Assisted Reproductive Technology Surveillance - United States, 2016

The impact of mitochondrial impairments on sperm function and male fertility: a systematic review

BACKGROUND

Besides adenine triphosphate (ATP) production for sustaining motility, the mitochondria of sperm also host other critical cellular functions during germ cell development and fertilization including calcium homeostasis, generation of reactive oxygen species (ROS), apoptosis, and in some cases steroid hormone biosynthesis. Normal mitochondrial membrane potential with optimal mitochondrial performance is essential for sperm motility, capacitation, acrosome reaction, and DNA integrity.

RESULTS

Defects in the sperm mitochondrial function can severely harm the fertility potential of males. The role of sperm mitochondria in fertilization and its final fate after fertilization is still controversial. Here, we review the current knowledge on human sperm mitochondria characteristics and their physiological and pathological conditions, paying special attention to improvements in assistant reproductive technology and available treatments to ameliorate male infertility.

CONCLUSION

Although mitochondrial variants associated with male infertility have potential clinical use, research is limited. Further understanding is needed to determine how these characteristics lead to adverse pregnancy outcomes and affect male fertility potential.

Predictors of gamete donation: a cross sectional survey study

PURPOSE

In 2015, assisted reproductive technology (ART) accounted for 1.7% of all U.S. births, donor eggs accounted for over 17,000 started cycles in 2015, and donor sperm accounting for 6.2% of all cycles started in 2014. With increasing utilization of donor gametes as a method of assisting patients with infertility, the number of babies born each year utilizing gamete donation will also continue to increase. This study aimed to elucidate factors impacting decision to donate, amongst a representative national population.

METHODS

A survey was distributed via the internet utilizing SurveyMonkey Enterprise with HIPAA compliance. Univariate regressions and frequencies were conducted between each demographic and personal characteristic and the willingness to donate. Log Binomial and linear regression was used categorical and continuous variables, and Risk ratios were calculated.

RESULTS

In this large survey study, 64% of men and 50% of women reported they would be willing to donate gametes, with the majority desiring monetary compensation. Men with a high Consumer Financial Protection Bureau score were less likely to report that they would consider donating sperm compared to a medium high CFPB score. No other financial indicators were associated with considering donating sperm. There were no associations between CFPB score and egg donation outcomes. Black or African American women were less likely to consider donating their eggs compared to other groups, and more likely to desire > $5000 in compensation.

CONCLUSIONS

In this large survey study, a small minority of participants reported they would be willing to donate to an unknown infertility patient for reproductive purposes. High and very high CFPB scores were associated with willingness to donate games, but not with desire for monetary compensation or amount.

A prediction tool for mode of delivery in twin pregnancies-a secondary analysis of the Twin Birth Study

BACKGROUND

One of the controversies regarding the management of twin gestations relates to the mode of delivery. Currently, counseling regarding the mode of delivery and the chance of successful vaginal twin delivery is based on the average risk for intrapartum cesarean delivery in the general population of twin pregnancies. Decision support tools that provide an individualized risk for intrapartum cesarean delivery based on the unique characteristics of each patient can improve counseling and decision-making regarding the choice of mode of delivery in twin pregnancies.

OBJECTIVE

This study aimed to develop and validate a prediction model to determine the risk for intrapartum cesarean delivery in twin pregnancies.

STUDY DESIGN

In this secondary analysis of the Twin Birth Study, a multicenter randomized controlled trial, we considered the subgroup of individuals who underwent a trial of vaginal delivery. Candidate predictors included maternal age, parity, previous cesarean delivery, conception method, chorionicity, diabetes and hypertension in pregnancy, gestational age at birth, the onset of labor, presentation of the second twin, sonographic fetal weight estimation, and fetal sex. The co-primary outcomes were overall intrapartum cesarean delivery and cesarean delivery of the second twin. Multivariable logistic regression models were used to estimate the probability of the study outcomes. Model performance was evaluated using measures of discrimination (the area under the receiver operating characteristic curve), calibration, and predictive accuracy. Internal validation was performed using the bootstrap resampling technique.

RESULTS

A total of 1221 individuals met the study criteria. The rate of overall intrapartum cesarean delivery and cesarean delivery for the second twin was 25.4% and 5.7%, respectively. The most contributory predictor variables were nulliparity, term birth (≥37 weeks), a noncephalic presentation of the second twin, previous cesarean delivery, and labor induction. The models for overall intrapartum cesarean delivery and cesarean delivery of the second twin had good overall discriminatory accuracy (area under the receiver operating characteristic curve, 0.720; 95% confidence interval, 0.688-0.752 and 0.736; 95% confidence interval, 0.669-0.803, respectively) and calibration (as illustrated by the calibration plot and Brier scores of 0.168; 95% confidence interval, 0.156-0.180 and 0.051; 95% confidence interval, 0.040-0.061, respectively). The models achieved good specificity (66.7% and 81.6%, respectively), high negative predictive value (86.0% and 96.9%, respectively), and moderate sensitivity (68.1% and 57.1%, respectively).

CONCLUSION

The prediction models developed in this study may assist care providers in counseling individuals regarding the optimal timing and mode of delivery in twin pregnancies by providing individualized estimates of the risk for intrapartum cesarean delivery.

The effect of fertility treatment and socioeconomic status on neonatal and post-neonatal mortality in the United States

OBJECTIVE

To determine the association between fertility treatment, socioeconomic status (SES), and neonatal and post-neonatal mortality.

STUDY DESIGN

Retrospective cohort study of all births (19,350,344) and infant deaths from 2014-2018 in the United States. The exposure was mode of conception-spontaneous vs fertility treatment. The outcome was neonatal (<28d), and post-neonatal (28d-1y) mortality. Multivariable logistic models were stratified by SES.

RESULT

The fertility treatment group had statistically significantly higher odds of neonatal mortality (high SES OR 1.59; CI [1.5, 1.68], low SES OR 2.11; CI [1.79, 2.48]) and lower odds of post-neonatal mortality (high SES OR 0.87, CI [0.76, 0.996], low SES OR 0.6, CI [0.38, 0.95]). SES significantly modified the effect of ART/NIFT on neonatal and post-neonatal mortality.

CONCLUSIONS

Fertility treatment is associated with higher neonatal and lower post-neonatal mortality and SES modifies this effect. Socioeconomic policies and support for vulnerable families may help reduce rates of infant mortality.

Access to assisted human reproduction techniques in Colombia: Disparity between the recognition of reproductive rights and their effective implementation

Public funding of assisted reproduction technologies (ARTs) is a controversial issue. Some health systems have proposed public funding of ARTs. In recent years, there has been evidence of a change in the line of jurisprudence and legislation in Colombia about this topic. This article analyzes the tension between the recognition of individual sexual and reproductive rights and the common good, in terms of the sustainability of the health system and the reasonable use of limited resources to meet the health needs of the population. This article concludes that, despite regulatory progress, there has been a lack of corresponding progress in their effective implementation and the recognition of reproductive rights.

Serum Cu, Zn and IL-1β Levels May Predict Fetal Miscarriage Risk After IVF Cycles: A Nested Case-Control Study

To explore the association between serum-related indicators (levels of inflammatory cytokines and essential trace elements) and miscarriage risk among infertile women undergoing assisted reproductive techniques (ART) on the 14th day after embryo transfer, and to develop and establish a multivariable algorithm model that might predict pregnancy outcome. According to a nested case-control study design, a total of 100 miscarriage cases and 100 live birth controls were included in this study, and women in both groups were infertile and have underwent in vitro fertilization (IVF). Pregnancy tests were performed and serum levels of five essential trace elements (vanadium (V), copper (Cu), zinc (Zn), selenium (Se) and molybdenum (Mo)) and five inflammatory cytokines (interleukin-1β (IL-1β), IL-6, IL-8, IL-10 and tumor necrosis factor-α (TNF-α)) of the participants were measured on the 14th day after embryo transfer. The serum levels of five inflammatory cytokines were determined by multiple magnetic bead enzyme immunity analyzer; and the serum concentrations of five elements were determined simultaneously by inductively coupled plasma‒mass spectrometry (ICP ‒ MS). The logistic regression was used to evaluate the relationship between these serum indices and miscarriage risk among women undergoing ART, and a predictive model of pregnancy outcome based on these indices was established. The levels of IL-10, IL-1β and TNF-α of infertile women in the live birth group were significantly higher than those in the miscarriage group (p = 0.009, p < 0.001, p = 0.006), and the levels of V, Cu, Zn and Se of infertile women in the live birth group were also significantly higher than those in the miscarriage group (all p < 0.001). Through logistic regression analyses, we found that serum levels of IL-1β, TNF-α, V, Cu, Zn and Se were significantly and negatively associated with miscarriage risk. Different combination prediction models were generated according to the results of logistic regression analyses, and the combination of IL-1β, Cu and Zn had the best prediction performance. The area under the curve (AUC) was 0.776, the sensitivity of the model was 60% and the specificity was 84%. In conclusion, the serum-related indicators of women undergoing ART on the 14th day after embryo transfer, including the inflammatory cytokines such as IL-1β and TNF-α and the essential trace metal elements such as V, Cu, Zn and Se, were negatively correlated with miscarriage risk. A multivariate algorithm model to predict pregnancy outcome among women undergoing ART was established, which showed that IL-1β, Cu and Zn might synergistically predict pregnancy outcome.

Using feature optimization and LightGBM algorithm to predict the clinical pregnancy outcomes after in vitro fertilization

Background

According to a recent report by the WHO, approximately 17.5\% (about one-sixth) of the global adult population is affected by infertility. Consequently, researchers worldwide have proposed various machine learning models to improve the prediction of clinical pregnancy outcomes during IVF cycles. The objective of this study is to develop a machine learning(ML) model that predicts the outcomes of pregnancies following in vitro fertilization (IVF) and assists in clinical treatment.

Methods

This study conducted a retrospective analysis on provincial reproductive centers in China from March 2020 to March 2021, utilizing 13 selected features. The algorithms used included XGBoost, LightGBM, KNN, Naïve Bayes, Random Forest, and Decision Tree. The results were evaluated using performance metrics such as precision, recall, F1-score, accuracy and AUC, employing five-fold cross-validation repeated five times.

Results

Among the models, LightGBM achieved the best performance, with an accuracy of 92.31%, recall of 87.80%, F1-score of 90.00\%, and an AUC of 90.41%. The model identified the estrogen concentration at the HCG injection(etwo), endometrium thickness (mm) on HCG day(EM TNK), years of infertility(Years), and body mass index(BMI) as the most important features.

Conclusion

This study successfully demonstrates the LightGBM model has the best predictive effect on pregnancy outcomes during IVF cycles. Additionally, etwo was found to be the most significant predictor for successful IVF compared to other variables. This machine learning approach has the potential to assist fertility specialists in providing counseling and adjusting treatment strategies for patients.

Normal and Abnormal Appearances of the Ovaries during Assisted Reproduction: Multimodality Imaging Review

Infertility is a common diagnosis that prompts many couples and individuals to seek assisted reproductive technology (ART) for assistance with conception. These technologies have become increasingly used in the United States in the past several decades, with 326 468 ART cycles performed in 2020, resulting in 75 023 live births. This ubiquity of ART also increases the likelihood that radiologists will encounter both normal and abnormal imaging findings associated with these treatments. Thus, radiologists of all subspecialties should be familiar with the multimodality appearance of the ovaries and pelvis in patients undergoing ART treatments. Furthermore, it is imperative that radiologists understand the appearance expected during different stages of the ART process. During stimulated ovulatory cycles, it is normal and expected for the ovaries to appear enlarged and to contain numerous cystic follicles, often with a small to moderate volume of pelvic free fluid. After oocyte retrieval, hemorrhagic ovarian follicles and a small to moderate volume of blood products in the cul-de-sac can be expected to be seen. Multiple nonemergency and emergency complications are related to ART, many of which can be seen at imaging. The most encountered emergency complications of ART include ovarian hyperstimulation syndrome, ectopic pregnancy, heterotopic pregnancy, multiple gestations, ovarian torsion, and procedural complications related to oocyte retrieval. These complications have important clinical implications, thus necessitating accurate and timely detection by the radiologist and the clinical team. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Cerebral palsy in children born after assisted reproductive technology in Norway: Risk, prevalence, and clinical characteristics

INTRODUCTION

The aim was to investigate the risk, prevalence, and clinical characteristics of cerebral palsy among children born after assisted reproductive technology (ART) in Norway.

MATERIAL AND METHODS

All liveborn children from 2002 to 2015 were included. Information was collected from the Medical Birth Registry of Norway, linked to the Norwegian Quality and Surveillance Registry for Cerebral Palsy as of December 31, 2022. Logistic regression analyses were used to calculate the prevalence of cerebral palsy per 1000 live births after ART and natural conception with birth year as covariate, crude odds ratios (OR) for cerebral palsy among children born after ART using children born after natural conception as reference, and OR adjusted for potential confounders, with 95% confidence intervals (CI). Potential mediators of the association were studied in stratified analyses. Descriptive statistics were used to compare proportions in clinical characteristics among children with cerebral palsy born after ART and natural conception.

RESULTS

Among 833 645 livebirths, 23 645 children were born after ART and of the latter 97 were diagnosed with cerebral palsy. The overall prevalence of cerebral palsy after ART was 4.10 per 1000 live births (95% CI 3.36-5.00), decreasing from 7.79 per 1000 in 2002 to 3.55 in 2015. Compared with children born after natural conception, the OR for cerebral palsy was 2.01 (95% CI 1.63-2.47) adjusted for mother's age at birth, parity, and pre-pregnancy health. When restricted to singletons born at term, the adjusted OR for cerebral palsy was 1.13 (95% CI 0.76-1.69). The distribution of cerebral palsy subtypes and the severity of gross and fine motor function and associated impairments did not differ significantly between children with cerebral palsy born after ART and natural conception.

CONCLUSIONS

Children born after ART had a risk of cerebral palsy that was twice that of children born after natural conception. The increased risk of cerebral palsy after ART is likely attributed to multiple pregnancies and preterm births. The prevalence of cerebral palsy after ART decreased significantly during the study period, despite an increased use of ART in the population. The distribution of clinical characteristics did not differ between children with cerebral palsy born after ART and those born after a natural conception, suggesting that the risk factors for, and causes of cerebral palsy were similar.

Perinatal Outcomes of Monochorionic Twin Pregnancies Conceived Naturally Versus through Assisted Reproductive Techniques

Objective: It has been reported that monochorionic twin pregnancies conceived through assisted reproductive techniques (ART) display a higher risk of second-trimester miscarriage, cesarean delivery, and neonatal death than those conceived naturally. The aim of this study was to compare the perinatal outcomes of monochorionic diamniotic (MCDA) twin pregnancies conceived naturally and through ART in a tertiary hospital. Methods: This was a retrospective cohort study of all MCDA twin pregnancies that received obstetric care and delivered at La Fe University and Polytechnic Hospital between 2015 and 2021. MCDA pregnancies that were referred to the tertiary hospital for specialized management, follow-up, and delivery were also included. The study was approved by The Health Research Institute Hospital La Fe (IIS La Fe). Results: Among the 184 MCDA pregnancies, 149 (81%) had a natural conception, and 35 (19%) were conceived through ART. Patients with an MCDA pregnancy who conceived through ART had a significantly older maternal age (38.0 [35.5-42.5] vs. 32.0 [29.0-36.0], p < 0.001) and an elevated rate of nulliparity (80.0% vs. 50.3%, p = 0.001). Regarding pregnancy complications, MCDA pregnancies through ART were associated with a significantly higher incidence of gestational diabetes (22.9% vs. 2.7%, p < 0.001), hypertensive disorders during pregnancy (22.9% vs. 9.4%, p = 0.04), and other pregnancy complications such as threatened labor or preterm prelabor rupture of membranes (14.3% vs. 36.2%, p = 0.015), than naturally conceived MCDA pregnancies. No differences were found in the incidence of twin-to-twin transfusion syndrome (20% vs. 33.6%, p = 0.155). MCDA pregnancies through natural conception had a greater rate of vaginal delivery than MCDA through ART (16.8% vs. 2.9%, p = 0.032). When adjusted for confounding factors, MCDA pregnancies through ART were only more likely to develop gestational diabetes than those naturally conceived (aOR 7.86, 95% CI 1.55-39.87). No differences were found regarding neonatal outcomes between groups. Conclusions: Compared with naturally conceived MCDA twin pregnancies, those conceived through ART displayed a significantly higher risk of developing gestational diabetes. No differences regarding other pregnancy complications, mode of delivery, or neonatal outcomes were found between groups.

Assisted Reproductive Technology and Perinatal Mortality: Selected States (2006-2011)

OBJECTIVE

This study aimed to compare trends and characteristics of assisted reproductive technology (ART) and non-ART perinatal deaths and to evaluate the association of perinatal mortality and method of conception (ART vs. non-ART) among ART and non-ART deliveries in Florida, Massachusetts, and Michigan from 2006 to 2011.

STUDY DESIGN

Retrospective cohort study using linked ART surveillance and vital records data from Florida, Massachusetts, and Michigan.

RESULTS

During 2006 to 2011, a total of 570 ART-conceived perinatal deaths and 25,158 non-ART conceived perinatal deaths were identified from the participating states. Overall, ART perinatal mortality rates were lower than non-ART perinatal mortality rates for both singletons (7.0/1,000 births vs. 10.2/1,000 births) and multiples (22.8/1,000 births vs. 41.2/1,000 births). At <28 weeks of gestation, the risk of perinatal death among ART singletons was significantly lower than non-ART singletons (adjusted risk ratio [aRR] = 0.46, 95% confidence interval [CI]: 0.26-0.85). Similar results were observed among multiples at <28 weeks of gestation (aRR = 0.64, 95% CI: 0.45-0.89).

CONCLUSION

Our findings suggest that ART use is associated with a decreased risk of perinatal deaths prior to 28 weeks of gestation, which may be explained by earlier detection and management of fetal and maternal conditions among ART-conceived pregnancies. These findings provide valuable information for health care providers, including infertility specialists, obstetricians, and pediatricians when counseling ART users on risk of treatment.

KEY POINTS

· ART use is associated with a decreased risk of perinatal deaths prior to 28 weeks of gestation.. · ART perinatal mortality rates were lower than that for non-ART perinatal mortality.. · This study used linked data to examine associations between use of ART and perinatal deaths..

The risk factors and impact of subchorionic hematoma in the first trimester in IVF twin pregnancies: a prospective cohort study

Objective

This study aimed to identify the risk factors for subchorionic hematoma (SCH) in the first trimester of in vitro fertilization (IVF) twin pregnancies and investigate the impact of SCH on pregnancy outcomes.

Study design

A prospective cohort study was conducted at Chengdu Women and Children's Central Hospital. The study recruited patients who were identified with twin pregnancies in the first trimester, undergoing IVF treatment from January 2020 to May 2021. The demographic characteristics and pregnancy outcomes were compared between the SCH and the non-SCH groups. A logistic regression analysis was used to determine the risk factors for SCH and adverse pregnancy outcomes.

Results

In the first trimester, 38% of patients developed SCH. The independent risk factors for SCH included male factor, hydrosalpinx, polycystic ovary syndrome (PCOS), previous miscarriage, and adenomyosis. With respect to the pregnancy outcomes, only the rate of twin pregnancy loss before 20 gestational weeks was significantly higher in the SCH group than in the non-SCH group. After adjusting for the confounding factors, the presence of SCH diminished the ovarian reserve, and previous miscarriage was independently related to twin pregnancy loss before 20 gestational weeks.

Conclusion

This may be the first study to evaluate the risk factors of SCH in twin pregnancies who underwent IVF-ET/FET treatment, which may provide some theoretical basis for clinical practice in the future. Furthermore, it was found that the occurrence of SCH was associated with the loss of both pregnancies before 20 gestational weeks. Therefore, these patients should be offered increased surveillance and timely treatment.

The impact of the use of immunosuppressive treatment after an embryo transfer in increasing the rate of live birth

The tolerance of the immune system for the semi-allogeneic embryo is promoted by several factors and the cells involved in the immune system and factors in the mother during pregnancy. The dysregulation of the immune responses between the mother and fetus is a risk factor that raises the likelihood of rejection of the embryo and reproductive failure. To safeguard embryos and prevent immunological attacks, it is critical to suppress immunological rejection and encourage immunological tolerance. Based on current medical literature, it seems that immune cell management through immunosuppressive therapies can address reproductive failures. Immunosuppressive treatment has demonstrated encouraging results in terms of enhancing outcomes related to pregnancy and rates of live birth by regulating the immune responses of mothers and positively impacting the reproductive processes of humans. Currently, there is scarcity of high-quality data regarding the safety and efficacy of immunosuppressive therapies for children and mothers. Therefore, it is important to exercise caution while selecting use of any immunosuppressive therapy in pregnancy. This mini review provides a comprehensive overview of the existing literature regarding the impact of Calcineurin Inhibitors and anti-TNF treatment on improving the live birth rate following embryo transfer.

Associations of childhood allergies with parental reproductive and allergy history

PURPOSE

There has been a noted parallel rise in both the use of Assisted Reproductive Technology (ART) to conceive and childhood allergies in the last few decades. The purpose of this study was to investigate the possible association between reproductive and allergy history in parents and allergies in their children.

METHODS

This exploratory study used a cross-sectional study design and web-based survey to collect anonymous data on demographics, allergy, and health history from parents and about each of their children under 18 years of age. Children were stratified into two groups by allergy status (yes/no), and associations between each variable and the odds of allergies were tested using univariable and multivariable mixed logistic regression models.

RESULTS

Of the 563 children in the study, 237 were reported to have allergies whereas 326 did not. Age, residential community, household income, mode of conception, paternal age at conception, biological parental allergy status, and history of asthma and eczema were significantly associated with allergies in univariable analysis. Multivariable analysis revealed household income ($50 k to $99 k vs ≥ $200 k adj OR = 2.72, 95% CI 1.11, 6.65), biological parental allergies (mother-adj OR 2.74, 95% CI 1.59, 4.72, father-adj OR 2.06, 95% CI 1.24, 3.41) and each additional year of age of children (adj OR 1.17, CI 1.10, 1.24) were significantly associated with odds of allergies in children.

CONCLUSION

Although the exploratory nature of this convenience, snowballing sample limited the generalizability of the findings, initial observations warrant further investigation and validation in a larger more diverse population.

Examining attention-deficit/hyperactivity disorder and related behavioral disorders by fertility treatment exposure in a prospective cohort

PURPOSE

To evaluate whether underlying infertility and mode of conception are associated with childhood behavioral disorders.

METHODS

Oversampling on fertility treatment exposure using vital records, the Upstate KIDS Study followed 2057 children (of 1754 mothers) from birth to 11 years. Type of fertility treatment and time to pregnancy (TTP) were self-reported. Mothers completed annual questionnaires reporting symptomology, diagnoses, and medications at 7-11 years of age. The information identified children with probable attention-deficit/hyperactivity disorder, anxiety or depression, and conduct or oppositional defiant disorders. We estimated adjusted relative risks (aRR) for disorders by underlying infertility (TTP > 12 months) or treatment exposure groups compared to children born to parents with TTP ≤ 12 months.

RESULTS

Children conceived with fertility treatment (34%) did not have an increased risk of attention-deficit/hyperactivity disorder (aRR): 1.21; 95% CI: 0.88, 1.65), or conduct or oppositional defiant disorders (aRR: 1.31; 0.91, 1.86), but did have an increased risk of anxiety or depression (aRR: 1.63; 1.18, 2.24), which remained elevated even after adjusting for parental mood disorders (aRR: 1.40; 0.99, 1.96). Underlying infertility without the use of treatment was also associated with a risk of anxiety or depression (aRR: 1.82; 95% CI: 0.96, 3.43).

CONCLUSIONS

Underlying infertility or its treatment was not associated with risk of attention-deficit/hyperactivity disorder. Observations of increased anxiety or depression require replication.

Effect of increased gonadotropin dosing on maternal and neonatal outcomes in predicted poor responders undergoing IVF: follow-up of a randomized trial

OBJECTIVE

To evaluate, in women scheduled for IVF with predicted poor ovarian response, the effect of increased dosing of gonadotropin on maternal and neonatal outcomes compared with standard dosing.

STUDY DESIGN

We performed a follow-up study of an open-labelled randomized controlled trial comparing increased (225 or 300 IU/d) versus standard (150 IU/d) dose gonadotrophins on cumulative live birth rates. We randomized 661 women with a predicted poor ovarian response (based on their antral follicle count) scheduled for their first IVF/ICSI cycle. Here, we report on maternal and neonatal outcomes between increased and standard dosing groups.

RESULTS

There was a trend of increased risk of gestational diabetes mellitus in the increased gonadotrophin dose group compared with the standard group in both cumulative live birth pregnancies (14.8% vs. 7.8%, relative risk (RR) 1.90, 95% confidence interval (CI) 0.96-3.74, P = 0.06) and live birth pregnancies in the first transfer (15.2% vs. 7.7%, RR 1.98, 95 %CI 0.93-4.19, P = 0.08), without reaching statistical significance. The occurrence of gestational diabetes mellitus was significantly higher in the increased gonadotrophin dose group (24/149, 16.1% vs. 8/128, 6.3%; risk ratio (RR) 2.58, 95 %CI 1.19 to 5.54, P = 0.02) in singleton pregnancies. In women with first embryo transfer cycle, maternal hypothyroidism occurred also more frequent in the increased gonadotrophin dose group than the standard group (16.0% vs. 6.8%, RR 2.34, 95 %CI:1.07-5.11, P = 0.03).

CONCLUSIONS

In women with predicted poor ovarian response, increased dosing of gonadotropin may result in an increased risk of gestational diabetes mellitus and maternal hypothyroidism.

Body mass index is negatively associated with a good perinatal outcome after in vitro fertilization among patients with polycystic ovary syndrome: a national study

Objective

To evaluate the association between body mass index (BMI) and good perinatal outcomes after in vitro fertilization (IVF) among women with polycystic ovary syndrome (PCOS).

Design

Retrospective cohort study using 2012-2015 Society for Assisted Reproductive Technology Clinic Outcomes Reporting System data.

Setting

Fertility clinics.

Patients

To identify patients most likely to have PCOS, we included women with a diagnosis of ovulation disorder and serum antimüllerian hormone >4.45 ng/mL. Exclusion criteria included age ≥ 41 years, secondary diagnosis of diminished ovarian reserve, preimplantation genetic testing, and missing BMI or primary outcome data.

Interventions

None.

Main Outcome Measures

Good perinatal outcome, defined as a singleton live birth at ≥ 37 weeks with birth weight ≥ 2,500 g and ≤ 4,000 g.

Results

The analysis included 9,521 fresh, autologous IVF cycles from 8,351 women. Among women with PCOS, the proportion of cycles with a good perinatal outcome was inversely associated with BMI: underweight 25.1%, normal weight 22.7%, overweight 18.9%, class I 18.4%, class II 14.9%, and class III or super obesity 12.2%. After adjusting for confounders, women in the highest BMI category had 51% reduced odds of a good perinatal outcome compared with normal weight women (adjusted odds ratio 0.49, 95% confidence interval 0.36-0.67).

Conclusions

Among women with PCOS undergoing fresh, autologous IVF, the odds of a good perinatal outcome decline with increasing BMI. Women with PCOS should be counseled that the odds of achieving a good perinatal outcome decrease as their weight increases.

High prevalence of reduced fertility and use of assisted reproductive technology in a German cohort of patients with peripartum cardiomyopathy

BACKGROUND

Over the past decades the use of assisted reproduction technology (ART) increased worldwide. ARTs are associated with an elevated risk for cardiovascular complications. However, a potential relation between subfertility/ARTs and the heart disease peripartum cardiomyopathy (PPCM) has not been systematically analyzed yet.

METHODS

A retrospective cohort study was carried out, including n = 111 PPCM patients from the German PPCM registry. Data from PPCM patients were compared to those from postpartum women in the German general population.

RESULTS

The prevalence of reported subfertility was high among PPCM patients (30%; 33/111). Most of the subfertile PPCM patients (55%; 18/33) obtained vitro fertilizations (IVF) or intracytoplasmic sperm injections (ICSI). PPCM patients were older (p < 0.0001), the percentage of born infants conceived by IVF/ICSI was higher (p < 0.0001) with a higher multiple birth (p < 0.0001), C-section (p < 0.0001) and preeclampsia rate (p < 0.0001), compared to postpartum women. The cardiac outcome was comparable between subfertile and fertile PPCM patients. Whole exome sequencing in a subset of n = 15 subfertile PPCM patients revealed that 33% (5/15) carried pathogenic or likely pathogenic gene variants associated with cardiomyopathies and/or cancer predisposition syndrome.

CONCLUSIONS

Subfertility occurred frequently among PPCM patients and was associated with increased age, hormonal disorders, higher twin pregnancy rate and high prevalence of pathogenic gene variants suggesting a causal relationship between subfertility and PPCM. Although this study found no evidence that the ART treatment per se increases the risk for PPCM or the risk for an adverse outcome, women with subfertility should be closely monitored for signs of peripartum heart failure.

Lived experiences and coping strategies of persons seeking infertility treatment in the Kumasi metropolis: a descriptive phenomenological study

BACKGROUND

Women seeking fertility treatment face myriad challenges that they must adapt and adjust to daily. This aimed at exploring the experiences and coping strategies of such persons in the Kumasi. Metropolis.

METHODS

A qualitative approach was employed and a purposive sampling technique was used to select 19 participants. A semi-structured interview was used to collect data. The data collected were analyzed using Colaizzi's method of data analysis.

RESULTS

Persons living with infertility had emotional experiences of anxiety, stress, and depression. Socially, participants experienced isolation, stigma, societal pressure, and marital problems due to their inability to conceive. The key coping strategies adopted were spiritual (faith-based) and social support. Though formal child adoption can be an option, no participant preferred it as a coping strategy. Some participants also reported using herbal medicine before going to the fertility centre upon realizing that the approach was not helping in achieving their desired outcome.

CONCLUSION

Infertility is a source of suffering for most women diagnosed with it, resulting in significant negative experiences in their matrimonial homes, families, friends, and the community at large. Most participants rely on spiritual and social support as their immediate and basic coping strategies. Future research could evaluate the treatment and coping strategies and also determine the outcomes of other forms of treatment for infertility.

Autologous Human Mesenchymal Stem Cell-Based Therapy in Infertility: New Strategies and Future Perspectives

Infertility could be associated with a few factors including problems with physical and mental health, hormonal imbalances, lifestyles, and genetic factors. Given that there is a concern about the rise of infertility globally, increased focus has been given to its treatment for the last several decades. Traditional assisted reproductive technology (ART) has been the prime option for many years in solving various cases of infertility; however, it contains significant risks and does not solve the fundamental problem of infertility such as genetic disorders. Attention toward the utilization of MSCs has been widely regarded as a promising option in the development of stem-cell-based infertility treatments. This narrative review briefly presents the challenges in the current ART treatment of infertility and the various potential applications of autologous MSCs in the treatment of these reproductive diseases.

Association between chemical mixtures and female fertility in women undergoing assisted reproduction in Sweden and Estonia

OBJECTIVE

Women of reproductive age are exposed to ubiquitous chemicals such as phthalates, parabens, and per- and polyfluoroalkyl substances (PFAS), which have potential endocrine disrupting properties and might affect fertility. Our objective was to investigate associations between potential endocrine-disrupting chemicals (EDCs) and female fertility in two cohorts of women attending fertility clinics.

METHODS

In a total population of 333 women in Sweden and Estonia, we studied the associations between chemicals and female fertility, evaluating ovarian sensitivity index (OSI) as an indicator of ovarian response, as well as clinical pregnancy and live birth from fresh and frozen embryo transfers. We measured 59 chemicals in follicular fluid samples and detected 3 phthalate metabolites, di-2-ethylhexyl phthalate (DEHP) metabolites, 1 paraben, and 6 PFAS in >90% of the women. Associations were evaluated using multivariable-adjusted linear or logistic regression, categorizing EDCs into quartiles of their distributions, as well as with Bayesian Kernel Machine Regression.

RESULTS

We observed statistically significant lower OSI at higher concentrations of the sum of DEHP metabolites in the Swedish cohort (Q4 vs Q1, β = -0.21, 95% CI: -0.38, -0.05) and methylparaben in the Estonian cohort (Q3 vs Q1, β = -0.22, 95% CI: -0.44, -0.01). Signals of potential associations were also observed at higher concentrations of PFUnDA in both the combined population (Q2 vs. Q1, β = -0.16, 95% CI -0.31, -0.02) and the Estonian population (Q2 vs. Q1, β = -0.27, 95% CI -0.45, -0.08), and for PFOA in the Estonian population (Q4 vs. Q1, β = -0.31, 95% CI -0.61, -0.01). Associations of chemicals with clinical pregnancy and live birth presented wide confidence intervals.

CONCLUSIONS

Within a large chemical mixture, we observed significant inverse associations levels of DEHP metabolites and methylparaben, and possibly PFUnDA and PFOA, with OSI, suggesting that these chemicals may contribute to altered ovarian function and infertility in women.

Cardiovascular Complications During Delivery Admissions Associated With Assisted Reproductive Technology (from a National Inpatient Sample Analysis 2008 to 2019)

Women who conceive through assisted reproductive technology (ART) have a known increased risk of obstetric complications. However, whether ART is also associated with higher risk of developing cardiovascular complications during delivery admissions has not been well established. We used data from the National Inpatient Sample (2008 to 2019) and used the International Classification of Diseases codes to identify delivery hospitalizations and ART procedures. A total of 45,867,086 weighted delivery cases were identified, of which 0.24% were among women who conceived through ART (n = 108,542). Women with an ART history were older at the time of delivery (median 35 vs 28 years, p <0.01) and had a higher prevalence of hypertension, gestational diabetes, and dyslipidemia (all, p <0.01). After adjustment for age, race/ethnicity, co-morbidities, multiple gestation, insurance, and income, ART remained an independent predictor of peripartum cardiovascular complications, including pre-eclampsia/eclampsia (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.45 to 1.51), heart failure (aOR 1.94, 95% CI 1.10 to 3.40), and cardiac arrhythmias (aOR 1.39, 95% CI 1.30 to 1.48), compared with natural conception. Likewise, the risk of acute kidney injury (aOR 2.57, 95% CI 2.25 to 2.92), ischemic stroke (aOR 1.73, 95% CI 1.24 to 2.43), hemorrhagic stroke (aOR 1.63, 95% CI 1.27 to 2.11), pulmonary edema (aOR 2.29, 95% CI 2.02 to 2.61), and venous thromboembolism (aOR 1.92, 95% CI 1.63 to 2.25) were higher with ART. However, odds of developing peripartum cardiomyopathy or acute coronary syndrome were not associated with ART. Length of stay (3 vs 2 days, p <0.01) and cost of hospitalization ($5,903 vs $3,922, p <0.01) were higher for deliveries among women with a history of ART. In conclusion, women who conceived with ART had higher risk of pre-eclampsia, heart failure, arrhythmias, stroke, and other complications during their delivery hospitalizations. This may, in part, contribute to their increased resource utilization seen.

Markers of ovarian reserve are associated with reproductive age acceleration in granulosa cells from IVF patients

STUDY QUESTION

Is reproductive aging in granulosa cells associated with markers of ovarian reserve?

SUMMARY ANSWER

Age acceleration was associated with anti-Mullerian hormone (AMH) levels, antral follicle count (AFC), oocyte yield and maturity, and the number of successfully fertilized embryos.

WHAT IS KNOWN ALREADY

The rate of reproductive aging varies among women of the same age. DNA methylation can be used to predict epigenetic age in a variety of tissues.

STUDY DESIGN, SIZE, DURATION

This was a cross-sectional study of 70 women at the time of oocyte retrieval.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 70 participants were recruited for this study at an academic medical center and they provided follicular fluid samples at the time of oocyte retrieval. Granulosa cells were isolated and assessed on the MethylationEPIC array. Linear regression was used to evaluate the associations between DNA methylation-based age predictions from granulosa cells and chronological age. Age acceleration was calculated as the residual of regressing DNA methylation-based age on chronological age. Linear regressions were used to determine the associations between age acceleration and markers of ovarian reserve and IVF cycle outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

Participants were a mean of 36.7 ± 3.9 years old. In regards to race, 54% were white, 19% were African American and 27% were of another background. Age acceleration was normally distributed and not associated with chronological age. Age acceleration was negatively associated with AMH levels (t = -3.1, P = 0.003) and AFC (t = -4.0, P = 0.0001), such that women with a higher age acceleration had a lower ovarian reserve. Age acceleration was also negatively correlated with the total number of oocytes retrieved (t = -3.9, P = 0.0002), the number of mature oocytes (t = -3.8, P = 0.0003) and the number of fertilized oocytes or two-pronuclear oocytes (t = -2.8, P = 0.008) in the main analysis.

LIMITATIONS, REASONS FOR CAUTION

This study used pooled follicular fluid, which does not allow for the investigation of individual follicles. Infertility patients may also be different from the general population, but, as we used granulosa cells, the participants had to be from an IVF population.

WIDER IMPLICATIONS OF THE FINDINGS

This study demonstrated that epigenetic age and age acceleration can be calculated from granulosa cells collected at the time of oocyte retrieval. GrimAge most strongly predicted chronological age, and GrimAge acceleration was associated with baseline and cycle characteristics as well as cycle outcomes, which indicates its potential clinical relevance in evaluating both oocyte quantity and quality.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the National Institutes of Health (UL1TR002378) and the Building Interdisciplinary Research Careers in Women's Health Program (K12HD085850) to A.K.K. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding source had no role in any aspect of this study. J.B.S. serves as Vice Chair for the American Society for Reproductive Medicine Education Committee, is a Medical Committee Advisor for the Jewish Fertility Foundation and works with Jscreen. J.B.S. has received funding from Georgia Clinical Translational Research Alliance. H.S.H., J.B.S. and A.K.S. have received NIH funding for other projects. A.K.K., S.A.G., S.G., Q.S.K., L.J.M. and W.S. have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Clomifene and Assisted Reproductive Technology in Humans Are Associated with Sex-Specific Offspring Epigenetic Alterations in Imprinted Control Regions

Children conceived with assisted reproductive technology (ART) have an increased risk of adverse outcomes, including congenital malformations and imprinted gene disorders. In a retrospective North Carolina-based-birth-cohort, we examined the effect of ovulation drugs and ART on CpG methylation in differentially methylated CpGs in known imprint control regions (ICRs). Nine ICRs containing 48 CpGs were assessed for methylation status by pyrosequencing in mixed leukocytes from cord blood. After restricting to non-smoking, college-educated participants who agreed to follow-up, ART-exposed (n = 27), clomifene-only-exposed (n = 22), and non-exposed (n = 516) groups were defined. Associations of clomifene and ART with ICR CpG methylation were assessed with linear regression and stratifying by offspring sex. In males, ART was associated with hypomethylation of the PEG3 ICR [β(95% CI) = -1.46 (-2.81, -0.12)] and hypermethylation of the MEG3 ICR [3.71 (0.01, 7.40)]; clomifene-only was associated with hypomethylation of the NNAT ICR [-5.25 (-10.12, -0.38)]. In female offspring, ART was associated with hypomethylation of the IGF2 ICR [-3.67 (-6.79, -0.55)]. Aberrant methylation of these ICRs has been associated with cardiovascular disease and metabolic and behavioral outcomes in children. The results suggest that the increased risk of adverse outcomes in offspring conceived through ART may be due in part to altered methylation of ICRs. Larger studies utilizing epigenome-wide interrogation are warranted.

A Case-Control Study of Follicular Fluid Cytokine Profiles in Women with Diminished Ovarian Reserve

Ovarian reserve is an important determinant of a woman's reproductive potential, and women with diminished ovarian reserve (DOR) often seek in vitro fertilization (IVF). The underlying etiology of DOR is unknown, but follicular fluid cytokine concentrations likely play a role in follicular development and maturation. The present study seeks to investigate the expression of cytokines in follicular fluid (FF) of women with DOR undergoing IVF and explore correlated functional pathways. One hundred ninety-four women undergoing ovarian stimulation were recruited at the time of oocyte retrieval. Women were classified as having DOR if they met one or more of the following criteria: AMH < 1 ng/ml, FSH > 10 mIU/ml, and/or AFC < 10. Controls included women undergoing IVF for male factor, tubal factor due to tubal ligation, or planned oocyte cryopreservation (non-oncologic). The concentrations of 480 cytokines and related growth factors in follicular fluid were determined using a multiplex immunoassay. Fifty-nine cytokines had significantly different concentrations (53 higher and 6 lower) in the DOR relative to the control group after adjusting for age and body mass index (BMI) (false discovery rate; FDR < 0.1). Using the most informative 44 biomarkers as indicated by a random forest (RF) model, an area under the curve (AUC) of 0.78 was obtained. Thus, follicular microenvironment differs between women with DOR and normal ovarian reserve. The differentially expressed cytokines belong to diverse processes that are primarily involved in follicular maturation and ovulation. These changes may play an important role in treatment outcomes in women with DOR.

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.

Isolation of cfDNA from spent culture media and its association with implantation rate and maternal immunomodulation

OBJECTIVES

This investigation aims to evaluate the association between the concentration of cell-free DNA (cfDNA) in the spent culture medium (SCM) with implantation rate and the maternal immune system in the invitro fertilization (IVF). In this study, 30 embryos were cultured and scored according to Gardner's criteria. SCM was gathered on day five from every embryo to analyze the quantity of cfDNA. The real-time PCR technique evaluated the expression level of transcription factors, including Foxp3, RORγt, GATA3, and T-bet. The percentage of Th1, Th2, Th17, Treg, NK cells, and NK cells cytotoxicity was evaluated by flow cytometry.

RESULTS

The concentration of cfDNA in the β-HCG (-), β-HCG ( +), and ongoing pregnancy groups were 20.70 ± 9.224 ng/µL, 27.97 ± 7.990 ng/µL, and 28.91 ± 8.566 ng/µL, respectively. The ratio of Th1/Th2 and Th17/Treg reduced significantly in pregnant women, as well as the level of NK cells and NK cytotoxicity cells fell dramatically in the ongoing pregnancy group. The expression level of RORγt and T-bet declined while the expression level of Foxp3 and GATA3 increased considerably in pregnant mothers. Our investigation revealed that the concentration level of cfDNA in SCM could not be associated with implantation rate, prediction of ongoing pregnancy, and maternal immune system.

The Consequences of Assisted Reproduction Technologies on the Offspring Health Throughout Life: A Placental Contribution

The use of assisted reproductive technologies (ART) worldwide has led to the conception and birth of over eight million babies since being implemented in 1978. ART use is currently on the rise, given growing infertility and the increase in conception age among men and women in industrialized countries. Though obstetric and perinatal outcomes have improved over the years, pregnancies achieved by ART still bear increased risks for the mother and the unborn child. Moreover, given that the first generation of ART offspring is now only reaching their forties, the long-term effects of ART are currently unknown. This is important, as there is a wealth of data showing that life-long health can be predetermined by poor conditions during intrauterine development, including irregularities in the structure and functioning of the placenta. In the current review, we aim to summarize the latest available findings examining the effects of ART on the cardiometabolic, cognitive/neurodevelopmental, and behavioral outcomes in the perinatal period, childhood and adolescence/adulthood; and to examine placental intrinsic factors that may contribute to the developmental outcomes of ART offspring. Altogether, the latest knowledge about life outcomes beyond adolescence for those conceived by ART appears to suggest a better long-term outcome than previously predicted. There are also changes in placenta structure and functional capacity with ART. However, more work in this area is critically required, since the potential consequences of ART may still emerge as the offspring gets older. In addition, knowledge of the placenta may help to foresee and mitigate any adverse outcomes in the offspring.

Placental abruption: assessing trends in risk factors over time

PURPOSE

To evaluate changes in the independent contribution of different risk factors for placental abruption over time.

METHODS

In this retrospective nested case-control study, trends of change in ORs for known risk factors for placental abruption occurring in three consecutive 8-year intervals were compared. A univariate assessment of factors associated with placental abruption and two multivariable logistic regression models were constructed to identify independent risk factors for placental abruption. Trends of change in the incidence and specific contribution of various risk factors were compared along the study time-period.

RESULTS

During the study period, 295,946 pregnancies met the inclusion criteria; of these, 2170 (0.73%) were complicated with placental abruption. Using logistic regression models, previous cesarean delivery, in vitro fertilization (IVF) pregnancy, hypertensive disorders, polyhydramnios, and inadequate prenatal care were recognized as independent risk factors for placental abruption. While the relative contribution of IVF pregnancy and polyhydramnios to the overall risk for abruption decreased over the course of the study, previous cesarean delivery became a stronger contributor for placental abruption.

CONCLUSION

In our study, a change over time in the specific contribution of different risk factors for placental abruption has been demonstrated.

The parent trap: desire for multifetal gestation among patients treated for infertility

Objective

To evaluate predictors for patient preference regarding multifetal or singleton gestation among women presenting for infertility care.

Design

Cross-sectional study.

Setting

Academic university hospital-based infertility clinic.

Patient(s)

Five hundred thirty-nine female patients with infertility who presented for their initial visit.

Main outcome measure(s)

Demographic characteristics, infertility history, insurance coverage, desired treatment outcome, acceptability of multifetal reduction, and knowledge of the risks of multifetal pregnancies were assessed using a previously published 41-question survey. Univariate analysis was performed to assess patient factors associated with the desire for multiple births. Independent factors associated with this desire were subsequently assessed by multivariate logistic regression analysis.

Result(s)

Nearly a third of women preferred multiples over a singleton gestation. Nulliparity, lower annual household income, older maternal age, marital status, larger ideal family size, openness to multifetal reduction, and lack of knowledge of the maternal/fetal risks of twin pregnancies were associated with pregnancy desire. Older age (OR (95% CI) 1.66 (1.20–2.29)), nulliparity (OR (95% CI) 0.34 (0.20–0.58)), larger ideal family size (OR (95% CI) 2.34 (1.73–3.14)), and lesser knowledge of multifetal pregnancy risk (OR (95% CI) 0.67 (0.55–0.83)) were independently associated with desire.

Conclusion(s)

A large number of patients undergoing fertility treatment desire multifetal gestation. Although a lack of understanding of the risks associated with higher order pregnancies contributes to this desire, additional individual specific variables also contribute to this trend. Efforts to reduce the incidence of multiples should focus not only on patient education on comparative risks of multiples vs singleton pregnancies but also account for individual specific reservations.

Effectiveness and safety of intrauterine insemination vs. assisted reproductive technology: emulating a target trial using an observational database of administrative claims

OBJECTIVE

To compare the effectiveness and safety of 1 cycle of assisted reproductive technology (ART) vs. 3 cycles of intrauterine insemination (IUI).

DESIGN

Target trial emulation using observational data.

SETTING

A healthcare claims database (2011-2015).

PATIENT(S)

The patients were 29,021 women aged 18-45 years with an infertility diagnosis and no history of IUI or ART within the past 12 months.

INTERVENTION(S)

One ART cycle immediately, with no more cycles of ART or IUI within the next 4 months; or 1 IUI cycle immediately, with 2 additional consecutive cycles of IUI within the next 4 months unless pregnancy occurred.

MAIN OUTCOME MEASURE(S)

Live births, multiple births, congenital malformations, preterm births, small-for-gestational-age newborns, large-for-gestational-age newborns, admission to neonatal intensive care unit (NICU), gestational diabetes, preeclampsia, and gestational hypertension.

RESULT(S)

The probability of live birth was 27.3% for ART and 26.3% for IUI. The observational analogue of per-protocol risk difference (95% confidence interval) for ART compared with IUI was 1.0% (-0.1%, 2.2%) for live births, 4.3% (3.7%, 4.9%) for multiple births, 3.4% (2.8%, 4.0%) for preterm births, 1.5% (0.9%, 2.1%) for NICU admissions, and 0.6% (0.2%, 1.0%) for gestational diabetes. The risk differences for the other outcomes were <0.5%. The results of the 2 strategies were similar in women ≤40 years, but in women >40 years the probability of live birth was greater for ART (14.4%) than for IUI (7.4%).

CONCLUSION(S)

Compared with 3 cycles of IUI, 1 cycle of ART was estimated to have a similar probability of live birth but slightly higher risks of multiple gestations, preterm births, and NICU admissions.

Racial/ethnic disparities in infertility treatment utilization in the US, 2011-2019

With delayed child-bearing age, there has been an increase in infertility rates globally and in the United States (US). Unsurprisingly, there has been a concomitant substantial increase in the number of individuals seeking infertility treatments over the last decade. This study aimed to examine the relationship between race/ethnicity and the utilization of different infertility treatments over the previous decade. We conducted this retrospective cohort study using the United States (US) Birth data files 2011-2019. We calculated the rates of infertility treatment and its subtypes over the study period. Descriptive statistics were utilized to examine the sociodemographic and birth characteristics for overall births and those associated with any infertility treatment and each of its subtypes. We calculated the level of association between race/ethnicity and utilization of infertility treatment and the subtypes using adjusted logistic regression models. We found that the rate of infertility treatments for all subtypes considered, had steadily increased by 63.7% within the past decade. In contrast, fertility enhancing drugs or Intrauterine Insemination (IUI) increased by 134%, and in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) treatments increased by 40% over the 9-year study period. Non-Hispanic (NH) Asian women had the highest rate of any infertility treatment with a rate of 25 per 1000 births whereas Hispanic women had the lowest rate of any infertility treatment at 5.8 per 1000 births. When compared with NH-White women, NH-Asian women had a modest 7% lower likelihood (OR = 0.93, 95% CI = 0.92-0.94) of receiving any infertility treatment while NH-Black and Hispanic women had about 70% lower likelihood of receiving any infertility treatment. Our report of increased assisted reproductive technology (ART) utilization rates, and marked racial/ethnic differences in ART utilization highlight the importance of expanding knowledge of inequities that continue to impact marginalized groups, a critical step for informing actionable strategy formulations (i.e., advocacy, policy change, patient education, provider training) to address these inequities.

In-Hospital Complications in Pregnancies Conceived by Assisted Reproductive Technology

Background Assisted reproductive technology (ART) has emerged as a common treatment option for infertility, a problem that affects an estimated 48 million couples worldwide. Advancing maternal age with increasing prepregnancy cardiovascular risk factors, such as chronic hypertension, obesity, and diabetes, has raised concerns about pregnancy complications associated with ART. However, in-hospital complications following pregnancies conceived by ART are poorly described. Methods and Results To assess the patient characteristics, obstetric outcomes, vascular complications and temporal trends of pregnancies conceived by ART, we analyzed hospital deliveries conceived with or without ART between January 1, 2008, and December 31, 2016, from the United States National Inpatient Sample database. We included 106 248 deliveries conceived with ART and 34 167 246 deliveries conceived without ART. Women who conceived with ART were older (35 versus 28 years; P<0.0001) and had more comorbidities. ART-conceived pregnancies were independently associated with vascular complications (acute kidney injury: adjusted odds ratio [aOR], 2.52; 95% CI 1.99-3.19; and arrhythmia: aOR, 1.65; 95% CI, 1.46-1.86), and adverse obstetric outcomes (placental abruption: aOR, 1.57; 95% CI, 1.41-1.74; cesarean delivery: aOR, 1.38; 95% CI, 1.33-1.43; and preterm birth: aOR, 1.26; 95% CI, 1.20-1.32), including in subgroups without cardiovascular disease risk factors or without multifetal pregnancies. Higher hospital charges ($18 705 versus $11 983; P<0.0001) were incurred compared with women who conceived without ART. Conclusions Pregnancies conceived by ART have higher risks of adverse obstetric outcomes and vascular complications compared with spontaneous conception. Clinicians should have detailed discussions on the associated complications of ART in women during prepregnancy counseling.

The neurodevelopmental morbidity of children born after assisted reproductive technology: a Nordic register study from the Committee of Nordic Assisted Reproductive Technology and Safety group

OBJECTIVE

To assess the risk of neurodevelopmental disorders in singletons born after the use of assisted reproductive technology (ART) compared with singletons born without the use of ART.

DESIGN

Nordic register-based study.

SETTING

Cross-linked data from Medical Birth Registers and National ART and Patient Registers; liveborn singletons in 1995-2014 in Denmark and Finland, 2005-2015 in Norway, and 1995-2015 in Sweden with follow-up to 2014 (Denmark and Finland) or 2015 (Norway and Sweden).

PATIENTS

A total of 5,076,444 singletons: 116,909 (2.3%) born with and 4,959,535 (97.7%) born without the use of ART (non-ART).

INTERVENTIONS

In vitro fertilization, intracytoplasmic sperm injection, and fresh and frozen embryo transfer.

MAIN OUTCOME MEASURES

The primary outcomes (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes) were learning and motor functioning disorders (F80-F83), autism spectrum disorder (F84), attention-deficit/hyperactivity disorder and conduct disorders (F90-F92), and tic disorders (F95). Crude hazard ratios (HRs) and adjusted hazard ratios (aHRs) with 95% confidence intervals were calculated.

RESULTS

Singletons in the ART cohort had a higher adjusted risk of learning and motor functioning disorders (HR, 1.01 [0.96-1.07]; aHR, 1.17 [1.11-1.24]) and a tendency toward a higher risk of autism spectrum disorder (HR, 1.12 [1.04-1.21]; aHR, 1.07 [0.98-1.16]) and attention-deficit/hyperactivity disorder and conduct disorders (HR, 0.82 [0.77-0.86]; aHR, 1.17 [0.99-1.12]) but not of tic disorders (HR, 1.21 [1.06-1.38]; aHR, 1.17 [0.96-1.27]). No differences in risk were found between children born after in vitro fertilization and intracytoplasmic sperm injection or after fresh and frozen embryo transfer.

CONCLUSIONS

Our findings of only small differences in neurodevelopment between ART and non-ART singletons are reassuring and in line with previous studies.

NBMA Promotes Spermatogenesis by Mediating Oct4 Pathway

Non-obstructive azoospermia is one of the most common causes of male infertility, but there is still no specific treatment drug. Given that the Oct4 (Octamer-binding transcription factor 4) has an important regulatory effect on spermatogenesis, activating it can effectively promote spermatogenesis, so it is of great value to develop Oct4-targeted drug design and elucidating its mechanism of action. Here, we screened out the Oct4-targeted drug molecule NBMA (N-benzyl-4-methoxy-2-(1-(4-(trifluoromethyl)phenyl)vinyl)aniline) by computer-assisted technology, and found that it has a significant promoting effect on spermatogenesis in the established mouse azoospermia model. Subsequently, through transcriptome sequencing and enrichment analysis, real-time fluorescent quantitative PCR (qPCR) and western blot experiments revealed that NBMA promotes the differentiation of spermatogonial stem cells by activating the Oct4 pathway, thereby promoting spermatogenesis. This study proves that NBMA is a molecule with great potential to be developed as a therapeutic drug for azoospermia. It also shows that computer-assisted, chemical and biological multidisciplinary methods play a very important role in innovative drug discovery.

Dichorionic quadruplet pregnancy comprising monozygotic triplets and singleton after intracytoplasmic sperm injection and transfer of two fresh embryos: a case report

Monozygotic triplet pregnancies are very rare in assisted reproductive technology, and the relationship between monozygotic multiple pregnancies and several assisted reproductive techniques, including blastocyst transfer, remains unclear. Here, the case of a 28-year-old female patient with dichorionic quadruplet pregnancy following intracytoplasmic sperm injection and transfer of two day-3 fresh embryos, without assisted hatching, is reported. At 7 weeks following embryo transfer, the dichorionic quadruplet pregnancy, comprising monozygotic monochorionic triamniotic (MCTA) triplets plus a singleton, was detected by a transabdominal ultrasound scan. After counselling, the patient underwent selective reduction of the MCTA triplet pregnancy at 7 weeks after embryo transfer. The remaining singleton pregnancy was uneventful, resulting in a live birth at 38⁺ weeks. As the predictors of monozygotic multiple gestations remain poorly characterized, clinicians and patients should give great consideration to the risks associated with monozygotic multiple pregnancies, even if the patient has not undergone blastocyst transfer.

Informative predictors of pregnancy after first IVF cycle using eIVF practice highway electronic health records

The aim of this study is to determine the most informative pre- and in-cycle variables for predicting success for a first autologous oocyte in-vitro fertilization (IVF) cycle. This is a retrospective study using 22,413 first autologous oocyte IVF cycles from 2001 to 2018. Models were developed to predict pregnancy following an IVF cycle with a fresh embryo transfer. The importance of each variable was determined by its coefficient in a logistic regression model and the prediction accuracy based on different variable sets was reported. The area under the receiver operating characteristic curve (AUC) on a validation patient cohort was the metric for prediction accuracy. Three factors were found to be of importance when predicting IVF success: age in three groups (38-40, 41-42, and above 42 years old), number of transferred embryos, and number of cryopreserved embryos. For predicting first-cycle IVF pregnancy using all available variables, the predictive model achieved an AUC of 68% + /- 0.01%. A parsimonious predictive model utilizing age (38-40, 41-42, and above 42 years old), number of transferred embryos, and number of cryopreserved embryos achieved an AUC of 65% + /- 0.01%. The proposed models accurately predict a single IVF cycle pregnancy outcome and identify important predictive variables associated with the outcome. These models are limited to predicting pregnancy immediately after the IVF cycle and not live birth. These models do not include indicators of multiple gestation and are not intended for clinical application.

Placental Dysfunction in Assisted Reproductive Pregnancies: Perinatal, Neonatal and Adult Life Outcomes

Obstetric and newborn outcomes of assisted reproductive technology (ART) pregnancies are associated with significative prevalence of maternal and neonatal adverse health conditions, such as cardiovascular and metabolic diseases. These data are interpreted as anomalies in placentation involving a dysregulation of several molecular factors and pathways. It is not clear which extent of the observed placental alterations are the result of ART and which originate from infertility itself. These two aspects probably act synergically for the final obstetric risk. Data show that mechanisms of inappropriate trophoblast invasion and consequent altered vascular remodeling sustain several clinical conditions, leading to obstetric and perinatal risks often found in ART pregnancies, such as preeclampsia, fetal growth restriction and placenta previa or accreta. The roles of factors such as VEGF, GATA3, PIGF, sFLT-1, sEndoglin, EGFL7, melatonin and of ART conditions, such as short or long embryo cultures, trophectoderm biopsy, embryo cryopreservation, and supraphysiologic endometrium preparation, are discussed. Inflammatory local conditions and epigenetic influence on embryos of ART procedures are important research topics since they may have important consequences on obstetric risk. Prevention and treatment of these conditions represent new frontiers for clinicians and biologists involved in ART, and synergic actions with researchers at molecular levels are advocated.

Cardiovascular function in 8- to 9-year-old singletons born after ART with frozen and fresh embryo transfer

STUDY QUESTION

Do 8- to 9-year-old singletons conceived after frozen embryo transfer (FET) or fresh embryo transfer (Fresh-ET) have increased arterial stiffness compared to naturally conceived (NC) children?

SUMMARY ANSWER

The process of FET or Fresh-ET is not associated with altered cardiovascular function in 8- to 9-year-old singletons, including arterial stiffness, as compared to NC children.

WHAT IS KNOWN ALREADY

ART has been suggested to influence cardiovascular risk factors (i.e. endothelial dysfunction, increased arterial blood pressure and insulin resistance). It is not known if ART procedures alter arterial stiffness in singletons.

STUDY DESIGN, SIZE, DURATION

A cohort study was carried out, including 8- to 9-year-old singletons conceived after FET, Fresh-ET and NC children (50 children in each group). This study was conducted between November 2018 and August 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 150 singletons were identified through the Danish IVF Registry and the Medical Birth Registry. They underwent cardiac magnetic resonance imaging (CMR) and anthropometric measurements. Parental data were collected using questionnaires. NC children were matched by sex and birth year with FET/Fresh-ET children. Exclusion criteria were congenital heart disease, maternal gestational diabetes or maternal diabetes mellitus. Our primary outcome was arterial stiffness, which is assessed from noninvasive arterial blood pressure and aortic ascendens distensibility. The secondary outcome was the pulse wave velocity of total aorta and exploratory outcomes were left ventricular ejection fraction, mean arterial pressure, cardiac output and total peripheral resistance. Measurements and analyses were performed blinded to the child group.

MAIN RESULTS AND THE ROLE OF CHANCE

Aortic ascendens distensibility of children conceived after FET and Fresh-ET did not differ from NC children (mean (SD): FET 11.1 (3.6) 10-3 mmHg-1, Fresh-ET 11.8 (3.0) 10-3 mmHg-1, NC 11.4 (2.8) 10-3 mmHg-1, P > 0.05). Multivariate linear regression was performed to adjust for potential confounders (i.e. child sex and age, maternal BMI at early pregnancy and maternal educational level). Data showed no statistically significant differences between study groups and aortic ascendens distensibility. However, the fully adjusted model showed a non-significant tendency of lowered aortic ascendens distensibility in children born after FET compared to Fresh-ET (β estimate (95% CI): -0.99 10-3 mmHg-1 (-2.20; 0.21)) and NC children (β estimate (95% CI): -0.77 10-3 mmHg-1 (-1.98; 0.44)). Lastly, secondary and exploratory outcomes did not differ between the groups. Primary and secondary outcomes showed good intra-rater reliability.

LIMITATIONS, REASONS FOR CAUTION

This study is possibly limited by potential selection bias as the participation rate was higher in the ART compared to the NC group. Also, in some variables, the study groups differed slightly from the non-participant population. The non-participant population (n = 1770) included those who were excluded, not invited to CMR scan, or declined to participate in this study.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings indicate that children born after FET or Fresh-ET do not have altered cardiovascular function, including arterial stiffness. This is reassuring for the future use of ART.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Novo Nordisk Foundation (grant reference number: NNF19OC0054340) and The Research Foundation of Rigshospitalet. All authors declared no conflict of interests.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT03719703.

Protective placental inflammatory and oxidative stress responses are attenuated in the context of twin pregnancy and chorioamnionitis in assisted reproduction

PURPOSE

Assisted reproduction technologies (ART) are associated with increased risks of pregnancy complications and obstetric interventions. Here, we aimed to determine if ART affects placental inflammation and oxidative stress as a mechanism for unfavorable pregnancy outcomes.

METHODS

The levels of six cytokines (IFN-γ, IL-1β, IL-6, IL-8, IL-10, TNFα) were measured using multiplex ELISA. The activity of four antioxidant enzymes (glutathione S-transferase (GST), glutathione peroxidase (GPx), glutathione reductase, superoxide dismutase) and levels of two antioxidants (GSH, vitamin E) were measured using commercial/in-house assays. Markers were compared between ART and unassisted pregnancies, and then groups were stratified using ICD9/10 codes to determine differences in specific clinical contexts.

RESULTS

In unassisted twin pregnancies, there was a trend of decreased cytokine levels (IL-1β, IL-6, IL-8, TNFα, p < 0.05), but cytokines in ART twins were the same or higher. Additionally, GST and GPx activities were lower in unassisted twins, and vitamin E levels were higher in ART twins (p < 0.05). In pregnancies complicated by chorioamnionitis, there was a trend of increased cytokine levels in unassisted pregnancies (IL-1β, IL-6, and IL-8, p < 0.05). No increase was observed in ART, and IFN-γ and TNFα were decreased (p < 0.05). Placental GST and GPx activities were higher in unassisted pregnancies with chorioamnionitis compared to ART (p < 0.05).

CONCLUSION

Attenuation of protective placental inflammatory and oxidative stress responses may play a role in the underlying pathogenesis of negative birth outcomes in ART, expanding our understanding of adverse pregnancy outcomes when ART is used to conceive.

A developed HPLC-MS/MS method to quantitate 5 steriod hormones in clinical human serum by using PBS as the surrogate matrix

Steroid hormones play an essential role in regulating physiological and reproductive development throughout the lifetime of an individual. One of the difficulties in determining endogenous substances is the lack of a blank matrix. Especially when the level of analytes is lower than the level in the so-called blank matrix. In the present study, an optimized HPLC-MS/MS method was developed and validated to quantify androstenedione (ASD), testosterone (Ts), dehydroepiandrosterone (DHEA), 5α-dihydrotestosterone (DHT), and progesterone (P) in serum samples from healthy people using PBS (pH = 7.4) as the blank surrogate matrix. Simultaneously, the method investigated the characteristics of NaCl, bull serum albumin, pure water as surrogate matrices for the analysis of steroid hormones. The data showed that the matrix effects of ASD, Ts, DHEA, DHT, and P in the same groups were not significantly different between PBS and twice charcoal-stripped serum (CS₂S) as a blank surrogate matrix. Furthermore, the LLOQ using PBS as the blank matrix was up to 0.005 ng/mL for ASD, Ts, and P and 0.05 ng/mL for DHEA and DHT. The reference ranges of concentration (C_PBS) of 5 steroid hormones were provided. Compared to the concentration with CS₂S (C_CSS) as the blank surrogate matrix, the relative biases (RBs) of Ts, DHT, P, and DHEA were finally stabilized at approximately -0.7%, -15%, -1.2%, and 9.2%, respectively. The results suggest that, in the cases of special required, the developed HPLC-MS/MS method can be used to determine the absolute concentration of 5 hormones in biological samples with PBS as the blank surrogate matrix.

Elective cesarean delivery at term and its effects on respiratory distress at birth in Japan: The Japan Environment and Children's Study

BACKGROUND AND AIMS

Early-term birth between 37 and 38 weeks of gestation increases the risk of mortality and morbidity. This study investigated the status and impact of early-term birth among neonates born by cesarean section in Japan.

METHODS

All singleton live births that had data of gestational age at birth available in the Japan Environment and Children's Study (JECS), a nationwide birth cohort study launched in 2011, were eligible for this study. Neonates born by cesarean delivery at term without indications for early delivery were included to examine the association between early-term birth and respiratory distress at birth. The gestational age at birth was categorized as 37 weeks 0 day to 38 weeks 6 days (early-term), 39 weeks 0 day to 40 weeks 6 day (full-term), and 41 weeks 0 day to 41 weeks 6 days (late-term). Respiratory distress at birth included respiratory distress syndrome, transient tachypnea, and difficulty in breathing after birth. Univariable and multivariable analyses were performed using logistic regression models with a two-tailed significance level of 5%. All statistical analyses were performed using SAS, version 9.4, for Windows (SAS Institute, Cary, NC).

RESULTS

In total, 32 078 of 100 011 (32.1%) neonates had early-term birth. At 37 gestational weeks, 49.7% of the deliveries were via cesarean section, and half of the cesarean deliveries were due to a previous cesarean section. Among the 10 051 neonates born by elective cesarean delivery at term, neonates with early-term births were more likely to have respiratory distress at birth (adjusted odds ratio: 4.19; 95% confidence interval, 1.70, 10.34) than those born at full term.

CONCLUSIONS

Early-term birth is associated with a high risk of respiratory distress in births involving cesarean delivery without indication for early delivery. There is a need for guidelines for early delivery considering adverse effects of early-term births.

Impact of Mode of Conception on Early Pregnancy Human Chorionic Gonadotropin Rise and Birthweight

Objective

To assess whether the mode of conception and embryo biopsy impact first-trimester human chorionic gonadotropin (hCG) dynamics and subsequent risk of small for gestational age (SGA) or large for gestational age (LGA).

Design

Retrospective cohort study.

Setting

University fertility center.

Patient(s)

Six hundred-two pregnant patients with singleton live births.

Intervention(s)

Serial serum hCG measurements were obtained between 10 and 28 days postconception to determine the within-woman rate of change in hCG (slope) by mode of conception (unassisted pregnancy, fresh embryo transfer (ET), frozen ET, and frozen ET following preimplantation genetic testing for aneuploidy (PGT-A).

Main Outcome Measure(s)

Primary outcomes included birth weight, SGA, and LGA.

Result(s)

Mode of conception is not independently associated with birth weight, SGA, or LGA. Mediation analysis revealed an expected one-day increase in log-transformed hCG varied by mode of conception: unassisted (0.41), fresh ET (0.39), frozen ET (0.42), PGT-A (0.44). Human chorionic gonadotropin rise has a positive effect on birth weight (55 g per SD increase in hCG slope) and is associated with SGA (odds ratio, 0.65), but not with LGA (odds ratio, 1.18).

Conclusion(s)

Human chorionic gonadotropin rise is an important mediator of the mode of conception/birth weight relationship. Preimplantation genetic testing for aneuploidy has the highest rate of hCG rise, followed by frozen ET, unassisted, and fresh ET. Faster rise is associated with higher birth weight and lower risk of SGA but does not impact LGA risk. Importantly, PGT-A does not increase the risk of extreme birth weight relative to other modes of conception evaluated.

The Association between Assisted Reproductive Technology and Preterm delivery in Twin pregnancies

OBJECTIVE

To determine whether ART is associated with a higher risk of preterm deliveries in twin gestations compared with non-exposure to ART.

STUDY DESIGN

This is a secondary analysis of a randomized, double-blinded, placebo-controlled trial of weekly progesterone to prevent preterm delivery in twin gestations. For our analysis, all subjects with twin gestations and known gestational age at delivery were included. Women were excluded if they had intrauterine insemination or congenital fetal anomalies. Our primary exposure was ART, defined as IVF and ICSI. Subjects non-exposed to ART either had spontaneous conceptions or were conceived with ovarian stimulation. Our primary outcome was preterm delivery, defined as delivery prior to 35 weeks gestation. Secondary outcomes included spontaneous or indicated preterm delivery less than 35 weeks.

RESULTS

Of the 1261 subjects, 309 (24.5%) had ART, and 952 (75.5%) were not exposed to ART. Women exposed to ART were more likely to be white, older, and have dichorionic twins, and they were less likely to be smokers. The groups had similar rates of prior preterm births. The rates of overall PTB (40.8% v. 39.3%, p=0.642) and spontaneous PTB (20.8% v. 24.1%, p=0.221) were similar. After adjusting for confounders, ART exposure was not related to any preterm birth category, and the strongest predictors for spontaneous preterm birth was a prior preterm birth (aOR: 3.38, 95% CI: 2.04-5.59, p=<0.0001) and Black race (aOR 1.61, 95% CI: 1.06-2.45, p=0.026).

CONCLUSION

In our cohort of twin pregnancies, ART was not an independent risk factor for preterm birth.

Predicting personalized cumulative live birth following in vitro fertilization

OBJECTIVE

To develop in vitro fertilization (IVF) prediction models to estimate the individualized chance of cumulative live birth at two time points: pretreatment (i.e., before starting the first complete cycle of IVF) and posttreatment (i.e., before starting the second complete cycle of IVF in those couples whose first complete cycle was unsuccessful).

DESIGN

Population-based cohort study.

SETTING

National data from the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System.

PATIENT(S)

Based on 88,614 women who commenced IVF treatment using their own eggs and partner's sperm in SART member clinics.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

The pretreatment model estimated the cumulative chance of a live birth over a maximum of three complete cycles of IVF, whereas the posttreatment model did so over the second and third complete cycles. One complete cycle included all fresh and frozen embryo transfers resulting from one episode of ovarian stimulation. We considered the first live birth episode, including singletons and multiple births.

RESULT(S)

Pretreatment predictors included woman's age (35 years vs. 25 years, adjusted odds ratio 0.69, 95% confidence interval 0.66-0.73) and body mass index (35 kg/m² vs. 25 kg/m², adjusted odds ratio 0.75, 95% confidence interval 0.72-0.78). The posttreatment model additionally included the number of eggs from the first complete cycle (15 vs. 9 eggs, adjusted odds ratio 1.10, 95% confidence interval 1.03-1.18). According to the pretreatment model, a nulliparous woman aged 34 years with a body mass index of 23.3 kg/m², male partner infertility, and an antimüllerian hormone level of 3 ng/mL has a 61.7% chance of having a live birth over her first complete cycle of IVF (and a cumulative chance over three complete cycles of 88.8%). If a live birth is not achieved, according to the posttreatment model, her chance of having a live birth over the second complete cycle 1 year later (age 35 years, number of eggs 7) is 42.9%. The C-statistic for all models was between 0.71 and 0.73.

CONCLUSION(S)

The focus of previous IVF prediction models based on US data has been cumulative live birth excluding cycles involving frozen embryos. These novel prediction models provide clinically relevant estimates that could help clinicians and couples plan IVF treatment at different points in time.