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Objective: The objective of this study was to use high-throughput sequencing to describe the vaginal eukaryotic DNA virome in patients undergoing in vitro fertilisation (IVF) to examine associations between the vaginal virome, antibiotic exposure and IVF outcomes.Design: Prospective exploratory study.Setting: Single academic fertility centre.Population: Subfertile women age 18-43 years undergoing their first IVF cycle with a fresh embryo transfer.Methods: The primary exposure was prophylactic azithromycin or no azithromycin before IVF. A mid-vaginal swab was obtained at the time of embryo transfer for virome analysis.Main Outcome Measures: The primary outcomes compared between exposure groups were characteristics of vaginal virome and clinical pregnancy rates. Secondary outcomes were virome associations with number of oocytes retrieved, number of blastocysts and implantation rate.Results: Twenty-six women contributed a vaginal swab before embryo transfer. There were no significant differences in IVF outcomes between azithromycin groups. There was no association between viral diversity and clinical pregnancy overall. A higher diversity of herpesviruses and α-papillomaviruses was observed in samples from the azithromycin-treated group compared with the no azithromycin group (P = 0.04). In women that received azithromycin, viral diversity was higher in the group that did not achieve clinical pregnancy compared with those who did (P = 0.06).Conclusions: We demonstrate that the vaginal eukaryotic virome in women undergoing IVF is associated with antibiotic exposure. Additionally, we demonstrate an inverse trend between viral diversity and pregnancy, with a higher number of viruses detected associated with failure to achieve clinical pregnancy in the azithromycin group.Tweetable Abstract: Higher viral diversity is associated with prophylactic antibiotic exposure in subfertile women undergoing IVF. [ABSTRACT FROM AUTHOR]

Purpose: Fertility preservation is an increasingly important topic in adolescent and young adult cancer survivorship, yet treatments remain under-utilized, possibly due to lack of awareness and understanding. The internet is widely used by adolescents and young adults and has been proposed to fill knowledge gaps and advance high-quality, more equitable care. As a first step, this study analyzed the quality of current fertility preservation resources online and identified opportunities for improvement., Methods: We conducted a systematic analysis of 500 websites to assess the quality, readability, and desirability of website features, and the inclusion of clinically relevant topics., Results: The majority of the 68 eligible websites were low quality, written at college reading levels, and included few features that younger patients find desirable. Websites mentioned more common fertility preservation treatments than promising experimental treatments, and could be improved with cost information, socioemotional impacts, and other equity-related fertility topics., Conclusions: Currently, the majority of fertility preservation websites are about, but not for, adolescent and young adult patients. High-quality educational websites are needed that address outcomes that matter to teens and young adults, with a priority on solutions that prioritize equity., Implications for Cancer Survivors: Adolescent and young adult survivors have limited access to high-quality fertility preservation websites that are designed for their needs. There is a need for the development of fertility preservation websites that are clinically comprehensive, written at appropriate reading levels, inclusive, and desirable. We include specific recommendations that future researchers can use to develop websites that could better address AYA populations and improve the fertility preservation decision making process., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In medical school and residency, clinical experiences influence trainee's decisions on what medical specialty they choose. Most trainees have limited access to opportunities to engage in the field of reproductive endocrinology and infertility (REI). Due to the COVID-19 pandemic and the shutdown of away electives, exposure to REI was especially limited. This study aims to evaluate the effectiveness of a live Q and A webinar on improving trainees' access to mentorship and knowledge of the path to becoming a reproductive endocrinology and infertility (REI) physician., Materials and Methods: This study is a prospective paired cohort study. Medical students and OBGYN residents participated in a global Q and A webinar featuring REI physicians and fellows. 70 pre- and post-webinar surveys were included in the analysis. Paired nonparametric tests (Wilcoxon signed-rank test) were performed to assess whether post-webinar knowledge was significantly different from pre-webinar knowledge., Results: Of the 268 registrants, 162 (60%) attended the live webinar. A majority of the respondents who completed both surveys were female (90%) and allopathic medical students (80%). Seventy-seven percent reported receiving only minimal advice about an REI career from their medical school or residency program, while 22% reported receiving some advice, and 1% extensive advice. Thirty-four percent had previously shadowed an REI physician and 23% had rotated in an REI office. Post-webinar significantly more trainees had a better understanding of the REI field, the path required to become an REI physician, opportunities to find mentors in the field, opportunities that are conducive to learning more about REI, and applying for rotations in the REI field (p = <.00001). Eighty-two percent agreed that their interest in REI increased due to this webinar., Conclusions: A webinar featuring REI physicians and fellows was effective in providing mentorship and career advisement for prospective REI trainees who otherwise expressed having limited access to the field., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Education and Health Promotion.)

There is a recent decrease in fertility rates among the general population in the United States. Female physicians, who are seeking assisted reproductive technology at growing rates often because of delayed childbearing while completing medical training, are included in this statistic. With more than 340,000 practicing female physicians within the United States, female physician infertility is especially relevant. However, despite the increasing number of female physicians seeking assisted reproductive technology, there is a lack of access to adequate insurance coverage for this higher-risk patient subset. This commentary reviewed the importance of increasing infertility rates among female physicians, the associated economic burden, limited insurance coverage, and disparities in access to infertility insurance coverage. Recent studies suggest that up to 25% of female physicians are seeking assisted reproductive technology. Currently, 1 cycle of assisted reproductive technology, or egg retrieval, is estimated at approximately $19,000, with many people needing multiple cycles. Many top academic institutions do not offer enough infertility benefits to cover 1 egg retrieval cycle and the often prerequisite, less invasive procedures. Among those seeking oocyte or embryo cryopreservation for elective fertility preservation, few institutions offer coverage. Addressing and highlighting limited and variable institutional infertility coverage are crucial to gaining equal and accessible reproductive care for female physicians., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To study patient satisfaction with new patient telehealth visits in a reproductive endocrinology and infertility (REI) office., Methods: A cross-sectional study in a university-based fertility clinic was completed including all new patients seen via telehealth between March 1, 2021, and August 19, 2021. Primary outcomes were perceived patient satisfaction, access, and preferences to telehealth visits., Results: A total of 351 participants were contacted, 61.8% (n = 217) agreed to participate in the study, and 28.8% (n = 101) completed the survey. There were no significant differences in age, BMI, distance from clinic, or length of infertility with response to survey. Ninety-three percent of responders would use telehealth services again and were satisfied with the telehealth system. Telehealth improved access to healthcare for 88% and travel time for 96%. The median distance from clinic was 24 miles, and there was no significance difference in preference for telehealth visits over in person visits (p = 0.696)., Conclusions: In the era of COVID-19, healthcare implementation has dramatically changed with a drastic increase in telehealth services. Based on our survey, majority of patients were satisfied with telehealth visits and believed it saved travel time while improving access to REI care. Despite no differences in patient preference for in person versus telehealth depending on their distance from clinic, this is reassuring because patients are satisfied with telehealth for reasons other than distance from clinic., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Problem: Physicians' voices are valued in society and should be present in mainstream social media where they can provide valuable public health messaging and patient education as well as increase opportunities for medical education, mentoring, and collaboration. However, lack of formal education on effective use of social media prevents many physicians from using it., Approach: The authors developed a physician-led social media training program to address the need for formal instruction on social media use. The program was presented to medical students, trainees, and faculty at an academic medical institution in August and September 2020. The virtual format included 5 hour-long sessions with presentations by peer experts in social media. Peer physicians with experience using social media presented on a range of topics, including introductions to platforms, how to reach and grow audiences, and use of social media to advance patient education, medical education, and advocacy., Outcomes: There were 425 cumulative registrations for the 5 sessions of the Social Media Summit. The number of registrants increased for each session, suggesting that interest increased over time. Qualitative and quantitative participant feedback was collected via a brief, voluntary survey. All of the participants who completed the survey (n = 24) reported they were "very satisfied" (58.3%) or "somewhat satisfied" (41.7%) with the Summit., Next Steps: Physician involvement in social media presents opportunities for public health knowledge, medical education, scientific collaboration, and career advancement. Physicians who have been successful in using social media for these purposes are excellent peer educators and can fill the medical education void in social media training. Future plans include building sustainability of the program, collecting additional quantitative and qualitative feedback to guide improvement, and encouraging reproducibility., (Copyright © 2022 by the Association of American Medical Colleges.)

Objective: To evaluate the use of a web-based application that assists in medication management during in vitro fertilization (IVF) treatment., Design: Multicenter randomized controlled trial., Setting: University hospitals., Patient(s): Women undergoing IVF., Intervention(s): Subjects were recruited to assess quality of life during IVF and were randomly assigned to use either the OnTrack application to assist with medication management or conventional medication management. Surveys were administered at four time points., Main Outcome Measure(s): Medication surplus, incidence of medication errors, amount of patient-initiated communication, and patient satisfaction., Result(s): A total of 153 women participated. The average number of portal messages and telephone calls was similar between groups. Twelve patients in the control group (12/69, 17.4%) and 8 patients in the case group (8/72, 11.1%) made medication errors. There were similar amounts of medication surplus in the two groups. The estimated cost of medication waste was $2,578 ± $2,056 in the control group and $2,554 ± $1,855 in the case group. Patient satisfaction was similar between the two groups., Conclusion(s): Use of a web-based application did not decrease medication errors, medication surplus, or patient-initiated messages. Many patients had a medication surplus, which can be an area of cost reduction during IVF., Clinical Trial Registration Number: Clinicaltrials.gov NCT03383848., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To report a successful case of ovarian hyperstimulation and oocyte cryopreservation in a transgender male adolescent after suppression with a gonadotropin-releasing hormone (GnRH) agonist while using the aromatase inhibitor letrozole to maintain low serum estradiol., Design: Case report., Setting: Division of Reproductive Endocrinology and Infertility, Washington University in St. Louis School of Medicine, St Louis, Missouri., Patient(s): A 15-year-old Tanner II transgender male adolescent with a GnRH agonist implant., Intervention(s): The GnRH agonist implant was removed. The patient was given letrozole (5 mg daily) while undergoing ovarian stimulation with an antagonist protocol. After oocyte retrieval, the patient began taking testosterone., Main Outcome Measure(s): Successful oocyte cryopreservation with minimal changes in breast budding., Result(s): The patient's peak serum estradiol concentration was 510 pg/mL. Twenty-two mature oocytes were cryopreserved. Small increases in breast budding occurred between baseline and the time of oocyte retrieval., Conclusion(s): We successfully used letrozole to maintain low serum estradiol in a transgender male adolescent during ovarian stimulation. Maintaining low estradiol to minimize pubertal development and possibly prevent gender dysphoria symptoms may make oocyte cryopreservation more desirable for transgender male adolescents., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Male infertility is a prevalent clinical presentation for which there is likely a strong genetic component due to the thousands of genes required for spermatogenesis. Within this study we investigated the role of the gene Scrn1 in male fertility. Scrn1 is preferentially expressed in XY gonads during the period of sex determination and in adult Sertoli cells based on single cell RNA sequencing. We investigated the expression of Scrn1 in juvenile and adult tissues and generated a knockout mouse model to test its role in male fertility., Results: Scrn1 was expressed at all ages examined in the post-natal testis; however, its expression peaked at postnatal days 7-14 and SCRN1 protein was clearly localized to Sertoli cells. Scrn1 deletion was achieved via removal of exon 3, and its loss had no effect on male fertility or sex determination. Knockout mice were capable of siring litters of equal size to wild type counterparts and generated equal numbers of sperm with comparable motility and morphology characteristics., Conclusions: Scrn1 was found to be dispensable for male fertility, but this study identifies SCRN1 as a novel marker of the Sertoli cell cytoplasm., (© 2021 American Association of Anatomists.)

Background: Since 1992 ART clinics have been required to report outcome data. Our objective was to assess practitioners' opinions of the impact of public reporting of assisted reproductive technology (ART) outcomes on treatment strategies, medical decision-making, and fellow training., Methods: Survey study performed in an academic medical center. Members of the Society of Reproductive Endocrinology and Infertility and the Society of Reproductive Surgery were recruited to participate in an online survey in April 2012. : Categorical survey responses were expressed as percentages. Written responses were categorized according to common themes regarding effects of reporting on participants' medical management of patients. The study was primarily qualitative and was not powered to make statistical conclusions., Results: Of 1019 surveys sent, 323 participants (31.7%) responded from around the United States, and 275 provided complete data. Nearly all (273 of 282; 96.8%) participants responded that public reporting sometimes or always affected other providers' practices, and 264 of 281 (93.9%) responded that other practitioners were motivated to deny care to poor-prognosis patients to improve reported success rates. However, only 121 of 282 (42.9%) indicated that public reporting influenced their own medical management. The majority of respondents agreed that public reporting may hinder adoption of single embryo transfer practices (194 of 299; 64.9%) and contribute to the persistent rate of twinning in in vitro fertilization (187 of 279; 67%). A small majority (153 of 279; 54.8%) felt that public reporting did not benefit fellow training, and 58 (61.7%) of the 94 participants who trained fellows believed that having fellows perform embryo transfers reduced pregnancy rates. A small majority (163 of 277; 58.8%) of respondents reported their ART success rates on clinical websites. However, the majority (200 of 275; 72.7%) of respondents compared their success rates with those of other clinics. Finally, most respondents (211 of 277; 76%) believed that most centers that advertised their success rates did so in ways that were misleading to patients., Conclusions: Public reporting of ART clinical outcomes is intended to drive improvement, promote trust between patients and providers, and inform consumers and payers. However, providers reported that they modified their practices, felt others denied care to poor-prognosis patients, and limited participation of trainees in procedures in response to public reporting of ART outcomes., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Objective: The objective of this study was to use high-throughput sequencing to describe the vaginal eukaryotic DNA virome in patients undergoing in vitro fertilisation (IVF) to examine associations between the vaginal virome, antibiotic exposure and IVF outcomes., Design: Prospective exploratory study., Setting: Single academic fertility centre., Population: Subfertile women age 18-43 years undergoing their first IVF cycle with a fresh embryo transfer., Methods: The primary exposure was prophylactic azithromycin or no azithromycin before IVF. A mid-vaginal swab was obtained at the time of embryo transfer for virome analysis., Main Outcome Measures: The primary outcomes compared between exposure groups were characteristics of vaginal virome and clinical pregnancy rates. Secondary outcomes were virome associations with number of oocytes retrieved, number of blastocysts and implantation rate., Results: Twenty-six women contributed a vaginal swab before embryo transfer. There were no significant differences in IVF outcomes between azithromycin groups. There was no association between viral diversity and clinical pregnancy overall. A higher diversity of herpesviruses and α-papillomaviruses was observed in samples from the azithromycin-treated group compared with the no azithromycin group (P = 0.04). In women that received azithromycin, viral diversity was higher in the group that did not achieve clinical pregnancy compared with those who did (P = 0.06)., Conclusions: We demonstrate that the vaginal eukaryotic virome in women undergoing IVF is associated with antibiotic exposure. Additionally, we demonstrate an inverse trend between viral diversity and pregnancy, with a higher number of viruses detected associated with failure to achieve clinical pregnancy in the azithromycin group., Tweetable Abstract: Higher viral diversity is associated with prophylactic antibiotic exposure in subfertile women undergoing IVF., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Objective: To evaluate the perceptions of current and former fellows in obstetrics and gynecology (OBG) subspecialties of their readiness for fellowship training., Methods: A previously used survey was modified and distributed in 2016 to current and former fellows in gynecologic oncology, maternal-fetal medicine, reproductive endocrinology-infertility, and female pelvic medicine and reconstructive surgery. The survey explored domains of professionalism, independent practice, psychomotor ability, clinical evaluation, and scholarship. A standard Likert scale was employed and domains/responses were tailored to each subspecialty. Standard statistical models were utilized., Results: A total of 478 fellows responded to the survey. Nearly 75% of fellows from each specialty reported feeling prepared or very prepared for fellowship. More than 65% of fellows from each specialty reported feeling very prepared to perform core surgical procedures. More than 90% of respondents reported having opportunities during residency to independently develop a plan of action for patients on labor and delivery. Fewer respondents reported opportunities to independently manage postoperative complications-40.7% of gynecologic oncology and 44.7% of female pelvic medicine and reconstructive surgery reported having such opportunities, whereas 91.9% of maternal-fetal medicine respondents reported having had such opportunities. While 46.4% of respondents received education on scientific writing during residency, 80% reported writing a manuscript as a resident., Conclusions: The majority of current and former fellows in OBG subspecialties report feeling prepared for fellowship in terms of clinical and surgical skills. Their feedback reveals opportunities for improvement of independent practice in gynecologic scenarios, as well as formal education on scientific research, for OBG residencies., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The growing use of preimplantation genetic testing with in vitro fertilization has provided clinicians with more information about the genetics of embryos. Embryos, however, sometimes result with a mixed composition of both aneuploid and euploid cells, called mosaic embryos. The interpretation of these results has varied, leading some clinicians to transfer mosaic embryos and some opt not to. In addition, laboratories providing preimplantation genetic testing for aneuploidy have differing thresholds for determining an embryo aneuploid, mosaic, or euploid. Overall practice patterns for mosaic embryo transfer practices in the United States are unknown., Objective(s): The objectives of the study were to characterize national mosaic embryo transfer practices, including the use of preimplantation genetic testing for aneuploidy, prior history of transferring mosaic embryos, thresholds for determining mosaicism, and willingness to transfer mosaic embryos among assisted reproductive technology clinics in the United States., Study Design: A 14 question online survey assessing current use of preimplantation genetic testing for aneuploidy, thresholds for determining mosaicism, and clinic experience and willingness to transfer mosaic embryos was e-mailed to 405 assisted reproductive technology clinics across the United States. Descriptive statistics and logistic regression were used to analyze survey responses and identify clinical factors associated with reporting having ever transferred a mosaic embryo., Results: Of the 405 US assisted reproductive technology clinics contacted, 252 (62.2%) completed a survey, including 157 private (62.3%), 55 academic (21.8%), and 40 hybrid (15.9%) clinics. Most clinics (168, 66.7%) reported conducting preimplantation genetic testing for aneuploidy on less than 50% of all in vitro fertilization cycles. The most common type of preimplantation genetic testing for aneuploidy technology used was next-generation sequencing at 88.9%. Ninety-one clinics (36.1%) receive mosaicism data on their preimplantation genetic testing for aneuploidy report; the most common thresholds for determining embryo aneuploidy and euploidy by clinics' primary genetics laboratories were <20% normal (36.3%) and >80% normal (46.2%), respectively. Thirty-nine (42.9%) of the 91 have transferred and 57 (62.6%) would transfer a mosaic embryo. Nearly 40% of clinics were unsure about their thresholds for mosaic transfer and one fourth of clinics reported they had no threshold. Private (odds ratio, 1.0, 95% confidence interval, 0.5-1.8) and hybrid (odds ratio, 0.9, 95% confidence interval, 0.4-2.1) clinics were just as likely as academic clinics to report having transferred a mosaic embryo. Clinics in the northeastern United States were more likely to have transferred a mosaic embryo than clinics in other regions (odds ratio, 1.5, 95% confidence interval, 0.9-2.7). Most clinics (72.6%) report they do not have a unique consent for transfer of mosaic embryos., Conclusion: There is uncertainty and variability in the transfer practices of mosaic embryos and classification of mosaicism among US assisted reproductive technology clinics. These findings provide an opportunity to establish mosaicism thresholds and create standardized guidelines for transferring mosaic embryos., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To evaluate the perceptions of fellowship program directors of incoming clinical fellows for subspecialty training., Methods: A validated survey by the American College of Surgeons was modified and distributed to all fellowship program directors in four subspecialties within obstetrics and gynecology: female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology-infertility. The 59-item survey explored five domains concerning preparedness for fellowship: professionalism, independent practice, psychomotor ability, clinical evaluation, and academic scholarship. A Likert scale with five responses was used and tailored to each subspecialty. Standard statistical methods were used to compare responses between subspecialties and to analyze data within each subspecialty individually., Results: One hundred thirty directors completed the survey, for a response rate of 60%. In the domain of professionalism, more than 88% of participants stated that incoming fellows had appropriate interactions with faculty and staff. Scores in this domain were lower for gynecologic oncology respondents (P=.046). Responses concerning independent practice of surgical procedures (hysterectomy, pelvic reconstruction, and minimally invasive) were overwhelmingly negative. Only 20% of first-year fellows were able to independently perform a vaginal hysterectomy, 46% an abdominal hysterectomy, and 34% basic hysteroscopic procedures. Appropriate postoperative care (63%) and management of the critically ill patient (71%) were rated adequate for all subspecialties., Conclusion: Graduating residents may be underprepared for advanced subspecialty training, necessitating an evaluation of the current structure of resident and fellow curriculum., Level of Evidence: III.

Objective: To determine practice patterns for insulin resistance (IR) evaluation and management in women with polycystic: ovary syndrome (PCOS) among physician members of the American Society for Reproductive Medicine (ASRM)., Study Design: Cross-sectional survey using a web-based questionnaire., Results: A total of 205 members responded. Respondents were board-certified (94%), or board-eligible (6%), in obstetrics and gynecology. Sixty-four percent of the respondents use the Rotterdam 2003 Criteria for a diagnosis of PCOS. Two-thirds (68%) screenfor IR in women with PCOS. Respondents who screen for IR were more likely to also screen for diabetes and impaired glucose tolerance (OR 3.37, 95% CI 1.48-7.21). The 2-hour oral glucose tolerance test with glucose and insulin concentrations was the most common IR screening test used (45%). Metformin therapy was used by 33% of respondents for, "all women with PCOS who have IR." The majority (68%) responded that there is a need for a committee opinion from ASRM on IR testing in PCOS., Conclusion: Two-thirds of ASRM physician members surveyed screen women with PCOS for IR in spite of the lack of general consensus on the need for such screening from endocrine societies.

Purpose of Review: To take inventory of the past and present and project the future direction of our field to help train the next generation of providers., Recent Findings: Review the history of the subspecialty and factors contributing to its evolution., Summary: Reproductive endocrinology and infertility's in-vitro fertilization future is shaping the intellectual priorities and surgical skill requirements of the next generation.

We set out to determine whether the addition of an aryl hydrocarbon receptor (AHR) antagonist has an effect on glucose/fructose utilization in the spermatocyte when exposed to cigarette smoke condensate (CSC). We exposed male germ cells to 5 and 40 μg/mL of CSC ± 10 μmol/L of AHR antagonist at various time points. Immunoblot expression of specific glucose/fructose transporters was compared to control. Radiolabeled uptake of 2-deoxyglucose (2-DG) and fructose was also performed. Spermatocytes utilized fructose nearly 50-fold more than 2-DG. Uptake of 2-DG decreased after CSC + AHR antagonist exposure. Glucose transporters (GLUTs) 9a and 12 declined after CSC + AHR antagonist exposure. Synergy between CSC and the AHR antagonist in spermatocytes may disrupt the metabolic profile in vitro. Toxic exposures alter energy homeostasis in early stages of male germ cell development, which could contribute to later effects explaining decreases in sperm motility in smokers., (© The Author(s) 2014.)

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1-1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1-1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5-1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance. Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend "neutralizing" the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non -mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not., (Copyright © 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Melittin is a cytolytic peptide component of bee venom which rapidly integrates into lipid bilayers and forms pores resulting in osmotic lysis. While the therapeutic utility of free melittin is limited by its cytotoxicity, incorporation of melittin into the lipid shell of a perfluorocarbon nanoparticle has been shown to reduce its toxicity in vivo. Our group has previously demonstrated that perfluorocarbon nanoparticles containing melittin at concentrations <10 µM inhibit HIV infectivity in vitro. In the current study, we assessed the impact of blank and melittin-containing perfluorocarbon nanoparticles on sperm motility and the viability of both sperm and vaginal epithelial cells. We found that free melittin was toxic to sperm and vaginal epithelium at concentrations greater than 2 µM (p<0.001). However, melittin nanoparticles were not cytotoxic to sperm (p = 0.42) or vaginal epithelium (p = 0.48) at an equivalent melittin concentration of 10 µM. Thus, nanoparticle formulation of melittin reduced melittin cytotoxicity fivefold and prevented melittin toxicity at concentrations previously shown to inhibit HIV infectivity. Melittin nanoparticles were toxic to vaginal epithelium at equivalent melittin concentrations ≥20 µM (p<0.001) and were toxic to sperm at equivalent melittin concentrations ≥40 µM (p<0.001). Sperm cytotoxicity was enhanced by targeting of the nanoparticles to the sperm surface antigen sperm adhesion molecule 1. While further testing is needed to determine the extent of cytotoxicity in a more physiologically relevant model system, these results suggest that melittin-containing nanoparticles could form the basis of a virucide that is not toxic to sperm and vaginal epithelium. This virucide would be beneficial for HIV serodiscordant couples seeking to achieve natural pregnancy.

Study Objective: To quantify our experience and that of the literature with diagnosis and management of the auto-amputated adnexa in a pediatric population., Design: Case series and literature review., Setting: Tertiary care medical center., Participants: Case series of pediatric patients (<18 years of age) with surgically documented adnexal auto-amputation collected from our medical center and the literature., Interventions: None., Main Outcome Measure: Auto-amputated adnexa., Results: In addition to the 3 cases discussed from our institution, 91 cases of auto-amputated adnexa were identified in the literature dating back to 1943, for a total of 94 cases. Forty-nine percent (46/94) of the cases involved girls in a pediatric population (<18 years of age). Of these, the majority (n = 26) were identified in a subgroup of girls who were diagnosed with an adnexal cyst by antenatal ultrasound. Most of these neonates were asymptomatic at birth or had a palpable abdominal mass (n = 6) and at the time of surgical exploration were found to have an auto-amputated adnexa. 34 out of 46 cases were analyzed in detail. The right adnexa were involved in 56% of the cases. The most common presenting complaint verbalized by the older girls was pain; however, 8 cases were identified in asymptomatic girls undergoing unrelated diagnostic testing., Conclusion: The auto-amputated adnexa is a rare finding in the pediatric population, but it must be considered as a possible explanation for the incidental finding of absence of the fallopian tube or ovary in the subgroup of patients who undergo surgery for any reason. Patients with an antecedent history of pelvic pain either chronic or intermittent in nature may be diagnosed with torsion or less frequently auto-amputation of the adnexa. A fetal "pelvic mass" or "ovarian cyst" may predispose the adnexa to torsion and subsequent auto-amputation either in-utero or post-delivery. Many of these antenatally diagnosed cysts and even subsequent auto-amputations are completely asymptomatic, however, and do not compromise fertility assuming the contralateral adnexa are normal. Thus expectant management is appropriate for small (less than 4 cm), asymptomatic simple cysts and even suspected auto-amputated adnexa in an asymptomatic patient., (Copyright © 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Industries are quick to adopt online applications that consumers are using to attract attention to products or services. The adoption of social media among medical professionals, although slow, is an inexorable reality particularly in reproductive health, where patients typically use online resources to pursue their health concerns. On the basis of the literature and personal experience with social media in infertility care, we provide guidance for reproductive health practitioners on how to use social media effectively.

Objective: Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation., Patients: One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm., Outcome Measures: Successful sperm recovery defined as 1-2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and "other"(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician's office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm., Results: Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%)., Conclusion: Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.

The Supreme Court's decision upholding the constitutionality of the Affordable Care Act (ACA) provides an opportunity to review its impact on fertility care in the United States. After examining the legislation, we identified several core areas that might affect patients struggling with infertility. Although changes to the tax code, elimination of denying insurance to those with pre-existing conditions, and an overriding theme of maternity care within the ACA are easy to qualify and quantify, due to the incremental nature of the ACA, it remains to be seen whether the ACA will alter the current status quo of access to fertility care., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the management of hydrosalpinges among Society for Reproduction Endocrinology and Infertility (SREI)/Society of Reproductive Surgeons (SRS) members., Design: Cross-sectional survey of SREI/SRS members., Setting: Academic and private practice-based reproductive medicine physicians., Participant(s): A total of 442 SREI and/or SRS members., Intervention(s): Internet-based survey., Main Outcome Measure(s): To understand how respondents evaluate, define, and manage hydrosalpinges., Result(s): Of 1,070 SREI and SRS members surveyed, 442 responded to all items, for a 41% response rate. Respondents represented both academic and private practice settings, and differences existed in the evaluation and management of hydrosalpinges. More than one-half (57%) perform their own hysterosalpingograms (HSGs), and 54.5% involve radiologists in their interpretation of tubal disease. Most respondents thought that a clinically significant hydrosalpinx on HSG is one that is distally occluded (80.4%) or visible on ultrasound (60%). Approximately one in four respondents remove a unilateral hydrosalpinx before controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI) and clomiphene citrate (CC)/IUI (29.3% and 22.8%, respectively), and physicians in private practice were more likely to intervene (COH: risk ratio [RR] 1.81, 95% confidence interval [CI] 1.31-2.51; CC: RR 1.98, 95% CI 1.33-2.95). Although laparoscopic salpingectomy was the preferred method of surgical management, nearly one-half responded that hysteroscopic tubal occlusion should have a role as a primary method of intervention., Conclusion(s): SREI/SRS members define a "clinically significant hydrosalpinx" consistently, and actual practice among members reflects American Society for Reproductive Medicine/SRS recommendations, with variation attributed to individual patient needs. Additionally, one in four members intervene before other infertility treatments when there is a unilateral hydrosalpinx present., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Akt is serine/threonine protein kinase associated with various cellular processes and 3 different isoforms exist. This work describes the reproductive phenotype of Akt1-/- and Akt2-/- in male mice. The seminiferous tubule diameter in Akt1-/- testes was less than wild-type or Akt2-/- testes. The expression of phospho-phosphatase and tensin homologue deleted on chromosome 10 (p-PTEN) and phospho-glycogen synthase kinase 3β (GSK-3β) was elevated in Akt1-/- testes. Alterations in expression and localization to the plasma membrane of several facilitative glucose transporters (Slc2a8, 9a and 9b) were detected in these knockout compared to wild-type mice. Apoptotic sperm were more prevalent in both null mice compared to wild-type mice, whereas sperm concentration and motility were significantly lower in the null sperm. Finally, Akt2-/- sperm had a markedly decreased fertilization rate by in vitro fertilization (IVF) and resulting embryos displayed increased fragmentation and poor growth. These results suggest that altered SLC2A expression and increased PTEN and GSK3β activity may be responsible for the decreased spermatogenesis, sperm maturation, and fertilization in the Akt1-/- and Akt2-/- male mice.

Objective: To study and describe the use of social networking websites among Society for Assisted Reproductive Technology (SART) member clinics., Design: Cross-sectional study., Setting: University-based practice., Patient(s): Not applicable., Intervention(s): Not applicable., Main Outcome Measure(s): Prevalence of social networking websites among SART member clinics and evaluation of content, volume, and location (i.e., mandated state, region) using multivariate regression analysis., Result(s): A total of 384 SART-registered clinics and 1,382 social networking posts were evaluated. Of the clinics, 96% had a website and 30% linked to a social networking website. The majority of clinics (89%) with social networking websites were affiliated with nonacademic centers. Social networking posts mostly provided information (31%) and/or advertising (28%), and the remaining offered support (19%) or were irrelevant (17%) to the target audience. Only 5% of posts involved patients requesting information. Clinic volume correlated with the presence of a clinic website and a social networking website., Conclusion(s): Almost all SART member clinics have a website. Nearly one-third of these clinics host a social networking website such as Facebook, Twitter, and/or a blog. Large-volume clinics commonly host social networking websites. These sites provide new ways to communicate with patients, but clinics should maintain policies on the incorporation of social networks into practice., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To present a case report of a patient with epidermal inclusion cyst as a late complication of female circumcision, the management of the patient, and a review of the literature., Design: Case report and literature review., Setting: University hospital., Patient(s): A 37-year-old female from Guinea with a large clitoral mass of 6 months' duration., Intervention(s): Complete history and physical exam of the patient and subsequent surgical resection of the cyst., Main Outcome Measure(s): Diagnosis, surgical management, and postoperative sexual function and emotional well-being., Result(s): Resolution of swelling and discomfort, satisfactory postoperative sexual function and emotional well-being., Conclusion(s): There should be awareness of one of the relatively common delayed complications of female genital circumcision and familiarity with its surgical management. Overall, surgical management appears to be effective, and there is no documented risk of recurrence.

Objective: To present a case in which the use of a titanium/nickel microinsert in the management of unilateral hydrosalpinx contributed to a spontaneous intrauterine pregnancy., Design: Case report., Setting: University hospital., Patient(s): A 37-year-old nulligravid female with dense pelvic adhesive disease and unilateral hydrosalpinx., Intervention(s): Unilateral proximal occlusion of left fallopian tube with titanium/nickel microinsert., Main Outcome Measure(s): Pregnancy., Result(s): Spontaneous intrauterine pregnancy after confirmation via hysterosalpingogram of left tubal occlusion and right tubal patency., Conclusion(s): Transcervical proximal tubal occlusion using titanium/nickel microinserts provides an alternative in the management of hydrosalpinx in the setting of tubal factor infertility. Additionally, in the setting of a unilateral hydrosalpinx, unilateral occlusion can contribute to spontaneous intrauterine pregnancy.