Characteristics of patients seeking fertility care in a low-income setting.

OBJECTIVE: Patients face challenges accessing fertility treatment due to barriers such as financial burdens, delayed referral to Reproductive Endocrinologists (REI), low medical literacy, language barriers and numerous other health disparities. Medicaid in New York offers coverage for office visits, blood tests, hysterosalpingograms (HSGs), and pelvic ultrasounds for infertility. The aim of this study is to delineate the characteristics of this underserved population and determine their ability to complete the initial fertility workup. METHODS: This was a retrospective study of all patients seeking fertility care at a single resident/fellow REI clinic in New York from September 2020 - January 2022. RESULTS: During the study period, 87 patients (avg age = 35.2y) sought care at the resident/fellow clinic over 126 appointments. The majority of patients had Medicaid insurance and most primary languages spoken included English (70.1%), Spanish (21.8%), and Bengali (3.4%). Documented Race was comprised of mostly Other (46%), African American (21.8%), Asian (17.2%), and White (11.5%). The majority of patients completed a lab workup (70-80%). Fewer patients underwent a scheduled HSG (59.8%) and patients' partners completed a semen analysis (SA) (27.6%). Overall, there was a significant difference in the ability to complete the initial infertility workup (lab tests vs. HSG vs. SA) across all groups regardless of age, insurance type, primary language spoken, race and ethnicity (p<0.05). CONCLUSIONS: Completing the fertility workup, particularly the male partner workup and imaging studies, can present challenges for underserved patients with infertility. Understanding which patient characteristics and societal factors restrict access to fertility care requires further investigation to improve access to fertility care in underserved communities.

New Therapies in Veterinary Oncology.

The expanding number of specialized oncology therapeutics available in veterinary oncology can make staying updated on the most recent advances challenging. This article summarizes the mechanism of action, available supporting data, and clinical use of three key veterinary cancer/supportive care therapeutics: Laverdia-CA1, Canalevia-CA1, and Stelfonta. This information will help guide clinical use within your practice and can be incorporated into discussions with clients regarding the newest available options for their dogs with cancer.

The impact of fresh versus frozen-thawed embryos on maternal serum analyte levels in IVF singleton and twin pregnancies.

PURPOSE: To determine whether embryo cryopreservation is associated with a difference in maternal serum analyte levels in singleton and twin pregnancies conceived via in vitro fertilization (IVF). METHODS: This was a retrospective cohort study of singleton and twin pregnancies conceived via IVF from a university health system from 01/2014 to 09/2019. Patients with available first and second trimester serum analyte data were included and analyzed separately. Multiple of the median (MoM) values for free ß-human chorionic gonadotropin (ß-hCG), pregnancy-associated plasma protein A, alpha-fetoprotein (AFP), Inhibin A, and unconjugated estriol (uE3) were compared between two groups: pregnancies conceived after the transfer of fresh embryos versus pregnancies conceived after the transfer of frozen-thawed embryos. Multiple linear regression of log MoM values with F test was performed to adjust for potential confounders. RESULTS: For singletons, fresh embryos were associated with a lower median first trimester free ß-hCG (1.00 MoM vs. 1.14 MoM; parameter estimate [PE] 0.90, 95% CI 0.82-0.99, p = .03) compared to frozen-thawed embryos. Fresh embryos were also associated with a lower median second trimester uE3 (0.93 MoM vs. 1.05 MoM; PE 0.88, CI 0.83-0.95, p = .0004) and AFP (1.02 MoM vs. 1.19 MoM; PE 0.91, CI 0.84-0.99, p = .02) compared to frozen-thawed embryos in singletons. There were no significant differences between median first and second trimester serum analytes in twin pregnancies compared between the two groups. CONCLUSION: Singleton pregnancies derived from fresh embryos had lower first (free ß-hCG) and second (uE3 and AFP) trimester analytes compared to frozen-thawed embryos. Twin pregnancies demonstrated no difference between the groups.

Novel genomic prognostic biomarkers for dogs with cancer.

BACKGROUND: Growing evidence from dogs and humans supports the abundance of mutation-based biomarkers in tumors of dogs. Increasing the use of clinical genomic diagnostic testing now provides another powerful data source for biomarker discovery. HYPOTHESIS: Analyzed clinical outcomes in dogs with cancer profiled using SearchLight DNA, a cancer gene panel for dogs, to identify mutations with prognostic value. ANIMALS: A total of 127 cases of cancer in dogs were analyzed using SearchLight DNA and for which clinical outcome information was available. METHODS: Clinical data points were collected by medical record review. Variables including mutated genes, mutations, signalment, and treatment were fitted using Cox proportional hazard models to identify factors associated with progression-free survival (PFS). The log-rank test was used to compare PFS between patients receiving and not receiving targeted treatment before first progression. RESULTS: Combined genomic and outcomes analysis identified 336 unique mutations in 89 genes across 26 cancer types. Mutations in 6 genes (CCND1, CCND3, SMARCB1, FANCG, CDKN2A/B, and MSH6) were significantly associated with shorter PFS. Dogs that received targeted treatment before first progression (n = 45) experienced significantly longer PFS compared with those that did not (n = 82, P = .01). This significance held true for 29 dogs that received genomically informed targeted treatment compared with those that did not (P = .05). CONCLUSION AND CLINICAL IMPORTANCE: We identified novel mutations with prognostic value and demonstrate the benefit of targeted treatment across multiple cancer types. These results provide clinical evidence of the potential for genomics and precision medicine in dogs with cancer.

Third-Party Reproduction - What's Trending on Instagram?

OBJECTIVE: The objective of this study was to determine the prevalence, authorship and content type of third-party reproduction-related information shared on Instagram by hashtag analysis. METHODS: A list of 10 hashtags consisting of terms related to third-party reproduction was derived. Content analysis was performed in December 2021 on the most recent 100 posts for each hashtag to determine authorship and content type. RESULTS: Our search yielded 838,151 posts. The 3 most popular hashtags were 'surrogacy', 'surrogate' and 'surrogacy journey.' Authorship of the top posts were: patients (59.2%), professional society (14.2%), for-profit commercial groups (11.4%), allied health professional (9.4%), physicians (3.3%), and other (2.5%). Patient experiences accounted for the largest share of posts (39.4%), followed by personal posts unrelated to diagnosis (21.5%), outreach posts (19.5%), advertisements (14.2%) and educational (4.8%). Patients authored the majority of posts. CONCLUSIONS: The vast majority of Instagram posts related to third-party reproduction were authored by patients who shared their own personal experiences. Within surrogacy, both gestational carriers and intended parents shared their experiences providing perspective into the surrogacy process. Physician participation may improve the quality and quantity of educational posts and offer a low-cost platform for networking and connecting with patients.

The voice of infertility: a review of fertility podcasts.

Over the past several years, there has been a significant increase in the popularity of podcast use. The purpose of this study was to review the availability, content, and authorship of podcasts on the topic of fertility and to compare those hosted by physicians vs patients. A search for podcasts relating to the term 'fertility' was performed using 10 podcast platforms. Information relating to each podcast was recorded. Chi-square was used for comparison of proportions and the Mann-Whitney test for continuous variables. Of the 133 podcasts that met inclusion criteria, the most common subject was patient education (62%), followed by fertility awareness (30%), and Third Party Reproduction (13%). A majority of podcasts were hosted by patients (40%), holistic health professionals (28%), and physicians (16%). When comparing podcasts hosted by physicians vs. patients, there was no difference in overall content (p = 0.07), frequency of episodes (p = 0.77), number of episodes (p = 0.63) and number of listener ratings (p = 0.47). We conclude that many fertility podcasts exist with most hosted by patients describing their fertility experiences. Understanding the landscape of fertility podcasts will allow physicians to identify areas of interest and create content which educates and enhances connection with patients.

Weekday vs. weekend oocyte retrievals: is there a difference?

The purpose of this study was to evaluate whether there is a difference in procedure duration and time spent in the post anaesthesia care unit (PACU) between weekday (WD) and weekend (WE) oocyte retrievals (ORs). This was a retrospective cohort study of patients compared and stratified based on number of oocytes retrieved (1-10, 11-20, and >20). Student's t-test and linear regression models were used to assess the relationship between AMH, BMI, and a number of oocytes retrieved with the duration of procedure and total time spent in the PACU. 664 patients underwent OR of which 578 met inclusion criteria and were analyzed. There were 501 WD OR cases (86%) and 77 (13%) WE ORs. When stratified by number of oocytes retrieved, there was no difference in procedure duration or PACU time between WD vs. WE OR. Longer procedure times were associated with higher BMI (p = 0.04), AMH (p = 0.01) and oocytes retrieved (p < 0.01). Increased PACU times positively correlated with the number of oocytes retrieved (p = 0.04), but not AMH or BMI. While BMI, AMH, and number of oocytes retrieved are associated with longer intra-operative and post-operative recovery times, there is no difference in procedure or recovery time when comparing WD vs. WE procedures.

The impact of preimplantation genetic testing on first- and second-trimester maternal serum analyte levels.

OBJECTIVE: To determine whether preimplantation genetic testing (PGT) is associated with a change in maternal serum analyte levels in pregnancies conceived via in vitro fertilization (IVF). METHODS: Retrospective cohort of singleton and twin IVF pregnancies with available first- or second-trimester serum analyte data from 01/2014 to 09/2019. Multiple of the median (MoM) values for free ß-human chorionic gonadotropin (ß-hCG), pregnancy-associated plasma protein A (PAPP-A), alpha-fetoprotein (AFP), inhibin A, and unconjugated estriol, were compared between two groups: pregnancies conceived after transfer of PGT screened euploid embryos vs. those conceived after transfer of untested embryos. Multiple linear regression of log MoM values with F test was performed to adjust for potential confounders. RESULTS: Nine hundred and sixty-two singleton and 165 twin IVF pregnancies with serum analyte data available for analysis were included. PGT was associated with a higher median first- and second-trimester AFP compared to no PGT in singletons (1.23 MoM vs. 1.13 MoM; parameter estimate [PE] 1.08, 95% CI 1.00-1.17, p= .04, and 1.21 MoM vs. 1.07 MoM; PE 1.07, 95% CI 1.01-1.13, p= .01, respectively). PGT was also associated with a lower median PAPP-A compared to no PGT in twins (0.75 MoM vs. 1.18 MoM, PE 0.74, 95% CI 0.60-0.92, p= .006). CONCLUSIONS: Our data suggest that PGT is associated with higher maternal serum levels of second-trimester AFP in singleton and lower levels of first-trimester PAPP-A in twin pregnancies conceived via IVF.

Employer-based insurance coverage increases utilization of planned oocyte cryopreservation.

PURPOSE: To determine the utilization of planned oocyte cryopreservation (OC) in the year immediately prior to, and the year of, insurance coverage commencement for employees at our institution. METHODS: Patient demographics and cycle outcomes were retrospectively compared between the first OC cycles occurring in 2017 vs. 2018 according to insurance coverage and type, age, and the number of oocytes retrieved and cryopreserved. Continuous demographic variables including age, BMI, day 3 FSH and E2, AMH, gravidity, and parity were compared using student T-tests. Cycle outcomes, including the number of oocytes retrieved and cryopreserved were compared using linear regression models, adjusting for potential confounders including age, BMI, and ovarian reserve parameters. RESULTS: Between January 2017 and December 2018, 123 patients underwent planned OC at our institution. Patient age ranged from 23 to 44 years and did not significantly differ from 2017 to 2018 (mean 34.9 vs. 35.2). There was a 12% increase in planned OC utilization from 2017 (N = 58) to 2018 (N = 65). Significantly, more patients had any insurance coverage in 2018 vs. 2017 (71.9% vs. 40.4%, p = 0.001), a 78% increase. From 2017 to 2018, the number of patients with hospital-based insurance coverage undergoing planned OC increased by a factor of 8 (5 to 41.5%, p < 0.001), while the number of self-pay patients significantly decreased (p = 0.001). No differences were found regarding cycle outcomes. CONCLUSION: A greater proportion of women at our institution had insurance coverage for planned OC in 2018 vs. 2017. Employer-based insurance coverage for planned OC was associated with a significant increase in utilization by hospital employees.

The impact of preimplantation genetic testing for aneuploidy on prenatal screening.

OBJECTIVES: To determine whether preimplantation genetic testing for aneuploidy (PGT-A) is associated with a reduced risk of abnormal conventional prenatal screening results in singleton pregnancies conceived using in vitro fertilization (IVF). METHODS: This was a retrospective cohort study of singleton IVF pregnancies conceived from a single tertiary care center between January 2014 and September 2019. Exclusion criteria included mosaic embryo transfers, vanishing twin pregnancies, and cycles with missing outcome data. Two cases of prenatally diagnosed aneuploidy that resulted in early voluntary terminations were also excluded. The primary outcome of abnormal first or second-trimester combined screening results was compared between two groups: pregnancy conceived after transfer of a euploid embryo by PGT-A vs. transfer of an untested embryo. Multivariable backwards-stepwise logistic regression with Firth method was used to adjust for potential confounders. RESULTS: Of the 419 pregnancies included, 208 (49.6%) were conceived after transfer of a euploid embryo by PGT-A, and 211 (50.4%) were conceived after transfer of an untested embryo. PGT-A was not associated with a lower likelihood of abnormal first-trimester (adjusted OR 1.64, 95% CI 0.82-3.39) or second-trimester screening results (adjusted OR 0.96, 95% CI 0.56-1.64). The incidences of cell-free DNA testing, fetal sonographic abnormalities, genetic counseling, and invasive prenatal diagnostic testing were similar between the two groups. CONCLUSIONS: Our data suggest that PGT-A is not associated with a change in the likelihood of abnormal prenatal screening results or utilization of invasive prenatal diagnostic testing. Counseling this patient population regarding the importance of prenatal screening and prenatal diagnostic testing, where appropriate, remains essential.

Virtual obstetrics and gynecology fellowship interviews during the coronavirus disease 2019 (COVID-19) pandemic: a survey study.

BACKGROUND: Due to the coronavirus disease 2019 (COVID-19) pandemic, all Obstetrics and Gynecology fellowship interviews were held virtually for the 2020 fellowship match cycle. The aim of this study was to describe our initial experience with virtual Obstetrics and Gynecology fellowship interviews and evaluate its effectiveness in assessing candidates. METHODS: This was a cross-sectional survey study that included all interviewing attending physicians and fellows from five Obstetrics and Gynecology subspecialties at a single academic institution following the 2020-2021 fellowship interview season. The survey consisted of 19 questions aimed to evaluate each subspecialty's virtual interview process, including its feasibility and performance in evaluating applicants. The primary outcome was the subjective utility of virtual interviews. Secondary outcomes included a comparison of responses from fellows and attending physicians. RESULTS: Thirty-six attendings and fellows completed the survey (36/53, 68% response rate). Interviewers felt applicants were able to convey themselves adequately during the virtual interview (92%) and the majority (70%) agreed that virtual interviews should be offered in future years. Attending physicians were more likely than fellows to state that the virtual interview process adequately assessed the candidates (Likert Scale Mean: 4.4 vs. 3.8, respectively, p = 0.02). Respondents highlighted decreased cost, time saved, and increased flexibility as benefits to the virtual interview process. CONCLUSION: The use of virtual interviews provides a favorable method for conducting fellowship interviews and should be considered for use in future application cycles. Most respondents were satisfied with the virtual interview process and found they were an effective tool for evaluating applicants.

Maternal and neonatal outcomes in pregnancies conceived after preimplantation genetic testing.

OBJECTIVE: To determine whether preimplantation genetic testing (PGT) is associated with an increase in adverse maternal or neonatal outcomes in singleton and twin live births conceived via in vitro fertilization (IVF). METHOD: Retrospective cohort of live births resulting from IVF within a university health system between January 2014 and August 2019. Adverse maternal outcomes (e.g., hypertensive disorders of pregnancy, abnormal placentation, and preterm birth), and adverse neonatal outcomes were compared in singleton and twin pregnancies conceived after transfer of one or two PGT-screened euploid embryos versus untested embryos in separate analyses. Multivariate backwards-stepwise logistic regression was used to adjust for potential confounders. RESULTS: Of 1160 live births, 539 (46.5%) resulted from PGT-screened embryos, 1015 (87.5%) were singletons, and 145 (12.5%) were twins. After adjusting for potential confounders, there were no significant differences between the two groups with respect to hypertensive disorders of pregnancy, fetal growth restriction, preterm birth, and adverse neonatal outcomes in both analyses, as well as abnormal placentation for singletons. CONCLUSION: Our data suggest that IVF with PGT is not associated with an increased risk of adverse maternal or neonatal outcomes compared to IVF without PGT. Further research utilizing larger cohorts are needed before drawing definitive conclusions.

Clinical outcomes of dogs with transitional cell carcinoma receiving medical therapy, with and without partial cystectomy.

The objective of this retrospective study was to evaluate the effects of surgery on outcome for dogs with naturally occurring urinary bladder transitional cell carcinoma. Forty-seven dogs met the inclusion criteria. Thirty-one dogs (Group A) were treated with partial cystectomy and adjunctive medical therapy and 16 dogs (Group B) were treated with medical therapy alone. Overall survival was greater in dogs treated with partial cystectomy and adjunctive medical therapy (498 days for Group A versus 335 days for Group B, hazard ratio 2.5; 95% confidence interval: 1.1 to 5.7; P = 0.026). Progression-free survival was not different between groups (85 days for Group A versus 83 days for Group B; P = 0.663). No prognostic factors were identified for progression-free survival. Due to the many cases in Group A that were lost to follow-up, time-to-event survival analysis was performed. No significant difference in overall survival was noted, and no prognostic factors were identified in the time-to-event analysis. Prospective, randomized studies are needed to determine the role of partial cystectomy in the treatment of transitional cell carcinoma.

Résultats cliniques des chiens atteints d'un carcinome à cellules transitionnelles recevant un traitement médical, avec et sans cystectomie partielle. L'objectif de cette étude rétrospective était d'évaluer les effets de la chirurgie sur les résultats chez des chiens atteints d'un carcinome à cellules transitionnelles de la vessie d'origine naturelle. Quarante-sept chiens répondaient aux critères d'inclusion. Trente et un chiens (Groupe A) ont été traités par cystectomie partielle et traitement médical d'appoint et 16 chiens (Groupe B) ont été traités par thérapie médicale seule. La survie globale était plus élevée chez les chiens traités par cystectomie partielle et traitement médical d'appoint (498 jours pour le Groupe A contre 335 jours pour le Groupe B, rapport de risque de 2,5; intervalle de confiance à 95 % : 1,1 à 5,7; P = 0,026). La survie sans progression n'était pas différente entre les groupes (85 jours pour le Groupe A contre 83 jours pour le Groupe B; P = 0,663). Aucun facteur pronostique n'a été identifié pour la survie sans progression. En raison des nombreux cas dans le Groupe A qui ont été perdus de vue lors du suivi, une analyse du temps de survie a été realisée. Aucune différence significative dans la survie globale n'a été notée et aucun facteur pronostique n'a été identifié dans l'analyse du temps de survive. Des études prospectives randomisées sont nécessaires pour déterminer le rôle de la cystectomie partielle dans le traitement du carcinome à cellules transitionnelles.(Traduit par Dr Serge Messier).

A content and quality evaluation of ACGME-accredited reproductive endocrinology and infertility fellowship program webpages.

PURPOSE: To analyze the content of websites of ACGME-accredited REI fellowship programs in the USA and to determine whether there are differences in content across geographic regions. METHODS: All ACGME-accredited REI fellowship websites active as of September 2020 were evaluated and reviewed using 20 criteria in the following nine domains: program overview, contact information, application information, curriculum, current fellows, research, alumni, faculty, and fellowship benefits. Website content was compared across geographic regions (Northeast, Midwest, South, and West) of the USA. Analyses were completed using chi-squared univariate tests with p < 0.05 considered statistically significant. RESULTS: Out of the 49 accredited REI fellowship programs, 45 (92%) had a dedicated website. The most commonly available information included a program description (88%), clinical sites (84%), and application requirements (78%). Programs less commonly shared information regarding research requirements and didactics (65% for each). Current fellows were featured in 55% of websites with their pictures displayed in 41% and ongoing research in 20%. Salary and alumni information were included in only 14% and 12% of sites, respectively. When comparing content by geographic region, programs in the South had less information regarding application requirements (p < 0.001), interview dates (p = 0.03), and clinical sites (p = 0.04) compared to all other regions. CONCLUSIONS: REI fellowship websites have significant variability in content available to applicants, and many are lacking information about core fellowship requirements. An informative and well-constructed website has the potential to improve perception of a graduate program.

Fertility education: what's trending on Instagram.

OBJECTIVE: To determine the prevalence, authorship, and types of fertility-related information shared on Instagram targeted toward a new patient interested in fertility options using hashtag and content analysis. Secondary outcomes included comparison of post content stratified by author type (physicians versus patients). METHODS: A list of ten hashtags consisting of fertility terms for the new patient was derived. Content analysis was performed in April 2019 on the top 50 and most recent 50 posts for each hashtag to determine authorship and content type. The distribution of fertility terms in posts made by physicians was compared to that of patients and differences in use of terms were analyzed. RESULTS: Our search yielded 3,393,636 posts. The two most popular hashtags were IVF (N = 912,049), and Infertility (N = 852,939). Authorship of the top posts for each hashtag (N = 1000) were as follows: patients (67 %), physicians (10 %), for-profit commercial groups (6.0 %), allied health professional (4.5 %), professional societies (1 %), and other (11 %). Of these posts, 60 % related to patient experiences, 10 % advertisements, 10 % outreach, and 8 % educational. Physicians were more likely to author posts related to oocyte cryopreservation compared to IVF, while patients were more likely to author posts about IVF (p < 0.0001). CONCLUSIONS: Over 3 million posts related to fertility were authored on Instagram. A majority of fertility posts are being mobilized by patients to publicly display and share their personal experiences. Concurrent with the rising utilization of planned oocyte cryopreservation, there is a trend toward physicians educating their patients about the process using social media as a platform. Physician participation on social media may offer a low-cost platform for networking and connecting with patients. Future studies examining the educational quality of posts by author type should be explored.

Histiocytic Sarcoma and Hemangiosarcoma Update.

Histiocytic sarcoma (HS) and hemangiosarcoma (HSA) are uncommon and aggressive neoplasms that develop much more frequently in dogs than in cats. Breed-specific predispositions have been identified for both cancers. The development of novel diagnostics is underway and may aid in earlier diagnosis. Therapeutic approaches to HS and HSA depend on the stage of disease and may include surgery, radiation therapy, and chemotherapy. Such interventions improve outcome; however, aside from a small number of clinical circumstances, both diseases are considered largely incurable. Continued efforts toward the identification of driver mutations and subsequent druggable targets may lead to improvements in long-term prognosis.

Choosing an expanded carrier screening panel: comparing two panels at a single fertility centre.

RESEARCH QUESTION: What are the factors contributing to similarities and differences in carrier rates between two expanded carrier screening (ECS) panels? DESIGN: Retrospective cross-sectional study. A total of 7700 infertility patients who underwent ECS from one of two genetic testing laboratories (Panel A or Panel B) using a genotyping microarray were included in the study. Individuals presenting to the Centre between June 2013 and July 2015 underwent screening via Panel A. Those presenting between August 2015 and April 2017 underwent screening via Panel B. Self-reported ethnicity was recorded. Panel content, carrier rates for the overall study population and for comparable self-reported ethnicities, carrier couple rates, and the top 10 identified disorders were compared. RESULTS: Of 4232 individuals screened by Panel A, 1243 were identified as carriers (29.4%). Panel B identified 1503 carriers among the 3468 (43.3%) participants (P < 0.0001). Carrier couple rate also varied between panels (1.2% versus 3.1%; P = 0.0017). A total of 311 disorders covering 2746 mutations were observed across the two ECS panels, with 372 (13.5%) shared mutations. Carrier rates did not differ for the shared mutations overall and across ethnicities. Significant differences were observed when comparing unique content in the overall population (P < 2 .2 × 10-16) and across ethnicities (P < 2.2 × 10-16 to 0.0010). CONCLUSIONS: Carrier rates in the overall population and across ethnicities vary widely based on panel content, and highlight the need to expand panel content as well as incorporate preconception carrier screening coupled with genetic counselling into routine assisted reproduction practice.