Association between arthritis treatments and ovarian reserve: a prospective study.

RESEARCH QUESTION: How do anti-Müllerian hormone (AMH) concentrations in women with and without arthritis compare? Is there an association between AMH and arthritis drug regimen? DESIGN: In this prospective cohort study, AMH was measured at two time points (T0 and T1) in 129 premenopausal women with arthritis. AMH at T0 was compared with that from a bank of serum samples from 198 premenopausal women without arthritis. Primary outcomes were: (i) diminished ovarian reserve (DOR) (AMH <1.1 ng/ml) and (ii) annual rate of AMH decrease. Univariate, multivariable and Firth logistic regression identified variables associated with annual AMH decrease in excess of the 75th percentile. RESULTS: Median time between T0 and T1 was 1.72 years. At time T0, median age-adjusted AMH in women with arthritis was significantly lower than that of women without arthritis (median 2.21 ng/ml versus 2.78 ng/ml; P = 0.009). Women with arthritis at highest risk for DOR had a history of tubal sterilization or were over the age of 35. Those with highest odds of having an annual AMH decrease in excess of the 75th percentile (over 28% decrease per year) were those: over the age of 35 or who sought care for infertility. Women with arthritis taking methotrexate alone (OR 0.08, 95% CI 0.01-0.67) or methotrexate plus tumour necrosis factor-alpha antagonists (OR 0.13, 95% CI 0.02-0.89) were less likely to be in the highest quartile of annual AMH decrease than women with arthritis not taking medication. CONCLUSIONS: Women with arthritis had lower AMH than healthy controls. Long-term methotrexate use was not associated with an annual AMH decrease.

Imaging of the Vagina: Spectrum of Disease with Emphasis on MRI Appearance.

The vagina is a median fibromuscular structure of the female reproductive system that extends from the vulva inferiorly to the uterine cervix superiorly. As most vaginal lesions are detected at gynecologic examination, imaging performed for nongynecologic indications can frequently cause concomitant vaginal pathologic conditions to be overlooked. The vagina is often underevaluated at routinely performed pelvic transvaginal US because of a narrow scan area and probe positioning. MRI has progressively become the imaging method of choice for vaginal pathologic conditions, as it provides excellent soft-tissue detail with unparalleled delineation of the complex pelvic floor anatomy and helps establish a diagnosis for most vaginal diseases. It is important that radiologists use a focused approach toward understanding and correctly recognizing different vaginal entities that may otherwise go unnoticed. In this case-based review, the authors discuss the key imaging features of wide-ranging vaginal pathologic conditions, with emphasis on appearance at MRI. Knowledge of vaginal anatomy and embryology is helpful in evaluating congenital anomalies at imaging. Often seen incidentally, vaginal inflammation can cause diagnostic confusion. Because of its central location in the pelvis, the vagina can form fistulas to the urinary bladder, colon, rectum, or anus. Vaginal masses can be neoplastic and nonneoplastic and include a myriad of benign and malignant conditions, some of which have characteristic imaging features. Therapeutic and nontherapeutic vaginal foreign bodies include pessaries, vaginal mesh, and packing that can be seen with or without associated complications. Online supplemental material is available for this article. ©RSNA, 2021.

Correction to: Effect of endometrial mechanical stimulation in an unselected population undergoing in vitro fertilization: futility analysis of a double-blind randomized controlled trial.

The original version of this article unfortunately contained mistakes. The complete list of corrections is given below.

Effect of endometrial mechanical stimulation in an unselected population undergoing in vitro fertilization: futility analysis of a double-blind randomized controlled trial.

PURPOSE: Implantation failure is a major limiting factor of successful in vitro fertilization (IVF). The objective of this study was to determine if endometrial mechanical stimulation (EMS) by endometrial biopsy in the luteal phase of the cycle prior to embryo transfer (ET) improves clinical outcomes in an unselected subfertile population. METHODS: Double-blind, randomized controlled trial of EMS versus sham biopsy and odds of clinical pregnancy after IVF and embryo transfer. Secondary outcomes included spontaneous miscarriage and live birth. RESULTS: One hundred women enrolled and were randomized from 2013 to 2017. Enrollment was terminated after futility analysis showed no difference in clinical pregnancy between EMS versus control, 47.2% vs 61.7% (OR 0.55, 95% CI 0.25-1.23, p = 0.15). There were no significant differences between women who underwent EMS and those who did not in terms of positive pregnancy test 54.7% vs 63.8% (OR 0.69, 95% CI 0.31-1.53, p = 0.36), miscarriage 7.5% vs 2.1% (OR 3.76 95% CI 0.41-34.85, p = 0.22), or live birth 43.4% vs 61.7% (OR 0.48 95% CI 0.21-1.06, p = 0.07). CONCLUSIONS: EMS in the luteal phase of the cycle preceding embryo transfer does not improve clinical outcomes in an unselected subfertile population and may result in a lower live birth rate. We caution the routine use of EMS in an unselected population.

Antral follicle count is increased in obese women placed on oral contraceptive pills.

OBJECTIVE: To determine the effect of short-term combined oral contraceptive (OCP) use on antral follicle count (AFC) in obese and nonobese women with infertility. STUDY DESIGN: A retrospective review of women who had an AFC (sum of 2-10 mm bilateral ovarian follicles on basal follicular phase ultrasound) measured before and after short-term OCP use between the years 2005 and 2010. These were women who had a baseline AFC measurement during an unsuccessful controlled ovarian hyperstimulation/intrauterine insemination who were then placed on OCPs prior to an in vitro fertilization (IVF) cycle that included a subsequent AFC measurement at baseline. RESULTS: A total of 57 IVF cycles met criteria for inclusion in the study. AFC was not impacted by OCP use in the nonobese cohort (BMI < 30). Baseline AFC in obese women (BMI ≥ 30), however, increased after OCP use (18 ± 6 vs. 28 ± 9, p = 0.002). CONCLUSION: Use of suppressive medications like OCPs in obese women increases AFC during IVF, potentially by AFC cohort synchrony. This observation warrants consideration when using AFC to predict gonadotropin/ART response as well as future prospective research to further elucidate potential etiologies.

Severe ovarian hyperstimulation syndrome in patients with autoimmune disorders: a report of two cases.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) following ovulation induction is common and varies in severity from mild to severe. Severe OHSS can be life threatening and requires hospitalization and procedures to reduce the extracellular fluid accumulation. Ovulation induction regimen and patient characteristics such as young age and low body weight have been identified as risk factors for OHSS, and follicle count >20 may be predictive of increased risk for moderate to severe OHSS. Whether any other patient factors are important in this risk equation is unknown. CASES: We report on 2 patients with type 1 diabetes mellitus (T1DM) and other autoimmune diseases who experienced a total of 4 episodes of OHSS, 2 of which were severe. CONCLUSION: T1DM, with or without other concomitant autoimmune diseases, may increase the risk for severe OHSS. Awareness of the interaction of preexisting conditions and risk for vascular leak disorders is needed for comprehensive counseling prior to embarking on ovarian stimulation. Preventive measures may be important considerations in this population.

A retrospective cross-sectional study: fresh cycle endometrial thickness is a sensitive predictor of inadequate endometrial thickness in frozen embryo transfer cycles.

BACKGROUND: The purpose of this study is to assess predictors of inadequate endometrial cavity thickness (ECT), defined as < 8 mm, in frozen embryo transfer (FET) cycles. METHODS: This is a retrospective cross-sectional study at an academic fertility center including 274 women who underwent their first endometrial preparation with estradiol for autologous FET in our center from 2001-2009. Multivariable logistic regression was performed to determine predictors of inadequate endometrial development in FET cycles. RESULTS: Neither age nor duration of estrogen supplementation were associated with FET endometrial thickness. Lower body mass index, nulliparity, previous operative hysteroscopy and thinner fresh cycle endometrial lining were associated with inadequate endometrial thickness in FET cycles. A maximum thickness of 11.5 mm in a fresh cycle was 80% sensitive and 70% specific for inadequate frozen cycle thickness. CONCLUSIONS: Previous fresh cycle endometrial cavity thickness is associated with subsequent FET cycle endometrial cavity thickness. Women with a fresh cycle thickness of 11.5 mm or less may require additional intervention to achieve adequate endometrial thickness in preparation for a frozen cycle.

Noninvasive electrophysiological imaging identifies 4D uterine peristalsis patterns in subjects with normal menstrual cycles and patients with endometriosis.

Throughout the menstrual cycle, spontaneous mild contractions in the inner layer of the uterine smooth muscle cause uterine peristalsis, which plays a critical role in normal menstruation and fertility. Disruptions in peristalsis patterns may occur in women experiencing subfertility, abnormal uterine bleeding, ovulatory dysfunction, endometriosis, and other disorders. However, current tools to measure uterine peristalsis in humans have limitations that hamper their research or clinical utilities. Here, we describe an electrophysiological imaging system to noninvasively quantify the four-dimensional (4D) electrical activation pattern during human uterine peristalsis with high spatial and temporal resolution and coverage. We longitudinally imaged 4968 uterine peristalses in 17 participants with normal gynecologic anatomy and physiology over 34 hours and 679 peristalses in 5 participants with endometriosis over 12.5 hours throughout the menstrual cycle. Our data provide quantitative evidence that uterine peristalsis changes in frequency, direction, duration, magnitude, and power throughout the menstrual cycle and is disrupted in endometriosis patients. Moreover, our data suggest that disrupted uterine peristalsis contributes to excess retrograde menstruation and infertility in patients with endometriosis and potentially contributes to infertility in this cohort.

Photoacoustic laser effects in live mouse blastocysts: pilot safety studies of DNA damage from photoacoustic imaging doses.

OBJECTIVES: To investigate the laser safety of photoacoustic imaging. In photoacoustic imaging, a pulsed laser of several nanoseconds is used to illuminate biological tissue, and photoacoustic waves generated by optical absorption are used to form images of the tissue. Photoacoustic imaging is emerging in clinical applications; however, its potential use in reproductive medicine has yet to be reported. DESIGN: Assessment of photoacoustic laser safety before its adoption by clinical reproductive medicine. SETTING: Academic medical center. ANIMALS: Blastocyst-stage mouse embryos. INTERVENTIONS: Potential DNA damage of photoacoustic laser exposure on preimplantation mouse blastocyst stage embryos was examined. Different embryos groups were exposed to either 5- or 10-minute 15-Hz laser doses (typical clinical doses) and 1-minute 1-kHz laser dose (significantly higher dose), respectively. MAIN OUTCOME MEASURES: A terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay was used to identify the rate of DNA damage in the laser-exposed blastocysts. RESULTS: The negative control blastocyst group (no laser exposure) had a mean of 10.7 TUNEL-positive nuclei. The 5- and 10-minute 15-Hz laser-exposed groups had a mean of 11.25 and 12.89 TUNEL-positive nuclei, respectively. The embryos exposed to the 1-kHz laser for 1 minute had an average mean of 12.0 TUNEL-positive nuclei. CONCLUSION: We demonstrated that typical lasers and exposure times used for photoacoustic imaging do not induce increased cell death in mouse blastocysts.

Risk of multiple gestation after ovulation induction in polycystic ovary syndrome.

OBJECTIVE: To compare the incidence of multiple gestation following treatment with clomiphene citrate (CC), metformin (MET) or gonadotropins in polycystic ovary syndrome (PCOS) patients undergoing ovulation induction. STUDY DESIGN: This was a retrospective, cohort study performed in an academic reproductive endocrine practice. PCOS patients presenting for first-trimester ultrasound were identified and assigned to 1 of 3 groups: CC-resistant patients who conceived after use of metformin +/- CC (group A), CC-resistant patients who conceived after gonadotropins (group B) and PCOS patients who conceived with CC only (group C). Multiple pregnancy outcome data were collected by chart review and patient interview. RESULTS: One hundred one pregnancies were identified in PCOS patients who had conceived after ovulation induction (OI). The rate of multiple gestation was higher in group B (36%) than in A (0%) or C (11%). CONCLUSION: The rate of multiple births was significantly lower with MET use during OI. Because multiple gestation is associated with higher complication rates and medical costs, our data offer an additional reason for use of MET for OI in PCOS patients who fail CC.

Risk of surgery after use of potassium chloride for treatment of tubal heterotopic pregnancy.

BACKGROUND: Spontaneous heterotopic pregnancies are rare, but with assisted reproductive techniques the incidence may approach 1:100. With the widespread use of transvaginal ultrasonography, physicians have attempted treatment of heterotopic pregnancies with minimally invasive procedures such as transvaginal guided potassium chloride (KCl) injection. However, there are few data on the success of this treatment. CASE: A 30-year-old primigravida presented with a desired pregnancy and was found to have a tubal pregnancy in addition to an intrauterine pregnancy. Ultrasound-guided KCl injection into the heterotopic pregnancy was complicated by abdominal pain, surgical abdomen, and hemoperitoneum requiring salpingectomy. CONCLUSION: A review of the literature revealed that 55% of tubal heterotopic pregnancies treated by KCl injection required subsequent salpingectomy. This raises concerns about the advisability of this treatment.

Programming ovulation using estrogens for patients to time intercourse.

BACKGROUND: A woman wishing to conceive may be separated from her spouse at the time of ovulation. Moreover, some orthodox Jewish women have a unique problem when they are unable to initiate intercourse before ovulation. They are prohibited from participating in sexual relations from the start of menstruation until 7 days after the end of flow when they go to the ritual bath (mikveh). CASES: Two orthodox Jewish women who ovulated before restarting intercourse were treated with oral estrogens to delay ovulation. CONCLUSION: Women separated from their husbands at the time of ovulation and Jewish women who ovulate before ritual cleansing can effectively use oral estrogens to program ovulation.

Radiographic and hysteroscopic findings of a placental site nodule.

OBJECTIVE: To report a case of placental site nodule discovered on hysterosalpingogram and evaluated by sonohysterography and hysteroscopy in a patient presenting with infertility. DESIGN: Case report. SETTING: Academic reproductive endocrinology center. PATIENT(S): A 30-year-old gravida 1 para 1 receiving evaluation for secondary infertility. INTERVENTION(S): Hysterosalpingogram, sonohysterography, and operative hysteroscopy with excision. MAIN OUTCOME MEASURE(S): Diagnosis and treatment of intrauterine lesion. RESULT(S): Pathology of the excisional biopsy from operative hysteroscopy revealed a placental site nodule. CONCLUSION(S): We report one of the first radiographic and hysteroscopic findings of a placental site nodule. This case demonstrates that in addition to the most common causes of uterine filling defects seen on hysterosalpingogram and sonohysterography, rarer lesions like placental site nodule also need to be considered in the differential diagnosis. Placental site nodule is a benign lesion that requires correct diagnosis to distinguish it from other more serious placental findings, but long-term follow-up is unnecessary. Therapy consists of diagnosis and expectant management.

Variability in the practice of fertility preservation for patients with cancer.

Fertility is important to women and men with cancer. While options for fertility preservation (FP) are available, knowledge regarding the medical application of FP is lacking. Therefore we examined FP practices for cancer patients among reproductive endocrinologists (REs). A 36 item survey was sent to board-certified REs. 98% of respondents reported counseling women with cancer about FP options. Oocyte and embryo cryopreservation were universally offered by these providers, but variability was noted in reported management of these cases-particularly for women with breast cancer. 86% of the respondents reported using letrozole during controlled ovarian stimulation (COS) in patients with estrogen receptor positive (ER+) breast cancer to minimize patient exposure to estrogen. 49% of respondents who reported using letrozole in COS for patients with ER+ breast cancer reported that they would also use letrozole in COS for women with ER negative breast cancer. Variability was also noted in the management of FP for men with cancer. 83% of participants reported counseling men about sperm banking with 22% recommending against banking for men previously exposed to chemotherapy. Overall, 79% of respondents reported knowledge of American Society for Clinical Oncology FP guidelines-knowledge that was associated with providers offering gonadal tissue cryopreservation (RR 1.82, 95% CI 1.14-2.90). These findings demonstrate that RE management of FP in cancer patients varies. Although some variability may be dictated by local resources, standardization of FP practices and communication with treating oncologists may help ensure consistent recommendations and outcomes for patients seeking FP.

Septate uterus with cervical duplication and longitudinal vaginal septum: a report of five new cases.

OBJECTIVE: To describe a unique congenital müllerian anomaly. DESIGN: Case report. SETTING: A university-based reproductive endocrine center. PATIENT(S): Five reproductive-age, nulligravida patients who underwent clinical, radiologic, and surgical work-up. INTERVENTION(S): Retrospective review of prior medical records and studies. MAIN OUTCOME MEASURE(S): Definition of abnormal pelvic anatomy. RESULT(S): Five patients from a university-based, reproductive endocrine center were found to have cervical duplication with a longitudinal vaginal septum, uterine septum, and a normal fundus. The patients most often presented initially to their primary obstetrician-gynecologists with symptomatic complaints secondary to their vaginal septums. Diagnoses were obtained with physical examinations, ultrasound imaging, hysterosalpingograms, magnetic resonance imaging, and surgical evaluation. CONCLUSION(S): These findings call into question the classic hypothesis of unidirectional (caudal to cranial) müllerian development and supports an alternative embryologic hypothesis of Müller et al., which states that fusion and resorption begins at the isthmus and proceeds simultaneously in both the cranial and caudad directions. The high number of cases reported here might be due to the increased accessibility and accuracy of such imaging modalities as magnetic resonance imaging. These patients will be followed longitudinally so that it can be determined whether this anomaly affects fertility and so that the optimal treatment plans can be developed.

The auto-amputated adnexa: a review of findings in a pediatric population.

STUDY OBJECTIVE: To quantify our experience and that of the literature with diagnosis and management of the auto-amputated adnexa in a pediatric population. DESIGN: Case series and literature review. SETTING: Tertiary care medical center. PARTICIPANTS: Case series of pediatric patients (<18 years of age) with surgically documented adnexal auto-amputation collected from our medical center and the literature. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Auto-amputated adnexa. RESULTS: In addition to the 3 cases discussed from our institution, 91 cases of auto-amputated adnexa were identified in the literature dating back to 1943, for a total of 94 cases. Forty-nine percent (46/94) of the cases involved girls in a pediatric population (<18 years of age). Of these, the majority (n = 26) were identified in a subgroup of girls who were diagnosed with an adnexal cyst by antenatal ultrasound. Most of these neonates were asymptomatic at birth or had a palpable abdominal mass (n = 6) and at the time of surgical exploration were found to have an auto-amputated adnexa. 34 out of 46 cases were analyzed in detail. The right adnexa were involved in 56% of the cases. The most common presenting complaint verbalized by the older girls was pain; however, 8 cases were identified in asymptomatic girls undergoing unrelated diagnostic testing. CONCLUSION: The auto-amputated adnexa is a rare finding in the pediatric population, but it must be considered as a possible explanation for the incidental finding of absence of the fallopian tube or ovary in the subgroup of patients who undergo surgery for any reason. Patients with an antecedent history of pelvic pain either chronic or intermittent in nature may be diagnosed with torsion or less frequently auto-amputation of the adnexa. A fetal "pelvic mass" or "ovarian cyst" may predispose the adnexa to torsion and subsequent auto-amputation either in-utero or post-delivery. Many of these antenatally diagnosed cysts and even subsequent auto-amputations are completely asymptomatic, however, and do not compromise fertility assuming the contralateral adnexa are normal. Thus expectant management is appropriate for small (less than 4 cm), asymptomatic simple cysts and even suspected auto-amputated adnexa in an asymptomatic patient.

Sperm recovery and IVF after testicular sperm extraction (TESE): effect of male diagnosis and use of off-site surgical centers on sperm recovery and IVF.

OBJECTIVE: Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation. PATIENTS: One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm. OUTCOME MEASURES: Successful sperm recovery defined as 1-2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and "other"(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician's office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm. RESULTS: Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%). CONCLUSION: Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.

Sperm banking for fertility preservation: a 20-year experience.

OBJECTIVE: Sperm banking is an effective method to preserve fertility, but is not universally offered to males facing gonadotoxic treatment in the United States. We compared the disposition and semen parameters of cryopreserved sperm from individuals referred for sperm banking secondary to a cancer diagnosis to those of sperm from men banking for infertility reasons. STUDY DESIGN: We performed a retrospective cohort study that reviewed 1118 records from males who presented to bank sperm at Washington University between 1991 and 2010. We collected and analyzed demographics, semen parameters, and disposition of banked sperm. RESULTS: Four hundred and twenty-three men with cancer and 348 banking for infertility reasons attempted sperm cryopreservation in our unit during the specified time period. The most prevalent cancers in our cohort were testicular (32%), lymphoma (25%), and leukemia (11%). Patients with leukemia had the lowest pre-thaw counts and motility. Most cancer patients (57%) who banked elected to use, transfer to another facility, or keep their specimens in storage. The remaining samples were discarded electively (34%) or following death (8%). Overall semen parameters were similar between the cancer and infertility groups, but demographics, ability to bank a sample, azoospermia rates, length of storage, current banking status, and use of banked sperm differed significantly between the two groups. CONCLUSIONS: The majority of cancer patients who banked survived their cancer and chose to continue storage of banked samples. Cancer patients were more likely than infertility patients to use or continue storage of banked samples. Our study provides evidence that sperm banking is a utilized modality of fertility preservation in patients with a myriad of cancer diagnoses and should be offered to all men facing gonadotoxic therapies. Further work is needed to determine where disparities in access to sperm banking exist to improve the potential for future fertility in these males.

The ART of social networking: how SART member clinics are connecting with patients online.

OBJECTIVE: To study and describe the use of social networking websites among Society for Assisted Reproductive Technology (SART) member clinics. DESIGN: Cross-sectional study. SETTING: University-based practice. PATIENT(S): Not applicable. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Prevalence of social networking websites among SART member clinics and evaluation of content, volume, and location (i.e., mandated state, region) using multivariate regression analysis. RESULT(S): A total of 384 SART-registered clinics and 1,382 social networking posts were evaluated. Of the clinics, 96% had a website and 30% linked to a social networking website. The majority of clinics (89%) with social networking websites were affiliated with nonacademic centers. Social networking posts mostly provided information (31%) and/or advertising (28%), and the remaining offered support (19%) or were irrelevant (17%) to the target audience. Only 5% of posts involved patients requesting information. Clinic volume correlated with the presence of a clinic website and a social networking website. CONCLUSION(S): Almost all SART member clinics have a website. Nearly one-third of these clinics host a social networking website such as Facebook, Twitter, and/or a blog. Large-volume clinics commonly host social networking websites. These sites provide new ways to communicate with patients, but clinics should maintain policies on the incorporation of social networks into practice.

Associations between free fatty acids, cumulus oocyte complex morphology and ovarian function during in vitro fertilization.

OBJECTIVE: To determine if follicular free fatty acid (FFA) levels are associated with cumulus oocyte complex (COC) morphology. DESIGN: Prospective cohort study. SETTING: University in vitro fertilization (IVF) practice. PATIENT(S): A total of 102 women undergoing IVF. INTERVENTION(S): Measurement of FFAs in serum and ovarian follicular fluid. MAIN OUTCOME MEASURE(S): Total and specific follicular and serum FFA levels, correlations between follicular and serum FFAs, and associations between follicular FFA levels and markers of oocyte quality, including COC morphology. RESULT(S): Predominant follicular fluid and serum FFAs were oleic, palmitic, linoleic, and stearic acids. Correlations between follicular and serum FFA concentrations were weak (r=0.252, 0.288, 0.236, 0.309, respectively for specific FFAs; r=0.212 for total FFAs). A receiver operating characteristic curve determined total follicular FFAs≥0.232 µmol/mL distinguished women with a lower versus higher percentage of COCs with favorable morphology. Women with elevated follicular FFAs (n=31) were more likely to have COCs with poor morphology than others (n=71; OR 3.3, 95% CI1.2-9.2). This relationship held after adjusting for potential confounders, including age, body mass index, endometriosis, and amount of gonadotropin administered (ß=1.2; OR 3.4, 95% CI 1.1-10.4). CONCLUSION(S): Elevated follicular FFA levels are associated with poor COC morphology. Further work is needed to determine what factors influence follicular FFA levels and if these factors impact fertility.