The Australian New Zealand Consortium in Children, Adolescents, and Young Adults Oncofertility action plan.

International and national oncofertility networks, including the US-led Oncofertility Consortium, FertiProtekt, and the Danish Network, have played pivotal roles in advancing the discipline of oncofertility over the last decade. Many other countries lack a shared approach to pediatric oncofertility health service delivery. This study aims to describe baseline oncofertility practices at Australian New Zealand Children's Haematology/Oncology Group centers in 2019-2021, describe binational priorities for care, and propose a 5-year action plan for best practice to be implemented by the newly formed Australian New Zealand Consortium in Children, Adolescents, and Young Adults (CAYA) Oncofertility (ANZCO).

Assessing obstetric outcomes: A systematic review and meta-analysis comparing fresh, artificial, and natural thaw embryo transfer cycles.

BACKGROUND: The increasing utilisation of in vitro fertilisation (IVF) has prompted significant interest in determining the optimal endometrial environment to increase pregnancy rates and minimise the obstetric complications associated with various embryo transfer strategies. AIMS: To determine which cycle is associated with increased obstetric complications: fresh embryo transfer (FreshET), natural thaw (NatThawET) or artificial thaw (ArtThawET). Outcomes of interest included: hypertensive disorders of pregnancy (HDP), gestational diabetes (GD), pre-term birth (PTB), post-partum haemorrhage (PPH) and large for gestational age (LGA). MATERIALS AND METHODS: A comprehensive search of MEDLINE, EMBASE, CENTRAL, and PUBMED was conducted from 1947 to May 17, 2022. Two independent reviewers carried out the screening, and data extraction for the following comparisons: ArtThawET vs NatThawET, ArtThawET vs FreshET, and NatThawET vs FreshET. Meta-analysis was conducted using a fixed-effect Mantel-Haenszel model. The quality of the studies was assessed using GRADEpro. RESULTS: A total of 23 studies were included in this review. ArtThawET was associated with a significantly increased odds of HDP (odds ratio (OR) 1.76, confidence interval (CI) 1.66-1.86), PTB (OR 1.18, CI 1.13-1.23), PPH (OR 2.61, CI 2.3-2.97) and LGA (OR 1.11, CI 1.07-1.15), compared to NatThawET. ArtThawET was also associated with increased odds of HDP (OR 2.13, CI 1.89-2.4), PPH (OR 3.52, CI 3.06-4.04) and LGA (OR 2.12, CI 1.77-2.56), compared to FreshET. Furthermore, NatThawET demonstrated increased odds of HDP (OR 1.20, CI 1.11-1.29), PPH (OR 1.25, CI 1.14-1.38) and LGA (OR 1.85, CI 1.66-2.07) compared to FreshET. CONCLUSION: When clinically feasible, ArtThawET should be avoided as a first-line option for IVF to reduce the risk of obstetric complications. An adequately powered, multicentre randomised controlled trial is necessary to confirm these findings and investigate the underlying pathophysiology.

Exploring the complexities of posthumous reproduction in fertility preservation for oncology patients with poor prognosis.

The field of fertility preservation (FP) for oncology patients has evolved significantly in recent years, offering new possibilities for individuals with life-threatening illnesses. We commend Jones et al. for their comprehensive ethical review of offering FP to patients with poor prognoses, acknowledging the potential benefits that it may bring. "Poor prognosis" in this context implies a high likelihood of death due to cancer progression. We highlight the importance of considering posthumous reproduction, involving the use of cryopreserved gametes or embryos to conceive a child after one or both partners have passed away, a topic briefly mentioned by Jones et al. Posthumous reproduction raises complex ethical, logistical, and legal questions. Distinctions between cryopreserved sperm and oocytes are discussed, with each scenario presenting unique challenges. The article also examines the complexities faced by same-sex couples in posthumous reproduction, addressing issues related to donor selection, legal parentage, and rights. Legal and regulatory aspects play a crucial role, including obtaining clear and legally valid consent, defining parental rights, navigating surrogacy laws, and addressing inheritance and estate planning. Ethical dilemmas require healthcare professionals to ensure informed decision-making, consider psychological impacts, and offer information on alternative family-building options.

Posthumous conception in Australia - legal and ethical considerations.

Posthumous conception, the ability to conceive a child after the death of one partner, is increasingly prevalent due to advances in Artificial Reproduction Technology (ART). This paper considers the complexities surrounding the practice in Australia, focusing primarily on the ethical and legal dimensions. It observes that state-based regulations in Australia create disparities in accessibility: some states prohibit the procedure without the deceased's written consent, while others permit it based on guidelines or lack explicit prohibitions. Addressing the juxtaposition of Will Theory and Interest Theory, it emphasises the ongoing debate on whether rights, particularly reproductive autonomy, outlive a person's demise. Finally, the paper highlights an evident inconsistency in Australian legislation and promotes a uniform approach across states.

Providers' attitudes towards payment to egg donors: an international survey.

The research question 'How do fertility professionals worldwide perceive the issue of payment for egg donation and does this view change under different circumstances?' was addressed. A worldwide online survey was conducted between January and March 2023, focusing on the views of fertility providers concerning egg donor payments. From the 3,790 IVF-Worldwide.com members invited, 532 (14%) from 88 countries responded. The majority of participants, primarily from Europe (38.9%) and Asia (20.1%), were fertility specialists, embryologists, and fertility nurses. Most (60.3%) favoured regulated donor compensation, with only 13% advocating for unrestricted amounts. Compensation opposition (22.4%) was often rooted in concerns about donors' best interests. When considering egg donation from low-resource to high-resource countries, 38.5% were opposed. When asked about compensating women who underwent elective, non-medical egg freezing should they choose to donate their unused oocytes, most responders supported it to some degree, with only 28.4% opposing any compensation. The survey revealed that a significant majority of fertility professionals worldwide are supportive of some form of compensation for egg donors. However, perspectives diverge depending on the specific scenario and the country of practice.

Controlled ovarian hyperstimulation in breast cancer patients: Does oestrogen receptor status make a difference?

BACKGROUND: The presence of different breast cancer receptor status may impact ovarian stimulation outcomes. AIM: To study the association between oestrogen receptor (ER) status in breast cancer patients and fertility preservation outcomes in a major tertiary referral centre. MATERIALS AND METHODS: Women who underwent fertility preservation following the diagnosis of breast cancer from 2008 to 2018 were included in the study. Patient age, ovarian stimulation parameters and laboratory outcomes were recorded and compared between the ER positive and negative groups. The primary outcome was total number of oocytes frozen. Secondary outcomes included total number of oocytes collected, mature oocytes, and embryos frozen. RESULTS: The women included in the study (n = 214) were analysed in the following groups based on their fertility preservation method: oocyte freezing (n = 131), embryo freezing (n = 70), and both embryo and oocyte freezing (n = 13). There was an increase in the mean (but not mature) number of oocytes frozen (12.4 and 9.2, P-value = 0.03) favouring the ER positive group, even though the women in this group were older (35.0 and 33.4, P-value of 0.03). There is no difference in the starting follicle-stimulating hormone dose, duration of stimulation, mature oocytes collected, and embryos frozen in both groups. CONCLUSION: Patients with ER positive breast cancer may have more positive ovarian stimulation outcomes.

Live birth rates in day 5 fresh versus vitrified single blastocyst transfer cycles: A cross-sectional analysis.

Background: The use of frozen embryo transfers (FET) in assisted reproduction has increased worldwide. Controlled ovarian hyperstimulation in a fresh transfer may impair endometrial-embryo synchronicity. However, there is conflicting evidence on live birth rates (LBR) and clinical pregnancy rates (CPR). Objective: To compare LBRs and CPRs between single autologous day 5 fresh vs. vitrified blastocyst transfer cycles, to investigate the impact of controlled ovarian hyperstimulation on embryo-endometrium asynchrony. Materials and Methods: A large cross-sectional analysis of 6002 embryo transfers (ET) comprised 3774 fresh and 2228 FET cycles from 2016 to 2019. Multivariate and subgroup analysis were performed for high responders ( > 20 oocytes). Results: Univariate analysis showed no difference in LBR (28.3% vs. 27.4%, p = 0.43) and CPR (32.2% vs. 30.9%, p = 0.30); however, multivariate analysis demonstrated significantly lower LBR (OR 0.864, p = 0.046, 95% CI 0.749-0.997) and CPR (OR 0.852, p = 0.024, 95% CI 0.742-0.979) in FET compared to fresh ETs. Younger participant age, previous in vitro fertilization pregnancy, advanced blastocyst expansion, higher trophectoderm quality, and lower cumulative number of ETs all improved the odds of LBR and CPR. Conventional in vitro fertilization, rather than intracytoplasmic sperm injection, improved CPR but not LBR. Body mass index affected neither LBR nor CPR. In the subgroup, multivariate analysis of high responders showed no difference in LBR or CPR. Conclusion: This study demonstrates relatively higher LBR and CPR of nearly 14% for fresh ETs compared to FETs, in multivariate analysis. A universal freeze-all strategy, without appropriate indication, may lead to suboptimal outcomes. In high responders, freeze-all cycles may be beneficial, as outcomes appear similar.

The ovarian hyperstimulation that truly matters: Admissions, severity and prevention strategies.

INTRODUCTION: Ovarian hyperstimulation syndrome (OHSS) is a common but serious complication of in vitro fertilisation. Despite available strategies to reduce OHSS incidence, a small proportion of patients will develop the clinically significant disease with substantial morbidity. Efforts toward better understanding and the prevention of severe disease are required to improve patient outcomes. AIMS: The aims are to: (1) formulate clinically relevant OHSS classification for inpatient settings and data collection/reporting; (2) estimate OHSS prevalence requiring hospital admission in Victoria; and (3) determine the extent of OHSS preventability with clinical strategies. MATERIALS AND METHODS: This retrospective cohort study included all OHSS admissions in a tertiary referral centre, January 2016-December 2021, which included approximately 40% of all cases of hospitalisation for OHSS in the State of Victoria. Patient characteristics, treatment regimes, fertility treatment outcomes, timing classification, and clinical markers of disease severity were studied. Patients were classified as having mild, moderate, or severe OHSS with a novel inpatient classification system. RESULTS: Of 199 OHSS cases presenting to the tertiary institution, 107 were classified as moderate/severe, with no significant difference between age, body mass index, length of stimulation and follicle number between mild/moderate and severe groups. There were more cases of early hyperstimulation (137) compared to late (62) presentation, of which 53% were severe. The average length of stay overall was 3.1 days, and 5.2 days for severe presentations. In 15% of severe cases, an agonist trigger was used. CONCLUSIONS: The overall prevalence of OHSS requiring hospital admission appears to be low (approximately 0.6% of all stimulated cycles). Established risk factors may not accurately predict clinically relevant OHSS risk. Further monitoring, clinician and patient education are required to minimise the risk of significant OHSS that results in hospital admissions.

Barriers to reproductive treatments in Australia.

BACKGROUND: Most couples in Australia want to have children but some might not attain their reproductive goals, experiencing involuntary childlessness or not reaching their desired family size. There is increased focus on helping couples achieve their reproductive goals. Identifying existing barriers, such as those related to social and societal factors, access to treatment and treatment success, is crucial to optimising outcomes. OBJECTIVE: This article discusses existing barriers to reproduction to help general practitioners (GPs) raise the topic of future fertility with patients, care for those presenting with fertility concerns and support those undergoing fertility treatment. DISCUSSION: Recognition of the impact of barriers such as age to achieving reproductive goals remains the highest priority for GPs. This will help them to broach this topic with patients, carry out a timely evaluation or provide referral, as well as discuss opportunities such as elective egg freezing. Other barriers can be mitigated by educating patients, informing them about available resources and supporting those undergoing fertility treatment as part of a multidisciplinary reproductive team.

An update on fertility assistance and assisted reproductive technologies.

BACKGROUND: Conception difficulties are a common reason for presentation to general practitioners (GPs), who play an integral part in advising couples regarding optimisation of trying to conceive, timely and relevant investigations, as well as referral to non-GP specialist care. Lifestyle modification to optimise reproductive and offspring health is a crucial, though sometimes overlooked, component of pre-pregnancy counselling. OBJECTIVE: This article provides an update on fertility assistance and reproductive technologies to help GPs care for patients presenting with fertility concerns as well as those who require donor gametes to conceive or are carrying genetic conditions that may affect the chance of having a healthy baby. DISCUSSION: Recognition of the impact of a woman's (and, to a slightly lesser degree, man's) age remains the highest priority for primary care physicians to allow thorough and timely evaluation/referral. Advising patients about lifestyle modification, such as diet, physical activity and mental health, prior to conception is crucial for overall and reproductive health outcomes. Various treatment options exist to provide personalised and evidence-based care for patients for infertility. Other indications for using assisted reproductive technology include preimplantation genetic testing of embryos to avoid transmission of serious genetic conditions, elective oocyte freezing and fertility preservation.

Elective egg freezing: State of the ART.

BACKGROUND: Women are having children later in life, and the risk and prevalence of involuntary childlessness is thus increasing. Oocyte storage is widely available and increasingly used for elective (non-medical) indications by women trying to safeguard future fertility. There is controversy, however, regarding who should consider oocyte freezing, at what age and how many oocytes should be frozen. OBJECTIVE: The aim of this article is to provide an update on the practical management of non-medical oocyte freezing, including patient counselling and selection. DISCUSSION: The latest studies indicate that younger women are less likely to return to use their frozen oocytes, while a live birth is far less likely to result from oocytes frozen at an older age. While not guaranteeing a future pregnancy, oocyte cryopreservation is also associated with a substantial financial burden and uncommon but serious complications. Therefore, patient selection, appropriate counselling and maintenance of realistic expectations are crucial for this new technology to be used with the greatest positive impact.

Novel embryo selection strategies-finding the right balance.

The use of novel technologies in the selection of embryos during in vitro fertilisation (IVF) has the potential to improve the chances of pregnancy and birth of a healthy child. However, it is important to be aware of the potential risks and unintended consequences that may arise from the premature implementation of these technologies. This article discusses the ethical considerations surrounding the use of novel embryo selection technologies in IVF, including the growing uptake of genetic testing and others, and argues that prioritising embryos for transfer using these technologies is acceptable, but discarding embryos based on unproven advances is not. Several historical examples are provided, which demonstrate possible harms, where the overall chance of pregnancy may have been reduced, and some patients may have missed out on biological parenthood altogether. We emphasise the need for caution and a balanced approach to ensure that the benefits of these technologies outweigh any potential harm. We also highlight the primacy of patients' autonomy in reproductive decision-making, especially when information gained by utilising novel technologies is imprecise.

Serum progesterone concentration on the day of embryo transfer in stimulated cycles does not correlate with reproductive outcomes.

RESEARCH QUESTION: Is the live birth rate (LBR) in fresh embryo transfer IVF cycles affected by serum progesterone concentration on the day of embryo transfer? DESIGN: A single-centre retrospective analysis of prospectively collected data from women who underwent IVF or intracytoplasmic sperm injection between July 2019 and July 2020, and had a fresh day 5 single embryo transfer. Overall, 825 first and second stimulation cycles were included. Patients underwent a gonadotrophin-releasing hormone antagonist protocol with human chorionic gonadotrophin (HCG) trigger, and received vaginal-only luteal phase support. The study population was an everyday patient cohort, treated with the unit's usual stimulation protocols. The correlation between serum progesterone concentrations on the day of embryo transfer and the incidence of positive HCG, clinical pregnancy and live birth were examined. Patients were divided into four groups based on serum progesterone concentrations (<150, 150-250, 251-400 and >400 nmol/l). The data were further interrogated using additional progesterone cut-offs. RESULTS: There was no concentration of progesterone below or above which the chance of pregnancy was reduced. The chance of live birth following a blastocyst transfer was no different across the four groups (29.8, 26.6, 32.7 and 31.5%, respectively, P = 0.55). There was no negative association between progesterone and chance of pregnancy when other progesterone thresholds were applied. Estimates were adjusted for confounding factors such as maternal age. CONCLUSION: Serum progesterone concentration on the day of fresh embryo transfer does not correlate with the LBR.

Polygenic risk score for embryo selection-not ready for prime time.

Numerous chronic diseases have a substantial hereditary component. Recent advances in human genetics have allowed the extent of this to be quantified via genome-wide association studies, producing polygenic risk scores (PRS), which can then be applied to individuals to estimate their risk of developing a disease in question. This technology has recently been applied to embryo selection in the setting of IVF and preimplantation genetic testing, with limited data to support its utility. Furthermore, there are concerns that the inherent limitations of PRS makes it ill-suited for use as a screening test in this setting. There are also serious ethical and moral questions associated with this technology that are yet to be addressed. We conclude that further research and ethical reflection are required before embryo selection based on PRS is offered to patients outside of the research setting.

Timing of progesterone luteal support in natural cryopreserved embryo transfer cycles: back to basics.

Moderate quality evidence suggests that the administration of progesterone luteal phase support (LPS) is beneficial in natural and modified (HCG-triggered) natural frozen embryo transfer (FET) cycles. No comparative studies examining the optimal timing of progesterone LPS administration in natural FET cycles have been conducted, and the common practice differs greatly between clinics worldwide. In the absence of clinical trials, we aimed to provide a scheme for progesterone supplementation in an attempt to mimic its natural secretion by the corpus luteum. On the basis of early studies of ovulation physiology, we suggest that progesterone luteal support administration in natural FET cycles should start 36 h after the onset of the LH surge when measured in a morning serum test, or 36 h after the administration of HCG for triggering final follicular maturation. Blastocyst transfer should be carried out after 5 full days of progesterone supplementation. Randomized clinical trials are required to confirm these recommendations.

Treatment outcomes of blastocysts thaw cycles, comparing the presence and absence of a corpus luteum: a systematic review and meta-analysis.

PURPOSE: This study aims to review the literature and perform a meta-analysis to determine if the presence of a corpus luteum has an impact on treatment outcomes in thaw cycles, where blastocyst embryos are transferred. METHOD: PUBMED, EMBASE, CENTRAL and CINAHL were searched for papers published between January 2017 and 27 July 2020. Additional articles were selected from the reference list of the results and previous reviews. Three reviewers independently reviewed and extracted data. The meta-analysis was conducted though RevMan V.5.4.1. Studies were quality assessed with the Cochrane risk of bias tool and the Newcastle-Ottawa Scale. RESULTS: Nine publications were included for data extraction and subsequent meta-analysis. Two studies were randomised controlled trials, and seven were cohort studies. Subgroup analysis of the different study designs was performed. While the rates of positive human chorionic gonadotropin results (relative risk, RR 1.0, 95% CI 0.95 to 1.05) and clinical pregnancies (RR 1.06, 95% CI 0.96 to 1.18) were comparable between the two groups, the rates of live births were higher in thaw cycles with a corpus luteum (RR 1.14, 95% CI 1.06 to 1.22). Analysis of pregnancy losses demonstrated that both biochemical pregnancy (early miscarriage) (RR 0.71, 95% CI 0.62 to 0.82) and miscarriages (RR 0.72, 95% CI 0.62 to 0.83) were increased in cycles without a corpus luteum. CONCLUSION: Where clinically appropriate, the use of cycle types that have a functional corpus luteum should be favoured. There were several limitations to this study, including the quality of studies and the inherent bias of retrospective cohort studies. Further, high-quality research, particularly randomised controlled trials with blastocysts embryos, is required to further explore these findings. PROSPERO REGISTRATION NUMBER: CRD42020209583.