The psychological impact of the COVID-19 pandemic on fertility care: a qualitative systematic review.

The objective of this systematic review was to characterise psychological impacts of the COVID-19 pandemic related to fertility care. We conducted a systematic search following PRISMA guidelines of five databases (EMBASE, Medline-OVID, CINAHL, Web of Science, and PsycINFO) from March 17th 2020 to April 10th 2021. Citing articles were also hand-searched using Scopus. Of the 296 original citations, we included fifteen studies that encompassed 5,851 patients seeking fertility care. Eleven studies only included female participants, while four included both male and female participants. The fifteen studies unanimously concluded that the COVID-19 pandemic caused negative psychological impacts on fertility care. Risk factors included female sex, single marital state, previous ART failure, prior diagnoses of anxiety or depression, and length of time trying to conceive. Specific concerns included the worry and frustration of clinic closure, concerns about pregnancy and COVID-19 infection, and advancing age. There were contrasting beliefs on whether the decision to stop fertility treatments during the COVID-19 pandemic was justified. In addition, we found that many patients preferred to resume fertility treatment, despite anxieties regarding the risk of the COVID-19 virus. We recommend that fertility providers screen patients for risk factors for poor mental health and tailor support for virtual care.

Cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people: a systematic review of patient and provider perspectives.

OBJECTIVE: To characterize the patient and provider perspectives on cultural competence in lesbian, gay, bisexual, transgender, and queer (LGBTQ+) fertility care. DESIGN: Systematic review. SETTING: Not applicable. PATIENT(S): LGBTQ+ patients and their partners treated for fertility-related care; fertility providers who treat LGBTQ+ patients. INTERVENTION(S): We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines of six databases: Medline-OVID, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.Gov, and PsycInfo. Citations of full-text articles were hand-searched using the Scopus database. Eligible studies were assessed using the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices, as well as the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. All screening, extraction, and appraisal were completed in duplicate with two independent reviewers. MAIN OUTCOME MEASURE(S): Patient-reported or provider-reported views on LGBTQ+ cultural competence in fertility care, including barriers and facilitators to inclusive care. RESULT(S): Of the 1,747 original database citations, we included 25 studies that met the inclusion criteria. Of the 21 studies that evaluated patient perspectives, 13 studies targeted same-sex cisgender couples while the remainder targeted transgender and gender-nonconforming participants (n = 6) or any individual who identified as a sexual or gender minority (n = 2). Key barriers for LGBTQ+ participants included gender dysphoria, heteronormativity, stigmatization, and psychological distress. The lack of tailored information for LGBTQ+ populations was repeatedly highlighted as a concern. Promising solutions included tailored information, psychosocial interventions, gender-neutral language, and inclusive intake processes. CONCLUSION(S): LGBTQ+ individuals face unique barriers in fertility care, as described by both patients and providers. This review describes a number of implementable solutions for equitable care, which should be given priority for both research and hospital interventions.

Recurrent implantation failure in IVF: A Canadian Fertility and Andrology Society Clinical Practice Guideline.

Recurrent implantation failure (RIF) after IVF is a challenging topic for clinicians and can be a devastating reality for some patients with infertility. The purpose of this guideline from the Canadian Fertility and Andrology Society (CFAS) is to provide the most relevant evidence to date for the assessment and management of RIF. This guideline was developed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. This guideline recognizes the presence of heterogeneity in the definition of RIF. Recommendations are offered here on the investigation of RIF and management options that may increase the chance of a live birth.

Micronized vaginal progesterone to prevent miscarriage: a critical evaluation of randomized evidence.

Progesterone is essential for the maintenance of pregnancy. Several small trials have suggested that progesterone supplementation may reduce the risk of miscarriage in women with recurrent or threatened miscarriage. Cochrane Reviews summarized the evidence and found that the trials were small with substantial methodologic weaknesses. Since then, the effects of first-trimester use of vaginal micronized progesterone have been evaluated in 2 large, high-quality, multicenter placebo-controlled trials, one targeting women with unexplained recurrent miscarriages (the PROMISE [PROgesterone in recurrent MIScarriagE] trial) and the other targeting women with early pregnancy bleeding (the PRISM [PRogesterone In Spontaneous Miscarriage] trial). The PROMISE trial studied 836 women from 45 hospitals in the United Kingdom and the Netherlands and found a 3% greater live birth rate with progesterone but with substantial statistical uncertainty. The PRISM trial studied 4153 women from 48 hospitals in the United Kingdom and found a 3% greater live birth rate with progesterone, but with a P value of .08. A key finding, first observed in the PROMISE trial, and then replicated in the PRISM trial, was that treatment with vaginal micronized progesterone 400 mg twice daily was associated with increasing live birth rates according to the number of previous miscarriages. Prespecified PRISM trial subgroup analysis in women with the dual risk factors of previous miscarriage(s) and current pregnancy bleeding fulfilled all 11 conditions for credible subgroup analysis. For the subgroup of women with a history of 1 or more miscarriage(s) and current pregnancy bleeding, the live birth rate was 75% (689/914) with progesterone vs 70% (619/886) with placebo (rate difference 5%; risk ratio, 1.09, 95% confidence interval, 1.03-1.15; P=.003). The benefit was greater for the subgroup of women with 3 or more previous miscarriages and current pregnancy bleeding; live birth rate was 72% (98/137) with progesterone vs 57% (85/148) with placebo (rate difference 15%; risk ratio, 1.28, 95% confidence interval, 1.08-1.51; P=.004). No short-term safety concerns were identified from the PROMISE and PRISM trials. Therefore, women with a history of miscarriage who present with bleeding in early pregnancy may benefit from the use of vaginal micronized progesterone 400 mg twice daily. Women and their care providers should use the findings for shared decision-making.

The management of unexplained infertility: an evidence-based guideline from the Canadian Fertility and Andrology Society.

Unexplained infertility is a common diagnosis affecting as many as 50% of couples seeking infertility care. As a diagnosis of exclusion, its treatment remains largely empirical. Historically, a step-wise progression in treatment has been initiated with the least invasive, least expensive option followed by a gradual progression to therapies using assisted reproductive technology. In recent years there have been advocates for more rapid-progression IVF. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based recommendations for the treatment of unexplained infertility, including expectant management, laparoscopy, intrauterine insemination (IUI) alone, ovarian stimulation with oral agents or gonadotropins alone, ovarian stimulation + IUI, and IVF. The quality of supporting evidence for each recommendation is evaluated using the framework outlined by the Canadian Task Force on Preventive Health Care. This guideline recognizes that the therapeutic approach should be individualized taking into account patient age and duration of infertility, and emphasizes those strategies that are most likely to result in a healthy live birth.

Pregnancy outcomes in women with polycystic ovary syndrome undergoing in vitro fertilization.

OBJECTIVE: To determine whether the diagnosis of polycystic ovary syndrome (PCOS) independently predicts increased rates of pregnancy complications relative to control subjects, after adjusting for important confounders. DESIGN: Retrospective cohort. SETTING: Not applicable. PATIENT(S): A review of all pregnancies after fresh IVF with or without intracytoplasmic sperm injection transfers from December 2006 to 2012 (n = 1,084) identified 394 eligible singleton births (71 women with PCOS; 323 controls without). INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Singleton births were assessed for selected adverse pregnancy and birth outcomes. RESULT(S): Women with PCOS demonstrated a higher risk of developing the following pregnancy complications after adjusting for differences in age, parity, body mass index, and time to conception: gestational diabetes (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.35-7.33), hypertensive disorders of pregnancy (AOR 4.25, 95% CI 1.94-9.32), preterm birth <37 weeks (AOR 2.30, 95% CI 1.07-4.97), and large for gestational age >90th percentile (AOR 2.77, 95% CI 1.21-6.35). The increased risk of preterm birth <37 weeks was eliminated after adjusting for development of hypertensive disorders of pregnancy, whereas the increased risk of large for gestational age remained significant after adjusting for gestational diabetes mellitus status. Time to conception did not differ significantly between groups, nor did rates of antepartum hemorrhage, cesarean section, or perinatal mortality. CONCLUSION(S): Polycystic ovary syndrome independently predicts higher risk of adverse pregnancy outcomes after adjusting for differences in maternal age, parity, body mass index, and time to conception. This new information may be of relevance in counseling and monitoring women with PCOS, although larger prospective studies may be needed to validate our findings.

Pregnancy outcomes after assisted human reproduction.

OBJECTIVE: To review the effect of assisted human reproduction (AHR) on perinatal outcomes, to identify areas requiring further research with regard to birth outcomes and AHR, and to provide guidelines to optimize obstetrical management and counselling of prospective Canadian parents. OUTCOMES: This document compares perinatal outcomes of different types of AHR pregnancies with each other and with those of spontaneously conceived pregnancies. Clinicians will be better informed about the adverse outcomes that have been documented in association with AHR, including obstetrical complications, adverse perinatal outcomes, multiple gestations, structural congenital abnormalities, chromosomal abnormalities, and imprinting disorders. EVIDENCE: Published literature was retrieved through searches of MEDLINE and the Cochrane Library from January 2005 to December 2012 using appropriate controlled vocabulary and key words (assisted reproduction, assisted reproductive technology, ovulation induction, intracytoplasmic sperm injection, embryo transfer, and in vitro fertilization). Results were not restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies; studies of all designs published in English from January 2005 to December 2012 were reviewed, and additional publications were identified from the bibliographies of these articles. Searches were updated on a regular basis and incorporated in the guideline to August 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. There is increasing evidence that infertility or subfertility is an independent risk factor for obstetrical complications and adverse perinatal outcomes, even without the addition of assisted human reproduction. (II-2) 2. The relative risk for an imprinting phenotype such as Silver-Russell syndrome, Beckwith-Wiedemann syndrome, or Angelman syndrome is increased in the assisted reproduction population, but the actual risk for one of these phenotypes to occur in an assisted pregnancy is estimated to be low, at less than 1 in 5000. The exact biological etiology for this increased imprinting risk is likely heterogeneous and requires more research. (II-2) Recommendations 1. All men with severe oligozoospermia or azoospermia (sperm count < 5 million/hpf) should be offered genetic/clinical counselling, karyotype assessment for chromosomal abnormalities, and Y-chromosome microdeletion testing prior to in vitro fertilization with intracytoplasmic sperm injection. (II-2A) 2. All men with unexplained obstructive azoospermia should be offered genetic/clinical counselling and genetic testing for cystic fibrosis prior to in vitro fertilization with intracytoplasmic sperm injection. (II-2A) 3. Multiple pregnancy is the most powerful predictive factor for adverse maternal, obstetrical, and perinatal outcomes. Couples should be thoroughly counselled about the significant risks of multiple pregnancies associated with all assisted human reproductive treatments. (II-2A) 4. The benefits and cumulative pregnancy rates of elective single embryo transfer support a policy of using this protocol in couples with good prognosis for success, and elective single embryo transfer should be strongly encouraged in this population. (II-2A) 5. To reduce the incidence of multiple pregnancy, health care policies that support public funding for assisted human reproduction, with regulations promoting best practice regarding elective single embryo transfer, should be strongly encouraged. (II-2A) 6. Among singleton pregnancies, assisted reproductive technology is associated with increased risks of preterm birth and low birth weight infants, and ovulation induction is associated with an increased risk of low birth weight infants. Until sufficient research has clarified the independent roles of infertility and treatment for infertility, couples should be counselled about the risks associated with treatment. (II-2B) There is a role for closer obstetric surveillance of women who conceive with assisted human reproduction. (III-L) 7. There is growing evidence that pregnancy outcomes are better for cryopreserved embryos fertilized in vitro than for fresh embryo transfers. This finding supports a policy of elective single embryo transfer for women with a good prognosis (with subsequent use of cryopreserved embryos as necessary), and may reassure women who are considering in vitro fertilization. (II-2A) 8. Women and couples considering assisted human reproduction and concerned about perinatal outcomes in singleton pregnancies should be advised that (1) intracytoplasmic sperm injection does not appear to confer increased adverse perinatal or maternal risk over standard in vitro fertilization, and (2) the use of donor oocytes increases successful pregnancy rates in selected women, but even when accounting for maternal age, can increase the risks of low birth weight and preeclampsia. (II-2B) 9. Any assisted reproductive technology procedure should be prefaced by a discussion of fetal outcomes and the slight increase in the risk of congenital structural abnormalities, with emphasis on known confounding factors such as infertility and body mass index. (II-2B) 10. In pregnancies achieved by artificial reproductive technology, routine anatomic ultrasound for congenital structural abnormalities is recommended between 18 and 22 weeks. (II-2A) 11. Pregnancies conceived by intracytoplasmic sperm injection may be at increased risk of chromosomal aberrations, including sex chromosome abnormalities. Diagnostic testing should be offered after appropriate counselling. (II-2A) 12. The possible increased risk for late onset cancer due to gene dysregulation for tumour suppression requires more long-term follow-up before the true risk can be determined. (III-A) 13. The clinical application of preimplantation genetic testing in fertile couples must balance the benefits of avoiding disease transmission with the medical risks and financial burden of in vitro fertilization. (III-B) 14. Preimplantation screening for aneuploidy is associated with inconsistent findings for improving pregnancy outcomes. Any discussion of preimplantation genetic screening with patients should clarify that there is no adequate information on the long-term effect of embryo single cell biopsy. (I-C).

Objectif : Analyser l'effet du recours à la procréation assistée (PA) sur les issues périnatales, identifier les aspects propres aux issues de naissance et à la PA qui nécessitent des recherches approfondies, et fournir des lignes directrices permettant l'optimisation de la prise en charge obstétricale et du counseling des parents potentiels canadiens. Issues : Le présent document compare les issues périnatales constatées dans le cadre de différents types de grossesse attribuable à la PA les unes aux autres, ainsi qu'à celles qui sont constatées dans le cadre des grossesses conçues de façon spontanée. Les cliniciens seront mieux renseignés au sujet des issues indésirables associées à la PA qui ont été documentées, y compris les complications obstétricales, les issues périnatales indésirables, les gestations multiples, les anomalies congénitales structurelles, les anomalies chromosomiques et les troubles de l'empreinte génomique. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans MEDLINE et The Cochrane Library entre janvier 2005 et décembre 2012 au moyen d'un vocabulaire contrôlé et de mots clés appropriés (« assisted reproduction ¼, « assisted reproductive technology ¼, « ovulation induction ¼, « intracytoplasmic sperm injection ¼, « embryo transfer ¼ et « in vitro fertilization ¼). Les résultats n'ont pas été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles; les études (tous devis confondus) publiées en anglais entre janvier 2005 et décembre 2012 ont été analysées, et des publications additionnelles ont été identifiées à partir des bibliographies de ces études. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en août 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Déclarations sommaires 1. De plus en plus de données indiquent que l'infertilité ou l'hypofertilité constitue un facteur de risque indépendant en ce qui concerne les complications obstétricales et les issues périnatales indésirables, même sans l'ajout de la procréation assistée. (II-2) 2. Bien que le risque relatif de voir apparaître un phénotype d'empreinte génomique (comme le syndrome de Silver-Russell, le syndrome de Beckwith-Wiedemann ou le syndrome d'Angelman) soit accru au sein de la population issue de la procréation assistée, on estime que le risque réel de voir apparaître un de ces phénotypes dans le cadre d'une grossesse attribuable à la procréation assistée est faible (inférieur à 1 sur 5 000). L'étiologie biologique exacte de cette hausse du risque lié à l'empreinte génomique est probablement hétérogène et nécessite la tenue d'autres recherches. (II-2) Recommandations 1. Tous les hommes qui présentent une oligozoospermie ou une azoospermie graves (numération de spermatozoïdes < 5 millions/hpf) devraient se voir offrir des services de counseling génétique / clinique, une évaluation du caryotype visant les anomalies chromosomiques et un dépistage des microdélétions du chromosome Y avant la tenue d'une fécondation in vitro-injection intracytoplasmique d'un spermatozoïde. (II-2A) 2. Tous les hommes qui présentent une azoospermie obstructive inexpliquée devraient se voir offrir des services de counseling génétique / clinique et un dépistage génétique visant la fibrose kystique avant la tenue d'une fécondation in vitro-injection intracytoplasmique d'un spermatozoïde. (II-2) 3. La grossesse multiple constitue le facteur prédictif le plus puissant en ce qui concerne les issues indésirables maternelles, obstétricales et périnatales. Les couples devraient bénéficier de services de counseling exhaustifs au sujet des risques importants que posent les grossesses multiples associées aux traitements de procréation assistée, tous types confondus. (II-2A) 4. Les avantages et les taux cumulatifs de grossesse associés au transfert sélectif d'un seul embryon soutiennent la mise en œuvre d'une politique en instaurant l'utilisation chez les couples qui présentent un bon pronostic de réussite; le recours au transfert sélectif d'un seul embryon devrait être fortement encouragé chez cette population. (II-2) 5. Pour réduire l'incidence de la grossesse multiple, la mise en œuvre de politiques de santé soutenant le financement public de la procréation assistée (le tout s'accompagnant de règlements faisant la promotion de l'adoption de pratiques optimales à l'égard du transfert sélectif d'un seul embryon) devrait être fortement encouragée. (II-2A) 6. Dans le cas des grossesses monofœtales, les techniques de procréation assistée sont associées à un risque accru de connaître un accouchement préterme et d'obtenir un enfant présentant un faible poids de naissance, et le déclenchement de l'ovulation est associé à un risque accru d'obtenir un enfant présentant un faible poids de naissance. Jusqu'à ce qu'un nombre suffisant de recherches aient été menées pour clarifier les rôles indépendants de l'infertilité et des traitements contre l'infertilité, les couples devraient bénéficier de services de counseling au sujet des risques associés au traitement. (II-2B) La mise en œuvre d'une surveillance obstétricale plus étroite a un rôle à jouer dans la prise en charge des femmes qui ont recours à la procréation assistée. (III-L) 7. De plus en plus de données indiquent que les issues de grossesse sont meilleures lorsque l'on a recours au transfert d'embryons fécondés in vitro, puis cryoconservés, plutôt qu'au transfert d'embryons frais. Cette constatation soutient la mise en œuvre d'une politique instaurant l'utilisation du transfert sélectif d'un seul embryon chez les couples qui présentent un bon pronostic de réussite (suivie de l'utilisation d'embryons cryoconservés, au besoin) et pourrait rassurer les femmes qui envisagent d'avoir recours à la fécondation in vitro. (II-2A) 8. Les femmes et les couples qui envisagent d'avoir recours à la procréation assistée, et qui entretiennent des préoccupations au sujet des issues périnatales associées aux grossesses monofœtales devraient être avisés que (1) l'injection intracytoplasmique d'un spermatozoïde ne semble pas donner lieu à une hausse du risque maternel ou du risque d'obtenir des issues périnatales indésirables, par comparaison avec la fécondation in vitro standard, et que (2) le recours à des ovocytes issus de donatrices entraîne la hausse des taux de grossesse réussie chez certaines femmes, mais qu'il peut également accroître le risque de faible poids de naissance et de prééclampsie, même en tenant compte de l'âge maternel. (II-2B) 9. Le recours à toute intervention faisant appel aux techniques de procréation assistée devrait être précédé d'une discussion sur les issues fœtales et la légère hausse du risque d'anomalies congénitales structurelles, en s'assurant de mettre l'accent sur les facteurs de confusion connus (tels que l'infertilité et l'indice de masse corporelle). (II-2B) 10. Dans le cas des grossesses attribuables aux techniques de procréation assistée, la tenue systématique d'une échographie anatomique visant les anomalies congénitales structurelles est recommandée entre 18 et 22 semaines. (II-2A) 11. Les grossesses attribuables à l'injection intracytoplasmique d'un spermatozoïde pourraient être exposées à un risque accru d'aberrations chromosomiques, y compris des anomalies affectant les chromosomes sexuels. Des tests diagnostiques devraient être offerts à la suite de l'offre de services de counseling appropriés. (II-2A) 12. La hausse possible du risque de cancer d'apparition tardive attribuable à la dysrégulation génique de la suppression tumorale nécessite la mise en œuvre d'un suivi à plus long terme, et ce, jusqu'à ce que le risque réel puisse être déterminé. (III-A) 13. La mise en œuvre clinique du dépistage génétique préimplantatoire chez les couples fertiles doit mettre en balance les avantages du fait d'éviter la transmission de pathologies et les risques médicaux (et le fardeau financier) de la fécondation in vitro. (III-B) 14. Le dépistage préimplantatoire de l'aneuploïdie est associé à des constatations hétérogènes pour ce qui est de l'amélioration des issues de grossesse. Toute discussion avec les patientes au sujet du dépistage génétique préimplantatoire devrait mettre au clair que nous ne disposons pas de renseignements adéquats quant aux effets à long terme de la biopsie unicellulaire de l'embryon. (I-C).

Advanced reproductive age and fertility: no. 269, November 2011.

OBJECTIVE: To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management,and to review investigations in the assessment of ovarian aging. OPTIONS: This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility. OUTCOMES: The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility. EVIDENCE: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table). BENEFITS, HARMS, AND COSTS: Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology.

Ovulation induction in polycystic ovary syndrome: No. 242, May 2010.

OBJECTIVE: To review current non-pharmacologic and pharmacologic options for ovulation induction in women with polycystic ovary syndrome (PCOS). OPTIONS: This guideline reviews the evidence for the various options for ovulation induction in PCOS. OUTCOMES: Ovulation, pregnancy and live birth rates, risks, and side effects are the outcomes of interest. EVIDENCE: Published literature was retrieved through searches of Medline using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and of health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The evidence gathered was reviewed and evaluated by the Reproductive Endocrinology and Infertility Committee of the Society of Obstetricians and Gynaecologists of Canada. The quality of evidence was quantified using the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: Benefits include weight reduction and improvements in ovulation, pregnancy, and live birth rates. Potential harms include medication side effects and multiple pregnancies. VALIDATION: These guidelines have been reviewed and approved by the Reproductive Endocrinology and Infertility Committee of the SOGC.

Hysterosalpingography in the investigation of women requesting reversal of sterilization. Should it play a role?

OBJECTIVE: To evaluate the role of hysterosalpingography (HSG) in the investigation of women requesting reversal of sterilization (ROS). STUDY DESIGN: A prospective, cohort study at a university-affiliated, tertiary fertility clinic. All women proceeding to surgery were investigated with HSG in addition to other routine screening. Findings from HSG were tabulated to document the prevalence of abnormalities and correlated with histologic findings in resected tubal segments. RESULTS: One hundred sixteen women of 166 referred for ROS underwent HSG during the initial evaluation. HSG depicted abnormal tubal images in only 2 cases (1.7%) and abnormal uterine images in 15 (12.9%) cases. In the cases of abnormal tubal findings, there was no association with histologic findings. The specificity of HSG as a diagnostic screening tool was 90%; however, the small number of cases with abnormal histology prevented calculation of an accurate estimate of sensitivity of HSG as an investigative tool before ROS. A less invasive method of imaging the uterus, such as a vaginal ultrasound, may provide more valuable information in evaluating the future fertility outcome in these women. CONCLUSION: The prevalence of abnormalities of the proximal oviductal segment identified by HSG is too low to warrant the routine use of HSG as a diagnostic tool.

Preliminary counseling with age-related fertility rates does not influence whether women undergo reversal of sterilization.

Our objective was to assess the influence of preliminary counseling that provided information about age-related fertility rates on the decision of women to undergo reversal of sterilization. There was no apparent influence; this raises the question as to whether couples seeking fertility therapy base their decision making on factual information provided by the clinician.

Reproductive outcomes in recurrent pregnancy loss associated with a parental carrier of a structural chromosome rearrangement.

BACKGROUND: Reproductive outcome studies of couples with a history of recurrent pregnancy loss (RPL) associated with a maternal or paternal carrier of a structural chromosome rearrangement are limited. Correlation of carrier status and cytogenetics of miscarriage specimens is critical to estimate subsequent pregnancy outcome. METHODS: Couples found to have a structural chromosome rearrangement were followed prospectively in a tertiary academic centre. Descriptive analysis and subsequent pregnancy outcomes were tabulated and compared to historic controls. RESULTS: In 1893 RPL couples, 51 carriers of a structural chromosome rearrangement were identified (2.7%). Overall, this cohort had a total of 273 documented pregnancies. Prior to evaluation, the mean maternal age at the time of delivery or miscarriage was 29.8 years and the live birth rate was 15%. Following evaluation and treatment of concomitant factors, there were 58 monitored pregnancies, with a live birth rate of 71%. Amniocentesis was performed on 22% of the ongoing pregnancies; all were diploid or balanced structural chromosome rearrangements. Thirty-six per cent of the miscarriages were found to have an unbalanced structural chromosome rearrangement. CONCLUSIONS: Following evaluation and management of RPL, the live birth rate for carriers of a structural chromosome rearrangement is highly encouraging at 71%, without the addition of assisted reproductive technology.

Genetics of recurrent pregnancy loss.

Recurrent pregnancy loss (RPL) is a devastating reproductive problem affecting approximately 5% of couples trying to conceive. Genetic factors appear to be highly associated with reproductive loss. In this article, genetic factors are reviewed in terms of random numerical chromosome errors in miscarriage specimens and carriers of structural chromosome rearrangements that may result in unbalanced chromosome errors in pregnancies. Recently, research has generated interest in genetic markers for recurrent loss such as skewed X-chromosome inactivation and human leukocyte antigen-G polymorphisms. Assisted reproductive technologies (specifically, preimplantation genetic diagnosis) have been offered to couples with recurrent pregnancy loss; however, more data need to be evaluated before routine use can be advocated. Management of genetic factors in RPL should include therapy based on the highest level of evidence, genetic counseling, and close monitoring of subsequent pregnancies.