Attitudes, concerns, and perceptions of patients undergoing fertility treatments in an abortion restrictive state in the aftermath of the Roe v. Wade reversal.

PURPOSE: To investigate the abortion views and reproductive concerns of current in vitro fertilization patients after the US Supreme Court Dobbs v. Jackson decision, which overturned the Roe v. Wade decision guaranteeing abortion access. METHODS: This is a cross-sectional survey of English-speaking patients undergoing in vitro fertilization from January to November 2022 at a large academic institution in a state with restricted abortion care. Participants completed a 43-question electronic survey which measured feelings about abortion, future fertility treatments, and embryo disposition both quantitatively and qualitatively. RESULTS: Of 543 eligible patients, 267 (49%) consented to participate when called and were sent the survey. Of those, 180 (67%) completed it, resulting in a total completion rate of 33%. The majority believe abortion should be legal in the case of birth defects (90.8%) or rape or incest (90.3%). A significant proportion (91.4%) expressed concerns about abortion being illegal in the state that they receive infertility care. They reported some concern about making embryos (89.6%), controlling what happens to them (95.4%), and discarding them (94.4%). Patients wrote about their concerns with pursuing fertility treatments, fear of not having access to needed medical care, and the desire to remain close to states with less restrictive abortion laws. CONCLUSIONS: The evolving political landscape surrounding access to reproductive care has created significant concerns regarding legal regulation of these treatments and the disposition of embryos. By understanding patients' concerns, health care providers can more effectively advocate for the protection of fertility treatments and patients' autonomy in embryo disposition.

Diverse monogenic subforms of human spermatogenic failure.

Non-obstructive azoospermia (NOA) is the most severe form of male infertility and typically incurable. Defining the genetic basis of NOA has proven challenging, and the most advanced classification of NOA subforms is not based on genetics, but simple description of testis histology. In this study, we exome-sequenced over 1000 clinically diagnosed NOA cases and identified a plausible recessive Mendelian cause in 20%. We find further support for 21 genes in a 2-stage burden test with 2072 cases and 11,587 fertile controls. The disrupted genes are primarily on the autosomes, enriched for undescribed human "knockouts", and, for the most part, have yet to be linked to a Mendelian trait. Integration with single-cell RNA sequencing data shows that azoospermia genes can be grouped into molecular subforms with synchronized expression patterns, and analogs of these subforms exist in mice. This analysis framework identifies groups of genes with known roles in spermatogenesis but also reveals unrecognized subforms, such as a set of genes expressed across mitotic divisions of differentiating spermatogonia. Our findings highlight NOA as an understudied Mendelian disorder and provide a conceptual structure for organizing the complex genetics of male infertility, which may provide a rational basis for disease classification.

Fertility preservation discussions, referral and follow-up in male-to-female and female-to-male adolescent transgender patients.

The number of patients seeking transgender healthcare is growing, and there is a potential impact of gender-affirming therapies on fertility. The use of fertility preservation (FP), particularly among transgender adolescents, has been limited. We aimed to examine differences in FP counselling, referral and utilisation between male-to-female (MtF) and female-to-male (FtM) transgender adolescents. A retrospective review of the medical records of patients ages 12-17 seen at an academic medical centre between 2012 and 2017 with a diagnosis of gender dysphoria was conducted. A total of 22 MtF and 45 FtM adolescents were included. The counselling on the potential fertility impact of gender-affirming therapy was documented in 55%, and of those counselled, 73% were counselled before receiving medication. There was no significant difference between the timing of counselling for MtF versus FtM adolescents. Of patients with documented reproductive wishes, 77% reported either desire for adopted children or no desire for biological children. Among patients offered FP referral, 2 (22.2%) MtF and 3 (12.5%) FtM patients accepted; both MtF patients cryopreserved sperm. While most adolescents were counselled on the fertility impact of gender-affirming therapy, there is room for improvement as 45% of patients had no documented counselling. The rate of transgender adolescents pursuing FP consultation and gamete cryopreservation was low, consistent with prior studies in this population.

Traits of patients seen via telemedicine versus in person for new-patient visits in a fertility practice.

OBJECTIVE: To assess the differences in demographics, the likelihood of receiving treatment, and the clinical outcomes between new patients seen via telemedicine and those seen in person in an academic fertility practice. DESIGN: Retrospective cohort study. SETTING: University-based fertility clinic. PATIENTS: All new patients seen via telemedicine between June 1, 2017, and February 29, 2020, were compared with an equal number of all new patients seen in person between May 1, 2019, and June 30, 2019. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The primary outcome was receiving treatment after a new-patient visit. Binary logistic regression analyses were performed to estimate the odds ratio for not receiving treatment according to distance to the clinic and duration of infertility. The secondary outcomes included treatment recommendation, time to treatment initiation, and time to positive pregnancy test (if achieved). In addition we assessed patient demographics and visit traits per patient encounter. RESULTS: The telemedicine and in-person groups each contained 70 patients. The following were similar between the groups: age, body mass index, Area Deprivation Index, diagnosis made at the new-patient visit, and the number of clinic contacts before starting treatment. Compared with patients who had in-person new-patient visits, those who had telemedicine new-patient visits lived farther from the clinic (mean, 223.6 vs. 69.28 miles) and had a longer duration of infertility (mean, 41.9 vs. 19.49 months). No differences were noted between the groups in the following outcomes: percent that received treatment, time to treatment initiation, or time to pregnancy. Telemedicine new-patient visits were shorter than in-person new-patient visits (mean, 56.3 ± 9.1 vs. 59.3 ± 4.6 minutes) and less likely to contain documentation of height or weight. CONCLUSIONS: Telemedicine appears to be of particular interest to patients who live farther from clinics and have longer durations of infertility, and it could reduce visit times. New patients seen in person and those seen via telemedicine are equally likely to pursue treatment. Telemedicine consultation for new-patient visits is feasible in an academic fertility practice and may be especially useful during a pandemic and in non-pandemic times in areas with limited access to fertility specialists.

Outcomes of in vitro fertilization pregnancies complicated by subchorionic hematoma detected on first-trimester ultrasound.

OBJECTIVE: To estimate the association between subchorionic hematoma (SCH) on ultrasound and pregnancy outcomes in in vitro fertilization (IVF) pregnancies. DESIGN: Institutional Review Board-approved, retrospective cohort study. SETTING: Tertiary care university-based facility. PATIENTS: In this study, 1,004 patients who underwent IVF with a viable singleton pregnancy from January 1, 2009 through December 31, 2017. INTERVENTIONS: Subchorionic hematoma versus no hematoma diagnosed on first-trimester ultrasound. MAIN OUTCOME MEASURES: Live birth, preterm birth, and spontaneous abortion. RESULTS: We found that 1,004 women met the criteria and 187 (18.6%) had an SCH. In bivariate and multivariate regression models, there were no associations between SCH and the outcomes of live birth, preterm birth, or birth weight. CONCLUSIONS: Subchorionic hematoma detected on first-trimester ultrasound after IVF is not associated with probability of live birth, probability of preterm birth, or infant birth weight in this patient population.

Correction to: Effect of endometrial mechanical stimulation in an unselected population undergoing in vitro fertilization: futility analysis of a double-blind randomized controlled trial.

The original version of this article unfortunately contained mistakes. The complete list of corrections is given below.

Effect of endometrial mechanical stimulation in an unselected population undergoing in vitro fertilization: futility analysis of a double-blind randomized controlled trial.

PURPOSE: Implantation failure is a major limiting factor of successful in vitro fertilization (IVF). The objective of this study was to determine if endometrial mechanical stimulation (EMS) by endometrial biopsy in the luteal phase of the cycle prior to embryo transfer (ET) improves clinical outcomes in an unselected subfertile population. METHODS: Double-blind, randomized controlled trial of EMS versus sham biopsy and odds of clinical pregnancy after IVF and embryo transfer. Secondary outcomes included spontaneous miscarriage and live birth. RESULTS: One hundred women enrolled and were randomized from 2013 to 2017. Enrollment was terminated after futility analysis showed no difference in clinical pregnancy between EMS versus control, 47.2% vs 61.7% (OR 0.55, 95% CI 0.25-1.23, p = 0.15). There were no significant differences between women who underwent EMS and those who did not in terms of positive pregnancy test 54.7% vs 63.8% (OR 0.69, 95% CI 0.31-1.53, p = 0.36), miscarriage 7.5% vs 2.1% (OR 3.76 95% CI 0.41-34.85, p = 0.22), or live birth 43.4% vs 61.7% (OR 0.48 95% CI 0.21-1.06, p = 0.07). CONCLUSIONS: EMS in the luteal phase of the cycle preceding embryo transfer does not improve clinical outcomes in an unselected subfertile population and may result in a lower live birth rate. We caution the routine use of EMS in an unselected population.

Social media in the REI clinic: what do patients want?

PURPOSE: To elicit patient preferences for social media utilization and content in the infertility clinic. METHODS: This was a cross-sectional survey study conducted in three US fertility practices. Women presenting to the infertility clinic for an initial or return visit were offered an anonymous voluntary social media survey. The survey elicited patient perception of whether social media use in the infertility clinic is beneficial, and preferences regarding topics of interest. RESULTS: A total of 244 surveys were collected during the study period, of which 54.5% were complete. Instagram is a more popular platform than Twitter across all age groups. Use of both platforms varies by age, with patients ≥ 40 less likely to be active users. The majority of respondents felt that social media provided benefit to the patient experience in the infertility clinic (79.9%). "Education regarding infertility testing and treatment" and "Myths and Facts about infertility" were the most popular topics for potential posts, with 93.4 and 92.0% of patients endorsing interest respectively. The least popular topic was "Newborn photos and birth announcements," with only 47.4% endorsing interest. A little over half of respondents (56.3%) would feel comfortable with the clinic posting a picture of their infant. The vast majority of patients (96.2%) feel comfortable communicating electronically with their infertility clinic. CONCLUSION: Patients are interested in the use of social media as a forum for patient education and support in the infertility clinic. Patient preferences regarding post topics should be carefully considered.

Ultrasound-guided follicle aspiration at time of laparotomy in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To demonstrate a unique case of direct ultrasound-guided follicle aspiration at time of a laparotomy in a patient with Mayer-Rokitansky-Küster-Hauser Syndrome. DESIGN: Video presentation. SETTING: Academic fertility center PATIENT(S): A 32-year-old gravida 0 with Mayer-Rokitansky-Küster-Hauser Syndrome and bilateral ovarian masses presented as a fertility preservation consult from gynecologic oncology due to the possibility of bilateral oophorectomy. Due to the appearance and size of the left ovary oncology planned to perform an exploratory laparotomy and left oophorectomy, with possible right oophorectomy. The patient and her partner desired embryo cryopreservation with plans for future use in a gestational carrier. She had previously undergone vaginal dilator therapy, however her ovaries were inaccessible transvaginally due to their cephalad location and small caliber of the vaginal pouch. The plan was made to proceed with controlled ovarian stimulation and concurrent ultrasound-guided follicle aspiration of the right ovary at the time of laparotomy following left oophorectomy. INTERVENTION(S): Ultrasound-guided follicle aspiration in vivo at time of laparotomy. MAIN OUTCOME MEASURE(S): Successful controlled ovarian stimulation, oocyte retrieval and embryo cryopreservation. RESULT(S): The patient underwent a long agonist protocol and received a total of 2,525 units of gonadotropin with a peak estradiol of 3,264 pg/ml. She required a total of 9 days of stimulation. The normal right ovary responded as expected, and the left ovary remained unchanged. Following laparotomy and left oophorectomy, direct application of the transvaginal ultrasound probe was used to aspirate all visible follicles on the right side in vivo. Twenty-four oocytes were retrieved, 15 were mature and 5 blastocysts were cryopreserved. Final pathology of left ovary returned as serous cystadenoma. The right ovary was examined by gynecologic oncology prior to and following retrieval and was thought to be normal and remained in situ. CONCLUSION(S): Although the approach described here is not feasible in most cases, this video demonstrates a unique and successful fertility preservation technique by direct ultrasound-guided follicle aspiration in vivo at the time of laparotomy in a Mayer-Rokitansky-Küster-Hauser Syndrome patient and to our knowledge, is the first description of its kind. This retrieval would have otherwise been limited by lack of access transvaginally and limited visualization transabdominally. This combined approach should be considered in future patients with müllerian anomalies and similar complicating factors necessitating laparotomy.

Ovarian hyperstimulation syndrome management strategies: where are we going?

Ovarian hyperstimulation syndrome (OHSS) is one of the most frequent, serious and potentially lethal iatrogenic complications of controlled ovarian stimulation. Despite extensive research, the exact pathogenesis of this syndrome remains less clear, but there appears to be a relationship of increased vascular permeability mediated by HCG and other downstream mediators. Adequate experience with ovulation induction therapy and identifying patients with known risk factors are essential in preventing OHSS. As this is a completely iatrogenic disease numerous strategies have been investigated to help decrease the risk of OHSS and their effects on pregnancy and live birth rate. What follows is a review of the common strategies apply today to minimize risk of OHSS in patients undergoing assisted reproductive technologies.

Spanish language content on reproductive endocrinology and infertility practice websites.

OBJECTIVE: To analyze the use of Spanish language translation on the websites of reproductive endocrinology and infertility (REI) practices in the context of evidence of underuse of infertility services by minority populations. DESIGN: Cross-sectional survey of websites from REI practices. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Assessment of the relationship between having a Spanish-translated website and REI practice characteristics. Variables included concurrent use of social media, size of the practice, Spanish-speaking practitioner in the practice, being a private or a university-based practice, being in a mandated insurance state, and being in an area with different levels of percentage of Hispanic population, adjusted for annual income levels of the population. RESULT(S): Of the 376 REI practice websites analyzed, 101 (27%) offered at least some information in Spanish. We identified 97 Spanish-speaking practitioners at 71 REI practices. Having a Spanish-translated website was significantly associated with the practice's use of social media, having an international/out-of-town web page, and having a Spanish-speaking physician in the practice. The size of the practice, as measured in number of cycles reported per year, was not associated with having a translated website. In practices located in the top 60 metropolitan areas by Hispanic population, the odds of having a Spanish-translated website were only related to the percentage of Hispanic population after adjusting for state-mandated insurance and average annual income level of the Hispanic population. Sixty-six of the websites with Spanish-translated content had been automatically translated. An additional eight websites were partially translated automatically. CONCLUSION(S): REI practices in metropolitan areas with a higher percentage of Hispanics were more likely to reach out to this minority population by translating their website content into Spanish. These practices were also more likely to use social media. Future studies are needed to determine whether the availability of Spanish language content on REI websites is associated with increased use of reproductive services by this minority population.

Cycle cancellation and pregnancy after luteal estradiol priming in women defined as poor responders: a systematic review and meta-analysis.

STUDY QUESTION: Does a luteal estradiol (LE) stimulation protocol improve outcomes in poor responders to IVF? SUMMARY ANSWER: LE priming is associated with decreased cycle cancellation and increased chance of clinical pregnancy in poor responders WHAT IS KNOWN ALREADY: Poor responders to IVF are one of the most challenging patient populations to treat. Many standard protocols currently exist for stimulating these patients but all have failed to improve outcomes. STUDY DESIGN, SIZE, DURATION: Systematic review and meta-analysis including eight published studies comparing assisted reproduction technology (ART) outcomes in poor responders exposed to controlled ovarian hyperstimulation with and without LE priming. A search of the databases MEDLINE, EMBASE and PUBMED was carried out for studies in the English language published up to January 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: Studies evaluating women defined as poor responders to ART were evaluated. These studies were identified following a systematic review of the literature and data were analyzed using the DerSimonian-Laird random effects model. The main outcomes of interest were cycle cancellation rate and clinical pregnancy. Although the definition of clinical pregnancy varied between studies, the principal definition included fetal cardiac activity as assessed by transvaginal ultrasonography after 5 weeks of gestation. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 2249 publications were identified from the initial search, and the bibliographies, abstracts and other sources yielded 11 more. After excluding duplications, 1227 studies remained and 8 ultimately met the inclusion criteria. Compared with women undergoing non-LE primed protocols (n = 621), women exposed to LE priming (n = 468) had a lower risk of cycle cancellation [relative risk (RR): 0.60, 95% confidence interval (CI): 0.45-0.78] and an improved chance of clinical pregnancy (RR: 1.33, 95% CI: 1.02-1.72). There was no significant improvement in the number of mature oocytes obtained or number of zygotes obtained per cycle. LIMITATIONS, REASONS FOR CAUTION: These findings are limited by the body of literature currently available. As the poor responder lacks a concrete definition, there is some heterogeneity to these results, which merits caution when applying our findings to individual patients. Furthermore, the increased clinical pregnancy rate demonstrated when using the LE protocol may be principally related to the decreased cycle cancellation rate. WIDER IMPLICATIONS OF THE FINDINGS: The LE protocol may be of some utility in the poor responder to IVF and may increase clinical pregnancy rates in this population by improving stimulation and thereby decreasing cycle cancellation. STUDY FUNDING/COMPETING INTERESTS: NIH K12 HD063086 (ESJ, MGT), NIH T32 HD0040135-11 (KAR), F32 HD040135-10 NIH (KRO), 5K12HD000849-25 (PTJ). No competing interests.

Economic implications of insurance coverage for in vitro fertilization in the United States. A review.

OBJECTIVE: To analyze cost-effectiveness studies in regard to the costs of in vitro fertilization (IVF) and discuss specific economic trends that may affect the future utilization of IVF in the United States. STUDY DESIGN: Health economics. A Pub Med literature review and the Centers for Disease Control's (CDC) Fertility Clinic Success Rate registry served to access cost analyses and trends, respectively. RESULTS: The average cost of an IVF cycle in the U.S. is $9,226. Among policies that provide IVF services, the increase in premium per month ranges from $0.67 to $14. CONCLUSION: When IVF is provided as a health benefit, the cost increases can be variable. As utilization increases, contemporary cost analyses and outcomes research will aid providers, third-party payers and policymakers in better understanding the economic impact of lVF.