Preimplantation genetic testing for Neurofibromatosis type 1: more than 20 years of clinical experience.

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder that affects the skin and the nervous system. The condition is completely penetrant with extreme clinical variability, resulting in unpredictable manifestations in affected offspring, complicating reproductive decision-making. One of the reproductive options to prevent the birth of affected offspring is preimplantation genetic testing (PGT). We performed a retrospective review of the medical files of all couples (n = 140) referred to the Dutch PGT expert center with the indication NF1 between January 1997 and January 2020. Of the couples considering PGT, 43 opted out and 15 were not eligible because of failure to identify the underlying genetic defect or unmet criteria for in vitro fertilization (IVF) treatment. The remaining 82 couples proceeded with PGT. Fertility assessment prior to IVF treatment showed a higher percentage of male infertility in males affected with NF1 compared to the partners of affected females. Cardiac evaluations in women with NF1 showed no contraindications for IVF treatment or pregnancy. For 67 couples, 143 PGT cycles were performed. Complications of IVF treatment were not more prevalent in affected females compared to partners of affected males. The transfer of 174 (out of 295) unaffected embryos led to 42 ongoing pregnancies with a pregnancy rate of 24.1% per embryo transfer. There are no documented cases of misdiagnosis following PGT in this cohort. With these results, we aim to provide an overview of PGT for NF1 with regard to success rate and safety, to optimize reproductive counseling and PGT treatment for NF1 patients.

Case Management Improves Satisfaction, Anxiety, and Depression of Patients with Pregnancy Loss after In Vitro Fertilization and Embryo Transfer.

Objective: Pregnancy loss has negative impacts on both the physical and the mental health of expectant mothers, which calls for an in-depth investigation. In this study, we examined the effects of case management on patients with pregnancy loss after in vitro fertilization and embryo transfer (IVF-ET). Methods: 100 participants that had suffered pregnancy loss after IVF-ET-assisted pregnancy from January 2019 to March 2020 were divided into routine care and case management groups, each with 50 cases. For the routine care group, a doctor led the diagnostic and treatment processes and a nurse assisted with the treatment. For the case management group, a nurse led the patient diagnostic and treatment processes and a doctor controlled the diagnosis and treatment plan formulation. Case management models were established according to the comprehensive peripregnancy loss care of patients with pregnancy loss after IVF-ET-assisted pregnancy. The participants' outcomes (satisfaction, anxiety, and depression) were assessed at the time of pregnancy loss and 1 and 3 months after pregnancy loss during follow-up of the routine care and case management groups. Results: There was no statistical difference between the patients in the two groups with regard to their general information statistics (P > 0.05) or their satisfaction, anxiety, and depression at the time of pregnancy loss (P > 0.05). One month after pregnancy loss, there was no statistical difference in anxiety between the two groups (P > 0.05), but satisfaction was greater and depression was significantly reduced in the case management group compared with the routine care group (P < 0.05). Conclusion: Case management care can have a positive effect on improving the satisfaction, anxiety, and depression of patients that have had pregnancy loss after IVF-ET.

Perceived stress and sleep quality before oocyte pick-up, embryo transfer, and pregnancy test in women receiving in vitro fertilization treatment.

BACKGROUND: Infertility is a major health problem that affects both the family and the community. Women receiving infertility treatment may suffer from stress and even experience sleep disturbance. Sleep quality is an important factor of human health and well-being. Sleep disturbances tend to occur among infertile women during in vitro fertilization treatment. Many studies have focused on the stress and sleep quality associated with their treatment in infertile women. However, few studies have investigated factors linked to their sleep disturbances. OBJECTIVE: This study investigated the relationship between perceived stress and sleep quality before oocyte pick-up, in vitro fertilization-embryo transfer, and pregnancy test in women receiving in vitro fertilization treatment. MATERIAL AND METHODS: This prospective, longitudinal study was conducted between January and May 2020. One hundred fifty-seven women receiving infertility treatment were included in the study. A personal information form, the Perceived Stress Scale (PSS), and the Pittsburgh Sleep Quality Index (PSQI) were used to collect data. RESULTS: The relationship between the Perceived Stress Scale scores and the Pittsburgh Sleep Quality Index scores in all stages of infertility treatment was found to be positively significant at the p < .001 significance level. CONCLUSION: Perceived stress level was high in women throughout the infertility treatment. Our study suggested that sleep quality was impaired as stress increased. TRIAL REGISTRATION: 70904504/38.

Impact of psychological stress on the outcomes of assisted reproduction in Tunisian infertile women.

INTRODUCTION: childlessness is an emotionally difficult experience for infertile couples. Undergoing assisted reproductive treatments (ART) could generate further stress in these patients. Studies investigating the impact of anxiety on ART outcomes have shown controversial results. Moreover, there are no publications focusing on anxiety symptomsin infertile Tunisian couples. METHODS: we conducted a prospective study including 79 infertile women undergoing in vitro fertilization at the Reproductive Medicine Unit of the Farhat Hached Hospital (Tunisia). Participants were asked to answer to the Beck anxiety inventory (BAI) on the day of oocyte retrieval. Accordingly, they were classified into the 3 groups: group A: very low anxiety (n= 36; BAI<21), group B: moderate anxiety (n= 24; 22≤BAI≤35) and group C: severe anxiety (n=19; BAI≥36). For each patient, two blood samples were collected to assess free cortisol level on the day of oocyte retrieval and on the day of embryo transfer. RESULTS: results showed that women with primary infertility were significantly more stressed than those with secondary infertility (p= 0.011). Cortisol level was significantly higher on the day of embryo transfer than on the day of oocyte pick-up (p<0.0001). A lower implantation rate was found in severely anxious patients compared with moderately anxious women (p= 0.03) and those having low levels of anxiety (p= 0.001) and was negatively correlated to BAI score (r= -0.65; p= 0.001). Both clinical pregnancy and livebirth rates were similar among the three groups. CONCLUSION: the day of embryo transfer is the most stressful timepoint and psychological counseling is crucial to enhance implantation rate. Hence implantation took place, no effect of stress on pregnancy and live birth was found.

Literacy assessment of preimplantation genetic patient education materials exceed national reading levels.

PURPOSE: In vitro fertilization with preimplantation genetic testing (IVF+PGT-M) reduces the risk of having a child affected by a heritable condition, yet only one-third of eligible patients are aware of this reproductive option. Access to education materials written at appropriate literacy levels could raise patients' awareness, but there is a mismatch between patient reading ability and the literacy demand of most materials. This study aimed to systematically identify written education materials on IVF+PGT-M and evaluate their literacy levels. We hypothesized that materials would fail to meet standards set by the Joint Commission and Centers for Disease Control and Prevention (CDC). METHODS: To identify patient education materials about IVF+PGT-M from academic databases and public-facing sources, an environmental scan was performed. Materials were analyzed using three validated scales: Simple Measure of Gobbledygook, Patient Education Materials Assessment Tool, and Clear Communication Index. RESULTS: Seventeen patient education materials about IVF+PGT-M were identified from patient education databases, a consumer search engine, and professional organizations. The median reading level was 14.5 grade, median understandability was 74.2%, and median comprehensibility was 73.3%. CONCLUSIONS: For most American adults, materials about IVF+PGT-M are not readable, understandable, or clear. The Joint Commission requires patient education materials be written at or below 5th grade reading level and the CDC recommends a 90% minimum score for comprehensibility. No evaluated material met these guidelines. Patient education materials that exceed average American literacy skills may perpetuate disparities in the utilization of IVF+PGT-M. Materials that communicate this complicated subject at an understandable level are needed.

Analyses of medical coping styles and related factors among female patients undergoing in vitro fertilization and embryonic transfer.

OBJECTIVE: This study investigated the medical coping styles of female patients treated with in vitro fertilization and embryonic transfer (IVF-ET), and analyzed the effects of alexithymia and social support on their choice of coping style. METHODS: A survey was conducted with 285 female patients undergoing IVF-ET in a reproductive medical center of a third-grade class-A hospital in China using the Medical Coping Modes Questionnaire, the Social Support Rating Scale, and the Toronto Alexithymia scale. RESULTS: Patients who underwent IVF-ET treatment had a higher score for avoidance as a coping mode than did normal controls. Utilization of social support predicted the use of confrontation as a coping style. Difficulty identifying feelings, objective support, and utilization of social support were factors in the choice of avoidance as a coping style, and length of infertility treatment, difficulty identifying feelings, and subjective support predicted patients' use of the acceptance-resignation as a coping style. CONCLUSION: Patients who undergo IVF-ET generally select the coping style of avoidance, which is not conducive to treatment. Targeted intervention strategies should be developed based on the factors influencing patients' choice of coping style(s) to guide them in choosing positive coping methods, improve compliance, and achieve successful pregnancy outcomes.

Effectiveness of acupuncture on pregnancy success rates for women undergoing in vitro fertilization: A randomized controlled trial.

OBJECTIVE: To investigate the effect of acupuncture on pregnancy success rates applied before and after embryo transfer (ET) among women undergoing in vitro fertilization (IVF). MATERIALS AND METHODS: In this randomized controlled trial, 72 infertile women undergoing IVF were randomized to acupuncture (AG; n = 36) and control group (CG; n = 36). Three sessions of acupuncture were applied to AG, the first was one week before ET, the second was 30 min before ET, and the third was 30 min after ET. CG received no acupuncture. The primary outcome was pregnancy success rate (Beta-HCG level, clinical pregnancy, ongoing pregnancy, live birth). Secondary outcome was anxiety level (STAI-1 state anxiety scale). Beta-HCG levels were assessed for conception 12 days after ET. Additionally, STAI-1 state anxiety scale was administered 30 min before and after ET to measure anxiety levels in both groups. RESULTS: The mean age was 30.9 ± 3.7 years. Positive Beta HCG was detected in 63.9% (n = 23) of the AG and 33.3% (n = 12) of CG (p = 0.009). Clinical pregnancy, ongoing pregnancy, and live birth rates were higher in AG (p < 0.05). There was no difference between the groups concerning anxiety scores before ET (p > 0.05). The mean STAI-1 score was decreasing from 57.3 ± 9.8 to 28.8 ± 3.3 in AG, while it was decreasing from 57.0 ± 8.0 to 41,1 ± 6,8 in CG after ET (p < 0.000). CONCLUSIONS: It was observed that three sessions of acupuncture before and after ET significantly increased the pregnancy rates in women with unexplained infertility. It was also found that acupuncture significantly reduced anxiety levels that occurred before ET.

Compassionate transfer: patient requests for embryo transfer for nonreproductive purposes.

A patient request to transfer embryos into her body in a location or at a time when pregnancy is highly unlikely to occur is deemed a request for "compassionate transfer" and often reflects the patient's deeply personal, strongly held preferences and values. It is ethically permissive for physicians to honor or decline such requests if they do so in a nondiscriminatory manner.

Psychological Intervention in the Oocyte Pick-up Room and Recovery Room in Assisted Reproduction: new listening accounts.

OBJECTIVE: This study seeks to identify the role and possible participation of a psychologist/psychoanalyst inside an Oocyte Pick-up Room and Recovery Room (OPR-RR) in an Assisted Reproduction clinic and its implications on patients and team. METHODS: Prospective study of psychological support during the procedures from September 2014 to December 2018. Most visits took place during oocyte retrievals, for either IVF/ICSI or gamete freezing. RESULTS: Of the 2,343 cases, the psychologist was present in 965 of them (41%), during oocyte retrievals, with available professionals in 59% of the times (722 cases). The embryo transfers (1,011) had psychological assistance in 20% of the time (218 cases). The intrauterine insemination cases were excluded for not happening in a surgical environment. The recovery room was identified as one of the spaces for welcoming and listening to anxieties, desires, projects, worries, fears, frustrations, joys and expectations for those who come to the clinic seeking the desire to gestate. The patients' talks, collected in observations transcribed from what was heard, with dates and types of procedures, were discussed with either the team or the assistant physician. The team stands positively in the presence of a psychologist/psychoanalyst, who brings new perceptions and the development of the whole art of listening, for all involved. CONCLUSION: The presence of a psychologist/psychoanalyst in the Oocyte Pick-up Room and the Recovery Room in an Assisted Reproduction clinic means an opportunity to listen to patients' emotions, providing well-being to patients and echoing in the teamwork relationships.

Single or double embryo transfer? Decision-making process in patients participating in an oocyte donation program.

In IVF/ICSI programs, after receiving the information about the success results of single embryo transfer (SET) vs double embryo transfer (DET) and the risks of multiple pregnancy, a significant number of patients opt for SET. Up to date, no comparable studies have been published in oocyte recipients. The aim of this study was to evaluate if the counseling provided to oocyte recipients influence their decision on the number of embryos to be transferred. Fifty-five recipients expressed their preference and the relevance for the decision-making process that they attribute to certain factors through an anonymous questionnaire completed pre and post-counseling. Before counseling, 32 out of 55 recipients preferred DET, 13 preferred SET and 10 were undecided. From the 32 recipients who preferred DET, 16 (50%) maintained their preference after counseling, 13 (40.6%) changed their decision to SET and 3 (9.4%) changed to undecided (McNemar's test: p < .05). After counseling, the patients attached less importance to the probability of pregnancy and more importance to maternal and perinatal risks (p < .05). We conclude that after counseling, a significant number of recipients changed their preferences from DET to SET.

An analysis of the anxiety and hopelessness levels of women during IVF-ET treatment.

PURPOSE: This study determined the anxiety and hopelessness levels of women during in vitro fertilization-embryo transfer. DESIGN AND METHODS: This cross-sectional and descriptive study was conducted with 50 infertile women. The Personal Information Form, State-Trait Anxiety Inventory, and Beck Hopelessness Scale (BHS) were used to collect data. FINDINGS: A statistically significant difference between the BHS total score before oocyte pick-up and after embryo transfer was found (P < .05). However, no statistically significant relationship was found between state anxiety in the same process (P > .05). PRACTICE IMPLICATIONS: This study showed that women had high levels of hopelessness and as a woman's state anxiety level increased, her level of hope decreased.

Quantitative and Qualitative Analyses of Psychological Experience and Adjustment of In Vitro Fertilization-Embryo Transfer Patients.

BACKGROUND The aim of this study was to quantitatively analyze the psychosocial characteristics of in vitro fertilization-embryo transfer (IVF-ET) couples and normal couples, and to identify the influencing factors of psychological characteristics and pregnancy outcomes. MATERIAL AND METHODS There were 260 infertile couples undergoing IVF-ET and 277 healthy couples of childbearing age in Shengjing Hospital of China Medical University recruited into 2 groups. Psychosocial characteristics were compared to analyze the influencing factors of pregnancy outcomes after IVF-ET. In-depth interviews (n=11) and infertility-related forum posts (n=12) were adopted to obtain the data related to the psychological experience and adjustment. Nvivo 11 software was utilized to collect and analyze the data. RESULTS The levels of anxiety and depression in the IVF-ET group were significantly higher (both P<0.01), the total scores of marital quality scale and social support scale were significantly lower (both P<0.05), immature defense mechanism score was significantly higher (P<0.05), and mature defense mechanism score (P<0.05) was significantly lower than those in the control group. Bod mass index (BMI), family's rural residence, marital quality, and immature and mature defense mechanisms were influencing factors of depression in IVF-ET female patients (all P<0.05). Marital quality, mature and immature defense mechanisms, concealment factors, and Harm Avoidance (HA) score were influencing factors of depression in IVF-ET males (all P<0.05). The age of the female patient was an independent influencing factor of IVF-ET pregnancy success rate (P<0.01). CONCLUSIONS The mental health levels of IVF-ET patients were worse than those of fertile couples. The younger the female infertile patient, the higher pregnancy rate of IVF-ET.

Beyond the biopsy: predictors of decision regret and anxiety following preimplantation genetic testing for aneuploidy.

STUDY QUESTION: What factors are associated with decision regret and anxiety following preimplantation genetic testing for aneuploidy (PGT-A)? SUMMARY ANSWER: The majority of patients viewed PGT-A favourably regardless of their outcome; although patients with negative outcomes expressed greater decision regret and anxiety. WHAT IS KNOWN ALREADY: PGT-A is increasingly utilized in in vitro fertilization (IVF) cycles to aid in embryo selection. Despite the increasing use of PGT-A technology, little is known about patients' experiences and the possible unintended consequences of decision regret and anxiety related to PGT-A outcome. STUDY DESIGN, SIZE, DURATION: Anonymous surveys were distributed to 395 patients who underwent their first cycle of autologous PGT-A between January 2014 and March 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS: There were 69 respondents who underwent PGT-A at a university-affiliated fertility centre, completed the survey and met inclusion criteria. Respondents completed three validated questionnaires including the Brehaut Decision Regret (DR) Scale, short-form State-Trait Anxiety Inventory (STAI-6) and a health literacy scale. The surveys also assessed demographics, fertility history, IVF and frozen embryo transfer cycle data. MAIN RESULTS AND THE ROLE OF CHANCE: The majority of respondents were Caucasian, >35 years of age and educated beyond an undergraduate degree. The majority utilized PGT-A on their first IVF cycle, most commonly to 'maximize the efficiency of IVF' or reduce per-transfer miscarriage risk. The overall median DR score was low, but 39% of respondents expressed some degree of regret. Multiple regression confirmed a relationship between embryo ploidy and decision regret, with a lower number of euploid embryos associated with a greater degree of regret. Patients who conceived following euploid transfer reported less regret than those who miscarried or failed to conceive (P < 0.005). Decision regret was inversely associated with number of living children but not associated with age, education, race, insurance coverage, religion, marital status or indication for IVF/PGT-A. Anxiety was greater following a negative pregnancy test or miscarriage compared to successful conception (P < 0.0001). Anxiety was negatively associated with age, time since oocyte retrieval and number of living children, and a relationship was observed between anxiety and religious affiliation. Overall, decision regret was low, and 94% of all respondents reported satisfaction with their decision to pursue PGT-A; however, patients with a negative outcome were more likely to express decision regret and anxiety. LIMITATIONS, REASON FOR CAUTION: This survey was performed at a single centre with a relatively homogenous population, and the findings may not be generalizable. Reasons for caution include the possibility of response bias and unmeasured differences among those who did and did not respond to the survey, as well as the possibility of recall bias given the retrospective nature of the survey. Few studies have examined patient perceptions of PGT-A, and our findings should be interpreted with caution. WIDER IMPLICATIONS OF THE FINDINGS: Overall decision regret was low following PGT-A, and the vast majority deemed the information gained valuable for reproductive planning regardless of outcome. However, more than one-third of the respondents expressed some degree of regret. Respondents with no euploid embryos were more likely to express regret, and those with a negative outcome following euploid embryo transfer expressed both higher regret and anxiety. These data identify unanticipated consequences of PGT-A and suggest opportunities for additional counselling and support surrounding IVF with PGT-A. STUDY FUNDING/COMPETING INTEREST(S): No external funding was obtained for this study. D.H.M. reports personal fees, honorarium, and travel expenses from Ferring Pharmaceuticals, personal fees and travel expenses from Granata Bio, and personal fees from Biogenetics Corporation, The Sperm and Embryo Bank of New York, and ReproART: Georgian American Center for Reproductive Medicine. All conflicts are outside the submitted work.

Does stress affect IVF outcomes? A prospective study of physiological and psychological stress in women undergoing IVF.

RESEARCH QUESTION: What are the effects of physiological and psychological stress on fertility outcomes for women undergoing IVF? DESIGN: A prospective cohort study of 72 patients undergoing IVF in 2017 and 2018. Physiological stress was assessed by salivary cortisol measurements: (i) pretreatment, when the patient received the IVF protocol; (ii) before oocyte retrieval (follicular cortisol was also measured); and (iii) before embryo transfer. Emotional stress was evaluated at each assessment with the State-Trait Anxiety Inventory and a 1-10 Visual Analogue Scale (VAS, referred to as the 'Stress Scale'. Correlations between cortisol concentrations, psychological stress and IVF outcome were assessed. RESULTS: Salivary cortisol concentrations increased by 28% from pretreatment phase (0.46 ± 0.28 µg/dl) to maximum concentration on oocyte retrieval day (0.59 ± 0.29 µg/dl, P = 0.029) and then decreased by 29% on embryo transfer day (0.42 ± 0.23 µg/dl, P = 0.0162). On embryo transfer day, cortisol among women in their first cycle was higher than women who underwent more than one treatment (P = 0.024). Stress Scale score increased by 39% from pretreatment to a maximum score on oocyte retrieval day and then decreased by 12% on embryo transfer day. Salivary cortisol and Stress Scale were not related to subsequent embryo transfer, fertilization rate, embryo quality or clinical pregnancy rate. Follicular cortisol concentration was positively correlated with fertilization rate (r = 0.4, P = 0.004). CONCLUSION: It can be cautiously concluded that physiological and psychological stress do not negatively affect IVF outcomes. Moreover, high follicular cortisol concentrations might have positive effects on pregnancy rates.

Preimplantation genetic testing for more than one genetic condition: clinical and ethical considerations and dilemmas.

STUDY QUESTION: Which clinical and ethical aspects of preimplantation genetic testing for monogenic disorders or structural rearrangements (PGT-M, PGT-SR) should be considered when accepting requests and counselling couples for PGT when applied for more than one condition (combination-PGT; cPGT-M/SR)? SUMMARY ANSWER: cPGT is a feasible extension of the practice of PGT-M/SR that may require adapting the criteria many countries have in place with regard to indications-setting for PGT-M/SR, while leading to complex choices that require timely counselling and information. WHAT IS KNOWN ALREADY: Although PGT-M/SR is usually performed to prevent transmission of one disorder, requests for PGT-M/SR for more than one condition (cPGT-M/SR) are becoming less exceptional. However, knowledge about implications for a responsible application of such treatments is lacking. STUDY DESIGN, SIZE, DURATION: Retrospective review of all (40) PGT-M/SR applications concerning more than one genetic condition over the period 1995-2018 in the files of the Dutch national PGT centre. This comprises all relevant national data since the start of PGT in the Netherlands. PARTICIPANTS/MATERIALS, SETTING AND METHODS: Data regarding cPGT-M/SR cases were collected by means of reviewing medical files of couples applying for cPGT-M/SR. Ethical challenges arising with cPGT-M/SR were explored against the background of PGT-M/SR regulations in several European countries, as well as of relevant ESHRE-guidance regarding both indications-setting and transfer-decisions. MAIN RESULTS AND THE ROLE OF CHANCE: We report 40 couples applying for cPGT-M/SR of which 16 couples started their IVF treatment. Together they underwent 39 IVF cycles leading to the birth of five healthy children. Of the couples applying for cPGT, 45% differentiated between a primary and secondary condition in terms of perceived severity. In the light of an altered balance of benefits and drawbacks, we argue the 'high risk of a serious condition' standard that many countries uphold as governing indications-setting, should be lowered for secondary conditions in couples who already have an indication for PGT-M/SR. As a consequence of cPGT, professionals will more often be confronted with requests for transferring embryos known to be affected with a condition that they were tested for. In line with ESHRE guidance, such transfers may well be acceptable, on the condition of avoiding a high risk of a child with a seriously diminished quality of life. LIMITATIONS, REASONS FOR CAUTION: We are the first to give an overview of cPGT-M/SR treatments. Retrospective analysis was performed using national data, possibly not reflecting current trends worldwide. WIDER IMPLICATIONS OF THE FINDINGS: Our observations have led to recommendations for cPGT-M/SR that may add to centre policy making and to the formulation of professional guidelines. Given that the introduction of generic methods for genomic analysis in PGT will regularly yield incidental findings leading to transfer requests with these same challenges, the importance of our discussion exceeds the present discussion of cPGT. STUDY FUNDING/COMPETING INTEREST(S): The research for this publication was funded by the Dutch Organization for Health Research and Development (ZonMw), project number: 141111002 (Long term safety, quality and ethics of Preimplantation Genetic Diagnosis). None of the authors has any competing interests to declare.

'Compassionate transfer': an alternative option for surplus embryo disposition.

Compassionate transfer is a procedure wherein in vitro-created embryos are placed in a patient's cervix, vagina or uterus at an infertile period in the menstrual cycle where they are expected to perish. Patients report that they feel this procedure is a more natural means of disposition and provides them with the opportunity to grieve the loss of a potential child. However, some have argued that the procedure is an unnecessary, and illogical, addition to fertility treatment and that it detracts resources from medical care. Here, we introduce compassionate transfer as an alternative disposition option and argue that, for certain patients, it may constitute an ethical extension of fertility care that respects patient autonomy and psychosocial health.

Stress increases the risk of pregnancy failure in couples undergoing IVF.

Stress plays an important role in reproductive health and likely is one of the psychological factors affecting ART success. This study was designed to examine the relationship between the stress level as inferred from the amount of the enzyme alpha-amylase secreted in saliva (SAA) and pregnancy outcome in infertile couples undergoing in vitro fertilization and embryo transplantation (IVF-ET). A prospective cohort study was conducted in the Reproductive Medicine Centre of Zhengzhou University Hospital in Henan, China. Four hundred fifty-seven infertile couples undergoing in vitro fertilization and embryo transplantation (IVF-ET) for the first time participated in the study. Couples collected saliva samples the morning before the start of their first treatment cycle for the measurement of SAA. We found that the level of SAA (and hence, the amount of stress) in female partners, male partners, and couples analyzed together significantly affected IVF-ET outcome. Cutoff levels of SAA that predicted pregnancy failure were 136 µmol/L, 149 µmol/L, and 288 µmol/L in female partners, male partners, and couples, respectively. Female partners, male partners, and couples with high SAA levels had increased risk of pregnancy failure compared to those with low SAA levels. The SAA level directly correlated with the follicle-stimulating hormone level and was inversely proportional to the anti-Müllerian hormone level and endometrial thickness. Some semen parameters of male partners, such as density, survival rate, sperm rapid progressive motility (A%), and progressive motility [(A + B)%], were significantly lower in the high-SAA than in the low-SAA group. Furthermore, couples in the high SAA group had fewer transferable and high-quality embryos. We concluded that a high SAA level, known to be an objective indicator of high stress, increases the risk of pregnancy failure in infertile couples undergoing IVF-ET. Lay summary To explore the relationship between stress, as measured by the levels of the stress biomarker salivary alpha-amylase (SAA), and pregnancy outcome in infertile couples undergoing in vitro fertilization, a prospective cohort study was conducted in the Reproductive Medicine Centre of Zhengzhou University Hospital in Henan, China. Four hundred fifty-seven infertile couples undergoing IVF-ET collected saliva samples the morning before the start of their first treatment cycle for the measurement of SAA. Results of this study demonstrated that a high SAA level, known to be an objective indicator of high stress, increases the risk of pregnancy failure in infertile couples undergoing IVF-ET.

A prospective observational study on the stress levels at the time of embryo transfer and pregnancy testing following in vitro fertilisation treatment: a comparison between women with different treatment outcomes.

OBJECTIVE: To ascertain whether stress biomarkers and psychological indices of stress may predict both conception and miscarriage rates in women undergoing in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI). DESIGN: Prospective observational study. SETTING: A university-affiliated tertiary hospital. POPULATION: Infertile women who were undergoing fresh or frozen IVF/ICSI cycles. METHODS: Women were recruited to (1) complete validated psychological questionnaires (visual analogue scale of stress, state-trait anxiety inventory, perceived stress scale, fertility problem inventory, Beck depression inventory, and general health questionnaire), at the time of embryo transfer (ET) and pregnancy testing (PT), and (2) provide saliva samples for α-amylase (sAA) measurement before and after ET and at PT. MAIN OUTCOME MEASURES: Women were grouped according to subsequent reproductive outcome; scores/levels of all tests were then compared between groups at each time-point. RESULTS: In all, 197 women completed the study, of which 92 conceived and 28 miscarried. The level of psychological stress, as measured by questionnaires, was highest at the time of PT, whereas the level of biological stress as measured by sAA level (IU/l) post-ET (1.8 × 105  ± 1.5 × 105 ) was significantly (P < 0.001) higher than pre-ET (1.2 × 105  ± 1.0 × 105 ) and at PT (1.0 × 105  ± 1.1 × 105 ). However, there was no difference in psychological scoring and in sAA levels between women who did or did not conceive and who had miscarried or had an ongoing pregnancy. CONCLUSIONS: The level of sAA is highest following ET, whereas psychological stress is highest at PT. However, neither stress level appeared to be of prognostic value in predicting conception or miscarriage. TWEETABLE ABSTRACT: Stress level fluctuated at different time-points, but it did not predict conception or miscarriage.

What are patients doing with their mosaic embryos? Decision making after genetic counseling.

OBJECTIVE: To assess patient decisions regarding mosaic embryos and their impact on clinical outcomes. DESIGN: Review of patients who had genetic counseling regarding mosaic embryos. SETTING: Academic department. PATIENT(S): Ninety-eight patients who had mosaic embryos but no euploid embryos. INTERVENTION(S): Genetic counseling to discuss mosaic-embryo transfer (MET) after preimplantation genetic testing for aneuploidy. MAIN OUTCOME MEASURE(S): Patient decisions regarding MET. Outcomes for patients who pursued MET were compared with those for patients who pursued additional in vitro fertilization or intrauterine insemination cycles. Decisions regarding prenatal testing after MET were assessed. RESULT(S): Initially, 29.6% of patients pursued MET and 41.8% attempted a new treatment cycle. Only 6.1% of patients discarded their mosaic embryos without further treatment. Of the remaining patients, 2.0% transported their mosaic embryos to a different facility and 20.5% had not taken further action while their embryos remain stored. Patients who pursued additional cycles were more likely to have an ongoing pregnancy compared with those who pursued MET (51.2% vs. 27.6%; P<.05); however, there was no statistically significant difference in the percentage of patients who had at least one biochemical pregnancy or spontaneous abortion. Ultimately, 32.7% of patients underwent MET, and 54.5% of pregnant patients pursued amniocentesis. CONCLUSION(S): MET is desired by a substantial proportion of patients who do not have euploid embryos. Patients who opt for additional treatment cycles have a greater chance of achieving an ongoing pregnancy compared with those who pursue MET; however, future studies are needed to compare the cost-effectiveness for both options.