Social egg freezing: Motivations, treatment experiences and the impact of Covid-19 - a single-center experience.

INTRODUCTION: This study aims to assess the motivations and treatment experiences of women undergoing social egg freezing and to understand the impact of the Covid-19 pandemic. MATERIAL AND METHODS: Between January 2011 to December 2021, 191 social egg freezing patients were recruited from the Lister Fertility Clinic, London UK. Participants completed a validated questionnaire investigating patients' perspectives of social egg freezing. A response rate of 46.6% was achieved. RESULTS: In all, 93.9% of women expressed concern regarding age-related fertility decline which influenced their decision to undergo social egg freezing. The majority (89.5%) of women were not in a relationship at the time of social egg freezing and considered this a motivating factor. Also, 39.0% of participants had side effects related to treatment which affected work and social life. Participants were significantly more likely to experience side effects if they underwent multiple egg freezing cycles (χ2 , p < 0.01) or if they cryopreserved oocytes during the COVID-19 pandemic (χ2 , p < 0.05). Of the women, 64.0% wished to have cryopreserved oocytes at a younger age, a view significantly more likely if older than 37 years at first social egg freezing cycle (χ2 , p < 0.001). Also, 82.3% of women reported their decision to undergo social egg freezing was not delayed due to concerns regarding COVID-19 exposure during treatment; 44.1% considered the pandemic made them more willing to undergo social egg freezing. CONCLUSIONS: Most participants did not regret their decision to undergo social egg freezing but the majority wished they had cryopreserved oocytes at a younger age. This highlights the importance of early education to optimize outcomes and patient choice. The egg freezing process can be stressful, women may have concerns around social egg freezing and unprecedented situations such as the COVID-19 pandemic may alter treatment experience.

Age-related fertility decline: is there a role for elective ovarian tissue cryopreservation?

Age-related fertility decline (ARFD) is a prevalent concern amongst western cultures due to the increasing age of first-time motherhood. Elective oocyte and embryo cryopreservation remain the most established methods of fertility preservation, providing women the opportunity of reproductive autonomy to preserve their fertility and extend their childbearing years to prevent involuntary childlessness. Whilst ovarian cortex cryopreservation has been used to preserve reproductive potential in women for medical reasons, such as in pre- or peripubertal girls undergoing gonadotoxic chemotherapy, it has not yet been considered in the context of ARFD. As artificial reproductive technology (ART) and surgical methods of fertility preservation continue to evolve, it is a judicious time to review current evidence and consider alternative options for women wishing to delay their fertility. This article critically appraises elective oocyte cryopreservation as an option for women who use it to mitigate the risk of ARFD and introduces the prospect of elective ovarian cortex cryopreservation as an alternative.

Uterine Transplantation in 2021: Recent Developments and the Future.

Uterine transplantation has evolved rapidly over the last decade. As the number of cases performed increases exponentially worldwide, emerging evidence continues to improve collective knowledge and understanding of the procedure, with the aim of improving both surgical and reproductive outcomes. Although currently restricted to women with absolute uterine factor infertility, increasing awareness as a method of fertility restoration has resulted in a demand for the procedure to be undertaken in transgender women. This manuscript summarizes the recent advances in uterine transplantation, and elaborates further upon the key novel avenues research within the field will focus on over the coming years.

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.

Novel use of COMET parameters of sperm DNA damage may increase its utility to diagnose male infertility and predict live births following both IVF and ICSI.

STUDY QUESTION: Do the Comet parameters of the proportions of sperm with low or high DNA damage improve the power of the test in the diagnosis of male infertility and/or prediction of IVF and ICSI live birth rates? SUMMARY ANSWER: The mean Comet score and the scores for proportions of sperm with high or low DNA damage were useful in diagnosing male infertility and provided additional discriminatory information for the prediction of both IVF and ICSI live births. WHAT IS KNOWN ALREADY: Sperm DNA damage impacts adversely on male fertility and IVF outcomes. STUDY DESIGN, SIZE, DURATION: A retrospective study was performed involving a total of 457 participants (381 patients and 76 fertile donors). Data was collected from a fertility clinic between 2015 and 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 381 consecutive male partners of couples attending for ART and 76 fertile donors were included in the study. DNA fragmentation was measured by the alkaline Comet assay. Receiver operator characteristic curve analysis (area under the ROC curve (AUC)) was used to determine the value of average Comet score (ACS), low Comet score (LCS) and high Comet score (HCS) to diagnose male factor infertility. In total, 77 IVF and 226 ICSI cycles were included to determine thresholds for each parameter (AUC analysis) and to compare live birth rates (LBRs) following each ART. MAIN RESULTS AND THE ROLE OF CHANCE: ACS, HCS and LCS were predictive of male infertility (AUC > 0.9, P < 0.0001). IVF LBRs declined once DNA damage exceeded the threshold levels. HCS showed the sharpest decline. Following ICSI, the highest LBRs were in men whose DNA damage levels approached the fertile range. Trends differed in IVF. LBRs decreased as damage increased whereas in ICSI the LBRs decreased but then remained stable. LIMITATIONS, REASONS FOR CAUTION: Since this is the first study to show the impact of sperm DNA damage on ICSI live births, a prospective study should be performed (stratifying patients to IVF or ICSI based on these thresholds) to validate this study. WIDER IMPLICATIONS OF THE FINDINGS: Our study presents novel information towards elucidating the genetic basis of male infertility and secondly on relevance of the extent of DNA damage as an impending factor in both IVF and ICSI success. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by Examenlab Ltd, The Lister Clinic, Cryos International and Imperial College London NHS Trust. No external funding was obtained for this study. SL and KL are employees of Examenlab Ltd, a university spin-out company with a commercial interest in sperm DNA damage. No other author has a conflict of interest to declare. TRIAL REGISTRATION NUMBER: Non-applicable.

Treatment and preservation at the extremes of reproductive age: a case report outlining the ethical dilemmas.

PURPOSE: The purpose of the study was to report a livebirth from a cryopreserved embryo created from autologous oocytes collected at 47 years and 9 months that outlines the ethical difficulties of decision-making at the extreme of reproductive age. METHODS: The method used was IVF and embryo cryopreservation within an assisted conception unit prior to adjuvant cancer treatment in a nulliparous patient diagnosed with breast carcinoma (47 years and 9 months at oocyte collection). RESULTS: A 47-year-old nulliparous woman was diagnosed with breast malignancy during work-up for fertility treatment. Ovarian stimulation yielded one embryo from four oocytes that was cryopreserved to allow completion of adjuvant treatment. Subsequent embryo transfer cycle led to a live birth of a healthy baby girl at term, weighing 3.37 kg. CONCLUSION: This paper demonstrates the oldest reported age of autologous oocyte collection to have achieved a livebirth. In women where most would consider treatment futile, we highlight the difficulties in decision-making in this group of patients.

Case reports to suggest an algorithm for management of total fertilisation failure prior to use of donor gametes.

PURPOSE: Total fertilisation failure (TFF), even with intracytoplasmic sperm injection (ICSI), occurs in approximately 3 % of cycles, can be recurrent and the exact cause is difficult to elucidate. Differentiation between oocyte and sperm-related cause of TFF is possible using mouse oocyte-activation techniques, but is not an option within most clinical settings. Therefore, the management of these couples is clinically driven, and the endpoint, if recurrent, is often the use of donor gametes. However, with the invariable lack of a definitive cause of TFF, any decision between the use of donor sperm or oocytes remains an emotive one. We present two case reports demonstrating the importance of appropriate investigation, activation techniques (mechanical and chemical) and clinical management options to develop a clinical algorithm prior to the use of donor gametes. METHODS: This study is composed of two case reports of assisted reproduction investigation and treatment within an assisted conception unit for couples with recurrent total fertilisation failure. RESULTS: Using appropriate investigation (endocrine, urological and embryological) and treatments (ICSI, IMSI, oocyte-activation techniques), a fertilisation rate of 48 % was achieved in two cycles in couples following a total of nine previous cycles (and 200 previously collected eggs) with TFF. CONCLUSIONS: Oocyte activation requires the triggering of intracellular calcium oscillations by the release of a sperm-specific factor (phospholipase C zeta (PLCζ)) into the oocyte cytoplasm. Although, PLCζ deficiencies have been demonstrated as putative causes of failed activation, impaired oocyte responsiveness may also be a factor. The use of donor gametes is often recommended and is often the required endpoint of treatment. However, these reports outline a clinical algorithm that potentially offers success without donation, and also offers a systematic approach to help decide whether donor oocytes or sperm should be recommended.

Does egg-sharing negatively impact on the chance of the donor or recipient achieving a live birth?

This study aimed to discover whether egg sharing compromises the chance of donors or recipients achieving a live birth. A descriptive cohort study was performed of 4,545 fertility patients and 5,316 stimulation cycles at a London based fertility clinic between 2010 and 2019. There was no significant difference in clinical pregnancy rate (CPR) or live birth rate (LBR) between egg sharers and standard IVF patients or between egg sharing recipients and non-egg sharing recipients. Both egg sharers and their recipients had fewer oocytes and fewer day 3 embryos available for fresh embryo transfer or cryopreservation than standard IVF patients or non-egg sharing recipients. The cumulative LBR were significantly lower amongst egg sharers than standard IVF patients (p < 0.05), and significantly lower amongst egg sharing recipients than non-egg sharing recipients (p < 0.05). This study demonstrates that egg sharing does not compromise the chances of donors or their recipients achieving a live birth. However, participants may occasionally require additional ovarian stimulation cycles to conceive. With government funding for IVF treatment falling, egg sharing provides a practical option to allow more women access to IVF. Egg sharing is currently the most efficient way of maximising the use of the precious resource of human oocytes.

The Clinical Application of Platelet-Rich Plasma in the Female Reproductive System: A Narrative Review.

Platelet-rich plasma is an autologous plasma containing platelets prepared from fresh whole blood drawn from a peripheral vein. Through processing, it can be prepared to contain supraphysiologic levels of platelets at three to five times greater than the level of normal plasma. PRP has been explored both in vivo and ex vivo in the human endometrium model in its ability to harness the intrinsic regenerative capacity of the endometrium. Intrauterine autologous PRP infusions have been shown to increase endometrial thickness and reduce the rate of intrauterine adhesions. In the setting of recurrent implantation failure, intrauterine infusion of PRP has been shown to increase clinical pregnancy rate. PRP also appears to hold a potential role in select patients with premature ovarian insufficiency, poor ovarian responders and in improving outcomes following frozen-thawed transplantation of autologous ovarian tissue. Further studies are required to explore the potential role of PRP in reproductive medicine further, to help standardise PRP protocols and evaluate which routes of administration are most effective.

Fertility preservation and realignment in transgender women.

Medical care for transgender people is multi-faceted and attention to individual reproductive aspirations and planning are an essential, yet often overlooked aspect of care. Given the impact of hormonal therapy and other gender affirmation procedures on reproductive function, extensive counselling and consideration of fertility preservation is recommended prior to their commencement. This review article explores the reproductive aspirations of transgender women and considers the current disparity between stated desires regarding utilisation of fertility preservation services. Current fertility preservation options and prospective treatments currently showing promise in the research arena are explored.

INvestigational Study Into Transplantation of the Uterus (INSITU): a cross-sectional survey among women with uterine factor infertility in the UK assessing background, motivations and suitability.

IMPORTANCE: The study summarises the selection prescreen criteria currently used in the UK for a uterus transplant and highlights the number of women who are suitable to proceed. OBJECTIVES: To assess the demographics, motivations, reasons and suitability among women with absolute uterine factor infertility (AUFI) to undergo uterine transplantation (UTx). DESIGN: A cross-sectional survey. SETTING: An electronic questionnaire was sent via email to women with AUFI who had previously been referred to the UTx research team or approached the Womb Transplant UK Charity. The questions assessed suitability to undergo UTx based on demographic information, perceptions to adoption and surrogacy and reasons why UTx was preferable. Responses were assessed against the study selection criteria. PARTICIPANTS: Women with AUFI. RESULTS: 210 women completed the questionnaire. The most common aetiology of AUFI in our cohort was Mayer-Rokitansky-Küster-Hauser (68%; n=143) whereas 29% (n=62) had previously undergone hysterectomy. 63% (n=132) of the cohort had previously considered adoption, 5% (n=11) had attempted it and 2 (1%) had successfully adopted. The most common reason cited to undergo UTx over adoption was to experience gestation (n=63; 53%), while 37% (n=44) wanted a biologically related child. 76% (n=160) of participants had previously considered surrogacy, 22 (10%) had attempted it and 2 (1%) had successfully become mothers using a surrogate. The most common reason to undergo UTx over surrogacy was to experience gestation (n=77; 54%). 15% (n=21) were concerned about the legal implications, 14% (n=20) identified the financial cost as a barrier and 8% (n=12) could not consider it due to religious reasons. On adhering to the selection criteria, 65 (31%) women were suitable to proceed with the trial. CONCLUSION: The study demonstrates that implementing commonly used selection criteria for a UTx led to an attrition rate of more than two-thirds of women who requested to initially undergo the process. As more studies present outcomes following UTx, critical assessment of the selection criteria currently used is warranted to ensure potential recipients are not being unnecessarily excluded. TRIAL REGISTRATION NUMBER: NCT02388802.

A decade of sperm washing: clinical correlates of successful insemination outcome.

BACKGROUND: Since 1999, we have treated HIV-positive men with sperm washing as part of a risk-reduction programme. METHODS: Retrospective analysis of the sperm-washing database from the treatment of 245 couples with 439 cycles of intrauterine insemination assessed the effects of patient factors (age, maternal FSH, rank of attempt), markers of HIV-disease [time since diagnosis, CD4 count, viral load (VL), use of highly active antiretroviral therapy (HAART)], cycle factors (natural versus stimulated, number of follicles, fresh versus frozen sperm) and sperm parameters on clinical (CPR) and ongoing pregnancy rate (OPR). RESULTS: Overall 111-245 (45.4%) couples achieved a clinical pregnancy (CPR: 13.5% and OPR: 9.6% per insemination) with no seroconversions. The mean duration since HIV diagnosis was 5.8 years, 73% of men were on antiretroviral therapy, there was an undetectable VL in 64% and the median CD4 was 409 cells/mm(3). A significantly decreased OPR and a non-significantly increased miscarriage rate (MR) was observed after the female age of 40. Similarly, there was a significant increased OPR and decreased MR for women with a mean cycle maternal FSH of <6.4 IU/l. There was no effect of VL, CD4 count, use of HAART or time since diagnosis on the outcome. Nor was there a difference in the OPR according to paternal age, rank of attempt, cycle regime or number of follicles. Semen volume, sperm concentration, total count and progressive motility and post-wash concentration, progressive motility and total motile count inseminated were significantly higher in successful cycles. The use of frozen sperm had a significant negative impact on outcome. CONCLUSIONS: This study of the potential safe and successful reproductive options available to HIV-positive men demonstrates that maternal age and semen quality, rather than HIV factors, remain the most important determinants of cycle success.

Reporting on longitudinal live birth rates and cumulative delivery rates are more realistic outcome measures than sperm retrieval rates in couples undergoing mTESE-ICSI.

The live birth rates (LBRs) in men with non-obstructive azoospermia (NOA) undergoing microdissection TESE (mTESE) are under reported, with surgical sperm retrieval rate often used as the primary outcome measure. We analysed longitudinal and cumulative delivery rates following mTESE- intracytoplasmic sperm injection (ICSI) in NOA. Sperm was retrieved in 45% of patients undergoing mTESE. Median male and female age were 42 years (IQR 37-47) and 35 years (IQR 31-38) respectively. A total of 141 ICSI cycles and 23 frozen embryo transfers resulted in 62 pregnancies and 37 LBRs. The longitudinal LBR, crude and expected cumulative delivery rates after five cycles were 15.5%, 48.7% and 71.1%, respectively. Reassuringly, there was no significant difference in pregnancy rate (PR) (p = 0.37) or LBR (p = 0.68) using fresh or frozen sperm or embryo (p = 0.74). Sperm retrieval was significantly correlated with Johnsen score (JS) (p = 0.006) and hypospermatogenesis (HS) (p = 0.04), whilst LBR only significantly correlated with female age (p = 0.04). The longitudinal LBR for a couple embarking on mTESE for azoospermia is only 15.5%, although the cumulative delivery rates are promising. Reassuringly, the outcomes using fresh versus frozen embryos or sperm are comparable. Reporting on delivery rates from a single mTESE procedure are more objective and realistic measures of treatment success in men with NOA.

Sperm DNA fragmentation in subfertile men: the effect on the outcome of intracytoplasmic sperm injection and correlation with sperm variables.

OBJECTIVE: To present the first UK data on sperm DNA fragmentation levels in subfertile men and fertile controls, the correlation with semen variables, and to assess the effect on the outcome of intracytoplasmic sperm injection (ICSI). PATIENTS, SUBJECTS AND METHODS: In all, 56 subfertile men undergoing ICSI (28 with positive and 28 with a negative outcome for paternity) and 10 control fertile semen donors were recruited. The sperm DNA fragmentation index (DFI) was assessed on raw pre-preparation samples using the sperm chromatin structure assay. A mean of 5212 sperm were analysed per sample and DFI data are presented by fertility status, ICSI outcome and correlated with semen variables (assessed using World Health Organisation criteria). RESULTS: Total DFI was significantly higher in subfertile men than in fertile controls (mean and median of 22.8% and 17.0% vs 8.4% and 5.0%; P < 0.001), as was the proportion of both moderate DFI (16.4% and 13.0% vs 6.4% and 4.0%; P = 0.001) and high DFI (6.2% and 6.1 vs 2.0% and 1.0%; P = 0.01). This difference remained significant when the control men were compared only with the subfertile men with successful paternity. There was no significant difference in DFI in the subfertile men when analysed by ICSI outcome (mean and median of 24.5% and 17.0% vs 22.3% and 21.0% for successful and unsuccessful cycles, respectively; P = 0.94). There was a positive statistically significant correlation (r = 0.37; P = 0.02) between the DFI and sperm morphology. CONCLUSIONS: This study confirms a relationship between male subfertility and sperm DFI; we discuss the correct role for genetic testing of sperm in the evaluation of subfertile men. Although DNA fragmentation data might help to decide a suitable treatment, once it is decided to proceed with ICSI, DFI levels have no effect on the outcome.

Effect of time since vasectomy and maternal age on intracytoplasmic sperm injection success in men with obstructive azoospermia after vasectomy.

OBJECTIVE: To determine the effects of time since vasectomy and maternal age on intracytoplasmic sperm injection (ICSI) outcome in azoospermic men after vasectomy. DESIGN: Retrospective analysis. SETTING: Assisted conception unit. PATIENT(S): Thirty-seven azoospermic men (after vasectomy) who were undergoing 56 cycles of ICSI. INTERVENTION(S): Surgical sperm retrieval and standard ICSI protocol. The ICSI cycles were analyzed in four groups, according to years since vasectomy, and were reanalyzed in three groups, according to maternal age. MAIN OUTCOME MEASURE(S): Fertilization rate, implantation rate, clinical pregnancy rate, and live-birth rate (LBR) per ET. RESULT(S): No effect of time since vasectomy was seen on any outcome. The highest fertilization rate and LBR were found in the group with the longest time interval. These findings could not be explained by differences in either patient characteristics or stimulation regimes. When reanalyzed by maternal age, there was an improvement in implantation rate and LBR with decreasing maternal age. Live birth rates of 38.5%, 22.7%, and 11.8% were achieved for maternal ages of <32, 32-37, and >38 years, respectively. Logistic regression confirmed a statistically significant effect on outcome of maternal age but not time since vasectomy. CONCLUSION(S): Our data suggest that maternal age, and not interval since vasectomy, remains the principal determinant of ICSI success in men with obstructive azoospermia after vasectomy.

Use of surgical sperm retrieval in azoospermic men: a meta-analysis.

OBJECTIVE: To compare the outcome of intracytoplasmic sperm injection (ICSI) cycles [1] using epididymal and testicular sperm in patients with obstructive azoospermia (OA); [2] using surgically retrieved sperm in patients with OA and nonobstructive azoospermia (NOA); and [3] using fresh and frozen-thawed sperm. DESIGN: Meta-analysis of published data. SETTING: Assisted conception unit. PATIENT(S): Ten reports (734 cycles: 677 transfers) were identified as suitable to assess source of sperm; 9 reports (1,103 cycles: 998 transfers) to assess etiology; and 17 reports (1,476 cycles: 1,377 transfers) to assess the effect of cryopreservation. INTERVENTION(S): Surgical sperm retrieval/ICSI. MAIN OUTCOME MEASURE(S): Fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR), and ongoing pregnancy rate (OPR) per embryo transfer. RESULT(S): Meta-analysis demonstrated no significant difference in any outcome measure between the use of epididymal or testicular sperm in men with OA. Meta-analysis showed a significantly improved FR (relative risk [RR] 1.18; 95% confidence interval [CI]: 1.13-1.23) and CPR (RR 1.36; 95% CI: 1.10-1.69) in men with OA as compared to NOA with a nonsignificant increase in OPR. There was no difference in either IR or miscarriage rate between the two groups. Comparing fresh with frozen-thawed epididymal sperm there was no difference in FR or IR, a significantly higher CPR (RR 1.20; 95% CI: 1.0-1.42), and no difference in OPR. No difference in fertilization or pregnancy outcome was noted when the testicular cycles were analyzed separately, but IR was significantly impaired using frozen-thawed sperm (RR 1.75; 95% CI: 1.10-2.80). CONCLUSION(S): Meta-analysis of published data confirms that etiology of azoospermia and cryopreservation of surgically retrieved sperm impacts on ICSI outcome, and allows us to make several recommendations for clinical practice. Origin of sperm, in men with similar etiology, does not affect outcome.

Synchronous sperm retrieval and sperm washing in an intracytoplasmic sperm injection cycle in an azoospermic man who was positive for human immunodeficiency virus.

OBJECTIVE: To present the first reported case of synchronous sperm retrieval followed by sperm washing before an intracytoplasmic sperm injection (ICSI) cycle in an HIV-positive azoospermic man. DESIGN: Case report. SETTING: Assisted reproduction center. PATIENT(S): A 40-year-old HIV-positive man with obstructive azoospermia due to vasal aplasia. INTERVENTION(S): Synchronous sperm retrieval, sperm washing, nucleic acid-based sequence amplification testing, and intracytoplasmic sperm injection. MAIN OUTCOME MEASURE(S): Successful sperm retrieval sufficient for sperm washing and fertilization. RESULT(S): Sufficient quantity of spermatozoa for washing was obtained at epididymal aspiration. After the wash, HIV ribonucleic acid (RNA) was undetectable with nucleic acid-based sequence amplification testing, enabling injection of oocytes collected after routine gonadotropin superovulation. Of seven oocytes collected from the 39-year-old woman partner, six were injected and five fertilized (83%). Three embryos were transferred on day 2. The pregnancy test was negative on this occasion. CONCLUSION(S): This case demonstrates that sperm washing can be applied in cases of sperm retrieval where sperm volume and density is low, allowing the treatment of azoospermic HIV-positive men.

Poor response cycles: when should we cancel? Comparison of outcome between egg collection, intrauterine insemination conversion, and follow-up cycles after abandonment.

OBJECTIVE: To determine optimal management with one or two mature follicles after stimulation. DESIGN: Retrospective analysis. SETTING: Lister fertility clinic. PATIENT(S): A total of 1,350 IVF/intracytoplasmic sperm injection cycles (7.3% of total) during 1998-2009 were found to have one or two mature follicles. INTERVENTION(S): Group 1 (n = 807) comprised those who proceeded to vaginal egg collection (VEC) (59.8%; outcome per egg collection), group 2 (n=248) those who converted to IUI (18.4%; outcome per insemination) and group 3 (n=259) those who abandoned the current cycle (21.9%; outcome per abandoned cycle in first subsequent cycle). MAIN OUTCOME MEASURE(S): Live birth rate, clinical pregnancy rate, and biochemical pregnancy rate. RESULT(S): Biochemical pregnancy rates of 13.1%, 4.9%, and 9.7%, clinical pregnancy rates of 8.1%, 3.6%, and 7.2%, and ongoing pregnancy rates of 6.8%, 2.0%, and 5.5% were achieved in groups 1, 2, and 3, respectively. All pregnancy outcomes were significantly higher after VEC (group 1) than for those converted to IUI (group 2), and all pregnancy outcomes were higher with borderline significance in group 3 vs. group 2. There was no significant difference in outcome between groups 1 and 3. CONCLUSION(S): Our data suggest that for such poor responders, proceeding to VEC may represent their best chance of successful outcome. Conversion to IUI offers the poorest outcome, and despite the potential for improvements in cycle protocol, abandoning and a further attempt does not improve outcome (using abandoned cycle as the denominator).

The effect of duration of coasting and estradiol drop on the outcome of assisted reproduction: 13 years of experience in 1,068 coasted cycles to prevent ovarian hyperstimulation.

OBJECTIVE: To determine the effect of duration of coasting (Cd), estradiol levels at trigger (E(2)), and level of estradiol drop (E(2)d) on live birth rate (LBR) in cycle outcome. DESIGN: Retrospective analysis. SETTING: Hospital-based fertility clinic. PATIENT(S): A total of 1,068 coasted cycles (5.7% of total) of IVF/ICSI from 1996 to 2008. INTERVENTION(S): Coasting in IVF/ICSI cycles. MAIN OUTCOME MEASURE(S): Live birth rate and secondary cycle outcomes. RESULT(S): Mean Cd, E(2), and E(2)d were 4.7 days, 11,567 pmol/L, and 9,760 pmol/L, respectively. Maternal age, duration of subfertility, and serum FSH were significantly lower, and AMH (39.7 vs. 15.1 pmol/L) and prevalence of polycystic ovary syndrome (31.8% vs. 17.8%) significantly higher, in coasted cycles. Fertilization rate, clinical pregnancy rate, and LBR per cycle and implantation rate of 64.4%, 40.7%, 35.7%, and 24.7%, respectively, were demonstrated, with no significant difference in LBR in cycles coasted for up to 8 days or when divided according to E(2) or E(2)d. Lack of predictive capability on LBR was confirmed by receiver operator curve analysis which demonstrated areas under the curve of 0.51, 0.53, and 0.54 for E(2), Cd, and E(2)d, respectively. CONCLUSION(S): Although cycle numbers beyond 6 days are limited, coasting for up to 8 days does not affect LBR, and E(2) and E(2)d levels do not significantly affect cycle outcome.