 Of the 291 participants included in the final analysis, participants scored an average of 20/29 (69%) on the FIT-KS. Around 44.8% (n=130) of participants overestimated the fecundability of a 30-year-old woman, and 36.9% (n=107) underestimated the chance of miscarriage in peak reproductive years. Five out of eight questions pertaining to infertility treatment had a <50% correct response rate. About 76.6% (n=216) of participants underestimated in vitro fertilization (IVF) success for a woman <35 years old, and 56% (n=158) overestimated the success of IVF for a woman >44 years old. Around 43.6% (n=123) of participants overestimated the average cost of IVF. Of the main outcome measures, only those participants representing obstetrics and gynecology (OB-GYN) performed better on average than all other specialties (FIT-KS=21.7 vs. 19.5).

CONCLUSION

Participants overestimated fecundity with increasing age and had insufficient knowledge of infertility treatment success. More awareness and early discussion about family planning and fertility goals are needed in medical training.

Fertility and fertility preservation knowledge in Portuguese women

BACKGROUND

Knowledge about fertility and factors affecting it, for example, the impact of age, seem to be lacking, even in highly educated populations. The same applies to fertility preservation knowledge, pointing to the relevance of increasing fertility preservation awareness and education among young women.

OBJECTIVE

To describe general fertility knowledge and factors affecting fertility, fertility preservation knowledge and attitudes, and the desire to access more information on this topic in a sample of reproductive-age Portuguese women.

METHODS

The sample comprised 257 Portuguese women aged 18-45, mostly single and nulliparous. A questionnaire was developed explicitly for this study and disseminated through social media advertisements.

RESULTS

Career building/development and financial stability were the more endorsed options for delaying childbearing, with 90 (35%) and 68 (26.5%), respectively. Most participants considered becoming a mother important (n = 185; 72%). More than halve provided an incorrect answer regarding the age range of women being more fertile (n = 132; 51.4%) and the age range of fertility decline (n = 168; 65.4%). Participants were aware of the influence of lifestyle and sexual health factors as well as the effect of age. Oocytes cryopreservation was the technique participants knew more (n = 206; 80.1%), but 177 (68.9%) showed no interest in using it. Most participants agreed that fertility and fertility preservation information should be provided during medical consultations or at school.

CONCLUSIONS

More information regarding fertility and fertility preservation is relevant to ensure that more women can make informed decisions concerning their reproductive life.

What do women undergoing in vitro fertilization (IVF) understand about their chance of IVF success?

STUDY QUESTION

How well informed are Australian women who undergo IVF about their chances of having a baby?

SUMMARY ANSWER

Only one in four women estimated their individual chance of success with IVF accurately, with most women overestimating their chance.

WHAT IS KNOWN ALREADY

Limited knowledge about infertility and infertility treatment in the general population is well-documented. The few studies that have investigated patients' knowledge about the chance of IVF success suggest that while IVF patients are aware of average success rates, they tend to be unrealistic about their own chance of success.

STUDY DESIGN, SIZE, DURATION

We conducted an anonymous online survey of 217 women who had started IVF since 2018 in Australia. The survey was advertised on social media, enabling women from across Australia to participate. Responses were collected in June 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey included questions on demographic characteristics and IVF history. It asked what participants thought their chance of having a baby from one IVF treatment cycle was, how they rated their knowledge about chance of success, and about their experience of receiving IVF-related information. Participants' estimations of their chance of success were compared with their chance as calculated by the Society for Assisted Reproductive Technology's (SART) online calculator. Responses to a free-text question about what information women wished they had been given when they started treatment were analysed thematically.

MAIN RESULTS AND THE ROLE OF CHANCE

Only about a quarter (58/217, 27%) of participants accurately estimated their chance of having a baby within 20% relative to their SART calculated chance, with more than half (118/217, 54%) overestimating their chance. Ninety percent of women indicated that their preferred source of treatment information was a consultation with their doctor, despite less than half (44%) reporting that doctors explained the probability of having a baby with IVF well (mean 5.9/10). In free-text responses, many women also reported that they wished they had been given more realistic information about IVF and their chance of success.

LIMITATIONS, REASONS FOR CAUTION

The dissemination method precludes calculation of response rate, and it is not possible to know if participants are representative of all women undergoing IVF. Additionally, we only surveyed women undergoing IVF, while those who decided not to have IVF were not included. Therefore, women who overestimated their chance may have been overrepresented. There is also inherent imprecision in the way understanding of chance of success was estimated. The potential impact of recall bias could neither be quantified nor excluded. It is difficult to determine to what extent women's lack of understanding of what is possible with IVF is due to poor information-provision by clinicians and the clinic, and how much can be explained by optimism bias.

WIDER IMPLICATIONS OF THE FINDINGS

The finding of poor understanding of personal chance of success amongst women undergoing IVF in Australia requires further investigation to determine potential reasons for this. The findings can be used by clinics to develop strategies for improvement in the information-provision process to ensure that women can make informed decisions about their fertility treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no external funding. S.L. is supported by a NHMRC Investigator Grant (APP1195189). R.W. is supported by a NHMRC Investigator Grant (APP2009767). B.W.M. is supported by a NHMRC Investigator Grant (GNT1176437). B.W.M. reports consultancy for Merck and ObsEva and has received research funding and travel funding from Merck. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Early or late response in poor responders: does it make a difference in cycle outcome?

Ovarian response to stimulation mainly determines the length of stimulation. However, there is no clarity in the literature regarding the optimal duration required to achieve oocyte maturity in patients with the poor ovarian response (POR) defined by Bologna criteria. Therefore, a total of 267 cycles that fulfilled the inclusion criteria were selected retrospectively. Group A constitute of patients with a stimulation period < 9 d (n = 70); and group B included patients with a stimulation period ≥ 9 d (n = 133). The results showed that antral follicle count (5.72 ± 1.82 vs. 5.10 ± 1.78, p = 0.023), serum oestradiol level on hCG day (1286.88 ± 778.18 pg/mL vs. 820.14 ± 479.04 pg/mL, p = 0.001), and total gonadotropin dose used (2949.53 ± 727.92 IU vs 2020.94 ± 415.17 IU, p = 0.0001) were higher in group B when compared to group A. Although the number of total (5.47 ± 3.32 vs 3.86 ± 2.15, p = 0.0001) and mature oocytes retrieved (4.34 ± 2.88 vs 2.84 ± 1.67, p = 0.0001) were higher in group B, no significant difference was observed in the pregnancy rates between groups (25.6 vs 15.7%, p > 0.05). In conclusion, no deleterious effect of a shorter duration of stimulation on cycle outcome was seen in patients with POR.

Exploring the Complex Landscape of Delayed Childbearing: Factors, History, and Long-Term Implications

This review article delves into the intricate landscape of delayed childbearing, shedding light on the factors influencing individuals' decisions to postpone parenthood. In a world undergoing rapid social, economic, and technological transformations, the concept of when and why to become a parent has evolved significantly. We explore historical trends, societal norms, psychological dynamics, policy implications, and prospects surrounding delayed childbearing. This review underscores the diverse influences shaping this trend, from economic considerations and changing cultural perspectives to advancements in reproductive technologies and the complexities of work-life balance. By examining the emotional dimensions and long-term consequences, we comprehensively understand the implications for individuals, families, and societies. As we conclude, we emphasize the importance of addressing challenges and embracing opportunities to create a supportive environment for those navigating the complex decisions tied to delayed childbearing.

The development and phase 1 evaluation of a Decision Aid for elective egg freezing

BACKGROUND

Elective egg freezing decisions are complex. We developed a Decision Aid for elective egg freezing and conducted a phase 1 study to evaluate its acceptability and utility for decision-making.

METHODS

The online Decision Aid was developed according to International Patient Decision Aid Standards and evaluated using a pre/post survey design. Twenty-six Australian women aged 18-45 years, interested in receiving elective egg freezing information, proficient in English, and with access to the internet were recruited using social media and university newsletters. Main outcomes were: acceptability of the Decision Aid; feedback on the Decision Aid design and content; concern raised by the Decision Aid, and; utility of the Decision Aid as measured by scores on the Decisional Conflict Scale and on a study-specific scale assessing knowledge about egg freezing and age-related infertility.

RESULTS

Most participants found the Decision Aid acceptable (23/25), balanced (21/26), useful for explaining their options (23/26), and for reaching a decision (18/26). Almost all reported satisfaction with the Decision Aid (25/26) and the level of guidance  it provided (25/26). No participant reported serious concerns about the Decision Aid, and most would recommend it to other women considering elective egg freezing (22/26). Median Decisional Conflict Scale score decreased from 65/100 (Interquartile range: 45-80) pre-Decision Aid to 7.5/100 (Interquartile range: 0-37.5) post-Decision Aid review (p < 0.001). Median knowledge score increased from 8.5/14 (Interquartile range: 7-11) pre-Decision Aid to 11/14 (Interquartile range: 10-12) post-Decision Aid review (p = 0.01).

CONCLUSION

This elective egg freezing Decision Aid appears acceptable and useful for decision-making. It improved knowledge, reduced decisional conflict and did not raise serious concerns. The Decision Aid will be further evaluated using a prospective randomised control trial.

STUDY REGISTRATION

ACTRN12618001685202 (retrospectively registered: 12 October 2018).

Racial and ethnic differences in reproductive knowledge and awareness among women in the United States

Objective

To evaluate if knowledge and awareness of concepts and concerns pertaining to reproductive health and fertility vary by race/ethnicity among reproductive-aged women in the United States.

Methods

A 2013 cross-sectional web-based survey assessed reproductive health-related knowledge, awareness, and perceptions of 1,000 women (18–40 years). Multivariable logistic regression analyses, adjusting for age, education, income, marital status, employment, region, and pregnancy history, examined the association between race/ethnicity and subfertility-related risk factor awareness; knowledge of factors that may affect pregnancy susceptibility; and future fertility-related concerns.

Results

Knowledge and awareness related to reproductive wellness and fertility differed by race/ethnicity in US women. Compared with Caucasians, Hispanic women were less likely to be aware of smoking-related harm to fertility (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.38–0.86); African American women were more aware of the implications of sexually transmitted infections on fertility (OR, 2.13; 95% CI, 1.15–3.94); and Asian women demonstrated greater awareness of a possible relationship between dysmenorrhea and subfertility (OR, 2.05; 95% CI, 1.09–3.86). Asian women consider fertility socially taboo to talk about and a private affair that is difficult to discuss (OR, 2.63; 95% CI, 1.32–5.29 and OR, 1.99; 95% CI, 1.05–3.75, respectively), were more concerned about their future fertility (OR, 2.36; 95% CI, 1.24–4.52), and more likely to perceive a need for future fertility treatment (OR, 2.36; 95% CI, 1.18–4.71).

Conclusion

Among reproductive-aged women in the United States, knowledge, awareness, and perceptions relating to reproductive health vary by race/ethnicity. Our findings suggest race/ethnicity as potential modulators of population perceptions regarding reproductive health and infertility.

Clinical Trial Registration Number

NIH ZIA# HD008985.

Persevering in Fertility Treatments Despite Failures: Unrealistic Optimism and the Reality of a Pronatalist Culture

BACKGROUND

Fertility treatment discontinuation is difficult as it entails accepting childlessness. In most countries, financial limitations provide sufficient justification to terminate treatment. In Israel, unlimited funding enables women to undergo multiple treatment cycles, even when the odds of success are poor, thus providing a context for studying the psychological mechanisms involved when financial constraints are set aside. The study aimed to investigate the contribution of unrealistic optimism to Israeli women's willingness to continue fertility treatments even after repeated failures and to their psychological adjustment, comparing age groups.

METHODS

A longitudinal study of 100 women (ages 31-45) undergoing in vitro fertilization (IVF) treatment (1-22 previous cycles), who filled in questionnaires assessing their estimates of treatment success (theirs/for same-age patient), estimates received from the physician, intentions to continue treatment, and psychological adjustment. Follow-up was conducted 17(± 4) months later, by phone (n = 71) and/or medical records (n = 90).

RESULTS

Most women (57%) reported that they will continue as long as needed till they have a child, 13% did not know, and 25% mentioned a specific plan; 5 did not reply. Women's estimates of treatment success showed vast unrealistic optimism, which was unrelated to their age, history of unsuccessful treatment cycles, or intentions for treatment continuation, yet was related to better psychological adjustment. At follow-up, almost all women who did not conceive were found to have continued treatments.

CONCLUSIONS

Unrealistic optimism helps women maintain hope and well-being along the demanding journey to (biological) parenthood, where childlessness is highly stigmatized, and contributes to perseverance in treatment, regardless of objective factors.

The ART clock: Temporal limits to assisted reproduction

Conceptualizations of the 'biological clock' in popular imaginary in the USA centre on the temporal limits of fertility, with assisted reproductive technology (ART) an increasingly proposed answer to these constraints (at least in the public imaginary). In this study, I analyse how surrogates in the USA understand their own bioavailability for others' reproductive needs in the commercial ART market vis-à-vis their own reproductive trajectories. Based on interview data with gestational surrogates, I propose a new concept of the 'ART clock' to capture how time shapes the experiences of reproductive workers in the US fertility clinic. My findings point to four important ART time-related issues: (i) women desiring to extend their own 'biological clocks' via surrogacy; (ii) significant time being needed to achieve and sustain third-party pregnancy; (iii) women extending their total reproductive time via repeat surrogacy 'journeys'; and (iv) temporal constraints to surrogacy reproduction regarding time of year, the day-to-day time effort, the number of surrogacy journeys, the total number of pregnancies, and surrogates' age and the ages of their children. Each of these aspects point to important ways that reproductive desire and time shape the labour of reproductive workers, highlighting temporal constraints to assisted reproduction and limits to ART as a solution to delayed reproduction and the biological clock.

"It's hard to become mothers": The moral economy of postponing motherhood in neoliberal Chile

The delay of childbearing is one of the most prominent transformations of contemporary fertility and reproductive patterns. This article provides a novel approach to understanding why women are postponing motherhood and having children later in life. Drawing on 24 life story interviews with women from Santiago de Chile, I argue that the transition to motherhood is shaped by a moral economy in which women postpone childbearing to enable becoming "good" mothers. In a context in which social fertility is being redefined by neoliberalism, intensive mothering, and lone motherhood, I find that women delay childbearing until after achieving professional and financial milestones that allow them to fulfil the normative conditions for having children. These findings suggest that women postpone the transition to motherhood not because they reject childbearing and traditional gender roles, but rather because they aspire to become "good" mothers in a context characterized by institutional precariousness, relational insecurity, and increasing demands on mothering. Through these findings, I challenge prevalent interpretations of why women are having children later in life, extend accounts of the gendered norms of social fertility, and contest the nature of autonomy driving change in women's lives.

Couples undergoing Assisted Reproductive Techniques: An Actor-Partner Interdependence Model of dyadic adjustment, attachment, and body-image avoidance

The aim is to assess the commonalities and interdependence referred to body-image avoidance among 118 couples newly introduced to first-level assisted reproductive techniques. Results showed non-clinical functioning levels, and partners showed a correlated, yet low, dyadic adjustment. The couple-effect was modeled through an Actor Partner Interdependence Model. For both partners, dyadic adjustment’s actor-effect associates with body-image avoidance. Moreover, psychological symptoms’ actor-effect associate to body-image avoidance, resulting significantly more influential than the partner-effect. Only for males, alexithymia’s actor-effect was significant. To conclude, partners’ functioning is quite specular yet not interdependent, as they do not show a couple-as-a-unit modality of functioning. Clinical implications are discussed.

Knowledge and attitudes about assisted reproductive technology: Findings from a Hungarian online survey

This study aimed to evaluate the general knowledge and attitudes about assisted reproductive technology (ART) and the influence of sociodemographic features on knowledge and attitudes in a large sample of men and women of reproductive age in Hungary. A cross-sectional online survey study was conducted among 1370 men and women between 18 and 50 years of age in Hungary. The questionnaire included questions about self-rated knowledge, an attitude item, and eight questions concerning general knowledge about ART. In addition, participants were asked sociodemographic background questions. The results show that approximately half of the respondents (49.3%) rated themselves as fairly knowledgeable about ART. However, 56% of the respondents answered just three of the eight knowledge questions correctly. Both men and women had limited knowledge about the success rate of ART, the costs of ART and the age limit to access ART. The greatest lack of knowledge about ART was about its risks: the majority of respondents did not know that in-vitro fertilization poses health risks for women and conceived children. Regarding attitudes, the majority of respondents had a very positive attitude towards ART. Only those respondents who were religious were less supportive of ART. These data suggest that men and women of reproductive age overestimate their ART-related knowledge. As most men and women would like to have biological children in Hungary, there is a critical need for public education.

Reproductive senescence and energetic metabolism of human luteinized granulosa cells: is it all about ATP? A prospective cohort and critical view

Mitochondria are known to play a key role in the regulation of reproductive capacity. Senescence is known to impair mitochondrial function and, ultimately, cellular energetic metabolism. Therefore, as women age, a deficient energy supply is likely to affect oocyte quality. The analysis of granulosa cells is considered a valuable noninvasive strategy to assess factors implicated in oocyte competence. Thus, we conducted an observational prospective cohort to evaluate the impact of aging on energy production by luteinized granulosa cells (LGCs). The control group comprised 13 young oocyte donors, whereas the comparison group included 13 infertile women over 38 years of age undergoing in vitro fertilization. Women with diseases that could potentially impact mitochondrial function were excluded. No differences were detected in the ATP levels in LGCs from young donors and infertile patients of advanced reproductive age (1.9 ± 0.99 picomoles in the control group vs. 2.1 ± 0.59 picomoles; p-value = .139). Likewise, the ATP levels in our series did not correlate with either oocyte number or maturity. Despite the similar ATP levels in LGCs, an age effect on the bioenergetic status cannot be excluded. Energy metabolism is very complex, and ATP does not seem to be the most important and reliable parameter.

Planned Oocyte Cryopreservation: Outcomes, Motivations, and Involvement of Primary Health Care Providers

Background: With improvements in oocyte cryopreservation and widespread delays in childbearing, planned oocyte cryopreservation (POC) has become an increasingly attractive option. This study aimed to (1) review POC cycle outcomes at an academic in vitro fertilization (IVF) center and (2) examine POC users' motivations for pursuing POC, fertility knowledge, and the involvement of their primary health care providers (PHP). Materials and Methods: POC cycle outcomes were collected from IVF records of the 224 women who underwent ≥1 cycle from 2012 to 2018. The 198 who were reachable by e-mail were invited to complete an online survey. The study was approved by the University of Toronto Research Ethics Board (No. 32951). Results: Mean age of the 224 women at first cycle was 36.4 (range: 25-42), with a significant decrease in anti-Müllerian hormone level (p = 0.001) and mean number of oocytes retrieved (p = 0.006) and cryopreserved per cycle (p = 0.042) with increasing age. From those invited for survey participation, 98 (49.5%) questionnaires were returned, with 86 evaluable. Majority of respondents were Caucasian (66%), single (93%), and earned a gross annual income of >$70,000 (74%). Strongest motivation for pursuing POC was concern about age-related fertility decline in the absence of a partner. Respondents' annual income was positively correlated with the number of completed cycles (p = 0.032). Half the respondents correctly identified age of onset of marked fertility decline as ≥35 years. In only 19% of cases was the conversation PHP initiated, and 29% never discussed POC with their PHP. Conclusions: More than 50% of women underwent POC at an age when fertility has begun to markedly decline. It is important for PHPs to identify and discuss POC with appropriate patients and offer accurate preliminary information and timely referrals for those interested in exploring this option.

Is increasing paternal age negatively associated with donor oocyte recipient success? A paired analysis using sibling oocytes

OBJECTIVE

To determine if increasing paternal age has an adverse effect on pregnancy outcomes in paired donor egg recipients who received oocytes from the same donor in the same stimulation cycle.

DESIGN

Retrospective cohort study.

SETTING

Reproductive Medicine Center.

PATIENT(S)

The study included 154 recipients who received oocytes from a split donor oocyte cycle and received sperm from men in discrepant age groups (group A: <45 years old; group B: ≥45 years old).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Implantation rate, pregnancy loss rate, pregnancy rate, and live birth rate.

RESULT(S)

The median paternal age was 41 years old for group A and 48 years old for group B. The pregnancy rate was 81% in group A compared with 69% in group B. The live birth rate was 65% in group A compared with 53% in group B. The rate of pregnancy loss was 19% in group A and 23% in group B. The implantation rate was 69% in group A compared with 66% in group B. The adjusted odds of pregnancy were found to be 65% lower for patients in the older partner age group (95% confidence interval [CI], 0.13, 0.95). The adjusted odds of live birth rate (odds ratio [OR], 0.45; 95% CI, 0.20, 1.00), implantation rate (OR, 0.91; 95% CI, 0.43, 1.92), and rate of pregnancy loss (OR, 1.5; 95% CI, 0.5, 4.5) favored the younger partner age group; however, these results were not statistically significant.

CONCLUSION(S)

In this model that controlled for oocyte quality to the greatest degree possible by using paired recipients from the same donor from the same stimulation cycle, we found that increased paternal age had a negative effect on pregnancy rates.

Childless by circumstance - Using an online survey to explore the experiences of childless women who had wanted children

Childlessness is increasing globally. This study aimed to explore the experiences of childless women who had wanted children. An online survey study was promoted through social media to recruit women aged ≥46 years who were childless by circumstance. The survey remained open for 15 days. In total, 303 survey responses were collected, 176 of which were complete surveys. In total, 15.3% (27/176) of women who had wanted children reported that they had not tried to have children, most commonly due to the lack of a partner (40.7%, 11/27). Of the 139 women who had tried to have children, 70.5% (98/139) had used calendar-based menstrual cycle tracking methods to identify their fertile window, and many had undergone fertility checks including hormone tests (75.5%, 105/139) and ultrasound scans (71.2%, 99/139). A significant proportion of women had experienced a miscarriage (40.2%, 56/139). Many women had decided not to have any fertility treatment (43.2%, 60/139). For those who did, the majority had tried in-vitro fertilization (74.6%, 59/79). The most common reason that women gave for stopping fertility treatment was due to emotional reasons (74.7%, 59/79). When asked how women felt now about their childlessness, the most common issues identified were unhappiness (85/158, 54%), acceptance (43/158, 27%) and happiness (30/158, 19%). There should be more support for unsuccessful fertility patients and other childless women, and more emphasis should be placed upon fertility education in order to ensure that women are better informed about fertility issues.

Psychosocial determinants of women's intentions and willingness to freeze their eggs

OBJECTIVE

To examine the psychosocial factors that influence Australian women's intentions to freeze their eggs.

DESIGN

Initially, a qualitative elicitation study followed by a larger-scale quantitative study.

SETTING

Both studies were conducted online.

PATIENTS

A total of 234 Australian women 25-43 years of age, who identifed as heterosexual, had no children, were open to the idea of having children, were currently not pregnant, and did not have a diagnosis of medical infertility.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Intentions and willingness of women to freeze their eggs.

RESULT(S)

Hierarchical multiple regression analyses showed that after accounting for demographic variables, there was strong support for the psychosocial predictors of attitude, pressure from others, and control perceptions as predictors of women's intentions to freeze their eggs. Of the additional variables, cognitive bias (influence of the media) was significant, and the final model accounted for 52.7% of variance in women's intentions to freeze their eggs.

CONCLUSION(S)

This study was the first to predict women's intentions to freeze their eggs using a well-established decision-making model, the theory of planned behavior. Messages designed to develop a positive attitude toward egg freezing, and to encourage an increased perception of personal control of the egg freezing process, as well as approval from others, could support women to investigate egg freezing, in consultation with appropriate medical advice, as an option when faced with possible future infertility. Effective strategies broaden fertility options for women faced with age-related fertility decline, maximize women's chances of a successful pregnancy, and, critically, prevent the often substantial psychological distress associated with involuntary childlessness.

'Your hopes can run away with your realistic expectations': a qualitative study of women and men's decision-making when undergoing multiple cycles of IVF

STUDY QUESTION

What are the factors that contribute to the decision to continue or stop IVF treatment after multiple unsuccessful cycles?

SUMMARY ANSWER

Factors contributing to the decision included external factors, such as their doctor's guidance, success rates, the outcomes of previous cycles and anecdotal stories of success, as well as emotional and cognitive drivers, including perception of success, hope and fear of regret.

WHAT IS KNOWN ALREADY

Infertility affects about one in six Australian couples of reproductive age. Regarding IVF, some couples with a good prognosis drop out of treatment prematurely, whilst others continue for multiple cycles, despite limited chances of success. Little is known about what factors contribute to the decision to continue IVF after multiple failed cycles.

STUDY DESIGN SIZE DURATION

Semi-structured face-to-face and telephone interviews were conducted with 22 participants. Interviews were audio-recorded, transcribed and analysed thematically using Framework analysis.

PARTICIPANTS/MATERIALS SETTING METHODS

Doctors and nurses at an Australian private fertility clinic recruited individuals and/or couples who had undergone three or more complete unsuccessful cycles of IVF.

MAIN RESULTS AND THE ROLE OF CHANCE

The majority of participants had decided to or were leaning towards continuing treatment. Participants expressed a range of common factors important in their decision-making, which were evident both within and across couples. For most, their doctor's advice and hope were key factors influencing their decision. Most participants expressed they would continue as long as there was a chance of success and until their doctor advised otherwise. Other factors included participants' perception of their likelihood of success, hearing anecdotal stories of success after multiple cycles, positive outcomes of previous cycles and fear of regret.

LIMITATIONS REASONS FOR CAUTION

The sample was highly educated and recruited from one private Australian fertility clinic only. Many participants were also couples, which may have resulted in more homogenous data as they shared the same diagnosis for infertility and outcomes of previous cycles. Factors influencing the decision to continue or stop may differ in different sociodemographic populations and in other healthcare systems.

WIDER IMPLICATIONS OF THE FINDINGS

Given the important role of the doctor's guidance and patients' own perceptions of their likelihood of success, which they tended to overestimate, it is vital that fertility specialists give accurate and transparent information regarding their likelihood of success and continue to regularly communicate this throughout the IVF journey. Anecdotal stories of success against the odds appeared to be influential in the decision to continue and underpinned unrealistic perceptions of possible success. More personalized, cumulative estimates of likelihood of success may help couples with their decision-making as well as with discussions about ending treatment or setting a limit before commencing IVF.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the National Health and Medical Research Council (NHMRC) Program Grant (APP1113532). No further competing interests exist.

A cross-sectional survey of fertility knowledge in obstetrics and gynecology residents

Background

To evaluate fertility knowledge among current Obstetrics and Gynecology (OB-GYN) residents using a recently published validated instrument, the Fertility and Infertility Treatment Knowledge Score (FIT-KS).

Methods

OB-GYN residents in the United States were recruited through an email to all residency coordinators nationwide. They were asked to voluntarily respond to a short questionnaire including demographic information and the FIT-KS instrument, through an online survey platform. Of approximately 5000 OB-GYN residents in the country, 177 responded.

Results

The sample was 91% female, with 69% between the ages of 26 and 30. Participants evenly represented all 4 years of training. Mean FIT-KS score was 21.2 (73% correct; range 17–26). No statistically significant differences were noted across the level of training. Several knowledge gaps were noted. Residents could define the common assisted reproductive technologies; however overestimated their success rates per cycle.

Conclusions

Substantial gaps exist in fertility knowledge among OB-GYN residents, with understanding of male fertility and success rates of Assisted Reproductive Technologies (ART) being particularly limited. Knowledge of fertility does not change throughout residency training, demonstrating consistent gaps in fertility knowledge. Knowledge during post graduate year (PGY)-1 year is consistent with mean scores found in prior research in Internal Medicine residents (65%), as well as a cohort of female medical students and obstetrics and gynecology residents and fellows (64.9%) (Fertil Steril 108:711-7, 2017; Fertil Steril 110:e239, 2018).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40738-020-00091-2.

Exploring women's attitudes, knowledge, and intentions to use oocyte freezing for non-medical reasons: A systematic review

INTRODUCTION

Women are postponing childbearing and preventing age-related fertility decline with oocyte freezing for non-medical reasons (OFNMR). The objective of this systematic evaluation was to gain an understanding of women's attitudes and knowledge of, and intentions to use OFNMR among users of OFNMR and the general public.

MATERIAL AND METHODS

A systematic search of MEDLINE, EMBASE, and PyschINFO databases was undertaken, for studies that examined the psychosocial attitudes among women toward OFNMR. The search was limited to English language and no time restriction was set for publications. Extracted data were analyzed using thematic analysis and the study was performed according to PRISMA guidelines with prospective PROSPERO registration (CRD4201912578).

RESULTS

Overall, 35 studies met the inclusion criteria. Studies were broadly categorized into studies investigating users or potential users of OFNMR, and studies examining the views of members of the general public. Users of OFNMR have good knowledge of age-related fertility decline and awareness of the OFNMR procedure. Lack of partner was identified as the most common motivating factor to undertake OFNMR, with cost as a predominant concern. Knowledge among the general public of OFNMR is highly variable. Underestimation of age-related fertility decline is common among the general public. Intentions of women to use OFNMR also varied drastically between studies.

CONCLUSIONS

Women are predominantly motivated to freeze eggs by the lack of a suitable partner, but cost is a significant barrier. Increasing the number of women pursuing OFNMR at an earlier stage may positively impact upon the risk of future involuntary childlessness. Better information should be made available to both women and men about their fertility and options to inform their reproductive decision-making.

The Biological Clock: Age, Risk, and the Biopolitics of Reproductive Time

The present article explores the social and subjective dimensions of the biological clock and its implications for reproductive time through a qualitative study based on 40 life story interviews of women from Santiago de Chile. Although the narrative of the biological clock has become a prevalent frame for addressing reproductive time in the context of late childbearing, age-related infertility, and the use of assisted reproductive technologies, few studies engage in an in-depth analysis of the biological clock—its boundaries, dynamics, and the particular ways in which it shapes women’s views and experiences of reproductive time. The present article aims to advance current knowledge on the intersection of time, reproduction, and biopolitics by arguing that the biological clock regulates reproductive time by shaping the boundaries and dynamics of female fertility through the clock. By determining reproductive time as quantitative, standardised, linear, and irreversible and by outlining the passing of time through pressure, risk, and burden, the biological clock determines when it is possible and desirable to have children and regulates reproduction, gender, and the female life course. These findings highlight the importance of critically addressing the narrative of the biological clock and its implications for women’s views and experiences of reproductive time.

Is intrauterine insemination a viable treatment option for women over 43 years old? An analysis by ovarian stimulation protocol and sperm source

PURPOSE

The aim of this study was to determine how female age at the end of the reproductive spectrum effects success of natural cycle intrauterine insemination (IUI) or IUI in combination with ovarian stimulation.

METHODS

We performed a retrospective cohort study of women 43 years of age and older at the time of IUI in a single academic fertility center between January 2011 and March 2018. Primary outcomes were both pregnancies and live births per cycle of IUI. Data are presented as percentage or mean ± SD. Fisher exact and chi-squared analyses were performed.

RESULTS

There were 9334 IUI cycles conducted during the study period. Of these cycles, 325 IUIs (3.5%) were for women aged 43 years and over at the time of insemination (43.6 ± 0.8, range 43 to 47 years). Analysis of these 325 IUI cycles revealed 5 biochemical pregnancies (1.5%) and only 1 live birth (0.3%). The pregnancy rate did not differ between IUIs using donor sperm (N = 1/49, 2.0%) compared to IUIs with partner sperm (N = 4/276, 1.4%). The pregnancy rate did not differ between IUIs with gonadotropins (N = 2/211, 0.9%), clomiphene or letrozole (N = 2/78, 2.6%), or natural cycle (N = 1/36, 2.8%).

CONCLUSIONS

The use of intrauterine inseminations in women 43 years of age and older is an ineffective treatment strategy. This is irrespective of the use of ovarian stimulation or donor sperm. Costly gonadotropin injections did not increase the chance of pregnancy nor did oral medication when compared to natural cycle IUIs.

Parenthood desire, childbearing plans and oocyte utilization among women who previously underwent planned oocyte cryopreservation

RESEARCH QUESTION

To examine the motivations, life circumstances and parenthood aspirations of a cohort of women who underwent planned oocyte cryopreservation (POC) at a Canadian academic IVF centre.

DESIGN

A single-site, cross-sectional, anonymous quantitative study using a study-specific questionnaire administrated via SurveyMonkey®. Of the 224 women who completed at least one POC cycle between 2012 and 2018, 198 were reached by email and invited to participate.

RESULTS

Of the 98 (49.5%) questionnaires returned, 86 were fully completed and were analysed. Mean age at first POC cycle was 35.7 ± 2.4 (range 27-43) and at survey was 37.7 ± 2.5 years. At POC, 77% were single and 97.7% childless. At survey, 96% had not attempted to use their cryopreserved oocytes, yet 26 (30%) had tried natural conception or fertility treatments. Of these, three conceived naturally and two by assisted reproduction. Eighty-five per cent expressed a strong motherhood desire and 67.1% indicated that usage of their cryopreserved oocytes was mostly contingent on relationship status. Many expressed a desire for shared genetic parenthood within a committed relationship. Forty-seven per cent did not want to carry a pregnancy beyond the age of 46.

CONCLUSION

The findings of this study confirm the central role of age and relationship status in influencing women's POC decisions and oocyte utilization plans. The late age at POC could be explained by women using it toward the end of their peak reproductive years to leverage their remaining chances of genetic motherhood. Surveying women at later points following POC would help to gain a more comprehensive picture of their oocyte utilization and disposition plans.

Knowledge gaps in the understanding of fertility among non-medical graduate students

Objective

To assess knowledge of female and male fertility among students enrolled in a Master of Business Administration (MBA) program.

Design

Web-based cross-sectional survey.

Setting

Academic setting.

Patient(s)

Not applicable.

Intervention(s)

None.

Main Outcome Measure(s)

Knowledge of how female and male age impacts reproduction, fecundability, and success rates with in vitro fertilization (IVF).

Result(s)

A total of 133 female and male MBA students completed the survey. Nearly 10% of participants were not aware that women are born with a fixed number of oocytes and that oocyte quantity and quality decline with age. More than 30% of participants overestimated fecundability in women aged ≥35 years, and >50% overestimated IVF success rates in women older than 40 years. Fifteen percent of participants did not know that men have stem cells in the testes, and >25% were not aware that men experience a decrease in sperm concentration and quality with age. Nearly 30% believed that a man’s age never impacts reproductive outcomes. Less than 30% of participants correctly estimated fecundability and IVF success rates based on male age.

Conclusion(s)

These data highlight important knowledge gaps in a highly educated group of MBA students, most whom desire future childbearing. Specifically, there is a lack of understanding of both male and female reproductive aging and an overestimation of treatment success. As delayed childbearing continues, particularly among those with high educational attainment, attention should be focused on introducing broad fertility education at a younger age to improve future reproductive success.

Salt-inducible Kinases Are Critical Determinants of Female Fertility

Follicle development is the most crucial step toward female fertility and is controlled mainly by follicle-stimulating hormone (FSH). In ovarian granulosa cells (GCs), FSH activates protein kinase A by increasing 3',5'-cyclic adenosine 5'-monophosphate (cAMP). Since cAMP signaling is impinged in part by salt-inducible kinases (SIKs), we examined the role of SIKs on the regulation of FSH actions. Here, we report that SIKs are essential for normal ovarian function and female fertility. All SIK isoforms are expressed in human and rodent GCs at different levels (SIK3>SIK2>SIK1). Pharmacological inhibition of SIK activity potentiated the stimulatory effect of FSH on markers of GC differentiation in mouse, rat, and human GCs and estradiol production in rat GCs. In humans, SIK inhibition strongly enhanced FSH actions in GCs of patients with normal or abnormal ovarian function. The knockdown of SIK2, but not SIK1 or SIK3, synergized with FSH on the induction of markers of GC differentiation. SIK inhibition boosted gonadotropin-induced GC differentiation in vivo, while the genomic knockout of SIK2 led to a significant increase in the number of ovulated oocytes. Conversely, SIK3 knockout females were infertile, FSH insensitive, and had abnormal folliculogenesis. These findings reveal novel roles for SIKs in the regulation of GC differentiation and female fertility, and contribute to our understanding of the mechanisms regulated by FSH. Furthermore, these data suggest that specific pharmacological modulation of SIK2 activity could be of benefit to treat ovulatory defects in humans and to increase the propagation of endangered species and farm mammals.

Mothers who have given birth at an advanced age - health status before and after childbirth

Women postpone childbirth to an age when morbidity is higher and fertility has decreased and yet the knowledge of mothers' morbidity related to age remains scarce. Swedish national register data from the Medical Birth Register and National Patient Register was used to investigate the incidence of diseases listed in the International Classification of Diseases, version 10 (ICD-10) in women who gave birth 2007-8. The index group consisted of women 40 years of age or older (n = 8 203) were compared to a control group of women, younger than 40 years (n = 15 569) at childbirth. The period studied was five years before childbirth to five years after. The main outcome measures were incidence of disease diagnosed in specialized hospital care. Demographical data and use of assisted reproduction (ART) were adjusted for. The results showed that older women were more likely to be single; less frequently used tobacco; were educated on a higher level; had a higher BMI and more often had used ART to become pregnant. The older women showed a higher morbidity rate. In the diagnostic groups: Neoplasms, Blood and immune system, Eye and adnexa, Ear and mastoid, Circulatory, Digestive, Skin and subcutaneous tissue, Musculoskeletal and connective tissue, and Genitourinary. The results add to the body of knowledge of a number of specific risks faced by older mothers and may be used to identify preventive actions concerning fertility and morbidity both before and after childbirth.

Mitochondrial Function in Modulating Human Granulosa Cell Steroidogenesis and Female Fertility

Ovarian follicle steroidogenesis associated with embryo quality results in a successful pregnancy. Each follicle consists of an oocyte surrounded by granulosa cells, which secrete several steroid and peptide hormones. Follicles harvested from women who conceived after assisted reproductive therapy (ART) had significantly higher estradiol levels in follicular fluids than the follicles from women who failed to conceive after ART. The higher follicular estradiol levels correlate well with successful fertilization following ART. Mitochondria are the central sites for steroid hormone biosynthesis. The first and rate-limiting step in the biosynthesis of steroid hormones occurs in the mitochondria of granulosa cells. In the present study, we hypothesized that the mitochondria in granulosa cells are critical for maintaining oocyte quality and fertility capacity. This study aims to clarify the relationship between mitochondrial function and granulosa cell steroidogenesis, and the relationship between hormone levels and fertility capacity. Sera, follicular fluids and granulosa cells were obtained from individuals undergoing IVF-ET treatment. The oocyte numbers, oocyte quality, fertilization rate, and pregnancy rate were also recorded. The patients who provided the granulosa cells were further classified into four groups: endometriosis, ovarian endometrioma, endometriosis without ovarian endometrioma, and polycystic ovary syndrome (PCOS); patients with other female factor infertility and male factor infertility were used as controls. We measured the levels of estradiol (E2) by radioimmunoassay. Concurrently, we analyzed the mitochondrial mass and membrane potential, and apoptosis by flow cytometry using nonyl acridine orange, TMRE, Annexin V-FITC and PI. Mitochondrial morphology was visualized by transfection with pLV-mitoDsRed. In addition, we assessed the protein levels of steroidogenic enzymes, steroidogenic acute regulatory protein (StAR) and 3β-hydroxysteroid dehydrogenase (3β-HSD) by Western blot. The results showed significantly decreased serum E2 and follicular E2 levels, and decreased IVF outcomes, in the patients with endometriosis. Reduced mitochondrial mass and decreased mitochondrial membrane potential were correlated with lower E2. Furthermore, a significant decrease in StAR and 3β-HSD was found in patients with ovarian endometrioma. The enzyme levels of StAR and 3β-HSD were highly correlated with E2 levels. Finally, elevated cumulus cell apoptosis was found in the patient group with ovarian endometrioma and PCOS. In conclusion, mitochondrial dysfunction of human granulosa cells may contribute to the decline of steroidogenesis, decreased fertilization rate, oocyte maturation rate, and oocyte quality, and it can ultimately jeopardize fertility.

Multicentric, prospective observational data show sperm capacitation predicts male fertility, and cohort comparison reveals a high prevalence of impaired capacitation in men questioning their fertility

RESEARCH QUESTIONS

Can a previously defined relationship between sperm capacitation and the probability of a man generating pregnancy within three cycles, prospectively predict male fertility in diverse clinical settings? A second study asked, what is the prevalence of impaired sperm fertilizing ability in men questioning their fertility (MQF), and does this relate to traditional semen analysis metrics?

DESIGN

In the multicentric, prospective observational study, data (n = 128; six clinics) were analysed to test a published relationship between the percentage of fertilization-competent, capacitated spermatozoa (Cap-Score) and probability of generating pregnancy (PGP) within three cycles of intrauterine insemination. Logistic regression of total pregnancy outcomes (n = 252) assessed fit. In the cohort comparison, Cap-Scores of MQF (n = 2155; 22 clinics) were compared with those of 76 fertile men.

RESULTS

New outcomes (n = 128) were rank-ordered by Cap-Score and divided into quintiles (25-26 per group); chi-squared testing revealed no difference between predicted and observed pregnancies (P = 0.809). Total outcomes (n = 252; 128 new + 124 previous) were pooled and the model recalculated, yielding an improved fit (P < 0.001). Applying the Akaike information criterion found that the optimal model used Cap-Score alone. Cap-Scores were performed on 2155 men (with semen analysis data available for 1948). To compare fertilizing ability, men were binned by PGP (≤19%, 20-29%, 30-39%, 40-49%, 50-59%, ≥60%). Distributions of PGP and the corresponding Cap-Scores were significantly lower in MQF versus fertile men (P < 0.001). Notably, 64% of MQF with normal volume, concentration and motility (757/1183) had PGP of 39% or less (Cap-Scores ≤31), versus 25% of fertile men.

CONCLUSIONS

Sperm capacitation prospectively predicted male fertility. Impaired capacitation affects many MQF with normal semen analysis results, informing diagnosis versus idiopathic infertility.

The association between reproductive health smartphone applications and fertility knowledge of Australian women

Background

Previous studies have identified that women living in developed countries have insufficient knowledge of factors which may be contributing to the increasingly high global infertility rates such as maternal age and assisted reproductive technologies. There is a large market of reproductive health smartphone applications, yet little is known about the advantages these apps may confer to users in regards to reproductive health knowledge.

Methods

An anonymous, online survey of women living in Australia aged 18 and above was open March–June 2018, until ≥200 responses were acquired for statistical power. Respondents answered questions regarding knowledge about general fertility and related factors (age, cyclic fertility, smoking, obesity, miscarriage rate, and success of assisted reproductive technologies). Fertility knowledge was compared in respondents who did or did not use apps relating to female reproductive health. Additionally the functions preferred in reproductive health apps was described by app using respondents. Sociodemographic information was also collected, and relevant data within the dataset was subject to multivariable modelling for the outcome of the fertility knowledge questions.

Results

Of the 673 respondents that completed the survey, 43.09% reported using mobile phone applications relating to female reproductive health. On average, respondents answered only three of the six fertility knowledge questions correctly. App using respondents were more likely to score better on one question, related to fertility during the menstrual cycle (p < 0.001). App users most commonly reported using the menstrual tracking function in apps (82.4%), which may account for the increased knowledge of cyclic fertility.

Conclusions

This data provides preliminary evidence toward the usefulness of smartphone applications as a medium for providing information about fertility to women. A limited understanding of one’s own fertility was demonstrated despite being essential for the decision-making of women throughout their reproductive years.

Knowledge, attitude, intention, and religion aspect toward fertility preservation among obstetrics and gynecology residents in Indonesia: A cross-sectional study

Background

The lack of knowledge from healthcare providers regarding fertility preservation will certainly affect the patient's knowledge, attitude, behavior, and also perspective. Obstetrics and Gynecology (OB/GYN) residents may most likely be the first line professionals to integrate fertility preservation technologies into their practice which plays an important task in giving an understanding of the relationship between age and fertility for patients.

Objective

This study aims to assess OB/GYN resident knowledge and beliefs regarding age-related fertility decline, intentions, and religion aspect toward fertility preservation.

Materials and Methods

A cross-sectional study was conducted on 92 Indonesian OB/GYN residents at the Cipto Mangunkusomo Hospital between November and December 2017. Data were collected using a questionnaire which had four sections, knowledge, attitude, intention, and religion aspect toward fertility preservation.

Results

The majority of participants believed that an OB/GYN should encourage discussions about potential childbearing desires (96.74%) and age-related fertility decline (94.57%) with patients, of which 79.34% believed that these discussions should be part of a woman's annual health examination. Cancer patients are likely to undergo oocyte cryopreservation than people who choose career as priority. From the religion aspect, fertility preservation options such as sperm, oocyte, embryo, and ovarian cortex cryopreservation were accepted by most residents with varied religions, while oocyte and sperm donor methods were unacceptable (48% and 57%, respectively) because of the belief that oocyte/sperm should only be given to legitimate partners, but many still do not know that oocyte and sperm donor were prohibited by all religions.

Conclusion

Age-related fertility decline and frozen egg storage should be discussed during annual woman wellness examinations by OB/GYN specialists.

Luteal phase after conventional stimulation in the same ovarian cycle might improve the management of poor responder patients fulfilling the Bologna criteria: a case series

OBJECTIVE

To assess the clinical contribution of luteal-phase stimulation (LPS) to follicular-phase stimulation (FPS) in a single ovarian cycle (DuoStim) for poor responder patients fulfilling the Bologna criteria.

DESIGN

Observational study (years 2015-2017) including women satisfying ≥2 of the following characteristics: maternal age ≥40 years and/or ≤3 oocytes retrieved after previous conventional stimulation and/or reduced ovarian reserve (i.e., antral follicle count <7 follicles or antimüllerian hormone <1.1 ng/mL). The LPS was started regardless of the outcome of the FPS.

SETTING

Private in vitro fertilization center.

PATIENT(S)

A total of 100 of 297 patients fulfilling the Bologna criteria chose to undergo DuoStim.

INTERVENTION(S)

The FPS and LPS with the same antagonist protocol and agonist trigger, intracytoplasmic sperm injection with ejaculated sperm, preimplantation genetic testing for aneuploidies, and vitrified-warmed euploid single blastocyst transfer.

MAIN OUTCOME MEASURE(S)

The contribution of LPS to the cumulative live birth rate (CLBR) per intention-to-treat (ITT).

RESULT(S)

Patients (100) underwent FPS (maternal age, 42.1 ± 1.4 y; previous in vitro fertilization cycles with ≤3 collected oocytes, 0.7 ± 0.9; antral follicle count, 3.8 ± 1.2 follicles; and antimüllerian hormone, 0.56 ± 0.3 ng/mL). Ninety-one patients completed DuoStim. All patients were included in the analysis. More oocytes were obtained after LPS with similar developmental and chromosomal competence as paired FPS-derived ones. The CLBR per ITT increased from 7% after FPS to 15% after DuoStim. Conversely, the CLBR per ITT among the 197 patients that chose a conventional controlled ovarian stimulation strategy was 8%, as only 17 patients who were not pregnant returned for a second stimulation after the first attempt (drop-out rate, 81%).

CONCLUSION(S)

The LPS-derived oocytes increased the CLBR per ITT in a single ovarian cycle in patients fulfilling the Bologna criteria. The DuoStim strategy is promising to manage this thorny population of patients, especially to avoid discontinuation after a first failed attempt.

"Delayed start" gonadotropin-releasing hormone antagonist protocol in Bologna poor-responders: A systematic review and meta-analysis of randomized controlled trials

To evaluate the effectiveness of delay start protocol in improving the success of in vitro fertilization (IVF) in poor responders according to Bologna's criteria. Only randomized controlled trial (RCT) of infertile women undergoing a single IVF/ICSI cycle with ovarian stimulation protocol based on daily injections with delay start protocol or a conventional antagonist protocol were included in this systematic review and meta-analysis. The review protocol was registered in PROSPERO before starting the data extraction (CRD42019128284). Primary outcome was clinical pregnancy rate. Ongoing pregnancy rate, miscarriage rate, number of oocytes, number of MII oocytes, stimulation length, gonadotropin amount and cancellation rate were considered as secondary outcomes. Four randomized controlled trials were included with a total number of 380 participants. 189 patients were included in the delayed start protocol and 191 were allocated to the comparison group. The results showed a significant higher clinical pregnancy rate (CPR) in patients allocated to the intervention. Data from all studies failed to detect a statistical difference between groups in terms of ongoing pregnancy rate (OPR), miscarriage rate (MR), Total-Oocyte, MII-Oocyte and Total-Embryos. Gonadotropin amount (GA) was significantly lower in the intervention group in comparison to controls, with no difference in stimulation length (SL) and cancelled cycle (CC). Delayed start GnRH-antagonist protocol may reduce GA and improve CPR in poor ovarian responder according to Bologna criteria.

[Thoughts on the revision of the bioethics law in the field of assisted reproductive technologies (ART). The end of a conceptual framework?]

This contribution aims at analysing and presenting a comparative dimension concerning the issues raised for the upcoming French Bioethics law revision in the field of assisted reproductive technologies (ART) : access of female same-sex couples and single women to ART ; the authorization of post-mortem procreation ; enlarging eligibility criteria for oocyte self-conservation ; and lifting the anonymity of gamete donation. These questions touch at the very heart of the French bioethics model conceived in 1994, and their revision would constitute a conceptual upheaval.

Evaluation of the Second Follicular Wave Phenomenon in Natural Cycle Assisted Reproduction: A Key Option for Poor Responders through Luteal Phase Oocyte Retrieval

Background: Emergence of Luteal Phase Oocyte Retrieval (LuPOR) may revolutionize the practice regarding the time-sensitive nature of poor responders ascertaining a higher number of oocytes, in a shorter amount of time. This may be especially important in view of employing the approach of natural cycles for Poor Responders. We suggest the acronym LuPOR describing the clinical practice of luteal phase oocyte retrieval. The aim of the study is to offer insight regarding the identity of LuPOR, and highlight how this practice may improve management of the special subgroup of poor responders. Materials and Methods: The present retrospective observational clinical study includes the collection and statistical analysis of data from 136 poor responders who underwent follicular oocyte retrieval (FoPOR) and subsequent LuPOR in natural cycles, during their In Vitro Fertilization (IVF) treatment, from the time period of 2015 to 2018. All 136 participants were diagnosed with poor ovarian reserve (POR) according to Bologna criteria. The 272 cycles were categorized as follows: 136 natural cycles with only FoPORs (Control Group) and 136 natural cycles including both FoPORs and LuPORs. Results: Our primary results indicate no statistically significant differences with regards to the mean number of oocytes, the maturation status, and fertilization rate between FoPOR and LuPOR in natural cycles. Secondarily, we demonstrate a statistically significant higher yield of oocytes (2.50 ± 0.78 vs. 1.25 ± 0.53), better oocyte maturity status (1.93 ± 0.69 vs. 0.95 ± 0.59) and higher fertilization rate (1.31 ± 0.87 vs. 0.61 ± 0.60) in natural cycles including both FoPOR and LuPOR, when compared to cycles including only FoPOR. Conclusion: Our study may contribute towards the establishment of an efficient poor responders’ management through the natural cycle approach, paving a novel clinical practice and ascertaining the opportunity to employ oocytes and embryos originating from a luteal phase follicular wave.

Double stimulation in the same ovarian cycle (DuoStim) is an intriguing strategy to improve oocyte yield and the number of competent embryos in a short timeframe

Proper ovarian stimulation regimens are crucial for any patient undergoing in-vitro fertilization (IVF). However, maximizing the oocyte yield in advanced maternal age patients with poor or suboptimal response is still a challenge. In fact, no standard treatment has been outlined yet to manage these women. Across the last years, an improved efficiency of the IVF units via blastocyst culture, vitrification and reliable embryo selection approaches paved the way to the investigation of novel unconventional stimulation protocols, like double stimulation in a single ovarian cycle (DuoStim). DuoStim, by conjugating follicular phase stimulation (FPS) and luteal phase stimulation (LPS) in the same ovarian cycle, allows to maximize the number of oocytes obtained in a short timeframe, a precious outcome when we aim at shortening time to pregnancy. In this regard, LPS seems to contribute to conventional stimulation with more oocytes with a comparable competence as FPS, retrieved per ovarian cycle. Although any stimulation protocol which exploits anovulatory waves of follicular growth needs a thorough investigation, no evidence has been produced to question the safety of DuoStim, which to date represents the most intriguing strategy to treat poor prognosis in IVF.

Lesbians' experiences and attitudes towards parenthood in Greece

Same-sex parenthood is controversial subject. In this paper, we provide insights into the attitudes and experiences of self-reported lesbians regarding parenthood or the prospect of becoming a parent in the current Greek social and cultural context. In Greece, lesbians are not allowed access to in vitro fertilisation (IVF), while a solitary ('single') woman is allowed access for medical reasons. Fifty-nine (59) semi-structured in-depth interviews were conducted with women. What emerged from our data was a clear trend for participants to wish to have their own biological children based mostly on the belief that pregnancy would lead to a sense of self-completeness and/or fulfilment. Women also reported the negative impact of prejudice and social oppression on their reproductive autonomy. Interviewees reported that their reproductive choices were negatively influenced by their family and the wider socio-cultural environment. Even within a semi-permissive legal framework, impaired social acceptance of lesbian parenthood prohibits lesbians from becoming mothers. A major reason responsible for the positive attitude of most participants to shared biological motherhood was an altruistic attitude towards their partners.

Mid-life fertility: Challenges & policy planning

This review highlights the challenges, priority areas of research and planning, strategies for regulation of services and the need to develop guidelines and laws for fertility treatments during mid-life. The success rate of all treatments is poor in advanced age women because of declining ovarian reserve and natural fertility. There is often a need of third-party involvement which has its own ethical, legal and medical issues. Welfare of children born to older women and early death of parents are important concerns. Most of the new techniques such as the pre-implantation genetic diagnosis, oocyte augmentation, use of stem cells or artificial gametes, ovarian tissue preservation and ovarian transplantation are directed to improve, preserve or replace the declining ovarian reserve. These techniques are costly and have limited availability, safety and efficacy data. Continued research and policies are required to keep pace with these techniques. The other important issues include the patients' personal autonomy and right of self-determination, welfare of offspring, public vs. private funding for research and development of new technologies vs. indiscriminate use of unproven technology. It is important that mid-life fertility is recognized as a distinct area of human reproduction requiring special considerations.

Bibliometric Study of Obstetrics Articles Published in the Journal of the American Medical Association, 1997-2016

Introduction

A recent increase in cases of advanced maternal age in the US has been partly associated with a higher incidence of pregnancy-related complications and infertility. However, little is known on how such social changes may have influenced obstetrics articles published in high-impact medical journals subscribed by diverse physicians. The objective of this study is to elucidate the presence and trend of obstetrics investigations in high-profile medical journals.

Material and methods

This bibliometric study retrospectively analyzed original articles published in the Journal of the American Medical Association (JAMA) from 1997 to 2016. Two reviewers extracted obstetrics articles from PubMed, assessed whether to include specific articles, and categorized them by subtopic. Main outcomes measure was the annual number of original investigations in obstetrics divided by that of original investigations from all fields during the study period, expressed as a trend.

Results

A total of 3486 original investigations were published during the study period. Regarding obstetrics, 1989 articles were originally extracted from PubMed; after a two-step review process, 199 (10.0%) obstetrics-related original investigations remained. Among them, 134 (67.4%) were classified as pregnancy-related abnormalities or complications (non-infection). The proportion of obstetrics articles decreased during the first 10 years but increased in the last 10 years. The highest figures in the first 10 and last 10 years were 8.5% in 1999 and 9.4% in 2014, respectively, whereas the lowest was 1.4% in 2008. The proportion articles on pregnancy-associated complications or abnormalities (non-infection) steadily increased during the study period, that of articles on infertility increased, and that of articles on human immunodeficiency virus (HIV) infection steadily decreased.

Conclusions

The observed trend may suggest a changing interest in obstetrics investigations among general physicians in the last 20 years. What is particularly notable is a heightened presence of research on pregnancy-related complications and infertility, which may reflect an increasing frequency in advanced maternal age in the US.

Reproductive aging and elective fertility preservation

Reproductive aging is a natural process that occurs in all women, eventually leading to reproductive senescence and menopause. Over the past half century there has been a trend towards delayed motherhood. Postponing reproduction can increase the chance of a woman remaining involuntarily childless as well as an increase in pregnancy complications in those that do achieve pregnancy at advanced maternal age. Despite the well-documented decrease in fecundity that occurs as a woman ages, reproductive aged women frequently overestimate the age at which a significant decline in fertility occurs and overestimate the success of assisted reproductive technologies (ART) to circumvent infertility. Oocyte cryopreservation enables women to achieve genetically related offspring in the event that they desire to postpone their childbearing to an age after which a significant decline in fertility occurs or in circumstances in which their reproductive potential is compromised due to medical pathology. Available success rates and safety data following oocyte cryopreservation have been reassuring and is not considered experimental according to the American Society for Reproductive Medicine and the European Society for Human Reproduction and Embryology. This review article will focus on an evidence-based discussion relating to reproductive aging and oocyte cryopreservation.

Counseling patients on reproductive aging and elective fertility preservation-a survey of obstetricians and gynecologists' experience, approach, and knowledge

PURPOSE

What are the experience, approach, and knowledge of US Obstetricians and Gynecologists' (ob-gyn) towards counseling patients on reproductive aging (RA) and elective fertility preservation (EFP).

METHODS

A cross-sectional survey emailed by the American College of Obstetricians and Gynecologists (ACOG) to 5000 ACOG fellows consisting of 9 demographic and 28 questions relating to counseling patients on RA and EFP.

RESULTS

Seven hundred and eighty-four responders completed the survey. Although 82.8% agreed that conversations relating to RA should take place with patients desiring future childbearing and delaying due to social reasons, only 27.6% stated that they frequently counsel these women aged 18-34 years old, compared to 75.8% aged 35-44 years old (P < 0.01). Limited time (75.8%) and limited knowledge (41.4%) were amongst the most frequent reported barriers towards counseling patients on RA. Fifty-eight percent stated that they have been asked about EFP by patients. Although 74.8% agreed that conversations should take place related to EFP in women desiring future childbearing and delaying due to social reasons, only 27.6% stated that they frequently counsel these patients on EFP (P < 0.01). Limited time (75%) and limited knowledge (59.9%) were amongst the most frequent barriers towards counseling on EFP.

CONCLUSIONS

In the USA, methods to improve patient counseling and provider knowledge on RA and EFP are warranted and further studies are needed to address optimal methods to improve counseling and knowledge related to these topics.

Initiating patient discussions about oocyte cryopreservation: Attitudes of obstetrics and gynaecology resident physicians

This study examined the attitudes of obstetrics and gynaecology (OB/GYN) resident physicians to initiating patient discussions regarding medical and elective oocyte cryopreservation (OC). The study used a cross-sectional online survey of OB/GYN medical residents in the USA, sampled from residency programmes approved by the American Council for Graduate Medical Education. In total, 208 medical residents, distributed evenly between postgraduate years 1-4, participated in the study. Residents' fertility knowledge and attitudes to initiating discussions about OC were gathered. Forty percent (n = 83) believed that OB/GYN residents should initiate discussions about OC with patients (initiators), while 60% (n = 125) did not (non-initiators). Initiators were less likely to overestimate the age at which a woman's fertility begins to decline, and were more likely to believe that discussions about OC and age-related fertility decline should take place during a well-woman annual examination. Initiators and non-initiators did not differ in their attitudes towards discussing OC with patients undergoing cancer treatments; however, initiators were significantly more likely to discuss elective OC with patients who were currently unpartnered or who wished to delay childbearing to pursue a career. Given the increasing age of childbearing among women, and the fact that women prefer to receive reproductive information from their healthcare providers, it is critical that such topics are discussed in consultations to assist patients in making more informed reproductive decisions. Further research is needed to assess the existing barriers to these discussions from both physician and patient perspectives.