Does proximity to a fertility centre increase the chance of achieving pregnancy in Northeastern Ontario?

INTRODUCTION: Northern Ontario has a population of approximately 800,000 people distributed over 806,707 km2. Before 2018, the only fertility treatment centre in Northern Ontario was located in Thunder Bay; many patients travelled south for care. In 2018, the Northeastern Ontario Women's Health Network (NEOWHN) opened in Sudbury, providing fertility treatments to people living in Northeastern Ontario. The goal of this study was to determine if proximity to this new fertility centre increases one's chance of achieving pregnancy when undergoing fertility treatment. Secondary outcomes included the quantity and types of fertility investigations and treatments completed by patients. MATERIALS AND METHODS: A retrospective chart review was performed for all patients seeking fertility treatment at NEOWHN between January 2019 and December 2020. Traveling >100 km to access healthcare was considered to be a clinically significant determinant of health. RESULTS: Seven hundred and 5 patients were seen in consultation for fertility services at NEOWHN during the study period. One hundred eighty-one of 478 (37.9%) patients living <100 km from NEOWHN achieved pregnancy compared to 39 of 227 (17.2%) patients living >100 km from NEOWHN (P < 0.01). CONCLUSION: Living in proximity (<100 km) to NEOWHN increased the likelihood that individuals in Northeastern Ontario would seek fertility services and would achieve pregnancy. Financial constraints and inaccessibility likely play a role in this, but further studies are needed to explain this difference. INTRODUCTION: Le Nord de l'Ontario compte une population d'environ 800,000 personnes réparties sur 806,707 km2. Avant 2018, le seul centre de traitement de la fertilité du Nord de l'Ontario était situé à Thunder Bay; de nombreux patients SE rendaient dans le sud pour recevoir des soins. En 2018, le Northeastern Ontario Women's Health Network (NEOWHN-le Réseau de santé des femmes du Nord-Est de l'Ontario) a ouvert ses portes à Sudbury, offrant des traitements de fertilité aux personnes vivant dans le Nord-Est de l'Ontario. L'objectif de cette étude était de déterminer si la proximité de ce nouveau centre de fertilité augmente les chances d'obtenir une grossesse lors d'un traitement de fertilité. Les résultats secondaires comprenaient la quantité et les types d'examens et de traitements de fertilité effectués par les patients. MTHODES: Une étude rétrospective des dossiers a été réalisée pour tous les patients cherchant un traitement de fertilité au NEOWHN entre janvier 2019 et décembre 2020. Le fait de voyager >100 km pour accéder aux soins de santé a été considéré comme un déterminant de la santé cliniquement significatif. RSULTATS: Seven hundred and 5 patients ont été vus en consultation pour des services de fertilité au NEOWHN pendant la période d'étude. One hundred eighty-one des 478 (37.9%) patientes vivant à moins de 100 km du NEOWHN ont obtenu une grossesse, contre 39 des 227 (17.2%) patientes vivant à plus de 100 km du NEOWHN (P < 0.01). CONCLUSION: Le fait de vivre à proximité (<100 km) du NEOWHN augmente la probabilité que les habitants du Nord-Est de l'Ontario aient recours à des services de fertilité et obtiennent une grossesse. Les contraintes financières et l'inaccessibilité jouent probablement un rôle à cet égard, mais d'autres études sont nécessaires pour expliquer cette différence.

Single mothers by choice - experiences of single women seeking treatment at a public fertility clinic in Denmark: A pilot study.

PROBLEM: There has been an increase in the number of single women deciding to have children through the use of medically assisted reproduction (MAR). These women are referred to as 'single mothers by choice' (SMC). BACKGROUND: Previous studies have shown how SMC can feel stigmatised. AIM: Explore if single women seeking fertility treatment in Denmark feel stigmatised. METHODS: Six single women undergoing MAR at a public fertility clinic in Denmark were interviewed. The interviews were audiotaped, anonymised, and transcribed in full, after provided written consent by the participants to take part in the study. Data were analysed using qualitative content analysis. FINDINGS: The women would have preferred to have a child in a relationship with a partner. Despite their dream of the nuclear family meaning a family group consisting of two parents and their children (one or more), the women choose to become SMC because motherhood was of such importance, and they feared they would otherwise become too old to have children. The participants did not experience stigma or negative responses to their decision, but they all had an awareness of the prejudices other people might have towards SMC. CONCLUSION: This study contributes to the understanding of the experiences of single women seeking fertility treatment in a welfare state where there are no differences in the possibilities for different social classes to seek MAR.

Ten years of in vitro fertilization in Indonesia: Access to infertility care in a developing country.

OBJECTIVE: This research was conducted to assess access to assisted reproductive technologies (ART) and the current status of the in vitro fertilization (IVF) program that have been implemented in Indonesia over the last 10 years. METHODS: We established a retrospective cohort study and descriptive analysis of the current state of access to infertility care in Indonesia. The data were collected from all IVF centers, clinics, and hospitals in Indonesia from 2011 to 2020, including the number of IVF clinics, total ART cycles, retrieved fresh and frozen embryos, average age of IVF patients, IVF pregnancy rate, and causes of infertility. RESULTS: The number of reported fertility clinics in Indonesia has increased from 14 clinics in 2011 to 41 clinics by 2020. As many as 69 569 ART cycles were conducted over the past 10 years, of which 51 892 cycles used fresh embryos and 17 677 cycles used frozen embryos. The leading cause of consecutive infertility diagnosis was male infertility. Nearly half of the women who underwent IVF procedures (48.9%) were under 35 years old. The pregnancy rate outcome of women who underwent IVF ranged from 24.6% to 37.3%. CONCLUSION: Developments in ART in Indonesia have led to improvements in the ART cycles performed throughout the 10 year period. The identification of key areas that require improvement can provide an opportunity to enhance access to infertility care.

Prevalence and performance of private equity-affiliated fertility practices in the United States.

OBJECTIVE: To quantify the proportion of annual assisted reproductive technology (ART) cycles performed at private equity-affiliated fertility practices and to test for differences in services and success rates between private equity-affiliated and nonaffiliated practices. DESIGN: Cross-sectional analysis of national data set. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): The primary outcome measures were the volume of ART cycles performed, the percentage of retrievals resulting in live births, and the percentage of transfers resulting in live births. The secondary outcomes included the median income of the practice location, the use of preimplantation genetic testing, the clinical service availability, and the patient reasons for seeking treatment. RESULT(S): Of the practices listed on the Centers for Disease Control's 2018 Fertility Clinic Success Rates Report, 14.7% had a private equity affiliation. Of the 305,883 ART cycles performed in 2018, 29.3% (89,535) occurred at private equity-affiliated practices. Patients at private equity-affiliated practices were 6.75% (95% confidence interval [CI], -10.15%, -3.36%) less likely to initiate a cycle due to male factor infertility, and 10.60% (95% CI, 3.49, 17.76) more likely to use preimplantation genetic testing before embryo transfer. No statistically significant differences were found in success rates among women aged <35 years. The average median household income (standard error) in zip codes with private equity-affiliated practices compared with nonaffiliated practices was $83,610 ($35,990) and $72,161 ($32,314), respectively. CONCLUSION(S): A major portion of fertility practices in the United States are private equity-affiliated, and these practices perform an even greater portion of ART cycles in the United States each year. Fertility appears to be the medical specialty with the greatest market share owned by private equity. Our findings corroborate preliminary research, which forecasts the increasing involvement and consolidation by private equity in fertility. Future research should continue monitoring for differences in outcomes, financing, case mix, service use, and accessibility.

Immediate versus delayed frozen embryo transfer in women following a failed IVF-ET attempt: a multicenter randomized controlled trial.

BACKGROUND: The optimal time at which to perform a frozen-thawed embryo transfer (FET) following a failed in-vitro fertilization-embryo transfer (IVF-ET) attempt remains elusive to most reproductive experts. Physicians often delay the introduction of FET due to concerns related to potential residual effects of ovarian hyperstimulation which may interfere with the regular menstrual cycle. Moreover, given that most of the published studies on the topic are retrospective and have inconsistent findings, it is crucial to develop evidence-based randomized control guides for clinical practice. Therefore, this well-designed randomized controlled trial (RCT) was conducted to determine whether it is necessary to delay FET for at least one menstrual cycle after the failure of fresh embryo transfer. METHODS: Infertile women eligible for IVF-ET were invited to participate in this multicenter, randomized, non-inferiority, parallel-group, unblinded, controlled trial at the academic fertility centers of four public hospitals in Chinese Mainland. Infertile women scheduled to receive their first FET cycle after a failed IVF-ET attempt were randomly assigned to either (a) the immediate FET group in which FET was performed in the first menstrual cycle following the failed IVF-ET cycle (n = 366) or (b) the delayed FET group in which FET was performed in the second or subsequent menstrual cycle following the failed IVF-ET cycle (n = 366). All FET cycles were performed during hormone replacement cycles for endometrial preparation. The primary outcome was the ongoing pregnancy, defined as a detectable fetal heart beat beyond twelve weeks of gestation. Secondary outcomes were other pregnancy-related outcomes, maternal and neonatal complications. Analysis was performed by both intention-to-treat and per-protocol principles. RESULTS: A total of 646 FETs were completed. The frequency of moderate to severe depression and high stress level prior to FET in delayed FET group were significantly higher than that in immediate FET group (10.6% vs 6.1%, p = 0.039; 30.3% vs 22.4%, p = 0.022, respectively). Immediate FET resulted in a higher frequency of clinical pregnancy than did delayed FET (41.7% vs 34.1%), for a relative risk (RR) of 1.23 (95% confidence interval [CI], 1.00-1.50; p = 0.045). Women who underwent immediate FET also had a lower frequency of biochemical pregnancy loss (11.7% vs. 30.6%), with a RR of 0.28 (95% CI 0.23-0.63, p < 0.001), and a higher frequency of embryo implantation (25.2% vs. 20.2%), with a RR of 1.25 (95% CI 1.01-1.53; p = 0.038). Although the ongoing pregnancy and live birth rates did not differ significantly between the immediate FET and delayed FET groups (37.1% vs 30.3%, RR 1.22, 95% CI 0.99-1.52, p = 0.067; 36.5% vs 30.0%, RR 1.22, 95% CI 0.98-1.52, p = 0.079, respectively), a multivariate logistic regression analysis adjusted for potential confounders such as depression and stress levels revealed that the immediate FET group had a significantly higher ongoing pregnancy and live birth rates than the delayed FET group (odds ratio 0.68, 95% CI 0.47-0.99, p = 0.041; odds ratio 0.67, 95% CI 0.46-0.96, p = 0.031). The risks of maternal and neonatal complications were comparable between the two groups. CONCLUSIONS: In women with a previous failed IVF-ET attempt, immediate FET resulted in higher ongoing pregnancy and live birth rates than delayed FET. These findings warrant caution in the indiscriminate application of a delayed FET strategy when apparent risk of high stress level is perceived. TRIAL REGISTRATION: ChiCTR2000033313 .

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.

Long-term outcome of patients undergoing in-vitro fertilisation in France: The outcome study.

The Outcome study examines the fate of 4083 patients beginning IVF in 41 IVF centres, between January 2010 and December 2013. Cumulative live birth rate per patient (CLBR), the best reflection of IVF efficacy, is rarely presented in publications as it requires long-term follow-up, including all successive cycles, and pregnancies outcome. Analysis of international publications shows an average CLBR of 41.6 % and a drop-out rate of 49.5 %, both greatly varying by country and IVF centres. Because of the frequency with which patients change centre (8%), the Outcome study distinguishes patients with a past history of IVF in another centre (CLBR=47.2 %) and patients undergoing their first true cycle (CLBR=56.4 %). Survival techniques by Competing Risk, intended to take account of drop-out and lost to follow-up, assessed the overall CLBR as being 65.4 %. Differences in performance between centres are considerable for both CLBR (32-64%) and Performance Index, taking account of the number of cycles required to achieve a pregnancy (2-5). Multiple variance logistic regression analysis shows that the indicators influencing performance are age, parity, number of oocytes, smoking habit and overweight. These indicators are independent each other and are influencing performance in a high significant way. After adjusting for these indicators, the differences between centres are reduced but remain large and very significant. No centre appears to have specific expertise in the management of patients with adverse indicators. The Outcome study therefore confirms that the large differences in performance between centres are not explained by a difference in the treated population.

Society for Assisted Reproductive Technology advertising guidelines: How are member clinics doing?

OBJECTIVE: To examine whether Society for Assisted Reproductive Technology (SART) member in vitro fertilization (IVF) centers adhere to the Society's new advertising policy, updated in January 2018, and evaluate other services advertised by region, insurance mandate and university affiliation status. Historically, a large percentage of IVF clinics have not adhered to SART guidelines for IVF clinic website advertising and have had variability in how financial incentives and other noncore fertility services are advertised. DESIGN: Cross-sectional study. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Adherence of SART participating websites to objective criteria from the 2018 SART advertising guidelines. RESULT(S): All 361 SART participating clinic websites were evaluated. Approximately one third of clinics reported success rate statistics directly on their websites, but only 52.6% of those clinics reported current statistics. Similarly, only 67.5% of SART member clinics included the required disclaimer statement regarding their outcome statistics. Only 10.5% of websites were wholly compliant with SART guidelines regarding presentation of supplemental data. There were no significant differences between academic and nonacademic centers, programs in mandated versus nonmandated states, or East versus West Coast clinics in any of these areas. CONCLUSION(S): Many of the SART member websites failed to adhere to core guidelines surrounding reporting IVF clinic success rates. Consideration for additional education and streamlining as well as simplifying success rate advertising guidelines is recommended.

Managing the IVF laboratory during a pandemic: international perspectives from laboratory managers.

Fertility societies worldwide responded to the COVID-19 pandemic by recommending that fertility clinics close, or sharply reduce, the clinical operation, leading to a shift in the management of IVF laboratories in three phases: shutdown preparation; maintenance during shutdown; and restart. Each of these phases carries distinct risks that need identification and mitigation, forcing laboratory managers to rethink and adapt their procedures in response to the pandemic. The sudden and unprecedented nature of the pandemic forced laboratory managers from around the world to base decisions on opinion and experience when evidence-based response options were unavailable. These perspectives on pandemic response were presented during a virtual international symposium on COVID-19, held on 3 April 2020, and organized by the London Laboratory Managers' Group. Laboratory managers from seven different countries at different stages of the pandemic (China, Italy, Spain, France, UK, Brazil and Australia) presented their personal experiences to a select audience of experienced laboratory managers from 19 different countries. The intention of this paper is to collect the learnings and considerations from this group of laboratory managers who collaborated to share personal experiences to contribute to the debate surrounding what constitutes good IVF laboratory practice in extraordinary circumstances, such as the COVID-19 pandemic.

Aneuploid embryo transfer: clinical policies and provider opinions at United States fertility clinics.

OBJECTIVE: To describe institutional clinical policies and individual provider opinions regarding aneuploid embryo transfer (aET). DESIGN: A survey about clinical policies was electronically sent to Society for Assisted Reproductive Technology (SART) member laboratory directors, and a separate survey about personal opinions was electronically sent to all SART members. SETTING: Not applicable. PATIENTS: Patients pursuing preimplantation genetic testing for aneuploidy (PGT-A). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Current clinical policies about aET were described. Individual provider opinions about aET in the context of specific aneuploidies and mosaicism were also described. RESULTS: A total of 48 laboratory directors and 212 individual providers responded to their respective surveys. Twelve (25%) clinics report that they do not have a policy regarding aET, but clinics performing PGT-A in >100 cycles per year were more likely to have a policy. Half of the individual providers agree that an embryo with trisomy 21 should be available for aET, but most disagreed with aET of embryos with other aneuploidies and most were either unsure about or unwilling to transfer embryos with mosaicism. Those who worked in primarily patient-facing roles held more agreeable opinions regarding aET. CONCLUSION: There is no consensus regarding ideal clinical policies for aET. The wide range of current clinical practices and individual provider opinions regarding under what circumstances, if any, aET should be available to patients indicates that this is a divisive issue among ART providers, and there is a clear need for specific professional guidelines to address this issue.

What can be learned from the Chinese experience in response to infertility.

OBJECTIVES: The aims of the study were to reviews the history of China's population policy since 2011, and draw lessons from the Chinese experience in response to infertility. METHODS: Data from the Chinese infertility status survey report (2009) and national statistical yearbooks (2009-2019) are used to assess the severity of infertility and reproductive centers shortage in China. Lessons from China was informed by a review of existing literature. RESULTS: The proportion of couples suffering from infertility in China increased to 12.5% (166.8 million in 2009) from just 6.89% (86.6 million in 1988) two decades earlier, while the number of reproductive centers was one for every 3.1 million citizens. The total costs per live birth for medically assisted reproduction in Chinese public fertility clinics was 30,000 yuan in 2012. Among infertile couples, unemployed patients accounted for the largest proportion (21.9% in 2014). Currently in China, health regulations permit oocyte donation only from infertility patients who have 20 or more mature oocytes, of which at least 15 must be kept for their own treatment. CONCLUSION: It is necessary to integrate the reproductive health care of infertile people into the national public health service. In addition to relieving their economic burden, national policies should guide and support enterprises to guarantee employee medical leave for infertility. Growing numbers of bereaved older women who have lost their only child make it imperative to reconsider liberalizing the regulation of oocyte donation in China.

COVID-19 and fertility: a virtual reality.

The COVID-19 pandemic is an extraordinary global situation, and all countries have adopted their own strategies to diminish and eliminate the spread of the virus. All measures are in line with the recommendations provided by the World Health Organization. Scientific societies, such as the European Society for Human Reproduction and Embryology and American Society for Reproductive Medicine, have provided recommendations and guidance to overcome and flatten the growing curve of infection in patients who undergo IVF treatments. Although there is as yet no evidence that the virus causing COVID-19 might have negative effects on IVF outcomes, fertility treatments have been postponed in order to support healthcare systems by avoiding placing them under additional stress. The possibility of the virus affecting sperm function and egg performance cannot be excluded. In addition, an indirect effect of the virus on gametes and embryos during their manipulation cannot be ruled out. This commentary aims to provide some ideas on the possible effect of the virus on gametes and embryos, as well as how it could affect the normal functioning of the embryology laboratory.

Reporting assisted reproductive technology success rates on Australian and New Zealand fertility clinic websites.

BACKGROUND: Fertility clinics commonly report their success rates online. These can be difficult to interpret as they are influenced by the way the data are presented. To improve transparency, the Reproductive Technology Accreditation Committee (RTAC) has published guidelines to support fertility clinics with their online reporting of success rates. However, it is unclear whether compliance with these guidelines will allow patients to make fair comparisons between clinics. AIMS: To illustrate the variability in patient and treatment populations that contribute to fertility clinic published rates. MATERIALS AND METHODS: Fertility clinics offering in vitro fertilisation treatment in Australia or New Zealand were assessed for compliance with six guidelines adapted from RTAC's code of practice, for reporting success rates in the public domain. All graphs and/or tables reporting clinic success rates were assessed to illustrate the combination of outcome or treatment variables contributing to each dataset. RESULTS: Twenty of the 30 fertility clinic websites reported success rates. Of these only 17 reported live births. The median compliance score with RTAC guidelines was 8/8 (interquartile range: 6-8). Of 41 figures published across all websites, five reported clinical pregnancy rates as their only outcome measure. Thirty-seven figures reported success rates 'per embryo transfer', two figures used 'per egg collection', and no figures described success rates 'per cycle started'. Thirty-two different combinations of reporting variables were observed. CONCLUSIONS: Websites were broadly compliant with RTAC's guidelines. However, considering the variability in patient and treatment groups contributing to success rate data, patients cannot be expected to make an informed decision based on clinics' self-reported outcomes. RTAC guidelines could be improved by providing a clear definition of success, including the appropriate use of denominators.

The association of urinary phosphorous-containing flame retardant metabolites and self-reported personal care and household product use among couples seeking fertility treatment.

BACKGROUND: Phosphorous-containing flame-retardants (PFRs) are widely detected. They are used both as a flame retardant as well as plasticizer. METHODS: A subset of 230 women and 229 men were recruited from Massachusetts General Hospital fertility clinic between 2005 and 2015. At each visit, participants completed a questionnaire of personal care product (PCP) and household product (HP) use. Metabolites [bis(1,3-dichloro-2-propyl) phosphate, diphenyl phosphate (DPHP), isopropylphenyl phenyl phosphate (ip-PPP), tert-butylphenyl phenyl phosphate and bis(1-chloro-2-propyl) phosphate] were measured in urine (1-5 samples; n = 638 women, n = 335 men). Associations were assessed using generalized mixed models, adjusted for SG, age, BMI, smoking, education, and season. RESULTS: In women, moisturizer (60%), nail polish remover (77%), and nail polish (134%) use were associated (p < 0.05) with an increase in DPHP concentrations, while ip-PPP concentrations increased 21-27% with conditioner, cosmetics, deodorant, and hair product use. Mouthwash and vinyl glove use were associated with a respective 31% and 92% increase in DPHP among men. CONCLUSIONS: Our exploratory analysis suggests PFRs may be used as a plasticizer in consumer products, and nail polish use contributes to internal DPHP exposure. Further research is needed to understand how PFRs are used in these products and how it relates to exposure.

Sociodemographic factors associated with semen quality among Malaysian men attending fertility clinic.

The worldwide declining trend in male fertility has been a steady concern since the past few decades. Male infertility reportedly accounts for half of the overall infertility cases in the world. Despite the evidences of reduced fertility rates in Malaysia in the recent years, there is lack of interventions regarding the reproductive parameters in Malaysian men. Complexity in determining the underlying causatives in most of the male subfertility and infertility cases limits the scope of management. The sociodemographic impacts upon overall health as well as on reproductive health of men are undeniable. The present study has analysed the data collected from patients' records in the Fertility Clinic, International Islamic University Malaysia (IIUM), from the January 2009 until December 2018. A total of 300 male patients were included in the study and were categorised according to their seminal fluid analysis (SFA) records. The sociodemographic characteristics for each subject were analysed. The results presented significant correlations among essential sociodemographic factors, such as educational attainment, marital duration as well as the age of wife, with the levels of semen abnormalities in the subjects. The study thereby unleashes scope for further investigations focusing upon the demographic factors for better insights to ameliorate male reproductive health in the Malaysian population.

The Impact of the Ontario Fertility Program on Duplicate Fertility Consultations.

Objectives: The Ontario Fertility Program (OFP) funds 5,000 annual in vitro fertilization (IVF) cycles. We hypothesized that after introduction of the OFP, there would be an increase in duplicate infertility consultations by patients attempting to increase chances at obtaining publicly funded IVF through enlisting at multiple fertility clinics. Methods: This retrospective observational study included women eligible for healthcare services in Ontario from 2014 to 2016 and compared infertility consultations pre- and post-initiation of the OFP. Results: Post-OFP, the average number of consultations per patient and the proportion of patients with more than one consult increased (1.04 vs. 1.05, p = 0.015 and 3.8% vs. 4.2%, p = 0.027, respectively). Total consultations for infertility increased from 24,565 to 27,714 post-OFP. The OFP had the largest impact in the Greater Toronto Area (GTA). Conclusion: The OFP resulted in a statistically significant increase in duplicate consultations, although unlikely to be of clinical relevance. The disproportionate impact seen in the GTA highlights the inequitable access to fertility care in Ontario.

Time-Varying Exposure to Air Pollution and Outcomes of in Vitro Fertilization among Couples from a Fertility Clinic.

BACKGROUND: A few studies suggest that air pollution may decrease fertility, but prospective studies and examinations of windows of susceptibility remain unclear. OBJECTIVE: We aimed to examine the association between time-varying exposure to nitrogen dioxide ([Formula: see text]), ozone ([Formula: see text]), fine particulate matter [Formula: see text] ([Formula: see text]), and black carbon (BC) on in vitro fertilization (IVF) outcomes. METHODS: We included 345 women (522 IVF cycles) for the [Formula: see text], [Formula: see text], and [Formula: see text] analyses and 339 women (512 IVF cycles) for the BC analysis enrolled in a prospective cohort at a Boston fertility center (2004­2015). We used validated spatiotemporal models to estimate daily residential exposure to [Formula: see text], [Formula: see text], [Formula: see text], and BC. Multivariable discrete time Cox proportional hazards models with four periods [ovarian stimulation (OS), oocyte retrieval to embryo transfer (ET), ET to implantation, implantation to live birth] estimated odds ratios (OR) and 95% confidence intervals (CI) of failing at IVF. Time-dependent interactions were used to identify vulnerable periods. RESULTS: An interquartile range (IQR) increase in [Formula: see text], [Formula: see text], and BC throughout the IVF cycle was associated with an elevated odds of failing at IVF prior to live birth ([Formula: see text], 95% CI: 0.95, 1.23 for [Formula: see text]; [Formula: see text], 95% CI: 0.88, 1.28 for [Formula: see text]; and [Formula: see text], 95% CI: 0.96, 1.41 for BC). This relationship significantly varied across the IVF cycle such that the association with higher exposure to air pollution during OS was strongest for early IVF failures. An IQR increase in [Formula: see text], [Formula: see text], and BC exposure during OS was associated with 1.42 (95% CI: 1.20, 1.69), 1.26 (95% CI: 0.96, 1.67), and 1.23 (95% CI: 0.96, 1.59) times the odds of failing prior to oocyte retrieval, and 1.32 (95% CI: 1.13, 1.54), 1.27 (95% CI: 0.98, 1.65), and 1.32 (95% CI: 1.10, 1.59) times the odds of failing prior to ET. CONCLUSION: Increased exposure to traffic-related pollutants was associated with higher odds of early IVF failure. https://doi.org/10.1289/EHP4601.

Exploring Multiple Dimensions of Young Women's Fertility Preferences in Malawi.

INTRODUCTION: Standard survey measures of fertility preferences, such as the desire for and preferred timing of future births, do not capture the complexity of individuals' preferences. New research focuses on additional dimensions of emotions and expectations surrounding childbearing. Few quantitative studies, however, consider the influence of all three dimensions of fertility preferences concurrently. METHODS: Using longitudinal survey data from the Tsogolo la Thanzi project (2009-2012) in Malawi, this study employed logistic regression analysis to investigate the influence of young women's emotions, expectations, and a standard measure of fertility preferences on pregnancy and modern contraceptive use. RESULTS: Young women experienced high unmet need; across survey waves, over three-quarters of women who desired a child in more than 2 years were not currently using modern contraceptives and over three-quarters of women who thought a pregnancy in the next month would be bad news (garnered from a measure of emotions surrounding pregnancy) were not currently using modern contraceptives. In regression models including all three measures of fertility preferences, each was significantly associated with the likelihood of a future pregnancy. The standard measure and emotions measure were significantly associated with modern contraceptive use. DISCUSSION: Emotions and expectations surrounding pregnancy and childbirth appear to be distinct and salient aspects of fertility preferences in addition to the standard measure. A better understanding of the multidimensional nature of fertility preferences will help individuals define and achieve their reproductive goals and obtain appropriate services. Furthermore, future research should incorporate new measures of fertility preferences into surveys internationally.