Association of assisted reproductive technology with autism spectrum disorder in the offspring: an updated systematic review and meta-analysis

This study aims to provide an up-to-date meta-analysis of data from studies investigating the risk of bearing a child with autism spectrum disorder (ASD) after being conceived by assisted reproductive technology (ART). The study was conducted according to the PRISMA Statement. PubMed and Scopus databases were searched up to August 2, 2020. Observational studies using a type of conception of assisted reproductive technology and examined as outcome offspring with ASD were included. A random effect model was applied due to the heterogeneity of the studies. Statistical analysis was performed with Stata 13 software. The Newcastle-Ottawa scale was used to assess the methodological quality of the included studies. The search strategy identified 587 potentially relevant studies. A total of 15 studies provided adequate data for statistical comparisons and, therefore, were included in the meta-analysis. Analysis of the subset of studies that examined all offspring and controlled for confounder factors revealed that the use of ART is associated with a higher risk of ASD (RR = 1.11, 95% CI = 1.03-1.19, p < 0.009), while in the case of studies that focused on singletons, a statistically significant association between ART and ASD was not observed (RR = 0.96, 95% CI = 0.82-1.13, p = 0.654).Conclusion: The present meta-analysis confirmed the existing positive correlation between ART and ASD in offspring, suggesting that ART is correlated with a higher risk for bearing a child with ASD. In contrast, this relationship is not confirmed in singletons. High quality prospective studies with a larger number of participants are still required. What is Known: • Studies that investigated the association between ART and ASD in offspring have shown conflicting results. • A previous meta-analysis showed that offspring conceived by ART are 1.35 times more likely to develop ASD than offspring spontaneously conceived. What is New: • This investigation separately considered studies with and without adjustment for confounders. • The findings from the two analyses were similar.

Risk factors and clinical outcomes for placenta accreta spectrum with or without placenta previa

PURPOSE

To clarify risk factors and clinical outcomes for placenta accreta spectrum (PAS) stratified by placenta previa.

METHODS

We conducted registry-based multicenter cross-sectional study including 472,301 singleton deliveries between 2013 and 2015. PAS was considered as a primary outcome, as well as maternal age, parity, history of cesarean section, history of miscarriage, and assisted reproductive technology (ART) were considered as potential exposures. A multivariable Poisson regression analysis was conducted to assess the risk for PAS, stratified by placenta previa. In addition, the risk for subsequent blood transfusion and hysterectomy by each exposure using multivariable Poisson regression analysis was conducted.

RESULTS

There were 426 and 1827 cases of PAS with and without placenta previa. Among cases with placenta previa, the number of previous cesarean sections was the most powerful predictor for PAS [adjusted risk ratio (aRR) for one previous cesarean section 5.34, 95% confidence interval (CI) 3.70-7.71; aRR for two or more previous cesarean section 16.5, 95% CI 11.5-23.6]. Among cases without placenta previa, previous cesarean section was not a significant predictor, whereas the strongest predictor was conception through ART (aRR 5.05, 95% CI 4.50-5.66). Although the risks of PAS for blood transfusion and hysterectomy were higher among cases with placenta previa, those without placenta previa also demonstrated non-negligible risks.

CONCLUSION

The current study demonstrated that history of cesarean section was the strongest risk factor for PAS among women with placenta previa. Among those without placenta previa, ART was an important predictor, but not cesarean section.

High serum anti-Müllerian hormone concentrations have a negative impact on fertilization and embryo development rates

RESEARCH QUESTION

What is the impact of high serum anti-Müllerian hormone (AMH) concentrations on fertilization and embryo development among infertile women undergoing treatment with assisted reproductive technology (ART)?

DESIGN

Retrospective study of 1036 infertile women undergoing ART; women were divided into three groups according to serum AMH concentrations: AMH <1.1 ng/ml, 1.1-5.0 ng/ml and >5.0 ng/ml. The fertilization and embryo development rates of patients with different AMH concentrations and after stratification according to age were compared.

RESULTS

Women with high AMH concentrations were younger and had higher testosterone concentrations (0.4 ± 0.13 versus 0.3 ± 0.12 versus 0.3 ± 0.08 µg/dl, P < 0.001) than women with low AMH concentrations. However, analysis of the embryo development rate showed negative outcomes for women with high AMH concentrations, including a poor fertilization rate (76.3 ± 17.36 versus 82.1 ± 19.15 versus 82.4 ± 25.38, P = 0.003), and poor day 3 embryo development rate (55.6 ± 23.88 versus 62.6 ± 26.52 versus 62.8 ± 32.65, P = 0.014). Multivariate linear regression analysis showed significantly negative correlations of the AMH concentrations with the fertilization rate (P < 0.001) and day 3 embryo development rate (P = 0.006). Subgroup analysis showed that age 30 years or younger had a significant negative correlation with AMH and the embryo development rate, including the fertilization rate (P < 0.001) and day 3 embryo development rate (P = 0.037).

CONCLUSION

These results suggest that high serum AMH concentrations, contributing to a hyperandrogenic environment and leading to decreased oocyte developmental competence, may have a negative impact on fertilization and the early stage of embryo development in women undergoing treatment with ART.

Microdissection testicular sperm extraction (micro-TESE) in men with infertility due to nonobstructive azoospermia: summary of current literature

PURPOSE

Nonobstructive azoospermia (NOA) is associated with intrinsic testicular defects that severely impair sperm production. Although NOA invariably leads to infertility, focal sperm production may exist in the testicles of affected patients, which can be retrieved and used for intracytoplasmic sperm injection (ICSI) to generate healthy offspring. However, geographic locations of testicular sperm producing-areas are uncertain, making microsurgical-guided sperm retrieval (microdissection testicular sperm extraction; micro-TESE) an attractive method to identify and retrieve sperm in patients with NOA due to spermatogenic failure. Given the widespread use of micro-TESE, its effectiveness in harvesting sperm and related potential complications need to be clarified.

METHODS

We queried PubMed/MEDLINE for studies published in English, from inception to May 2021, concerning the effect of micro-TESE on sperm retrieval rate (SRR), complication rate and ICSI pregnancy rate-using retrieved testicular sperm in subfertile couples where the male had NOA.

RESULTS

We found 116 articles, including 70 original papers, 32 review articles, and 14 systematic reviews. The evidence accounted for 4895 patients. Micro-TESE retrieved sperm in 46.6% of men with NOA, but SRRs varied considerably (18.4-70.8%) and were mainly related to the treated population characteristics. Concerning the general population of NOA patients who have not undergone previous sperm retrieval (naïve population), the SRR by micro-TESE was 46.8% (1833 of 3914 patients; range 20-70.8%; 28 studies). In studies reporting SR by micro-TESE for men who had failed percutaneous testicular sperm aspiration or non-microsurgical testicular sperm extraction, the SRR was 39.1% (127 of 325 patients; range 18.4-57.1%; 4 studies). Data on adverse events indicated that micro-TESE was associated with low (~ 3%) short-term postoperative complication rates. The fertilizing ability of testicular sperm retrieved by micro-TESE and used for ICSI was adequate (~ 57%), whereas clinical pregnancy and live birth were obtained in 39% and 24% of couples who had an embryo transfer, respectively. The health of the resulting children seems reassuring, but the evidence is limited. The procedure increases sperm retrieval success compared to non-microsurgical retrieval methods, particularly in men with Sertoli cell-only testicular histopathology.

CONCLUSION

We concluded that micro-TESE is an effective and safe method to retrieve sperm from men with NOA-related infertility, with potential advantages over non-microsurgical methods. Nevertheless, high-quality, head-to-head comparative randomized controlled trials by sperm retrieval method, focusing on SRR, live birth rate and assessing long-term adverse events and health of children conceived using testicular sperm from NOA patients are lacking. Therefore, further research is required to determine the full clinical implications of micro-TESE in male infertility treatment.

[Genetic analysis of three cases of acephalic spermatozoa syndrome caused by SUN5 mutation and the outcome of assisted reproductive technology]

To explore the genetic causes of 3 male infertility patients with acephalospermia and the outcome of assisted reproductive technology. Clinical diagnosis, sperm morphology examination, sperm transmission electron microscopy examination were performed on 3 patients, and the whole exome sequencing technology was used for screening, Sanger sequencing verification, mutation pathogenicity analysis, and protein sequence homology comparison. Assisted reproductive technology was implemented to assist pregnancy treatment. The 3 patients were all sporadic infertile men, aged 25, 42 and 26 years, and there was no obvious abnormality in the general physical examination. Male external genitalia developed normally, bilateral testicles were normal in volume, and bilateral epididymis and spermatic vein were palpated without nodules, cysts, and tenderness. Repeated semen analysis showed that a large number of immature sperm could be seen, and they had the ability to move. The SUN5 gene of the 3 male infertile patients was a case of homozygous missense mutation c.7C>T (p.Arg3Trp), a case of compound heterozygous missense mutation c.1067G>A (p.Arg356His) and nonsense mutation c.216G>A (p.Trp72*) and a case of homozygous missense mutation c.1043A>T (p.Asn348Ile), of which c.7C>T (p.Arg3Trp) and c.1067G>A (p.Arg356His) were new variants that had not been reported. SIFT, Mutation Taster and PolyPhen-2 software function prediction results were all harmful, the nonsense mutation c.216G>A (p.Trp72*) led to the premature termination of peptide chain synthesis which might have a greater impact on protein function. The homology regions in the protein sequence homology alignment were all highly conserved.The 3 male patients and their spouses obtained 4 biological offspring through intracytoplasmic sperm injection, all of which were boys, and one of them was a twin.Three male infertile patients might be caused by SUN5 gene mutations. Such patients could obtain their biological offspring through assisted reproductive technology. It was still necessary to pay attention to the genetic risk of ASS, it was recommended that both men and women conduct genetic counseling and screening at the same time. In clinical diagnosis, whole exome sequencing technology could be used to perform auxiliary examinations to determine the treatment plan and assisted reproductive methods as soon as possible to reduce the burden on the family and society. The newly discovered mutation sites of SUN5 gene provided clues and directions for elucidating the pathogenic mechanism, and at the same time expanded the pathogenic mutation spectrum of ASS.

Heterotopic tubal pregnancy with a naturally conceived live twin intrauterine pregnancy in a patient with systemic lupus erythematosus: A case report

Heterotopic pregnancy (HP) is defined as the simultaneous occurrence of an intrauterine and extrauterine gestation. Risk factors contributing to this condition are similar to those which contribute to ectopic pregnancy. While a triple heterotopic gestation through natural conception is uncommon, here we present the case of a patient with spontaneous intrauterine twins and a concurrent tubal extrauterine gestation, where the patient also had systemic lupus erythematosus. During the seventh week of gestation, the patient presented with acute abdomen signs and hemodynamic instability; a decision was taken to perform an emergency laparotomy. Haemoperitoneum, a total torsion of the right ovary with salpinx, a ruptured tubal pregnancy and subsequent necrosis were found intraoperatively. The patient was discharged on the sixth postoperative day and monitored throughout her whole pregnancy, with the intrauterine pregnancy progressing uneventfully. Two healthy neonates were delivered by cesarean section at 36 weeks of gestation. In conclusion, physicians treating women of reproductive age should be aware of possible HP, even in the absence of risk factors.

•

Spontaneous heterotopic pregnancy (HP) occurs in approximately 2.3% of all cases of HP

•

Risk factors include assisted reproduction techniques and pelvic inflammatory disease

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The probability of an ovarian pregnancy accompanied by an intrauterine pregnancy, comprises 2.3% of all cases of HP

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Surgical intervention plays a key role in the management of HP, with laparoscopic salpingectomy being the gold-standard procedure

Objective sleep duration and timing predicts completion of in vitro fertilization cycle

PURPOSE

To examine associations between objectively measured sleep duration and sleep timing with odds of completion of an in vitro fertilization (IVF) cycle.

METHODS

This prospective cohort study enrolled 48 women undergoing IVF at a large tertiary medical center between 2015 and 2017. Sleep was assessed by wrist-worn actigraphy, 1-2 weeks prior to initiation of the IVF cycle. Reproductive and IVF cycle data and demographic and health information were obtained from medical charts. Sleep duration, midpoint, and bedtime were examined in relation to IVF cycle completion using logistic regression models, adjusted for age and anti-Müllerian hormone levels. A sub-analysis excluded women who worked non-day shifts to control for circadian misalignment.

RESULTS

The median age of all participants was 33 years, with 29% of women >35 years. Ten women had an IVF cycle cancelation prior to embryo transfer. These women had shorter sleep duration, more nocturnal awakenings, lower sleep efficiency, and later sleep timing relative to those who completed their cycle. Longer sleep duration was associated with lower odds of uncompleted IVF cycle (OR = 0.88; 95%CI 0.78, 1.00, per 20-min increment of increased sleep duration). Women with later sleep midpoint and later bedtime had higher odds of uncompleted cycle relative to those with earlier midpoint and earlier bedtime; OR = 1.24; 95%CI 1.09, 1.40 and OR = 1.33; 95%CI 1.17, 1.53 respectively, for 20-min increments. These results were independent of age, anti-Müllerian hormone levels, or sleep duration, and remained significant after exclusion of shift-working women.

CONCLUSIONS

Shorter sleep duration and later sleep timing increase the odds of uncompleted cycles prior to embryo transfer.

Low vitamin D levels in follicular fluid, but not in serum, are associated with adverse outcomes in assisted reproduction

PURPOSE

To assess the relationship between serum/follicular fluid (FF) vitamin D (VD) status and assisted reproductive technology (ART) treatment outcomes among infertile patients.

METHODS

A prospective cohort study, including 132 infertile patients scheduled for their first ART treatment cycle, was carried out in a Reproductive Medical Center. Serum and FF samples were collected to assess 25-hydroxy VD [25(OH)D] levels. Low VD level was defined as 25(OH)D concentration of less than 30 ng/mL.

RESULTS

Most infertile patients had low VD levels in serum (88%) and FF (90%). We observed a moderately positive correlation between VD levels in serum and FF (r = 0.34, p < 0.0001). Compared to the group of patients with low VD levels in the FF, those with sufficient VD levels had a significantly higher number of retrieved oocytes (p = 0.03), normal fertilization (p = 0.01), and high-quality embryos (p = 0.001). Moreover, patients with sufficient VD levels in the FF also had significantly higher implantation rates than those with low VD levels (76.92% vs. 46.58%, respectively, p = 0.01) and clinical pregnancy rates (92.31% vs. 61.54%, respectively, p = 0.04).

CONCLUSION

These data collectively revealed that low VD levels in serum and FF were common among infertile patients. VD levels in FF, but not in serum, were associated with embryo quality, normal fertilization, implantation rates, and clinical pregnancy rates. Further studies are mandatory to determine the molecular mechanism and VD's potential therapeutic benefits in infertile patients.

Analysis of pregnancy-associated factors after fertility-sparing therapy in young women with early stage endometrial cancer or atypical endometrial hyperplasia

BACKGROUND

Fertility-sparing therapy is an alternative conservative treatment for patients with early stage endometrioid cancer or atypical endometrial hyperplasia. In this study, we investigated pregnancy outcomes and pregnancy-associated factors in young patients receiving hormonal therapy.

METHODS

We retrospectively analyzed 68 patients who attempted to conceive after fertility-sparing therapy and achieving complete remission (CR). They were divided into a pregnancy group and a non-pregnancy group. A Cox proportional hazard regression model was applied for univariate and multivariate analysis to determine factors associated with pregnancy. Kaplan-Meier analysis, combined with the log-rank test, was used to calculate a patient's pregnancy probability and the distribution of recurrence-free survival (RFS).

RESULTS

A total of 36 patients became pregnant with 47 pregnancies. Univariate and multivariate Cox analysis revealed that several factors were associated with pregnancy, including BMI at the time of pregnancy permission, the time to CR, prolonged treatment time, the number of hysteroscopy procedures, the endometrium thickness after CR, and relapse before pregnancy. The mean RFS of patients who achieved pregnancy, and those who did not, was 27.6 months and 14.8 months, respectively (P = 0.002). No significant difference was detected in terms of cumulative RFS when compared between assisted reproductive technology (ART) cases and those involving natural conception (NC) (P = 0.707).

CONCLUSIONS

Normal BMI, a shorter time to CR, a prolonged three-month treatment, fewer hysteroscopy procedures, and a thicker endometrium may be positive indicators for successful pregnancies, while relapse before pregnancy may have a negative effect on conception. Moreover, a successful pregnancy protects the endometrium while ART does not increase the risk of recurrence.

Knowledge and attitudes about assisted reproductive technology: Findings from a Hungarian online survey

This study aimed to evaluate the general knowledge and attitudes about assisted reproductive technology (ART) and the influence of sociodemographic features on knowledge and attitudes in a large sample of men and women of reproductive age in Hungary. A cross-sectional online survey study was conducted among 1370 men and women between 18 and 50 years of age in Hungary. The questionnaire included questions about self-rated knowledge, an attitude item, and eight questions concerning general knowledge about ART. In addition, participants were asked sociodemographic background questions. The results show that approximately half of the respondents (49.3%) rated themselves as fairly knowledgeable about ART. However, 56% of the respondents answered just three of the eight knowledge questions correctly. Both men and women had limited knowledge about the success rate of ART, the costs of ART and the age limit to access ART. The greatest lack of knowledge about ART was about its risks: the majority of respondents did not know that in-vitro fertilization poses health risks for women and conceived children. Regarding attitudes, the majority of respondents had a very positive attitude towards ART. Only those respondents who were religious were less supportive of ART. These data suggest that men and women of reproductive age overestimate their ART-related knowledge. As most men and women would like to have biological children in Hungary, there is a critical need for public education.

Cerebral palsy in children born after assisted reproductive technology: a meta-analysis

BACKGROUND

Several studies have assessed the association between cerebral palsy (CP) and assisted reproductive technology (ART), but the results remain controversial. We conducted a meta-analysis to evaluate the risk of CP after ART compared with natural conceptions and to examine CP risk separately in ART singletons, multiples and preterm births.

METHODS

Web-based databases (PubMed, Embase, the Cochrane Library, and Web of Science) were searched until November 22, 2020. Studies which compare CP rates after ART with natural conceptions were included. The Newcastle-Ottawa Scale was used to assess the quality of the included studies. Effect estimates were extracted and combined using the fixed-effects or random-effects model depending on the heterogeneity test.

RESULTS

There were nine studies included in the meta-analysis. The included studies were of moderate or high quality. A significantly higher risk of CP [odds ratio (OR) = 2.17, 95% confidence interval (CI) 1.72-2.74] was found in ART children (n = 89,214) compared with naturally conceived children (n = 4,160,745). The significantly higher risk decreased when data were restricted to singletons (OR = 1.36, 95% CI 1.16-1.59) and disappeared when data were restricted to multiples (OR = 1.05, 95% CI 0.86-1.29) or preterm births (OR = 1.53, 95% CI 0.66-3.56). Subgroup and sensitivity analyses indicated that the overall results were robust.

CONCLUSIONS

The risk of CP is increased more than two-fold after ART. This increased risk is largely due to increased rates of multiple birth and preterm delivery in ART children.

Primary Myelin Oligodendrocyte Glycoprotein-Immunoglobulin G-associated Optic Neuritis Presenting after a Frozen Embryo Transfer

Myelin oligodendrocyte glycoprotein (MOG)-immunoglobulin G-associated optic neuritis (ON) is a newly recognized antibody-mediated demyelinating disease of the central nervous system, resulting in acute visual loss and pain with eye movement. The effects of pregnancy on disease pathogenesis remain incompletely understood. Herein, we present a novel association between a frozen embryo transfer (FET) and the first manifestation of MOG-ON in a previously healthy patient with unexplained infertility. The patient presented with acute bilateral visual loss 3 weeks after a single FET and was found to test positive for MOG antibodies with an otherwise unremarkable workup. The patient's vision returned to baseline with high-dose intravenous methylprednisolone and therapeutic plasma exchange. This is the first published case highlighting an association between MOG-ON and assisted reproductive technology (ART) in a patient without prior risk factors. Further studies are needed to clarify the effects of ART and pregnancy in general on disease pathogenesis.

[Risk of mayor and minor birth defects in children conceived by assisted reproductive technology (IVF/ICSI): A prospective controlled cohort study]

INTRODUCTION

About 0.2-6.1% of newborns in the developed world have been conceived by assisted reproductive techniques (ART). Higher rate of major and minor malformations have been described in this population, but the multiple possible confounders associated, make it difficult to establish a direct causal relationship, and the specific factors involved.

MATERIAL AND METHODS

To determine the risk of these malformations in our population, a collaborative prospective controlled cohort study was designed. We collected the specific ART-data related to the clinical gestation of women treated in a period of 2 years in the Reproduction Unit from a Spanish public tertiary-level hospital. 231 out of 267 newborns of these gestation (88%) were exhausted assessed by a Clinical Geneticist expertise in Dysmorphology at 12-20 and 26-40 months of age. At the same time a controlled group of children naturally conceived (NC) was selected according to the following criteria: the next NC newborn belonging to the same group of maternal and gestational age, and type of gestation (single or multiple). 230 controls were chosen and 208 participated in the study (90%).

RESULTS

Major malformations were presented in 7.8% of the ART-children and 7.2% of the controls, without founding statistically differences between groups. However, differences were found in the risk of some minor malformations such as capillary malformations and pigmentary lesions, higher in the ART-group. A recurrent pattern of craneofacial anomalies was also unexpectedly detected.

CONCLUSIONS

In spite of the high rate of major congenital malformations detected, there were no differences between groups. Thus, our results suggest that ART may affect the normal embryonic development but in a milder way than other confounding factors do. The facial phenotype identified has not previously, either the higher risk of capillary malformations and pigmentary lesions. More studies are needed to confirm this association.

Self-efficacy, coping strategies and quality of life in women and men requiring assisted reproductive technology treatments for anatomical or non-anatomical infertility

OBJECTIVE

To examine the magnitude and the predictors of emotional reactions to an infertility diagnosis, comparing women and men who were clinically diagnosed with an anatomical cause of infertility or non-anatomical cause of infertility.

STUDY DESIGN

Cross-sectional study involving a total of 133 adults waiting for infertility treatment at the IVF and Infertility Unit of the S. Orsola University Hospital in Bologna (Italy). Of these, 107 patients (55 with anatomical causes of infertility and 52 with non-anatomical causes of infertility; response rate: 80%) took part to the study. After providing informed written consent, each participant was asked to complete the Infertility Self-efficacy Scale, the Fertility Quality of Life, and the Brief Coping Orientation to Problem Experienced, which they returned at their second access to the Unit. Differences between the groups were analyzed through a series of univariate ANOVA, whereas a multiple regression analysis was used to jointly examine the predictors of fertility quality of life.

RESULTS

Results showed both gender related and diagnosis related differences. Women had statistically significant lower scores than men on the Infertility Self-Efficacy Scale and on the global, emotional, and mind-body subscales of the Fertility Quality of Life, while they scored significantly higher on the emotion focused and socially supported subscales of the Coping Orientation to Problem Experienced. Independently of gender, patients with non-anatomical causes of infertility scored poorly than patients with anatomical causes of infertility on the relational subscale of the Fertility Quality of Life and on the Avoidant scale of the Brief Coping Orientation to Problem Experienced. Hierarchical multiple regression analyses revealed that higher levels of self-efficacy and a lower use of avoidant coping strategies predicted a more positive quality of life over and above gender and cause of infertility.

CONCLUSION

This study partly confirms data on gender differences in experiencing the psychological burden of infertility and adds some new information, particularly with respect to the prediction of quality of life indicators over and above infertility cause.

The association between in vitro fertilization and intracytoplasmic sperm injection treatment and the risk of congenital heart defects

OBJECTIVE

Assisted reproductive technology (ART), an effective treatment modality for infertility, is associated with a higher prevalence of congenital anomalies such as congenital heart defects (CHDs). The present study aimed to evaluate data linking CHDs in infants to pregnancies resulting from in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI).

METHODS

In this study, we conducted a systematic literature search on CHDs in infants following IVF/ICSI in Google Scholar, Embase, Scopus, MEDLINE, and PubMed databases from inception to February 2020. The search strategy used combinations of search keywords that included assisted reproductive technology/ART, in vitro fertilization/IVF, intracytoplasmic sperm injection/ICSI, birth defect, congenital malformation, and congenital heart defects.

RESULTS

Fifty-six studies fulfilled the inclusion criteria and were selected in the current systematic review, which assessed the association between ART and the risk of CHDs.

CONCLUSION

Children conceived by IVF/ICSI manifested an increased risk of CHDs compared with spontaneously conceived children. Further studies are needed to assess the long-term cardiovascular safety of these techniques, which is important for the counseling of patients before the use of ART.

Assisted reproduction in Spain, outcome and socioeconomic determinants of access

Research question

We analyzed two questions. First, the effectiveness of public Assisted Reproductive Technologies (ART) in Spain compared with private ones, measured by the time since initiating ART treatment until achieving pregnancy, accounting for age and socioeconomic factors. Second, socioeconomic determinants of access to ART, referring primarily to financial means derived by employment, income, and wealth.

Design

We applied statistical models on data extracted from the national Spanish Fertility Survey from 2018. The first topic was analyzed by competing risk survival analysis conducted on a sample of 667 women who initiate ART treatment since 2000. The second, by a Bivariate Probit model conducted on a sample of 672 women older than 41 years who required ART services.

Results

The first analysis raised that throughout the treatment, patients treated exclusively in private clinics had on average a higher cumulative incidence of becoming pregnant compared with patients who approached public clinics. The second analysis raised that both higher household equivalent income and higher education increase the likelihood of accessing ART in a private clinic and decrease the tendency of accessing public clinics or failing to access any service. Moreover, being single decreases the likelihood of accessing public clinics or ART services in general.

Conclusions

Long waiting periods could be the main reason for the lower incidence of getting pregnant in public healthcare, explaining why patients choose private over public care. We develop a broader discussion over the extent of Spanish public funding of ART, the unequal medical outcome, and potential options for optimization.

Short Ejaculatory Abstinence in Normozoospermic Men is Associated with Higher Clinical Pregnancy Rates in Sub-fertile Couples Undergoing Intra-Cytoplasmic Sperm Injection in Assisted Reproductive Technology: A Retrospective Analysis of 1691 Cycles

BACKGROUND

The current WHO abstinence recommendations are ideal only for clinical diagnosis, as in recent years a negative correlation of abstinence duration with good embryo development and clinical pregnancy rate has been seen.

AIM

The aim of the study was to evaluate the impact of variation in abstinence period on fertilization, embryo development potential, pregnancy, and miscarriage rate in sub-fertile couples undergoing assisted reproductive technology (ART) treatment.

SETTING AND DESIGN

A prospective analysis was conducted at a tertiary (level 3) infertility care clinic.

MATERIALS AND METHODS

The study included analysis of 1691 cycles for the patient undergoing ART procedures between September 2017 and August 2019. The influence of ejaculatory abstinence (EA) was investigated based on variation in abstinence length with four groups: Group I - 1 day; Group II - 2-5 days; Group III - 6-7 days; and Group IV - EA length of ≥8 days.

STATISTICAL ANALYSIS

Analysis of variance and Chi-square test were used to calculate P value.

RESULTS

In our primary outcome, we have seen a strong positive correlation of abstinence duration with semen volume, total sperm count, total motile count, and difference between each group was significant. Secondary outcomes showed a significantly higher implantation rate, biochemical pregnancy rate was observed in Group I (1 day) per embryo transfer as compared to longer abstinence groups. This resulted in significantly higher clinical pregnancy rates in Group I 30.0% vs. 25.4% in comparison to longer abstinence groups.

CONCLUSIONS

Our study has shown duration of abstinence is negatively correlated with positive β-human chorionic gonadotropin rate, clinical pregnancy rate, and implantation rate. Lower miscarriage rate was also observed with shorter abstinence duration.

Reframing the Australian Medico-Legal Model of Infertility

Australian law affirms a binary construction of fertility/infertility. This model is based upon the medical categorization of infertility as a disease. Law supports medicine in prioritizing technology, such as in vitro fertilization, as treatment for infertility. This prioritization of a medico-legal model of infertility in turn marginalizes alternative means of family creation such as adoption, fostering, traditional surrogacy, and childlessness. This paper argues that this binary model masks the impact of medicalization upon reproductive choice and limits opportunity for infertile individuals to create families. While medical technology should be available to enhance reproductive opportunity, infertile individuals will benefit from regulatory change which disentangles the medico-legal construct of infertility as a disease from the desire to create a family. This paper suggests that the medico-legal model of infertility should be reframed to support all opportunities for family creation equally, including non-medical opportunities such as adoption, fostering, and childlessness.

Artificial intelligence-the future is now

The pros and cons of artificial intelligence in assisted reproductive technology are presented.

Assisted reproductive technology and hypertensive disorders of pregnancy: systematic review and meta-analyses

Background

Hypertensive disorders of pregnancy (HDP) is one of the most common pregnancy complications and causes of maternal morbidity and mortality. Assisted reproductive technology (ART) has been associated with adverse pregnancy outcomes, including HDP. However, the impact of multiple pregnancies, oocyte donation, as well as fresh and frozen embryo transfer needs to be further studied. We conducted a systematic review and meta-analyses to evaluate the association between ART and HDP or preeclampsia relative to spontaneous conception (SC).

Methods

We identified studies from EMBASE, MEDLINE, and Cochrane Library (up to April 8, 2020) and manually using structured search strategies. Cohort studies that included pregnancies after in vitro fertilization (IVF) with or without intracytoplasmic sperm fertilization (ICSI) relative to SC with HDP or preeclampsia as the outcome of interest were included. The control group was women who conceived spontaneously without ART or fertility medications. The pooled results were reported in odds ratios (OR) with 95% confidence intervals based on random effects models. Numbers needed to harm (NNH) were calculated based on absolute risk differences between exposure and control groups.

Results

Eighty-five studies were included after a screening of 1879 abstracts and 283 full text articles. Compared to SC, IVF/ICSI singleton pregnancies (OR 1.70; 95% CI 1.60–1.80; I² = 80%) and multiple pregnancies (OR 1.34; 95% CI 1.20–1.50; I² = 76%) were both associated with higher odds of HDP. Singleton pregnancies with oocyte donation had the highest odds of HDP out of all groups analyzed (OR 4.42; 95% CI 3.00–6.51; I² = 83%). Frozen embryo transfer resulted in higher odds of HDP (OR 1.74; 95% CI 1.58–1.92; I² = 55%) than fresh embryo transfer (OR 1.43; 95% CI 1.33–1.53; I² = 72%). The associations between IVF/ICSI pregnancies and SC were similar for preeclampsia. Most interventions had an NNH of 40 to 100, while singleton and multiple oocyte donation pregnancies had particularly low NNH for HDP (16 and 10, respectively).

Conclusions

Our meta-analysis confirmed that IVF/ICSI pregnancies are at higher odds of HDP and preeclampsia than SC, irrespective of the plurality. The odds were especially high in frozen embryo transfer and oocyte donation pregnancies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03938-8.

Restricted access to assisted reproductive technology and fertility preservation: legal and ethical issues

Access to assisted reproductive technology (ART) and fertility preservation remains restricted in middle and low income countries. We sought to review the status of ART and fertility preservation in Brazil, considering social indicators and legislative issues that may hinder the universal access to these services. Although the Brazilian Constitution expressly provides the right to health, and ordinary law ensures the state is obliged to support family planning, access to services related to ART and fertility preservation is neither easy nor egalitarian in Brazil. Only a handful of public hospitals provide free ART, and their capacity far from meets demand. Health insurance does not cover ART, and the cost of private care is unaffordable to most people. Brazilian law supports, but does not command, the state provision of ART and fertility preservation to guarantee the right to family planning; therefore, the availability of state-funded treatments is still scarce, reinforcing social disparities. Economic projections suggest that including ART in the Brazilian health system is affordable and may actually become profitable to the state in the long term, not to mention the ethical imperative of recognizing infertility as a disease, with no reason to be excluded from a health system that claims to be 'universal'.

Recombinant human luteinizing hormone co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Several studies suggest that luteinizing hormone (LH) could improve IVF outcome in women of advanced reproductive age by optimizing androgen production. In this review, we assessed the role of recombinant-human LH (r-hLH) and recombinant human follicle stimulating hormone (r-hFSH) co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age candidates for assisted reproduction.

MATERIAL AND METHODS

Using a preregistered protocol we systematically searched Medline/PubMed, Scopus and the ISI Web of Science databases to identify randomized controlled trials in which r-hFSH monotherapy protocols were compared with r-hFSH/r-hLH co-treatment in women ≥35 years undergoing fresh IVF cycles. We calculated the pooled odds ratio (OR) for dichotomous data and the weight mean difference (WMD) for continuous data with an associated 95% confidence interval (CI). The meta-analyses were conducted using the random-effect model. P values < 0.05 were considered statistically significant. Subgroup analyses of all primary and secondary outcomes were performed only in women aged 35-40 years.

RESULTS

Twelve studies were identified. In women aged between 35 and 40 years, r-hFSH/r-hLH co-treatment was associated with higher clinical pregnancy rates (OR 1.45, CI 95% 1.05-2.00, I² = 0%, P = 0.03) and implantation rates (OR 1.49, CI 95% 1.10-2.01, I² = 13%, P = 0.01) versus r-hFSH monotherapy. Fewer oocytes were retrieved in r-hFSH/r-hLH-treated patients than in r-hFSH-treated patients both in women aged ≥35 years (WMD -0.82 CI 95% -1.40 to - 0.24, I² = 88%, P = 0.005) and in those aged between 35 and 40 years (WMD -1.03, CI - 1.89 to - 0.17, I² = 0%, P = 0.02). The number of metaphase II oocytes, miscarriage rates and live birth rates did not differ between the two groups of women overall or in subgroup analysis.

CONCLUSION

Although more oocytes were retrieved in patients who underwent r-hFSH monotherapy, this meta-analysis suggests that r-hFSH/r-hLH co-treatment improves clinical pregnancy and implantation rates in women between 35 and 40 years of age undergoing ovarian stimulation for assisted reproduction technology. However, more RCTs using narrower age ranges in advanced age women are warranted to corroborate these findings.

Obstetrical outcomes of ART pregnancies in patients with male factor infertility

PURPOSE

Pregnancies conceived by in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are associated with an increased incidence of obstetrical and neonatal complications. With the growing rate of male factor infertility, which is unique by not involving the maternal milieu, we aimed to assess whether obstetrical outcomes differed between IVF/ICSI pregnancies due to male factor infertility and those not due to male factor infertility.

METHODS

A retrospective cohort study of women receiving IVF/ICSI treatments at a single hospital over a five-year period was involved in the study. Inclusion criteria were women with a viable pregnancy that delivered at the same hospital. Pregnancies were divided into male factor only related and non-male factor-related infertility. The groups were compared for several maternal and neonatal complications.

RESULTS

In total, 225 patients met the study criteria, with 94 and 131 pregnancies belonging to the male factor and non-male factor groups, respectively. Demographic and clinical characteristics were comparable, except for younger maternal age and higher incidence of twin pregnancies in the male factor group. A sub-analysis for singleton pregnancies revealed a less likelihood of cesarean delivery, preterm birth, and male gender offspring in the male factor group (p < 0.05). These differences were not observed in the sub-analysis for twin pregnancies. Other outcome measures were similar in both groups, both for singleton and twin pregnancies.

CONCLUSION

Singleton IVF pregnancies due to male factor infertility are associated with a reduced incidence of some adverse outcomes, likely due to lack of underlying maternal medical conditions or laboratory conditions related to ICSI. Our findings require validation by further studies on larger samples.

Homocysteine, vitamin B status and MTHFR polymorphisms in Italian infertile women

OBJECTIVE

The purpose of this study was to evaluate the vitamin B status related to the homocysteine pathway and the prevalence of polymorphisms of the MTHFR gene in infertile women programming homologous or heterologous ART.

STUDY DESIGN

We investigated 393 consecutive Caucasian women, referred to the Internal Medicine Clinic at the Center for Assisted Reproductive Technology, in order to be framed for their vascular risk before starting homologous or heterologous (oocyte donation) procedures. Total homocysteine, Vitamin B12, folate and vitamin B6 were measured. The women were divided into quartiles of serum concentration of folate, vitamin B12 and vitamin B6. The C677T and A1298C polymorphisms of the MTHFR gene were genotyped by an electronic microchip technology.

RESULTS

Sixty-one women (15.5%) had hyperhomocysteinemia, 22.9% had reduced levels of vitamin B12, 4.1% had reduced levels of serum folate and 0.1% had a deficiency of vitamin B6. Women in the highest quartile of vitamin B12 and folates had lower homocysteine ​​levels than women in the first and second quartiles (p < 0.0001). The homozygosity for MTHFR C677T polymorphism was detected in 33.3% (131), and heterozygosity for MTHFR C677T polymorphism in 45.3% (178) of women. We observed a significant association between hyperhomocysteinemia and 677T allele, but not 1298C, of the MTHFR polymorphisms (p = 0.04).

CONCLUSIONS

We found inadequate vitamin B status related to the homocysteine ​​pathway in women planning Assisted Reproductive Technology. Moreover, interesting association was found regarding hyperhomocysteinemia in women carrying T allele of the C677T MTHFR polymorphism. A specific supplementation with 5-MTHF and adequate vitamin B12 concentrations before Assisted Reproductive Technology warrant serious consideration, in particular in women carrying T allele of the C677T MTHFR polymorphism.

Oocyte stimulation parameters influence the number and proportion of mature oocytes retrieved in assisted reproductive technology cycles

PURPOSE

Whether differences in stimulation parameters alter the number and proportion of MII oocytes retrieved.

METHODS

Records of 2546 patients were examined, looking at age, day 2/3 follicle-stimulating hormone (FSH) and estradiol (E2) levels, total dose of gonadotropins administered (including FSH and human menopausal gonadotropin [hMG]), fraction of hMG administered, number of days of treatment with gonadotropins, and the dose of gonadotropins administered per day. We segregated the patients into 3 different classes depending on the trigger method used and 2 groups based on egg freeze vs. ICSI. Multiple regression methods were used to examine associations between stimulation parameters and the total number of eggs, number of immature oocytes (Poisson regression), and the fraction of retrieved oocytes that were immature (Logistic regression).

RESULTS

After adjustments for different triggers and egg freeze versus ICSI, both the #immature oocytes and the immature fraction of oocytes were associated with the total gonadotropin dose (inversely) and the gonadotropin dose/day (positively). Other parameters were associated with the number of immature oocytes but were also associated with the number of oocytes retrieved.

CONCLUSIONS

Stimulations using less total gonadotropin and more gonadotropin per day were associated with more immaturity. The type of trigger method used for final maturation was associated with immaturity but was believed to be predominantly due to trigger assignment to patients based on response. The association between use of ICSI and less immaturity was believed to be due to additional time for maturation in the ICSI group.

Individual culture leads to decreased blastocyst formation but does not affect pregnancy outcomes in the setting of a single, vitrified-warmed euploid blastocyst transfer

PURPOSE

To evaluate embryology and pregnancy outcomes following individual and group embryo culture in the setting of contemporary laboratory practices and freeze-all cycles.

METHODS

Patients underwent ovarian stimulation followed by intracytoplasmic sperm injection (ICSI). Embryos proceeded through individual culture and then underwent preimplantation genetic testing for aneuploidy (PGT-A) via trophectoderm biopsy. In a subsequent cycle, participants underwent single embryo transfer of a vitrified-warmed, euploid embryo. Outcomes were compared to controls undergoing group culture during the same time frame. The Mann-Whitney U test and logistic regression models were utilized.

RESULTS

Outcomes were assessed for 144 patients whose embryos underwent individual culture and 449 controls whose embryos underwent group culture. There were no significant differences in fertilization rates between groups (81.7% for individual culture vs. 84.1% for group culture, p = 0.22). However, individual culture was associated with a decreased rate of blastocyst formation compared to group culture (43.5% vs. 48.5%, p < 0.01). Following single, vitrified-warmed euploid blastocyst transfer, there were no significant differences between individual culture and group culture, respectively, in rates of positive βhCG (81.9% vs. 81.5%, p = 0.91), sustained implantation (63.9% vs. 65.0%, p = 0.80), biochemical miscarriage (16.7% vs. 12.3%, p = 0.18), or clinical miscarriage (1.4% vs. 4.2%, p = 0.13).

CONCLUSION

While individual culture appears to negatively impact the rate of usable blastocyst formation compared to group culture, there were no significant differences in pregnancy outcomes following transfer of a single, vitrified-warmed euploid blastocyst.

Multivariate analysis of the factors associated with live births during in vitro fertilisation in Southeast Asia: a cross-sectional study of 104,015 in vitro fertilisation records in Taiwan

PURPOSE

To investigate the factors associated with live births and the interaction between age and the number of embryos transferred after in vitro fertilisation (IVF) treatment.

METHODS

This study analyses data from a population-based-assisted reproductive database of all registered artificial reproduction institutions (n = 80) from 2010 to 2016 in Taiwan. The probability of a live birth in correlation with the treatment parameters was measured with multivariate logistic regression analyses using the generalised additive model (GAM) and Pearson's chi-square exact test.

RESULTS

A total of 104,015 IVF treatments performed between 2010 and 2016 were included in our analysis. From these treatments, 31,467 (30.3%) were successfully delivered, and 40,565 test-tube babies were born. Pearson's chi-square exact test indicated that parents' age, cause of infertility, type of ovarian stimulation, additional assisted reproductive technology techniques, donated egg or sperm, fresh or frozen embryo, presence or absence of ovarian hyperstimulation syndrome, and day of embryo transfer were significantly associated with live births after an IVF cycle (p < 0.05). Multiple logistic regression analysis with the GAM revealed that the odds of a live birth with IVF treatment in patients < 34 years of age were 2.55 times higher than that in patients ≥ 45 years of age (odds ratio = 2.55, 95% confidence interval = 1.69-2.90) for patients who underwent a single-embryo transfer (SET); a similar pattern was observed when two or more embryos were transferred. Egg donation, the assisted hatching technique, oral ovarian stimulation agents, and implantation of frozen embryos during SET were shown to improve the chance of a live birth by 29-90%. Implantation of the embryo after the 5th day of culture yielded the highest odds of a live birth. The interaction plot revealed that maternal age, especially < 40 years, was associated with the probability of a live birth. SET and double-embryo transfer showed similar associations with the probability of a live birth across age groups. Transferring more than two embryos might reduce the probability of a live birth during IVF treatment for women ≥ 40 years of age.

CONCLUSIONS

Implanting a greater number of embryos did not improve the age-related decrease in fertility for patients undergoing IVF. Therefore, we suggested that ≤ 2 blastocysts could be transferred during IVF treatments for women ≥ 40 years. Transferring a blastocyst on day 5 of culture was associated with a significant increase in the odds of a live birth resulting from IVF.

Assisted reproductive technology and multiple pregnancy in Malta - A population based study

INTRODUCTION

Assisted reproductive technology (ART) is increasingly used to overcome growing rates of infertility and subfertility. Perinatal and maternal morbidity and mortality are elevated in ART conceptions even in vaginally delivered singletons. Malta is a small archipelago with comprehensive national data. This study was carried out in order to investigate ART rates in Maltese deliveries for 2000-2019 inclusive.

METHODS

Anonymous data was obtained from the Malta National Obstetric Information System (NOIS). For this study all ART methods were aggregated into one group. Deliveries refer to single pregnancies. A p value ≤0.05 was taken to represent statistically significance.

RESULTS

This study analysed 82,356 deliveries over the period with overall 2% ART. There was a significant rising trend in all deliveries (ART plus non-ART) with time (p = 0.012). Of these, 1262 were twin deliveries (18% ART) and 56 were triplet deliveries (66% ART). Multiple deliveries (ART plus non-ART) also rose significantly (p = 0. 00035). The proportion of ART deliveries rose significantly overall and individually, for singletons (3.4-4.6%) since 2018, and over a quarter of such deliveries since 2013 for twin and further multiples.

DISCUSSION

The Maltese rate of twins and triplets plateaued before reaching the peaks experienced by other countries and it may be that more infertile couples were and are only having one embryo transferred. In smaller countries with only one neonatal unit, ART services should strive to produce a smooth throughput so as to minimize surges and strains on downstream neonatal services which may have deleterious effects on outcomes, especially neonatal.

Involvement of single nucleotide polymorphisms in ovarian poor response

PURPOSE

Unpredictability in acquiring an adequate number of high-quality oocytes following ovarian stimulation is one of the major complications in controlled ovarian hyperstimulation (COH). Genetic predispositions of variations could alter the immunological profiles and consequently be implicated in the variability of ovarian response to the stimulation.

DESIGN

Uncovering the influence of variations in AMHR2, LHCGR, MTHFR, PGR, and SERPINE1 genes with ovarian response to gonadotrophin stimulation in COH of infertile women.

METHODS

Blood samples of the women with a good ovarian response (GOR) or with a poor ovarian response (POR) were collected. Genomic DNA was extracted, and gene variations were genotyped by TaqMan SNP Genotyping Assays using primer-probe sets or real-time PCR Kit.

RESULTS

Except for PGR (rs10895068), allele distributions demonstrate that the majority of POR patients carried minor alleles of AMHR2 (rs2002555, G-allele), LHCGR (rs2293275, G-allele), MTHFR (rs1801131, C-allele, and rs1801133, T-allele), and SERPINE1 (rs1799889, 4G allele) genes compared to the GOR. Similarly, genotypes with a minor allele in AMHR2, LHCGR, MTHFR, and SERPINE1 genes had a higher prevalence among POR patients with the polymorphic genotypes. However, further genotype stratification indicated that the minor alleles of these genes are not associated with poor response. Multivariate logistic analysis of clinical-demographic factors and polymorphic genotypes demonstrated a correlation between FSH levels and polymorphic genotypes of SERPINE1 in poor response status.

CONCLUSIONS

Despite a higher prevalence of AMHR2, LHCGR, MTHFR, and SERPINE1 variations in the patients with poor ovarian response, it seems that these variations are not associated with the ovarian response.

Utilization of preimplantation genetic testing for monogenic disorders

OBJECTIVE

To determine the rate of utilization, factors influencing the decision-making process, and patient satisfaction with preimplantation genetic diagnosis for monogenic disorders (PGT-M).

DESIGN

Survey study.

SETTING

Academic center.

PATIENT(S)

Genetically at-risk patients seen for PGT-M consultation between January 2010 and 2018.

INTERVENTION(S)

Electronic survey including demographics, genetic history, consultation experience, decision-making process, and satisfaction with PGT-M process.

MAIN OUTCOME MEASURE(S)

Rate of utilization of PGT-M, importance of decision-making factors, and satisfaction with PGT-M process.

RESULT(S)

Among survey respondents (n = 49), the rate of utilization of PGT-M after consultation was 89.8%. Ninety-three percent of participants decided whether to pursue PGT-M within 3 months of consultation. Factors that were considered most important to this decision-making process included information provided at consultation, accuracy of test results after PGT-M, avoidance of suffering of an affected child, and ability to avoid termination of an affected pregnancy. Key barriers to utilization included financial burden and overall complexity of the in vitro fertilization (IVF)/PGT-M process. Of those utilizing PGT-M (n = 44), 72.1% had at least one live birth or were pregnant during the study period. Satisfaction with PGT-M was high, and most couples would use IVF/PGT-M for a future pregnancy (84.1%). Participants with a live birth were more satisfied with the PGT-M process than those who had no live birth.

CONCLUSION(S)

Most patients seeking consultation for PGT-M were likely to pursue this technology despite financial burden and complexity of the process. Exploring factors that influence patient decision-making regarding PGT-M is important for tailoring the consultation and optimizing the overall experience.

Importance of real-time measurement of sperm head morphology in intracytoplasmic sperm injection

Intracytoplasmic sperm injection (ICSI) is an important technique in male infertility treatment. Currently, sperm selection for ICSI in human assisted reproductive technology (ART) is subjective, based on a visual assessment by the operator. Therefore, it is desirable to develop methods that can objectively provide an accurate assessment of the shape and size of sperm heads that use low-magnification microscopy available in most standard fertility clinics. Recent studies have shown a correlation between sperm head size and shape and chromosomal abnormalities, and fertilization rate, and various attempts have been made to establish automated computer-based measurement of the sperm head itself. For example, a dictionary-learning technique and a deep-learning-based method have both been developed. Recently, an automatic algorithm was reported that detects sperm head malformations in real time for selection of the best sperm for ICSI. These data suggest that a real-time sperm selection system for use in ICSI is necessary. Moreover, these systems should incorporate inverted microscopes (×400-600 magnification) but not the fluorescence microscopy techniques often used for a dictionary-learning technique and a deep-learning-based method. These advances are expected to improve future success rates of ARTs. In this review, we summarize recent reports on the assessment of sperm head shape, size, and acrosome status in relation to fertility, and propose further improvements that can be made to the ARTs used in infertility treatments.

Intramuscular progesterone optimizes live birth from programmed frozen embryo transfer: a randomized clinical trial

OBJECTIVE

To determine whether vaginal progesterone for programmed endometrial preparation is noninferior to intramuscular progesterone in terms of live birth rates from frozen embryo transfer (FET).

DESIGN

Three-armed, randomized, controlled noninferiority trial.

SETTING

Multicenter fertility clinic.

PATIENT(S)

A total of 1,346 volunteer subjects planning vitrified-warmed transfer of high-quality nonbiopsied blastocysts were screened, of whom 1,125 subjects were ultimately enrolled and randomly assigned to treatment.

INTERVENTION(S)

The subjects were randomly assigned to receive, in preparation for FET, 50 mg daily of intramuscular progesterone (control group), 200 mg twice daily of vaginal micronized progesterone plus 50 mg of intramuscular progesterone every third day (combination treatment), or 200 mg twice daily of vaginal micronized progesterone.

MAIN OUTCOME MEASURE(S)

The primary outcome was live birth rate per vitrified-warmed embryo transfer. The secondary outcomes were a positive serum human chorionic gonadotropin test 2 weeks after FET, biochemical pregnancy loss, clinical pregnancy, clinical pregnancy loss, total pregnancy loss, serum luteal progesterone concentration 2 weeks after FET, and patient's experience and attitudes regarding the route of progesterone administration, on the basis of a survey administered to the subjects between FET and pregnancy test.

RESULT(S)

A total of 1,060 FETs were completed. The live birth rate was significantly lower in women receiving only vaginal progesterone (27%) than in women receiving intramuscular progesterone (44%) or combination treatment (46%). Fifty percent of pregnancies in women receiving only vaginal progesterone ended in miscarriage.

CONCLUSION(S)

The live birth rate after vaginal-only progesterone replacement was significantly reduced, due primarily to an increased rate of miscarriage. Vaginal progesterone supplemented with intramuscular progesterone every third day was noninferior to daily intramuscular progesterone, offering an effective alternative regimen with fewer injections.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02254577.

The association between previous induced abortion and in vitro fertilization outcomes: A retrospective cohort study in Hefei, China

OBJECTIVES

To assess the association between previous induced abortion and in vitro fertilization (IVF) outcomes among Chinese women.

STUDY DESIGN

In this retrospective cohort study, a total of 1436 infertility patients treated with IVF for the first time in the reproductive centre of Anhui Province Maternity and Child Health Hospital from February 2014 to April 2018 were selected as the study population, and 95 (6.6 %) had a history of induced abortion. Data were assessed from the hospital electronic database and medical records in the reproductive centre.

RESULTS

In total, 818 women (57.0 %) achieved clinical pregnancy, and 501 (34.9 %) achieved live birth. After adjustments for a series of potential confounding factors, women with a history of induced abortion had a significantly decreased probability of clinical pregnancy per transfer (OR: 0.71, 95 % CI: 0.53, 0.95, p = 0.037) and live birth per pregnancy (OR: 0.52, 95 % CI: 0.30, 0.90, p = 0.021) and a higher risk of miscarriage per pregnancy (OR: 1.89, 95 % CI: 1.24, 2.88, p = 0.009) than those without. Because relevant information was unavailable, the impacts of different types of previous induced abortion were not assessed.

CONCLUSIONS

Previous induced abortion may have an adverse effect on IVF outcomes among infertility patients.

Triggering change in stimulation protocols: a matter of oocyte maturation and beyond

Since the birth of Louise Brown, in vitro fertilization (IVF) stimulation protocols have evolved significantly. One particular area of focus has been the process of final oocyte maturation, during which the oocyte gains competence to support fertilization and early embryonic development up to implantation. The field of human assisted reproductive technology (ART) is witnessing increased utilization of GnRH agonists (GnRHa) as trigger agents, in addition to or instead of the traditionally used human chorionic gonadotropin (hCG). Future translational studies will reveal whether oocyte developmental competence, as reflected in live birth outcomes, are not only non-inferior, but also superior with the use of GnRHa as a trigger for both nuclear and cytoplasmic oocyte maturation.

Neonatal and maternal outcomes among twin pregnancies stratified by mode of conception in the United States

OBJECTIVE

To compare neonatal and maternal outcomes among twin pregnancies conceived as a result of different types of fertility treatments with those of spontaneously conceived twin pregnancies.

DESIGN

Retrospective Cohort.

SETTING

Population-based analysis.

PATIENT(S)

Population-based analysis of twin pregnancies in the United States based on their mode of conception using the natality data from the National Center for Health Statistics from the Centers for Disease Control and Prevention (from January 2015 through December 2017).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Adverse neonatal and maternal outcomes.

RESULT(S)

The overall prevalence of early adverse maternal outcomes and medical complications and obstetric complications including the risk of unplanned hysterectomy, intensive care unit admission, maternal blood transfusion, and perineal laceration were significantly higher in the fertility treatment group (including both ovulation induction/intrauterine insemination and assisted reproductive technology groups) compared with those of the spontaneous conception group, even after adjusting for several potential confounders. The risk of adverse composite neonatal outcomes was slightly lower in the spontaneous conception live twin birth group even after adjustment for several potential confounders.

CONCLUSION(S)

The rate of maternal and neonatal morbidity in twins conceived via different fertility treatments was slightly increased compared with those of twins conceived spontaneously. Because the absolute risks of maternal and neonatal morbidity were low, overall reassurance regarding these outcomes can be provided to the patients undergoing all types of fertility treatments.

Comparison of the Long-Acting GnRH Agonist Follicular Protocol with the GnRH Antagonist Protocol in Women Undergoing In Vitro Fertilization: A Systematic Review and Meta-analysis

INTRODUCTION

To evaluate the effectiveness and safety of long-acting GnRH agonist follicular and GnRH antagonist protocols among women undergoing in vitro fertilization (IVF) using data published in both English-language and Chinese studies.

METHODS

We systematically searched the PubMed, Embase, Cochrane, CNKI, and Wanfang databases up to March 2019 for studies comparing long-acting GnRH agonist follicular and GnRH antagonist protocols in women undergoing IVF. The primary outcome was live birth rate; secondary outcomes were clinical pregnancy rate and implantation rate; safety outcomes were ovarian hyperstimulation syndrome (OHSS) and miscarriage rate in fresh cycle. Statistical analysis was done using R software. The study protocol was registered with PROSPERO (CRD42019139396).

RESULTS

In 11 studies that met the inclusion criteria, 1994 women belonged to the long-acting GnRH agonist follicular protocol group and 1678 to the GnRH antagonist protocol group. Live birth rate (relative risk (RR) 1.61; 95% confidence interval (CI) 1.27, 2.05; P < 0.001), clinical pregnancy rate (RR 1.44; 95% CI 1.32, 1.58; P < 0.001), and implantation rate (RR 1.58; 95% CI 1.44, 1.73; P = 0.001) were higher in the long-acting GnRH agonist follicular protocol compared with the antagonist protocol group. There was no difference in miscarriage rate (RR 0.98; 95% CI 0.58, 1.64; P = 0.98) between the long-acting GnRH agonist follicular and antagonist protocols. However, OHSS rate (RR 1.63; 95% CI 1.15, 2.32; P = 0.0058) was lower in the GnRH antagonist protocol compared to the long-acting GnRH agonist protocol group.

CONCLUSION

The long-acting GnRH agonist follicular protocol was beneficial in improving live birth rate, clinical pregnancy rate, and implantation rate whereas the incidence of OHSS was significantly lower in women undergoing the GnRH antagonist protocol.

International Committee for Monitoring Assisted Reproductive Technologies (ICMART): world report on assisted reproductive technologies, 2013

OBJECTIVE

To report the utilization, effectiveness, and safety of practices in assisted reproductive technology (ART) globally in 2013 and assess global trends over time.

DESIGN

Retrospective, cross-sectional survey on the utilization, effectiveness, and safety of ART procedures performed globally during 2013.

SETTING

Seventy-five countries and 2,639 ART clinics.

PATIENT(S)

Women and men undergoing ART procedures.

INTERVENTION(S)

All ART.

MAIN OUTCOME MEASURE(S)

The ART cycles and outcomes on country-by-country, regional, and global levels. Aggregate country data were processed and analyzed based on methods developed by the International Committee for Monitoring Assisted Reproductive Technology (ICMART).

RESULT(S)

A total of 1,858,500 ART cycles were conducted for the treatment year 2013 across 2,639 clinics in 75 participating countries with a global participation rate of 73.6%. Reported and estimated data suggest 1,160,474 embryo transfers (ETs) were performed resulting in >344,317 babies. From 2012 to 2013, the number of reported aspiration and frozen ET cycles increased by 3% and 16.4%, respectively. The proportion of women aged >40 years undergoing nondonor ART increased from 25.2% in 2012 to 26.3% in 2013. As a percentage of nondonor aspiration cycles, intracytoplasmic sperm injection (ICSI) was similar to results for 2012. The in vitro fertilization (IVF)/ICSI combined delivery rates per fresh aspiration and frozen ET cycles were 24.2% and 22.8%, respectively. In fresh nondonor cycles, single ET increased from 33.7% in 2012 to 36.5% in 2013, whereas the average number of transferred embryos was 1.81-again with wide country variation. The rate of twin deliveries after fresh nondonor transfers was 17.9%; the triplet rate was 0.7%. In frozen ET cycles performed in 2013, single ET was used in 57.6%, with an average of 1.49 embryos transferred and twin and triplet rates of 10.8% and 0.4%, respectively. The cumulative delivery rate per aspiration was 30.4%, similar to that in 2012. Perinatal mortality rate per 1,000 births was 22.2% after fresh IVF/ICSI and 16.8% after frozen ET. The data presented depended on the quality and completeness of the data submitted by individual countries. This report covers approximately two-thirds of world ART activity. Continued efforts to improve the quality and consistency of reporting ART data by registries are still needed.

CONCLUSION(S)

Reported ART cycles, effectiveness, and safety increased between 2012 and 2013 with adoption of a better method for estimating unreported cycles.

Impact of thyroid cancer treatment on assisted reproductive technology outcomes in women with infertility

Purpose

We investigated the effect of different surgical procedures and radioactive iodine treatment (RAIT) on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes and evaluated whether possible risk factors, including age, thyroid-stimulating hormone (TSH) levels, and thyroid antibody positivity, were associated with adverse IVF/ICSI outcomes.

Methods

This retrospective study included 76 women with infertility who had received thyroid cancer (TC) treatment among 137,698 infertile women who underwent IVF/ICSI cycles at the Peking University Third Hospital between 2010 and 2019. Clinical pregnancy and live birth rates were assessed.

Results

We found that the clinical pregnancy and live birth rates in women who underwent partial thyroidectomy were 7- and 6-fold higher, respectively, than those in women who underwent total thyroidectomy. We observed no significant differences in the clinical pregnancy and live birth rates between the RAIT and non-RAIT groups, even after adjusting for age, TSH levels, surgical treatment, and thyroid antibody positivity. Multivariate logistic regression analysis showed that age and TSH levels were not associated with decreased clinical pregnancy and live birth rates. Women with thyroid antibody positivity had significantly lower clinical pregnancy and live birth rates than women without thyroid antibody positivity.

Conclusion

Our study showed lower clinical pregnancy and live birth rates in women who underwent total thyroidectomy than in women who underwent partial thyroidectomy. Thyroid antibody positivity is an important risk factor for adverse IVF/ICSI outcomes in women who have received TC treatment.

Impact of previous Caesarean section on reproductive outcomes after assisted reproductive technology: systematic review and meta-analyses

This meta-analysis investigated whether a previous Caesarean section has an impact on the outcomes of treatment with assisted reproductive technology (ART). PubMed, Embase, Cochrane Library, Web of Science and Google Scholar were searched. Clinical trials published in English up to May 2020 were included. Seven studies performed between 2016 and 2020 met all the inclusion criteria. It was found that previous Caesarean section leads to significantly decreased clinical pregnancy rate (CPR) (risk ratio [RR] 0.86; 95% confidence interval [CI], 0.81, 0.92; P < 0.00001) and live birth rate (LBR) (RR 0.80; 95% CI 0.73, 0.86; P < 0.00001). Caesarean section increased the miscarriage rate (RR 1.39; 95% CI 1.18, 1.64; P < 0.0001), and difficult transfer (RR 8.23; 95% CI 4.63, 14.65; P < 0.00001) after ART compared with women who had previous vaginal delivery. The combined results also showed similar endometrial thickness, number of oocytes retrieved, implantation rate, ectopic pregnancy rate, preterm birth and stillbirth between women with previous Caesarean section and women with previous vaginal delivery. In conclusion, Caesarean sections have a detrimental effect on CPR and LBR, and increase the risk of miscarriage and difficult transfer. The indications for Caesarean section should be strictly controlled, and full consultation should be provided to pregnant women. Further studies with stratification analysis of twin and single pregnancies are needed to evaluate the impact of Caesarean section.

Detection of paternal origin of fetal trisomy 18 in a pregnancy conceived by assisted reproductive technology and in vitro fertilization

OBJECTIVE

We present detection of paternal origin of fetal trisomy 18 in a pregnancy conceived by assisted reproductive technology (ART) and in vitro fertilization (IVF).

CASE REPORT

A 39-year-old woman underwent ART and IVF because of primary infertility. The woman was infertile because of myoma and endometriosis. Her husband was 39 years old, and the sperm analysis was normal. The couple was phenotypically normal. This pregnancy was conceived successfully by IVF. She received non-invasive prenatal testing at 11 weeks of gestation, the result showed a high risk for trisomy 18. She underwent chorionic villus sampling at 12 weeks of gestation, and the result was 47,XY,+18 in 24/24 cultured chorionic villi cells. Prenatal ultrasound findings were unremarkable. She underwent amniocentesis at 17 weeks of gestation, and the result was 47,XY,+18 in 20/20 colonies of cultured amniocytes. The pregnancy was subsequently terminated. Postnatal cytogeneic analysis confirmed the prenatal diagnosis. Polymorphic DNA marker analysis on the DNAs extracted from the umbilical cord and parental bloods showed a paternal origin of the extra chromosome 18, indicating a paternal origin of fetal trisomy 18. Cytogenetic analysis of paternal blood revealed a karyotype of 46,XY.

CONCLUSION

Fetal trisomy 18 in pregnancies conceived by ART may be of paternal origin, and determination of paternal origin by polymorphic DNA marker analysis is useful for genetic counseling under such a circumstance.

Elevated Serum Estradiol Levels Do Not Inhibit Implantation During Frozen Embryo Transfer Cycles

The aim of the study is to determine if the magnitude of serum estradiol levels in blastocyst frozen embryo transfer cycles are associated with clinical pregnancy. A retrospective cohort study of female patients 18-43 years old, who underwent vitrified blastocyst embryo transfers at Tripler Army Medical Center from October 1, 2006, to October 1, 2016, was evaluated to determine the impact of estradiol levels on ongoing pregnancy rates in frozen embryo transfer cycles. The study included 173 total frozen embryo transfer cycles during the 10-year study period. The mean age at time of transfer was 34.5 years old (±4.4) with a majority of women undergoing double embryo transfer (70%). There was no statistical difference in ongoing pregnancy rates across estradiol levels (p = 0.80). However, at estradiol levels >3000 pg/mL, a statistically significant ongoing pregnancy rate was observed (p = 0.009). Ongoing pregnancy rate in frozen embryo transfer cycles is not negatively impacted by elevated estradiol levels.

Cognitive achievements in school-age children born following assisted reproductive technology treatments: A prospective study

BACKGROUND

While assisted reproductive technology is increasingly prevalent, there is concern amid conflicting findings reported regarding the long-term outcomes of children born following these treatments. The aim of this research was to investigate aspects of cognitive development in early school-age Israeli children born following assisted reproductive technology (ART) treatments, compared to those spontaneously conceived (SC).

METHOD

This prospective follow-up study was based on an Israeli cohort recruited from June 2006 to December 2008, that included 561 women whose pregnancies were achieved by ART treatments and 600 women whose pregnancies were SC. When the children were 7-8 years old, 759 of their mothers were interviewed by telephone, and 294 were came for developmental assessment. The examination included: Kaufman Brief Intelligence Test; Kaufman Assessment Battery for Children (arithmetic only); Test of Everyday Attention for Children; Beery-Buktenica Developmental Test of Visual-Motor Integration and Supplemental Test for Visual Perception; Rey-Osterrieth Complex Figure Test; Aleph-ad-Tav Hebrew reading and writing; Tavor Picture Naming Expressive Vocabulary Test. Multivariable analyses were adjusted for maternal years of education (≤12, 13+) at child's birth and child's sex.

RESULTS

Cognitive function, visual-motor ability, attention, and verbal skills of children born after ART treatments were similar to those of SC children, upon both univariate and multivariable analysis.

CONCLUSION AND IMPLICATIONS

No significant differences were found between the ART and SC groups on any of the measures examined. This finding offers couples seeking ART treatments improved information regarding child development during the important and formative school years.

WHAT THIS PAPER ADDS

Increasing rates of ART treatments arouse concern about long-term outcomes for offspring, and conflicting findings have been reported with respect to the skills necessary to their academic success. This prospective follow-up study compared school-age children born following ART with spontaneously-conceived children. Children were examined by developmental psychologists, and cognitive function, visual-motor, attention, verbal, and performance skills were similar in both groups.

The Danish National Register of assisted reproductive technology: content and research potentials

The Danish National Register of assisted reproductive technology (ART) was initially established in 1994. The register comprises complete information on all ART procedures in public and private clinics in Denmark from 2013 and onwards, including baseline information on the cause of infertility and a number of health-related patient characteristics. The register enables monitoring and research on infertility treatment and reproductive topics in single women or couples seeking assisted reproduction, and the register is thus a key component of the Danish health information system within human reproduction. We aimed to provide an updated description of the register including advantages and pitfalls when using the register for reproductive epidemiological research, and a description of the accessibility for researchers. The Danish ART register is a valuable tool for epidemiological research. However, the inherent strengths and limitations ought to be in perspective when designing studies and interpreting the study results. Reports with annually aggregated data on ART treatments, can be accessed on the Danish Health Data Authority web page and researchers may obtain access to individual pseudonomized data via secure servers at the Danish Health Data Authority and Statistics Denmark.

Adolescent Transgender Females Present Impaired Semen Quality That Is Suitable for Intracytoplasmic Sperm Injection Even Before Initiating Gender-Affirming Hormone Treatment

The present study aimed to determine the semen quality and cryopreservation outcomes among adolescent transgender females at the time of fertility preservation (FP) before initiating gender-affirming hormone (GAH) treatment. This retrospective cohort study included 26 adolescent transgender females who underwent FP in our Fertility Institute between 06/2013 and 10/2020. Pre-freezing semen parameters were compared to WHO 2010 reference values. Post-thaw semen parameters were used to determine the adequate assisted reproductive technology (ART). A multivariate linear regression analysis was performed to assess the impact of medical and lifestyle factors on semen quality. The mean age at which adolescent transgender females underwent FP was 16.2 ± 1.38 years. The median values of all semen parameters in our study group were significantly lower compared to the WHO data, including volume (1.46 mL vs 3.2 mL, respectively, P = 0.001 ), sperm concentration (28 × 10⁶/mL vs 64 × 10⁶/mL, P < 0.001), total sperm number (28.2 × 10⁶ vs 196 × 10⁶, P < 0.001), total motility (51.6% vs 62%, P < 0.001), and normal morphology (2% vs 14%, P < 0.001). The frequency of semen abnormalities was teratozoospermia 72%, hypospermia 52%, oligozoospermia 28%, and azoospermia 4%. The median post-thaw total motile count was 0.17 × 10⁶/vial, and the quality was adequate only for ICSI in 87.7% of the thawed semen samples. No correlation was found between selected medical and lifestyle factors and poor semen parameters. Semen quality is strongly reduced among adolescent transgender females before hormone therapy and their stored sperm samples are suitable for intracytoplasmic sperm injection (ICSI) rather than conventional IVF/intrauterine insemination (IUI).

Circulating MMP-7 and VEGF as potential predictive biomarkers for recurrent implantation failures

Recurrent implantation failure (RIF) is considered to be one of the major limiting factors of assisted reproductive technology (ART) programme success. The current study focused on the investigation of matrix metalloproteinases (MMPs), tissue inhibitors of MMPs (TIMPs), cytokines and cell adhesion molecules in peripheral blood (PB) and follicular fluid (FF) obtained from 44 women aged between 25 and 39 years old and undergoing intracytoplasmic sperm injection (ICSI). These women were divided into two groups: 22 RIF women with embryo implantation failures after the transfer of at least four fresh or frozen-thawed good quality embryos in a minimum of three ICSI cycles, and 22 ICSI success women (controls) who achieved a clinical pregnancy at their first ICSI attempt. The PB and FF samples were obtained from each patient on the day of oocyte retrieval. MMP-1, -2, -3, -7, -9, TIMP-1, -2, vascular endothelial growth factor (VEGF), leukaemia inhibitory factor (LIF), vascular cell adhesion molecule 1 (VCAM1) and intercellular adhesion molecules 1 (ICAM1) were analyzed using enzyme-linked immunosorbent assay of PB and FF. Our results showed significant decreases in PB MMP-7 and PB VEGF in the RIF group compared with controls [281.11 (33-614) pg/ml vs 119.92 (27-441) pg/ml; P-value = 0.030] and [82.54 (25.94-210.20) pg/ml vs 30.93 (13.62-193.33) pg/ml; P-value = 0.022; respectively]. Receiver operating characteristic (ROC) curve analysis showed informative area under the curve values for PB MMP-7, as well as for PB VEGF, making them able to be proposed as biomarkers of the RIF. Therefore, circulating MMP-7 and VEGF seem to play an interesting role in embryo implantation in in vitro fertilization (IVF)/ICSI cycles and could be proposed as circulating biomarkers of the RIF. These results could be helpful for clinicians and patients to choose the best rescue strategy and treatment to minimize implantation failure in women undergoing IVF/ICSI procedures after the first attempt.

Association between maternal race and the use of assisted reproductive technology in the USA

Despite advances in the field of infertility medicine and its availability, disparities affect the accessibility status worldwide. Racial disparities could potentially affect the utilization of assisted reproductive technology (ART). We aimed at studying the association between maternal race and the use of ART treatment in the USA. We analyzed a secondary dataset (2017 Natality) obtained from the Centers for Disease Control and Prevention. This cross-sectional study acquired information on maternal race as well as ART utilization from women living within the reporting States and US territories. We analyzed the data using descriptive, bivariate, and regression analysis. A total of 3,864,754 live births out of 325,719,178 US races and origin populations were reported for the 2017 review year. A total of 42,846 women who had a live birth reported utilization of ART out of 67,554 respondents. The Chi-square test showed a statistically significant association between maternal race and the use of ART treatment, p value 0.01. Unadjusted regression odds of the utilization of ART at 95 % confidence interval (CI) was 87% higher among non-Hispanic Asian women as compared to the non-Hispanic White. We also found higher odds for maternal age 35-54 years 2.41 (95% CI 2.34-2.49), maternal education (above college degree) 1.36 (95% CI 1.31-1.42), and non-smoking status 2.44 (95% CI 2.02-2.94). Compared to the non-Hispanic white race, the adjusted regression odds were lower for all other racial/ethnic minorities except for the non-Hispanic Asian 63% (95% CI 1.09-2.44) and non-Hispanic mixed race 59% (95% CI 0.81-3.10) subgroups. The study finds the utilization of ART in the USA to be associated with maternal race.

Clinical Efficacy of Follitropin Alfa in GnRH-Antagonist Protocols: A Prospective Observational Phase IV Study on the Use of Biosimilar Follitropin Alfa r-hFSH in Assisted Reproductive Technology in a Routine Care Setting

Background

This phase IV routine care study evaluated ovarian responses when using a biosimilar follitropin alfa r-hFSH (Bemfola^®) for controlled ovarian stimulation (COS) in women undergoing assisted reproductive technology (ART) treatment who were pituitary-suppressed with a gonadotrophin-releasing hormone (GnRH) antagonist.

Methods

This multicenter, prospective, non-comparative, non-interventional study (Germany/Austria) was conducted with 885 women (Mean age of 34.0±4.4 years) for whom COS with Bemfola^® and GnRH-antagonist for pituitary suppression were applied as part of in vitro fertilization (IVF) treatment with/without intracytoplasmic sperm injection (ICSI) observing routine clinical-practice protocols. Primary endpoint was the number of retrieved cumulus-oocyte-complexes (COCs).

Results

Among 986 ART cycles, COS was given for 9.9±1.8 days (First-day r-hFSH dose of 220.7±68.9 IU; mean total dose of 2184.3±837.5 IU). It was revealed that 99.1% of cycles resulted in follicular puncture, with mean of 10.7±6.6 oocytes retrieved. Successful fertilization took place after IVF/ICSI in 93.8% of follicular punctures. Freeze-all was performed in 14.2% of cycles. Fresh embryo transfer was performed in 76.9% of cycles with follicular puncture; mean day of transfer was 3.5±1.3 and average number of transferred embryos was 1.76±0.50. Clinical pregnancy rate was 30.2% of embryo-transfer cycles and 23.4% of started cycles. Sixty-nine reports of ovarian hyperstimulation syndrome (7.0% of started cycles) were documented.

Conclusion

COS with Bemfola^® in GnRH-antagonist IVF/ICSI protocols in a routine care setting led to an appropriate ovarian response allowing oocyte retrieval in 99.1% of initiated cases.

Technicization of "Birth" and "Mothering": Bioethical Debates from Feminist Perspectives

Birthing is a natural phenomenon. However, in the era of modernisation, it has dramatically changed and transformed into a technological affair. Some feminists claim that advances in medicine and assisted reproductive technologies (ARTs) have opened up numerous opportunities and choices for women to free themselves from their destined role of maternity by separating sex from reproduction. But are these technological artefacts always there to emancipate women or just another way to keep them subordinated to serve social needs? Other feminists argue that technology is a controlling tool. It eliminates a woman's choice and uses her body as a baby-manufacturing machine to perpetuate pervasive social roles and responsibilities. Again, if technology is simply a patriarchal trap, then can technological exclusion be the key to all reproductive issues? It seems not! Technology is the inevitable new reality of the world influenced by socio-cultural practices, values, norms and belief system that has a strong impact on human existence. The present paper is an attempt to critically explore and evaluate the ethical challenges posed by technicization of motherhood from two opposite feminist perspectives. I argue that these ART-centred debates are significant but polarised and insufficient to resolve maternal problems. Thus, we need an egalitarian model of technology that saves women from the threat of technicization, and be able to provide a dignified use of it. The paper discusses the impact of technicization on maternal self in relation to ARTs and proposes suggestions to overcome this problem.

Unveiling the controversy on egg freezing in The Netherlands: A Q-methodology study on women's viewpoints

Preserving the option to conceive through egg freezing (oocyte cryopreservation) is surrounded by value conflicts and diverse viewpoints, particularly when non-medical or so-called 'social' reasons are involved. The debate is controversial and shaped by normative perceptions of the life course, including concepts regarding reproductive ageing, gender, motherhood and biomedicalization. To unravel the controversy and systematically identify the variety of viewpoints on egg freezing, a Q-methodology study was conducted in The Netherlands between December 2018 and October 2019. Thirty-four women of reproductive age participated in the study. They ranked 40 statements according to their level of agreement, and explained their ranking during follow-up interviews. Data were analysed using by-person factor analysis and interpreted using both quantitative and qualitative data. Four viewpoints, of which the fourth was bipolar, were identified: (1) cautious about egg freezing technology; (2) my body, my choice; (3) egg freezing is unnatural; and (4) have children and have them early. The distinct viewpoints illustrate different prioritizations of values and normative dimensions of biomedical innovations. By knowing more about the prevalent opinions on egg freezing and the surrounding controversy, policy makers and practitioners can make better informed decisions in terms of promoting and providing patient-centred infertility care. The findings furthermore stimulate continuing scholarly work on egg freezing and other innovations in reproductive medicine which may continue to disrupt normative standards.