Costs of infertility treatment: results from an 18-month prospective cohort study

Isolation, discrimination, and feeling "constant guilt": A mixed-methods analysis of female physicians' experience with fertility, family planning, and oncology careers

INTRODUCTION

Family planning among female physicians is harmed by high risks of infertility, workload burden, poor family leave policies, and gender discrimination. Many women report feeling unsupported in the workplace, despite national policies to protect against unfair treatment.

METHODS

This secondary analysis applied a modified version of the rigorous and accelerated data reduction technique to conduct a thematic analysis of comments to an open-ended prompt. Comments were coded by multiple trained researchers then grouped and merged into illustrative themes via qualitative techniques.

RESULTS

Of 1004 responses to the quantitative survey, 162 physicians completed the open-ended prompt. Initial codes (n = 16) were combined into eight groups including, from which three overarching themes were identified. Institutional barriers were highlighted with comments discussing the increased need for parental leave, part-time options and the concern for academic or professional punishment for being pregnant and/or having children. Departmental barriers were explored with comments grouped around codes of discrimination/negative culture and challenges with breastfeeding/pumping and childcare. Personal barriers were discussed in themes highlighting the difficulties that female physicians faced around the timing of family planning, challenges with reproductive health and assistance, and alternative circumstances and/or decisions against family planning.

CONCLUSION

Barriers to family planning in oncology exist across career domains from dysfunctional maternity leave to poor education on infertility risk. Solutions include improving institutional support, expanding parental leave, and general cultural change to improve awareness and promotion of family and career balance.

Making Sense of Memorable Messages About Infertility: Examining Message Valence by Theme and Sender

Fertility problems, often called infertility, have been defined as the inability to conceive or maintain pregnancy throughout one year of trying (World Health Organization, 2020). Because fertility problems can present unique medical, emotional, relational, and identity challenges, they are often difficult to talk about, and even well-intentioned messages can be perceived negatively. This study uses Communicated Sense-Making (CSM; Kellas & Kranstuber Horstman, 2015), particularly its mechanism of memorable messages, to explore what types of support-related messages people experiencing infertility find memorable. Results from semi-structured interviews (N = 54) indicate five supra-themes of memorable messages: (a) communicating solidarity; (b) attempting to minimize participants' stress; (c) communicating investment or interest in the patient's experience; (d) sharing expertise; and (e) absolving the patient of responsibility; we identify several sub-themes within each. We also explore patterns between message types, senders, and message valence: message themes were perceived as either positive, negative, or neutral based on the combination of sender and perceived intention. Theoretical and practical implications are discussed.

The Importance of Fertility Preservation in the Transgender Population

OBJECTIVE

To call to attention the often-overlooked aspect of pediatric transgender care: the importance of fertility preservation prior to instituting gender-affirming therapy. The transgender population has long been marginalized by society. Societal stigmata, fear to seek care, and dearth of provider knowledge regarding transgender health issues have caused disparities to widen. Gender-affirming procedures and hormone therapy affect the long-term reproductive potential of transgender individuals. While cost concerns and insurance coverage regarding oncofertility is a prominent area of discussion, the transgender community is often excluded.

METHODS

Sixteen genetically XY females, followed by their multidisciplinary transgender care teams, were interested in starting hormone therapy due to impending onset and/or progression of puberty. Their physicians were aware of fertility struggles after undergoing hormone therapy and therefore referred to urology. Sperm cryopreservation via open gonadal biopsy, testicular tissue cryopreservation (TTC), and semen sample (when age/maturity-appropriate) were discussed. Though requiring surgery, biopsy/TTC relieves patients of the psychological impact of semen sample production.

RESULTS

Under IRB approval, 15 patients (median age 12 years, range 10-16 years) underwent TTC (Fig. 1). One patient (aged years) opted for semen sample. All patients had success with spermatogonial stem cells cryopreserved for future patient use.

CONCLUSION

With more individuals beginning medical and surgical therapy at a younger age, fertility preservation discussions are essential but often overlooked, depriving these individuals the joy of becoming a biological parent. TTC can be safely done in pediatric populations, though research is necessary to expand beyond current experimental stage of tissue development.

Infertility care in an underserved population: A retrospective chart review of a resident-run clinic at an urban, public hospital

Despite major advances in infertility services, barriers to care as well as disparities in outcomes remain a significant problem. The cost of treatment, lack of or inadequate coverage, and location of infertility clinics are obvious contributors, however, advanced pathology, coexistent medical conditions, and lack of preconception care also contribute to delay in fertility particularly in underserved communities. Previous studies have discussed the role of trainee-run clinics in lower socioeconomic populations in providing low-cost infertility evaluation and management. This study uses a retrospective chart review to compare the etiology and duration of infertility in our patients to the general infertility patient population, to describe the coexistent medical pathologies within our population at initial presentation to infertility care, and to discuss how our clinic is addressing the gap in infertility care. PRECIS: Resident-run clinics offer a unique role in increasing access to care through preconception care and low-cost fertility treatment.

Hispanic Ethnicity and Fertility Outcomes

OBJECTIVE

To assess the association between ethnicity and fertility outcomes for men in a statewide cohort.

METHODS

We linked data from the Utah Population Database and Subfertility Health Assisted Reproduction and Environment database, to comprise a cohort of sub-fertile men who underwent semen analysis between 1998 and 2017 in Utah. A multivariable Cox proportional hazard model was constructed to understand the impact of ethnicity on fertility outcomes in our cohort.

RESULTS

A total of 11,363 men were included. 1039 (9.1%) were Hispanic. 39.7% of men in the lowest socioeconomic status group were Hispanic (P <.001). When controlling for demographic and clinical factors, the number of live births was reduced for Hispanic men (hazard ratios [HR] = 0.62 [0.57-0.67], P <.001). Though fertility treatment had a positive effect (HR 1.242 [1.085-1.421], P <.001), in competing risks models, Hispanic men were less likely to use fertility treatment (HR = 0.633 [0.526-0.762], P <.001).

CONCLUSION

Hispanic ethnicity is significantly associated with a lower likelihood of successful fertility outcomes in Utah. Hispanic men had nearly a 40% reduced likelihood of live births when controlling for sociodemographic factors. Our results indicate that, depending on age, Hispanic men have up to approximately 14 fewer live births per 100 men per year, pointing to a significant disparity in fertility outcomes in the state of Utah. Given 15.1% of Utah's population identifies as Hispanic and 18.7% of the United States population identifies as Hispanic on the 2020 Census, a better understanding of the association of ethnicity and fertility outcomes is imperative.

Impact of Mandated Insurance Coverage of Assisted Reproductive Technology on Clinic Website Transparency

Objective: The purpose of this study was to determine whether website transparency of service costs, accepted insurance plans, and financing options differs between reproductive endocrinology and infertility clinics located in states that do and do not mandate insurance coverage of assisted reproductive technology (ART). Methods: Six hundred forty-six clinics were identified using the Society for Assisted Reproductive Technology online locator. Clinics were excluded for missing website links, duplicate entries, broken websites, or permanent closure. Mandated coverage by state was gathered on resolve.org Chi-squared testing and logistic regression were performed. Results: Of the 311 clinic websites analyzed, 28.6% were in states that mandate ART coverage and 71.4% were not. Clinics in states that have mandated coverage were more likely to list specific prices on their websites. These clinics were 2.13 times more likely to list specific costs (odds ratio [OR]; 95% confidence interval [CI]: 1.19-3.81, p = 0.01). There was also a significant difference between the percent of clinics in mandated coverage states and nonmandated states that listed accepted insurance plans. These clinics were 2.44 times more likely to report accepted insurance plans (OR; 95% CI: [1.47-4.05], p = 0.005). There was no significant difference in the mention of financial assistance between the groups. Clinics in states with mandated coverage were more likely to mention discount programs, but there was no significant difference for other types of financial assistance. Conclusion: Clinics located in states that mandate insurance coverage of ART are more likely to list specific costs, accepted insurance plans, and the availability of discount programs on their website. Patients living in states without mandated coverage are more likely to need to finance their own treatment, yet these patients are less likely to have nearby clinics that provide financial transparency on their websites.

Fertility Knowledge and Educational Experiences of Graduating Medical Students: A Multi-Institution Survey

Objective: Our goal was to assess the fertility knowledge and educational experiences of graduating U.S. medical students to evaluate areas of improvement for future educational interventions. Design: Web-based cross-sectional survey. Subjects: Medical students graduating in 2023 from the University of Miami Miller School of Medicine (SOM), New York University (NYU) Grossman SOM, Wayne State University SOM, Perelman SOM at the University of Pennsylvania, and Mayo Clinic Alix SOM. Main Outcome Measures: Fertility-related knowledge and educational experiences of U.S. medical students in their final year of school. Results: In total, 117 students (14.4%) completed the survey. The average knowledge score was 78%. Twenty-three (22%) overestimated the age of most precipitous fertility decline, and 50 (52%) overestimated the chance of getting pregnant for a 40-year-old person with ovaries. One-third of students (30, 32%) incorrectly believe that physicians have equivalent infertility rates to the general population. Students were less cognizant of male fertility issues, incorrectly believing there was no negative impact on male fertility by age (43, 42%) among other factors. Seventy-five (81%) reported less than 5 hours of fertility-related education in medical school. Only one-third (32%) were satisfied or very satisfied with the fertility education they received. In an open-response question, students expressed interest in additional education on transgender and cancer patient care, fertility preservation, assisted reproductive technologies, and reproductive life planning in medicine. Conclusions: There is a need and an opportunity for medical education programs to enhance fertility education. Giving students and trainees the knowledge required to make informed decisions for their family-building purposes and improving their ability to counsel patients adequately should be a goal of future educational endeavors. The data collected in this study will serve as a guide for the development of fertility-related learning modules for medical students and trainees.

The influence of assisted reproductive technologies-related stressors and social support on perceived stress and depression

BACKGROUND

While assisted reproductive technologies (ART) have helped many people experiencing infertility become pregnant, the ART process can take a psychological toll. This study examined whether and how perceived stress- and depression-related symptoms vary among individuals at different stages of the infertility and ART process, and whether ART-specific stressors and emotional support are associated with mental health symptomatology.

METHODS

Data were collected using an online REDCap survey administered between July 2021 and March 2022. The survey was administered to 240 participants who had experienced infertility, including those who had not yet accessed ART, those undergoing ART but who were not yet pregnant, those currently pregnant through ART, and those who had given birth in the last year through ART. Each participant completed the Cohen Perceived Stress Scale (range 0-40) and the Edinburgh Depression Scale (range 0-30). Participants who had undergone ART were asked about their experience of ART-specific stressors and how helpful partner and provider support had been during the ART process. Survey data were analyzed using ANOVA and multivariate linear regressions.

RESULTS

88% of participants reported medium or high levels of perceived stress, and 43.8% of respondents showed probable indications of depression. Perceived stress and depression symptoms were significantly higher for individuals currently undergoing, but not yet pregnant from, ART treatments. These effect sizes were substantial; for example, depression scores in this group were five points higher than among currently pregnant individuals and nine points higher than among postpartum individuals. For the subset of participants who had used or were currently undergoing ART (N = 221), perceived social stigma and the physical and time demands of ART were significantly associated with higher stress and depression symptoms, while partner emotional support was associated with lower perceived stress.

CONCLUSIONS

The ART process exacerbates perceived stress and depression symptoms among individuals experiencing infertility. Given the potential long-term impacts on both parent and child wellbeing, clinicians and policymaking groups, including the American Society for Reproductive Medicine (ASRM), should consider making access to mental health services a standard of care during infertility treatment.

Assisted reproductive technology (ART) patient information-seeking behavior: a qualitative study

BACKGROUND

Approximately 13% of women in the United States of reproductive age seek infertility services. Assisted reproductive technology (ART), including in vitro fertilization, is used to help patients achieve pregnancy. Many people are not familiar with these treatments prior to becoming patients and possess knowledge gaps about care.

METHODS

This study employed qualitative methods to investigate how patients interact with information sources during care. Patients who underwent ART including embryo transfer between January 2017 and April 2022 at a large urban healthcare center were eligible. Semi-structured, in-depth interviews were conducted between August and October 2022. Fifteen females with an average age of 39 years participated. Reflexive thematic analysis was performed.

RESULTS

Two main themes emerged. Participants (1) utilized clinic-provided information and then turned to outside sources to fill knowledge gaps; (2) struggled to learn about costs, insurance, and mental health resources to support care. Participants preferred clinic-provided resources and then utilized academic sources, the internet, and social media when they had unfulfilled information needs. Knowledge gaps related to cost, insurance, and mental health support were reported.

CONCLUSION

ART clinics can consider providing more information about cost, insurance, and mental health support to patients.

TRIAL REGISTRATION

The Massachusetts General Hospital Institutional Review Board approved this study (#2022P000474) and informed consent was obtained from each participant.

Ex ovo omnia-why don't we know more about egg quality via imaging?

Determining egg quality is the foremost challenge in assisted reproductive technology (ART). Although extensive advances have been made in multiple areas of ART over the last 40 years, oocyte quality assessment tools have not much evolved beyond standard morphological observation. The oocyte not only delivers half of the nuclear genetic material and all of the mitochondrial DNA to an embryo but also provides complete developmental support during embryonic growth. Oocyte mitochondrial numbers far exceed those of any somatic cell, yet little work has been done to evaluate the mitochondrial bioenergetics of an oocyte. Current standard oocyte assessment in in vitro fertilization (IVF) centers include the observation of oocytes and their surrounding cell complex (cumulus cells) via stereomicroscope or inverted microscope, which is largely primitive. Additional oocyte assessments include polar body grading and polarized light meiotic spindle imaging. However, the evidence regarding the aforementioned methods of oocyte quality assessment and IVF outcomes is contradictory and non-reproducible. High-resolution microscopy techniques have also been implemented in animal and human models with promising outcomes. The current era of oocyte imaging continues to evolve with discoveries in artificial intelligence models of oocyte morphology selection albeit at a slow rate. In this review, the past, current, and future oocyte imaging techniques will be examined with the goal of drawing attention to the gap which limits our ability to assess oocytes in real time. The implications of improved oocyte imaging techniques on patients undergoing IVF will be discussed as well as the need to develop point of care oocyte assessment testing in IVF labs.

A Review: Biomechanical Aspects of the Fallopian Tube Relevant to its Function in Fertility

The fallopian tube (FT) plays a crucial role in the reproductive process by providing an ideal biomechanical and biochemical environment for fertilization and early embryo development. Despite its importance, the biomechanical functions of the FT that originate from its morphological aspects, and ultrastructural aspects, as well as the mechanical properties of FT, have not been studied nor used sufficiently, which limits the understanding of fertilization, mechanotrasduction, and mechanobiology during embryo development, as well as the replication of the FT in laboratory settings for infertility treatments. This paper reviews and revives valuable information on human FT reported in medical literature in the past five decades relevant to the biomechanical aspects of FT. In this review, we summarized the current state of knowledge concerning the morphological, ultrastructural aspects, and mechanical properties of the human FT. We also investigate the potential arising from a thorough consideration of the biomechanical functions and exploring often neglected mechanical aspects. Our investigation encompasses both macroscopic measurements (such as length, diameter, and thickness) and microscopic measurements (including the height of epithelial cells, the percentage of ciliated cells, cilia structure, and ciliary beat frequency). Our primary focus has been on healthy women of reproductive age. We have examined various measurement techniques, encompassing conventional metrology, 2D histological data as well as new spatial measurement techniques such as micro-CT.

The impacts of telemedicine on assisted reproduction: a systematic review and meta-analysis

Telemedicine is being applied in assisted reproduction technology (ART) to provide remote consultations, monitoring and support for patients. This study aimed to evaluate the potential advantages of telemedicine in ART treatment in the form of virtual consultations. Studies in which patients were using telemedicine during ART treatment were identified from four scientific databases (PudMed, EMBASE, Scopus, Web of Science). The success of fertility treatments was compared between telemedicine and in-office care, and patient satisfaction with ART through telemedicine was assessed. Eleven studies, comprising 4697 patients, were identified. Quality assessment (Joanna Briggs Institute Critical Appraisal and revised Cochrane risk-of-bias tools) revealed an acceptable risk of bias for both randomized controlled trials and observational studies. Using a fixed-effects model, telemedicine was comparable to in-person care regarding the pregnancy rate achieved (odds ratio 1.02, 95% confidence intervals 0.83-1.26, P = 0.83). A Q-test suggested that all the included studies were homogeneous. Patients who received telemedicine during fertility treatment reported a high level of satisfaction (91%, 95% confidence intervals 80-96%). Egger's test confirmed that no publication bias was found. Telemedicine could serve as a complementary tool during fertility treatment to facilitate patients' satisfaction and overcome some practical problems without compromising treatment outcomes. Future studies should continue exploring the potential applications of telemedicine in assisted reproduction.

Oral medroxyprogesterone acetate for the use of ovulation suppression in in vitro fertilization: a cohort trial

OBJECTIVE

To broadly assess the efficacy of medroxyprogesterone acetate (MPA) for ovulatory suppression during in vitro stimulation compared with gonadotropin-releasing hormone (GnRH) antagonist cycles.

DESIGN

Cohort trial.

SETTING

A single academic-affiliated private fertility practice.

PATIENTS

Patients of all diagnoses aged 18-44 years undergoing autologous in vitro fertilization (IVF) for fertility treatment between 2020 and 2023.

INTERVENTIONS

Comparison of MPA vs. antagonist IVF stimulation cycles.

MAIN OUTCOME MEASURES

Rates of premature ovulation, oocyte and embryo yield, embryo quality, pregnancy rates, and logistical benefits.

RESULTS

Prospective data was collected on 418 patients who underwent MPA protocol ovarian stimulation (MPA group), which was compared with 419 historical control gonadotropin hormone-releasing hormone antagonist cycles (control group). Age was similar between groups (35.6 ± 4.6 vs. 35.7 ± 4.8 years; P = .75). There were no cases of premature ovulation in the MPA group compared with a total of five cases in the control group (0% vs. 1.2%; risk ratio [RR] = 0.09; 95% confidence interval [CI], 0.01, 1.66). No differences were seen between number of oocytes retrieved (14.3 ± 10.2 vs. 14.3 ± 9.7; P = .83), blastocysts (4.9 ± 4.6 vs. 5.0 ± 4.6; P = .89), or euploid blastocysts (2.4 ± 2.6 vs. 2.2 ± 2.4; P = .18) in the MPA vs. control group respectively. Clinical pregnancy rate was similar between groups (70.4% vs. 64.2%; RR = 0.92; 95% CI, 0.72, 1.18). There was no difference in length of IVF stimulation or dose of stimulation medications. Patients in the MPA group saved an average of $491 ± $119 on medications, had an average of one less monitoring visit (4.4 ± 0.9 vs. 5.6 ± 1.1; P<.01), and 5.0 ± 1.2 less injections per cycle. When adjusting for age and ovarian reserve, protocol group (MPA vs. control) did not influence having an embryo available for transfer (76.6% vs. 73.4%; adjusted RR = 1.05; 95% CI, 0.94, 1.14).

CONCLUSION

For ovulatory suppression during IVF cycles, MPA was effective at preventing ovulation while demonstrating similar cycle and reproductive outcomes, with the additional benefits of patient cost savings, increased convenience with decreased number of visits, and fewer injections.

Genome-wide analyses identify 21 infertility loci and over 400 reproductive hormone loci across the allele frequency spectrum

Genome-wide association studies (GWASs) may help inform treatments for infertility, whose causes remain unknown in many cases. Here we present GWAS meta-analyses across six cohorts for male and female infertility in up to 41,200 cases and 687,005 controls. We identified 21 genetic risk loci for infertility (P≤5E-08), of which 12 have not been reported for any reproductive condition. We found positive genetic correlations between endometriosis and all-cause female infertility (rg=0.585, P=8.98E-14), and between polycystic ovary syndrome and anovulatory infertility (rg=0.403, P=2.16E-03). The evolutionary persistence of female infertility-risk alleles in EBAG9 may be explained by recent directional selection. We additionally identified up to 269 genetic loci associated with follicle-stimulating hormone (FSH), luteinising hormone, oestradiol, and testosterone through sex-specific GWAS meta-analyses (N=6,095-246,862). While hormone-associated variants near FSHB and ARL14EP colocalised with signals for anovulatory infertility, we found no rg between female infertility and reproductive hormones (P>0.05). Exome sequencing analyses in the UK Biobank (N=197,340) revealed that women carrying testosterone-lowering rare variants in GPC2 were at higher risk of infertility (OR=2.63, P=1.25E-03). Taken together, our results suggest that while individual genes associated with hormone regulation may be relevant for fertility, there is limited genetic evidence for correlation between reproductive hormones and infertility at the population level. We provide the first comprehensive view of the genetic architecture of infertility across multiple diagnostic criteria in men and women, and characterise its relationship to other health conditions.

The Prevalence of Endometriosis in Patients with Unexplained Infertility

Endometriosis, a systemic ailment, profoundly affects various aspects of life, often eluding detection for over a decade. This leads to enduring issues such as chronic pain, infertility, emotional strain, and potential organ dysfunction. The prolonged absence of diagnosis can contribute to unexplained obstetric challenges and fertility issues, necessitating costly and emotionally taxing treatments. While biopsy remains the gold standard for diagnosis, emerging noninvasive screening methods are gaining prominence. These tests can indicate endometriosis in cases of unexplained infertility, offering valuable insights to patients and physicians managing both obstetric and non-obstetric conditions. In a retrospective cross-sectional study involving 215 patients aged 25 to 45 with unexplained infertility, diagnostic laparoscopy was performed after unsuccessful reproductive technology attempts. Pathology results revealed tissue abnormalities in 98.6% of patients, with 90.7% showing endometriosis, confirmed by the presence of endometrial-like glands and stroma. The study underscores the potential role of endometriosis in unexplained infertility cases. Although the study acknowledges selection bias, a higher than previously reported prevalence suggests evaluating endometriosis in patients who have not responded to previous reproductive interventions may be justified. Early detection holds significance due to associations with ovarian cancer, prolonged fertility drug use, pregnancy complications, and elevated post-delivery stroke risk.

Economics of Fertility Care

Family building is a human right. The high cost and lack of insurance coverage associated with fertility treatments in the United States have made treatment inaccessible for many patients. The universal uptake of "add-on" services has further contributed to high out-of-pocket costs. Expansion in access to infertility care has occurred in several states through implementation of insurance mandates, and more employers are offering fertility benefits to attract and retain employees. An understanding of the economic issues shaping fertility should inform future policies aimed at promoting evidence-based practices and improving access to care in the United States.

Comparing infertility-related stress, coping, and quality of life among assisted reproductive technology and non-assisted reproductive technology treatments

Women who undergo assisted reproductive technology (ART) treatments experience infertility-related stress and have low quality of life (QOL). However, there is limited understanding of infertility-related stress, coping, or QOL among women who undergo non-ART treatments. The purpose of this study was to examine infertility-related stress, coping, and QOL among women who undergo ART and non-ART infertility treatments. Using a descriptive correlational cross-sectional design, we recruited 200 women who underwent infertility treatments. Participants completed the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Fertility Problem Stress Scale, COMPI Coping Styles Scale, Fertility Quality of Life tool, and a demographic infertility survey. Data analysis included descriptive statistics, independent t-test, chi-square, and hierarchical multiple regression. Women who underwent non-ART had more personal stress, used more active-avoidance coping, and had lower emotional, social, and treatment environment QOL compared to those in ART treatment. Women who underwent ART treatments used more meaning-based coping but had lower treatment tolerability QOL. Stress and coping contribute to core QOL differently among infertility treatment groups. Both treatment groups report low satisfaction with emotional services. Regardless of the treatment type, women who undergo infertility treatments may need care to address their psychological health.

Banking on Fertility Preservation: Financial Concern for Adolescent and Young Adult Cancer Patients Considering Oncofertility Services

Purpose: Financial concern is a major issue for adolescent and young adult (AYA) cancer patients. Furthermore, unaddressed oncofertility challenges (e.g., infertility) are linked to psychological distress and decreased overall quality of life. Little is known about how financial concern in terms of oncofertility (i.e., concern regarding affording fertility preservation [FP] services) impacts AYAs' decision making and experiences. Methods: AYA cancer patients (n = 27) aged 12-25 years whose cancer treatment conferred risk of infertility were recruited through electronic health record query. Participants completed semi-structured interviews, which were recorded, transcribed, and deductively coded for themes related to information needs, knowledge of treatment effects on fertility, and reproductive concerns after cancer. Emergent, inductive themes related to financial concern were identified. The Institutional Review Board at the University of Michigan approved this study (HUM#00157267). Results: Financial concern was a dominant theme across the qualitative data. Emergent themes included (1) varied access to health insurance, (2) presence of parental/guardian support, (3) reliance upon financial aid, (4) negotiating infertility risk, and (5) lack of preparation for long-term costs. AYAs relied heavily upon parents for out-of-pocket and insurance coverage support. Some participants sought financial aid when guided by providers. Several participants indicated that no financial support existed for their circumstance. Conclusions: Financial consequences in terms of oncofertility are a major issue affecting AYA cancer patients. The incidence and gravity of financial concern surrounding affording oncofertility services merits attention in future research (measuring financial resources of AYAs' parental/support networks), clinical practice (strategically addressing short- and long-term costs; tailored psychosocial support), and health care policy (promoting legislation to mandate pre- and post-treatment FP coverage).

Sexually dimorphic impact of preconceptional and gestational exposure to a real-life environmental chemical mixture (biosolids) on offspring growth dynamics and puberty in sheep

Humans are ubiquitously exposed to complex mixtures of environmental chemicals (ECs). This study characterised changes in post-natal and peripubertal growth, and the activation of the reproductive axis, in male and female offspring of sheep exposed to a translationally relevant EC mixture (in biosolids), during pregnancy. Birthweight in both sexes was unaffected by gestational biosolids exposure. In contrast to females (unaffected), bodyweight in biosolids males was significantly lower than controls across the peripubertal period, however, they exhibited catch-up growth eventually surpassing controls. Despite weighing less, testosterone concentrations were elevated earlier, indicative of early puberty in the biosolids males. This contrasted with females in which the mean date of puberty (first progesterone cycle) was delayed. These results demonstrate that developmental EC-mixture exposure has sexually dimorphic effects on growth, puberty and the relationship between body size and puberty. Such programmed metabolic/reproductive effects could have significant impacts on human health and wellbeing.

Evaluating group psychological interventions for mental health in women with infertility undertaking fertility treatment: A systematic review and meta-Analysis

ABSTRACTWe conducted a systematic review and meta-analysis of the published literature concerning the effectiveness of group psychological interventions in improving anxiety, depression, marital dissatisfaction, fertility quality of life and stress, and pregnancy outcomes of women with infertility, participating in fertility treatment. A search of five databases yielded 1603 studies; 30 articles met inclusion criteria, and computations of effect sizes ensued (Hedges' g and Odds Ratios (OR)). The total sample comprised 2752 participants, with 1279 participants receiving group intervention and 1473 participants in the comparison group. Group psychological interventions reduced depression (Hgw =  -1.277; 95% CI = [-1.739- -0.815]; p =  0.000), anxiety (Hgw = -1.136, 95% CI [-1.527- -0.744]; p =  0.000), fertility stress (Hgw = -0.250, 95% CI [-0.388- -0.122]; p =  0.000), and marital dissatisfaction (Hgw = -0.938; 95% [CI -1.455- -0.421]; p =  0.000), and pregnancy rates improved (OR = 2.422 95% CI [2.037-2.879]; p = 0.000). No improvement was observed regarding fertility quality of life (Hgw = 0. 144; 95% CI [-0.176- 0.463]; p =  0.379). Our findings highlight that participation in group psychological intervention improved the mental health, fertility stress and pregnancy rates of women with infertility.

Preimplantation genetic testing for sickle cell disease: a cost-effectiveness analysis

Objective

To evaluate the cost-effectiveness of in vitro fertilization with preimplantation genetic testing for monogenic disease (IVF + PGT-M) in the conception of a nonsickle cell disease (non-SCD) individual compared with standard of care treatment for a naturally conceived, sickle cell disease (SCD)-affected individual.

Design

A Markov simulation model was constructed to evaluate a one-time IVF + PGT-M treatment compared with the lifetime standard of care costs of treatment for an individual potentially born with SCD. Using an annual discount rate of 3% for cost and outcome measures, quality-adjusted life years were constructed from utility weights and life expectancy values and then used as the effectiveness measurement. An incremental cost-effectiveness ratio was calculated for both treatment arms, and a willingness-to-pay threshold of $50,000 per quality-adjusted life year was assumed.

Setting

Tertiary care or university medical center.

Patients

A hypothetical cohort of 10,000 patients was analzyed over a lifetime horizon using yearly cycles.

Interventions

In vitro fertilization with preimplantation genetic testing for monogenic disease use in conception of a non-SCD individual.

Main Outcome Measures

The primary outcomes of interest were the incremental cost and effectiveness of an IVF+PGT-M conception compared with the SOC treatment of an SCD-affected individual.

Results

In vitro fertilization with preimplantation genetic testing for monogenic disease was the optimal strategy in 93.17% of the iterations. An incremental savings of $137,594 was demonstrated with a gain of 1.96 QALYs and 3.69 life years over a lifetime. Sensitivity analysis demonstrated that SOC treatment never met equivalent cost-effectiveness.

Conclusions

Our model demonstrates that IVF + PGT-M for selection against SCD, compared with lifetime SOC treatment for those affected, is the most cost-effective strategy within the United States healthcare sector.

The impact of socioeconomic status on bulk semen parameters, fertility treatment, and fertility outcomes in a cohort of subfertile men

OBJECTIVE

To study the effect of socioeconomic status on the use of fertility treatment and the rate of live birth in men with subfertility.

DESIGN

A retrospective, time-to-event analysis of men with subfertility in Utah stratified by socioeconomic status.

SETTING

Patients seen in fertility clinics throughout Utah.

PATIENT(S)

All men in Utah undergoing semen analysis between 1998 and 2017 at the state's 2 largest health care networks.

INTERVENTION(S)

Socioeconomic status (defined as area deprivation index of patients' residential location).

MAIN OUTCOME MEASURE(S)

Categorical use of fertility treatment, the count of fertility treatments (in patients with ≥1 treatment), and live birth after semen analysis.

RESULT(S)

When controlling for age, ethnicity, and semen parameters (count and concentration), men from low socioeconomic areas were only 60%-70% as likely to use fertility treatment depending on type compared with men from high socioeconomic areas (intrauterine insemination [IUI] hazards ratio [HR] = 0.691 (0.581-0.821), P<.001; in vitro fertilization [IVF] HR = 0.602 (0.466-0.778), P<.001). Of men undergoing fertility treatment, those from low socioeconomic areas had 75%-80% the number of treatments as men from high socioeconomic areas depending on type (IUI incident rate ratio = 0.740 (0.645-0.847), P<.001; IVF incident rate ratios = 0.803 (0.585-1.094), P=.170). When controlling for age, ethnicity, semen parameters, and use of fertility treatment, men from low socioeconomic areas were only 87% as likely to experience a live birth as men from high socioeconomic areas (HR = 0.871 (0.820-0.925), P<.001). Given the overall higher likelihood of live birth in men from high socioeconomic areas, as well as their greater chance of using fertility treatment, we predicted an annual disparity of 5 additional live births in high socioeconomic men compared with low for every 100 men.

CONCLUSION(S)

Men from low socioeconomic areas undergoing semen analyses are significantly less likely to use fertility treatment and experience a live birth than their counterparts from high socioeconomic areas. Mitigation programs to increase access to fertility treatment may help to reduce this bias; however, our results suggest that additional discrepancies beyond fertility treatment require addressing.

Protocol for improving the costs and outcomes of assistive reproductive technology fertility care pathways: a study using cost measurement and process mining

INTRODUCTION

Value-based healthcare suggests that care outcomes should be evaluated in relation to the costs of delivering that care from the perspective of the provider. However, few providers achieve this because measuring cost is considered complex and elaborate and, further, studies routinely omit cost estimates from 'value' assessments due to lacking data. Consequently, providers are currently unable to steer towards increased value despite financial and performance pressures. This protocol describes the design, methodology and data collection process of a value measurement and process improvement study in fertility care featuring complex care paths with both long and non-linear patient journeys.

METHODS AND ANALYSIS

We employ a sequential study design to calculate total costs of care for patients undergoing non-surgical fertility care treatments. In doing so, we identify process improvement opportunities and cost predictors and will reflect on the benefits of the information generated for medical leaders. Time-to-pregnancy will be viewed in relation to total costs to determine value. By combining time-driven, activity-based costing with observations and process mining, we trial a method for measuring care costs for large cohorts using electronic health record data. To support this method, we create activity and process maps for all relevant treatments: ovulation induction, intrauterine insemination, in vitro fertilisation (IVF), IVF with intracytoplasmic sperm injection and frozen embryo transfer after IVF. Our study design, by showing how different sources of data can be combined to enable cost and outcome measurements, can be of value to researchers and practitioners looking to measure costs for care paths or entire patient journeys in complex care settings.

ETHICS AND DISSEMINATION

This study was approved by the ESHPM Research Ethics Review Committee (ETH122-0355) and the Reinier de Graaf Hospital (2022-032). Results will be disseminated through seminars, conferences and peer-reviewed publications.

Ethics Considerations Regarding Artificial Womb Technology for the Fetonate

Since the early 1980's, with the clinical advent of in vitro fertilization resulting in so-called "test tube babies," a wide array of ethical considerations and concerns regarding artificial womb technology (AWT) have been described. Recent breakthroughs in the development of extracorporeal neonatal life support by means of AWT have reinitiated ethical interest about this topic with a sense of urgency. Most of the recent ethical literature on the topic, however, pertains not to the more imminent scenario of a physiologically improved method of neonatal care through AWT, but instead to the remote scenario of "complete ectogenesis" that imagines human gestation occurring entirely outside of the womb. This scoping review of the ethical literature on AWT spans from more abstract concerns about complete ectogenesis to more immediate concerns about the soon-to-be-expected clinical life support of what we term the fetal neonate or fetonate. Within an organizing framework of different stages of human gestational development, from conception to the viable premature infant, we discuss both already identified and newly emerging ethical considerations and concerns regarding AWT and the care of the fetonate.

Prevalence and associated factors of medication adherence among infertile women undergoing frozen-thawed embryo transfer cycle: A cross-sectional study

Objective: This study aimed to explore the prevalence and associated factors of medication adherence among infertile women undergoing frozen-thawed embryo transfer (FET) cycle.

Methods: A cross-sectional study was conducted with 556 infertile women undergoing FET cycle in total. The Self-efficacy for Appropriate Medication Use Scale (SEAMS), Herth Hope Index (HHI) scale, and Social Support Rating Scale (SSRS) were used to evaluate the patients. Data were described by univariate and multivariate analyses. Logistic regression method was performed to analyse the factors potentially associated with medication adherence.

Results: The average score of Self-efficacy for Appropriate Medication Use Scale (SEAMS) was 30.38 ± 6.65, and 65.3% of participants showed non-adherence. Multiple regression analysis indicated that first-time FET cycle, treatment stage, methods of daily medication, social support and hope level were the main associated factors of the medication adherence among infertile women undergoing FET cycle (p &lt; 0.001).

Conclusion: This study revealed the medication adherence is at medium level among infertile women undergoing FET cycle, especially in patients with repeated FET cycles. The study also suggested that improving the hope level and social support of infertile women undergoing FET cycle may increase medication adherence.

Association of state insurance coverage mandates with assisted reproductive technology care discontinuation

BACKGROUND

Insurance coverage for fertility services may reduce the financial burden of high-cost fertility care such as assisted reproductive technology and improve its utilization. Patients who exit care after failing to reach their reproductive goals report higher rates of mental health problems and a lower sense of well-being. It is important to understand the relationship between state-mandated insurance coverage for fertility services and assisted reproductive technology care discontinuation.

OBJECTIVE

This study aimed to assess whether state-mandated insurance coverage for fertility services is associated with lower rates of care discontinuation after an initial assisted reproductive technology cycle that did not result in a live birth.

STUDY DESIGN

This is a retrospective, population-based cohort study using data from United States fertility clinics reporting to the National Assisted Reproductive Technology Surveillance System during 2016 and 2018. Patients who began their first autologous assisted reproductive technology cycle during 2016 and 2017 and did not have a live birth were included. We describe the rate of assisted reproductive technology care discontinuation (no additional cycle within 12 months of the previous cycle's date of failure). Multivariable analyses were conducted to evaluate factors independently associated with care discontinuation, including the scope of fertility services included in state coverage mandate at assisted reproductive technology cycle initiation that were as follows: comprehensive (≥3 assisted reproductive technology cycles), limited (1, 2, or an unspecified number of assisted reproductive technology cycles), mandate not including assisted reproductive technology, and no mandate.

RESULTS

Among 91,324 patients who underwent their first autologous assisted reproductive technology cycle that did not result in live birth, 24,072 (26.4%) discontinued care. Compared with patients who lived in states with mandates for comprehensive assisted reproductive technology coverage, those in states with mandates for fertility services coverage that did not include assisted reproductive technology or states with no mandate were 46% (adjusted relative risk, 1.46; 95% confidence interval, 1.31-1.63) and 26% (adjusted relative risk, 1.26; 95% confidence interval, 1.15-1.39) more likely to discontinue care, respectively, after controlling for patient and cycle characteristics. Increasing patient age, distance from clinic ≥50 miles, previous live birth, fewer oocytes retrieved, and not having embryos cryopreserved were also associated with higher rates of discontinuation. Non-Hispanic Black, non-Hispanic Asian, and Hispanic patients had higher rates of care discontinuation than non-Hispanic White patients regardless of the existence or scope of state-mandated assisted reproductive technology coverage.

CONCLUSION

Comprehensive state-mandated insurance coverage for assisted reproductive technology is associated with lower rates of assisted reproductive technology care discontinuation.

Cost of Cancer in Adolescents and Young Adults in the United States: Results of the 2021 Report by Deloitte Access Economics, Commissioned by Teen Cancer America

PURPOSE

The purpose of this report, commissioned by Teen Cancer America and performed by Deloitte Access Economics in 2021, was to estimate the total costs incurred by adolescent and young adults (AYAs) after cancer diagnosis in the United States (US) over their life course.

METHODS

The incidence of cancer in 2019 among AYAs age 15-39 years was estimated from the US Cancer Statistics Public Use Database, and relative survival was projected from the Surveillance, Epidemiology, and End Results Program. Cost domains included health system, productivity, and well-being costs. Components were estimated with published literature and pooled data from the Medical Expenditure Panel Survey from 2008 to 2012 and inflated to 2019 dollars.

RESULTS

The economic and human costs of cancer in AYAs are substantial-$23.5 billion overall, corresponding to $259,324 per person over the lifetime. The majority of costs are borne by AYA cancer survivors themselves in the form of lost productivity, loss of well-being, and loss of life.

CONCLUSION

These findings underscore the need to address the burden of cancer in AYAs through targeted programs for AYAs, such as financial navigation and health insurance literacy interventions, as well as local and national policy initiatives to address access to and enhanced coverage for clinical trials participation, fertility services, and survivorship care.

Physical intimate partner violence among women reporting prior fertility treatment: a survey of U.S. postpartum women

OBJECTIVE

To determine the prevalence of physical intimate partner violence (IPV) among postpartum women reporting preconception fertility treatment compared with those who conceived without the use of assisted reproduction.

DESIGN

Retrospective cross-sectional population-based study.

SETTING

Not applicable.

PATIENT(S)

Postpartum respondents of the Centers for Disease Control Pregnancy Risk Assessment Monitoring System survey.

INTERVENTION

Preconception fertility treatment utilization.

MAIN OUTCOME MEASURES

Physical IPV.

RESULTS

Of the 43,999 respondents included in this analytic sample, roughly 2% reported physical IPV. Respondents reporting preconception fertility treatment (12.6%) were less likely to endorse physical IPV than those who conceived without fertility treatment exposure (odds ratio, 0.5; 95% confidence interval, 0.4-0.7). In the multivariate regression model, the odds of physical IPV were similar among postpartum women regardless of the fertility treatment exposure (adjusted odds ratio, 1.2; 95% confidence interval, 0.8-2.0). Residing in a household with an income under the federal poverty level and increased preconception stressors were predictive of reported physical IPV. There was no difference in the type of fertility treatment and report of physical IPV. Among women exposed to fertility treatment, predictors of physical IPV included self-identification of Black or Hispanic race and ethnicity as well as report of 4 or more stressors in the 12 months before the most recent delivery.

CONCLUSION

The use of fertility treatment did not confer greater risk of physical IPV within this postpartum population. However, there are many individuals with infertility who never present for an assessment, proceed with treatment, or are unsuccessful, thus the extent to which infertility and fertility treatment exposure is associated with physical IPV remains to be elucidated. Women reporting a greater number of stressors may be uniquely at risk despite the access and exposure to fertility treatment. The preconception period, inclusive of encounters with infertility specialists, represents a novel opportunity to screen and counsel all women for IPV.

Preconception sleep duration, sleep timing, and shift work in association with fecundability and live birth among women with a history of pregnancy loss

OBJECTIVE

To evaluate the associations between preconception sleep characteristics and shift work with fecundability and live birth.

DESIGN

Secondary analysis of the Effects of Aspirin in Gestation and Reproduction study, a preconception cohort.

SETTING

Four US academic medical centers.

PATIENT(S)

Women aged 18-40 with a history of 1-2 pregnancy losses who were attempting to conceive again.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURES(S)

We evaluated baseline, self-reported sleep duration, sleep midpoint, social jetlag, and shift work among 1,228 women who were observed for ≤6 cycles of pregnancy attempts to ascertain fecundability. We ascertained live birth at the end of follow up via chart abstraction. We estimated fecundability odds ratios (FORs) using discrete, Cox proportional hazards models and risk ratios (RRs) for live birth using log-Poisson models.

RESULT(S)

Sleep duration ≥9 vs. 7 to <8 hours (FOR: 0.81, 95% confidence interval [CI], 0.61; 1.08), later sleep midpoints (3rd tertile vs. 2nd tertile: FOR: 0.85; 95% CI, 0.69, 1.04) and social jetlag (continuous per hour; FOR: 0.93, 95% CI: 0.86, 1.00) were not associated with reduced fecundability. In sensitivity analyses, excluding shift workers, sleep duration ≥9 vs. 7 to <8 hours (FOR: 0.62; 95% CI, 0.42; 0.93) was associated with low fecundability. Night shift work was not associated with fecundability (vs. non-night shift work FOR: 1.17, 95% CI, 0.96; 1.42). Preconception sleep was not associated with live birth.

CONCLUSION(S)

Overall, there does not appear to be a strong association between sleep characteristics, fecundability, and live birth. Although these findings may suggest weak and imprecise associations with some sleep characteristics, our findings should be evaluated in larger cohorts of women with extremes of sleep characteristics.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT00467363.

Impact of COVID-19 on mental health of infertile couple: A rapid systematic review

Infertile couples experience a lot of psychological stress due to the inability to achieve the desired social role. Couples who decide to continue assisted reproductive therapy (ART) during the epidemic also experience the psychological impact of the COVID-19 epidemic, which affects their daily lives due to social isolation, quarantine, travel restrictions, and cancellation of treatment. Therefore, the purpose of this study was to assess the mental health of infertile couple pausing or delaying their treatment due to the COVID-19 pandemic. PubMed, Scopus, Cochrane, Embase, Web of Science, ScienceDirect, Google Scholar, Research Gate, and the World Health Organization databases and websites were systematically searched for original studies concerning abortion in the era of COVID-19 pandemic published by August 15, 2021. We used the following keywords: "COVID-19 Corona virus, infertility, reproductive technique, fertilization, assisted reproduction, pregnant termination, psychological, in vitro mental status, depressive symptoms, and anxiety." In sum, after automatically and manually search and excluding duplicates, 269 articles were found. In final, after screening, 18 articles were selected. Most patients experienced negative emotions during the COVID-19 epidemic. When reproductive services were re-established, participants showed higher levels of anxiety and lower quality of life than before quarantine. Women who thought pregnancy was more important than getting COVID-19 had higher levels of anxiety than women who thought otherwise (P < 0.05). The COVID-19 pandemic has negative impacts on the mental health and quality of life of patients seeking fertility services and coping with it requires timely and appropriate psychological intervention, accurate information, and social and organizational support.

Is There a Relationship between Sperm DNA Fragmentation and Intra-Uterine Insemination Outcome in Couples with Unexplained or Mild Male Infertility? Results from the ID-Trial

BACKGROUND

Sperm DNA fragmentation has been proposed as a candidate test for the assessment of sperm function on the premise that damage to the sperm chromatin is associated with a detrimental reproductive outcome. The objective of our study was to investigate whether sperm DNA fragmentation testing has a prognostic value, and thus can play a pivotal role in selecting future patients for intra-uterine insemination (IUI) therapy.

METHODS

This was a prospective cohort study conducted in a University Hospital setting. SDF was measured through TUNEL assay on the fresh semen sample presented at diagnosis and at insemination in couples with idiopathic/mild male infertility undergoing natural cycle IUI treatment. The generalized estimating equation (GEE)-model and multivariable model were used to analyze the probability of live birth and clinical pregnancy, respectively. ROC analysis was carried out to determine an SDF cut-off.

RESULTS

There was an inverse relationship between SDF in the ejaculate of the diagnostic semen sample and CP (p = 0.02; OR 0.94 95% CI (0.90, 0.989)) as well as LB (p = 0.04; OR 0.95 95% CI (0.90, 0.9985)). No significant association was found between SDF after gradient and IUI outcome in the diagnostic sample nor between SDF (ejaculate/after gradient) in the IUI samples. The ROC analysis proposed a cutoff of 17.5% as the best compromise between sensitivity and specificity in the diagnostic SDF for live birth; however, the test diagnostics are low, with an AUC of 0.576.

CONCLUSIONS

Overall, this study strengthens the hypothesis of an inverse relationship between SDF and CP/LB. Furthermore, SDF taken together with other clinical characteristics might provide more insight into male reproductive potential and predicting IUI outcome. Couples with SDF ≥ 17.5% in the diagnostic semen sample did not reach live birth. Further research is necessary to establish the diagnostic and prognostic potential of SDF as an add-on test.

Systematic review and meta-analysis of the efficacy of acupuncture as an adjunct to IVF cycles in China and the world

Acupuncture has been introduced as an adjuvant therapy to in vitro fertilization (IVF) cycles in many randomized controlled trials (RCTs). However, there has been a debate among trials regarding the effectiveness and safety of the procedure. To determine how effective and safe acupuncture is as an adjunct to IVF cycles for primary and secondary female infertility. We conducted a literature search for relevant RCTs and ultimately included nine studies. The main selected outcomes included the rates of clinical pregnancy, ongoing pregnancy, miscarriage, live birth, and side effects. Patients receiving acupuncture were grouped together regardless of the acupuncture points used or the protocol for the insertion of needles. We performed a subgroup analysis according to whether studies originated inside and outside China to investigate the results of the different RCTs. We pooled outcomes as a risk ratio (RR) with 95% confidence interval (CI). The analysis revealed that in China, acupuncture led to lower clinical [RR=0.80, 95% CI (0.66, 0.97), p=0.02] and ongoing [RR=0.78, 95% CI (0.63, 0.97), p=0.03] pregnancy rates than placebo. Outside China, acupuncture increased clinical pregnancy rates [RR=1.38, 95% CI (1.11, 1.71), p=0.003] and ongoing [RR=1.73, 95% CI (1.29, 2.31), p<0.001] pregnancy rates. Rates of live birth and miscarriage did not significantly differ between the arms. Regarding side effects, acupuncture groups had a significantly higher rate of puncture site itching compared to control groups [RR=1.51, 95% CI (1.12, 2.04), p=0.007]. Overall analysis does not show a statistically significant increase in clinical pregnancy rates worldwide when using acupuncture as an adjunct therapy to IVF. There were no issues regarding patient safety from any included study. Subgroup results indicated that better rates for clinical pregnancy seem to be occurring more often in RCTs performed outside China than within.

The association between pregnancy intention, fertility treatment use, and postpartum depression

RATIONALE

Understanding whether postpartum depressive (PPD) symptoms vary by pregnancy intention and use of fertility treatments has implications for reproductive health policies and practices.

OBJECTIVE

The first aim of this study was to determine whether PPD symptoms differ between women who had unintended pregnancies, women who conceived spontaneously and were unsure about their pregnancy intention, women who used fertility treatments to conceive, and women who conceived spontaneously and intentionally. The second aim was to determine whether PPD symptoms differed based on the fertility treatment used to conceive (fertility drugs only, medicated insemination, or assisted reproductive technology [ART]).

METHODS

Data from the Pregnancy Risk Assessment Monitoring System (2012-2019), a cross-sectional survey administered to women throughout the U.S. who have recently given birth, was used to carry out our aims.

RESULTS

For the first aim (unweighted N = 243,677), compared to women who had spontaneous, intended pregnancies, women who had unintended pregnancies (OR: 1.32, 95% CI: 1.26-1.39, p < 0.01) and those with spontaneous pregnancies who were unsure about their intention (OR: 1.30, 95% CI: 1.23-1.38, p < 0.01) had higher odds of elevated PPD symptoms, adjusting for a range of covariates. Women who conceived with fertility treatments did not have higher odds of elevated PPD symptoms (OR: 0.97, 95% CI: 0.84-1.10, p = 0.61). For the second aim (unweighted N = 2,210), compared to those in the ART group, those who conceived using only fertility enhancing drugs had greater odds of developing elevated PPD symptoms (OR: 2.00, 95% CI: 1.24-3.24, p < 0.01).

CONCLUSIONS

These findings suggest that giving birth to an unintended pregnancy in the U.S. increases risk of elevated PPD symptoms. While overall women who conceive with the use of fertility treatments are not at increased risk of experiencing elevated PPD symptoms, there may be variability in risk based on the specific fertility treatments used.

The effects of endocrine-disrupting chemicals on ovarian- and ovulation-related fertility outcomes

Exposure to endocrine-disrupting chemicals (EDCs) is unavoidable, which represents a public health concern given the ability of EDCs to target the ovary. However, there is a large gap in the knowledge about the impact of EDCs on ovarian function, including the process of ovulation. Defects in ovulation are the leading cause of infertility in women, and EDC exposures are contributing to the prevalence of infertility. Thus, investigating the effects of EDCs on the ovary and ovulation is an emerging area for research and is the focus of this review. The effects of EDCs on gametogenesis, uterine function, embryonic development, and other aspects of fertility are not addressed to focus on ovarian- and ovulation-related fertility issues. Herein, findings from epidemiological and basic science studies are summarized for several EDCs, including phthalates, bisphenols, per- and poly-fluoroalkyl substances, flame retardants, parabens, and triclosan. Epidemiological literature suggests that exposure is associated with impaired fecundity and in vitro fertilization outcomes (decreased egg yield, pregnancies, and births), while basic science literature reports altered ovarian follicle and corpora lutea numbers, altered hormone levels, and impaired ovulatory processes. Future directions include identification of the mechanisms by which EDCs disrupt ovulation leading to infertility, especially in women.

The impact of insurance mandates on donor oocyte utilization: an analysis of 39,338 donor oocyte cycles from the Society for Assisted Reproductive Technology registry

BACKGROUND

A total of 19 states passed legislation mandating insurance coverage of assisted reproductive technology, and out-of-pocket costs associated with in vitro fertilization vary significantly depending on the region. Consequently, it has been observed that assisted reproductive technology utilization differs regionally and is associated with the presence of an insurance mandate. However, it is unknown whether regional differences exist among patients using donor oocytes.

OBJECTIVE

This study aimed to determine the patient and cycle-specific parameters associated with the use of donor oocytes according to the insurance mandate status of the Society for Assisted Reproductive Technology clinic in which the assisted reproductive technology cycle was performed.

STUDY DESIGN

This study was a retrospective cohort study using national data collected from the Society for Assisted Reproductive Technology registry for 39,338 donor oocyte cycles and 242,555 autologous oocyte cycles performed in the United States from January 1, 2014, to December 31, 2016. Cycles were stratified by insurance mandate of the state in which the assisted reproductive technology cycle was performed: comprehensive (coverage for at least 4 cycles of assisted reproductive technology), limited (coverage limited to 1-3 assisted reproductive technology cycles), offer (insurance mandates exist but exclude assisted reproductive technology treatment), and no mandate. The primary outcome was the number of previous autologous assisted reproductive technology cycles of the recipient. The secondary outcomes included age, serum follicle stimulating hormone level, frozen donor oocyte utilization, day of embryo transfer, number of embryos transferred, clinical pregnancy rate, and live birth rate. Analyses were adjusted for day of transfer, number of embryos transferred, and age of the recipient.

RESULTS

Patients in no mandate states underwent fewer autologous assisted reproductive technology cycles (mean, 1.1; standard deviation, 1.6) before using donor oocytes than patients in offer (mean, 1.7; standard deviation, 2.5; P<.01), limited (mean, 1.5; standard deviation, 2.5; P<.01), and comprehensive (mean, 1.7; standard deviation, 2.0; P<.01) states. Patients in no mandate states were more likely to use frozen oocytes than patients in offer (relative risk, 0.54; 95% confidence interval, 0.52-0.57), limited (relative risk, 0.50; 95% confidence interval, 0.46-0.54), and comprehensive (relative risk, 0.94; 95% confidence interval, 0.89-0.99) states. Clinical pregnancy and live birth rates were similar among recipients of donor oocytes, regardless of insurance mandate.

CONCLUSION

Despite similar ages and ovarian reserve parameters, patients without state-mandated insurance coverage of assisted reproductive technology were more likely to use frozen donor oocytes and undergo fewer autologous in vitro fertilization cycles than their counterparts in partial or comprehensive insurance coverage states. These differences in donor oocyte utilization highlight the financial barriers associated with pursuing assisted reproductive technology in uninsured states.

Perceptions of child vulnerability in first-time mothers who conceived using assisted reproductive technology

OBJECTIVES

There has been an absence of research investigating if infertility and the utilisation of Assisted Reproductive Technology (ART) to conceive increases maternal perceptions of child vulnerability. The purpose of the current study was to assess if there were differences in maternal ratings of child vulnerability between first-time mothers who conceived using ART procedures and first-time mothers who conceived spontaneously.

METHODS

This cross-sectional study was comprised of 171 first-time mothers who conceived using ART and 198 first-time mothers who conceived spontaneously. Study questionnaires were completed online via Qualtrics.

RESULTS

Mothers who conceived using ART (Mean Vulnerable Child Scale Total Score = 43.85; SD = 9.65) endorsed greater perceptions of child vulnerability compared to mothers who conceived spontaneously (Mean Vulnerable Child Scale Total Score = 49.03; SD = 7.15; p < .001). In a hierarchical multiple linear regression analysis, the dichotomous variable that indicated maternal mode of conception (i.e. ART or spontaneous) was associated with the Vulnerable Child Scale Total Score (standardised beta coefficient = -.25; p < .001). Bivariate correlations revealed a small, negative correlation between using a donor sperm and/or egg and the Vulnerable Child Scale Total Score (r = -.21; p < .01).

CONCLUSION

Our findings suggest that vulnerable child syndrome may be more likely to occur when mothers conceive using ART, particularly when a donor sperm and/or egg is utilised.

Family Planning, Fertility, and Career Decisions Among Female Oncologists

IMPORTANCE

Female oncologists often spend their childbearing years in training and establishing careers, with many later experiencing fertility issues when starting a family. Physician fertility and family planning are rarely discussed during training. Attitudes among female oncologists regarding family planning are unknown.

OBJECTIVES

To understand barriers to family planning as well as the association of fertility treatment with career decisions and to assess experiences of pregnancy-based discrimination among female oncologists.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, a novel 39-item questionnaire was distributed to US female oncologists from May 7 to June 30, 2020, via email and social media channels. Questions regarding factors associated with family planning, maternity leave, and discrimination were included.

MAIN OUTCOMES AND MEASURES

The distribution of survey responses was compared by oncology subspecialty. Multivariable logistic regression was performed to determine independent variables for discrimination experienced during maternity leave.

RESULTS

Responses were collected from 1004 female oncologists. Most respondents (847 [84.4%]) were married, and 713 (71.0%) were currently working full-time. A total of 351 oncologists (35.0%) worked in radiation oncology, 344 (34.3%) in medical oncology, 186 (18.4%) in surgical oncology, and 91 (9.1%) in pediatric oncology. A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training, and 275 (27.4%) gave birth in years 1 to 5 as an attending physician. Almost all respondents (951 [94.7%]) stated that their career plans were at least somewhat associated with the timing of when to start a family. Having a supportive partner was the most commonly cited positive association with family planning (802 [79.9%]), while long work hours and heavy workload (669 [66.6%]) were the most common negative factors. One-third (318 [31.7%]) had miscarried, and 315 (31.4%) reported difficulty with infertility that required fertility counseling and/or treatment; 660 (65.7%) thought fertility preservation should be discussed with women during medical school and/or residency. One-third (312 [31.1%]) reported experiencing discrimination during pregnancy, and 332 (33.1%) stated they experienced discrimination for taking maternity leave. On multivariable logistic regression, having more than 1 child was associated with increased likelihood of experiencing discrimination during maternity leave (2 children: odds ratio, 1.62 [95% CI, 1.10-2.39]; P = .02; ≥3 children: odds ratio, 1.84 [95% CI, 1.14-2.95; P = .01).

CONCLUSIONS AND RELEVANCE

In this survey study of female oncologists, 1 in 3 reported experiencing infertility and 1 in 3 stated they experienced discrimination during pregnancy and/or for taking maternity leave. Systemic changes are necessary to ensure women are supported and able to advance equitably in the field.

Comparison of Treatment Outcomes among Sibling Oocytes Using Different Culture Systems-Conventional IVF versus INVOcell Device-And Evaluation of INVOcell User Satisfaction: The INVOcIVF Study

INVOcell is considered an alternative to conventional IVF proposed for intravaginal embryo culture; however, implementation is still low because evidence is scanty regarding its outcome and, most importantly, the device's user satisfaction. Thus, we aim to compare the embryo outcome of sibling oocytes following INVOcell culture with conventional IVF (cIVF) by assessing its clinical outcome (fertilization, blastulation rate, and good embryo quality) and the user satisfaction evaluation based on a local validation questionnaire. A prospective study was done at a university-setting hospital for 12 months (July 2021-2022). The oocytes collected were divided into INVOcell and cIVF groups equally. Inclusion criteria included <40 years old and body mass index (BMI) < 30 kg/m². The pre- and post-satisfaction questionnaires were assessed. In total, 23 women were included following standard controlled ovarian stimulation (COS). The mean age was 32.9, and the mean BMI was 24.9 kg/m². Most of them suffered from tubal factors. A total of 252 oocytes were collected and incubated accordingly (cIVF; 138, INVOcell; 114). The blastulation rate was superior in the INVOcell group (p = 0.16); otherwise, the fertilization rate and good embryo quality were not significantly different between both methods (p > 0.05). Overall, women were satisfied with the INVOcell device as they were adequately advised, follow-up was scheduled, and the lowest score was obtained for all side effects of the device. Although both methods produce similar fertilization rates and good-quality embryos, the blastulation rates were better in the INVOcell group. Functionally, it is a user-friendly device and tolerable. Therefore, INVOcell can be used as an alternative method for reproductive treatment in carefully selected patients without jeopardizing the IVF outcomes.

Cost-effectiveness of early screening home semen analysis in couples attempting to conceive

OBJECTIVE

To study the cost-effectiveness of incorporating home semen analysis in screening for oligospermia and expediting time to evaluation.

METHODS

A decision analytic model was built using inputs from the medical literature. The index patient is the male partner in a couple seeking fertility, and entry into the model was assumed to be at the inception of the couple's attempts to conceive via natural means. Three main strategies are described and analyzed: 1) baseline strategy of no testing; 2) utilization of a home semen testing kit; 3) universal testing via a clinic visit and gold standard lab semen analysis. The primary outcome was detection of oligospermia (defined as sperm concentration < 15mil/mL). Strategies were ranked by months to evaluation by a male infertility specialist saved. Costs were considered from the patient perspective and were incorporated to determine the incremental cost per month saved to evaluation (ICMS) per 100,000 patients.

RESULTS

Compared to a baseline strategy of no screening, utilizing a home test would save 89,000 months at the incremental cost of $7,418,000 for an ICMS of $45.51. Shifting to a strategy of universal gold standard clinic and lab testing saves an additional 3,000 months but at an ICMS of $17,691 compared to the home testing strategy.

CONCLUSIONS

Widespread adoption and early usage of home semen analysis may be a cost-effective method of screening for oligospermia and facilitating further evaluation with an andrology specialist.

Impact of in vitro fertilization state mandates for third party insurance coverage in the United States: a review and critical assessment

The American Society for Reproductive Medicine estimates that fewer than a quarter of infertile couples have sufficient access to infertility care. Insurers in the United States (US) have long considered infertility to be a socially constructed condition, and thus in-vitro fertilization (IVF) an elective intervention. As a result, IVF is cost prohibitive for many patients in the US. State infertility insurance mandates are a crucial mechanism for expanding access to fertility care in the US in the absence of federal legislation. The first state insurance mandate for third party coverage of infertility services was passed by West Virginia in 1977, and Maryland passed the country's first IVF mandate in 1985. To date, twenty states have passed legislation requiring insurers to cover or offer coverage for the diagnosis and treatment of infertility. Ten states currently have "comprehensive" IVF mandates, meaning they require third party coverage for IVF with minimal restrictions to patient eligibility, exemptions, and lifetime limits. Several studies analyzing the impact of infertility and IVF mandates have been published in the past 20 years. In this review, we characterize and contextualize the existing evidence of the impact of state insurance mandates on access to infertility treatment, IVF practice patterns, and reproductive outcomes. Furthermore, we summarize the arguments in favor of insurance coverage for infertility care and assess the limitations of state insurance mandates as a strategy for increasing access to infertility treatment. State mandates play a key role in the promotion of evidence-based practices and represent an essential and impactful strategy for the advancement of gender equality and reproductive rights.

Impact of comprehensive state insurance mandates on in vitro fertilization utilization, embryo transfer practices, and outcomes in the United States

BACKGROUND

Previous studies have demonstrated that state mandated coverage of in vitro fertilization may be associated with increased utilization, fewer embryos per transfer, and lower multiple birth rates, but also lower overall live birth rates. Given new legislation and the delay between enactment and effect, a revisit of this analysis is warranted.

OBJECTIVE

This study aimed to characterize the current impact of comprehensive state in vitro fertilization insurance mandates on in vitro fertilization utilization, live birth rates, multiple birth rates, and embryo transfer practices.

STUDY DESIGN

We conducted a retrospective cohort study of in vitro fertilization cycles reported by the 2018 Centers for Disease Control and Prevention Assisted Reproductive Technology Fertility Clinic Success Rates Report in the United States. In vitro fertilization cycles were stratified according to state mandate as follows: comprehensive (providing coverage for in vitro fertilization with minimal restrictions) and noncomprehensive. The United States census estimates for 2018 were used to calculate the number of reproductive-aged women in each state. Outcomes of interest (stratified by state mandate status) included utilization rate of in vitro fertilization per 1000 women aged 25 to 44 years, live birth rate, multiple birth rate, number of embryo transfer procedures (overall and subdivided by fresh vs frozen cycles), and percentage of transfers performed with frozen embryos. Additional subanalyzes were performed with stratification of outcomes by patient age group.

RESULTS

In 2018, 134,997 in vitro fertilization cycles from 456 clinics were reported. Six states had comprehensive mandates; 32,029 and 102,968 cycles were performed in states with and without comprehensive in vitro fertilization mandates, respectively. In vitro fertilization utilization in states with comprehensive mandates was 132% higher than in noncomprehensive states after age adjustment; increased utilization was observed regardless of age stratification. Live birth rate per cycle was significantly higher in states with comprehensive mandates (35.4% vs 33.4%; P<.001), especially among older age groups. Multiple birth rate as a percentage of all births was significantly lower in states with comprehensive mandates (10.2% vs 13.8%; P<.001), especially among younger patients. Mean number of embryos per transfer was significantly lower in states with comprehensive mandates (1.30 vs 1.36; P<.001). Significantly fewer frozen transfers were performed as a percentage of all embryo transfers in states with comprehensive mandates (66.1% vs 76.3%; P<.001). Among fresh embryo transfers, significantly fewer embryos were transferred in comprehensive states among all patients (1.55 vs 1.67; P<.001).

CONCLUSION

Comprehensive state mandated insurance coverage for in vitro fertilization services is associated with greater utilization of these services, fewer embryos per transfer, fewer frozen embryo transfers, lower multiple birth rates, and higher live birth rates. These findings have important public health implications for reproductive-aged individuals in the United States and present notable opportunities for research on access to fertility care.

Cohort profile: Anhui Maternal-Child Health Study in China

PURPOSE

The Anhui Maternal-Child Health Study (AMCHS) aims to examine determinants of reproduction, pregnancy and postpartum maternal and child health outcomes in Chinese women who received assisted reproductive technology (ART).

STUDY DESIGN AND PARTICIPANTS

AMCHS is an ongoing cohort study starting from May 2017. AMCHS recruits participants from all couples who sought ART treatment in the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China. The participants are interviewed to document baseline sociodemography, lifestyles, dietary intake and environmental exposure. Their clinical characteristics are obtained from hospital records. Samples of blood, follicular fluid and semen are collected at the clinic. Participants receive a standard long pituitary downregulation or a short protocol with an antagonist for the treatment. They are followed up from preconception to delivery, or discontinuation of ART treatment. Details of their children's health are documented through a questionnaire focusing on developmental status and anthropometry measurement.

FINDINGS TO DATE

Until April 2021, AMCHS had recruited 2042 couples in the study. 111 women withdrew from the study and 19 failed to retrieve oocytes. Among the 1475 confirmed pregnancies, 146 had miscarriages or terminated their pregnancies, 9 had stillbirths and 263 were ongoing pregnancies. The implantation failure increased with maternal age; adjusted OR was 1.43 (95% CI 1.16 to 1.77) in the age of 31-35 years, 1.97 (95% CI 1.46 to 2.66) in 35-39 years and 6.52 (95% CI 3.35 to 12.68) in ≥40 years compared with those aged 20-30 years. Among the 1057 couples with successful ART who were followed up for delivering babies, 576 had their children examined at age 30-42 days, 459 at 6 months and 375 at 12 months.

FUTURE PLANS

The AMCHS will identify comprehensive risk factors for poor ART outcomes and explore potential interaction effects of multiple factors including sociopsychological aspects of environmental exposure, dietary intake and genetics on maternal and child health.

Evidence for the effectiveness of immunologic therapies in women with subfertility and/or undergoing assisted reproduction

Implantation is a critical step in the establishment of a successful pregnancy, depending on a complex immune-endocrine dialogue between the developing embryo and maternal endometrium. Research suggests that altered immunity in the maternal decidua results in implantation impairment and failure. Immunomodulatory drugs have, thus, been widely used in assisted conception to aid embryo implantation, despite an absence of consensus on their effectiveness and safety. We conducted a systematic review and meta-analysis of interventional studies investigating the use of immunomodulators in women undergoing assisted reproduction. Evidence was uncertain of an effect for most of the included interventions, owing to heterogeneous findings and a paucity of high-quality studies. For certain patient subgroups, however, the use of specific immunomodulatory therapies may offer some benefit. There is a need for further large randomized controlled trials to corroborate these findings.

Cost-effectiveness analysis of ferric carboxymaltose versus iron sucrose for the treatment of iron deficiency anemia in patients with inflammatory bowel disease in Spain

BACKGROUND

Iron deficiency anemia (IDA) is a common complication of inflammatory bowel disease (IBD) and can result in reduced quality of life and increased healthcare costs. IDA is treated with iron supplementation, commonly with intravenous iron formulations, such as ferric carboxymaltose (FCM), and iron sucrose (IS).

METHODS

This study assessed the cost-effectiveness of FCM compared with IS, in terms of additional cost per additional responder in patients with IDA subsequent to IBD in the Spanish setting. An economic model was developed to assess the additional cost per additional responder, defined as normalization or an increase of ⩾2 g/dl in hemoglobin levels, for FCM versus IS from a Spanish healthcare payer perspective. Efficacy inputs were taken from a randomized controlled trial comparing the two interventions (FERGIcor). Costs of treatment were calculated in 2021 Euros (EUR) using a microcosting approach and included the costs of intravenous iron, healthcare professional time, and consumables. Cost-effectiveness was assessed over one cycle of treatment, with a series of sensitivity analyses performed to test the robustness of the results.

RESULTS

FCM was more effective than IS, with 84% of patients achieving a response compared with 76%. When expressed as number needed to treat, 13 patients would need to switch treatment from IS to FCM in order to achieve one additional responder. Costs of treatment were EUR 323 with FCM compared with EUR 470 with IS, a cost saving of EUR 147 with FCM. Cost savings with FCM were driven by the reduced number of infusions required, resulting in a reduced requirement for healthcare professional time and use of consumables compared with the IS arm.

CONCLUSION

The present analysis suggests that FCM is less costly and more effective than IS for the treatment of IDA subsequent to IBD in Spain and therefore was considered dominant.

Knowledge of Fertility and Perspectives About Family Planning Among Female Physicians

Importance

Pervasive gender disparities exist in medicine regarding promotion, achievement of academic rank, and appointment to leadership positions. Fertility and childbearing concerns may contribute to these disparities.

Objective

To assess fertility knowledge and concerns and evaluate barriers to family building and impact on academic attrition reported by female physicians.

Design, Setting, and Participants

This qualitative study used mixed methods; first, structured 1:1 interviews exploring fertility knowledge and family-building concerns were conducted among 16 female physicians between November 2019 and May 2020. Transcripts were coded in Dedoose and used to develop a survey instrument with subsequent pilot testing conducted among 24 female physicians between April 2020 and September 2020. Data analysis was performed from January 2021 to March 2021.

Main Outcomes and Measures

Fertility knowledge, perceptions of peer and institutional support surrounding childbearing, factors contributing to delayed childbearing, and impact of family planning on career decisions.

Results

Among 16 women who completed qualitative interviews, 4 (25%) were Asian, 1 (6%) was Black, 1 (6%) was multiracial, and 10 (63%) were White; mean (SD) age was 34.9 (4.0) years. Evaluation of fertility knowledge revealed 3 notable themes: (1) inadequate formal fertility education, (2) informal learning through infertility experiences of patients, peers, or personal struggles, and (3) desire to improve medical education through early introduction and transparent discussions about infertility. Exploration of childbearing concerns similarly revealed several salient themes: (1) high incidence of delayed childbearing, (2) perceived lack of peer and administrative support, and (3) impact of family building on career trajectory. These themes were borne out in pilot testing of the survey instrument: of 24 female physicians (7 Asian women [27%], 1 Black woman [4%], 1 Hispanic or Latinx woman [4%], 1 multiracial woman [4%], 15 White women [58%]; mean [SD] age, 36.1 [6.7] years), 17 (71%) had delayed childbearing and 16 (67%) had altered their career for family-building reasons.

Conclusions and Relevance

Qualitative interviews identified fertility and family building concerns among female physicians and were used to develop a tailored survey for women in medicine. These findings suggest that female physicians may delay childbearing and make substantial accommodations in their careers to support family building. A large-scale national survey is needed to better characterize the unique fertility, childbearing, and parenting needs of women in academic medicine to better understand how these concerns may contribute to academic attrition.