Physician infertility: a structured literature review.

Physician infertility has become a growing concern because of the increasingly high rates of infertility physicians experience associated with their strenuous work schedules, environmental exposures, and delayed family planning due to their necessitated years of training. Fortunately, there has been an increase in awareness, advocacy, and urgency for institutional support alongside this suboptimal association. This awareness is reflected in the vast existing literature regarding physician infertility; in this scoping review, we aggregated and assessed the current data as well as identified gaps in the available research. Including 56 articles regarding various aspects of the current state of physician infertility, we compiled and synthesized the available data to understand the role of infertility in physician family planning, including specific analyses for surgeons and comparisons of male and female physicians. We discussed the utilization and downsides of artificial reproductive technologies for this population in terms of finances and logistics, contributing to this complex and, until recently, neglected issue. Lastly, we reported on a multitude of suggestions aimed at medical training programs to help combat the complex issue of physician infertility.

Modeling genetic benefits and financial costs of integrating biobanking into the conservation breeding of managed marsupials.

Managed breeding programs are an important tool in marsupial conservation efforts but may be costly and have adverse genetic effects in unavoidably small captive colonies. Biobanking and assisted reproductive technologies (ARTs) could help overcome these challenges, but further demonstration of their potential is required to improve uptake. We used genetic and economic models to examine whether supplementing hypothetical captive populations of dibblers (Parantechinus apicalis) and numbats (Myrmecobius fasciatus) with biobanked founder sperm through ARTs could reduce inbreeding, lower required colony sizes, and reduce program costs. We also asked practitioners of the black-footed ferret (Mustela nigripes) captive recovery program to complete a questionnaire to examine the resources and model species research pathways required to develop an optimized biobanking protocol in the black-footed ferret. We used data from this questionnaire to devise similar costed research pathways for Australian marsupials. With biobanking and assisted reproduction, inbreeding was reduced on average by between 80% and 98%, colony sizes were on average 99% smaller, and program costs were 69- to 83-fold lower. Integrating biobanking made long-standing captive genetic retention targets possible in marsupials (90% source population heterozygosity for a minimum of 100 years) within realistic cost frameworks. Lessons from the use of biobanking technology that contributed to the recovery of the black-footed ferret include the importance of adequate research funding (US$4.2 million), extensive partnerships that provide access to facilities and equipment, colony animals, appropriate research model species, and professional and technical staff required to address knowledge gaps to deliver an optimized biobanking protocol. Applied research investment of A$133 million across marsupial research pathways could deliver biobanking protocols for 15 of Australia's most at-risk marsupial species and 7 model species. The technical expertise and ex situ facilities exist to emulate the success of the black-footed ferret recovery program in threatened marsupials using these research pathways. All that is needed now for significant and cost-effective conservation gains is greater investment by policy makers in marsupial ARTs.

Los programas de reproducción controlada son una herramienta importante para los esfuerzos de conservación de marsupiales, aunque pueden resultar costosos y tener efectos genéticos adversos en las colonias cautivas incapaces de aumentar en tamaño. Los biobancos y las tecnologías de reproducción asistida (TRA) podrían ayudar a superar estos problemas, pero es necesario seguir demostrando su potencial para mejorar su adopción. Utilizamos modelos genéticos y económicos para analizar si la introducción de esperma fundador proveniente de biobancos mediante tecnologías de reproducción asistida a poblaciones cautivas hipotéticas de los marsupiales Parantechinus apicalis y Myrmecobius fasciatus podría reducir la endogamia, disminuir el tamaño efectivo de las colonias y reducir el costo de los programas. También pedimos a los profesionales del programa de recuperación en cautiverio del hurón de patas negras (Mustella nigripes) que respondieran un cuestionario para analizar los recursos y los métodos de investigación de las especies modelo necesarias para desarrollar un protocolo de biobanco optimizado para el hurón de patas negras. Utilizamos los datos de este cuestionario para diseñar métodos de investigación con costos similares para los marsupiales australianos. Con el biobanco y la reproducción asistida, la endogamia se redujo en promedio entre un 80 y un 98%, el tamaño de las colonias fue en promedio un 99% más pequeño y los costos del programa entre 69 y 83 veces menores. La integración del biobanco posibilitó los objetivos de retención genética en cautiverio a largo plazo en marsupiales (90% de heterocigosidad de la población de origen durante un mínimo de 100 años) dentro de un marco realista de costos. Entre el aprendizaje extraído del uso de la tecnología de biobancos que contribuyó a la recuperación del hurón de patas negras figuran la importancia de una financiación adecuada de la investigación (4.2 millones de dólares), colaboraciones profundas que faciliten el acceso a instalaciones y equipos, colonias de animales, especies modelo adecuadas para la investigación y el personal profesional y técnico necesario para abordar las lagunas de conocimiento y ofrecer un protocolo optimizado para los biobancos. Una inversión en investigación aplicada de 133 millones de dólares australianos para la investigación de los marsupiales podría proporcionar protocolos de biobancos para 15 de las especies de marsupiales australianos en mayor riesgo y 7 especies modelo. Existen los conocimientos técnicos y las instalaciones ex situ para emular el éxito del programa de recuperación del hurón de patas negras en marsupiales amenazados utilizando estas vías de investigación. Ahora sólo se necesita una mayor inversión por parte de los responsables políticos de las TRA para marsupiales para obtener beneficios de conservación significativos y rentables.

Pre-pregnancy complications - associated factors and wellbeing in early pregnancy: a Swedish cohort study.

BACKGROUND: Many couples experience difficulties to become pregnant or carry a pregnancy to term due to unknown causes. Here we define pre-pregnancy complications as having prior recurrent pregnancy loss, prior late miscarriages, time to pregnancy more than one year, or the use of artificial reproductive technologies. We aim to identify factors associated with pre-pregnancy complications and poor well-being in early pregnancy. METHODS: Online questionnaire data from 5330 unique pregnancies in Sweden were collected from November 2017 - February 2021. Multivariable logistic regression modelling was used to investigate potential risk factors for pre-pregnancy complications and differences in early pregnancy symptoms. RESULTS: Pre-pregnancy complications were identified in 1142 participants (21%). Risk factors included diagnosed endometriosis, thyroid medication, opioids and other strong pain medication, body mass index > 25 kg/m2 and age over 35 years. Different subgroups of pre-pregnancy complications had unique risk factors. The groups also experienced different pregnancy symptoms in early pregnancy, where women that had experienced recurrent pregnancy loss were at higher risk of depression in their current pregnancy. CONCLUSION: We report one of the largest pregnancy cohorts with high frequency of pre-pregnancy complications compared to the Swedish population. Prescribed drug use and body weight were the top potentially modifiable risk factors in all groups. Participants that experienced pre-pregnancy complications also had higher risk of depression and pregnancy problems in early pregnancy.

Speaking from the Heart-Pastoral Care for Those Suffering from Infertility.

Taking the heart into account while providing pastoral care to couples suffering from infertility is essential. The affective sphere is not irrational but has its own logic that needs to be addressed. Trying to bypass the wounds involved in something as painful as infertility by speaking merely to the mind can turn out to be counter-productive, especially when it comes to explaining the Church's teachings on artificial reproductive technologies. One first needs to connect on the level of the heart in an authentic way to bring some relief and initiate the healing-process before addressing the unethical nature of in vitro fertilization, for example. In this article, I therefore, explore what it means to speak the language of the heart and, briefly, what characterizes the affective sphere. It is key to meet people where they are rather than try to leverage them to where one thinks they ought to be. Compassion, that is, suffering with the other, is essential to ease their pain. Paradoxically, people need to mourn in order to get to a better place, but often do not know how to do it. Hence, I give some pointers as how to assist people to grieve before giving some advice on how to counsel specifically those suffering from infertility.

Even high normal blood pressure affects live birth rate in women undergoing fresh embryo transfer.

STUDY QUESTION: Do differences in blood pressure within the normal range have any impacts on the live birth rate (primary outcome) or biochemical pregnancy rate (beta-hCG positivity), clinical pregnancy rate (heart beating in ultrasound), abortion rate and ectopic pregnancy rate (secondary outcomes) of fresh embryo transfer in women undergoing their IVF/ICSI treatment? SUMMARY ANSWER: Even rather small differences in baseline blood pressure in women with normal blood pressure according to current guidelines undergoing fresh embryo transfer after IVF/ICSI affects substantially the live birth rate. WHAT IS KNOWN ALREADY: Pre-pregnancy hypertension is a well-known risk factor for adverse pregnancy events such as preeclampsia, fetal growth restriction, placental abruption and adverse neonatal events. It is likewise well known that hypertension during pregnancy in women undergoing ART is associated with adverse pregnancy outcomes. However, whether blood pressure at the high end of the normal range has an impact on ART is unknown. STUDY DESIGN, SIZE, DURATION: It is a prospective observational cohort study based on a single IVF center between January 2017 and December 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two thousand four hundred and eighteen women with normal blood pressure undergoing fresh embryo transfer after IVF/ICSI at the Reproductive and Genetic Hospital of CITIC-Xiangya were enrolled in this study. MAIN RESULTS AND THE ROLE OF CHANCE: Blood pressure was measured at the first visit when women consulted the IVF center due to infertility. In women with a successful pregnancy outcome (1487 live births out of 2418 women undergoing fresh embryo transfer after IVF/ICSI), systolic blood pressure (SBP) (114.1 ± 9.48 mmHg versus 115.4 ± 9.8 mmHg, P = 0.001) and diastolic blood pressure (DBP) (74.5 ± 7.5 mmHg versus 75.3 ± 7.34 mmHg, P = 0.006) were lower than in those who did not achieve live births. Multivariate logistic regression analysis revealed that SBP (OR: 0.987, 95% CI: 0.979-0.996, P = 0.004) and DBP (OR: 0.986, 95% CI: 0.975-0.998, P = 0.016) were negatively associated with live birth. Similarly, SBP was significantly negatively related to clinical pregnancy rate (OR: 0.990, 95% CI: 0.981-0.999, P = 0.033), while for DBP the association was not statistically significant (OR: 0.994, 95% CI: 0.982-1.006, P = 0.343). However, both SBP and DBP were positively associated with miscarriage OR: 1.021 (95% CI: 1.004-1.037, P = 0.013) and OR: 1.027 (95% CI: 1.005-1.049, P = 0.014), respectively. Both SBP and DBP were unrelated to biochemical pregnancy (hCG positivity), implantation and ectopic pregnancy rate. LIMITATIONS, REASONS FOR CAUTION: Whether lowering blood pressure before initiating ART treatment in women with SBP or DBP higher than the thresholds defined in our study will confer a benefit is unknown. Also, we cannot exclude bias due to different ethnicities. Moreover, participants in our study only received fresh embryo transfer, whether the results could apply to frozen embryo transfer is unclear. WIDER IMPLICATIONS OF THE FINDINGS: Our study challenges the current blood pressure goals in women undergoing fresh embryo transfer after IVF/ICSI. Further studies are needed to figure out the mechanism and effective approach to increase IVF/ICSI pregnancy outcomes. STUDY FUNDING/COMPETING INTEREST(S): Hunan Provincial Grant for Innovative Province Construction (2019SK4012). The authors declare that there were no conflicts of interest in this study. TRIAL REGISTRATION NUMBER: N/A.

Injustices Implied in the Assisted Reproductive Technologies Market.

This article critiques the current theological basis that deems assisted reproductive technologies (ART) as immoral, namely that it dissociates the unitive act from procreation, and that it violates the dignity of the embryo. It is argued that notwithstanding the validity of these moral truths, these issues are of little relevance to couples facing childlessness. Three alternative views are then presented, all based on the injustices related to the ART market: (a) injustices that directly affect the couple and their offspring, (b) unfairness related to the commercial aspect of ART markets, and (c) the overall effects that impinge on society at large. Therefore, instead of burdening childless couples wanting to have children of their own with the culpability of sin for resorting to ART, one must rather make them aware that they are prey to the ART market while calling for better regulation of this system in order to mitigate these injustices. The article ends with some recommendations on how to address these injustices.

A Spring in the Desert: Infertility and Merciful Accompaniment.

The mystery of love as it unfolds in marriage is an adventure filled with wonder and anticipation for what the future holds. Such is the excitement and optimism of the couple embarking on family life by actively trying to conceive a child. For the couple struggling with infertility, however, joyful anticipation can soon devolve into anguish as they realize that their hoped-for children might not come. Though the pain of infertility is a shared experience in marriage, it is to the woman that evaluation, testing, and treatment is often directed. She may experience infertility as an assault on her feminine identity, her marriage, and her faith, leaving her vulnerable to reliance on scientific and technological solutions as the only relief for her pain. This turn toward science, if not integrated into the larger framework of overall health and well-being, has the danger of making the natural, good desire for a child into a quest to achieve a single-minded goal. When the child becomes a "goal," husband, wife, and potential offspring become (unintentionally) objectified, and the woman's identity and the future of her marriage rest precariously on the shoulders of an ideal. It is within the context of the authors' lived experience of infertility, as well as hundreds of encounters with women in the Springs in the Desert community, that the authors contend that it is necessary to integrate the pain of infertility into a framework of merciful accompaniment. Pastors, physicians, and Fertility Care Providers are all uniquely well-placed to offer support and encouragement that affirm the intrinsic dignity of the wife and her husband, and the truth of their marriage as a witness to Christ in the world. When they meet the woman amidst her pain and longing, they can help her to understand infertility as a circumstance and not her identity. When the pain of infertility is seen and acknowledged, the medical and pastoral care she receives can positively impact her overall health and wellbeing, help her to turn to her husband, and ultimately encourage her to find God in the midst of the struggle.

Massive Vaginal Hematoma - A Complication of In Vitro Fertilization.

BACKGROUND: The rates of serious complications from IVF with transvaginal oocyte retrieval are low. However, as the usage of IVF continues to increase, more complications are presenting to acute care and physicians should be aware of management issues. CASE: A 36-year-old, gravida 4, para 1 woman presented to the emergency department with significant vaginal hemorrhage and severe abdominal pain after undergoing a routine transvaginal oocyte retrieval. She was taken to the operating room and found to have extensive lacerations of the posterior vaginal mucosa and a large vaginal hematoma tracking to the retroperitoneal space. CONCLUSION: This case represents a previously unreported but possible complication of oocyte retrieval. Although oocyte retrieval complications are not frequently reported, significant vaginal and pelvic vascular injury and hemorrhage can occur. Physicians should be cognizant of trauma that can occur secondary to vaginal instruments and not just intraperitoneal injuries.

Fertility after recurrent miscarriages: results of an observational cohort study.

PURPOSE: Recurrent pregnancy losses (RPL) are considered a pathological condition associated with heterogeneous laboratory and clinical findings, and are also linked to subfertility. We attempt to rank parameters derived from past history and diagnostic results with regard to the prognosis. METHODS: Observational trial on 719 consecutive couples who were referred to a tertiary immunological care centre (2006-2014) after three or more primary miscarriages. Information on past obstetric history and diagnostic procedures at baseline were correlated with cumulative pregnancy and delivery rates using Kaplan-Meier estimation, logistic regression and multivariate analysis. RESULTS: At baseline, median female age was 34.1 years, waiting time 3 years (1-17), number of preceding miscarriages 3 (3-9), 147 women (20.4%) had conceived at least once in ART or AIH cycles. After a median follow-up of 33.7 (1.7-123.0) months, 5-year pregnancy and delivery rates were 86.1 and 64.5%. Female age (< 35 years), waiting time (< 3 years) until baseline, tubal competence, and male factor fertility significantly correlated with favourable outcome (p < 0.001), while body mass index (> 29 kg/m2), number of preceding miscarriages (> 4), late miscarriages, preclinical losses and smoking revealed non-significant negative trends. Mode of conception until baseline (spontaneously or ART/AIH) and classification into idiopathic and non-idiopathic RPL showed no prognostic relevance. CONCLUSION: Although in general, chances to conceive a child are retained after three or more miscarriages, factors related to subfertility of both partners have an important impact on the outcome. Therefore, prolonged time to pregnancy (> 6-9 months) should result in preventive gynaecological care from the first miscarriage on, so that fertility can be preserved as best as possible.

The Assessment of Sperm DNA Integrity: Implications for Assisted Reproductive Technology Fertility Outcomes across Livestock Species.

Sperm DNA integrity is increasingly considered a useful measure of semen quality in mammalian reproduction. However, the definition of DNA integrity, the ideal means by which it should be measured, and its predictive value for fertility remain a topic of much discussion. With an emphasis on livestock species, this review discusses the assays that have been developed to measure DNA integrity as well as their correlation with in vitro and in vivo fertility.

Making human eggs in a dish: are we close?

In the space of 50 years, we have seen incredible achievements in human reproductive medicine. With these leaps forward, it is no wonder that there is a major interest in women's reproductive health research, including extension of reproductive lifespan. Substantial effort is currently being made to address this challenge, including from the commercial sector. In vitro gametogenesis (IVG) in mice is a spectacular breakthrough and has the potential to offer hope to women with intractable infertility. However, with such lofty goals, some reflection may be called for: mastering all of the techniques required for complete and safe IVG in women is likely to be extraordinarily difficult.

The Bleak Future of Reproductive Rights for Queer Indians.

Despite the decriminalization of homosexuality in India in 2018, LGBTQ+ rights are under threat in the nation under Prime Minister Modi's far-right government. In this commentary, I explain why two bills recently passed by the Indian parliament-the Artificial Reproductive Technologies (Regulation) Bill and the Surrogacy Regulation Bill-will have chilling effects on the reproductive rights of LGBTQ+ citizens. The biologically essentialist and heteropatriarchal framing of reproductive rights in the bills will prevent LGBTQ+ citizens from accessing reproductive technologies. Contextualizing this framing within Modi's wider far-right Hindu nationalist agenda, I argue that there is a need for a heightened bioethical call to action from queer and feminist bioethicists in India and across the globe.

Pregnancy Outcomes of Different Endometrial Preparation in Patients With a History of Cesarean Section.

Objective: To investigate the efficacies of three cycle regimens in women receiving frozen embryo transfer with a history of cesarean section: natural cycle treatment, hormone replacement therapy and treatment with gonadotropin-releasing hormone agonist. Design: Retrospective cohort study. Methods: patients (N = 6,159) with a history of caesarean section who fulfilled the inclusion criteria were enrolled in the study from January 2014 to December 2019 at the CITIC-Xiangya Hospital of Reproduction and Genetics. Reproductive outcomes of patients in the natural cycle (n = 4,306) versus hormone replacement therapy (n = 1,007) versus gonadotropin-releasing hormone agonist + hormone replacement therapy groups (n = 846) were compared. Continuous data were analyzed using Student's t-test, and categorical variables were analyzed using the χ2 test. Multivariable logistic regression was used to evaluate the possible relationships between the types of endometrial preparation and pregnancy outcomes after adjusting for confounding factors. Results: The unadjusted odds of the miscarriage rate of singleton pregnancies were significantly higher in the hormone replacement therapy compared with the natural cycle (25.5% versus 20.4%, respectively). After adjusting for possible confounding factors, the early miscarriage rate and the miscarriage rate of singleton pregnancies remained significantly higher in the hormone replacement therapy than the natural cycle. The clinical pregnancy rates in the natural cycle, hormone replacement therapy and gonadotropin- releasing hormone agonist + hormone replacement therapy of women with a history of cesarean section was 48.8%, 48% and 47.1%, respectively, and the live birth rates were 37%, 34.1% and 35.7%, respectively. Conclusions: In women undergoing frozen embryo transfer with a history of cesarean section, hormone replacement therapy for endometrial preparation was associated with a higher early miscarriage rate, albeit after statistical adjustment for confounding factors. However, the risk observed was little and did not influence the overall reproductive performances.

Modelling Genetic Benefits and Financial Costs of Integrating Biobanking into the Captive Management of Koalas.

Zoo and wildlife hospital networks are set to become a vital component of Australia's contemporary efforts to conserve the iconic and imperiled koala (Phascolarctos cinereus). Managed breeding programs held across zoo-based networks typically face high economic costs and can be at risk of adverse genetic effects typical of unavoidably small captive colonies. Emerging evidence suggests that biobanking and associated assisted reproductive technologies could address these economic and genetic challenges. We present a modelled scenario, supported by detailed costings, where these technologies are optimized and could be integrated into conservation breeding programs of koalas across the established zoo and wildlife hospital network. Genetic and economic modelling comparing closed captive koala populations suggest that supplementing them with cryopreserved founder sperm using artificial insemination or intracytoplasmic sperm injection could substantially reduce inbreeding, lower the required colony sizes of conservation breeding programs, and greatly reduce program costs. Ambitious genetic retention targets (maintaining 90%, 95% and 99% of source population heterozygosity for 100 years) could be possible within realistic cost frameworks, with output koalas suited for wild release. Integrating biobanking into the zoo and wildlife hospital network presents a cost-effective and financially feasible model for the uptake of these tools due to the technical and research expertise, captive koala colonies, and ex situ facilities that already exist across these networks.

Impact of in vitro embryo culture and transfer on blood pressure regulation in the adolescent lamb.

Nutrition during the periconceptional period influences postnatal cardiovascular health. We determined whether in vitro embryo culture and transfer, which are manipulations of the nutritional environment during the periconceptional period, dysregulate postnatal blood pressure and blood pressure regulatory mechanisms. Embryos were either transferred to an intermediate recipient ewe (ET) or cultured in vitro in the absence (IVC) or presence of human serum (IVCHS) and a methyl donor (IVCHS+M) for 6 days. Basal blood pressure was recorded at 19-20 weeks after birth. Mean arterial pressure (MAP) and heart rate (HR) were measured before and after varying doses of phenylephrine (PE). mRNA expression of signaling molecules involved in blood pressure regulation was measured in the renal artery. Basal MAP did not differ between groups. Baroreflex sensitivity, set point, and upper plateau were also maintained in all groups after PE stimulation. Adrenergic receptors alpha-1A (αAR1A), alpha-1B (αAR1B), and angiotensin II receptor type 1 (AT1R) mRNA expression were not different from controls in the renal artery. These results suggest there is no programmed effect of ET or IVC on basal blood pressure or the baroreflex control mechanisms in adolescence, but future studies are required to determine the impact of ET and IVC on these mechanisms later in the life course when developmental programming effects may be unmasked by age.

Pregnant people, inseminators and tissues of human origin: how ectogenesis challenges the concept of abortion.

The potential benefits of an alternative to physical gestation are numerous. These include providing reproductive options for prospective parents who are unable to establish or maintain a physiological pregnancy, and saving the lives of some infants born prematurely. Ectogenesis could also promote sexual equality in reproduction, and represents a necessary option for women experiencing an unwanted pregnancy who are morally opposed to abortion. Despite these broad, and in some cases unique benefits, one major ethical concern is the potential impact of this emerging technology on abortion rights. This article will argue that ectogenesis poses a challenge to many common arguments in favour of a pregnant woman's right to choose, but only insomuch as it highlights that their underlying justifications for abortion are based on flawed conceptions of what the foetus and pregnancy actually are. By interrogating the various interests and relationships involved in a pregnancy, this article will demonstrate that the emergence of artificial gestation need not impact existing abortion rights or legislation, nor definitions of independent viability or moral status.

A congenital cranial dysinnervation disorder: Möbius' syndrome.

Möbius' syndrome, also known as Möbius' sequence, is a nonprogressive cranial dysinnervation disorder characterized by congenital facial and abducens nerve paralysis. Here, we report a 5-day-old girl who was conceived after in vitro fertilization with poor suck and facial paralysis. She had bilaterally ptosis and lateral gaze limitation, left-sided deviation of the tongue, dysmorphic face, hypoplastic fingers and finger nails on the left hand, and was diagnosed as having Möbius' syndrome. Involvement of other cranial nerves such as three, four, five, nine, 9 and 12, and limb malformations may accompany this syndrome. However, several factors have been proposed for the etiology, some rare cases have also been reported with artificial reproductive technologies. Feeding difficulties and aspiration are the main problems encountered in infancy. The other cranial nerves should be examined further in newborns who present with congenital facial palsy, and other cranial dysinnervation disorders should be considered in the differential diagnosis.

Metabolomics as a tool to identify biomarkers to predict and improve outcomes in reproductive medicine: a systematic review.

BACKGROUND: Infertility is a complex disorder with significant medical, psychological and financial consequences for patients. With live-birth rates per cycle below 30% and a drive from the Human Fertilisation and Embryology Authority (HFEA) to encourage single embryo transfer, there is significant research in different areas aiming to improve success rates of fertility treatments. One such area is investigating the causes of infertility at a molecular level, and metabolomics techniques provide a platform for studying relevant biofluids in the reproductive tract. OBJECTIVE AND RATIONALE: The aim of this systematic review is to examine the recent findings for the potential application of metabolomics to female reproduction, specifically to the metabolomics of follicular fluid (FF), embryo culture medium (ECM) and endometrial fluid. To our knowledge no other systematic review has investigated this topic. SEARCH METHODS: English peer-reviewed journals on PubMed, Science Direct, SciFinder, were systematically searched for studies investigating metabolomics and the female reproductive tract with no time restriction set for publications. Studies were assessed for quality using the risk of bias assessment and ROBIN-I. OUTCOMES: There were 21 studies that met the inclusion criteria and were included in the systematic review. Metabolomic studies have been employed for the compositional analysis of various biofluids in the female reproductive tract, including FF, ECM, blastocoele fluid and endometrial fluid. There is some weak evidence that metabolomics technologies studying ECM might be able to predict the viability of individual embryos and implantation rate better than standard embryo morphology, However these data were not supported by randomized the controlled trials (RCTs) which showed no evidence that using metabolomics is able to improve the most important reproductive outcomes, such as clinical pregnancy and live-birth rates. This systematic review provides guidance for future metabolomic studies on biofluids of the female reproductive tract, with a summary of the current findings, promise and pitfalls in metabolomic techniques. The approaches discussed can be adapted by other metabolomic studies. WIDER IMPLICATIONS: A range of sophisticated modern metabolomic techniques are now more widely available and have been applied to the analysis of the female reproductive tract. However, this review has revealed the paucity of metabolomic studies in the field of fertility and the inconsistencies of findings between different studies, as well as a lack of research examining the metabolic effects of various gynecological diseases. By incorporating metabolomic technology into an increased number of well designed studies, a much greater understanding of infertility at a molecular level could be achieved. However, there is currently no evidence for the use of metabolomics in clinical practice to improve fertility outcomes.

Ultrasound in assisted reproduction: a call to fill the endometrial gap.

Ultrasound offers essential details and an overall view of the anatomic features of the reproductive organs, as well as physiologic assessment. There is still a great gap, however, in our understanding and interpretation of endometrial sonographic findings. Endometrial thickness, growth, and sonographic patterns have been repeatedly tested and compared with pregnancy rates in IVF cycles, yielding conflicting results. Generally, the data accrued so far suggest refraining from clinical decisions based solely on endometrial thickness. The three-layer ultrasound pattern reflects normal follicular/proliferative dynamics, and its presence in the pre-hCG period was reported to carry a better outcome: Significantly higher clinical pregnancy rates were found in patients with this pattern on the day of hCG administration among IVF cohorts. Subendometrial contractility (endometrial "waves") offers a tool that can be used in cases of repeated implantation failure in patients reporting cramps around the planned time of embryo transfer, or as a reassuring modality to assess uterine quiescence during preparations for embryo transfer. We support the creation of an integrated endometrial score incorporating conservative endometrial measurements, endometrial-myometrial junction studies, and endometrial contractility, as well as new concepts that remain to be tested, such as endometrial surface area. Such scores may enable us to improve the effectiveness of endometrial ultrasound imaging in the clinical setting.