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

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

Fertility preservation and realignment in transgender women.

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

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

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

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

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

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

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