Poor ovarian response classification systems in the clinical setting - time for an update?

PURPOSE OF REVIEW: Poor ovarian response (POR) remains a key challenge to the success of assisted reproductive technology. Here, we offer a comprehensive review of the two main classification systems for POR, discussing their promises and pitfalls, evaluating their performance, and exploring potential avenues for improving upon these definitions of POR. RECENT FINDINGS: The Bologna criteria represented the first meaningful attempt to create a universal POR definition. Subsequently, the POSEIDON classification system was published to provide a more nuanced view of POR, classifying patients into four groups based on age and ovarian reserve markers. A recent study evaluated the likelihood of achieving at least one euploid embryo for transfer and found that, indeed, these classification systems are effective predictors of this outcome.While these criteria provide an effective counseling tool, several limitations - not considering underlying conditions, selecting somewhat arbitrary cutoffs, and evaluating the number of oocytes retrieved regardless of maturity - highlight the importance of improving upon these systems to create a more useful tool to more accurately predict ovarian response for clinical and research purposes. SUMMARY: In the era of personalized medicine, it is time to reconsider whether diagnostic criteria for a continuous metric such as ovarian response should be based on meeting all-or-nothing thresholds for specific parameters.

Proposed classification of adenomyosis in Infertile women to simplify management options undergoing ART.

OBJECTIVE: Adenomyosis associated with subfertility is a situation of a dilemma for the treating clinician as the treatment is highly controversial and there remains an overall lack of consensus regarding the value of conservative surgery with or without medical management to improve reproductive out-comes. Hence we proposed this classification based on mapping of the size of adenomyoma, its location, distance from the endometrial cavity, and any associated endometriosis by studying 100 women with adenomyosis undergoing IVF. METHODS: We did a prospective study over 2 years in 100 women with adenomyosis who underwent IVF. They were classified into 4 categories based on our management-based proposed classification and the pregnancy outcomes were studied in each group. RESULTS: According to our classification, 56% of women belonged to grade 1, 24% to grade 2, 8% to grade 3, and 12% to Grade 4 Adenomyosis. The Pregnancy rates were 71% in Grade 1, 66% with Medical management, and 33% with surgical management in Grade 2, Grade 3 were offered surrogacy, and 66% in Grade 4 Adenomyosis. CONCLUSIONS: Our classification is simple and allows cost-effective management based on the location and ex-tent of the disease with the help of ultrasonography.

A comprehensive review of the new FIGO classification of ovulatory disorders.

BACKGROUND: The World Health Organization (WHO) system for the classification of disorders of ovulation was produced 50 years ago and, by international consensus, has been updated by the International Federation of Gynecology and Obstetrics (FIGO). OBJECTIVE AND RATIONALE: This review outlines in detail each component of the FIGO HyPO-P (hypothalamic, pituitary, ovarian, PCOS) classification with a concise description of each cause, and thereby provides a systematic method for diagnosis and management. SEARCH METHODS: We searched the published articles in the PubMed database in the English-language literature until October 2022, containing the keywords ovulatory disorders; ovulatory dysfunction; anovulation, and each subheading in the FIGO HyPO-P classification. We did not include abstracts or conference proceedings because the data are usually difficult to assess. OUTCOMES: We present the most comprehensive review of all disorders of ovulation, published systematically according to the logical FIGO classification. WIDER IMPLICATIONS: Improving the diagnosis of an individual's ovulatory dysfunction will significantly impact clinical practice by enabling healthcare practitioners to make a precise diagnosis and plan appropriate management.

A Uterine Motion Classification in MRI Data for Female Infertility.

AIMS: The purpose of this study was to classify complicated uterine movements obtained by MRI scanner and investigate the relationship between uterine peristalsis and female infertility. METHODS: Uterine movements are classified into six fundamental movements by their motility form and directions. Computer simulation of the uterine movements is performed. RESULTS: Comparison results between the real MRI images and the simulated images showed that any five in our dataset uterine movement was successfully reproduced by a combination of these six fundamental movements. The point and surface vibration model appropriately mimicked the movements with the propagation velocity of 0.68 [mm/sec]. CONCLUSION: By analyzing six fundamental movements using data from 26 MRI scans, it was found that two fundamental movements were identified as candidate factors for female infertility.

Comparison of endometrial prostanoid profiles in three infertile subgroups: the missing part of receptivity?

OBJECTIVE: To study the prostanoid profile of the endometria of patients with recurrent implantation failure (RIF), unexplained infertility (UIF), and recurrent miscarriages (RM), and to compare them with the endometria of healthy fertile controls. DESIGN: Prospective cohort study. SETTING: University hospital. PATIENT(S): Fifteen patients with RIF, 18 patients with UIF, 16 patients with RM, and 23 fertile controls were recruited. INTERVENTION(S): Endometrial samples were taken during the window of implantation. After tissue homogenization and extraction, analysis with ultra-performance liquid chromatography diode array detector electrospray ionisation tandem mass spectrometry was performed. MAIN OUTCOME MEASURES: Concentrations of prostaglandin (PG) D1, PGE1, PGF1α, 6-ketoPGF1α, PGD2, PGE2, PGF2α, 15-deoxy-Δ12,14-PGJ2, PGD3, PGE3, PGF3α, thromboxane B2, 13,14-dihydro-PGE1, 13,14-dihydro-PGF1α, 13,14-dihydro-PGF2α, 13,14-dihydro-15-keto-PGE1, 13,14-dihydro-15-keto-PGE2, and 13,14-dihydro-15-keto-PGF2α were assessed. RESULT(S): Comparison of the endometria of patients with UIF and the controls showed no statistically significant differences. When the endometria of patients with RIF were compared with the controls, thromboxane B2 (TXB2) was found significantly higher (843.1 pg/mg vs. 133.5 pg/mg). When the endometria of patients with RM were compared with controls, 13,14-dihydro-15-keto PGF2α and TXB2 were found significantly higher (3907.30 pg/mg vs. 17.80 pg/mg and 858.7 pg/mg vs. 133.5 pg/mg respectively). CONCLUSION(S): We identified increased endometrial presence of TXB2 in patients with RM and RIF, and 13,14-dihydro-15-keto PGF2α in patients with RM. Although common ground is observed for RM and RIF, prostanoids, on the other hand, might make their own contribution to endometrial receptivity as important as genes and proteins. Attempts to normalize the prostaglandin profile of the endometrium via enzymatic activity can open new therapeutic options.

Endometriosis classification according to pain symptoms: can the ASRM classification be improved?

Endometriosis is a chronic disease that affects 5-15% of women of the reproductive age. Different classifications systems have been proposed to categorize endometriosis. In 1979, the American Fertility Society proposed a new system for the classification of endometriosis to correlate surgical findings of endometriosis with fertility, and this system was revised in 1996 (rASRM). Despite the fact that the rASRM classification system is widely used and accepted worldwide, it has limitations. The objectives of this study were to critically assess and discuss the current classification of endometriosis according to pain.

What is new in the management of poor ovarian response in IVF?

PURPOSE OF REVIEW: The management and treatment of patients with poor ovarian response is still a controversial issue in IVF. Increasing evidences demonstrate that the number of oocytes retrieved after a controlled ovarian stimulation (COS) greatly influences the clinical outcome in terms of cumulative live birth per started cycle. For this reason, any COS should aim to optimize the number of oocytes according to the ovarian reserve of the patient. The aim of this review is to provide an overview of new strategies proposed to manage poor responders according to the novel POSEIDON classification. RECENT FINDINGS: Gonadotrophins cannot compensate for the absence of follicles in the ovary, therefore, COS in poor responders may benefit from the exploitation of multiple follicular waves within a single ovarian cycle, for instance, through luteal phase stimulation or double stimulation (follicular plus luteal) in the same ovarian cycle (DuoStim) protocols. SUMMARY: Many strategies have been proposed to manage poor responder patients, however, a consensus upon which is the most beneficial has not been yet reached. DuoStim is the most promising approach to increase the number of oocytes collected in a single ovarian cycle; however, more embryological and clinical data is required, as well as an analysis of its cost-effectiveness.

A comparative analysis of arterial blood flow in unexplained infertility, tubal infertility and fertile groups.

We aimed to compare ovarian (O), uterine (U) and spiral (S) artery (A) resistance of patients diagnosed as fertile, unexplained infertility (UI) and tubal factor infertility (TFI) in the peri-implantation period and independent from the impact of the treatment. UI (n = 70), TFI (n = 75) and fertile (n = 72) patients' ovarian, uterine and spiral artery pulsatility index (PI), resistance index (RI) and the endometrial thickness, serum estradiol and progesterone levels were compared. The specificity and sensitivity values were calculated according to determined cutoff values. Both TFI and control groups' UA PI values were significantly lower than the UI group's PI values. The highest UA RI values were found in UI group and the lowest values were in the control group. UI and TFI groups' OA PI/RI values were significantly higher than the control group. Both the control and TFI groups' SA PI/RI values were significantly lower than UI group's PI/RI values. UI patients' uterine and spiral arteries PI values >1.86 and >0.85, RI values >0.80 and >0.53 can be used as a valuable test showing reduced uterine perfusion. Ovarian artery PI values >0.96 and RI values >0.58 can be used as tests showing decreased ovarian perfusion in patients with TFI. In these patients, embryo cryopreservation can be considered.

Should uterus transplants be publicly funded?

Since 2000, 11 human uterine transplantation procedures (UTx) have been performed across Europe and Asia. Five of these have, to date, resulted in pregnancy and four live births have now been recorded. The most significant obstacles to the availability of UTx are presently scientific and technical, relating to the safety and efficacy of the procedure itself. However, if and when such obstacles are overcome, the most likely barriers to its availability will be social and financial in nature, relating in particular to the ability and willingness of patients, insurers or the state to pay. Thus, publicly funded healthcare systems such as the UK's National Health Service (NHS) will eventually have to decide whether UTx should be funded. With this in mind, we seek to provide an answer to the question of whether there exist any compelling reasons for the state not to fund UTx. The paper proceeds as follows. It assumes, at least for the sake of argument, that UTx will become sufficiently safe and cost-effective to be a candidate for funding and then asks, given that, what objections to funding there might be. Three main arguments are considered and ultimately rejected as providing insufficient reason to withhold funding for UTx. The first two are broad in their scope and offer an opportunity to reflect on wider issues about funding for infertility treatment in general. The third is narrower in scope and could, in certain forms, apply to UTx but not other assisted reproductive technologies (ARTs). The first argument suggests that UTx should not be publicly funded because doing so would be inconsistent with governments' obligations to prevent climate change and environmental pollution. The second claims that UTx does not treat a disorder and is not medically necessary. Finally, the third asserts that funding for UTx should be denied because of the availability of alternatives such as adoption and surrogacy.

[Endometriosis Fertility Index, or classification of the American Society of Reproductive Medicine for postoperative endometriosis patients with infertility: Which is more relevant?]. / Endometriosis Fertility Index ou classification de l'American Society of Reproductive Medicine pour les patientes infertiles endométriosiques opérées. Lequel est le plus pertinent ?

The revised American Fertility Society classification system has been most used after surgery by all consensus on endometriosis fertility. However, it does not predict pregnancy. The EFI score has been recently developed to aim at predicting clinical pregnancy after surgery. Several study performed its external validation. It may be a useful new tool to counsel couples for personalized postoperative management.

The role of anti-Müllerian hormone in the classification of anovulatory infertility.

OBJECTIVE: The World Health Organization (WHO) has defined three classes of anovulatory infertility, based on serum gonadotrophin and oestradiol levels: low gonadotrophin and oestradiol levels in women with WHO 1 anovulation, normal hormone levels in WHO 2 anovulation and high gonadotrophin but low oestradiol levels in WHO 3 anovulation. The number of follicles on the ovary also seems to be different in the three classes of anovulatory infertility. Serum anti-Müllerian hormone (AMH) levels correlate well with the number of pre-antral and small antral follicles. The objective of our study was to investigate whether a single AMH measurement might simplify the classification of the WHO classes of anovulatory dysfunction. STUDY DESIGN: In a tertiary hospital, 1863 patients with either oligomenorrhea or secondary amenorrhea were recruited. Standardized screening was performed, including transvaginal ultrasound and serum AMH measurement. Serum AMH levels were compared with those in 348 age-matched controls. RESULTS: Serum AMH levels were slightly elevated in women with hypogonadotropic anovulation (n=128) (P<0.001) as compared with controls. Normogonadotropic anovulatory women (n=1.465) had distinctly higher serum AMH levels than controls (P<0.001) and serum AMH levels were low in women with hypergonadotropic anovulation (n=270) (P<0.001). Although median AMH levels were distinctly different in each class of anovulatory dysfunction, serum AMH levels were comparable in hypogonadotropic women and normogonadotropic women without polycystic ovary syndrome. CONCLUSION: The clinical applicability of serum AMH as a diagnostic tool to differentiate between the different classes of anovulatory dysfunction seems to be limited to the prediction of hypergonadotropic anovulation.

Follicle-stimulating hormone receptor polymorphism affects the outcome of ovulation induction in normogonadotropic (World Health Organization class 2) anovulatory subfertility.

OBJECTIVE: To assess whether an FSH receptor polymorphism (Asn680Ser, rs6166) can affect the outcome of ovulation induction in normogonadotropic (World Health Organization class 2 [WHO2]) anovulatory subfertile women. DESIGN: Prospective, longitudinal, cohort study. SETTING: University-based fertility unit. PATIENT(S): A total of 240 consecutive women diagnosed with WHO2 anovulatory subfertility who underwent ovulation induction therapy. Results were replicated in a retrospective cohort of 185 patients with polycystic ovary syndrome (PCOS) (Rotterdam criteria). INTERVENTION(S): Ovulation induction using clomiphene citrate (CC) as first-line and exogenous gonadotropins (exFSH) as second-line therapy. MAIN OUTCOME MEASURE(S): Clomiphene-resistant anovulation (CRA), clomiphene failure (CCF), and ongoing pregnancy rate. RESULT(S): Genotyped patients (n = 159) were similar to nongenotyped women (n = 81) regarding clinical characteristics and outcomes of ovulation induction. The 680(Ser) allele was associated with CRA. A pooled analysis of both cohorts showed an 89% higher chance of CRA after CC treatment (odds ratio 1.9 [95% confidence interval 1.1-3.3]) in homozygous carriers of the FSH receptor variant (680(Ser/Ser)). A lower chance of ongoing pregnancy (hazard ratio 0.51 [95% confidence interval 0.27-0.98]) was observed among these patients during CC treatment in the prospective cohort. CONCLUSION(S): An FSH receptor polymorphism is associated with CRA during treatment with clomiphene citrate. These data may be used to design a treatment algorithm that is more efficacious and better tailored to the individual patient.

Anti-Müllerian hormone concentration as a biomarker of pregnancy success or failure.

OBJECTIVE: This study was conducted to determine serum anti-Müllerian hormone (AMH) concentration influence on pregnancy outcome. STUDY DESIGN: In this study we investigated sixty one infertile women (aged 27 to 44 years) who were diagnosed and treated between 2011 and 2013. We determine ovarian reserve measured by AMH concentration. Patients were divided in three groups according to their serum AMH concentration (<1 ng/ml; 1-2.5 ng/ml; >2.5 ng/ml respectively). We investigated the relationship between clinical pregnancy rate and AMH concentration. In addition, anti-thyroid antibodies (anti-TG and/or anti-TPO) positivity and insulin concentration were correlated with AMH level and pregnancy outcome in the study groups. RESULTS: We found no statistical differences between AMH concentration regarding number of pregnancies (42.3%; 41.1 %; 38.9% respectively in study groups; p>0.05). The miscarriage rate was highest in women with AMH>2.5 ng/mL (27.3%, 0%, 86% respectively in study groups; p>0.05). We found that anti-thyroid positivity is more frequent in women with lower AMH concentration (23.1%; 11.7%; 5.5% respectively; p>0.05) and patients with lower serum AMH had higher serum insulin concentration (p<0.05). CONCLUSIONS: It seems that AMH concentration might not reflect oocyte quality and the chance of pregnancy, but increased AMH concentration may be associated with negative pregnancy outcome. Moreover, it cannot be excluded that presence of anti-thyroid antibodies and increased insulin serum concentration may be connected to diminished ovarian reserve measured by AMH concentration.

Testing and interpreting measures of ovarian reserve: a committee opinion.

Currently, there is no uniformly accepted definition of decreased ovarian reserve (DOR), as the term may refer to three related but distinctly different outcomes: oocyte quality, oocyte quantity, or reproductive potential. Available evidence concerning the performance of ovarian reserve tests is limited by small sample sizes, heterogeneity among study design, analyses and outcomes, and the lack of validated outcome measures.

[Prevalence of gluten-sensitive celiac disease in women with reproductive dysfunction].

AIM: To determine prevalence of gluten-sensitive celiac disease (GSCD) in women with reproductive dysfunction (RD). MATERIAL AND METHODS: Tests for blood serum antibodies to tissue transglutaminase (ABtTG) of IgA class were made in 217 women with RD. Tests for antibodies to gliadin (ABG) were performed in 180 of them. Esophagogastroduodenoscopy (EGDS) with biopsy to verify GSCD was conducted in patients with elevated ABtTG. The control group consisted of 15 healthy females of a reproductive age. RESULTS: The examinees exhibited IgA ABtTG in the range 1 to 280 IU/ml, while 16 of them had elevated level - 50.2 +/- 194 IU/ml, on the average. The controls had 0-10 IU/ml level of ABtTG, mean level 4.3 +/- 1.5 IU/ml. EGDS with duodenobiopsy was performed in 14 women. The examination of biopsies from small intestinal mucosa has detected pathohistological signs of celiac disease in 7 of 14 women. At the moment of the study, two women with a history of spontaneous abortion were pregnant. Their ABtTG was 21.7 and 15.9 IU/mg, respectively EGDS was not performed because of potential pregnancy complication but in view of possible celiac disease they received recommendations on aglutenic diet. CONCLUSION: Incidence rate of GSCD in women with RD is 4,1%. Aglutenic diet in GSCD women with RD contributes to reproductive function recovery and normal outcome of pregnancy. Elevation of ABtTG titers in women with RD is an indication to histological examination of small intestinal mucosa to detect GSCD.

Patient and hospital characteristics associated with variation in guideline adherence in intrauterine insemination care.

OBJECTIVE: To assess the association of patient and hospital characteristics with adherence to guidelines for intrauterine insemination (IUI) care. DESIGN: Retrospective cohort study using multilevel regression analysis. Characteristics studied at the patient level were female age, type and duration of subfertility, diagnosis and number of started IUI cycles. At the hospital level, the characteristics studied were hospital size, teaching hospital, in vitro fertilization (IVF) licence and number of physicians involved in the IUI programme. Data were obtained from medical records and questionnaires for gynaecologists. SETTING AND PARTICIPANTS: Five hundred and fifty-eight subfertile couples who underwent IUI treatment at 10 Dutch hospitals. MAIN OUTCOME MEASURES: Adherence to systematically developed guideline-based performance indicators describing 20 processes of IUI care. RESULTS: A total of 558 couples who started 2,334 IUI cycles participated. Guideline adherence in IUI care was often substandard and varied considerably between hospitals. Variation in guideline adherence in IUI care was associated with the patient characteristics 'diagnosis' and 'female age'. Only adherence to the guideline recommendation regarding 'screening for tubal occlusion' was associated with hospital characteristics ('hospital size' and 'IVF licence'). Large explained variances up to 39% were found for the different models. CONCLUSIONS: A number of patient and hospital characteristics were associated with variation in guideline adherence in IUI care, particularly the patient characteristics 'diagnosis' and 'female age'. The identification of different subgroups in the patient population and different types of hospitals with regard to the extent of guideline adherence in IUI care is important for the tailoring of interventions to improve IUI care.

A new classification for female infertility.

Infertility is defined as the inability of a couple to conceive after 12 months of regular, unprotected intercourse. However infertility is a clinical presentation and not a disease. Thus to be able to offer a new classification, it is necessary to apply a clinical presentation (philosophy) suggested by the University of Calgary in 1991. In recent years several classification algorithms have been proposed which apply key predictors of clinical, imaging, or morphological types to determine the diseases that can cause infertility. On the other hand, an algorithm is a product of an expert's mind after many years of practice and experience, which is too difficult to understand by a medical student. However there has not been any simple schematic classification based on a logical justification applying integration of etiologies with basic science to break down etiologies into categories, subcategories and disease classes of this clinical presentation. Because etiology has also become an important criterion for the characterization of causes of infertility, a classification proposal is presented here that attempts to include all relevant (basic science) features of the causative diseases of this clinical presentation.

Discordances between follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) in female infertility.

BACKGROUND: Follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) represent the two most frequently utilized laboratory tests in determining ovarian reserve (OR). This study determined the clinical significance of their concordance and discordance in female infertility patients. METHODS: We investigated 366 consecutive infertility patients (350 reached IVF), excluding women with polycystic ovarian syndrome (PCOS). They were considered to have normal FSH and AMH if values fell within age-specific (as-) 95% confidence intervals (CI), and to suffer from diminished ovarian reserve (DOR) if FSH exceeded and/or AMH fell below those. The two hormones, thus, could be concordant (Group I), both normal (IA) or abnormal (IB), show normal AMH/abnormal FSH (Group II) or normal FSH/abnormal AMH (Group III). Oocyte yields, stratified for age categories, were then studied in each group as reflection of OR. RESULTS: Oocyte yields significantly decreased from groups IA to II to III and IB. Predictive values of as-FSH/AMH patterns changed, however, at different ages. Except at very young and very old ages, normal as-AMH better predicted higher oocytes yields than normal as-FSH, though above age 42 years normal as-FSH predicts good oocyte yields even with abnormally low AMH. Under age 42 discrepancies between as- FSH and as-AMH remain similarly predictive of oocyte yields at all ages. DISCUSSION: Concordances and discordances between as-FSH and as-AMH improve OR assessments and predictability of oocyte yields in IVF.

Hysterosalpingography in the evaluation of infertility: a five years review. (FGAE, 2001 -5).

BACKGROUND: Internal genital occlusion, mainly the fallopian tubes, secondary to pelvic inflammatory disease, is the most common causes of female infertility in sub-Saharan Africa and hysterosalpingography is a common diagnostic modality. OBJECTIVE: This was to discuss the findings of HSG and compare among primary and secondary infertility. PATIENTS AND METHODS: All infertility clinical records of five years (2001-2005) at FGAE central clinic were retrieved and those women who had undergone HSG procedure selected. The type and duration of infertility, socio-demographic factors and the recorded results of HSG were analyzed. RESULTS: Among the total of 8582 attendants of the infertility clinic, 96% were women and 4% males. HSG was undertaken on 1716 (21%) women. Secondary and primary infertility were 894 (53%) and 804 (47%) respectively. Addis Ababa residents were 84%; married 93%; house wives 61% and office workers were 25%. About 39% (n = 662) of the women came to the clinic for investigation after 30 years of age and 42% (n = 714) after five years duration of infertility. There were 55% (n = 934) with secondary and above level of education while 10% had no formal school. Normal HSG was 604 (36%); significantly more in primary than secondary (p = 0.0002). The uterine cavity was normal in 1253 (73%) of which 21% had bilateral tubal blockage while among the abnormal, 44% showed bilateral block (P = 0.0000000). Tubal abnormalities were significantly associated with the acquired uterine defects than that of the 2.8% congenital uterine abnormalities. Of the 847 (49%) bilateral tubal patency, 14% had luminal defects. Unilaterally patent tubes were demonstrated in 324 (19%) women: more in secondary type (p = 0.0001) without significant difference between the right and the left. Bilateral tubal obstructions were noted in 527 (31%) of which 25% were symmetrical and 6% asymmetrical. Of the blocked tubes, the sites were 60% terminal and 37% proximal. CONCLUSION: The review showed that most of the HSG were abnormal commonly tubal blockage: significantly more in secondary than primary infertility. End block was the commonest site and is associated with hydrosalpinx. The association of acquired uterine and tubal defects and secondary infertility is indicative of damage of internal genital tract following the previous pregnancies. Though applicable also to the primary infertility group, other infections (STI, TB) may contribute to the damage.

Changes in affect and state anxiety across an in vitro fertilization/intracytoplasmic sperm injection cycle.

OBJECTIVE: To identify pattern of change in average positive affect (PA), negative affect (NA), and state anxiety (St ANX) across three biological end points of an IVF/intracytoplasmic sperm injection (ICSI) procedure and to examine whether the pattern varied across sociodemographic and biomedical subgroups. DESIGN: Longitudinal follow-up study of PA, NA, and St ANX at three different time points: before start of study, before ovum pick-up (OPU), and before embryo transfer. SETTING: Three infertility centers in northern India. PATIENT(S): Baseline data were obtained from a consecutive sample of 85 women. However, final analysis was done on data obtained from 74 women who reached the embryo transfer stage and completed the questionnaires at both OPU and embryo transfer. INTERVENTION(S): The PA, NA, and St ANX scores. MAIN OUTCOME MEASURE(S): Change in PA, NA, and St ANX scores at three stages of the treatment: baseline (T(0)), before OPU (T(1)), before embryo transfer (T(2)). RESULT(S): The PA scores before OPU and embryo transfer were significantly lower than those at baseline. The mean NA and St ANX scores before OPU and embryo transfer were significantly higher than baseline scores. Furthermore, mean NA before embryo transfer was significantly higher than mean NA before OPU. The PA and St ANX scores showed statistically insignificance within cycle variations. Furthermore, the mean PA and St ANX for a subgroup of women who reported more than moderate level of burden were less variable. CONCLUSION(S): The OPU and embryo transfer stages are more stressful than the baseline stage for most women across various sociodemographic and biomedical subgroups. Women with more than a moderate level of financial burden were relatively more stable.