Psychological distress, vaccine, and booster acceptance in women considering or undergoing fertility treatments during the Omicron surge of the COVID-19 pandemic.

OBJECTIVE: Follow-up study to evaluate perceptions of COVID-19 vaccination and booster with psychological distress during the COVID-19 pandemic and Omicron surge in women considering or undergoing fertility treatment. MATERIALS AND METHODS: Cross-sectional anonymous survey (N = 2558) from a single academic fertility center. Five hundred forty patients completed the survey (response rate = 21.1%). Participants were randomized 1:1 to a one-page evidence-based graphic with information and benefits regarding COVID-19 vaccination. Mental health and vaccine hesitancy were assessed via the Patient Health Questionnaire Depression (PHQ-8), the Generalized Anxiety Disorder (GAD-7) scales, and the Medical Mistrust Index (MMI). RESULTS: Majority of participants were nulliparous, fully vaccinated with a booster dose, with > 1 year of infertility and mild to moderate distress. Patients with vaccine hesitancy had higher medical mistrust scores (r = .21,  p < .001). Higher MMI scores were not associated with vaccination during pregnancy. Participants that had higher PHQ-8 and GAD-7 scores were more likely to believe the omicron variant would cause delay in fertility treatments, would have impact on fertility outcome, and were more likely exhibiting medical system distrust (p < .001). Participants who received educational material were more likely to know pregnant women with COVID-19 had increased risk of death, stillbirth, and preterm birth (p < .05). CONCLUSION: The majority of women in this study were vaccinated and had received their booster dose but also with clinically significant levels of depression. Patients with higher levels of distress and greatest medical mistrust demonstrated a concern that the Omicron variant would delay treatment, lead to suboptimal fertility outcomes, and COVID-19 vaccination would impact risk of miscarriages.

Avi's Love-The Importance of Abortion Rights for Everyone.

This essay describes a physician's experience with terminating a wanted pregnancy and underscores the importance of access to abortion care.

Changing the "scope" of diagnosing endometriosis: the new frontier of noninvasive markers.

Endometriosis affects 1 in 9 women, and diagnosis is often delayed using conventional laparoscopy. Noninvasive markers of endometriosis have the potential to enable earlier diagnosis, leading to more timely treatment and better surgical planning. This issue's Views and Reviews seek to summarize the current status of noninvasive markers of endometriosis. Experts in reproductive medicine with prior work in this field summarize the key literature on endometrial biomarkers, blood biomarkers, and advanced imaging, including ultrasound and magnetic resonance imaging. At present, there is no single definitive biomarker that can diagnose endometriosis with high sensitivity and specificity. Advancing endometriosis biomarkers beyond the discovery phase is challenging, and more work is needed. Clinicians who have an improved understanding of noninvasive imaging and biomarkers will be able to identify endometriosis earlier and more easily, allowing for prompt consideration of treatment options. We believe that continued research, innovation, and development will lead to improved diagnostic accuracy and guidance toward the best treatments for endometriosis-related pain and infertility.

Do gender differences exist in letters of recommendation for reproductive endocrinology and infertility fellowship?

OBJECTIVE(S): To determine if gender differences exist in letters of recommendation (LORs) for reproductive endocrinology and infertility fellowship. DESIGN: Cohort study. SETTING: Academic medical center. PATIENTS: A cohort of applicants to a reproductive endocrinology and infertility fellowship program at a single Midwestern academic institution in a single year. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Quantitative measures included linguistics inquiry and word count analysis, with 4 summary variables and 25 word categories, to quantify tone and themes present by gender. Performing qualitative analysis in parallel to linguistic analysis allowed for the exploration of themes not conveyed in quantitative methods alone. Qualitative measures included the frequency of code themes in LOR by applicant gender. RESULTS: There were 272 letters from 72 applicants, 54 (76%) of which were women and 17 (24%) were men. One applicant was excluded because gender information was not specified; 269 letters were included in the quantitative linguistics and qualitative coding analysis. One hundred 10 letters (41%) were written by women and 159 (59%) by men. LOR written for men had a higher mean word count than those written for women (537 vs. 474, P=.04). Linguistics Inquiry and Word Count analysis exhibited more risk words used to describe men applicants (P=.01). When comparing word categories by letter writer gender, women letter writers more frequently used communal, affect, and home word categories whereas men writers more frequently used affiliation-related words. Qualitative analysis revealed that letters for men applicants described leadership, altruism, rapport with patients, and strong endorsements more frequently, whereas women applicants' letters more often mentioned doubt raisers and disclosures of personal life. In addition, letters for women applicants more often described candidates as drama free, not easy to "fluster," and not complainers. Furthermore, letters for women more frequently disclosed parenthood status. CONCLUSIONS: Gender differences exist among both letter writers and applicants. Qualitative analysis revealed that women applicants were more likely to be described with doubt raisers and personal life disclosures, whereas men were more likely to be described by their altruism and with a strong endorsement. Increasing bias awareness and implementing mitigation strategies would improve gender equity in LOR.

Validation of prognosis-based in vitro fertilization grant selection criteria.

Objective: To validate a prognosis-based scoring system for in vitro fertilization (IVF) grant allocation. Design: Retrospective cohort study. Setting: A 501(c)(3) nonprofit foundation that awards donated IVF cycles and grants to those with demonstrated financial need. In contrast to lottery-based or subjective allocation systems, applications are scored according to medical prognostic criteria in addition to personal characteristics. Patients: Grant recipients from 2015 to 2019. Interventions: None. Main outcome measures: Live birth rate (LBR) and cumulative LBR (CLBR) among grant recipients were compared with 2019 Society for Assisted Reproductive Technology (SART) national averages. Results: A total of 435 applications were reviewed, with 59 grants awarded for 51 autologous IVF cycles, 6 donor oocyte cycles, and 2 gestational carrier cycles, resulting in 39 live births after initial embryo transfer (LBR 61.9%) and 43 CLBRs (CLBR 72.9%). Among autologous cycles, the mean (±SD=3.9 years) age was 31.8 years, and LBR and CLBR were 62.8% and 68.6% vs. 28.2% and 37.1% among all autologous SART cycles, respectively. A subanalysis of grant recipients aged <35 years (n=39) revealed LBR and CLBR of 66.7% and 74.4% vs. 40.7% and 47.8% among autologous SART cycles aged <35 years, respectively. Conclusions: A scoring system incorporating medical criteria identified IVF grant applicants with a high likelihood of achieving a LB. Although most IVF grant programs select recipients through a lottery or personal characteristics, a prognosis-based scoring system should be considered to maximize LBR in a limited resource setting.

Childbearing, Infertility, and Career Trajectories Among Women in Medicine.

Importance: Although women are increasingly represented within medicine, gender disparities persist in time to promotion, achievement of academic rank, and appointment to leadership positions, with no narrowing of this gap over time. Career-specific fertility and family building challenges among women physicians may contribute to ongoing disparities and academic attrition. Objective: To evaluate delayed childbearing and infertility among women in medicine and investigate the extent to which women physicians may alter career trajectories to accommodate family building and parenthood. Design, Setting, and Participants: This survey study was conducted among women physicians, with surveys distributed through medical society electronic mailing lists (listserves) and social media from March to August 2022. Main Outcomes and Measures: Baseline demographic information and fertility knowledge were assessed. Descriptive data on delayed childbearing, infertility, use of assisted reproductive technology, and career alterations to accommodate parenthood were collected. Factors associated with timing of pregnancy and family building regret were assessed using Likert-type scales. Group differences in fertility knowledge, delayed childbearing, infertility, and family building regret were evaluated using χ2 analyses. Results: A total of 1056 cisgender women (mean [SD] age, 38.3 [7.7] years) were surveyed across level of training (714 attending physicians [67.6%] and 283 residents or fellows [26.8%]), specialty (408 surgical [38.6%] and 638 nonsurgical [60.4%] specialties), and practice setting (323 academic [45.2%], 263 private [24.9%], and 222 community [21.0%] settings). Among respondents, 1036 individuals [98.1%] resided in the US. Overall, 910 respondents (86.2%) were married or partnered and 690 respondents (65.3%) had children. While 824 physicians (78.0%) correctly identified the age of precipitous fertility decline, 798 individuals (75.6%) reported delaying family building and 389 individuals (36.8%) had experienced infertility. Concerning measures taken to accommodate childbearing or parenthood, 199 women (28.8%) said they had taken extended leave, 171 women (24.8%) said they had chosen a different specialty, 325 women (47.1%) said they had reduced their work hours, 171women (24.8%) said they had changed their practice setting, and 326 women (47.2%) said they had passed up opportunities for career advancement among those with children. Additionally, 30 women with children (4.3%) had left medicine entirely. Conclusions and Relevance: In this survey study, women physicians reported that career-related pressures influenced the timing of childbearing and led to marked alterations to career trajectories to accommodate family building and parenthood. These findings suggest that fertility and family building concerns among women in medicine may contribute to ongoing gender disparities and attrition and represent a potentially critical area for policy reform and future change.

REI clinics and fellowship training-a national snapshot to improve access to reproductive care.

PURPOSE: To analyze the geographic distribution of REI fellowships and clinics across the USA and to strategize ways to improve patient access to care. METHODS: Cross-sectional study using population data obtained from publicly available United States Census Bureau, Society for Assisted Reproductive Technology (SART), and National Resident Matching Program websites. Outcomes include the number of REI clinics, REI fellowship-trained physicians, and REI fellowship programs. RESULTS: In 2020, there were 643 assisted reproductive technology (ART) clinics reporting to SART and 1351 fellowship-trained REI physicians. Most clinics are located in the south (n = 209); however, the northeast has the highest density of REI clinics. Out of 301,316 in vitro fertilization (IVF) cycles in the USA in 2020, northeastern states initiated the most cycles (n = 93,565), and Midwestern states initiated the fewest cycles (n = 50,000). The northeast has the most REI physicians per million women aged 20-44 years (42.4) while the Midwest has the lowest ratio (19.5). There are fewer REI physicians per million women aged 20-44 years in states with a lower proportion of patients with health insurance (r = 0.56, 95% confidence interval ([CI] 0.34-0.73) and in states with a lower average income per resident (r = 0.65, 95% CI 0.46-0.79). Most of the 49 accredited REI fellowship programs in the USA are in the northeast (n = 18), and there are fewest in the south (n = 10) and west (n = 10). CONCLUSION: Access to REI care has large geographic disparities from a clinic, physician, and training program perspective. Creative solutions are needed to remedy this problem.

Anxiety, attitudes, and education about fertility among medical students in the United States.

BACKGROUND: As delayed family building is common among physicians, the goal of this study was to evaluate childbearing plans, anxiety related to future fertility, and interest in fertility education among medical students. METHODS: Using convenience and snowball sampling methods, an electronic REDCap survey was distributed via social media and group messaging applications to medical students enrolled in medical schools across the United States. Answers were collected, and analysis of the descriptive statistics was performed. RESULTS: The survey was completed by 175 participants, 72% of which were female (assigned at birth). The mean (± SD) age of participants was 24.9 ± 1.9 years. Of all participants, 78.3% desire to have children and 65.1% of these individuals plan to delay childbearing. On average, the planned age of first pregnancy is 31.0 ± 2.3 years. "Lack of time" was the greatest influence on decision regarding timing of childbearing. Of all respondents, 58.9% reported at least some anxiety related to future fertility. When females and males were compared, significantly more females (73.8%) versus males (20.4%) reported worrying about future fertility (p < 0.001). Participants reported that greater knowledge about infertility and potential treatments would help ease fertility related anxiety, and 66.9% of respondents showed interest in learning about how things such as age and lifestyle can impact fertility, preferably through medical curricula, videos, and podcasts. CONCLUSION: A majority of the medical students in this cohort intend to have children and most plan to delay childbearing. A large percentage of female medical students reported anxiety related to future fertility, but many students showed interest in receiving fertility education. This study highlights an opportunity for medical school educators to incorporate targeted fertility education into their curriculum with the intention of decreasing anxiety and improving future reproductive success.

Undergraduate students have low fertility knowledge and high anxiety regarding future fertility: An opportunity for education.

Objectives: To assess childbearing intentions, concerns about future fertility, knowledge about the age-related decline in fertility, and interest in receiving fertility education among undergraduate students. Design: From March to April 2021, a cross-sectional, web-based survey with 42 reproductive and fertility-related questions was administered to and completed by actively enrolled undergraduates at Northwestern University in the United States. Results: The survey was completed by 291 students (mean age 20.2 years). Of all participants, 62.5% plan to have children and 68.3% intend to delay childbearing. Significantly more females than males (70.7% vs 40.9%, P = 0.004) and premedical students compared to non-premedical students (78.2% vs 60.1%, P = 0.002) reported planning to delay childbearing due to educational or career aspirations. Significantly more females than males (43.5% vs 4.5%, P < 0.001) and premedical compared to non-premedical students (50.4% vs 31.5%, P = 0.002) also reported having anxiety about future fertility due to career aspirations.When surveyed about fertility knowledge, 31.1% of participants reported that females are as fertile in their forties as they are in their thirties, and 25.4% stated that female fertility does not dramatically decline until age 40 or later. When asked to estimate the oldest age a woman has conceived using autologous oocytes, 83.3% reported age 48 or older. Of all participants, 72.3% were interested in learning about fertility. Conclusions: The majority of surveyed undergraduates plan to delay childbearing, yet they have concerns about how career goals will impact future fertility. Notably, females and premedical students reported higher rates of anxiety when compared to their male and non-premedical counterparts. Knowledge about the age-related decline in fertility was limited, but students have a strong interest in learning about fertility, highlighting an opportunity for educational intervention at the undergraduate level. With education, students may be empowered to make informed decisions about future reproductive strategy earlier in time, potentially decreasing future anxiety.

Vaccine hesitancy, distress, and medical mistrust in women considering or undergoing fertility treatment during the COVID-19 pandemic.

OBJECTIVE: To evaluate perceptions of COVID-19 vaccination and psychological distress during the COVID-19 pandemic in women considering or undergoing fertility treatment. MATERIALS AND METHODS: Cross-sectional anonymous survey (n= 3558) from a single academic fertility center. A total of 1103 patients completed the survey (response rate = 31% of those emailed, 97.6% of those who opened the email). Participants were randomized 1:1 to a one-page educational graphic providing facts and benefits regarding COVID-19 vaccination. Assessment of vaccine hesitancy was conducted via the Medical Mistrust Index (MMI). Mental health was assessed via the Patient Health Questionnaire Depression Scale (PHQ-8) and the Generalized Anxiety Disorder-7 (GAD-7). RESULTS: The majority of participants were married, nulliparous, white women with > 1 year of infertility and moderate to severe distress. As compared to the non-intervention group, participants in the intervention group believed that COVID-19 vaccination does not cause genetic abnormalities in a fetus (98.0% v. 94.2%) and infertility (99% v. 96.2%) and that severe infection has been associated with pregnancy (81.3% v. 74.6%) (P <0.05). Higher MMI scores were associated with vaccine hesitancy (P = 0.01), higher GAD-7 scores (P = 0.01), and greater concerns about side effects of the vaccine (P < 0.05). GAD-7 and PHQ-8 scores were not associated with vaccine hesitancy. Nearly a quarter of participants initiated psychiatric treatment after March 2020. CONCLUSION: Vaccine hesitancy was associated with mistrust of the medical system. Psychological distress was highly prevalent in this study. Efforts should be made to improve patient trust and provide psychological support for fertility patients.

Embryo transfer-the who, what, when, how, and why does it matter?

Embryo transfer is the ultimate step in the in vitro fertilization process and is the culmination of months to years of preparation. Many factors contribute to embryo transfer success before, during, and after the transfer. This series is a comprehensive review of the factors that converge to influence embryo transfer success. Robust discussion is included regarding the impact of the physician who performs the transfer, adjunct therapies used, timing of embryo transfer, endometrial receptivity, and resultant health of the pregnancy and offspring.

A SART data cost-effectiveness analysis of planned oocyte cryopreservation versus in vitro fertilization with preimplantation genetic testing for aneuploidy considering ideal family size.

OBJECTIVE: To determine the cost-effectiveness of planned oocyte cryopreservation (OC) as a strategy for delayed childbearing to achieve 1 or 2 live births (LB) compared with in vitro fertilization (IVF) and preimplantation genetic testing for aneuploidy (PGT-A) at advanced reproductive age. DESIGN: Decision tree model with sensitivity analyses using data from the Society for Assisted Reproductive Technology Clinical Outcome Reporting System and other clinical sources. SETTING: Not applicable. PATIENT(S): A data-driven simulated cohort of patients desiring delayed childbearing with an ideal family size of 1 or 2 LB. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Probability of achieving ≥1 or 2 LB, average and maximum cost per patient, cost per percentage point increase in chance of LB, and population-level cost/LB. RESULT(S): For those desiring 1 LB, planned OC at age 33 with warming at age 43 decreased the average total cost per patient from $62,308 to $30,333 and increased the likelihood of LB from 50% to 73% when compared with no OC with up to 3 cycles of IVF/PGT-A at age 43. For those desiring 2 LB, 2 cycles of OC at age 33 and warming at age 40 yielded the lowest cost per patient and highest likelihood of achieving 2 LB ($51,250 and 77%, respectively) when compared withpursuing only 1 cycle of OC ($75,373 and 61%, respectively), no OC and IVF/PGT-A with embryo banking ($79,728 and 48%, respectively), or no OC and IVF/PGT-A without embryo banking ($79,057 and 19%, respectively). Sensitivity analyses showed that OC remained cost-effective across a wide range of ages at cryopreservation. For 1 LB, OC achieved the highest likelihood of success when pursued before age 32 and remained more effective than IVF/PGT-A when pursued before age 39, and for 2 LB, 2 cycles of OC achieved the highest likelihood of success when pursued before age 31 and remained more effective than IVF/PGT-A when pursued before age 39. CONCLUSION(S): Among patients planning to postpone childbearing, OC is cost-effective and increases the odds of achieving 1 or 2 LB when compared with IVF/PGT-A at a more advanced reproductive age.

Data-driven commentary on SARS-CoV-2 infection, vaccination, and fertility.

A recent study by Wesselink et al. (Am J Epidemiol. 2022 Jan 20;kwac011. doi: 10.1093/aje/kwac011. Online ahead of print) adds to the growing body of research finding that vaccination for coronavirus disease 2019 (COVID-19) is safe for individuals either seeking pregnancy or who are pregnant. The study's authors found no effect of COVID-19 vaccination on fecundity in a population of individuals with no known infertility who were attempting conception. The finding reinforces the messaging of the American Society for Reproductive Medicine COVID-19 Task Force, the aim of which is to provide data-driven recommendations to individuals contemplating pregnancy in the face of the COVID-19 pandemic. As safe and effective COVID-19 vaccines became available, and with an increasing number of studies showing a heightened risk of severe disease during pregnancy, an important role of the Task Force is to encourage vaccination during the preconceptual window and in early pregnancy. The Task Force supports ongoing research to address gaps in knowledge about safe and effective therapies and preventive measures for individuals contemplating pregnancy and during pregnancy. Such research will help optimize care for reproductive-age individuals in the face of current and future health crises.

Roe v Wade and the Threat to Fertility Care.

On June 24, 2022, the U.S. Supreme Court ruling in Dobbs v Jackson Women's Health overturned Roe v Wade , and authority to regulate abortion was returned to individual states. It is critically important for all physicians to understand the implications that this ruling may have on reproductive autonomy with regard to abortion care and in vitro fertilization (IVF). Although the intended consequence of abortion bans is to prohibit legal abortion, one unintended consequence may be undue restriction of in vitro fertilization. We summarize the potential of abortion bans, particularly those with personhood clauses, to affect IVF practice. We detail the implications of these bans on embryo cryopreservation, preimplantation genetic testing, single embryo transfer, and access to infertility treatments. In the United States in 2019, nearly 84,000 children were born as a result of IVF (2.2% of all births), and nearly 250,000 IVF cycles were performed. These bans will have a profound effect beyond abortion, and these implications are not widely understood in the medical community.