DNA methylation and gene expression changes in mouse pre- and post-implantation embryos generated by intracytoplasmic sperm injection with artificial oocyte activation.

BACKGROUND: The application of artificial oocyte activation (AOA) after intracytoplasmic sperm injection (ICSI) is successful in mitigating fertilization failure problems in assisted reproductive technology (ART). Nevertheless, there is no relevant study to investigate whether AOA procedures increase developmental risk by disturbing subsequent gene expression at different embryonic development stages. METHODS: We used a mouse model to explore the influence of AOA treatment on pre- and post-implantation events. Firstly, the developmental potential of embryos with or without AOA treatment were assessed by the rates of fertilization and blastocyst formation. Secondly, transcriptome high-throughput sequencing was performed among the three groups (ICSI, ICSI-AOA and dICSI-AOA groups). The hierarchical clustering and Principal Component Analysis (PCA) analysis were used. Subsequently, Igf2r/Airn methylation analysis were detected using methylation-specific PCR sequencing following bisulfite treatment. Finally, birth rate and birth weight were examined following mouse embryo transfer. RESULTS: The rates of fertilization and blastocyst formation were significantly lower in oocyte activation-deficient sperm injection group (dICSI group) when compared with the ICSI group (30.8 % vs. 84.4 %, 10.0 % vs. 41.5 %). There were 133 differentially expressed genes (DEGs) between the ICSI-AOA group and ICSI group, and 266 DEGs between the dICSI-AOA group and ICSI group. In addition, the imprinted gene, Igf2r is up regulated in AOA treatment group compared to control group. The Igf2r/Airn imprinted expression model demonstrates that AOA treatment stimulates maternal allele-specific mehtylation spreads at differentially methylated region 2, followed by the initiation of paternal imprinted Airn long non-coding (lnc) RNA, resulting in the up regulated expression of Igf2r. Furthermore, the birth weight of newborn mice originating from AOA group was significantly lower compared to that of ICSI group. The pups born following AOA treatment did not show any other abnormalities during early development. All offspring mated successfully with fertile controls. CONCLUSIONS: AOA treatment affects imprinted gene Igf2r expression and mehtylation states in mouse pre- and post-implantation embryo, which is regulated by the imprinted Airn. Nevertheless, no significant differences were found in post-natal growth of the pups in the present study. It is hoped that this study could provide valuable insights of AOA technology in assisted reproduction biology.

Oocyte competence is independent of the ovulation trigger adopted: a large observational study in a setting that entails vitrified-warmed single euploid blastocyst transfer.

PURPOSE: To assess whether the GnRH-agonist or urinary-hCG ovulation triggers affect oocyte competence in a setting entailing vitrified-warmed euploid blastocyst transfer. METHODS: Observational study (April 2013-July 2018) including 2104 patients (1015 and 1089 in the GnRH-a and u-hCG group, respectively) collecting ≥1 cumulus-oocyte-complex (COC) and undergoing ICSI with ejaculated sperm, blastocyst culture, trophectoderm biopsy, comprehensive-chromosome-testing, and vitrified-warmed transfers at a private clinic. The primary outcome measure was the euploid-blastocyst-rate per inseminated oocytes. The secondary outcome measure was the maturation-rate per COCs. Also, the live-birth-rate (LBR) per transfer and the cumulative-live-birth-delivery-rate (CLBdR) among completed cycles were investigated. All data were adjusted for confounders. RESULTS: The generalized-linear-model adjusted for maternal age highlighted no difference in the mean euploid-blastocyst-rate per inseminated oocytes in either group. The LBR per transfer was similar: 44% (n=403/915) and 46% (n=280/608) in GnRH-a and hCG, respectively. On the other hand, a difference was reported regarding the CLBdR per oocyte retrieval among completed cycles, with 42% (n=374/898) and 25% (n=258/1034) in the GnRh-a and u-hCG groups, respectively. Nevertheless, this variance was due to a lower maternal age and higher number of inseminated oocytes in the GnRH-a group, and not imputable to the ovulation trigger itself (multivariate-OR=1.3, 95%CI: 0.9-1.6, adjusted p-value=0.1). CONCLUSION: GnRH-a trigger is a valid alternative to u-hCG in freeze-all cycles, not only for patients at high risk for OHSS. Such strategy might increase the safety and flexibility of controlled-ovarian-stimulation with no impact on oocyte competence and IVF efficacy.

Role of Stem Cells in the Ovarian Tissue Cryopreservation and Transplantation for Fertility Preservation.

Although the cancer survival rate has increased, cancer treatments, including chemotherapy and radiotherapy, can cause ovarian failure and infertility in women of reproductive age. Preserving fertility throughout cancer treatment is critical for maintaining quality of life. Fertility experts should propose individualized fertility preservation methods based on the patient's marital status, pubertal status, partner status, and the urgency of treatment. Widely practiced fertility preservation methods, including ovarian transposition and embryo and oocyte cryopreservation, are inappropriate for prepubertal girls or those needing urgent initiation of cancer treatment. Ovarian tissue cryopreservation and transplantation, an emerging new technology, may be a solution for these cancer patients. The use of stem cells in ovarian tissue cryopreservation and transplantation increases oxygenation, angiogenesis, and follicle survival rates. This review discusses the recent advances in ovarian tissue cryopreservation and transplantation with special focus on the use of stem cells to improve fertilization techniques.

Fertility preservation before breast cancer treatment appears unlikely to affect disease-free survival at a median follow-up of 43 months after fertility-preservation consultation.

BACKGROUND: The objective of this study was to determine whether fertility preservation (FP) with oocyte/embryo cryopreservation is associated with differences in disease-free survival (DFS). METHODS: This retrospective study included patients aged 18 to 45 who were diagnosed with invasive breast cancer between 2007 and 2017 and were seen for FP consultation at a university fertility center before cancer treatment. The primary endpoint, DFS, was defined as the time from FP consultation until patients developed a locoregional recurrence, distant metastasis, a contralateral breast tumor, or a new primary malignancy. DFS was compared for FP versus no FP using Kaplan-Meier survival estimates and Cox proportional-hazard regression analysis. RESULTS: The study included 329 women, with 207 (63%) in the FP group and 122 (37%) in the no FP group. Patients who underwent FP had more aggressive initial disease profiles than those in the no FP group. In addition, they were younger (35 vs 37 years; P = .009), more often had stage II or III disease (67% vs 55%; P = .03), and had higher rates of requiring chemotherapy (77% vs 65%; P = .01). Over a median follow-up of 43 months, the rates of DFS were similar among patients in the FP group and the no FP group (93% vs 94%, respectively; hazard ratio [HR] 0.7; 95% CI, 0.3-1.7). Positive ER status (79% vs 83%; P = .38), neoadjuvant chemotherapy (41% vs 48%; P = .32), ER-positive DFS (HR, 0.4; 95% CI, 0.1-1.6), and neoadjuvant chemotherapy DFS (HR, 1.4; 95% CI, 0.2-9.1) were similar in the FP and no FP groups, respectively. CONCLUSIONS: At a median follow-up of 43 months, FP appears unlikely to affect DFS, even in the setting of tumors with positive ER status or treatment with neoadjuvant chemotherapy (in which the tumor remains in situ during FP).

In vitro fertilization and risk for hypertensive disorders of pregnancy: associations with treatment parameters.

BACKGROUND: Although in vitro fertilization has been associated with an increased risk for hypertensive disorders of pregnancy, the association of risk with in vitro fertilization treatment parameters is unclear. OBJECTIVE: To evaluate risk for hypertensive disorders of pregnancy by maternal fertility status and in vitro fertilization treatment parameters. MATERIALS AND METHODS: Women in 8 states who underwent in vitro fertilization resulting in a live birth during 2004-2013 were linked to their infant's birth certificates. A 10:1 sample of births from non-in vitro fertilization deliveries were selected for comparison. Those with an indication of infertility treatment on the birth certificate were categorized as subfertile and omitted from the study population; all others were categorized as fertile. The in vitro fertilization pregnancies were additionally categorized by oocyte source (autologous versus donor) and embryo state (fresh versus thawed). Both the fertile and in vitro fertilization births were limited to singletons only, and the in vitro fertilization pregnancies were limited to those using partner sperm. Hypertensive disorders of pregnancy (including gestational hypertension and preeclampsia) were identified from the birth certificate, modeled using logistic regression, and reported as adjusted odds ratios and 95% confidence intervals. For analyses of in vitro fertilization pregnancies from autologous oocytes-fresh embryos, the reference group was fertile women (subgroup analysis 1). For analyses within the in vitro fertilization group, the reference group was autologous oocytes-fresh embryos (subgroup analysis 2). RESULTS: The study population included 1,465,893 pregnancies (1,382,311 births to fertile women and 83,582 births to in vitro fertilization-treated women). Compared to fertile women, in vitro fertilization-treated women with autologous-fresh cycles were not at increased risk for hypertensive disorders of pregnancy (adjusted odds ratio, 1.04; 95% confidence interval, 0.99, 1.08). Among in vitro fertilization births (subgroup analysis 2), the risk for hypertensive disorders of pregnancy was increased for the autologous-thawed (adjusted odds ratio, 1.30; 95% confidence interval, 1.20, 1.40); donor-fresh (adjusted oddds ratio, 1.92; 95% confidence interval, 1.71, 2.15); and donor-thawed (adjusted odds ratio, 1.70; 95% confidence interval, 1.47, 1.96) groups. Excluding women with pregestational diabetes or chronic hypertension as well as adjusting for body mass index and infertility diagnoses did not substantially change the results. When stratified by <34 weeks (early-onset hypertensive disorders of pregnancy) versus ≥34 weeks (late-onset hypertensive disorders of pregnancy), only the donor-fresh group had an increased risk of early-onset hypertensive disorders of pregnancy, but the risks for all other oocyte source-embryo state groups compared to autologous-fresh were increased for late-onset hypertensive disorders of pregnancy. CONCLUSION: The risk for hypertensive disorders of pregnancy is increased for in vitro fertilization-treated women in pregnancies conceived via frozen embryo transfer (with both autologous or donor oocyte) and fresh donor oocyte embryo transfer. No increase in risk was seen with autologous oocyte-fresh embryo transfers in vitro fertilization cycles. Excluding women with pregestational diabetes or chronic hypertension as well as adjusting for body mass index and infertility diagnoses did not substantially change the results.

Improving the maturation rate of human oocytes collected ex vivo during the cryopreservation of ovarian tissue.

PURPOSE: The aim of the present study was to improve the in vitro maturation (IVM) procedure using oocytes from surplus ovarian tissue after fertility preservation. METHODS: Twenty-five patients aged 17-37 years were included in the study. Maturation was compared between oocytes collected in HEPES-buffered medium or saline, and we determined whether transport on ice prior to oocyte collection affected maturation. Two different IVM media were used that were supplemented with and without recombinant human midkine. Mature oocytes were assessed for aneuploidy using next-generation sequencing (NGS). RESULTS: On average, 36 immature oocytes were collected from each patient (range 7-90, N = 895). Oocytes recovered from HEPES-buffered medium matured at a higher rate than oocytes recovered from saline (36% vs 26%, p < 0.01). Ovarian transportation on ice prior to the procedure negatively affected maturation compared with non-transported samples (42% vs 27%, p < 0.01). The addition of midkine improved maturation rate (34% vs 27%, p < 0.05). On average, 11 MII oocytes were obtained per patient (range 1-30). NGS of 53 MII oocytes and their first polar bodies indicated that 64% were euploid. CONCLUSIONS: The study demonstrated unexpectedly high number of immature oocytes collected from surplus ovarian tissue without any stimulation. The overall MII rate was one in three, resulting in a total number of MII oocytes that was similar to the number obtained after ovarian stimulation. If these MII oocytes prove suitable for IVF, they will provide a substantial improvement in fertility preservation for patients and advance IVM as an interesting platform for further improvements in assisted reproduction.

Oncologic oocyte cryopreservation: national comparison of fertility preservation between women with and without cancer.

PURPOSE: The majority of data regarding oocyte cryopreservation (OC) outcomes focuses on healthy women. We compare trends, cycle characteristics, and outcomes between women freezing oocytes for fertility preservation due to cancer versus elective and other medical or fertility-related diagnoses. METHODS: Retrospective cohort using national surveillance data includes all autologous OC cycles between 2012 and 2016. Cycles were divided into 4 distinct groups: cancer, elective, infertility, and medically indicated. We calculated trends and compared cycle and outcome characteristics between the 4 groups. We used multivariable log-binomial models to estimate associations between indication and gonadotropin dose, hyperstimulation, and cancelation and used Poisson regression models to estimate associations between indication and oocyte yield and maturity. RESULTS: The study included 29,631 autologous OC cycles. Annual total (2925 to 8828) and cancer-related (177 to 504) cycles increased over the study period; the proportions remained constant. Compared to elective, cancer-related cycles were more likely to be performed among women < 35 years old, with higher BMI, living in the South, using an antagonist protocol. Compared to elective OC cycles, gonadotropin dose (aRR 0.89, 95%CI 0.80-0.99), cancelation (aRR 0.90, 95%CI 0.70-1.14), and hyperstimulation (aRR 1.46, 95%CI 0.77-2.29) were not different for cancer-related cycles. Oocyte yield and percent maturity were comparable in both groups. CONCLUSION: The number of OC cycles among women with cancer has increased; however, the percentage OC cycles for cancer have remained stable. While patient demographic characteristics were different among those undergoing OC for cancer indication, cycle outcomes were comparable to elective OC. The outcomes of the subsequent oocyte thaw, fertilization, and embryo transfer cycles remain unknown.

Cryopreservation of euploid blastocysts obtained after fertilization of in vitro matured ovarian tissue oocytes: a case report.

With the increased rate of stable remission after gonadotoxic cancer treatment, new methods of fertility preservation are required in order to provide the best possible care for oncological patients. Here, we report an original case of euploid blastocyst cryopreservation after in vitro maturation of ovarian tissue oocytes (OTO IVM). Thirty-three oocytes were obtained from the ovarian tissue after ovariectomy in the breast cancer patient. Six out of 12 matured oocytes fertilized successfully and 3 blastocysts were formed. Genetic investigation for mutations associated with this type of malignancy found that the patient is not a carrier. Preimplantation genetic testing was performed only for aneuploidies and found all 3 blastocysts to be euploid and suitable for embryo transfer. Our study showed that the ovarian tissue oocytes matured in vitro have the potential for euploid blastocyst formation after ICSI which could be screened for aneuploidies and inherited mutations and then be vitrified in order to provide the best fertility preservation strategy for women with cancer.

Outcomes of ovarian stimulation and fertility preservation in breast cancer patients with different hormonal receptor profiles.

PURPOSE: To evaluate fertility preservation outcomes in breast cancer women with different hormonal receptor profiles before oncological treatment. METHODS: The study population included women with a diagnosis of breast cancer who underwent fertility preservation from 2009 until 2018 at a university-affiliated tertiary hospital. Stimulation parameters and fertility preservation outcomes were compared among the following receptor-specific profile groups: (1) estrogen receptor positive (ER+) versus estrogen receptor negative (ER-), (2) triple-negative breast cancer (TNBC) versus estrogen and progesterone receptor positive (ER+/PR+), and (3) TNBC versus non-TNBC. Primary outcome was the total number of mature oocytes. Secondary outcomes included the number of retrieved oocytes, the peak estradiol level, and the number of follicles > 14 mm on the final oocyte maturation trigger day. RESULTS: A total of 155 cycles were included in the final analysis. These were divided into the exposure groups of ER+ (n = 97), ER- (n = 58), ER+/PR+ (n = 85), TNBC (n = 57), and non-TNBC (n = 98). Cycle outcomes revealed similar number of retrieved oocytes and follicles > 14 mm on the trigger day. Women with TNBC had significantly lower number of mature oocytes compared with those with ER + PR+ (7 (5-11) versus 9 (7-15); p = 0.02) and non-TNBC (7 (5-11) versus 9 (7-16); p = 0.01) status. Triple-negative breast cancer profile was associated with a significant reduction in the chance of developing over 10 mature oocytes (OR 0.41; 95% CI 0.19-0.92). CONCLUSION: Among the different hormonal receptor profiles in breast cancer, the TNBC subtype has a negative effect on fertility preservation outcomes.

Fertility preservation in breast cancer with case-based examples for guidance.

With more young breast cancer survivors, a trend toward having children later in life, and improvements in assisted reproductive technology (ART), fertility preserving techniques are of growing importance prior to initiation of gonadotoxic treatments. The American Society for Clinical Oncology (ASCO) updated their Fertility Preservation in Patients with Cancer guidelines in April of 2018. ASCO continues to recognize oocyte and embryo cryopreservation as standard practice for women interested in preserving fertility and sperm cryopreservation as standard practice for men. ASCO has clarified their statement on ovarian suppression during chemotherapy as an option when standard methods are unavailable but should not be used as the sole method of fertility preservation (FP) due to conflicting evidence. ASCO also updated their statement on ovarian tissue cryopreservation, which is still labeled experimental but ASCO acknowledges that it can restore global ovarian function and could be of use in specific patients. The NCCN's Version 1.2018 Clinical Practice Guidelines® for treatment of breast cancer include fertility counseling as part of their work-up in all types of breast cancer for premenopausal women.The purpose of this review is to explain the indications and evidence for the different methods of FP for young breast cancer patients in accordance with ASCO and NCCN guidelines. The guidance will then be applied to three theoretical clinical cases in order to highlight actual use in clinical practice.

Cost-effectiveness of social oocyte freezing in Germany: estimates based on a Markov model.

PURPOSE: Is oocyte freezing for non-medical reasons-the so-called "social freezing" (SF)-cost-effective compared to standard in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) in Germany today? METHODS: We developed a model based on three strategies for women planning to postpone pregnancy. In each strategy, women actively practiced contraception until 40 then tried to conceive naturally for 1 year. If unsuccessful, women using strategy I (oocyte cryopreservation) attempted ICSI with frozen oocytes in the 2nd year, while women using strategy II (no action) further attempted natural conception. In strategy III (IVF/ICSI), women underwent 1 year of IVF/ICSI. If still unsuccessful, each strategy was followed by attempting natural conception again until 45. We used an adaptive Markov model to estimate and compare live birth rates and cost-effectiveness measures. RESULTS: For strategy I, cumulative live birth rates at age 45 generally declined with the woman's age at freezing and were between 71.4% (25 years) and 67.6% (38 years), while the cumulative success rate was 51.5% for strategy II and 60.8% for strategy III. The costs per live birth of egg freezing were age-dependent ranging between 22,418 € (30 years) and 25,590 € (38 years). The costs for strategy III were lower at 20,293 € per live birth. CONCLUSION: Based on our results, social freezing in Germany may lead to additional pregnancies among women over 40 but also to significantly higher costs, since given the current live birth success rates and pricing, social freezing does not appear to be cost-effective.

Comparative analysis of different nuclear transfer techniques to prevent the transmission of mitochondrial DNA variants.

Prevention of mitochondrial DNA (mtDNA) diseases may currently be possible using germline nuclear transfer (NT). However, scientific evidence to compare efficiency of different NT techniques to overcome mtDNA diseases is lacking. Here, we performed four types of NT, including first or second polar body transfer (PB1/2T), maternal spindle transfer (ST) and pronuclear transfer (PNT), using NZB/OlaHsd and B6D2F1 mouse models. Embryo development was assessed following NT, and mtDNA carry-over levels were measured by next generation sequencing (NGS). Moreover, we explored two novel protocols (PB2T-a and PB2T-b) to optimize PB2T using mouse and human oocytes. Chromosomal profiles of NT-generated blastocysts were evaluated using NGS. In mouse, our findings reveal that only PB2T-b successfully leads to blastocysts. There were comparable blastocyst rates among PB1T, PB2T-b, ST and PNT embryos. Furthermore, PB1T and PB2T-b had lower mtDNA carry-over levels than ST and PNT. After extrapolation of novel PB2T-b to human in vitro matured (IVM) oocytes and in vivo matured oocytes with smooth endoplasmic reticulum aggregate (SERa) oocytes, the reconstituted embryos successfully developed to blastocysts at a comparable rate to ICSI controls. PB2T-b embryos generated from IVM oocytes showed a similar euploidy rate to ICSI controls. Nevertheless, our mouse model with non-mutated mtDNAs is different from a mixture of pathogenic and non-pathogenic mtDNAs in a human scenario. Novel PB2T-b requires further optimization to improve blastocyst rates in human. Although more work is required to elucidate efficiency and safety of NT, our study suggests that PBT may have the potential to prevent mtDNA disease transmission.

A randomized triple blind controlled trial comparing the live birth rate of IVF following brief incubation versus standard incubation of gametes.

STUDY QUESTION: Does brief incubation of oocytes and spermatozoa improve the live birth rate (LBR) of IVF when compared with that of standard incubation? SUMMARY ANSWER: Brief incubation of gametes does not improve the LBR of IVF when compared with standard incubation. WHAT IS KNOWN ALREADY: Some small randomized studies showed that brief incubation was associated with a significantly higher ongoing pregnancy rate than standard incubation. STUDY DESIGN, SIZE, DURATION: This is a randomized triple blind study of 320 infertile women for their first or repeated cycles undergoing IVF between September 2015 and October 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women were randomized into the brief incubation group (n = 160) or the standard incubation group (n = 160) according to a computer-generated randomization list. Oocytes were incubated with spermatozoa (0.3-1.2 million motile sperm/ml) for 3-4 h in the brief incubation group while oocytes were incubated with spermatozoa at similar concentration for 20 h in the standard incubation group. The primary outcome was the LBR (a baby born alive after 22 weeks gestation) in the fresh cycle. MAIN RESULTS AND THE ROLE OF CHANCE: There was no significant difference in the LBR between the brief and standard incubation groups based on both intention-to-treat [33.0% (53/160) versus 36.8% (59/160), relative risk (RR) 0.898 (95% CI = 0.666-1.212), P = 0.482] and per protocol [41.4%(53/128) versus 41.0% (59/144), RR1.011 (95% CI = 0.760-1.343), P = 0.942] analyses. Clinical pregnancy, ongoing pregnancy, miscarriage, multiple pregnancy and implantation rates were comparable for the two groups. Similar results were found with subgroup analysis of advanced maternal age, abnormal semen analysis and repeated IVF cycles. No differences were observed in cumulative LBR between two groups. LIMITATIONS, REASONS FOR CAUTION: Various motile sperm concentrations of 0.3-1.2 million per ml were used for insemination and the reactive oxygen species level in the insemination medium was not measured. The highest level at 1.2 million per ml is still relatively low compared to prior studies, therefore we do not know whether brief incubation can improve the LBR using higher concentrations of spermatozoa. The present sample size may not be adequate to detect a smaller difference in the LBR. WIDER IMPLICATIONS OF THE FINDINGS: The present study demonstrated that a brief incubation of gametes had no significant beneficial effect on the LBR when compared with the standard incubation. The practice of brief incubation of gametes is not necessary and this can save the already tight manpower in many laboratories. STUDY FUNDING/COMPETING INTERESTS: The study was supported by the Merck-Serono China Research Fund for Fertility Experts (2015), which was not involved in study design, execution, data analysis and manuscript preparation. There are no conflicts of interest for all authors. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier NCT02534857. TRIAL REGISTRATION DATE: 28 August 2015. DATE OF FIRST PATIENT'S ENROLMENT: 8 September 2015.

FERTILITY PRESERVATION: Progress and prospects for developing human immature oocytes in vitro.

Ovarian cryopreservation rapidly developed from basic science to clinical application and can now be used to preserve the fertility of girls and young women at high risk of sterility. Primordial follicles can be cryopreserved in ovarian cortex for long-term storage and subsequently autografted back at an orthotopic or heterotopic site to restore fertility. However, autografting carries a risk of re-introducing cancer cells in patients with blood-born leukaemias or cancers with a high risk of ovarian metastasis. For these women fertility restoration could only be safely achieved in the laboratory by the complete in vitro growth (IVG) and maturation (IVM) of cryopreserved primordial follicles to fertile metaphase II (MII) oocytes. Culture systems to support the development of human oocytes have provided greater insight into the process of human oocyte development as well as having potential applications within the field of fertility preservation. The technology required to culture human follicles is extremely challenging, but significant advances have been made using animal models and translation to human. This review will detail the progress that has been made in developing human in vitro growth systems and consider the steps required to progress this technology towards clinical application.

Risk of severe maternal morbidity associated with in vitro fertilisation: a population-based study.

OBJECTIVE: To investigate the association between in vitro fertilisation IVF and severe maternal morbidity (SMM) and to explore the role of multiple pregnancy as an intermediate factor. DESIGN: Population-based cohort-nested case-control study. SETTING: Six French regions in 2012/13. POPULATION: Cases were 2540 women with SMM according to the EPIMOMS definition; controls were 3651 randomly selected women who gave birth without SMM. METHODS: Analysis of the associations between IVF and SMM with multivariable logistic regression models, differentiating IVF with autologous oocytes (IVF-AO) from IVF with oocyte donation (IVF-OD). The contribution of multiple pregnancy as an intermediate factor was assessed by path analysis. MAIN OUTCOME MEASURES: Severe maternal morbidity overall and SMM according to its main underlying causal condition and by severity (near misses). RESULTS: The risk of SMM was significantly higher in women with IVF (adjusted OR = 2.5, 95% CI 1.8-3.3). The risk of SMM was significantly higher with IVF-AO, for all-cause SMM (aOR = 2.0, 95% CI 1.5-2.7), for near misses (aOR = 1.9, 95% CI 1.3-2.8), and for intra/postpartum haemorrhages (aOR = 2.3, 95% CI 1.6-3.2). The risk of SMM was significantly higher with IVF-OD, for all-cause SMM (aOR = 18.6, 95% CI 4.4-78.5), for near misses (aOR = 18.1, 95% CI 4.0-82.3), for SMM due to hypertensive disorders (aOR = 16.7, 95% CI 3.3-85.4) and due to intra/postpartum haemorrhages (aOR = 18.0, 95% CI 4.2-77.8). Path-analysis estimated that 21.6% (95% CI 10.1-33.0) of the risk associated with IVF-OD was mediated by multiple pregnancy, and 49.6% (95% CI 24.0-75.1) of the SMM risk associated with IVF-AO. CONCLUSION: The risk of SMM is higher in IVF pregnancies after adjustment for confounders. Exploratory results suggest higher risks among women with IVF-OD; however, confidence intervals were wide, so this finding needs to be confirmed. A large part of the association between IVF-AO and SMM appears to be mediated by multiple pregnancy. TWEETABLE ABSTRACT: The risk of severe maternal morbidity is higher in IVF-conceived pregnancies than in pregnancies conceived by other means.

Experiences and psychological outcomes of the oocyte donor: a survey of donors post-donation from one center.

PURPOSE: To assess the experiences and psychological outcomes of oocyte donors from one fertility center. METHODS: An anonymous survey was distributed via a secure email to 161 donors who underwent oocyte donation-anonymous, directed/known, and recruited agency-between January 2008 and January 2019 at the NYU Langone Fertility Center. RESULTS: Thirty-six donors completed the survey with the majority between 2 and 10 years since donation. Respondents reported a high prevalence of psychiatric symptoms or diagnoses post-donation. The majority of donors reported positive thoughts and feelings toward their donation process as well as to the knowledge of children born from their donation. Negative comments about donation were in the minority but focused on unexpected aspects about the process or outcome. Based on qualitative analysis, thoughts about family or "family-oriented thoughts" were the most frequent theme in respondent comments. 62.5% of respondents reporting that they would be open to identity-disclosure or open donation after experiencing the process. CONCLUSIONS: Despite a high reported prevalence of psychiatric symptoms, the majority of respondents felt positively about the donation experience as well as the prospect of open donation or identity-disclosure post-donation. Further research on long-term psychological outcomes, related to all aspects of donation, is important as the counseling and informed consent of oocyte donors continues to evolve. These data will be particularly important with regard to the aspect of disclosure, both planned and unplanned, in the modern era of electronic information sharing.

Ovarian stimulation for fertility preservation or family building in a cohort of transgender men.

PURPOSE: The purpose of this study was to compare ovarian stimulation and pregnancy outcomes between transgender men (1) with and without a history of testosterone use (HRT) and (2) to cisgender women. METHODS: Retrospective chart review between January 1st 2015 and March 1st, 2019 of transgender men and cisgender women seeking ovarian stimulation (OS) matched by BMI and age. Outcomes were compared using Fisher's exact or Wilcoxon's rank sum tests. RESULTS: Thirteen transgender men presented for OS, 7 who used HRT. When comparing transgender men with and without a history of HRT, there were no differences in the baseline follicle count, cycle length, or FSH and hmG used (p = 0.193, 0.306, 0.200, and 0.197, respectively). Transgender men who used HRT had lower peak estradiol and oocytes retrieved compared to transgender men with no HRT use; peak estradiol levels of 1175 pg/mL IQR [559.5-2684]) vs 2713.5 pg/mL IQR [2335-3105]; oocytes retrieved 12 IQR [4-26]) vs. 25.5 [18-28] (p = 0.046. and 0.038, respectively). There were no differences in the estradiol level per oocyte, meiosis II oocyte yield, or maturity rate (MII/oocytes) between the two groups (p = 1.000, 0.148, and 0.147, respectively). Peak estradiol levels were lower among transgender men compared to cisgender women (p = 0.016), but the remaining cycle characteristics were similar between the two groups. Three successful pregnancies were conceived using the oocytes of transgender men who used HRT. CONCLUSION: HRT use may not negatively impact ovarian stimulation outcomes. Clinical pregnancies are possible from the oocytes of transgender men with a history of HRT.

Biphasic in vitro maturation (CAPA-IVM) specifically improves the developmental capacity of oocytes from small antral follicles.

PURPOSE: To investigate the effectiveness of a biphasic IVM culture strategy at improving IVM outcomes in oocytes from small follicles (< 6 mm) compared with routine Standard IVM in patients with polycystic ovaries. METHODS: This prospective pilot study was performed in 40 women with polycystic ovaries whose oocytes were randomized to two IVM culture methods. Patients received a total stimulation dose of 450 IU rFSH. Cumulus-oocyte complexes (COCs) from follicles < 6 mm and ≥ 6 mm were retrieved and cultured separately in either a prematuration medium with c-type natriuretic peptide followed by IVM (CAPA-IVM), or STD-IVM. Primary outcomes were maturation rate, embryo quality, and the number of vitrified day 3 embryos per patient. RESULTS: Use of the CAPA-IVM system led to a significant improvement in oocyte maturation (p < 0.05), to a doubling in percentage of good and top-quality day 3 embryos per COC, and to an increased number of vitrified day 3 embryos (p < 0.001), compared to STD IVM. Oocytes from follicles < 6 mm benefited most from CAPA-IVM, showing a significant increase in the amount of good and top-quality embryos compared to STD IVM. CAPA-IVM yielded significantly (p < 0.0001) less GV-arrested oocytes and larger oocyte diameters (p < 0.05) than STD IVM. CONCLUSIONS: CAPA-IVM brings significant improvements in maturation and embryological outcomes, most notably to oocytes from small antral follicles (< 6 mm), which can be easily retrieved from patients with a minimal ovarian stimulation. The study demonstrates the robustness and transferability of the CAPA-IVM method across laboratories and populations.

Fertility preservation in women with malignancies: the accuracy of antral follicle count collected randomly during the menstrual cycle in predicting the number of oocytes retrieved.

PURPOSE: To evaluate the capacity of random antral follicle count (AFC), i.e., AFC recorded at any time during the menstrual cycle, to predict the number of retrieved mature oocytes in women with malignancies undergoing random start ovarian hyperstimulation METHODS: A consecutive series of 72 women with malignancies who underwent ovarian hyperstimulation aimed at egg freezing between July 2014 and December 2016 was retrospectively reviewed. A standardized random start protocol was used for all women. AFC and serum AMH were systematically assessed prior to initiating ovarian hyperstimulation. The main outcome was the retrieval of ≥ 10 mature oocytes. The accuracy of random AFC was tested with the c-statistics (area under the ROC curve). RESULTS: For the whole cohort, the c-statistics for the prediction of ≥ 10 mature oocytes using AFC and serum AMH were similar. Specifically, the areas under the curve were 0.76 (95%CI 0.66-0.87) and 0.82 (95%CI 0.72-0.92), respectively (p = ns). Moreover, when considering the subgroup of women recruited after day 5 of the cycle (proper random start, n = 52), the areas under the curve did not also differ. Specifically, they resulted in 0.77 (95%CI 0.64-0.89) and 0.83 (95%CI 0.72-0.95), respectively (p = ns). CONCLUSIONS: AFC collected at any time during the menstrual cycle can provide valuable information for the counseling of women with malignancies scheduled for oocyte cryopreservation. Its reliability appears to be non-inferior to that of serum AMH.

Generation of a Xenopus laevis F1 albino J strain by genome editing and oocyte host-transfer.

Completion of the Xenopus laevis genome sequence from inbred J strain animals has facilitated the generation of germline mutant X. laevis using targeted genome editing. In the last few years, numerous reports have demonstrated that TALENs are able to induce mutations in F0 Xenopus embryos, but none has demonstrated germline transmission of such mutations in X. laevis. In this report we used the oocyte host-transfer method to generate mutations in both tyrosinase homeologs and found highly-penetrant germline mutations; in contrast, embryonic injections yielded few germline mutations. We also compared the distribution of mutations in several F0 somatic tissues and germ cells and found that the majority of mutations in each tissue were different. These results establish that X. laevis J strain animals are very useful for generating germline mutations and that the oocyte host-transfer method is an efficient technique for generating mutations in both homeologs.