International gestational surrogacy in the United States, 2014-2020.

OBJECTIVE: To describe characteristics, trends, and outcomes of international gestational surrogacy cycles in the United States (US). DESIGN: Retrospective cohort study. SETTING: All assisted reproductive technology cycles in the US reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting Systems that included an embryo transfer to a gestational carrier from 2014 to 2020. PATIENTS: International vs. US intended parents. MAIN OUTCOME MEASURES: Cycle characteristics, geographic distributions, and obstetrical outcomes. RESULTS: Of 40,177 embryo transfers to a gestational carrier from 2014 to 2020, 32% were for international intended parents. The number and percent of international intended parents' gestational carrier cycles increased each year from 2014 (n = 2758, 22.0%) to 2019 (n = 4905, 39.8%) with a decrease in 2020 (n = 4713, 31.8%). Compared with cycles for US intended parents, there was a larger decrease in gestational carrier cycles between 2019 and 2020 for international intended parents (3.9% vs. 32.2%). International intended parents were more likely to be male sex (41.3% vs. 19.6%), older than 42 years (33.9% vs. 26.2%) and identify as Asian race (65.6% vs. 16.5%). International intended parents were largely from China (41.7%), followed by France (9.2%) and Spain (8.5%). Gestational carriers for international intended parents were more commonly younger than 30 years (42.8% vs. 29.1%) and identified as Hispanic race (28.6% vs. 11.7%) compared with gestational carriers for US intended parents. Cycles with international intended parents were more likely to use donor eggs (67.1% vs. 43.5%), intracytoplasmic sperm injection (72.8% vs. 55.4%), and preimplantation genetic testing (79.0% vs. 55.8%). Cycles with international and US intended parents had similar obstetrical outcomes, including live birth (adjusted risk ratio 1.01, 95% confidence interval 1.00-1.03) and multiple pregnancy (adjusted risk ratio 1.00, 95% confidence interval 0.94-1.06) rates. CONCLUSION: An increasing number of international intended parents are utilizing gestational surrogacy in the US and more frequently using cost-enhancing specialized treatment techniques. This increase is potentially because of restrictive international commercial surrogacy laws and the increased availability of reproductive medical expertise. Given this growing demographic, continued examination of the volume of cross-border reproductive treatment, as well as the legal and ethical considerations, is warranted.

The use of fertility treatments among reproductive-aged women after cancer.

OBJECTIVE: To examine whether female cancer survivors are more likely to pursue care for infertility after cancer than women without cancer. DESIGN: Population-based cohort study involving detailed interviews regarding reproductive history. SETTING: Not applicable. PATIENTS: Female cancer survivors aged 22-45 years, who were at least 2 years after a cancer diagnosis between the ages of 20 and 35 years (n = 1,036), and age-matched comparison women with no cancer history (n = 1,026). EXPOSURE: History of cancer vs. no history of cancer. MAIN OUTCOME MEASURE(S): Each cancer survivor was randomly matched to a comparison woman, who was assigned an artificial age at cancer diagnosis equal to that of her match. Matching was repeated 1,000 times. Outcomes of visiting a doctor for help becoming pregnant or undergoing fertility treatment were modeled using Cox proportional hazards regression, comparing survivors after a cancer diagnosis to age-matched comparison women, adjusted for race, income, residence, education, and parity. RESULTS: Only 25.5% of cancer survivors reported meeting their desired family size before a cancer diagnosis. The median time from diagnosis to interview among survivors was 7 (interquartile range 5-11) years. Cancer survivors were more likely to report having no children (32.6%) at the interview compared with women with no cancer history (19.5%). Survivors were not more likely to visit a doctor for help becoming pregnant compared with women without a cancer history, matched on birth year and followed by the age at which cancer survivors received their diagnosis (hazard ratio [HR] 1.16, 95% simulation interval [SI] 0.78-1.74). Compared with cancer-free women, cancer survivors had similar probabilities of pursuing any treatment (adjusted HR [aHR] 0.88, 95% SI 0.46-1.56), using hormones or medications (aHR 0.86, 95% SI 0.46-1.63), or undergoing intrauterine insemination (aHR 1.26, 95% SI 0.40-5.88) to conceive. Cancer survivors were slightly more likely to pursue surgical interventions to become pregnant (HR 1.55, 95% SI 0.67-3.71). Of those who visited a doctor but declined to pursue fertility treatment, one-quarter of women reported declining treatment due to cost. CONCLUSION: Cancer survivors did not use fertility treatments at higher rates than the general population. Further counseling and education surrounding fertility options are recommended for young adult female cancer patients after treatment is completed.

Trends and Outcomes of Assisted Reproductive Technology Cycles Using a Gestational Carrier Between 2014 and 2020.

This study used national surveillance data from the Society for Assisted Reproductive Technology to describe trends and outcomes in assisted reproductive technology cycles using a gestational carrier vs those not using a gestational carrier.

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.

The Risk of Infertility After Surgery for Benign Ovarian Cysts.

Background: There is a growing body of evidence that ovarian cystectomy may negatively impact ovarian reserve. However, it is unclear whether ovarian cyst surgery puts women at risk of future infertility. This study investigates whether surgery for benign ovarian cysts is associated with long-term infertility risk. Methods: Women aged 22-45 years (n = 1,537) were invited to participate in an interview about their reproductive histories, including whether they ever had infertility or ovarian cyst surgery. Each woman reporting cyst surgery was randomly matched to a comparison woman, who was assigned an artificial surgery age equal to that of her match. Matching was repeated 1,000 times. Adjusted Cox models were fit to examine time to infertility after surgery for each match. A subset of women was invited to participate in a clinic visit to assess markers of ovarian reserve (anti-Müllerian hormone [AMH], antral follicle count). Results: Approximately 6.1% of women reported cyst surgery. Infertility after surgery was more common for women reporting cyst surgery than those without surgery after adjusting for age, race, body mass index, cancer history, parity before assigned surgery age, history of infertility before surgery age, and endometriosis (median-adjusted hazard ratio 2.41, 95% simulation interval 1.03-6.78). The estimated geometric mean (95% confidence interval [CI]) AMH levels of those who reported a history of ovarian cyst surgery were 1.08 (95% CI: 0.57-2.05) times those of women who reported no history of surgery. Conclusions: Those with a history of ovarian cyst surgery were more likely to report having a history of infertility compared with age-matched women who reported no history of cyst surgery. It is possible that both ovarian surgery to remove cysts and the conditions that lead women to develop cysts requiring surgery may affect subsequent successful conception.

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.

Pelvic organ prolapse recurrence after apical prolapse repair: does obesity matter?

INTRODUCTION AND HYPOTHESIS: We hypothesized obesity increases the risk of pelvic organ prolapse recurrence (POP-R) after primary apical prolapse repair. METHODS: We conducted a retrospective cohort study of 353 women who underwent primary apical prolapse surgery from 2011 to 2016. Demographic and clinical data were abstracted from medical records. Multivariable Cox proportional hazard models were used to generate hazard ratios (HR) for association between obesity (BMI ≥ 30 kg/m2) and POP-R (leading edge > 0), adjusting for potential confounders. Given the potential for outcome ascertainment bias due to differential loss to follow-up, a sensitivity analysis was performed assuming all patients with < 6 months of follow-up developed POP-R. RESULTS: Ten percent of women developed POP-R. The median follow-up time was 7 months (range 1.4, 63.9). Twenty-four percent of patients were Black and 70% were White; 37% were obese. After controlling for confounders, obese women did not have an increased risk of POP-R (aHR 1.39; 95% CI 0.67, 2.86, p = 0.38). Although only marginally statistically significant, patients who developed POP-R were more likely to be current smokers (aHR 3.48, 95% CI 1.14, 10.67; p = 0.06) or previous smokers (aHR 1.86, 95% CI 0.82, 4.24, p = 0.06) in comparison to non-smokers. Sensitivity analysis showed loss to follow-up had the potential to influence our results. CONCLUSIONS: Obesity was not a risk factor for POP-R in our cohort. Larger, prospective studies with longer postoperative follow-up time are needed to fully elucidate the relationship between obesity and POP-R.

Factors Associated with Unplanned Pregnancy Among Cancer Survivors.

Background: Approximately half of all pregnancies in the United States are unintended. However, women who are diagnosed with cancer in their reproductive years may be a unique population. This study examines the prevalence of and identifies factors associated with unplanned pregnancy among cancer survivors. Materials and Methods: Female cancer survivors aged 22-45 years, diagnosed between ages 20-35 years and at least 2 years postdiagnosis, and women with no history of cancer were interviewed about their reproductive histories, including pregnancy intention. Using a random matching process, comparison women were assigned an artificial age at cancer diagnosis equal to that of her cancer survivor match. An adjusted Cox model was fit examining time to unintended pregnancy after cancer for each of 1,000 matches. Cox proportional hazards models were also fit to assess associations between participant characteristics and unplanned pregnancy after cancer among survivors. Results: Cancer survivors (n = 1,282) and comparison women (n = 1,073) reported a similar likelihood of having an unplanned pregnancy in models adjusted for race, income, history of sexually-transmitted infection, and history of unplanned pregnancy before diagnosis (adjusted hazard ratio [aHR] 1.06, 95% simulation interval 0.85-1.36). After adjusting for confounders, unplanned pregnancy among survivors was associated with age <30 years at diagnosis (hazard ratio [HR]: 1.79, 95% confidence interval [CI]: 1.32-2.44), black race (HR: 1.55, 95% CI: 1.13-2.12; referent: white), receiving fertility counseling (aHR: 1.41, 95% CI: 1.04-1.92), and having at least one child before diagnosis (aHR: 1.44, 95% CI: 1.05-1.97). Conclusion: Cancer survivors and comparison women had similar likelihood of unplanned pregnancy. Rates of unplanned pregnancy after cancer were not higher for cancer survivors compared with comparison women, but 46.4% of survivors with a postcancer pregnancy reported an unplanned pregnancy. Cancer patients may benefit from patient-centered guidelines and counseling before cancer treatment that covers both risks of infertility and risks of unplanned pregnancy.

National egg-freezing trends: cycle and patient characteristics with a focus on race/ethnicity.

OBJECTIVE: To describe the trends and characteristics of oocyte cryopreservation (OC) cycles stratified by self-reported race/ethnicity in the United States DESIGN: Retrospective cohort analysis using the Society for Assisted Reproductive Technology Clinical Outcome Reporting System SETTING: US fertility clinics PATIENTS: All patients undergoing OC from 2012 through 2016 INTERVENTIONS: None MAIN OUTCOME MEASURES: The OC cycle trends were analyzed on the basis of race/ethnicity: non-Hispanic white, non-Hispanic black, Asian/Pacific islander, Hispanic, and other (American Indian, Alaskan native, or mixed race). RESULTS: Between 2012 and 2016, there was a total of 29,631 OC cycles; the total number of cycles increased yearly from 2,925 in 2012 to 8,828 in 2016. When compared with the demographics of the United States, OC was underused by some minority patient groups because majority of the cycles (66.5%) were performed in white patients. The total number of OC cycles increased annually among all the ethnic groups, most notably among Asian patients. The patients of all the ethnic backgrounds were most commonly under 35 years of age and underwent 1 OC cycle, except for Asian patients, who most frequently underwent OC between the ages of 35 and 37 years and were more likely to have undergone ≥2 cycles than patients of other minority groups. After adjustment for cofounders, there were no clinically significant differences in oocyte yield and the percentage of maturation across the racial/ethnic groups. CONCLUSIONS: Nationally, OC cycles have been increasing in number, most often in patients under the age of 35 years, with similar proportions of patients of minority groups pursuing OC over time. The oocyte yield was comparable across the ethnic groups. Future research regarding subsequent thawing outcomes is warranted.

Patient-centered care: factors associated with reporting a positive experience at United States fertility clinics.

OBJECTIVE: To determine factors associated with a positive patient experience (PPE) at fertility clinics. DESIGN: Cross-sectional study. SETTING: Not applicable. PATIENT(S): Female respondents to the FertilityIQ questionnaire (www.fertilityiq.com) reviewing the first or only U.S. clinic visited from July 2015 to July 2018. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): PPE was defined as a score of 9 or 10 out of 10 on the question, "Would you recommend this fertility clinic to a best friend?" Examined predictors included demographics, payment details, infertility diagnoses and treatment, physician traits, and clinic operations and resources. Multiple imputation was used for missing variables. Logistic regression was used to calculate adjusted odds ratios for factors associated with PPE. RESULT(S): Of the 7,456 women included, 63.1% reported PPE. Pregnancy resulting from treatment was a predictor of PPE. In multivariable analysis, the strongest predictors of PPE were related to the patient-physician relationship ("feeling treated like a human rather than a number" and having a doctor with good communication skills and who set reasonable expectations). Multiple clinic-related factors were also independently associated with PPE, including satisfaction with billing, shorter wait times, and easy appointment scheduling. CONCLUSION(S): While pregnancy influences patients' views of their fertility clinic experience, there are other modifiable patient, physician, and clinic factors associated with PPE. Clinics may be able to optimize patient experience and improve the quality of care that they provide by being cognizant of such factors.

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.

Oocyte Cryopreservation in Adolescent Women.

STUDY OBJECTIVE: To describe oocyte cryopreservation (OC) cycles in adolescent women (<20 years of age) performed at Society for Assisted Reproductive Technology member clinics in the United States from 2012 to 2016. DESIGN: Retrospective cohort study. SETTING: Not applicable. PARTICIPANTS: OC cycles from the Technology Clinic Outcome Reporting System database. INTERVENTIONS: OC cycles from 2012 to 2016 among adolescent women were compared with cycles in older women. MAIN OUTCOME MEASURE: Number of oocytes retrieved. RESULTS: From 2012 to 2016, OC cycles in women younger than 20 years of age accounted for 1.5% of OC cycles in all women. The absolute number has increased over the 5-year period, parallel to the increase in older women. OC cycles in adolescent women were most likely performed for fertility preservation for impending gonadotoxic treatment. The women were most likely to be non-Hispanic white and reside in the Northeast. Ten percent of the cycles were cancelled, most commonly for low response, compared with 6.6% of cycles in other age groups. There was no difference in mean oocytes retrieved in women younger than 20 years (n = 18.0) compared with women 20-29 years (n = 18.4). Complications, including ovarian hyperstimulation syndrome, were very rare. CONCLUSION: OC cycles in adolescent women are similar with regard to stimulation characteristics and oocyte yield to those in women of other age groups. There is, however, a higher likelihood of cancellation because of poor response.

Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: A Systematic Review.

BACKGROUND: The incidence of colorectal cancer among reproductive-aged women is increasing. Concerns regarding future fertility are secondary only to concerns regarding survival and may significantly impact quality of life among reproductive-aged female cancer survivors. Fertility preservation counseling reduces long-term regret and dissatisfaction among cancer survivors. Health care providers counseling patients with colorectal cancer must understand the impact of cancer treatment on future reproductive potential. OBJECTIVE: This review aims to examine the effects that colorectal cancer treatments have on female fertility and summarize existing and emerging options for fertility preservation. DATA SOURCES: EMBASE, National Library of Medicine (MEDLINE)/PubMed, Cochrane Review Library were the data sources for this review. STUDY SELECTION: A systematic literature review was performed using exploded MeSH terms to identify articles examining the effect of surgery, chemotherapy, and radiation, as well as fertility preservation options for colorectal cancer on female fertility. Relevant studies were included. MAIN OUTCOME MEASURES: The primary outcome was the effect of colorectal cancer treatment on fertility. RESULTS: There are limited data regarding the impact of colorectal surgery on fertility. The gonadotoxic effects of chemotherapy on reproductive capacity depend on age at the time of chemotherapy administration, cumulative chemotherapy, radiation dose, type of agent, and baseline fertility status. Chemotherapy-induced risks for colorectal cancers are considered low to moderate, whereas pelvic radiation with a dose of 45 to 50 Gray induces premature menopause in greater than 90% of patients. Ovarian transposition may reduce but not eliminate the damaging effect of radiation on the ovaries. Embryo and oocyte cryopreservation are considered standard of care for women desiring fertility preservation, with oocyte cryopreservation no longer being considered experimental. Ovarian tissue cryopreservation remains experimental but may be an option for select patients. The use of gonadotropin-releasing hormone agonists remains controversial and has not been definitively shown to preserve fertility. LIMITATIONS: The limitations of this review are the lack of randomized controlled trials and high-quality studies, as well as the small sample sizes and the use of surrogate fertility markers. CONCLUSION: Reproductive-aged women with colorectal cancer benefit from fertility preservation counseling before the initiation of cancer 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.

Impact of cancer treatment on risk of infertility and diminished ovarian reserve in women with polycystic ovary syndrome.

OBJECTIVE: To compare markers of fertility and ovarian reserve between cancer survivors and cancer-free women with and without polycystic ovary syndrome (PCOS). DESIGN: Furthering Understanding of Cancer, Health, and Survivorship in Adult (FUCHSIA) Women's Study-a population-based cohort study. SETTING: Not applicable. PATIENT(S): Female cancer survivors (n = 1,090) aged 22-45 years, diagnosed between ages 20 and 35 years, and at least 2 years after diagnosis; 369 participated in a clinic visit. Three hundred seventy-four reproductive-aged women without cancer also completed a clinic visit. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Infertility, time to first pregnancy after cancer diagnosis, and measures of ovarian reserve (antimüllerian hormone [AMH] and antral follicle count [AFC]). RESULTS: Seventy-eight cancer survivors (7.2%) reported a PCOS diagnosis, with 41 receiving gonadotoxic treatment. Survivors with PCOS exposed to gonadotoxic treatment (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.2-4.5) and unexposed (OR 3.4, 95% CI 1.7-6.9) were more likely to report infertility than unexposed survivors without PCOS and were more likely to have fewer children than desired (exposed: OR 2.1, 95% CI 1.0-4.2; unexposed: OR 3.0, 95% CI 1.4-6.8). After adjusting for age, comparison women with PCOS had the highest markers of ovarian reserve (AMH: 2.43 ng/mL, 95% CI 1.22-4.82 ng/mL; AFC: 20.7, 95% CI 15.3-27.8), and cancer survivors without PCOS treated with gonadotoxic agents had the lowest levels (AMH: 0.19 ng/mL, 95% CI 0.14-0.26 ng/mL; AFC: 7.4, 95% CI 6.4-8.5). CONCLUSION(S): Despite having higher AMH and AFC on average after cancer treatment, cancer survivors with PCOS were less likely to meet their reproductive goals compared with survivors without PCOS.

Impact of tamoxifen therapy on fertility in breast cancer survivors.

OBJECTIVE: To determine whether tamoxifen use is associated with decreased ovarian reserve and decreased likelihood of having a child after a breast cancer diagnosis, using data from the Furthering Understanding of Cancer, Health, and Survivorship in Adult (FUCHSIA) Women Study. DESIGN: Population-based cohort study. SETTING: Not applicable. PATIENT(S): Three hundred ninety-seven female breast cancer survivors aged 22-45 years whose cancer was diagnosed between ages 20 and 35 years and who were at least 2 years after diagnosis; 108 survivors also participated in a clinic visit. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Time to first child after cancer diagnosis, clinical measures of ovarian reserve (antimüllerian hormone [AMH] and antral follicle count [AFC]) after cancer. RESULT(S): Women who had ever used tamoxifen were substantially less likely to have a child after the breast cancer diagnosis (hazard ratio [HR] 0.29; 95% confidence interval [CI], 0.16, 0.54) than women who had never used tamoxifen. After adjusting for age at diagnosis, exposure to an alkylating agent, and race, the HR was 0.25 (95% CI, 0.14, 0.47). However, after adjusting for potential confounders, women who had used tamoxifen had an estimated geometric mean AMH level 2.47 times higher (95% CI, 1.08, 5.65) than women who had never taken tamoxifen. Antral follicle count was also higher in the tamoxifen group compared with the tamoxifen nonusers when adjusted for the same variables (risk ratio 1.21; 95% CI, 0.84, 1.73). CONCLUSION(S): Breast cancer survivors who had used tamoxifen were less likely to have a child after breast cancer diagnosis compared with survivors who never used tamoxifen. However, tamoxifen users did not have decreased ovarian reserve compared with the tamoxifen nonusers.