Cancer statistics for adolescents and young adults, 2020.

Cancer statistics for adolescents and young adults (AYAs) (aged 15-39 years) are often presented in aggregate, masking important heterogeneity. The authors analyzed population-based cancer incidence and mortality for AYAs in the United States by age group (ages 15-19, 20-29, and 30-39 years), sex, and race/ethnicity. In 2020, there will be approximately 89,500 new cancer cases and 9270 cancer deaths in AYAs. Overall cancer incidence increased in all AYA age groups during the most recent decade (2007-2016), largely driven by thyroid cancer, which rose by approximately 3% annually among those aged 20 to 39 years and 4% among those aged 15 to 19 years. Incidence also increased in most age groups for several cancers linked to obesity, including kidney (3% annually across all age groups), uterine corpus (3% in the group aged 20-39 years), and colorectum (0.9%-1.5% in the group aged 20-39 years). Rates declined dramatically for melanoma in the group aged 15 to 29 years (4%-6% annually) but remained stable among those aged 30 to 39 years. Overall cancer mortality declined during 2008 through 2017 by 1% annually across age and sex groups, except for women aged 30 to 39 years, among whom rates were stable because of a flattening of declines in female breast cancer. Rates increased for cancers of the colorectum and uterine corpus in the group aged 30 to 39 years, mirroring incidence trends. Five-year relative survival in AYAs is similar across age groups for all cancers combined (range, 83%-86%) but varies widely for some cancers, such as acute lymphocytic leukemia (74% in the group aged 15-19 years vs 51% in the group aged 30-39 years) and brain tumors (77% vs 66%), reflecting differences in histologic subtype distribution and treatment. Progress in reducing cancer morbidity and mortality among AYAs could be addressed through more equitable access to health care, increasing clinical trial enrollment, expanding research, and greater alertness among clinicians and patients for early symptoms and signs of cancer. Further progress could be accelerated with increased disaggregation by age in research on surveillance, etiology, basic biology, and survivorship.

Gestational carrier cycles: embryology trends, national guideline compliance, and resultant perinatal outcomes in the United States, 2014-2020.

BACKGROUND: The increased use of gestational carriers has expanded family-building opportunities for people and couples unable to carry pregnancies on their own. National American Society of Reproductive Medicine guidelines for gestational carriers have changed over time to reflect advances in reproductive technology and mounting evidence supporting the medical benefits associated with singleton gestations. OBJECTIVE: Assess changes in gestational carrier cycle practice patterns and resultant pregnancy outcomes in the United States in relation to changing national American Society of Reproductive Medicine guidelines, which changed in 2013 and 2017. STUDY DESIGN: This retrospective study used data from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System and included all cycles that were reported from 2014-2020 involving an embryo transfer to a gestational carrier. Binomial regression models evaluated trends in preimplantation genetic testing for aneuploidy, American Society of Reproductive Medicine guideline adherence, number of embryos transferred, and pregnancy outcomes over time. RESULTS: Of the 40,177 gestational carrier transfer cycles from 2014-2020, there was a significant increase in frozen-thawed cycles (41.3% increase), use of assisted hatching (53.4% increase), intracytoplasmic sperm injection (50.0% increase), and preimplantation genetic testing for aneuploidy (155.7% increase). The likelihood of preimplantation genetic testing for aneuploidy was higher in 2020 than in 2014 for autologous oocyte transfers to gestational carriers, both for those aged ≥38 years (adjusted relative risk, 2.38 [95% confidence interval, 2.11-2.70]) and than those aged <38 years (adjusted relative risk, 2.85 [95% confidence interval, 2.58-3.15]). As preimplantation genetic testing for aneuploidy usage increased, single embryo transfer rose for both autologous (adjusted relative risk, 2.22 [95% confidence interval, 1.94-2.50]) and donor cycles (relative risk, 1.91 [95% confidence interval, 1.81-2.02]). This shift toward single embryo transfer corresponded with a decrease in multiple embryo transfer by 79.2% and subsequent decreases in multiple gestations by 68.8% in donor and 73.6% in autologous oocyte cycles from 2014-2020. Gestational carrier cycles remained highly adherent to changing American Society of Reproductive Medicine guidelines throughout the study period. Among live births, there was a 19.4% and 7.9% increase in term deliveries among donor and autologous oocyte cycles, respectively, from 2014 to 2020. CONCLUSION: Practice patterns have drastically changed throughout the study period, with major increases in the use of preimplantation genetic testing for aneuploidy, intracytoplasmic sperm injection, assisted hatching, and frozen transfers. In response to changing American Society of Reproductive Medicine guidelines, the use of multiple embryo transfers has decreased for gestational carrier cycles with subsequent decreases in multiple gestations and miscarriages and slight increases in live birth rates.

Neighborhood deprivation and racial differences in in vitro fertilization outcomes.

BACKGROUND: There are significant racial disparities in in vitro fertilization outcomes, which are poorly explained by individual-level characteristics. Environmental factors such as neighborhood-level socioeconomic factors may contribute to these disparities. However, few studies have directly addressed this research question in a large, racially diverse cohort. OBJECTIVE: This study aimed to investigate whether neighborhood deprivation is associated with differences in in vitro fertilization outcomes. STUDY DESIGN: Our retrospective cohort study included 1110 patients who underwent 2254 autologous in vitro fertilization cycles between 2014 and 2019 at an academic fertility center in the Southeastern United States. Neighborhood deprivation was estimated using the Neighborhood Deprivation Index, a composite variable measuring community levels of material capital based on poverty, occupation, housing, and education domains. Using multivariable log-binomial generalized estimating equations with cluster weighting, risk ratios and 95% confidence intervals were estimated for cycle cancellation, miscarriage (defined as spontaneous pregnancy loss before 20 weeks after a confirmed intrauterine gestation), and live birth according to patient Neighborhood Deprivation Index. RESULTS: There were positive associations between increasing Neighborhood Deprivation Index (indicating worsening neighborhood deprivation) and body mass index, as well as increasing prevalence of tubal and uterine factor infertility diagnoses. The crude probability of live birth per cycle was lower among Black (24%) than among White patients (32%), and the crude probability of miscarriage per clinical pregnancy was higher among Black (22%) than among White patients (12%). After adjustment, the Neighborhood Deprivation Index was not significantly associated with risk of cycle cancellation or live birth. Results were consistent when analyses were stratified by race. CONCLUSION: Our research demonstrates racial disparities between Black and White women in the incidence of miscarriage and live birth following in vitro fertilization. Although the level of neighborhood deprivation was closely related to race, it did not have strong associations with in vitro fertilization outcomes in our population as a whole or within strata of race.

Oocyte cryopreservation on TikTok and Instagram: Who is teaching whom?

PURPOSE: Oocyte cryopreservation (OC) is a medical intervention for reproductive-aged women, a demographic that uses social media heavily. This study characterizes the top TikTok videos and Instagram reels on OC. METHODS: Five hashtags pertaining to OC were selected: #oocytepreservation, #oocytecryopreservation, #eggfreezing, #oocytefreezing, and #fertilitypreservation. Top videos for each hashtag were evaluated for source, content, impact, and quality on both platforms. Descriptive and inferential statistics were performed to analyze differences between laypeople and medical professionals. RESULTS: From March to April 2023, 332 posts were reviewed. The most popular hashtags on TikTok and Instagram were #eggfreezing (n = 5.6 million views, n = 68,500 + posts) and #fertilitypreservation (n = 9 million views, n = 20,700 + posts). Laypeople dominated as sources (57.8%, 35.2%), followed by physicians (17.0%, 32.4%). No professional societies videos were found. Educational information (53.1%, 48.6%) was most frequently shared on both platforms respectively, followed by personal experiences (36.1%, 21.6%). Laypersons' posts were dominated by personal experiences (62.0%) with educational content second (33.3%). Educational content by medical professionals was more accurate on both TikTok and Instagram than patients (p < 0.001, p < 0.001). #Eggfreezing had the greatest impact for both patients and medical professionals based on shares (n = 9653, n = 3093), likes (n = 713,263, n = 120,700), and comments (n = 35,453, n = 1478). Notably, laypersons had a larger follower count than medical professionals (p < 0.001). CONCLUSION: The majority of available videos are from laypeople, focus on education topics, and are less accurate in comparison to those from medical professionals. Professional societies have an opportunity to enhance their social media presence for better availability and accuracy of OC information.

Natural cycle frozen embryo transfer: a survey of current assisted reproductive technology practices in the U.S.

PURPOSE: Emerging data suggests improved obstetric outcomes with frozen embryo transfer (FET) in an ovulatory or natural cycle (NC-FETs), as compared to programmed endometrial preparation. The objective of this study is to better understand practice patterns and provider attitudes regarding the use of NC-FETs in the United States (U.S.). METHODS: In this cross-sectional study, an anonymous 22-question survey was emailed to 441 U.S. Assisted Reproductive Technology (ART) clinics to assess the utilization of NC endometrial preparation for FET, protocols used, restrictions to offering NC-FET, and providers' perspectives on advantages and disadvantages of NC-FET. Descriptive statistics were used to analyze survey responses. RESULT(S): The survey response rate was 49% (216/441). Seventeen percent of responding clinics did not offer NC-FET. Of the clinics that did not offer NC-FET, 65% had only 1-2 physicians in their practice. Common reasons for not offering NC-FET included "lack of timing predictability for transfer" (81%) and "increased burden on staff/laboratory personnel on holidays and weekends" (54%). Of clinics offering NC-FET, 76% reported < 25% of cycles used the NC for endometrial preparation. Over half (52%) of clinics that offered NC-FET reported having eligibility restrictions for NC-FET. Reported benefits of NC-FET were "patient satisfaction" (18%), "decreased cost of medications" (18%), and "avoidance of intramuscular progesterone" (17%). The attitude towards NC-FET in their clinics was reported as positive by 65% of respondents. CONCLUSION: NC-FETs are offered by most U.S. ART clinics but are used only in the minority of FET cycles for endometrial preparation, and use is often restricted.

Factors associated with a positive experience at US fertility clinics: the male partner perspective.

OBJECTIVE: To determine factors associated with a positive male patient experience (PMPE) at fertility clinics among male patients. DESIGN: Cross-sectional study Setting: Not applicable Patients: Male respondents to the FertilityIQ questionnaire ( www.fertilityiq.com ) reviewing the first or only US clinic visited between June 2015 and August 2020. INTERVENTIONS: None Main outcome measures: PMPE was defined as a score of 9 or 10 out of 10 to the question, "Would you recommend this fertility clinic to a best friend?". Examined predictors included demographics, payment details, infertility diagnoses, treatment, and outcomes, physician traits, and clinic operations and resources. Multiple imputation was used for missing variables and logistic regression was used to calculate adjusted odds ratios (aORs) for factors associated with PMPE. RESULTS: Of the 657 men included, 60.9% reported a PMPE. Men who felt their doctor was trustworthy (aOR 5.01, 95% CI 0.97-25.93), set realistic expectations (aOR 2.73, 95% CI 1.10-6.80), and was responsive to setbacks (aOR 2.43, 95% CI 1.14-5.18) were more likely to report PMPE. Those who achieved pregnancy after treatment were more likely to report PMPE; however, this was no longer significant on multivariate analysis (aOR 1.30, 95% CI 0.68-2.47). Clinic-related factors, including ease of scheduling appointments (aOR 4.03, 95% CI 1.63-9.97) and availability of same-day appointments (aOR 4.93, 95% CI 1.75-13.86), were associated with PMPE on both univariate and multivariate analysis. LGBTQ respondents were more likely to report PMPE, whereas men with a college degree or higher were less likely to report PMPE; however, sexual orientation (aOR 3.09, 95% CI 0.86-11.06) and higher educational level (aOR 0.54, 95% CI 0.30-1.10) were not associated with PMPE on multivariate analysis. CONCLUSION: Physician characteristics and clinic characteristics indicative of well-run administration were the most highly predictive of PMPE. By identifying factors that are associated with a PMPE, clinics may be able to optimize the patient experience and improve the quality of infertility care that they provide for both men and women.

REI clinics and fellowship training-a national snapshot to improve access to reproductive care.

PURPOSE: To analyze the geographic distribution of REI fellowships and clinics across the USA and to strategize ways to improve patient access to care. METHODS: Cross-sectional study using population data obtained from publicly available United States Census Bureau, Society for Assisted Reproductive Technology (SART), and National Resident Matching Program websites. Outcomes include the number of REI clinics, REI fellowship-trained physicians, and REI fellowship programs. RESULTS: In 2020, there were 643 assisted reproductive technology (ART) clinics reporting to SART and 1351 fellowship-trained REI physicians. Most clinics are located in the south (n = 209); however, the northeast has the highest density of REI clinics. Out of 301,316 in vitro fertilization (IVF) cycles in the USA in 2020, northeastern states initiated the most cycles (n = 93,565), and Midwestern states initiated the fewest cycles (n = 50,000). The northeast has the most REI physicians per million women aged 20-44 years (42.4) while the Midwest has the lowest ratio (19.5). There are fewer REI physicians per million women aged 20-44 years in states with a lower proportion of patients with health insurance (r = 0.56, 95% confidence interval ([CI] 0.34-0.73) and in states with a lower average income per resident (r = 0.65, 95% CI 0.46-0.79). Most of the 49 accredited REI fellowship programs in the USA are in the northeast (n = 18), and there are fewest in the south (n = 10) and west (n = 10). CONCLUSION: Access to REI care has large geographic disparities from a clinic, physician, and training program perspective. Creative solutions are needed to remedy this problem.

Impact of access to care and race/ethnicity on IVF care discontinuation.

RESEARCH QUESTION: Is race/ethnicity or access to care, as defined by insurance coverage, distance to the clinic and zip code (postal code), associated with care discontinuation following IVF? DESIGN: A retrospective cohort study of 878 diverse women who underwent 1571 IVF cycles from 2014 to 2018 at a Southeastern academic medical centre was performed. Women were divided into low (LAC) and high (HAC) access to care groups. HAC was defined as possessing IVF insurance coverage, living ≤25 miles from the clinic, and living in a zip code with a median income ≥$75,000. Access groups and racial/ethnic groups were compared for differences in relative risk of care discontinuation following an unsuccessful IVF cycle. RESULTS: Women with HAC had a poorer IVF prognosis than the LAC group, which possibly impacted the association with care discontinuation. Distance to the clinic, but not insurance coverage or zip code, was associated with increased risk of care discontinuation. Among women ≤34 years, HAC showed some evidence of an association with an increased risk of care discontinuation (adjusted relative risk 2.5, 95% confidence interval 0.8-8.1). Despite having higher rates of insurance coverage (51.2% versus 36.5%), non-Hispanic Black women were more likely to discontinue care (58.3% versus 40.2%) and less likely to achieve a live birth (53.0% versus 68.0%) than non-Hispanic White women. CONCLUSIONS: Identification as non-Hispanic Black, and distance to the clinic, but not insurance coverage or zip code, were associated with increased risk of care discontinuation following an unsuccessful IVF cycle. In women ≤34 years old, HAC may be associated with a higher rate of care discontinuation.

Donor sperm recipients: fertility treatments, trends, and pregnancy outcomes.

PURPOSE: To report fertility treatment use and outcomes among patients who use donor sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), and reciprocal IVF (co-IVF). METHODS: This is a retrospective review of patients who used donor sperm at an urban, southeastern academic reproductive center between 2014 and 2020. RESULTS: Among the 374 patients presenting for care, 88 (23.5%) were single, 188 (50.3%) were in a same-sex female partnership, and 98 (26.2%) had a male partner with a diagnosis of male factor infertility. Most patients did not have infertility (73.2%). A total of 1106 cycles were completed, of which there were 931 IUI cycles, 146 traditional IVF cycles, and 31 co-IVF cycles. Live birth rates per cycle were 11% in IUI, 42% in IVF, and 61% in co-IVF. Of all resulting pregnancies, hypertensive disorders were most commonly experienced (18.0%), followed by preterm delivery (15.3%), neonatal complications (9.5%), gestational diabetes (4.8%), and fetal growth restriction (4.8%). Of the 198 infants born, fifteen (8.3%) required admission to the neonatal intensive care unit and three (1.7%) demised. Pregnancy and neonatal complications were more likely to occur in older patients and patients with elevated body mass index. CONCLUSION: The use of donor sperm for fertility treatment is increasing. These data show reassuring live birth rates; however, they also highlight the risks of subsequent pregnancy complications. With the expansion of fertility treatment options for patients, these data assist provider counseling of patients regarding anticipated cycle success rates and possible pregnancy complications.

Refining the risk for fragile X-associated primary ovarian insufficiency (FXPOI) by FMR1 CGG repeat size.

PURPOSE: Approximately 20-30% of women with an FMR1 premutation experience fragile X-associated primary ovarian insufficiency (FXPOI); however, current risk estimates based on repeat size only identify women with the midrange of repeats to be at the highest risk. METHODS: To better understand the risk by repeat size, we collected self-reported reproductive histories on 1,668 women and divided them into high-resolution repeat size bins of ~5 CGG repeats to determine a more accurate risk for FXPOI in relation to CGG repeat length. RESULTS: As previously reported, women with 70-100 CGG repeats were at the highest risk for FXPOI using various statistical models to compare average age at menopause and risk of FXPOI, with women with 85-89 repeats being at the highest risk. Importantly, women with <65 repeats or >120 repeats did not have a significantly increased risk for FXPOI compared to women with <45 repeats. CONCLUSION: Using a large cross-section study on 1,668 women, we have provided more personalized risk assessment for FXPOI using high-resolution repeat size bins. Understanding the variability in risk has important implications for family planning and overall health among women with a premutation.

The effect of donor and recipient race on outcomes of assisted reproduction.

BACKGROUND: A growing literature suggests that minority races, particularly Black women, have a lower probability of live birth and higher risk of perinatal complications after autologous assisted reproductive technology. However, questions still remain as to whether these racial disparities have arisen because of associations between race and oocyte/embryo quality, the uterine environment, or a combination of the two. Oocyte donation assisted reproductive technology represents a unique approach to examine this question. OBJECTIVE: This study aimed to evaluate the associations between the race of female oocyte donors and recipients and live birth rates following vitrified donor oocyte assisted reproductive technologies. STUDY DESIGN: This was a retrospective study conducted at a single, private fertility clinic that included 327 oocyte donors and 899 recipients who underwent 1601 embryo transfer cycles (2008-2015). Self-reported race of the donor and recipient were abstracted from medical records. Live birth was defined as the delivery of at least 1 live-born neonate. We used multivariable cluster weighted generalized estimating equations with binomial distribution and log link function to estimate the adjusted risk ratios of live birth, adjusting for donor age and body mass index, recipient age and body mass index, tubal and uterine factor infertility, and year of oocyte retrieval. RESULTS: The racial profile of our donors and recipients were similar: 73% white, 13% Black, 4% Hispanic, 8% Asian, and 2% other. Women who received oocytes from Hispanic donors had a significantly higher probability of live birth (adjusted risk ratio, 1.20; 95% confidence interval, 1.05-1.36) than women who received oocytes from white donors. Among Hispanic recipients, however, there was no significant difference in probability of live birth compared with white recipients (adjusted risk ratio, 1.07; 95% confidence interval, 0.90-1.26). Embryo transfer cycles using oocytes from Black donors (adjusted risk ratio, 0.86; 95% confidence interval, 0.72-1.03) and Black recipients (adjusted risk ratio, 0.84; 95% confidence interval, 0.71-0.99) had a lower probability of live birth than white donors and white recipients, respectively. There were no significant differences in the probability of live birth among Hispanic, Asian, and other race recipients compared with white recipients. CONCLUSION: Black female recipients had a lower probability of live birth following assisted reproductive technology, even when using vitrified oocytes from healthy donors. Female recipients who used vitrified oocytes from Hispanic donors had a higher probability of live birth regardless of their own race.

Pregnancy and Fertility Concerns: A Survey of United States Obstetrics and Gynecology Residents.

INTRODUCTION: Reproductive life planning is an important aspect of OBGYN resident education. Despite learning about declining fertility and the implications associated with delaying pregnancy, OBGYN residents overestimate the age when fertility declines and fertility treatment success rates. OBJECTIVE: To characterize attitudes towards infertility, pregnancy timing, and fertility preservation among OBGYN residents at academic programs in the United States. METHODS: Cross sectional study of female trainees from 27 academic OBGYN residency programs. A voluntary, anonymous online survey was used to assess reproductive experiences and characterize attitudes towards personal family planning and infertility. RESULTS: Of 756 trainees who were sent the survey, 487 opened the email, and 309 participated (63.4% response rate per opened email, 40.9% overall). The majority of residents expressed a desire to have children, but had not started childbearing (75.8%, n = 210) with a planned delay for career/educational reasons (84.5%, n = 196). The majority planned to have children before age 35 (90%, n = 210). Of those not finished with childbearing, 78.5% reported worrying about infertility (n = 205) and 40.8% reported considering fertility preservation (n = 111). If interested in fellowship, trainees were more worried about infertility (p = 0.01, OR 2.74 (95% CI 1.24 -6.04)). CONCLUSIONS FOR PRACTICE: Female OBGYN residents learn to help patients with reproductive planning and many may personally delay family building. To help alleviate anxiety, improve reproductive autonomy, and prevent future regret, OBGYN residents may benefit from counseling regarding declining fertility with age and the advantages and disadvantages of fertility preservation, specifically emphasizing the realistic chance of success with oocyte cryopreservation compared to conception at a young age.

More than the oocyte source, egg donors as patients: a national picture of United States egg donors.

PURPOSE: To characterize national oocyte donation practice patterns from the perspective of individual donors rather than of recipients. METHODS: Retrospective cohort including all donor oocyte retrievals and transfers reported to SARTCORS in 2016 and 2017 in the USA. Primary outcomes include characteristics of oocyte donors and of donor oocyte cycles. Secondary outcomes include overall pregnancy rates, elective single embryo transfer (eSET) rates, and perinatal outcomes among donor oocyte recipient transfers. RESULTS: During the study period, 49,193 donor oocyte retrievals were performed, of which the largest proportion were in the Western US. For all reported retrievals, there were 17,099 unique donors, each of whom underwent an average of 2.4 retrievals (range 1-22). Average donor age was 26.3 years (range 18-48). On average, 24.6 oocytes (SD 12.4) were retrieved each cycle, ranging from 0 to 102. Among 37,657 donor oocyte recipient transfers, 20,159 (53.5%) involved eSET, and 17,725 (47.1%) resulted in live birth. Miscarriage rates were 17.5%, and good perinatal outcome (GPO), defined as full-term normal birthweight delivery, was more likely among singleton (75.7%) than multiple (23.8%) pregnancies. CONCLUSION: The average number of retrievals that donors underwent and oocyte yield mirrored national guidelines; however outliers, exist that may unnecessarily increase donor risk. Additionally, among resultant donor transfers, 46.5% transferred more than one embryo despite national recommendations for eSET. The significantly higher likelihood of GPO among singleton pregnancies points to the need to further increase donor recipient eSET rates.

When using donor oocytes, does embryo stage matter? An analysis of blastocyst versus cleavage stage embryo transfers using a cryopreserved donor oocyte bank.

PURPOSE: Oocyte donor in vitro fertilization (IVF) represents an ideal model to study the effects of embryo stage on reproductive success, as embryos come from young women with high-quality oocytes. Our study aimed to determine if embryo transfer stage affected outcomes in oocyte donor IVF, including the common scenario where only a limited number of quality embryos are available after culture. METHODS: This retrospective cohort analyzed anonymous vitrified donor oocyte cycles at a single clinic between 2008 and 2015. Overall, 983 recipients underwent 1178 warming cycles resulting in fresh transfer of one-to-two embryos. Our primary outcome was live birth; secondary outcomes included multiple birth, birthweight, and gestational age. Log binomial regression with cluster-weighted generalized estimating equations were used to calculate adjusted risk ratios (aRR) accounting for recipient age, race, and transfer year. RESULTS: Among 132 cleavage and 1046 blastocyst transfer cycles, cleavage transfers were associated with lower probability of live birth (aRR 0.72, 95% CI 0.59-0.88). Subgroup analysis focused on cycles with a limited number of quality embryos 3 days post-fertilization (≤2), as clinically these women were most likely to be considered for cleavage transfers. Among these cycles (120 cleavage, 371 blastocyst), cleavage transfers were still associated with lower live birth rates compared to blastocyst (aRR 0.66, 95% CI 0.51-0.87) CONCLUSIONS: Even in a donor oocyte model with high-quality oocytes, there was a benefit to extended culture and blastocyst transfer, including when only one-to-two quality embryos were available after early culture. This is possibly owed to improved uterine synchronicity or decreased contractility.

Clustering of comorbid conditions among women who carry an FMR1 premutation.

PURPOSE: Emerging evidence indicates that women who carry an FMR1 premutation can experience complex health profiles beyond the two well-established premutation-associated disorders: fragile X-associated primary ovarian insufficiency (FXPOI, affects ~20-30% carriers) and fragile X-associated tremor-ataxia syndrome (FXTAS, affects ~6-15% carriers). METHODS: To better understand premutation-associated health profiles, we collected self-reported medical histories on 355 carrier women. RESULTS: Twenty-two health conditions were reported by at least 10% of women. Anxiety, depression, and headaches were reported by more than 30%. The number of comorbid conditions was significantly associated with body mass index (BMI) and history of smoking, but not age. Survival analysis indicated that women with FXPOI had an earlier age at onset for anxiety and osteoporosis than women without FXPOI. Cluster analysis identified eight clusters of women who reported similar patterns of comorbid conditions. The majority of carriers (63%) fell into three categories primarily defined by the presence of only a few conditions. Interestingly, a single cluster defined women with symptoms of FXTAS, and none of these women had FXPOI. CONCLUSION: Although some women with a premutation experience complex health outcomes, most carriers report only minimal comorbid conditions. Further, women with symptoms of FXTAS appear to be distinct from women with symptoms of FXPOI.

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.

Fertility, Pregnancy, and Postpartum: A Survey of Practicing Georgia Obstetrician Gynecologists.

PURPOSE: OBGYNs help patients plan families, conceive, and deliver children, however the personal reproductive history and goals, infertility experiences, and birth outcomes of OBGYNs are not well studied. We aim to characterize female OBGYN reproductive experiences with a particular focus on infertility, reproductive life planning (methods of pregnancy prevention, reasons why pregnancy is/was delayed), birth outcomes (mode of delivery, delivery timing), and the postpartum period (breastfeeding, maternity leave, postpartum depression). DESCRIPTION: An anonymous email survey was distributed to female members of Georgia OBGYN Society and Emory University Department of Gynecology and Obstetrics. Descriptive statistics and bivariable analysis were performed using Microsoft Excel and OpenEpi. ASSESSMENT: Of 352 surveys, 204 of 269 women who opened the survey agreed to participate (75.8% per opened email, 58.0% per sent email). Mean age of first childbirth was 30.7 (SD ± 4.2) years. Most pregnancies were intended (77%). Fertility treatments were used in 13% of pregnancies. Resident mothers compared to mothers who gave birth before or after residency were more likely to report postpartum depression [26% vs. 16%, OR 1.8 (95% CI 0.93-3.58)] and shorter maternity leave < 6 weeks [57% vs. 29%, OR 2.57 (CI 1.56-5.00)]; exclusive breastfeeding rates ≥ 6 months were similar [38% residents vs. 41% non-residents, OR 0.80 (CI 0.44-1.43)]. Among those not finished with childbearing, 68% worried about infertility, 29% were considering oocyte/embryo cryopreservation, and 5% had already cryopreserved oocytes. CONCLUSION: Compared to the general population, the average age of first childbirth among Georgia OBGYNs was 4 years higher (30.7) with a greater proportion of pregnancies planned. Use of fertility services and obstetric course matched national rates, however postpartum depression was more prevalent among Georgia OBGYNs. Awareness of increased postpartum depression among residents may allow for improved counseling and treatment.

Hypertensive disorders of pregnancy and infertility treatment: a population-based survey among United States women.

PURPOSE: To explore associations between infertility treatment and hypertensive disorders of pregnancy. METHODS: We collated multi-year as well as multi-state data from a national representative survey examining the association between self-reported infertility treatment (i.e., medication, intrauterine insemination, or assisted reproductive technology) and hypertensive disorders of pregnancy (i.e., high blood pressure, pregnancy-induced hypertension (PIH), preeclampsia, and toxemia). Data were analyzed using logistic regression. A total of 21,884 women in the United States (U.S.), from the Centers for Disease Control and Prevention's (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) survey (2009-2015), participated in the study. RESULTS: In our analysis, 12.91% women reported a history of infertility treatment and 15.19% reported a history of hypertensive disorder of pregnancy. Compared with women who had never had infertility treatment, women who reported infertility treatment had 1.18 (adjusted OR, 95% confidence interval (CI) 1.05, 1.33) higher odds of reporting hypertensive disorder of pregnancy. Neither types of infertility treatment nor proximity of treatment to pregnancy were independently associated with hypertensive disorder of pregnancy. CONCLUSIONS: Our results suggest that among U.S. women, the treatment of infertility may be associated with hypertension disorder of pregnancy regardless of type of treatment.

National mosaic embryo transfer practices: a survey.

BACKGROUND: The growing use of preimplantation genetic testing with in vitro fertilization has provided clinicians with more information about the genetics of embryos. Embryos, however, sometimes result with a mixed composition of both aneuploid and euploid cells, called mosaic embryos. The interpretation of these results has varied, leading some clinicians to transfer mosaic embryos and some opt not to. In addition, laboratories providing preimplantation genetic testing for aneuploidy have differing thresholds for determining an embryo aneuploid, mosaic, or euploid. Overall practice patterns for mosaic embryo transfer practices in the United States are unknown. OBJECTIVE(S): The objectives of the study were to characterize national mosaic embryo transfer practices, including the use of preimplantation genetic testing for aneuploidy, prior history of transferring mosaic embryos, thresholds for determining mosaicism, and willingness to transfer mosaic embryos among assisted reproductive technology clinics in the United States. STUDY DESIGN: A 14 question online survey assessing current use of preimplantation genetic testing for aneuploidy, thresholds for determining mosaicism, and clinic experience and willingness to transfer mosaic embryos was e-mailed to 405 assisted reproductive technology clinics across the United States. Descriptive statistics and logistic regression were used to analyze survey responses and identify clinical factors associated with reporting having ever transferred a mosaic embryo. RESULTS: Of the 405 US assisted reproductive technology clinics contacted, 252 (62.2%) completed a survey, including 157 private (62.3%), 55 academic (21.8%), and 40 hybrid (15.9%) clinics. Most clinics (168, 66.7%) reported conducting preimplantation genetic testing for aneuploidy on less than 50% of all in vitro fertilization cycles. The most common type of preimplantation genetic testing for aneuploidy technology used was next-generation sequencing at 88.9%. Ninety-one clinics (36.1%) receive mosaicism data on their preimplantation genetic testing for aneuploidy report; the most common thresholds for determining embryo aneuploidy and euploidy by clinics' primary genetics laboratories were <20% normal (36.3%) and >80% normal (46.2%), respectively. Thirty-nine (42.9%) of the 91 have transferred and 57 (62.6%) would transfer a mosaic embryo. Nearly 40% of clinics were unsure about their thresholds for mosaic transfer and one fourth of clinics reported they had no threshold. Private (odds ratio, 1.0, 95% confidence interval, 0.5-1.8) and hybrid (odds ratio, 0.9, 95% confidence interval, 0.4-2.1) clinics were just as likely as academic clinics to report having transferred a mosaic embryo. Clinics in the northeastern United States were more likely to have transferred a mosaic embryo than clinics in other regions (odds ratio, 1.5, 95% confidence interval, 0.9-2.7). Most clinics (72.6%) report they do not have a unique consent for transfer of mosaic embryos. CONCLUSION: There is uncertainty and variability in the transfer practices of mosaic embryos and classification of mosaicism among US assisted reproductive technology clinics. These findings provide an opportunity to establish mosaicism thresholds and create standardized guidelines for transferring mosaic embryos.

Assisted reproductive technology with donor sperm: national trends and perinatal outcomes.

BACKGROUND: Information regarding the use of donor sperm in assisted reproductive technology, as well as subsequent treatment and perinatal outcomes, remains limited. Outcome data would aid patient counseling and clinical decision making. OBJECTIVES: The objectives of the study were to report national trends in donor sperm utilization and live birth rates of donor sperm-assisted reproductive technology cycles in the United States and to compare assisted reproductive technology treatment and perinatal outcomes between cycles using donor and nondonor sperm. We hypothesize these outcomes to be comparable between donor and nondonor sperm cycles. STUDY DESIGN: This was a retrospective cohort study using data from all US fertility centers reporting to the Centers for Disease Control and Prevention's National Assisted Reproductive Technology Surveillance System, accounting for ∼98% of assisted reproductive technology cycles (definition excludes intrauterine insemination). The number and percentage of assisted reproductive technology cycles using donor sperm and rates of pregnancy, live birth, preterm birth (<37 weeks), and low birthweight (<2500 g) were the primary outcomes measured. Treatments assessed include use of donor vs nondonor sperm. The trends analysis included all banking and fresh assisted reproductive technology cycles using donor and autologous oocytes performed between 1996 and 2014 (n = 1,710,034). The outcomes analysis was restricted to include only fresh autologous cycles performed between 2010 and 2014 (n = 437,569) to focus on cycles with a potential outcome and cycles reflective of current practice, thereby improving the clinical relevance. Cycles canceled prior to retrieval were excluded. Statistical analysis included linear regression to explore polynomial trends and log-binomial regression to estimate relative risk for outcomes among cycles using donor and nondonor sperm. RESULTS: Of all banking and fresh donor and autologous oocyte assisted reproductive technology cycles performed between 1996 and 2014, 74,892 (4.4%) used donor sperm. In 2014, 7351 assisted reproductive technology cycles using donor sperm were performed, as compared with 1763 in 1996 (6.2% vs 3.8% of all cycles). Among all autologous oocyte cycles performed between 2010 and 2014, the live birth rate was lower for donor sperm (27.9%) than nondonor sperm cycles (32.5%); however, after adjustment for maternal age, donor sperm use was associated with an increased likelihood of live birth (adjusted relative risk, 1.06, 95% confidence interval, 1.01-1.10). Per transfer, there was no significant difference in live birth rates for donor vs nondonor sperm (31.9% vs 36.8%; adjusted relative risk, 1.04, 95% confidence interval, 0.998-1.09). Per singleton live birth, there was no significant difference in preterm birth (11.5% vs 11.8%; adjusted relative risk, 0.98, 95% confidence interval, 0.90-1.06); however, low birthweight delivery was slightly lower in donor sperm cycles (8.8% vs 9.4%; adjusted relative risk, 0.91, 95% confidence interval, 0.83-0.99). CONCLUSION: Donor sperm use in assisted reproductive technology has increased in the United States, accounting for approximately 6% of all assisted reproductive technology cycles in 2014. Assisted reproductive technology treatment and perinatal outcomes were clinically similar in donor and nondonor sperm cycles.