The cumulative live birth rate and cost-effectiveness of the clomiphene and gonadotropin cotreatment protocol versus the mid-luteal GnRH agonist protocol in women over 35 years old

The decrease in assisted reproductive technology success among older women, attributed to decreased oocyte quantity and quality, poses a significant challenge. Currently, no consensus on the optimal ovarian stimulation protocol for older women undergoing IVF exists. This retrospectively registered cohort study aimed to compare the cumulative live birth rate (CLBR), time to live birth (TTLB), and cost-effectiveness among women older than 35 years who were receiving either the gonadotropin-releasing hormone agonist (GnRHa) or clomiphene citrate and gonadotropin cotreatment with ovarian stimulation (CC cotreatment) protocol. To compare treatment outcomes, we performed propensity score matching (PSM) on 2871 IVF cycles in women older than 35 years who received either the GnRHa or CC cotreatment protocol, resulting in 375 cycles in each group. Additionally, a decision tree model was utilized to assess the cost-effectiveness of the two protocols. Following PSM, both groups had similar baseline characteristics. The CC cotreatment protocol resulted in a greater rate of cycle cancellation (13.07% vs. 8.00%, p = 0.032), but the groups maintained comparable fertilization rates and embryo quality. Although the TTLB was longer in the CC cotreatment group, the CLBR per initial cycle (41.07% vs. 45.33%, p = 0.269) and delivery outcomes were similar between the two groups at the 24 months follow-up. Additionally, the average cost per live birth in the CC cotreatment group was 21.27% lower than in the GnRHa group (¥32,301.42 vs. ¥39,174.22). In conclusion, for women older than 35 years undergoing IVF, the CC cotreatment protocol offered a comparable CLBR to the GnRHa protocol but with reduced costs, indicating its potential as a viable and cost-effective ovarian stimulation option.Clinical trial registration: https://www.chictr.org.cn/ , identifier [ChiCTR2300076537].

Factors influencing natural fecundity in fertile couples: a survey of puerperae and their partners

RESEARCH QUESTION

What is the fecundity rate among fertile couples, and which factors influence it?

DESIGN

Retrospective study of all puerperae attending Cruces University Hospital Human Reproduction Unit over 9 months. An anonymous questionnaire was circulated to all patients, and 2510 valid completed questionnaires were collected. The main inclusion criterion was natural conception resulting in delivery. Pregnancies resulting from ART and contraceptive method failure were excluded. Investigated parameters were time to pregnancy, age and smoking (in women and men), previous pregnancies and intercourse frequency. A mathematical formula was developed to predict the per-month fecundity rate (PMFR).

RESULTS

The cumulative fecundity rate was 29.08%, 54.26%, 68.61%, 89.88%, 96.95% and 98.63% (at 1, 3, 6, 12, 24 and 36 months); between 12 and 36 months, the average PMFR ranged from 8.53-7.48%. Only 1.68% of pregnancies occurred between 24 and 36 months, and only 1.37% thereafter. The best fecundity markers were obtained in the group who had sexual intercourse seven to eight times a week. Women and men younger than 25 years had lower fecundity markers than those aged between 25 and 40 years.

CONCLUSIONS

Fertile couples have a non-negligible per-month fecundity rate between 12 and 36 months, which should be considered when planning fertility studies. The lower fecundity rate observed in women and men aged younger than 25 years deserves more study. Coital frequencies of more than two or three times a week did not affect the fecundity rate and was better with frequencies of seven to eight times a week.

Association between visceral adipose tissue area and infertility: a cross-sectional analysis

RESEARCH QUESTION

Is intra-abdominal fat obesity associated with infertility?

DESIGN

This study analysed data from the 2013-2018 National Health and Nutrition Examination Survey, with a total of 3013 women enrolled. The participants were divided into two groups: infertility and non-infertility. Differences between the two groups were analysed using a weighted Student's t-test or Mann-Whitney U-test for continuous variables, or a weighted chi-squared test for categorical data. Visceral adipose tissue area (VATA) was assessed by dual-energy X-ray absorptiometry. The independent association between infertility and log VATA was assessed by weighted multivariate logistic regression models. Subgroup analyses were performed to assess the strength of the results. Interaction tests were used to examine whether covariates interacted with log VATA to influence infertility.

RESULTS

Log VATA was significantly higher in the infertility group compared with the non-infertility group (P < 0.001). After adjustment for potential confounders, the results of multivariate logistic regression analysis revealed that an increase in log VATA was associated with increased prevalence of female infertility (OR = 2.453, 95% CI 1.278-4.792). Subgroup analyses showed this association in individuals aged <35 years (P = 0.002), Mexican-Americans (P = 0.033), non-hypertensive individuals (P = 0.013) and non-diabetic individuals (P = 0.003).

CONCLUSIONS

An enlarged VATA is associated with increased risk of infertility. The direct effect of VATA on female infertility needs to be clarified further to provide a basis for future prevention and treatment of female infertility.

Economic evaluations of assisted reproductive technologies in high-income countries: a systematic review

STUDY QUESTION

Which assited reproductive technology (ART) interventions in high-income countries are cost-effective and which are not?

SUMMARY ANSWER

Among all ART interventions assessed in economic evaluations, most high-cost interventions, including preimplantation genetic testing for aneuploidy (PGT-A) for a general population and ICSI for unexplained infertility, are unlikely to be cost-effective owing to minimal or no increase in effectiveness.

WHAT IS KNOWN ALREADY

Approaches to reduce costs in order to increase access have been identified as a research priority for future infertility research. There has been an increasing number of ART interventions implemented in routine clinical practice globally, before robust assessments of evidence on economic evaluations. The extent of clinical effectiveness of some studied comparisons has been evaluated in high-quality research, allowing more informative decision making around cost-effectiveness.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review and searched seven databases (MEDLINE, PUBMED, EMBASE, COCHRANE, ECONLIT, SCOPUS, and CINAHL) for studies examining ART interventions for infertility together with an economic evaluation component (cost-effectiveness, cost-benefit, cost-utility, or cost-minimization assessment), in high-income countries, published since January 2011. The last search was 22 June 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two independent reviewers assessed publications and included those fulfilling the eligibility criteria. Studies were examined to assess the cost-effectiveness of the studied intervention, as well as the reporting quality of the study. The chosen outcome measure and payer perspective were also noted. Completeness of reporting was assessed against the Consolidated Health Economic Evaluation Reporting Standard. Results are presented and summarized based on the intervention studied.

MAIN RESULTS AND THE ROLE OF CHANCE

The review included 40 studies which were conducted in 11 high-income countries. Most studies (n = 34) included a cost-effectiveness analysis. ART interventions included medication or strategies for controlled ovarian stimulation (n = 15), IVF (n = 9), PGT-A (n = 7), single embryo transfer (n = 5), ICSI (n = 3), and freeze-all embryo transfer (n = 1). Live birth was the mostly commonly reported primary outcome (n = 27), and quality-adjusted life years was reported in three studies. The health funder perspective was used in 85% (n = 34) of studies. None of the included studies measured patient preference for treatment. It remains uncertain whether PGT-A improves pregnancy rates compared to IVF cycles managed without PGT-A, and therefore cost-effectiveness could not be demonstrated for this intervention. Similarly, ICSI in non-male factor infertility appears not to be clinically effective compared to standard fertilization in an IVF cycle and is therefore not cost-effective. Interventions such as use of biosimilars or HMG for ovarian stimulation are cheaper but compromise clinical effectiveness.

LIMITATIONS, REASONS FOR CAUTION

Lack of both preference-based and standardized outcomes limits the comparability of results across studies. The selection of efficacy evidence offered for some interventions for economic evaluations is not always based on high-quality randomized trials and systematic reviews. In addition, there is insufficient knowledge of the willingness to pay thresholds of individuals and state funders for treatment of infertility. There is variable quality of reporting scores, which might increase uncertainty around the cost-effectiveness results.

WIDER IMPLICATIONS OF THE FINDINGS

Investment in strategies to help infertile people who utilize ART is justifiable at both personal and population levels. This systematic review may assist ART funders decide how to best invest to maximize the likelihood of delivery of a healthy child.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this study. E.C. and R.W. receive salary support from the National Health and Medical Research Council (NHMRC) through their fellowship scheme (EC GNT1159536, RW 2021/GNT2009767). M.D.-T. reports consulting fees from King Fahad Medical School. All other authors have no competing interests to declare.

REGISTRATION NUMBER

Prospero CRD42021261537.

Moving toward Narrowing the United States Gap in Assisted Reproductive Technology (ART) Racial and Ethnic Disparities in the Next Decade

The Disparities in Assisted Reproductive Technology (DART) hypothesis, initially described in 2013 and further modified in 2022, is a conceptual framework to examine the scope and depth of underlying contributing factors to the differences in access and treatment outcomes for racial and ethnic minorities undergoing ART in the United States. In 2009, the World Health Organization defined infertility as a disease of the reproductive system, thus recognizing it as a medical problem warranting treatment. Now, infertility care is largely recognized as a human right. However, disparities in Reproductive Endocrinology and Infertility (REI) care in the US persist today. While several studies and review articles have suggested possible solutions to racial and ethnic disparities in access and outcomes in ART, few have accounted for and addressed the multiple complex factors contributing to these disparities on a systemic level. This review aims to acknowledge and address the myriad of contributing factors through the DART hypothesis which converge in racial/ethnic disparities in ART and considers possible solutions to effect large scale societal change by narrowing these gaps within the next decade.

Improved prediction of clinical pregnancy using artificial intelligence with enhanced inner cell mass and trophectoderm images

This study aimed to assess the performance of an artificial intelligence (AI) model for predicting clinical pregnancy using enhanced inner cell mass (ICM) and trophectoderm (TE) images. In this retrospective study, we included static images of 2555 day-5-blastocysts from seven in vitro fertilization centers in South Korea. The main outcome of the study was the predictive capability of the model to detect clinical pregnancies (gestational sac). Compared with the original embryo images, the use of enhanced ICM and TE images improved the average area under the receiver operating characteristic curve for the AI model from 0.716 to 0.741. Additionally, a gradient-weighted class activation mapping analysis demonstrated that the enhanced image-trained AI model was able to extract features from crucial areas of the embryo in 99% (506/512) of the cases. Particularly, it could extract the ICM and TE. In contrast, the AI model trained on the original images focused on the main areas in only 86% (438/512) of the cases. Our results highlight the potential efficacy of using ICM- and TE-enhanced embryo images when training AI models to predict clinical pregnancy.

Analysis of factors associated with IUI pregnancy outcomes in elderly and young patients

OBJECTIVE

The objective of this study was to investigate the correlation between various factors and the clinical outcomes of Intrauterine Insemination (IUI) in both young and aged patients, aiming to provide a theoretical basis for clinical consultations.

METHODS

This retrospective analysis examined a total of 4,221 IUI cycles conducted at the Reproductive Center of Changzhou Maternal and Child Health Hospital between January 2016 and December 2020. The patients were categorized into two groups based on age: the elder group (≥ 35 years) and the young group (< 35 years).

RESULTS

The findings of this study revealed a significant association between woman's age and BMI with pregnancy outcomes (0.93, 95% CI: 0.89-0.97) (1.04, 95% CI: 1.01-1.06). Moreover, in young women, both age and Body Mass Index (BMI)were found to be related to pregnancy outcomes (0.97, 95% CI: 0.89-0.97) (1.08, 95% CI: 1.01-1.06). Additionally, BMI and the number of cycles in aged IUI patients were found to be associated with pregnancy outcomes. The pregnancy rate in the second cycle was approximately 1.9 times higher than that in the first cycle (1.9, 95% CI: 0.97-3.77), and in the third cycle, it was approximately 3 times higher than that in the first cycle (3.04, 95% CI: 1.43-6.42).

CONCLUSIONS

In conclusion, there is an association between woman's age and BMI and the clinical outcomes of IUI. However, the number of cycles did not affect the pregnancy outcomes in young women. Conversely, in elder women, the number of cycles was found to be related to the IUI pregnancy outcomes, with significantly higher pregnancy rates observed in the second and third cycles compared to the first cycle.

Associations between Urinary Concentrations of Disinfection Byproducts and in Vitro Fertilization Outcomes: A Prospective Cohort Study in China

BACKGROUND

Experimental studies show that disinfection byproducts (DBPs) can inhibit oocyte maturation, decrease fertilization capacity, and impair embryo development, but human evidence is lacking.

OBJECTIVES

We aimed to evaluate the associations between exposure to drinking water DBPs and in vitro fertilization (IVF) outcomes.

METHODS

The study included 1,048 women undergoing assisted reproductive technology (ART) treatment between December 2018 and January 2020 from a prospective cohort study, the Tongji Reproductive and Environmental study in Wuhan, China. Exposure to DBPs was assessed by dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) in up to four urine samples, which were collected on the day of both enrollment and oocyte retrieval. Multivariable generalized linear mixed models, accounting for multiple IVF cycles per woman, were applied to evaluate the associations between urinary biomarkers of DBP exposures and IVF outcomes. Stratified analyses were used to explore the potential effect modifiers.

RESULTS

The included 1,048 women underwent 1,136 IVF cycles, with 960 (91.6%), 84 (8.0%), and 4 (0.4%) women contributing one cycle, two cycles, and three cycles, respectively. We found that elevated quartiles of urinary DCAA and TCAA concentrations were associated with reduced numbers of total oocytes and metaphase II oocytes and that urinary DCAA concentrations with a lower proportion of best-quality embryos (all p for trends < 0.05 ). Moreover, elevated quartiles of urinary DCAA concentrations were associated with decreased proportions of successful implantation, clinical pregnancy, and live birth (14%, 15%, and 15% decreases in adjusted means comparing the extreme quartiles, respectively; all p for trends < 0.05 ). Stratification analyses showed that the inverse associations of urinary TCAA concentrations with multiple IVF outcomes were stronger among women ≥ 30 y of age (p for interactions < 0.05 ).

DISCUSSION

Exposure to drinking water DBPs was inversely associated with some IVF outcomes among women undergoing ART treatment. Further study is necessary to confirm our findings. https://doi.org/10.1289/EHP12447.

[Predictive factors of spontaneous pregnancies among women with diminished ovarian reserve patients treated with DHEA]

INTRODUCTION

Diminished ovarian reserve remains a challenge in the reproductive medicine field. Treatment options for these patients are limited and there is no consensus to make any recommendations. Regarding adjuvant supplements, DHEA could play a role in follicular recruitment and, therefore, may increase spontaneous pregnancy rate.

MATERIALS AND METHODS

This study was a monocentric historical and observational cohort study carried out in the reproductive medicine department at the University Hospital, Femme-Mère-Enfant in Lyon. All women presenting with a diminished ovarian reserve treated with 75mg/day of DHEA were consecutively included. The main objective was to evaluate the spontaneous pregnancy rate. The secondary objectives were to identify predictive factors for pregnancy and the evaluation of treatment side effects.

RESULTS

Four hundred and thirty-nine women were included. In all, 277 were analyzed, 59 had a spontaneous pregnancy (21.3%). The probability of being pregnant was respectively 13.2% (IC95 9-17.2%), 21.3% (IC95 15.1-27%) and 38.8% (IC95 29.3-48.4%) at 6, 12 and 24 months. Only 20.6% of patients complained of side effects.

CONCLUSION

DHEA may improve spontaneous pregnancies in women with diminished ovarian reserve without any stimulation.

Assisted reproductive technology outcomes and gene expression in unexplained infertility patients

Background: Unexplained infertility (UI) can be a frustrating and challenging diagnosis for doctors and couples as it can be difficult to understand why they are unable to conceive despite increasing diagnostic tools. Assisted reproductive technology (ART) procedures have been successfully applied to many couples aiming to overcome UI. However, they can be not only expensive but also require multiple cycles to achieve a successful pregnancy. The endometrium and the follicular fluid have been investigated as target tissues not only to determine the cause of UI but also to increase conception rates. Results: In this study, we analyzed the outcomes of ART in 223 UI couples and gene expression associated with DNA modification, cell death, immune response and senescence (TET1, TET2, BCL2, BAK1, HMGA2, IL-6, IL-8) in infertile women's endometrium and follicular fluid. We found significant differences in women who successfully got pregnant compared to women unable to conceive depending on age, duration of infertility, number of retrieved oocytes, zygotes, transferred embryos. Further, the expression of genes BAK1 (pro-apoptotic), TET2 (associated with epigenetic DNA modification) and IL-6 (associated with immune responses) were significantly higher in the endometrium of women who successfully got pregnant. Conclusion: Younger parental age couples showed higher ART success rates, shorter duration of infertility, higher number of retrieved oocytes, zygotes and transferred embryos. The gene expression analysis revealed significant changes in the endometrium depending on genes associated with cell death and immune response which were upregulated in females with diagnosed unexplained infertility.

Comparative Evaluation of Sildenafil Citrate and Estrogen as an Adjuvant Therapy for Treatment of Unexplained Infertility in Women

BACKGROUND

Uterine blood flow determines endometrial thickness. This study examined how vaginal sildenafil citrate and estradiol valerate altered endometrial thickness, blood flow, and fertility in infertile women.

METHODS

This study observed 148 infertile women whose infertility was unexplained. Group 1 comprised 48 patients who received oral estradiol valerate (Cyclo-Progynova 2 mg/12 h white tablets) from day 6 till ovulation was initiated with clomiphene citrate. A number of 50 participants in group 2 received oral sildenafil (Respatio 20 mg/12 h film-coated tablets) for 5 days starting the day after their previous menstrual period and finishing on the day they ovulated with clomiphene citrate. Group 3 was the control group, with 50 patients receiving clomiphene citrate (Technovula 50 mg/12 h tablets) ovulation induction from the 2nd to 7th day of cycle. All patients had transvaginal ultrasounds to determine ovulation, follicle count, and fertility. Miscarriage, ectopic pregnancy, and multiple pregnancies were monitored for three months.

RESULTS

The three groups' mean ETs differed statistically at p = 0.0004. A statistically significant difference was found between the three groups in terms of the number of follicles, with 69% of patients in group 1 having one and 31% having two or more, 76% of patients in group 2 having one and 24% having two or more, and 90% of patients in the control group having one and 10% having two or more (p = 0.038). The clinical pregnancy rates of the three groups were 58%, 46%, and 27%, respectively (p = 0.005). The distribution of all side effects was not statistically different between the three groups.

CONCLUSION

It is possible to claim that adding oral estrogen to clomiphene citrate therapy as an adjuvant therapy can improve endometrial thickness and, as a result, increase the pregnancy rates in unexplained infertility compared to sildenafil, especially in cases where the infertility has lasted less than two years. Most people who take sildenafil end up with a mild headache.

Gender Equity in Medicine and Dermatology in the United States: The Long Road Traveled and the Journey ahead

Over the past 50 years there has been an increase in the representation of women in medicine with similar rates of men and women graduating from medical training today. Nevertheless, gender gaps in leadership, research publications, and compensation persist. Herein, we review trends in gender differences among leadership positions in academic medicine with a particular focus on dermatology, evaluate the roles of mentorship, motherhood, and gender bias on gender equity, and discuss constructive solutions for addressing gender inequities that persist in academic medicine today.

Should we adopt a prognosis-based approach to unexplained infertility?

The treatment of unexplained infertility is a contentious topic that continues to attract a great deal of interest amongst clinicians, patients and policy makers. The inability to identify an underlying pathology makes it difficult to devise effective treatments for this condition. Couples with unexplained infertility can conceive on their own and any proposed intervention needs to offer a better chance of having a baby. Over the years, several prognostic and prediction models based on routinely collected clinical data have been developed, but these are not widely used by clinicians and patients. In this opinion paper, we propose a prognosis-based approach such that a decision to access treatment is based on the estimated chances of natural and treatment-related conception, which, in the same couple, can change over time. This approach avoids treating all couples as a homogeneous group and minimizes unnecessary treatment whilst ensuring access to those who need it early.

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.

Does Post-Warming Extended Culture Duration Affect the Clinical and Obstetric Outcomes of Patients of Advanced Maternal Age? A Single-Center Study

BACKGROUND

The single vitrified-warmed blastocyst transfer (SVBT) cycle has been increasingly utilized for assisted reproductive technology. Women of advanced maternal age (AMA) comprise a significant portion of patients who have undergone 'freeze-all' cycles. This study investigated the association between the post-warming extended culture duration and pregnancy outcomes in patients of AMA.

METHODS

This retrospective cohort study analyzed the outcomes of 697 SVBT cycles between January 2016 and December 2017. The cycles were divided into 3 groups based on the age of the female partners: group I: < 35 years (n = 407), group II: 35-37 years (n = 176); and group III, 38-40 years (n = 114). Data are shown as the mean ± standard error of the mean. Data were analyzed using one-way ANOVA followed by Duncan's multiple range test. Statistical significance was set at P < 0.001.

RESULTS

The blastocyst rate, clinical pregnancy rate, and live birth rate (LBR) was significantly lower in the AMA groups. However, there were no significant differences in LBR in the transfer between the AMA and younger groups according to blastocyst morphology and post-warming extended culture duration.

CONCLUSION

Post-warming extended culture of blastocysts is not harmful to patients of AMA. It could be a useful parameter in clinical counseling and decision making for fertility treatments.

Clinical outcomes after elective double-embryo transfer in frozen cycles for women of advanced maternal age: A retrospective cohort study

We aimed to determine the clinical outcome of double cleavage-stage embryo transfers in frozen-thawed embryo transfer cycles for older women.This study analyzed a total of 8189 cleavage-stage frozen-thawed embryo transfer cycles between January 2013 and December 2017 at Sir Run Run Shaw Hospital. All cycles were sorted into 3 groups based on patient age: ≤35 years (Group A), 36 to 37 years (Group B), and ≥38 years (Group C). The clinical pregnancy rate (CPR), implantation rate (IR), live birth rate (LBR), miscarriage rate, multiple pregnancy rate (MPR), preterm birth rate, and low-birth-weight rate were compared between the 3 groups.Significant differences in CPR, IR, LBR, MPR, and premature birth rate were found among the 3 groups. The CPR, IR, LBR, and MPR in Group A were higher than those in Group C. Transfers of 2 high-quality embryos resulted in significant differences in CPR, IR, LBR, MPR, and neonatal weight among the 3 groups, but no differences in premature birth and abortion rates were observed. Transfers with 1 high-quality and 1 fair-quality embryo resulted in significant differences in CPR, IR, and LBR among the 3 groups. Comparison of transfers of 2 high-quality embryos with 1 high-quality and 1 fair-quality embryo showed that the CPR and LBR were significantly lower for the latter in Groups A and C, but Group B had no salient changes.Higher IR and LBR and lower MPR may be achieved by selection of optimal embryo types for patients of different ages. Two high-quality embryos need to be transferred in women older than 38 years. For women aged 36 to 37 years, 1 high-quality embryo or 1 high-quality plus 1 fair-quality embryo should be singled out for transfer. For women younger than 35 years, a single high-quality embryo should be selected for transfer.

The effect of cytokine leukemia-inhibitory factor (LIF) and interleukin-11 (IL-11) gene expression on the primary infertility related to polycystic ovary syndrome, Tubal factor, and Unexplained infertility in Turkish women

Background

Successful implantation of blastocysts is indeed an important path in mammalian reproduction that is governed by a complicated web of cytokines interactions. Leukemia inhibitory factor (LIF) and interleukin-11 (IL-11) part of the interleukin (IL)-6 groups are cytokines that are needed for effective implantation and prevent infertility symptoms. This study aimed to determine the expression level (LIF, IL-11) genes in patients with primary infertility related to polycystic ovary syndrome (PCOS), tubal factor infertility (TFI), and unexplained infertility (UI).

Results

In this study, 75 infertility women and 40 controls were involved. The expressions of LIF and IL-11 genes were evaluated by quantitative real-time polymerase chain reaction qRT–PCR Light Cycler in patients and healthy controls. PCOS, TFI, and UI groups showed promising results regarding LIF gene, which appeared at very small levels compared to the control (p < 0.0001). Regarding IL-11, the two groups TFI and UI were significantly linked to the lower level of gene expression, while the PCOS group has no significant difference when it is compared to the control group (p < 0.0001, < 0.05, 0.19), respectively.

Conclusion

The current findings show that low levels of LIF and IL-11 gene expression are linked to various primary infertility conditions, including PCOS, tubal factor, and unexplained infertility since they play a fundamental role in embryo implantation.

Hysteroscopy as a Primary Tool in Exploration and Treatment of Infertility: Single Center Experience in Western Romania

(1) Background: Infertility is a disease that affects millions of individuals worldwide. Intrauterine lesions are common in infertile women, hysteroscopy being considered the gold standard for assessing them, even if in routine clinical practice indirect imaging techniques are the first-line investigative tools. The aim of the study was to evaluate hysteroscopic findings among women with unexplained infertility and to analyze fertility outcomes after operative hysteroscopy; (2) Methods: a retrospective cohort study was conducted among 198 women with infertility that had undergone hysteroscopy as the first step of their infertility workup. (3) Results: The median age of the participants was 34 years, 67.7% of them being diagnosed with primary infertility. The most common abnormalities were endometrial polyps, uterine synechiae and uterine fibroids. In addition, pregnancy rates were 23.1% after hysteroscopic polypectomy, 11.1% after hysteroscopic myomectomy and 23.8% after uterine synechiae resection; (4) Conclusions: Endometrial polyps were the most common uterine abnormality found in women with infertility. Hysteroscopic interventions appeared to increase pregnancy rates and outcomes among these women.

Can time to menopause be predicted?

Menopause represents the definite end of a woman's reproductive life and the onset of a persistent hypoestrogenic state. This postmenopausal period will for most women last several decades. Although mean menopausal age seems to have increased somewhat during the last century, there is a significant individual variation in age at natural menopause. With efficient contraception, women of reproductive age can now, to some extent, choose when they want to have children. As a consequence of this and other sociodemographic changes, age at first birth has increased significantly over the last 50 years. It is well documented that long before a woman enters the menopausal transition and subsequent menopause, fertility declines and finally ceases. Being able to predict when a woman will enter menopause would therefore, from a reproductive perspective, be of major interest. Several sociodemographic, morphometric, and endocrine factors are associated with age at menopause or time to menopause. Unfortunately the sensitivity and specificity of these in predicting time to or age at menopause are low. Therefore, with the exception of anti-Müllerian hormone measurements, either alone or in combination with chronological age close to menopause, there are as of now no reliable ways of predicting when a woman will enter menopause.

Spontaneous pregnancies among infertile couples during assisted reproduction lockdown for COVID-19 pandemic

Background

The worldwide spread of the SARS‐CoV‐2 infection has profoundly affected all aspects of human life, with tangible consequences in several contexts, including reproduction. However, evidences on the inter‐relation between psychological distress and reproductive medicine are still conflicting.

Methods

The national lockdown imposed in Italy in March‐May 2020 and the consequent assisted reproductive techniques (ART) activity blockage allowed to evaluate the conception ability of couples who suffered the postponement of ART cycles. In particular, we collected anamnestic, anthropometrical and demographic data of those women attending ART straddling the lockdown period attending to the Fertility Centre of Reggio Emilia.

Results

Among the 431 couples recalled to reschedule ART cycles, 34 couples (7.9%) obtained a spontaneous pregnancy during the lockdown. Comparing spontaneously pregnant to non‐pregnant women, the pregnant group resulted younger (P = 0.009) and with a shorter infertility history (P = 0.029). Interestingly, the sexual activity frequency was significantly higher in pregnant women compared to non‐pregnant ones (P < 0.001). In a multivariate logistic analysis, number of sexual intercourses per week and the infertility history duration were significantly related to pregnancy (P < 0.001 and P = 0.030, respectively). In addition, the application of neural network technology including data about women age, body mass index, infertility duration, weekly sexual intercourses and infertility causes allowed to correctly classify pregnant women with an accuracy of 92.7%.

Conclusion

The high pregnancy rate observed in a very short time‐frame interval probably revealed an under‐explored cause of idiopathic infertility, that is the frequency of sexual intercourses, resulting the best predictive variable on achieving a spontaneous pregnancy. This factor is commonly under‐investigated during the anamnestic workup of infertile couples. Clinicians involved in ART should better investigate the sexual habits of infertile couples, with the aim to correctly apply ART to those couples who really need it, avoiding unnecessary over‐treatment for those couples able to conceive spontaneously.

Treatment Strategies for Unexplained Infertility

Unexplained infertility is a common diagnosis among couples with infertility. Pragmatic treatment options in these couples are directed at trying to improve chances to conceive, and consequently intrauterine insemination (IUI) with ovarian stimulation and in vitro fertilization (IVF) are standard clinical practice, while expectant management remains an important alternative. While evidence on IVF or IUI with ovarian stimulation versus expectant management was inconclusive, these interventions seem more effective in couples with a poor prognosis of natural conception. Strategies such as strict cancellation criteria and single-embryo transfer aim to reduce multiple pregnancies without compromising cumulative live birth. We propose a prognosis-based approach to manage couples with unexplained infertility so as to expose less couples to unnecessary interventions and less mothers and children to the potential adverse effects of ovarian stimulation or laboratory procedures.