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Objective To investigate the association between paternal race and reproductive outcomes following in vitro fertilization (IVF). Materials and Methods We compared demographic and clinical characteristics, IVF cycle characteristics, and reproductive outcomes (pregnancy, miscarriage, and live birth), stratified by male and female partner race, for all IVF cycles performed at our institution between 2014 and 2019. Wilcoxon Rank Sum test and Pearson's Chi Square test were used to compare continuous and categorical data, respectively. A Poisson regression model was used to determine the association between race and clinical outcomes. Significance was set as P Results We examined 1878 IVF cycles involving 1069 couples. The study population was diverse; 50.1% of male partners were white, 28.5% black, 15.1% Asian, and 2.3% Hispanic. The majority of couples (86.5%) shared a common self-reported race category. Black males were older than white males (39.6 vs 37.0 years), with higher BMI (30.4 vs 28.0) and higher frequency of male factor infertility (45.9% vs 33.5%). Female partners of black males were older than those of white males (35.6 vs 33.8 years), with higher BMI (29.6 vs 25.2), and higher frequency of female factor infertility (91.8% vs 83.9%). Although we noted race-related variability in IVF cycle characteristics, no significant differences in the outcomes of pregnancy, biochemical pregnancy, clinical intrauterine pregnancy, or ectopic pregnancy were observed between races. Conclusion Although paternal race was associated with IVF cycle characteristics, after controlling for potential confounders, paternal race did not independently contribute to outcomes in this institutional dataset.

Ovarian reserve is an important determinant of a woman’s reproductive potential, and women with diminished ovarian reserve (DOR) often seek in vitro fertilization (IVF). The underlying etiology of DOR is unknown, but follicular fluid cytokine concentrations likely play a role in follicular development and maturation. The present study seeks to investigate the expression of cytokines in follicular fluid (FF) of women with DOR undergoing IVF and explore correlated functional pathways. One hundred ninety-four women undergoing ovarian stimulation were recruited at the time of oocyte retrieval. Women were classified as having DOR if they met one or more of the following criteria: AMH 10 mIU/ml, and/or AFC

To characterize national outcomes of oocyte thaw (OT) cycles.Retrospective descriptive study.All autologous OT cycles reported to the Society of Assisted Reproductive Technology Clinic Outcome Reporting System from 2012 to 2018.All women undergoing OT cycles in the United States.None.Absolute numbers of oocyte cryopreservation (OC) and OT cycles over time. Among OT cycles, patient and cycle characteristics, the ratio of the total number of oocytes thawed to the number of live births by maternal age at the time of cryopreservation (ATOC), and outcomes including pregnancy, miscarriage, live birth, and good perinatal outcome (GPO) by age ATOC.From 2012 to 2018, 54,675 OC and 6,413 OT cycles were performed; the absolute numbers increased from 2,719 to 13,824 and from 348 to 1,810, respectively. The ratio of the total number of oocytes thawed to the number of live births increased significantly with increasing age ATOC, from 41.4 (age35 years) to 122.4 (age41 years). Among OT cycles resulting in embryo transfer, the live birth rate decreased with increasing age ATOC from 42.8% (age35 years) to 10.8% (age42 years). The live birth rate was higher when calculated per transfer (42.8% in women aged35 years ATOC) rather than per thaw cycle (31.5% in women aged35 years ATOC) because of the number of patients with no transfer. Among 1,124 cycles resulting in pregnancy, the chance of a GPO was highest among women aged35 years ATOC (65.8%) and decreased as age at ATOC increased.Among reported OT cycles, the rates of pregnancy and live birth decreased as age ATOC increased. The number of oocytes thawed to achieve one live birth increased significantly with increasing age ATOC. In addition, among the resulting pregnancies, the rate of GPO decreased as age ATOC increased.

Objective To identify modifying genes that explains the risk of fragile X-associated primary ovarian insufficiency (FXPOI). Design Gene-based, case/control association study, followed by a functional screen of highly ranked genes using a Drosophila model. Setting Participants were recruited from academic and clinical settings. Patient(s) Women with a premutation (PM) who experienced FXPOI at the age of 35 years or younger (n = 63) and women with a PM who experienced menopause at the age of 50 years or older (n = 51) provided clinical information and a deoxyribonucleic acid sample for whole genome sequencing. The functional screen was on the basis of Drosophila TRiP lines. Intervention(s) Clinical information and a DNA sample were collected for whole genome sequencing. Main Outcome Measures A polygenic risk score derived from common variants associated with natural age at menopause was calculated and associated with the risk of FXPOI. Genes associated with the risk of FXPOI were identified on the basis of the P-value from gene-based association test and an altered level of fecundity when knocked down in the Drosophila PM model. Results The polygenic risk score on the basis of common variants associated with natural age at menopause explained approximately 8% of the variance in the risk of FXPOI. Further, SUMO1 and KRR1 were identified as possible modifying genes associated with the risk of FXPOI on the basis of an untargeted gene analysis of rare variants. Conclusions In addition to the large genetic effect of a PM on ovarian function, the additive effects of common variants associated with natural age at menopause and the effect of rare modifying variants appear to play a role in FXPOI risk.

PURPOSE: To characterize national oocyte donation practice patterns from the perspective of individual donors rather than of recipients. METHODS: Retrospective cohort including all donor oocyte retrievals and transfers reported to SARTCORS in 2016 and 2017 in the USA. Primary outcomes include characteristics of oocyte donors and of donor oocyte cycles. Secondary outcomes include overall pregnancy rates, elective single embryo transfer (eSET) rates, and perinatal outcomes among donor oocyte recipient transfers. RESULTS: During the study period, 49,193 donor oocyte retrievals were performed, of which the largest proportion were in the Western US. For all reported retrievals, there were 17,099 unique donors, each of whom underwent an average of 2.4 retrievals (range 1–22). Average donor age was 26.3 years (range 18–48). On average, 24.6 oocytes (SD 12.4) were retrieved each cycle, ranging from 0 to 102. Among 37,657 donor oocyte recipient transfers, 20,159 (53.5%) involved eSET, and 17,725 (47.1%) resulted in live birth. Miscarriage rates were 17.5%, and good perinatal outcome (GPO), defined as full-term normal birthweight delivery, was more likely among singleton (75.7%) than multiple (23.8%) pregnancies. CONCLUSION: The average number of retrievals that donors underwent and oocyte yield mirrored national guidelines; however outliers, exist that may unnecessarily increase donor risk. Additionally, among resultant donor transfers, 46.5% transferred more than one embryo despite national recommendations for eSET. The significantly higher likelihood of GPO among singleton pregnancies points to the need to further increase donor recipient eSET rates.

Purpose Approximately 20–30% of women with an FMR1 premutation experience fragile X–associated primary ovarian insufficiency (FXPOI); however, current risk estimates based on repeat size only identify women with the midrange of repeats to be at the highest risk. Methods To better understand the risk by repeat size, we collected self-reported reproductive histories on 1,668 women and divided them into high-resolution repeat size bins of ~5 CGG repeats to determine a more accurate risk for FXPOI in relation to CGG repeat length. Results As previously reported, women with 70–100 CGG repeats were at the highest risk for FXPOI using various statistical models to compare average age at menopause and risk of FXPOI, with women with 85–89 repeats being at the highest risk. Importantly, women with 120 repeats did not have a significantly increased risk for FXPOI compared to women with

Reproductive life planning is an important aspect of OBGYN resident education. Despite learning about declining fertility and the implications associated with delaying pregnancy, OBGYN residents overestimate the age when fertility declines and fertility treatment success rates. To characterize attitudes towards infertility, pregnancy timing, and fertility preservation among OBGYN residents at academic programs in the United States. Cross sectional study of female trainees from 27 academic OBGYN residency programs. A voluntary, anonymous online survey was used to assess reproductive experiences and characterize attitudes towards personal family planning and infertility. Of 756 trainees who were sent the survey, 487 opened the email, and 309 participated (63.4% response rate per opened email, 40.9% overall). The majority of residents expressed a desire to have children, but had not started childbearing (75.8%, n = 210) with a planned delay for career/educational reasons (84.5%, n = 196). The majority planned to have children before age 35 (90%, n = 210). Of those not finished with childbearing, 78.5% reported worrying about infertility (n = 205) and 40.8% reported considering fertility preservation (n = 111). If interested in fellowship, trainees were more worried about infertility (p = 0.01, OR 2.74 (95% CI 1.24 –6.04)). Female OBGYN residents learn to help patients with reproductive planning and many may personally delay family building. To help alleviate anxiety, improve reproductive autonomy, and prevent future regret, OBGYN residents may benefit from counseling regarding declining fertility with age and the advantages and disadvantages of fertility preservation, specifically emphasizing the realistic chance of success with oocyte cryopreservation compared to conception at a young age.

Purpose Emerging evidence indicates that women who carry an FMR1 premutation can experience complex health profiles beyond the two well-established premutation-associated disorders: fragile X–associated primary ovarian insufficiency (FXPOI, affects ~20–30% carriers) and fragile X–associated tremor–ataxia syndrome (FXTAS, affects ~6–15% carriers). Methods To better understand premutation-associated health profiles, we collected self-reported medical histories on 355 carrier women. Results Twenty-two health conditions were reported by at least 10% of women. Anxiety, depression, and headaches were reported by more than 30%. The number of comorbid conditions was significantly associated with body mass index (BMI) and history of smoking, but not age. Survival analysis indicated that women with FXPOI had an earlier age at onset for anxiety and osteoporosis than women without FXPOI. Cluster analysis identified eight clusters of women who reported similar patterns of comorbid conditions. The majority of carriers (63%) fell into three categories primarily defined by the presence of only a few conditions. Interestingly, a single cluster defined women with symptoms of FXTAS, and none of these women had FXPOI. Conclusion Although some women with a premutation experience complex health outcomes, most carriers report only minimal comorbid conditions. Further, women with symptoms of FXTAS appear to be distinct from women with symptoms of FXPOI.

Purpose: Women who carry an FMR1 premutation (PM) can experience two well-established PM-associated disorders: fragile X-associated primary ovarian insufficiency (FXPOI, affects ~20–30% carriers) and fragile X-associated tremor-ataxia syndrome (FXTAS, affects ~6–15% carriers); however, emerging evidence indicates that some of these women experience complex health profiles beyond FXPOI and FXTAS.Methods: In an effort to better understand predictors for these comorbid conditions, we collected self-reported medical histories on 413 women who carry an FMR1 PM.Results: There were 22 health conditions reported by at least 9% of women. In an exploratory analysis, 12 variables were tested in logistic regression models for each comorbid condition, including demographic variables, environmental variables, PM-associated factors, and endorsement of depression and/or anxiety. More than half of the comorbid conditions studied were associated with women who self-reported having anxiety. Age, smoking, body mass index (BMI), and depression were also significant predictor variables for specific comorbid conditions.Conclusions: Age, smoking, and BMI were significantly associated with a subset of the comorbid conditions analyzed. Importantly, depression or anxiety were also significantly associated with many of the comorbid health conditions. This work highlights some of the modifiable factors associated with complex health profiles among women with an FMR1 PM.

INTRODUCTION AND OBJECTIVE:Men at risk for subfertility should undergo further evaluation by a urologist, ideally with specialization in male reproduction. We investigated patient access to reprodu...

Research Question Is race/ethnicity or access to care, as defined by insurance coverage, distance to clinic, and zip code, associated with care discontinuation following in vitro fertilization (IVF)? Design A retrospective cohort study of 878 diverse women who underwent 1,689 IVF cycles from 2014-2018 at a Southeastern academic medical center was performed. Women were divided into low (LAC) and high (HAC) access to care groups. HAC was defined as possessing IVF insurance coverage, living ≤25 miles from the clinic, and living in a zip code with a median income ≥$75,000. Access groups and racial/ethnic groups were compared for differences in relative risk of care discontinuation following an unsuccessful IVF cycle. Results Women with HAC had a poorer IVF prognosis than the LAC group, which possibly impacted the association with care discontinuation. Distance to clinic, but not insurance coverage or zip code, was associated with increased risk of care discontinuation. Variation in insurance coverage existed among patients, possibly impacting its association with discontinuation. Among women ≤34 years, HAC was associated with an increased risk of care discontinuation (aRR 2.5, 95% CI: 0.8-8.1). Despite having higher rates of insurance coverage (51.2% vs. 36.5%), non-Hispanic Black women were more likely to discontinue care (58.3% vs. 40.2%) and less likely to achieve a live birth (53% vs. 68%) than non-Hispanic White women. Conclusions HAC women ≤34 years old, identification as non-Hispanic Black, and distance to clinic, but not insurance coverage or zip code, were associated with an increased risk of care discontinuation following an unsuccessful IVF cycle.

OBGYNs help patients plan families, conceive, and deliver children, however the personal reproductive history and goals, infertility experiences, and birth outcomes of OBGYNs are not well studied. We aim to characterize female OBGYN reproductive experiences with a particular focus on infertility, reproductive life planning (methods of pregnancy prevention, reasons why pregnancy is/was delayed), birth outcomes (mode of delivery, delivery timing), and the postpartum period (breastfeeding, maternity leave, postpartum depression). An anonymous email survey was distributed to female members of Georgia OBGYN Society and Emory University Department of Gynecology and Obstetrics. Descriptive statistics and bivariable analysis were performed using Microsoft Excel and OpenEpi. Of 352 surveys, 204 of 269 women who opened the survey agreed to participate (75.8% per opened email, 58.0% per sent email). Mean age of first childbirth was 30.7 (SD ± 4.2) years. Most pregnancies were intended (77%). Fertility treatments were used in 13% of pregnancies. Resident mothers compared to mothers who gave birth before or after residency were more likely to report postpartum depression [26% vs. 16%, OR 1.8 (95% CI 0.93–3.58)] and shorter maternity leave

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

Background A growing literature suggests that minority races, particularly Black women, have a lower probability of live birth and higher risk of perinatal complications after autologous assisted reproductive technology. However, questions still remain as to whether these racial disparities have arisen because of associations between race and oocyte/embryo quality, the uterine environment, or a combination of the two. Oocyte donation assisted reproductive technology represents a unique approach to examine this question. Objective This study aimed to evaluate the associations between the race of female oocyte donors and recipients and live birth rates following vitrified donor oocyte assisted reproductive technologies. Study Design This was a retrospective study conducted at a single, private fertility clinic that included 327 oocyte donors and 899 recipients who underwent 1601 embryo transfer cycles (2008–2015). Self-reported race of the donor and recipient were abstracted from medical records. Live birth was defined as the delivery of at least 1 live-born neonate. We used multivariable cluster weighted generalized estimating equations with binomial distribution and log link function to estimate the adjusted risk ratios of live birth, adjusting for donor age and body mass index, recipient age and body mass index, tubal and uterine factor infertility, and year of oocyte retrieval. Results The racial profile of our donors and recipients were similar: 73% white, 13% Black, 4% Hispanic, 8% Asian, and 2% other. Women who received oocytes from Hispanic donors had a significantly higher probability of live birth (adjusted risk ratio, 1.20; 95% confidence interval, 1.05–1.36) than women who received oocytes from white donors. Among Hispanic recipients, however, there was no significant difference in probability of live birth compared with white recipients (adjusted risk ratio, 1.07; 95% confidence interval, 0.90–1.26). Embryo transfer cycles using oocytes from Black donors (adjusted risk ratio, 0.86; 95% confidence interval, 0.72–1.03) and Black recipients (adjusted risk ratio, 0.84; 95% confidence interval, 0.71–0.99) had a lower probability of live birth than white donors and white recipients, respectively. There were no significant differences in the probability of live birth among Hispanic, Asian, and other race recipients compared with white recipients. Conclusion Black female recipients had a lower probability of live birth following assisted reproductive technology, even when using vitrified oocytes from healthy donors. Female recipients who used vitrified oocytes from Hispanic donors had a higher probability of live birth regardless of their own race.

Introduction Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the best therapeutic option in primary and some secondary peritoneal malignancies. The ramifications of this procedure on fertility are unknown. The aim of this study was to assess the current association of CRS/HIPEC with fertility following surgery. Methods A review of patients who underwent CRS/HIPEC between 2009 and 2018 was performed. Female patients were included if they were between ages 18-50 at the time of surgery. Gynecologic and obstetric history before and following CRS/HIPEC was collected by phone interview. Results Of 48 eligible participants, 21 completed the survey. Sixty-five percent of women underwent a total abdominal hysterectomy before or during CRS. Twenty-nine percent of these women recall fertility counseling before CRS/HIPEC, while 14.3% saw a fertility specialist for consultation, and only one patient proceeded with oocyte cryopreservation before treatment. There were no pregnancies reported following treatment with CRS/HIPEC. Conclusion Few patients after CRS/HIPEC retain child-bearing potential, partly due to the high rate of hysterectomy and oophorectomy at time of surgery. Efforts towards improved preoperative counseling, increased oocyte cryopreservation, and evaluating the safety of preserving reproductive organs at the time of surgery are needed.

Cancer statistics for adolescents and young adults (AYAs) (aged 15-39 years) are often presented in aggregate, masking important heterogeneity. The authors analyzed population-based cancer incidence and mortality for AYAs in the United States by age group (ages 15-19, 20-29, and 30-39 years), sex, and race/ethnicity. In 2020, there will be approximately 89,500 new cancer cases and 9270 cancer deaths in AYAs. Overall cancer incidence increased in all AYA age groups during the most recent decade (2007-2016), largely driven by thyroid cancer, which rose by approximately 3% annually among those aged 20 to 39 years and 4% among those aged 15 to 19 years. Incidence also increased in most age groups for several cancers linked to obesity, including kidney (3% annually across all age groups), uterine corpus (3% in the group aged 20-39 years), and colorectum (0.9%-1.5% in the group aged 20-39 years). Rates declined dramatically for melanoma in the group aged 15 to 29 years (4%-6% annually) but remained stable among those aged 30 to 39 years. Overall cancer mortality declined during 2008 through 2017 by 1% annually across age and sex groups, except for women aged 30 to 39 years, among whom rates were stable because of a flattening of declines in female breast cancer. Rates increased for cancers of the colorectum and uterine corpus in the group aged 30 to 39 years, mirroring incidence trends. Five-year relative survival in AYAs is similar across age groups for all cancers combined (range, 83%-86%) but varies widely for some cancers, such as acute lymphocytic leukemia (74% in the group aged 15-19 years vs 51% in the group aged 30-39 years) and brain tumors (77% vs 66%), reflecting differences in histologic subtype distribution and treatment. Progress in reducing cancer morbidity and mortality among AYAs could be addressed through more equitable access to health care, increasing clinical trial enrollment, expanding research, and greater alertness among clinicians and patients for early symptoms and signs of cancer. Further progress could be accelerated with increased disaggregation by age in research on surveillance, etiology, basic biology, and survivorship.

Objective In female cancer patients anticipating chemotherapy or radiation, oocyte retrieval for fertility should be performed as efficiently as possible to avoid postponing cancer treatments. Our objective was to compare clinical outcomes among female cancer patients who underwent a conventional early follicular phase-start ovarian stimulation cycle and those who underwent a random-start ovarian stimulation cycle. Evidence review A systematic review of the literature was performed in accordance with PRISMA guidelines. Medline, Embase.com, Scopus, Cochrane Library, and Clinicaltrials.gov databases were searched to identify all original research published in English through July 2020 on the topic of female cancer patients undergoing ovarian stimulation with a random or conventional start. Studies lacking a comparison group or including women who had already undergone chemotherapy at the time of ovarian stimulation were excluded. The primary author assessed all identified article titles and abstracts, and two independent reviewers assessed full-text articles and extracted data. A meta-analysis with a random-effects model was used to calculate weighted mean differences (WMDs) for outcomes of interest. The primary outcome was the number of mature (meiosis II) oocytes retrieved. Secondary outcomes included duration of stimulation, total dose of gonadotropins, total number of oocytes retrieved, fertilization rate, and number of embryos or zygotes cryopreserved. Results A total of 446 articles were screened, and 9 full-text articles (all retrospective cohort or prospective observational) were included for review. Additionally, pooled primary retrospective data from two institutions were included. In total, data from 10 studies including 1653 women were reviewed. Five studies reported the number of embryos cryopreserved, and four reported fertilization rates. Random-start cycles were slightly longer (WMD 0.57 days, 95 % confidence interval [CI] 0.0–1.14 days) and used more total gonadotropins (WMD 248.8 international units, 95 % CI 57.24–440.40) than conventional-start cycles. However, there were no differences in number of mature oocytes retrieved (WMD 0.41 oocytes, 95 % CI −0.84–1.66), number of total oocytes retrieved (WMD 0.90 oocytes, 95 % CI −0.21–2.02), fertilization rates (WMD −0.12, 95 % CI −1.22–0.98), or number of embryos cryopreserved (WMD 0.12 embryos, 95 %CI −0.98–1.22) between random-start and conventional-start cycles. All outcomes except for the parameter “total oocytes retrieved” yielded an I2 of over 50 %, indicating substantial heterogeneity between studies. Conclusion(s) Although random-start cycles may entail a longer duration of stimulation and use more total gonadotropins than conventional-start cycles, the absolute differences are small and likely do not significantly affect treatment costs. The similar numbers of mature oocytes retrieved, fertilization rates, and number of embryos cryopreserved in the two start-types suggest that they do not differ in any clinically important ways. Given that random-start cycles can be initiated quickly, they may help facilitate fertility preservation for cancer patients.

PURPOSE: This study aimed to determine the current percentage of United States (U.S.) assisted reproductive technology (ART) clinics offering sex selection via pre-implantation genetic screening (PGS) for non-medical purposes. METHODS: The authors conducted website review and telephone interview survey of 493 U.S. ART clinics performing in vitro fertilization (IVF) in 2017. Main outcome measures were pre-implantation genetic screening (PGS)/pre-implantation genetic diagnosis (PGD) practices and non-medical sex selection practices including family balancing. RESULTS: Of the 493 ART clinics in the USA, 482 clinics (97.8%) responded to our telephone interview survey. Among all U.S. ART clinics, 91.9% (n = 449) reported offering PGS and/or PGD. Furthermore, 476 clinics responded to survey questions about sex selection practices. Of those ART clinics, 72.7% (n = 346) reported offering sex selection. More specifically among those clinics offering sex selection, 93.6% (n = 324) reported performing sex selection for family balancing, and 81.2% (n = 281) reported performing for elective purposes (patient preference, regardless of rationale for the request). For couples without infertility, 83.5% (n = 289) of clinics offer sex selection for family balancing and 74.6% (n = 258) for non-specific elective reasons. CONCLUSIONS: The majority of U.S. ART clinics offer non-medical sex selection, a percentage that has increased substantially since last reported in 2006.

Objective To investigate the associations among underweight body mass index (BMI), pregnancy, and obstetric outcomes among women using assisted reproductive technology (ART). Design Retrospective cohort study using national data and log binomial regression. Setting Not applicable. Patient(s) Women undergoing IVF in the United States from 2008 to 2013. Intervention(s) None. Main Outcome Measure(s) Pregnancy outcomes (intrauterine pregnancy, live birth rates) per transfer, miscarriage rate per pregnancy, and low birth weight and preterm delivery rates among singleton and twin pregnancies. Result(s) For all fresh autologous in vitro fertilization (IVF) cycles in the United States from 2008 to 2013 (n = 494,097 cycles, n=402,742 transfers, n=180,855 pregnancies) reported to the national ART Surveillance System, compared with normal weight women, underweight women had a statistically significant decreased chance of intrauterine pregnancy (adjusted risk ratio [aRR] 0.97; 95% confidence interval [CI], 0.96–0.99) and live birth (aRR 0.95; 95% CI, 0.93–0.98) per transfer. Obese women also had a statistically decreased likelihood of both (aRR 0.94; 95% CI, 0.94–0.95; aRR 0.87; 95% CI, 0.86–0.88, respectively). Among cycles resulting in singleton pregnancy, both underweight and obese statuses were associated with increased risk of low birth weight (aRR 1.39; 95% CI, 1.25–1.54, aRR 1.26; 95% CI, 1.20–1.33, respectively) and preterm delivery (aRR 1.12; 95% CI, 1.01–1.23, aRR 1.42; 95% CI, 1.36–1.48, respectively). The association between underweight status and miscarriage was not statistically significant (aRR 1.04; 95% CI, 0.98–1.11). In contrast, obesity was associated with a statistically significantly increased miscarriage risk (aRR 1.23; 95% CI, 1.20–1.26). Conclusion(s) Among women undergoing IVF, prepregnancy BMI affects pregnancy and obstetric outcomes. Underweight status may have a limited impact on pregnancy and live-birth rates, but it is associated with increased preterm and low-birth-weight delivery risk. Obesity negatively impacts all ART and obstetric outcomes investigated.

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

Hormonal therapy and gender-affirming surgeries in transgender people have known deleterious impacts on future fertility using one's own gametes. This review focuses on fertility preservation, including the effects of medical hormone treatment on fertility, available and experimental options of fertility preservation in transgender adults, including sperm cryopreservation for transwomen and oocyte cryopreservation for transmen, and options for prepubertal transgender adolescents, including testicular and ovarian tissue cryopreservation. Transgender patients continue to face barriers and receive infrequent counseling regarding fertility preservation. Physicians should ideally counsel and discuss fertility preservation options before transgender patients undergo hormone therapy of gender-affirmation surgery.

PURPOSE: To explore associations between infertility treatment and hypertensive disorders of pregnancy. METHODS: We collated multi-year as well as multi-state data from a national representative survey examining the association between self-reported infertility treatment (i.e., medication, intrauterine insemination, or assisted reproductive technology) and hypertensive disorders of pregnancy (i.e., high blood pressure, pregnancy-induced hypertension (PIH), preeclampsia, and toxemia). Data were analyzed using logistic regression. A total of 21,884 women in the United States (U.S.), from the Centers for Disease Control and Prevention’s (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) survey (2009–2015), participated in the study. RESULTS: In our analysis, 12.91% women reported a history of infertility treatment and 15.19% reported a history of hypertensive disorder of pregnancy. Compared with women who had never had infertility treatment, women who reported infertility treatment had 1.18 (adjusted OR, 95% confidence interval (CI) 1.05, 1.33) higher odds of reporting hypertensive disorder of pregnancy. Neither types of infertility treatment nor proximity of treatment to pregnancy were independently associated with hypertensive disorder of pregnancy. CONCLUSIONS: Our results suggest that among U.S. women, the treatment of infertility may be associated with hypertension disorder of pregnancy regardless of type of treatment.

Study Objective To describe oocyte cryopreservation (OC) cycles in adolescent women ( Design Retrospective cohort study. Setting Not applicable. Participants OC cycles from the Technology Clinic Outcome Reporting System database. Interventions OC cycles from 2012 to 2016 among adolescent women were compared with cycles in older women. Main Outcome Measure Number of oocytes retrieved. Results From 2012 to 2016, OC cycles in women younger than 20 years of age accounted for 1.5% of OC cycles in all women. The absolute number has increased over the 5-year period, parallel to the increase in older women. OC cycles in adolescent women were most likely performed for fertility preservation for impending gonadotoxic treatment. The women were most likely to be non-Hispanic white and reside in the Northeast. Ten percent of the cycles were cancelled, most commonly for low response, compared with 6.6% of cycles in other age groups. There was no difference in mean oocytes retrieved in women younger than 20 years (n = 18.0) compared with women 20-29 years (n = 18.4). Complications, including ovarian hyperstimulation syndrome, were very rare. Conclusion OC cycles in adolescent women are similar with regard to stimulation characteristics and oocyte yield to those in women of other age groups. There is, however, a higher likelihood of cancellation because of poor response.

Objective Approximately 20% of women with a premutation in the FMR1 gene experience primary ovarian insufficiency (POI). We explored diagnostic patterns, frequency of appropriate hormone replacement, obstetric outcomes, fertility treatment, reproductive decisions, and counseling of women with fragile X-associated POI (FXPOI). Methods Semistructured interviews with 79 women with FXPOI were conducted by a single interviewer. FMR1 cytosine-guanine-guanine repeat size was determined from a blood, saliva, or buccal sample. Results The median age of POI onset for women in our study was 33 years. Seventy-two percent of the women had an FMR1 cytosine-guanine-guanine repeat length of 80 to 100. Mean length of time from symptom onset to POI diagnosis was 1.12 years, longer in women with a younger age of POI onset and shorter in women who knew they were carriers. After diagnosis, 52% of women never took hormone therapy, started it years after POI diagnosis, or stopped it before 45 years of age. Forty-nine percent of the women had infertility, but 75% had had at least one genetically related child. Obstetric outcomes were similar to the general population. Forty-six percent of women had a diagnosis of low bone mineral density or osteoporosis, and an additional 19% had never had a bone density assessment. Conclusions Women with FXPOI are at significant risk for delayed POI diagnosis and undertreatment with hormone therapy. Although approximately 50% of women had infertility, most were able to conceive at least one child and had no elevated risk of adverse obstetric outcomes.

Fragile X-associated primary ovarian insufficiency (FXPOI) occurs in about 20% of women who carry a premutation allele (55–200 CGG repeats). These women develop hypergonadotropic hypogonadism and have secondary amenorrhea before age 40. A non-linear association with repeat size and risk for FXPOI has been seen in multiple studies women with a premutation: those with a mid-range of repeats are at highest risk (∼70–100 CGG repeats). Importantly, not all carriers with 70–100 repeats experience FXPOI. We investigated whether AGG interruptions, adjusted for repeat size, impacted age at secondary amenorrhea. We have reproductive history information and AGG interruption data on 262 premutation women: 164 had an established age at amenorrhea (AAA) (for some, age at onset of FXPOI) or menopause, 16 had a surgery involving the reproductive system such as a hysterectomy, and 82 women were still cycling at the last interview. Reproductive status was determined using self-report reproductive questionnaires and interviews with a reproductive endocrinologist. For each of these 262 women, FMR1 repeat size and number of AGG interruptions were determined. We confirmed the association of repeat size with AAA or menopause among women with a premutation. As expected, both premutation repeat size and the quadratic form of repeat size (i.e., squared term) were significant in a survival analysis model predicting AAA (p < 0.0001 for both variables). When number of AGG interruptions was added to the model, this variable was not significant (p = 0.59). Finally, we used a regression model based on the 164 women with established AAA to estimate the proportion of variance in AAA explained by repeat size and its squared term. Both terms were again highly significant (p < 0.0001 for both), but together only explained 13% of the variation in AAA. The non-linear association between AAA and FMR1 repeat size has been described in several studies. We have determined that AGG interruption pattern does not contribute to this association. Because only 13% of the variation is described using repeat size, it is clear that further research of FXPOI is needed to identify other factors that affect the risk for FXPOI.

Objective To examine the degree to which paternal variables of age, body mass index (BMI), and sperm parameters affect vitrified donor oocyte IVF outcomes. Previous studies examining the impact of male partner characteristics on in-vitro fertilization (IVF) have found conflicting results. Concerns are rising over the potential effects of paternal factors, such as age and obesity, on pregnancy and child health. Frozen donor oocyte IVF offers an ideal model to study these effects. Design Retrospective chart review. Setting Private fertility clinic. Patient(s) Nine hundred forty-nine recipients undergoing transfer of blastocyst embryo(s) from a vitrified oocyte donor bank between 2008-2015. Intervention(s) None. Main Outcome Measure(s) Implantation rate, clinical pregnancy rate, live birth rate, rate of low birth weight singleton infants (≤2500 g), and preterm deliveries (PTD) of singleton infants ( Results After adjusting for covariates known to affect oocyte donation cycle success, male age, BMI and sperm parameters were not associated with differences in IVF outcomes. There were higher PTD rates for men ≥51 years and BMI ≥35 kg/m2, however, these were not significant after adjustment. There were no differences in rates of low birth weight infants with men >35 years or BMI >25 kg/m2. Lastly, there were no differences in rates of PTD or low birth weight infants with abnormal sperm parameters. Conclusions Neither advancing male age, elevated BMI, nor poor sperm quality were associated with outcomes in frozen donor oocyte IVF cycles in this study. Intracytoplamic sperm injection and “oocyte quality” likely mitigate some of the effects of male variables on outcomes following cryopreserved oocyte donation.

Anti-Mullerian hormone (AMH) has potential local effects on ovarian function and endometrial tissue, including endometriosis, but its presence in peritoneal fluid is not fully understood. This is a cross-sectional study evaluating AMH in peritoneal fluid and plasma from women with endometriosis (N = 61) and from control women without endometriosis (N = 36). There was a significant correlation between AMH in plasma and peritoneal fluid from both patients with endometriosis (r(2) = .767 [P < .001]) and control participants (r(2) = .647 [P < .001]) less than 45 years of age. Anti-Mullerian hormone declined with women's increasing age in both plasma and peritoneal fluid in women with and without endometriosis. There were no differences in the plasma or peritoneal fluid AMH in women with endometriosis versus control women. The strong relationship between plasma and peritoneal fluid may allow plasma AMH to be a marker for peritoneal AMH in studies evaluating the local effects of AMH.

The purpose of the study was to describe trends in and investigate variables associated with clinical pregnancy and live birth in autologous in vitro fertilization (IVF) cycles among women ≥40 years. We used autologous IVF cycle data from the National ART Surveillance System (NASS) for women ≥40 years at cycle start. We assessed trends in fresh and frozen cycles (n = 371,536) from 1996 to 2013. We reported perinatal outcomes and determined variables associated with clinical pregnancy and live birth in fresh cycles between 2007 and 2013. From 1996 to 2013, the total number of cycles in women ≥40 years increased from 8672 to 28,883 (p

Objective To determine the average number of family members diagnosed with a Fragile X Mental Retardation-1 ( FMR1 ) mutation after a proband receives the initial diagnosis of fragile X syndrome (FXS). Study design We reviewed pedigrees of families who had been evaluated at the Fragile X Syndrome Center at Emory University in Atlanta, Georgia. Through these pedigrees, we determined the number of additional family members diagnosed as FMR1 premutation carriers or with full mutation FXS after the initial diagnosis in each proband. Results The fragile X pedigree review identified 176 probands, including 108 males (61%) and 68 females (39%). A total of 785 family members were diagnosed with expanded fragile X alleles, including 278 males (35%) and 507 females (65%). These family members included 227 individuals with full mutation FXS (219 males and 8 females) and 558 premutation carriers (59 males and 499 females). After the initial diagnosis of a proband with FXS, on average at least 5 additional family members were diagnosed with an FMR1 mutation. Conclusion Our findings confirm that obtaining a detailed family history after diagnosis of a proband with FXS is likely to identify multiple family members with FMR1 mutations. It is important that the pediatrician or other health care provider making a diagnosis of FXS recognize the value of a detailed family history for timely diagnosis and treatment of additional individuals who may be FMR1 premutation carriers or have full mutation FXS.

Background The growing use of preimplantation genetic testing with in vitro fertilization has provided clinicians with more information about the genetics of embryos. Embryos, however, sometimes result with a mixed composition of both aneuploid and euploid cells, called mosaic embryos. The interpretation of these results has varied, leading some clinicians to transfer mosaic embryos and some opt not to. In addition, laboratories providing preimplantation genetic testing for aneuploidy have differing thresholds for determining an embryo aneuploid, mosaic, or euploid. Overall practice patterns for mosaic embryo transfer practices in the United States are unknown. Objective(s) The objectives of the study were to characterize national mosaic embryo transfer practices, including the use of preimplantation genetic testing for aneuploidy, prior history of transferring mosaic embryos, thresholds for determining mosaicism, and willingness to transfer mosaic embryos among assisted reproductive technology clinics in the United States. Study Design A 14 question online survey assessing current use of preimplantation genetic testing for aneuploidy, thresholds for determining mosaicism, and clinic experience and willingness to transfer mosaic embryos was e-mailed to 405 assisted reproductive technology clinics across the United States. Descriptive statistics and logistic regression were used to analyze survey responses and identify clinical factors associated with reporting having ever transferred a mosaic embryo. Results Of the 405 US assisted reproductive technology clinics contacted, 252 (62.2%) completed a survey, including 157 private (62.3%), 55 academic (21.8%), and 40 hybrid (15.9%) clinics. Most clinics (168, 66.7%) reported conducting preimplantation genetic testing for aneuploidy on less than 50% of all in vitro fertilization cycles. The most common type of preimplantation genetic testing for aneuploidy technology used was next-generation sequencing at 88.9%. Ninety-one clinics (36.1%) receive mosaicism data on their preimplantation genetic testing for aneuploidy report; the most common thresholds for determining embryo aneuploidy and euploidy by clinics’ primary genetics laboratories were 80% normal (46.2%), respectively. Thirty-nine (42.9%) of the 91 have transferred and 57 (62.6%) would transfer a mosaic embryo. Nearly 40% of clinics were unsure about their thresholds for mosaic transfer and one fourth of clinics reported they had no threshold. Private (odds ratio, 1.0, 95% confidence interval, 0.5–1.8) and hybrid (odds ratio, 0.9, 95% confidence interval, 0.4–2.1) clinics were just as likely as academic clinics to report having transferred a mosaic embryo. Clinics in the northeastern United States were more likely to have transferred a mosaic embryo than clinics in other regions (odds ratio, 1.5, 95% confidence interval, 0.9–2.7). Most clinics (72.6%) report they do not have a unique consent for transfer of mosaic embryos. Conclusion There is uncertainty and variability in the transfer practices of mosaic embryos and classification of mosaicism among US assisted reproductive technology clinics. These findings provide an opportunity to establish mosaicism thresholds and create standardized guidelines for transferring mosaic embryos.

Limited published data exist detailing outcomes of donor embryo cycles. Patients and clinicians would benefit from information specific to donor embryo cycles to inform fertility treatment options, counselling, and clinical decision-making.We sought to quantify trends in donor embryo cycles in the United States, to characterize donor embryo recipients, and to report transfer, pregnancy, and birth outcomes of donor embryo transfers.This retrospective cohort study of frozen donor embryo transfers uses data from Centers for Disease Control and Prevention National ART Surveillance System to quantify trends in the use of donor embryos and corresponding rates of pregnancy and live birth from 2000 through 2013. For 2007 through 2013, years reflective of current practice, rates of cancellation, pregnancy, miscarriage, live birth, singleton and twin live birth, and delivery of a full-term singleton infant of normal birthweight (≥37 weeks, ≥2500 g) are reported.Among all frozen transfers from 2000 through 2013 (n = 391,662), the annual number of donor embryo transfers increased significantly from 332-1374, however the proportion of donor embryo transfers among all frozen transfers did not change significantly (2.3-2.6%). Both overall pregnancy and live birth rates per frozen donor embryo transfer increased significantly (33.3-49.1% and 26.5-40.8%, respectively) (P.01). Among all initiated donor embryo cycles from 2007 through 2013 (n = 7289), the overall cancellation rate prior to transfer was 7.1%. Among all transfers from 2007 through 2013 (n = 6773), 3193 (47.2%) resulted in pregnancy and 2589 (38.2%) resulted in a live birth. Among all pregnancies, 535 (16.9%) resulted in a miscarriage. Among all live births, 1929 (74.5%) delivered a singleton of which 1482 (76.8%) were full term and normal birthweight.The increasing availability of donor embryos, low chance of cancellation, and increasing likelihood of achieving live birth can inform consumers and providers who are considering assisted reproductive technology options. Collection of data surrounding donated embryo formation would allow for additional studies that can elucidate predictors of success among donor embryo transfers.

Background Inflammatory cytokines including the IL-1 family, TNF-α and IL-6 mediate the formation of thrombosis on the luminal surface of atherosclerotic plaques. Gene polymorphisms that regulate these cytokines' expression may explain part of the variation in susceptibility to stroke in patients with carotid atherosclerosis. The aim of this study was to evaluate the role of single-nucleotide polymorphisms (SNPs) and haplotypes in inflammatory genes as they relate to symptomatic carotid atherosclerosis. Methods The study included 95 subjects with symptomatic (transient ischaemic attacks or stroke) and 113 subjects with asymptomatic carotid atherosclerotic disease. A panel of evenly spaced SNPs including previously reported functionally significant polymorphisms were genotyped for IL-1β (10 SNPs), IL-1α (nine SNPs), IL-1RN (11 SNPs), IL-6 (seven SNPs) and TNF-α and TNF-β (seven SNPs). Results Using single SNP analysis, IL-1RN rs315934 ( P = 0·025), IL-1RN rs315946 ( P = 0·042), IL-1RN rs315921 ( P = 0·035), IL-6 rs1180243 ( P = 0·018) and IL-1α rs2071373 ( P = 0·025) were associated with decreased odds of symptomatic carotid disease. Additionally, two diplotypes of the IL-1 RN gene ( P = 0·023 and 0·0064) and one diplotype in the IL-1α gene ( P = 0·02) were associated with a protective affect from cerebral ischaemic events. Logistic analysis for interaction of the protective SNPs reveals an additive effect of all SNP pair combinations. Conclusion These results suggest that genetic polymorphisms in proinflammatory genes may contribute to interindi-vidual differences in the development of symptomatic carotid atherosclerotic disease.

Information regarding the use of donor sperm in assisted reproductive technology, as well as subsequent treatment and perinatal outcomes, remains limited. Outcome data would aid patient counseling and clinical decision making.The objectives of the study were to report national trends in donor sperm utilization and live birth rates of donor sperm-assisted reproductive technology cycles in the United States and to compare assisted reproductive technology treatment and perinatal outcomes between cycles using donor and nondonor sperm. We hypothesize these outcomes to be comparable between donor and nondonor sperm cycles.This was a retrospective cohort study using data from all US fertility centers reporting to the Centers for Disease Control and Prevention's National Assisted Reproductive Technology Surveillance System, accounting for ∼98% of assisted reproductive technology cycles (definition excludes intrauterine insemination). The number and percentage of assisted reproductive technology cycles using donor sperm and rates of pregnancy, live birth, preterm birth (37 weeks), and low birthweight (2500 g) were the primary outcomes measured. Treatments assessed include use of donor vs nondonor sperm. The trends analysis included all banking and fresh assisted reproductive technology cycles using donor and autologous oocytes performed between 1996 and 2014 (n = 1,710,034). The outcomes analysis was restricted to include only fresh autologous cycles performed between 2010 and 2014 (n = 437,569) to focus on cycles with a potential outcome and cycles reflective of current practice, thereby improving the clinical relevance. Cycles canceled prior to retrieval were excluded. Statistical analysis included linear regression to explore polynomial trends and log-binomial regression to estimate relative risk for outcomes among cycles using donor and nondonor sperm.Of all banking and fresh donor and autologous oocyte assisted reproductive technology cycles performed between 1996 and 2014, 74,892 (4.4%) used donor sperm. In 2014, 7351 assisted reproductive technology cycles using donor sperm were performed, as compared with 1763 in 1996 (6.2% vs 3.8% of all cycles). Among all autologous oocyte cycles performed between 2010 and 2014, the live birth rate was lower for donor sperm (27.9%) than nondonor sperm cycles (32.5%); however, after adjustment for maternal age, donor sperm use was associated with an increased likelihood of live birth (adjusted relative risk, 1.06, 95% confidence interval, 1.01-1.10). Per transfer, there was no significant difference in live birth rates for donor vs nondonor sperm (31.9% vs 36.8%; adjusted relative risk, 1.04, 95% confidence interval, 0.998-1.09). Per singleton live birth, there was no significant difference in preterm birth (11.5% vs 11.8%; adjusted relative risk, 0.98, 95% confidence interval, 0.90-1.06); however, low birthweight delivery was slightly lower in donor sperm cycles (8.8% vs 9.4%; adjusted relative risk, 0.91, 95% confidence interval, 0.83-0.99).Donor sperm use in assisted reproductive technology has increased in the United States, accounting for approximately 6% of all assisted reproductive technology cycles in 2014. Assisted reproductive technology treatment and perinatal outcomes were clinically similar in donor and nondonor sperm cycles.

To characterize risks for early pregnancy loss after fresh and frozen IVF cycles and to investigate whether risk is modified by infertility diagnoses or transfer of embryos in fresh versus frozen cycles.Retrospective cohort study using data from the National Assisted Reproductive Technology (ART) Surveillance System.Fertility centers.Clinical pregnancies achieved with fresh and frozen IVF cycles between 2007 and 2012 (N = 249,630).None.First trimester pregnancy loss.A diagnosis of uterine factor was associated with an increased risk of loss in women aged 40 years and younger (30 years: adjusted risk ratio (aRR) = 1.24, 95% confidence interval (CI) 1.04-1.48; 30-34 years: aRR = 1.27, 95% CI 1.17-1.38; 35-37 years: aRR = 1.12, 95% CI 1.03-1.21; 38-40 years: aRR = 1.08, 95% CI 1.01-1.17). There was an increased risk of loss in women with diminished ovarian reserve aged 30-34 years (aRR = 1.08, 95% CI 1.01-1.15) and in women with ovulatory dysfunction younger than 35 years (30 years: aRR = 1.12, 95% CI 1.05-1.19; 30-34 years: aRR = 1.07, 95% CI 1.02-1.13). There was an increased risk of loss after frozen ETs versus fresh among women younger than 38 years, but this remained significant in the subanalysis of similar quality embryos only in women younger than 30 years (aRR = 1.16, 95% CI 1.04-1.32).Uterine factor had the largest increased risk of loss among infertility diagnoses, although the magnitudes of all risks were small. When transferring embryos of similar quality, the risks of loss were similar between fresh and frozen cycles.

Aim: The chapter reviews the incidence, diagnosis, and surgical management of patients with cervical agenesis and dysgenesis, with or without vaginal aplasia. The various treatment options are reviewed, taking into account the specific anatomical characteristics of the defect. Brief description of the reviewed data: The different surgical techniques for cervical agenesis and dysgenesis, including hysterectomy, coring of the cervix, utero- vaginal anastomosis, along with the use of grafts, are evaluated, along with their risks and benefits. Clinical implications: New surgical techniques are being improved upon to optimize the outcome of patients with this rare congenital anomaly and preserve uterine integrity. Open Issues for further research: Despite case series of patients and their surgical outcomes, this remains a rare disorder with no randomized trials to support best case management. There is also limited research regarding pregnancy outcomes in patients with good surgical outcomes.