Women's preventive services initiative: fertility counseling overlooked.

The 2021 Women's Preventive Services Initiative Well-Woman Chart outlines a framework for incorporating preventive health services recommended by the Women's Preventive Services Initiative, the US Preventive Services Task Force, and Bright Futures based on age, health status, and risk factors. Following the previous guidelines for preventive care, this document failed to offer recommendations or guidelines for infertility screening and fertility counseling in the course of well-woman care. Healthcare providers may be less likely to address fertility with their patients in the absence of clear, evidence-based recommendations, potentially resulting in underinformed reproductive choices and compromised reproductive potential. Given the devastating consequences of infertility and unintended childlessness, we, herein, propose that infertility screening and fertility counseling should become an integral part of well-woman care and that organizations, such as the Women's Preventive Services Initiative, put forth guidelines to assist providers in addressing fertility throughout a woman's reproductive lifespan.

Guidelines informing counseling on female age-related fertility decline: a systematic review.

PURPOSE: To identify, appraise, and assess clinical practice guidelines informing patient counseling on female age-related fertility decline. METHODS: Searched electronic database records from January 1, 2006, to September 10, 2018, and professional society websites. The search terms included iterations of "guideline," "counseling," "preconception," "age-related fertility decline," and "reproductive life planning." English-language professional organization guidelines addressing patient counseling on age-specific reproductive health topics were included. Assessed the methodological quality of included guidelines using the AGREE II instrument. Guidelines were categorized as high quality or low quality based on AGREE II scores. Extracted age-specific reproductive health recommendations of high-quality guidelines. RESULTS: The search identified 2918 records. Nineteen records addressed counseling on age-related fertility decline; only 6 focused only on reproductive aging, with the remaining 13 covering related topics. Eleven met criteria for high quality. All high-quality guidelines had high "rigor of development" scores on AGREE II. Ten high-quality guidelines stated an age at which female fertility declines, ranging from 30 to "late 30s." One recommended a specific age at which patients should be counseled. Five of eleven high-quality guidelines did not discuss the obstetric and perinatal risks of advanced maternal age. CONCLUSIONS: Few high-quality guidelines address counseling on female age-related fertility decline, and existing guidance on reproductive aging counseling is inconsistent and incomplete. Greater rigor of development and incorporation of age-specific counseling recommendations into clinical practice guidelines could lead to improved patient anticipatory guidance and more informed reproductive choices.

A View from the past into our collective future: the oncofertility consortium vision statement.

PURPOSE: Today, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium. METHODS: The Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process. RESULTS: This interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity. CONCLUSION: The goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.

mTORC1/2 inhibition preserves ovarian function and fertility during genotoxic chemotherapy.

The ovary contains oocytes within immature (primordial) follicles that are fixed in number at birth. Activation of follicles within this fixed pool causes an irreversible decline in reproductive capacity, known as the ovarian reserve, until menopause. Premenopausal women undergoing commonly used genotoxic (DNA-damaging) chemotherapy experience an accelerated loss of the ovarian reserve, leading to subfertility and infertility. Therefore, there is considerable interest but little effective progress in preserving ovarian function during chemotherapy. Here we show that blocking the kinase mammalian/mechanistic target of rapamycin (mTOR) with clinically available small-molecule inhibitors preserves ovarian function and fertility during chemotherapy. Using a clinically relevant mouse model of chemotherapy-induced gonadotoxicity by cyclophosphamide, and inhibition of mTOR complex 1 (mTORC1) with the clinically approved drug everolimus (RAD001) or inhibition of mTORC1/2 with the experimental drug INK128, we show that mTOR inhibition preserves the ovarian reserve, primordial follicle counts, serum anti-Mullerian hormone levels (a rigorous measure of the ovarian reserve), and fertility. Chemotherapy-treated animals had significantly fewer offspring compared with all other treatment groups, whereas cotreatment with mTOR inhibitors preserved normal fertility. Inhibition of mTORC1 or mTORC1/2 within ovaries was achieved during chemotherapy cotreatment, concomitant with preservation of primordial follicle counts. Importantly, our findings indicate that as little as a two- to fourfold reduction in mTOR activity preserves ovarian function and normal birth numbers. As everolimus is approved for tamoxifen-resistant or relapsing estrogen receptor-positive breast cancer, these findings represent a potentially effective and readily accessible pharmacologic approach to fertility preservation during conventional chemotherapy.

Access to infertility care in a low-resource setting: bridging the gap through resident and fellow education in a New York City public hospital.

PURPOSE: Improving access to care is an issue at the forefront of reproductive medicine. We sought to describe how one academic center, set in the background of a large and diverse metropolitan city, cares for patients with extremely limited access to reproductive specialists. METHODS: The NYU Reproductive Endocrinology and Infertility (REI) Fellowship program provides a "fellow-run clinic" within Manhattan's Bellevue Hospital Center, which is led by the REI fellows and supervised by the REI attendings of the NYU Langone Health system. A description of the history of the hospital as well as the logistics of the fertility clinic is provided as a logistical template for implementation. RESULTS: The fellow-run fertility clinic at Bellevue hospital is held on two half days per month seeing approximately 150 new patients per year. The fertility workup, counseling, surgery, as well as ovulation induction, and early pregnancy management are offered within the construct of the fellowship and residency at NYU. Barriers to care and ways to circumvent those barriers are discussed in detail. CONCLUSION: By utilizing the ambition and construct of the OB/GYN programs, we greatly improve care for an otherwise underserved patient population by offering an efficient and optimal infertility workup and treatment in a population that would otherwise be without care. We utilize the framework of graduate medical education to provide autonomy, experience, and mentorship to both residents and fellows in our programs in an effort to provide a solution to combating inequity in infertility care.

Beyond the biopsy: predictors of decision regret and anxiety following preimplantation genetic testing for aneuploidy.

STUDY QUESTION: What factors are associated with decision regret and anxiety following preimplantation genetic testing for aneuploidy (PGT-A)? SUMMARY ANSWER: The majority of patients viewed PGT-A favourably regardless of their outcome; although patients with negative outcomes expressed greater decision regret and anxiety. WHAT IS KNOWN ALREADY: PGT-A is increasingly utilized in in vitro fertilization (IVF) cycles to aid in embryo selection. Despite the increasing use of PGT-A technology, little is known about patients' experiences and the possible unintended consequences of decision regret and anxiety related to PGT-A outcome. STUDY DESIGN, SIZE, DURATION: Anonymous surveys were distributed to 395 patients who underwent their first cycle of autologous PGT-A between January 2014 and March 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS: There were 69 respondents who underwent PGT-A at a university-affiliated fertility centre, completed the survey and met inclusion criteria. Respondents completed three validated questionnaires including the Brehaut Decision Regret (DR) Scale, short-form State-Trait Anxiety Inventory (STAI-6) and a health literacy scale. The surveys also assessed demographics, fertility history, IVF and frozen embryo transfer cycle data. MAIN RESULTS AND THE ROLE OF CHANCE: The majority of respondents were Caucasian, >35 years of age and educated beyond an undergraduate degree. The majority utilized PGT-A on their first IVF cycle, most commonly to 'maximize the efficiency of IVF' or reduce per-transfer miscarriage risk. The overall median DR score was low, but 39% of respondents expressed some degree of regret. Multiple regression confirmed a relationship between embryo ploidy and decision regret, with a lower number of euploid embryos associated with a greater degree of regret. Patients who conceived following euploid transfer reported less regret than those who miscarried or failed to conceive (P < 0.005). Decision regret was inversely associated with number of living children but not associated with age, education, race, insurance coverage, religion, marital status or indication for IVF/PGT-A. Anxiety was greater following a negative pregnancy test or miscarriage compared to successful conception (P < 0.0001). Anxiety was negatively associated with age, time since oocyte retrieval and number of living children, and a relationship was observed between anxiety and religious affiliation. Overall, decision regret was low, and 94% of all respondents reported satisfaction with their decision to pursue PGT-A; however, patients with a negative outcome were more likely to express decision regret and anxiety. LIMITATIONS, REASON FOR CAUTION: This survey was performed at a single centre with a relatively homogenous population, and the findings may not be generalizable. Reasons for caution include the possibility of response bias and unmeasured differences among those who did and did not respond to the survey, as well as the possibility of recall bias given the retrospective nature of the survey. Few studies have examined patient perceptions of PGT-A, and our findings should be interpreted with caution. WIDER IMPLICATIONS OF THE FINDINGS: Overall decision regret was low following PGT-A, and the vast majority deemed the information gained valuable for reproductive planning regardless of outcome. However, more than one-third of the respondents expressed some degree of regret. Respondents with no euploid embryos were more likely to express regret, and those with a negative outcome following euploid embryo transfer expressed both higher regret and anxiety. These data identify unanticipated consequences of PGT-A and suggest opportunities for additional counselling and support surrounding IVF with PGT-A. STUDY FUNDING/COMPETING INTEREST(S): No external funding was obtained for this study. D.H.M. reports personal fees, honorarium, and travel expenses from Ferring Pharmaceuticals, personal fees and travel expenses from Granata Bio, and personal fees from Biogenetics Corporation, The Sperm and Embryo Bank of New York, and ReproART: Georgian American Center for Reproductive Medicine. All conflicts are outside the submitted work.

Uterus transplantation in women who are genetically XY.

Uterus transplantation is an emerging technology adding to the arsenal of treatments for infertility; specifically the only available treatment for uterine factor infertility. Ethical investigations concerning risks to uteri donors and transplant recipients have been discussed in the literature. However, missing from the discourse is the potential of uterus transplantation in other groups of genetically XY women who experience uterine factor infertility. There have been philosophical inquiries concerning uterus transplantation in genetically XY women, which includes transgender women and women with complete androgen insufficiency syndrome. We discuss the potential medical steps necessary and associated risks for uterus transplantation in genetically XY women. Presently, the medical technology does not exist to make uterus transplantation a safe and effective option for genetically XY women, however this group should not be summarily excluded from participation in trials. Laboratory research is needed to better understand and reduce medical risk and widen the field to all women who face uterine factor infertility.

Interactive case-based learning improves resident knowledge and confidence in reproductive endocrinology and infertility.

Resident physicians' scores on the REI section of the CREOG exam are traditionally low, and nearly 40% of house staff nation-wide perceive their REI knowledge to be poor. We aimed to assess whether an interactive case-based group-learning curriculum would narrow the REI knowledge gap by improving understanding and retention of core REI concepts under the time constraints affecting residents. A three-hour case-based workshop was developed to address four primary CREOG objectives. A multiple-choice test was administered immediately before and after the intervention and 7 weeks post-workshop, to evaluate both knowledge and confidence. Following the intervention, residents self-reported increased confidence with counseling and treatment of PCOS, ovulation induction cycle monitoring, counseling and treatment of POI, and breaking bad news related to infertility (p < 0.05). The multiple-choice exam was re-administered 7 weeks post-intervention, and scores remained significantly improved compared to pre-workshop scores (p < 0.05). At that time, all residents either strongly agreed (91.7%) or agreed (8.3%) that the case-based interactive format was preferable to traditional lecture-based teaching. In conclusion, a nontraditional curriculum aimed at teaching core REI concepts to residents through interactive case-based learning can be successfully integrated into a residency curriculum, and significantly improves knowledge and confidence of critical concepts in REI.

2017 in-training initiative of the Journal of Assisted Reproduction and Genetics: the JARG Young Investigator Forum.

The Journal of Assisted Reproduction and Genetics introduces the JARG Young Investigator Forum, an in-training initiative aimed to expand opportunities for young investigators. The JARG Young Investigator Forum has three primary goals: first, to increase opportunities for trainees and young investigators to contribute as researchers and writers. Trainees will be invited to publish mini-reviews based on their area of research interest/expertise and will have the opportunity to indicate "in-training" when submitting manuscripts as first author Educational research pertaining to reproductive medicine training will be added to the purview of the journal. Second, the Young Investigator Forum will increase opportunities for trainees to serve as journal reviewers and will provide mentorship throughout the peer review process. Third, trainees will have the unique opportunity to gain editorial experience by serving as a "guest editor" of the Young Investigator Forum, overseeing all editorial aspects of their assigned particular issue. Through authorship, peer review, and editorial experience, we seek to nurture the academic skills that are critical to a well-rounded career. The JARG Young Investigator Forum aims to foster career development for a generation of trainees who represent the future of reproductive medicine, and here, we outline the primary goals and objectives of the initiative.

Preimplantation Genetic Diagnosis (PGD) for Monogenic Disorders: the Value of Concurrent Aneuploidy Screening.

Pre-implantation genetic diagnosis (PGD) has changed the landscape of clinical genetics by helping families reduce the transmission of monogenic disorders. However, given the high prevalence of embryonic aneuploidy, particularly in patients of advanced reproductive age, unaffected embryos remain at high risk of implantation failure or pregnancy loss due to aneuploidy. 24-chromosome aneuploidy screening has become widely utilized in routine in vitro fertilization (IVF) to pre-select embryos with greater pregnancy potential, but concurrent 24-chromosome aneuploidy screening has not become standard practice in embryos biopsied for PGD. We performed a retrospective cohort study of patients who underwent PGD with or without 24-chromosome aneuploidy screening to explore the value of concurrent screening. Among the PGD + aneuploidy-screened group (n = 355 blastocysts), only 25.6 % of embryos were both Single Gene Disorder (SGD)-negative (or carriers) and euploid; thus the majority of embryos were ineligible for transfer due to the high prevalence of aneuploidy. Despite a young mean age (32.4 ± 5.9y), 49.9 % of Blastocysts were aneuploid. The majority of patients (53.2 %) had ≥1 blastocyst that was Single Gene Disorder (SGD)-unaffected but aneuploid; without screening, these unaffected but aneuploid embryos would likely have been transferred resulting in implantation failure, pregnancy loss, or a pregnancy affected by chromosomal aneuploidy. Despite the transfer of nearly half the number of embryos in the aneuploidy-screened group (1.1 ± 0.3 vs. 1.9 ± 0.6, p < 0.0001), the implantation rate was higher (75 % vs. 53.3 %) and miscarriage rate lower (20 % vs. 40 %) (although not statistically significant). 24-chromosome aneuploidy screening when performed concurrently with PGD provides valuable information for embryo selection, and notably improves single embryo transfer rates.

Is there an androgen level threshold for aneuploidy risk in infertile women?

BACKGROUND: Low functional ovarian reserve (LFOR) has been associated with hypoandrogenemia and increased embryo aneuploidy, while androgen supplementation has been reported to improve aneuploidy rates. We, therefore, assessed whether in infertile women undergoing in vitro fertilization (IVF) androgen concentrations are associated with aneuploidy rates. METHODS: This study was performed in 2 academically affiliated fertility centers in New York City and an academically affiliated steroid chemistry laboratory in Utah. Androgen concentrations were measured in blinded fashion from 84 infertile women (age 40.3+/-2.4 years) at New York University (NYU), using a validated LC-MS/MS method, in cryopreserved serum samples of patients who had undergone IVF with concomitant preimplantation genetic screening (PGS), utilizing a 24-chromosome platform. The Center for Human Reproduction (CHR) provided plasma samples of 100 historical controls (ages 38.6+/-5.0 years) undergoing IVF without PGS. Statistical comparisons were made of androgen concentrations, and of associations between androgen concentrations and embryo aneuploidy. RESULTS: Women undergoing IVF+PGS at NYU revealed no association between embryo aneuploidy and androgen concentrations but demonstrated significantly lower androgen concentrations than the 100 control patients from CHR, CONCLUSIONS: Though this study revealed no association between androgen levels and embryo ploidy, the extremely low androgen levels in the NYU study group raise the possibility of a threshold effect below which testosterone no longer affects aneuploidy. Before an androgen effect on embryo ploidy can be completely ruled out, a patient population with more normal androgen levels has to be investigated.

Heterotopic Gestation with Twin Intrauterine Implantation Following Transfer of Three Developmentally-delayed Embryos from Cryopreserved Oocytes: A Case Report.

BACKGROUND: In vitro fertilization (IVF) data suggest improved live birth rates for embryos transferred at the blastocyst versus the cleavage stage. Embryos that have not reached the blastocyst stage by day 5 postthaw have diminished potential for implantation and live birth. Few data exist regarding embryogenesis and optimal timing of transfer for embryos derived from previously cryopreserved oocytes, but we report the case of 100% implantation following transfer of 3 developmentally-delayed embryos derived from cryopreserved oocytes. CASE: A 38-year-old woman cryopreserved 20 oocytes for the purpose of future childbearing. At age 42 she returned to thaw and fertilize 8 oocytes using donor sperm. Embryos were cultured to day 5 postthaw, at which time 1 morula and 2 cleavage-stage embryos were available for transfer. Three-embryo transfer resulted in a heterotopic tubal pregnancy and twin intrauterine gestation. Laparoscopic salpingectomy was performed for the ectopic gestation. The twin intrauterine pregnancy spontaneously reduced to singleton, and the patient delivered a live-born infant. CONCLUSION: While heterotopic and multifetal pregnancy are known risks of multiembryo transfer, 3 lesser-quality embryos derived from cryopreserved oocytes would be unlikely to have high implantation potential. Future studies are needed to delineate timing of embryogenesis events in previously cryopreserved oocytes.

The oocyte microenvironment is altered in adolescents compared to oocyte donors.

Study question: Are the molecular signatures of cumulus cells (CCs) and follicular fluid (FF) of adolescents undergoing fertility preservation differ from that of reproductively adult oocyte donors? Summary answer: The microenvironment immediately surrounding the oocyte, including the CCs and FF, is altered in adolescents undergoing fertility preservation compared to oocyte donors. What is known already: Adolescents experience a period of subfecundity following menarche. Recent evidence suggests that this may be at least partially due to increased oocyte aneuploidy. Reproductive juvenescence in mammals is associated with suboptimal oocyte quality. Study design size duration: This was a prospective cohort study. Adolescents (10-19 years old, N=23) and oocyte donors (22-30 years old, N=31) undergoing ovarian stimulation and oocyte retrieval at the Northwestern Fertility and Reproductive Medicine Center between November 1, 2020 and May 1, 2023 were enrolled in this study. Participants/materials setting methods: Patient demographics, ovarian stimulation, and oocyte retrieval outcomes were collected for all participants. The transcriptome of CCs associated with mature oocytes was compared between adolescents (10-19 years old, n=19), and oocyte donors (22-30 years old, n=19) using bulk RNA-sequencing. FF cytokine profiles (10-19 years old, n=18 vs. 25-30 years old, n=16) were compared using cytokine arrays. Main results and the role of chance: RNA-seq analysis revealed 581 differentially expressed genes (DEGs) in cumulus cells of adolescents relative to oocyte donors, with 361 genes downregulated and 220 upregulated. Genes enriched in pathways involved in cell cycle and cell division (e.g., GO:1903047, p= 3.5 × 10-43; GO:0051983, p= 4.1 × 10-30; GO:0000281, p= 7.7 × 10-15; GO:0044839, p= 5.3 × 10-13) were significantly downregulated, while genes enriched in several pathways involved in cellular and vesicle organization (e.g., GO:0010256, p= 1.2 × 10-8; GO:0051129, p= 6.8 × 10-7; GO:0016050, p= 7.4 × 10-7; GO:0051640, p= 8.1 × 10-7) were upregulated in CCs of adolescents compared to oocyte donors. The levels of 9 cytokines were significantly increased in FF of adolescents compared to oocyte donors: IL-1 alpha (2-fold), IL-1 beta (1.7-fold), I-309 (2-fold), IL-15 (1.6-fold), TARC (1.9-fold), TPO (2.1-fold), IGFBP-4 (2-fold), IL-12-p40 (1.7-fold) and ENA-78 (1.4-fold). Interestingly, 7 of these cytokines have known pro-inflammatory roles. Importantly, neither the CC transcriptomes or FF cytokine profiles were different in adolescents with or without cancer. Large scale data: Original high-throughput sequencing data will be deposited in Gene Expression Omnibus (GEO) before publication, and the GEO accession number will be provided here. Limitations reasons for caution: This study aims to gain insights into the associated gamete quality by studying the immediate oocyte microenvironment. The direct study of oocytes is more challenging due to sample scarcity, as they are cryopreserved for future use, but will provide a more accurate assessment of oocyte reproductive potential. Wider implications of the findings: Understanding the underpinnings of altered immediate oocyte microenvironment of adolescent patients may provide insights into the reproductive potential of the associated gametes in the younger end of the age spectrum. This has implications for the fertility preservation cycles for very young patients. Study funding/competing interests: This project was supported by Friends of Prentice organization SP0061324 (M.M.L and E.B.), Gesualdo Family Foundation (Research Scholar: M.M.L.), and NIH/NICHD K12 HD050121 (E.B.). The authors have declared that no conflict of interest exists.

A Geospatial Analysis of Disparities in Access to Oncofertility Services.

Importance: Fertility preservation (FP), including oocyte and embryo cryopreservation prior to gonadotoxic therapy, is an urgent and essential component of comprehensive cancer care. Geographic proximity to a center offering FP is a critical component of ensuring equitable access for people with cancer desiring future fertility. Objective: To characterize the distribution of centers offering FP services in the US, quantify the number of self-identified reproductive-age female individuals living outside of geographically accessible areas, and investigate the association between geographic access and state FP mandates. Design, Setting, and Participants: This cross-sectional analysis calculated 2-hour travel time isochrone maps for each center based on latitude and longitude coordinates. Population-based geospatial analysis in the US was used in this study. Fertility clinics identified through the 2018 Centers for Disease Control and Prevention Fertility Clinic Success Rates Report were defined as oncofertility centers by meeting 4 criteria: (1) offered oocyte and embryo cryopreservation, (2) performed at least 1 FP cycle in 2018, (3) served people without partners, and (4) had an accredited laboratory. County-level data were obtained from the 2020 US Census, with the primary at-risk population identified as reproductive-age female individuals aged 15 years to 44 years. The analysis was performed from 2021 to 2022. Exposures: Location outside of 2-hour travel time isochrone of an oncofertility center. Main Outcomes and Measures: Oncofertility centers were compared with centers not meeting criteria and were classified by US region, state FP mandate status, number of assisted reproductive technology cycles performed, and number of FP cycles performed. The number and percentage of at-risk patients, defined as those living outside of accessible service areas by state, were identified. Results: Among 456 Centers for Disease Control and Prevention-reporting fertility clinics, 86 (18.9%) did not meet the criteria as an oncofertility center. A total of 3.63 million (5.70%) reproductive-age female individuals lack geographic access to an oncofertility center. States with FP mandates have the highest rates of eligible female patients with geographic access (98.54%), while states without active or pending legislation have the lowest rates (79.57%). The greatest disparities in geographic access to care are most concentrated in the Mountain West and West North Central regions. Conclusions and Relevance: Patients face numerous barriers to comprehensive cancer care, including a lack of geographic access to centers capable of offering FP services. This cross-sectional study identified disparities in geographic access and potential opportunities for strategic expansion.

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

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

Natural Cycle Frozen Embryo Transfer: Evaluating Optimal Protocols for Preparation and Timing.

Background: While natural cycle frozen embryo transfer (NC-FET) is becoming increasingly common, significant practice variation exists in the use of ovulation induction medications, administration of ovulation trigger, and timing of embryo transfer without consensus as to the optimal protocol. Aims: The objective of this study is to evaluate the association of key aspects of the NC-FET protocol with implantation, pregnancy and live birth. Settings and Design: This was a retrospective cohort study of blastocyst stage NC-FET cycles from October 2019 to July 2021 at a single academic fertility centre. Materials and Methods: Protocols varied between cycles across three key parameters which were evaluated as primary predictors of cycle outcomes: (1) use of letrozole for mild ovarian stimulation/ovulation induction, (2) administration of exogenous ovulation trigger versus spontaneous luteinising hormone surge and (3) transfer timing based on ovulation trigger versus sequential progesterone monitoring. Primary outcomes included implantation rate, clinical pregnancy and ongoing pregnancy. Statistical Analysis Used: Generalised estimating equations were fitted to obtain adjusted odds ratios or rate ratios as appropriate with 95% confidence intervals for each outcome across the three primary predictors. Results: A total of 183 cycles from 170 unique patients were eligible for inclusion. The average implantation rate was 0.58, resulting in an overall clinical pregnancy and ongoing pregnancy rate of 59.0% and 51.4%, respectively. After adjusting for age at embryo freeze and history of a failed embryo transfer, there were no significant associations between any predictor and implantation rate, clinical pregnancy, ongoing pregnancy, or live birth. Conclusion: In NC-FET, a variety of preparation and timing protocols may lead to comparable cycle outcomes, potentially allowing for flexibility on the basis of patient and physician preference. These findings warrant validation in a larger, randomised trial.

Disaster preparedness in assisted reproductive technology.

The American Society for Reproductive Medicine compels centers providing reproductive medicine care to develop and implement an emergency preparedness plan in the event of a disaster. Reproductive care is vulnerable to disruptions in energy, transportation, and supply chains as well as may have potential destructive impacts on infrastructure. With the relentless progression of events related to climate change, centers can expect a growing number of such disruptive events and must prepare to deal with them. This article provides a case study of the impact of Hurricane Sandy on one center in New York City and proposes recommendations for future preparedness and mitigation.

Fertility Preservation During the COVID-19 Pandemic: Modified But Uncompromised.

Purpose: Throughout COVID-19, our clinic remained operational for patients requiring urgent fertility preservation (FP). This study aimed to characterize changes to clinical protocols during the first wave of COVID-19 and compare outcomes to historical controls. Methods: We performed a retrospective cohort study at a university fertility center examining all patients who underwent medically indicated FP cycles during the American Society for Reproductive Medicine (ASRM) COVID-19 Task Force-recommended suspension of fertility treatment (March 17-May 11, 2020) and patients from the same time period in 2019. FP care was modified for safety during the first wave of COVID-19 with fewer monitoring visits and infection control measures. FP cycle characteristics and outcomes were compared across years. Results: The volume of cycles was nearly 30% higher in 2020 versus 2019 (27 vs. 19). Diagnoses, age, and anti-Mullerian hormone were similar between cohorts. More patients elected to pursue embryo cryopreservation over oocyte cryopreservation in 2020 versus 2019 (45.8% vs. 5.2%, p < 0.005). Patients managed during COVID-19 had fewer monitoring visits (5 ± 1 vs. 6 ± 1, p = 0.02), and 37.5% of cycles utilized a blind trigger injection. There was no difference in total days of ovarian stimulation (11 ± 1 vs. 11 ± 2, p > 0.05), but 2020 cycles utilized more gonadotropin (4770 ± 1480 vs. 3846 ± 1438, p = 0.04). There was no difference in total oocytes retrieved (19 ± 14 vs. 22 ± 12, p > 0.05) or mature oocytes vitrified (15 ± 12 vs. 17 ± 9, p > 0.05) per cycle. Conclusions: FP continued during COVID-19, and more cycles were completed in 2020 versus 2019. Despite minimized monitoring, outcomes were optimal and equivalent to historical controls, suggesting FP care can be adapted without compromising outcomes.