The effect of COVID-19 vaccination during IVF stimulation on cycle outcomes- a retrospective cohort study

The effect of the mRNA-BNT162b2 vaccine administered prior to fertility treatments has been addressed in several studies, presenting reassuring results. Cycle outcomes of patients receiving the vaccine during the stimulation itself have not been previously described. This retrospective cohort study included patients who received mRNA-BNT162b2-vaccine during the stimulation of fresh IVF cycles, between January-September 2021, age matched to pre-stimulation vaccinated patients and to non-vaccinated patients. Demographics, cycle characteristics and cycle outcomes were compared between groups. A total of 132 in-treatment vaccinated patients (study group), 132 pre-treatment vaccinated and 132 non-vaccinated patients that underwent fresh IVF cycles were included. Mean time from vaccination to retrieval in the study group was 6.68 days (SD 3.74; range 0-12). Oocyte yield was similar between groups (9.35 versus10.22 and 10.05 respectively; p=0.491). A linear regression model demonstrated no effect of vaccination before or during the stimulation, on oocyte yield (p>0.999). Clinical pregnancy rates (30 % versus 30 % versus 28 %) and ongoing pregnancy rates (25 % for all groups) did not differ between groups. In a logistic regression model for clinical pregnancy rates, vaccine administration and timing of vaccination were not a significant factor. This is the first study reporting the outcome of the mRNA BNT162b2 vaccine administration during the IVF stimulation itself. The vaccine administration had no impact on fresh IVF treatment outcomes compared to pre-treatment vaccinated or non-vaccinated patients. This adds to the growing evidence of COVID-19 vaccine safety in relation to fertility treatments and enables more flexibility regarding timing of vaccine administration.

Sperm Donors' Identity Disclosure: Is It REALLY Crucial? For Whom?

OBJECTIVE

To study the preference of sperm donors with identity disclosure (ID) versus anonymous donors (AD) and to understand if this selection affects clinical outcomes in an Israeli population.

METHODS

This retrospective study included patients who chose imported sperm donation during 2017-2021. Of these, 526 used their own (autologous) oocytes and 43 patients used donated oocytes (DO). The primary endpoint was the type of chosen donor with ID versus AD. We examined the tendency toward ID according to demographic parameters and the theoretical impact of donor-type selection on reproductive outcome and compared patients who performed cycles with autologous oocytes with those using DO.

RESULTS

Single women had a significantly higher probability of choosing sperm donors with ID than heterosexual couples (55.6% vs. 33.3%, OR 2.5, CI 95% 1.52-4.11, P < 0.001). Although not significant, same-sex couples were more likely to choose sperm donors with ID than heterosexual couples (49.1% vs. 33.3%, OR 1.93, CI 95% 0.97-3.85, P = 0.06). Sperm donor samples, 2501 vials, were imported. It was performed 698 intra-uterine insemination and 812 in vitro fertilization cycles were performed, respectively, resulting in 283 pregnancies without differences between patients who chose sperm donors with ID versus AD sperm. No significant differences were observed regarding the option for sperm donors with ID between patients using DO (44.2%) and those using autologous oocytes (51.3%).

CONCLUSION

While ID is important for a certain section (mainly single) of recipients, it is far from the only dominant factor during donor selection. Sperm donation type does not impact clinical outcomes.

Follicular challenge test to predict suboptimal response to gonadotropin releasing hormone agonist trigger in elective oocyte cryopreservation cycles

This prospective study aimed to test the ability of follicular GnRH agonist challenge test (FACT) to predict suboptimal response to GnRH agonist trigger, assessed by LH levels post ovulation trigger in non-medical oocyte cryopreservation program. The study included 91 women that underwent non-medical fertility preservation. On day two to menstrual cycle, blood tests were drawn (basal Estradiol, basal FSH, basal LH, Progesterone) and ultrasound (US) was performed. On that evening, the women were instructed to inject 0.2 mg GnRH agonist (FACT) and arrive for repeated blood workup 10-12 h later in the next morning, followed by a flexible antagonist protocol. LH levels on the morning after ovulation trigger were compared to FACT LH levels. The results demonstrated that LH levels following agonist ovulation trigger below 15IU/L occurred in 1.09% of cycles and were predicted by FACT, r = 0.57, p < 0.001. ROC analysis demonstrated that FACT LH > 42.70 IU/L would predict LH post trigger of more than 30 IU/L with 75% sensitivity and 70% specificity, AUC = 0.81. LH levels post trigger also displayed significant positive correlation to basal FSH (r = 0.35, p = 0.002) and basal LH (r = 0.54, p < 0.001). LH levels post ovulation trigger were not associated with total oocytes number or maturity rate. The strongest correlation to the number of frozen oocytes was progesterone levels post agonist trigger (r = 0.746, p < 0.001). We concluded that suboptimal response to agonist trigger, as assessed by post trigger LH levels was a rare event. FACT could serve as an adjunct pre-trigger, intracycle tool to predict adequate LH levels elevation after agonist ovulation trigger. Future studies should focus on optimization of agonist trigger efficacy assessment and prediction, especially in high responders.

Autologous sperm usage after cryopreservation-the crucial impact of patients' characteristics

BACKGROUND

The wide implementation of sperm freezing presents a growing burden on sperm banks.

OBJECTIVES

To evaluate sperm freezing and usage patterns over 30 years, according to demographic parameters of age at first cryopreservation and number of children, and indication for cryopreservation.

MATERIAL AND METHODS

This retrospective, population based, cohort study included all sperm cryopreservation cases performed at a tertiary referral center from October 1993 to December 2021, among patients aged 18 years and older. First, we determined the interval between first sperm sample and use. Then, we examined sperm usage separately for: (1) age, comparing patients grouped into 5-year age cohorts; (2) paternal status according to number of children; (3) indication, comparison among seven indications. Secondary analysis included correlations between main age groups and paternal status versus the four most common indications found.

RESULTS

During the study period 1490 men who cryopreserved sperm met the inclusion criteria. Average age at cryopreservation of the first sample was 33.9 ± 8.1 years. Average age at first sperm use was 37 ± 8.5 years. Cumulative sperm usage was 38.7% after 17.8 years. Increasing age was associated with progressive increase in sperm usage rate and shorter preservation period. Use significantly decreased with increasing number of children. Examination of seven reasons for sperm cryopreservation found the highest cumulative sperm usage was related to azoospermia (67.7%), followed by functional cryopreservation (39.3%), oligoasthenoteratospermia (27.3%), other (26.5%), patient's request (24%), cancer (19%), and systemic disease (7.2%). Secondary analysis defined specific usage patterns mainly related to age and indication, with less of an effect based on the number of children.

DISCUSSION AND CONCLUSION

After decades of cryopreservation, the paradigm of sperm cryopreservation is mostly related to cancer patients. This should be reevaluated and evolve to include broader patient-targeted factors and perceptions.

Critical Demographic Changes among Sperm Donation Recipients Over Three Decades

BACKGROUND

Sperm banks initially focused on providing sperm donation (SD) to heterosexual couples grappling with severe male infertility. Notable advancements in fertility treatments and sociological trends have broadened the scope of SD toward single women and same sex female couples.

OBJECTIVES

To evaluate SD recipient characteristics over the last three decades in Israel according to demographic parameters.

METHODS

This retrospective cohort study included 5489 women who received SD between January 1992 and December 2021 from a tertiary referral center. We divided the overall period into six groups of five years each. A comparison of demographic characteristics of women who received SD in different periods was performed according to age at the beginning of the treatment, marital status (single women and same sex female couples, heterosexual couples), and ethnic origin.

RESULTS

The average age of women who received SD was 37.02 ± 5.36 years. The average patient age rose from 35.08 years in 1992-1997 to 37.43 years in 2017-2021 (P-value < 0.01). The use of SD was more common among single women and same sex female couples compared to heterosexual couples in later years. Regarding single and same sex female couple, the percentage of SD recipients increased radically from 33% to 88.1% (P-value < 0.01).

CONCLUSIONS

Modern sperm banks treat older patients in non-heterosexual relationships. These trends encompass not only medical implications (e.g., in vitro fertilization vs. intrauterine insemination) but also delve into the personal and sociological impact experienced by both patients and offspring.

Motivational stimuli to donate sperm among non-donor students

BACKGROUND

Sperm banks face a continuously evolving gap between the increasing demand for sperm donation (SD) vs. limited available reserve. To improve donors' recruitment and increase supply, motivations towards SD should be investigated specifically among young men who have the potential to become donors. Our aim was to evaluate factors which increase and decrease predisposition to donate sperm among non-donor students, who represent a "potential pool" for possible donors' recruitment.

RESULTS

Ninety-three men fulfilled the questionnaire with mean age of 28.2 ± 4.5 years. The most powerful incentive to donate sperm was financial reward followed by a willingness to help others to build a family (3.8 and 3.4, respectively). The most dominant consideration to decline donation was the fear of anonymity loss and future regret (4 and 3.8). While participants' willingness for anonymous SD was fair (2.8), the open-identity donation was rated significantly lower (1.75, p < 0.01). Familiarity with recipients and offspring had lower scores (1.9-2.2) as well.

CONCLUSIONS

Young single men represent a suitable cohort for anonymous donation. Financial reward and willingness to help others are important positive incentives while anonymity preservation is crucial to maintain their willingness towards SD. Regulatory shifting towards open-identity SD necessitates the establishment of an alternative "potential pool" population as a reliable source to recruit donors.

Treatment safety of ART cycles with extremely high oestradiol concentrations using GnRH agonist trigger

RESEARCH QUESTION

Are IVF treatments with extremely high peak oestradiol levels and gonadotrophin releasing hormone (GnRH) agonist trigger associated with higher complication rates?

DESIGN

A retrospective cohort study including patients from two large medical centres treated between 2019 and 2021. A study group with extremely high peak oestradiol levels (≥20,000 pmol/l on the day of ovarian stimulation, or ≥15,000 pmol/l on the previous day) and a control group with normal range oestradiol levels (3000-12000 pmol/l) that received GnRH agonist triggering. Patients were surveyed about complaints and medical care related to ovum retrieval and medical files were reviewed. Major complication rates and the need for medical assistance were compared.

RESULTS

Several differences between the study and control group were observed because of the study design: mean age was 33.01 ± 5.14 versus 34.57 ± 4.52 (P < 0.001), mean peak oestradiol levels was 26645.34 ± 8592.57 pmol/l versus 7229.75 ± 2329.20 pmol/l (P < 0.001), and mean number of oocytes were 27.55 ± 13.46 versus 11.67 ± 5.76 (P < 0.001) for the study and control group, respectively. Major complications and hospitalization rates were similar between the study and control groups (three [1.25%] versus one [0.48%]; P = 0.62 and three [1.25%] versus two [0.96%]; P = 1.0, respectively). Thirty-six patients (15.1%) in the study group and 11 (5.3%) in the control group sought medical care after retrieval, mostly due to abdominal pain, without the need for further workup or hospitalization (P < 0.001).

CONCLUSIONS

Extremely high oestradiol levels were not associated with thromboembolic events, higher major complication or hospitalization rates, and therefore may be considered safe. Nevertheless, patients may be informed of possible higher rates of discomfort, mostly abdominal pain. Larger studies are warranted to confirm our results.

P-634 Safety of ART cycles with extremely high estradiol levels - A retrospective cohort study

Study question

Are IVF treatments with extremely high peak estradiol levels during ovarian hyperstimulation associated with higher complication rates?

Summary answer

Extremely high estradiol levels were not associated with higher major complication rates, but patients were more likely to seek medical care following retrieval.

What is known already

The freeze-all policy and the increasing popularity of social oocyte freezing, have led to an increase in gonadotropin doses and number of oocytes retrieved and, as a direct effect, higher estradiol levels. Studies reporting major ART complications (OHSS, bleeding, infection, torsion, thromboembolic events) are based on heterogeneous patient populations without stratification by oocyte number or estradiol levels, except for a single study reporting an association between peak estradiol levels and the risk of ovarian torsion. Extreme estradiol levels, are associated with larger ovaries, repeated ovarian punctures, and possibly a thrombogenic effect. Therefore, higher complication rates can be expected.

Study design, size, duration

A retrospective cohort study including patients from two large medical centers treated between 2019-2021.

Participants/materials, setting, methods

A study group (239 patients) with extremely high peak estradiol levels (&gt;20,000 pmol/L on the day of ovulation induction, or &gt; 15,000 pmol/L on the previous day) and a control group (208 patients) with normal range estradiol levels (3000-12000pmol/L), treated at two large units were included. Patients were surveyed about complaints and medical care related to ovum pick up (OPU), and medical files were reviewed. Complication rates and the need for medical assistance were compared.

Main results and the role of chance

Several differences between the study and control group were observed as a consequence of the study design: Mean age was 33.01±5.14 vs. 34.57±4.52 (p = 0.01), Mean peak estradiol levels was 26645.34±8592.56 vs.7229.750±2329.20 (p &lt; 0.001), mean number of oocytes were 27.55±13.46 vs. 11.63±5.77 (p &lt; 0.001) for the study and control group respectivly. More patients in the control group underwent fertility preservation. Mean FSH levels and total gonadotropin dosage were higher in the control group. Major complications [3 (1.25%) in the study group vs. 1 (0.96%) in the control group] were similar between groups (p = 0.62). In the study group Two patients were diagnosed with ovarian torsion (0.83%), and one (0.41%) with early severe OHSS as a result of a positive BhCG related to an undiagnosed pregnancy prior to OPU. All three were admitted (1.25%). In the control group one patient was diagnosed with PID requiring inpatient IV antibiotic treatment (0.48%). One more patient was admitted with severe abdominal pain following OPU, for a total of 2 admissions (0.96%) (p = 1). 33 patients (13.8%) in the study group and 10 (4.8%) in the control group sought medical care after OPU, mostly due to abdominal pain, without further workup or hospitalization (p = 0.001).

Limitations, reasons for caution

A retrospective study with possible recall bias. Major adverse events are rare in IVF and may not be fully captured in the study population.

Wider implications of the findings

Based on our results, extremely high estradiol levels during ovarian hyperstimulation were not associated with thromboembolic events, higher major complication or hospitalization rates, thus may be considered safe. Nevertheless, patients may be informed of possible higher rates of discomfort, mostly abdominal pain. Larger studies are warranted to confirm our results.

Trial registration number

0090-21-ASF

P-710 COVID-19 Vaccination and Infertility Treatment Outcomes

Study question

Is there an influence of mRNA COVID-19 vaccine on ovarian response and in vitro fertilization (IVF) treatment outcomes?

Summary answer

COVID-19 mRNA vaccine did not affect the ovarian response nor pregnancy rates in IVF treatment

What is known already

Studies demonstrated that infection with COVID-19 during pregnancy increased the risk of the development of severe disease and pregnancy complications.

A recent meta-analysis of international data showed a declining tendency to be vaccinated, possibly influenced by public concerns over safety of the vaccines. Specifically, concerns were raised about a possible detrimental effect on fertility and pregnancy outcomes due to similarity between syncytin-1, a human placental fusion protein, and the SARS-CoV-2 spike protein expressed after administration of the COVID-19 vaccine.

To date, only one retrospective analysis on 36 infertility patients has assessed the influence of COVID-19 vaccination on IVF treatment outcomes.

Study design, size, duration

A retrospective cohort study . The study included a total of 400 patients, 200 vaccinated women and 200 age matched non-vaccinated women, undergoing IVF treatments during January-April 2021.

Participants/materials, setting, methods

All vaccinated women aged 20-42 that underwent IVF treatment cycles between January 1, 2021 and April 31 2021 were included. All participants completed two doses of the BNT162b2 (Pfizer-BioNTech) vaccine at least two weeks before starting ovarian stimulation. The study group was matched by age to non-vaccinated patients that underwent IVF treatments during the same period. Patients with a positive COVID 19 test in the past were excluded.

Main results and the role of chance

Two hundred patients underwent oocyte retrieval 14-68 days after receiving COVID-19 vaccination. No difference was found between vaccinated and non-vaccinated patients in mean number of oocytes retrieved per cycle (10.63 vs 10.72, p = 0.93). Among 128 vaccinated patients and 133 non-vaccinated patients that underwent fresh embryos transfers, no difference was demonstrated in clinical pregnancy rates (32.8% vs. 33.1%, p-value=0.96), 42 and 44 pregnancies respectively. The fertilization rates and mean number of cryopreserved embryos were similar between the two groups in freeze all cycles (55.43% vs. 54.29%, p-value=0.73), (3.59 vs. 3.28, p-value=0.80). Among vaccinated patients and non-vaccinated patients that underwent fresh embryos transfers, no difference was demonstrated in the fertilization rate (64.81% vs. 61.98%, p = 0.51), and transferred embryos quality. Regression models applied demonstrated no effect of the vaccine on oocyte yields and pregnancy rates.

Limitations, reasons for caution

Limitations include retrospective nature and different treatment protocols.

Additional limitation is the lack of information about vaccination status of the partners. One would assume that if unbalanced, the proportion of vaccinated males would be higher in the study group as partners tend to choose similarly in regard to vaccine administration.

Wider implications of the findings

Women should consider vaccination prior to their attempts to conceive via IVF treatments.

Trial registration number

ASF-0094-21

O-140 The impact of past COVID-19 infection on pregnancy rates in frozen embryo transfer cycles

Study question

What is the effect of COVID-19 infection on pregnancy rates in frozen embryo transfer (FET) cycles?

Summary answer

Past COVID-19 infection decreased pregnancy rates in FET cycles, especially in patients with recent infection.

What is known already

ACE2 and TMPRSS2 are expressed in the endometrium, potentially enabling SARS-COV-2 viral invasion of the cells. Unlike with bacterial infections, the effect of viral infections in general on implantation and pregnancy rates is unclear. Some evidence suggests that early embryonic and trophoblastic infection, may result in impaired implantation or placentation. A recently published study including both recovered and vaccinated patients did not find an effect of COVID-19 immunity on FET cycle outcomes. The study did not stratify by time from infection thus the immediate consequences of infection on pregnancy rates could not be properly evaluated.

Study design, size, duration

A retrospective cohort study, including 41 COVID-19 recovered women, aged 20-42 years that underwent FET cycles, and 41 controls between January 1, and June 31, 2021, at a large IVF unit.

Participants/materials, setting, methods

Embryos transferred were the product of fresh cycles performed prior to infection. Maximal time from infection to transfer was defined as one year. The study group was matched by age, number of embryos transferred and day of transfer, to unvaccinated patients, with no history of past infection that underwent FET cycles during the same period. Demographics and cycle characteristics were recorded. Clinical and ongoing pregnancy rates were compared, with further stratification by time from infection.

Main results and the role of chance

Clinical pregnancy rates were 29.3% and 48.8% for the recovered and control patients respectively (p = 0.070). Ongoing pregnancy rates were 26.6% vs. 43.4% (p = 0.093). Mean age at ovum pickup (30.72 vs. 30.69; p = 0.929) and at transfer (31.56 vs. 31.58; p = 0.966) was similar between groups, as were the demographic characteristics and previous retrievals and transfers. The predominant transfer protocol used was different between groups with higher rates of natural cycle (NC) protocol in the COVID group (61% vs. 33.3%; p = 0.013. All other cycle characteristics including endometrial width, number of embryos transferred, day of embryo transfer and embryo grade were similar. Stratification by time from COVID-19 infection to transfer into ≤60 and >60 days revealed a significant difference in pregnancy rates, with recovered women having lower pregnancy rates if infected in proximity to the transfer (20.7% vs. 55.2%; p = 0.006). In a logistic regression model, infection was a significant variable (p = 0.05, OR 0.325, 95% CI 0.106-0.998). Logistic regression applied on the subgroup of women infected in proximity to the transfer, further strengthened the univariate results, with COVID-19 infection remaining a significant parameter (p = 0.005, OR 0.072, 95% CI 0.012-0.450).

Limitations, reasons for caution

A retrospective study, with a limited sample size, but nevertheless our results showed significant differences. 

Wider implications of the findings

Further studies with larger groups are warranted to support these findings. Pending further information, in cases of FET cycles with limited numbers of embryos (advanced age, embryo donation, fertility preservation, embryos following sperm extraction), postponing embryo transfer for at least 60 days following recovery might be considered, if feasible.

Trial registration number

HMC-0010-21

P-673 GnRH Agonist Early Follicular Challenge Test as a Predictor of Ovarian Response in Short Antagonist Cycles for Fertility Preservation

Study question

Does the response to GnRH agonist can be used to predict ovarian function in short GnRH antagonist cycles in women undergoing oocyte cryopreservation IVF cycles?

Summary answer

Response to a single GnRH agonist dose at the beginning of stimulation during short antagonist cycle can predict the outcome of the fertility preservation cycle

What is known already

There is a need for a reliable test for ovarian reserve. Gonadotrophin agonist stimulation test (GAST) is considered a valid marker for ovarian reserve but the test was never validated for short antagonist protocol. The reported dose for this test was 0.1 mg, however, from the vast experience with GnRH agonist triggering, it is now agreed that the optimal dose for GnRH agonist flare effect is 0.2 mg.

Study design, size, duration

A prospective observational study of fertility preservation cycles patient in an academic hospital setting. Seventy-four Short GnRH antagonist cycles that underwent an oocyte retrieval between 1 December 2020 and 1 January 2022.

Participants/materials, setting, methods

On day 2, blood was sampled for basal FSH, LH, and E2 measurements, followed by a subcutaneous injection of 0.2mg GnRH agonist as part of the initial ovarian stimulation. Twelve hours later blood sampling was repeated. E2 response was used as test parameter. The major outcome was the number of cryopreserved oocytes.

Main results and the role of chance

Participants were divided to groups according to Day 3 E2 to Day 2 E2 response (E3/E2 ratio) to lower and upper third percentiles (&lt;3.32, n = 24 and &gt;5.41, n = 25). Age (32.68 vs. 32.79, p = 0.965), total gonadotropin dose injected 3216.67 vs. 2773.42 IU p = 0.16) and day 3 FSH levels (7.39 vs. 7.16, p = 0.768) were not significantly different between groups. Ovarian response as measured by E2 levels on ovulation trigger (7879.72 vs. 17572.54 pmol/ml, p = 0.001) and number of M2 oocytes retrieved were significantly different (17.92 vs. 6.24, p &lt; 0.001). Linear correlation between E3/E2 ratio and number of M2 oocytes was calculated (R = 0.48, p &lt; 0.001). ROC curve analysis of E3/E2 ratio for more than fifteen M2 oocytes indicate AUC value of 0.82 (cutoff value of 4.22, p &lt; 0.001, 84.6% sensitivity, 70.8% specificity) and for less than five M2 oocytes AUC value of 0.84 (cutoff value of 3.34, p &lt; 0.001, 76.3% sensitivity, 73.3% specificity). The results suggest that the testing response to 0.2mg GnRH agonist positively correlates with treatment outcome of the current cycle.

Limitations, reasons for caution

Although all patients were tested for FSH levels for ovarian reserve, they were not tested for AMH levels.

Wider implications of the findings

The response to single GnRH agonist dose during short antagonist cycle can be used as another biomarker of ovarian reserve. This simple, widely available marker, which reflect the estradiol response of small follicles, might predict accurately the outcome of the specific cycle, and potentially used to adjust the treatment dose.

Trial registration number

NCT04973969

O-141 IVF under COVID-19: treatment outcomes of fresh and frozen cycles

Study question

Does prior SARS-CoV-2 infection in women undergoing fertility treatments affect outcomes of fresh ART cycles? 

Summary answer

SARS-CoV-2 infection does not affect fresh ART treatment outcomes. A possible long term negative effect on oocyte yield should be further explored.

What is known already

There is evidence that the renin–angiotensin–aldosterone system (RAS) is involved in female reproductive processes such as folliculogenesis, steroidogenesis, oocyte maturation and ovulation. The existence of the ACE2 axis and ACE2 markers were confirmed in all stages of follicular maturation in the human ovary, including the granulosa cells and follicular fluid. A single previous study found no evidence that a history of asymptomatic or mild SARS-CoV-2 infection in females caused impairment of fresh ART treatment outcomes. 

Study design, size, duration

Retrospective cohort study, including all SARS-CoV-2 infected women that underwent fresh ART cycles within a year from infection (the first cycle post infection), between October 2020 and June 2021, matched to uninfected controls. 

Participants/materials, setting, methods

Retrospective cohort study, including all SARS-CoV-2 infected women that underwent fresh ART cycles within a year from infection (the first cycle post infection), between October 2020 and June 2021, matched to uninfected controls. 

Main results and the role of chance

121 infected patients and 121 controls that underwent fresh ART cycles were included. Oocyte yield (12.50 vs. 11.29; p = 0.169) and mature oocyte rate (77.71 vs. 81.76; p = 0.144) in all fresh cycles were similar between groups, as werefertilization rates, number of frozen embryos per cycle and clinical pregnancy rates (42.9% vs. 40.4%; p = 0.737) in fresh cycles with an embryo transfer. Stratification by time from COVID-19 infection by time from infection <90 day, 90-180 days and > 180 days revealed similar results with no difference in pregnancy rates. In a logistic regression model, COVID-19 infection did not affect pregnancy rates except for the small subgroup of patients who recovered more than 180 days prior to retrieval with a negative effect on oocyte yield (p = 0.018, Slope=-4.08, 95%CI 95% CI -0.7.41 – -0.75).

Limitations, reasons for caution

A retrospective study with data that was not uniformly generated under a study protocol, no antibody testing for the control group. 

Wider implications of the findings

The study findings suggest that COVID-19 infection does not affect treatment outcomes in fresh ART cycles, except for a possible long term negative effect on oocyte yield when retrieval occurs > 180 days post COVID-19 infection. Further studies are warranted in order to support these findings. 

Trial registration number

HMC-0010-21

Covid-19 vaccination BNT162b2 temporarily impairs semen concentration and total motile count among semen donors

BACKGROUND

The development of covid-19 vaccinations represents a notable scientific achievement. Nevertheless, concerns have been raised regarding their possible detrimental impact on male fertility OBJECTIVE: To investigate the effect of covid-19 BNT162b2 (Pfizer) vaccine on semen parameters among semen donors (SD).

METHODS

Thirty-seven SD from three sperm banks that provided 216 samples were included in that retrospective longitudinal multicenter cohort study. BNT162b2 vaccination included two doses, and vaccination completion was scheduled 7 days after the second dose. The study included four phases: T0 - pre-vaccination baseline control, which encompassed 1-2 initial samples per SD; T1, T2 and T3 - short, intermediate, and long terms evaluations, respectively. Each included 1-3 semen samples per donor provided 15-45, 75-125 and over 145 days after vaccination completion, respectively. The primary endpoints were semen parameters. Three statistical analyses were conducted: (1) generalized estimated equation model; (2) first sample and (3) samples' mean of each donor per period were compared to T0.

RESULTS

Repetitive measurements revealed -15.4% sperm concentration decrease on T2 (CI -25.5%-3.9%, p = 0.01) leading to total motile count 22.1% reduction (CI -35% - -6.6%, p = 0.007) compared to T0. Similarly, analysis of first semen sample only and samples' mean per donor resulted in concentration and total motile count (TMC) reductions on T2 compared to T0 - median decline of 12 million/ml and 31.2 million motile spermatozoa, respectively (p = 0.02 and 0.002 respectively) on first sample evaluation and median decline of 9.5 × 10⁶ and 27.3 million motile spermatozoa (p = 0.004 and 0.003, respectively) on samples' mean examination. T3 evaluation demonstrated overall recovery without. Semen volume and sperm motility were not impaired.

DISCUSSION

This longitudinal study focused on SD demonstrates selective temporary sperm concentration and TMC deterioration 3 months after vaccination followed by later recovery verified by diverse statistical analyses.

CONCLUSIONS

Systemic immune response after BNT162b2 vaccine is a reasonable cause for transient semen concentration and TMC decline. Long-term prognosis remains good.

What can we learn about posthumous sperm retrieval after extra long-term follow-up?

PURPOSE

To describe spermatozoa extraction rate by testicular sperm extraction (TESE) for posthumous sperm retrieval (PMSR) and examine harvest time impact on sperm motility; to compare long-term sperm usage between married vs. single deceased men.

METHODS

This retrospective study included all PMSR cases in Shamir Medical Center during 2003-2021. We evaluated sperm cryopreservation according to latency time after death. Then, we assessed sperm usage according to Israeli PMSR regulations.

RESULTS

The study included 69 (35 married and 34 singles) deceased men with average age of 30.3 ± 7.8 years. Sperm was cryopreserved in 65 cases (94.2%) after maximum and average harvest time of 40 and 16.5 ± 8.1 h, respectively. Motile sperm extraction was associated with significantly shorter harvest time compared with non-motile sperm (13.8 ± 7.3 vs. 18.7 ± 8.1 h, p = 0.046). Sperm usage among married deceased was significantly higher than single (15.6% vs. 0%, p = 0.05). Disposal requests were lower among single compared to married men relatives without reaching statistical difference. Eventually, single men had significantly higher rate of non-used cryopreserved samples (93.8% vs 69.6%, p = 0.01).

CONCLUSION

This large long-term cohort study demonstrates high efficacy of PMSR. We found significant harvest latency time difference between motile and non-motile preserved sperm. Clinical sperm usage rate justifies the efforts for PMSR among married deceased. However, contradicting policy on the topic of single men (which implies liberal sperm preservation but rigid prevention of usage) results with high non-used sperm rate and relatives' extremely sophisticated emotional burden.

The impact of past COVID-19 infection on pregnancy rates in frozen embryo transfer cycles

PURPOSE

To study the effect of SARS-CoV-2 infection on pregnancy rates in frozen embryo transfer (FET) cycles.

METHODS

A retrospective cohort study including women under the age of 42 with documented SARS-CoV-2 infection up to 1 year prior to treatment, undergoing FET cycles in the first half of 2021, with transfer of embryos generated prior to the infection. Controls were SARS-CoV-2 non-diagnosed, non-vaccinated women matched by age, number, and day of embryo transfer. Demographic and cycle characteristics and outcomes were compared.

RESULTS

Forty-one recovered women and 41 controls were included. Pregnancy rates were 29% and 49% respectively (p = 0.070). Stratification by time from SARS-CoV-2 infection to transfer into ≤ 60 and > 60 days revealed a difference in pregnancy rates, with women in the COVID group having lower pregnancy rates if infected in proximity to the transfer (21% vs. 55%; p = 0.006). In a logistic regression model, infection was a significant variable (p = 0.05, OR 0.325, 95% CI 0.106-0.998). Logistic regression applied on the subgroup of women infected in proximity to the transfer further strengthened the univariate results, with COVID-19 remaining a significant parameter (p = 0.005, OR 0.072, 95% CI 0.012-0.450).

CONCLUSIONS

In FET cycles of patients with past SARS-CoV-2 infection, in which oocytes were retrieved prior to infection, decreased pregnancy rates were observed, specifically in patients who recovered less than 60 days prior to embryo transfer. Pending further studies, in cases of FET cycles with limited number of embryos, postponing embryo transfer for at least 60 days following recovery from COVID-19 might be considered when feasible.

IVF under COVID-19: treatment outcomes of fresh ART cycles

Study Question

Does prior SARS-CoV-2 infection in women undergoing fertility treatments affect the outcomes of fresh ART cycles?

Summary Answer

SARS-CoV-2 infection does not affect fresh ART treatment outcomes, except for a possible long term negative effect on oocyte yield (>180 days post infection).

What Is Known Already

A single previous study suggested no evidence that a history of asymptomatic or mild SARS-CoV-2 infection in females caused impairment of fresh ART treatment outcomes.

Study Design, Size, Duration

Retrospective cohort study, including all SARS-CoV-2 infected women who underwent fresh ART cycles within a year from infection (the first cycle post infection), between October 2020 and June 2021, matched to non-diagnosed controls.

Participants/Materials, Setting, Methods

Patients from two large IVF units in Israel who were infected with SARS-CoV-2 and later underwent fresh ART cycles were matched by age to non-diagnosed, non-vaccinated controls. Demographics, cycle characteristics and cycle outcomes, including oocyte yield, maturation rate, fertilization rate, number of frozen embryos per cycle, and clinical pregnancy rates, were compared between groups.

Main Results And The Role Of Chance

One hundred and twenty-one infected patients and 121 controls who underwent fresh ART cycles were included. Oocyte yield (12.50 versus 11.29; p = 0.169) and mature oocyte rate (78% versus 82%; p = 0.144) in all fresh cycles were similar between groups, as were fertilization rates, number of frozen embryos per cycle and clinical pregnancy rates (43% versus 40%; p = 0.737) in fresh cycles with an embryo transfer. In a logistic regression model, SARS-CoV-2 infection more than 180 days prior to retrieval had a negative effect on oocyte yield (p = 0.018, Slope=-4.08, 95% CI -7.41 – -0.75), although the sample size was small.

Limitations, Reasons For Caution

A retrospective study with data that was not uniformly generated under a study protocol, no antibody testing for the control group.

Wider Implications Of The Findings

The study findings suggest that SARS-CoV-2 infection does not affect treatment outcomes, including oocyte yield, fertilization and maturation rate, number of good quality embryos, and clinical pregnancy rates, in fresh ART cycles, except for a possible long term negative effect on oocyte yield when retrieval occurs > 180 days post SARS-CoV-2 infection. Further studies are warranted to support these findings.

Study funding/competing interest(s)

None.

Trial registration number

0010-21-HMC, 0094-21-ASF

COVID-19 Vaccination and Infertility Treatment Outcomes

Objective

Design

Setting

Patient(s)

Intervention(s)

Main Outcome Measure(s)

Result(s)

Conclusion(s)

The Involvement of Lumican in Human Ovulatory Processes

Based on a previous global transcriptome sequencing project, we hypothesized that Lumican (LUM) might play a role in ovulatory processes. We sought to determine LUM gene expression under various conditions in human preovulatory follicles. The in vitro expression of LUM mRNA in mural (MGCs) and cumulus (CGCs) granulosa cells was characterized using quantitative real-time polymerase chain reaction (qRT-PCR). Immunohistochemical staining was used to identify human LUM expression in follicles at different developmental stages. Cell signaling studies were performed by treating human MGCs with human chorionic gonadotropin (hCG) and both, different stimulators and inhibitors to determine their effect on LUM expression by using qRT-PCR. Cell confluence studies were carried out to study the correlation between LUM expression and follicle cell proliferation. Follicular MGCs and CGCs of women undergoing in vitro fertilization (IVF) procedures due to endometriosis were analyzed for differences in LUM expression patterns by qRT-PCR. LUM mRNA expression was significantly higher in MGCs as compared to CGCs. In CGCs, LUM mRNA was higher in mature metaphase II (MII) oocytes than in germinal vesicle (GV) and metaphase I (MI) oocytes. LUM expression was significantly upregulated in response to hCG in cultured MGCs. Immunohistochemistry of human ovaries revealed LUM was mostly present in MGCs of large preovulatory and postovulatory follicles and absent from primordial follicles. Using pharmacological activators and inhibitors, we demonstrated that LUM induction by luteinizing hormone (LH)/hCG is carried through the mitogen-activated protein kinase (MEK) pathway. LUM expression was induced in high-density cell cultures in a confluence-dependent manner. MGCs from follicles of subjects with endometriosis exhibited reduced mRNA transcription levels compared to control subjects. Our study confirms that LUM is a newly discovered ovulatory gene. LUM might play an important role during the preovulatory period up until ovulation as well as in endometriosis infertility. A better understanding of LUM's role might provide potential new treatment paradigms for some types of female infertility.

Suspension of fertility treatment during the COVID-19 pandemic: views, emotional reactions and psychological distress among women undergoing fertility treatment

RESEARCH QUESTION

What are the views and emotional reactions of patients towards the suspension of fertility treatment during the COVID-19 pandemic, and what are the factors affecting their psychological distress?

DESIGN

A cross-sectional study conducted in an academic fertility centre. Online questionnaires were distributed between 18 April 2020 and 23 April 2020 to patients whose treatment cycle had been postponed or discontinued. The outcome measures included agreement with the reproductive society guidelines to postpone treatments; willingness to resume treatments, given the choice; patients' emotional reactions; and psychological distress level, measured by the Mental Health Inventory validated scale. A multivariate linear regression was conducted to identify factors associated with psychological distress.

RESULTS

Because of the small number of male respondents, only women were included in the analysis (n = 181). Forty-three per cent expressed disagreement with the guidelines and 82% were willing to resume treatments, given the choice. Sadness and anxiety were the most common emotional reactions expressed towards the guidelines. In the multivariate analysis, COVID-19-related anxiety (B = 0.145, P = 0.04) and disagreement with treatment suspension (B = -0.44, P = 0.001) were found to be significantly associated with patients' psychological distress. Background characteristics of patients did not contribute significantly to their distress.

CONCLUSIONS

Suspension of fertility treatment during the initial phase of the COVID-19 pandemic was associated with patients' negative emotional reactions. Anxiety related to COVID-19 and disagreement with treatment suspension were found to be significantly associated with psychological distress among women undergoing fertility treatment, regardless of their background characteristics. Our findings suggest the need to monitor the mental health of patients and provide psychological support should a shutdown of fertility care re-occur.

Fertility patients under COVID-19: attitudes, perceptions and psychological reactions

STUDY QUESTION

What are the perceptions of infertility patients and the factors correlating with their psychological distress, following suspension of fertility treatments during the Corona Virus Disease-19 (COVID-19) pandemic?

SUMMARY ANSWER

Most patients preferred to resume treatment given the chance regardless of background characteristics; higher self-mastery and greater perceived social support were associated with lower distress, while feeling helpless was associated with higher distress.

WHAT IS KNOWN ALREADY

Infertility diagnosis and treatment frequently result in significant psychological distress. Recently published data have shown that clinic closure during the COVID-19 pandemic was associated with a sharp increase in the prevalence of anxiety and depression among infertile patients undergoing IVF and was perceived as an uncontrollable and stressful event. Personal resources play an important protective role in times of crisis, helping reduce levels of distress.

STUDY DESIGN, SIZE, DURATION

This cross-sectional questionnaire study included patients whose fertility treatment was suspended following the COVID-19 pandemic, in a tertiary hospital. The survey was delivered to 297 patients within 12 days at the beginning of April 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The self-administered questionnaire included items addressing: (i) patients' demographic characteristics, (ii) anxiety related to COVID-19 infection risk and level of social support, (iii) patients' perceptions of the new guidelines and description of subsequently related emotions and (iv) two validated scales assessing levels of emotional distress and self-mastery. Multivariate analysis was conducted to assess factors alleviating or increasing emotional distress during the COVID-19 pandemic.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 168 patients who completed the survey, giving a response rate of 57%. Study variables in the regression model explained 38.9% of the variance in psychological distress experienced by patients during treatment suspension. None of the background characteristics (e.g. age, marital status, parity, economic level or duration of treatments) had a significant contribution. Feeling helpless following the suspension of treatments was associated with higher distress (P < 0.01). Higher self-mastery and greater perceived social support were associated with lower distress (P < 0.01). Despite the ministry of health's decision, 72% of patients wished to resume treatment at the time of survey.

LIMITATIONS, REASONS FOR CAUTION

This was a cross-sectional study, thus information about patients' characteristics prior to the COVID-19 pandemic was not available. The length and implications of this pandemic are unknown. Therefore, the ability to draw conclusions about the psychological consequences of the crisis is limited at this point of time.

WIDER IMPLICATIONS OF THE FINDINGS

Personal resources play an important protective role in times of crisis, helping to reduce levels of distress. Study findings suggest that attention should be paid to strengthening and empowering patients' personal resources together with directly confronting and containing feelings of helplessness. In line with the European Society for Human Reproduction and Embryology (ESHRE) guidelines, especially at this time of high levels of distress, it is imperative to offer emotional support to reduce stress and concerns. Furthermore, as the pandemic is stabilizing, resumption of treatment should be considered as soon as appropriate according to local conditions.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the IVF unit of the Shamir Medical Center. All authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Obstetric, neonatal and child development outcomes following assisted hatching treatment: a retrospective cohort study

Assisted hatching (AH) involves artificial disruption of the zona pellucida prior to embryo transfer. The purpose of this study is to examine the safety of AH technique and its effect on obstetrical, perinatal and neonatal outcomes and risk of developmental delay. This is a retrospective cohort of ART cycles using laser AH technique. The study group consisted of 120 cases of AH cycles resulting in singleton pregnancies and live births compared with 113 control cases. A current phone questionnaire was conducted to assess child development in the first year of life. AH was not associated with increased risk for all obstetrical and perinatal outcomes examined including PPROM, gestational diabetes, hypertensive diseases of pregnancy, delivery by cesarean section, gestational age at delivery, low birth weight (LBW), preterm birth and neonatal Apgar score (p>.05). No significant differences were observed between AH and control group in rates and risk of congenital malformations (5.8 vs. 4.4%, respectively, OR 1.33, 95% CI 0.41-4.34) and developmental delay (19.2 vs. 12.8%, respectively, OR 1.62, 95% CI 0.74-3.52). AH did not increase the risk of obstetrical and neonatal complications in singleton pregnancies, including congenital malformations and child developmental delay. AH may therefore be considered a safe method of ART.

Do fertility treatments affect labor induction success rate? A retrospective cohort study

Purpose: To evaluate labor induction success rate by Foley catheter (FC) on patients who conceived spontaneously, as compared to those who underwent fertility treatments.Materials and methods: This retrospective cohort study included all pregnant women hospitalized at a single tertiary care center between January 2011 and May 2018 for induction of labor with FC. The study groups included patients with a singleton pregnancy who conceived after fertility treatments: controlled ovarian hyperstimulation (COH) or in vitro fertilization (IVF), while control group included patients who conceived spontaneously. Our primary outcome was the rate of cesarean deliveries. Regression analysis was conducted on the following parameters: age, gravidity, parity, the gestational week, and IVF.Results: The study groups included 59, 321, and 3159 patients who conceived following COH, IVF, or spontaneously, respectively. While 72.1% of patients who conceived spontaneously had a vaginal delivery, only 62.7% and 58% of patients who conceived by COH and IVF had successful labor induction (respectively, p < .01). Similarly, significantly higher cesarean section (CS) rates were demonstrated by patients who conceived by COH and IVF (28.8% and 30%, respectively), compared to the control group (18.7%, p < .01). Regression analysis demonstrated that although age, parity, and the gestational week were significantly related to cesarean sections, no statistically significant association was found regarding fertility treatments (p = .050).Conclusions: The possible association between fertility treatments and cesarean delivery remains an important dilemma for obstetricians and fertility experts. While unadjusted analysis demonstrated such association among patients who undergo labor induction by FC, adjusted analysis has not supported that finding. Further studies focusing on the causes of failed vaginal delivery are needed to further expand our knowledge and to improve patient consultation.

Elucidating Decorin's role in the preovulatory follicle

Background

DCN (decorin) is a proteoglycan known to be involved in regulating cell proliferation, collagen fibril organization and migration. In our global transcriptome RNA-sequencing approach to systematically identify new ovulation-associated genes, DCN was identified as one of the highly regulated genes. We therefore hypothesize that DCN may have a role in ovulatory processes such as cell migration and proliferation.

Aim

To characterize the expression, regulation and function of the proteoglycan DCN in the human ovarian follicles during the preovulatory period.

Methods

The in-vivo expression of DCN mRNA in mural (MGCs) and cumulus (CGCs) granulosa cells was characterized using quantitative RT-PCR and western blot.

A signaling study was performed by treating human MGCs cultures with gonadotropins and different stimulators and inhibitors to determine their effect on DCN expression by qRT- PCR and elucidate the pathways regulating these proteins.

In a functional study, KGN granulosa cell line was used to study cell migration with a scratch assay.

Results

DCN mRNA expression was significantly higher in MGCs compared to CGCs. DCN mRNA was significantly higher in CGCs surrounding mature metaphase II (MII) oocytes compared to CGCs of germinal vesicle (GV) and metaphase I (MI) oocytes.

hCG significantly increased DCN mRNA and protein expression levels in cultured MGCs. Using signal transduction activators and inhibitors, we demonstrated that DCN induction by LH/hCG is carried out via PKA, PKC, ERK/MEK, and PI3K pathways.

We showed that DCN expression is also induced in high-density cell cultures, in a dose-dependent pattern. In addition, progesterone induced a significant increase in DCN secretion to the media. MGCs from follicles of endometriosis patients exhibited reduced (about 20% of) mRNA transcriptions levels compared to MGCs follicles of control patients. More significantly, we found that DCN has an inhibiting effect on KGN cell migration.

Conclusions

Our study indicates that DCN is a unique ovulatory gene.

Our findings support the hypothesis that DCN plays an important new role during the preovulatory period and ovulation, and stress its involvement in endometriosis infertility. A better understanding of DCN role in ovulation and endometriosis may provide treatment for some types of infertility.

Impact of the mode of conception on gestational hypertensive disorders at very advanced maternal age

RESEARCH QUESTION

To study gestational hypertensive disorders in oocyte donation pregnancies compared with other modes of conception at very advanced maternal age.

DESIGN

A historical cohort study of all women aged 45-47 years who gave birth to singletons at a tertiary medical centre between March 2011 and May 2018, at 24 weeks' gestation or later. Pregnancy outcomes were compared between donor oocyte (IVF-OD), IVF using autologous oocytes (IVF-A) and naturally conceived pregnancies. A multivariate logistic regression was used to evaluate the association between the mode of conception and gestational hypertensive disorders.

RESULTS

The final analysis included 159, 68 and 73 patients in the IVF-OD, IVF-A and natural conception groups, respectively. The rate of gestational hypertensive disorders was significantly higher among those who conceived by IVF compared with those who conceived naturally but did not differ between the two IVF groups (27.0% for IVF-OD, 19.1% for IVF-A, P = 0.204; 5.5% for natural conception, P < 0.001 and P = 0.013 compared with IVF-OD and IVF-A, respectively). The results remained similar in a multivariate logistic regression analysis. The rate of Caesarean deliveries was significantly higher in the IVF-OD and IVF-A groups compared with the natural conception group (83.6%, 70.6% and 37.0%, respectively, P < 0.001), but other pregnancy outcomes did not differ between the groups.

CONCLUSIONS

IVF pregnancies in the late fifth decade of life were associated with significantly higher rates of gestational hypertensive disorders compared with naturally conceived pregnancies. No difference existed between the two IVF groups. These results may highlight the impact of IVF itself on gestational hypertensive disorders at very advanced maternal age.

How Artificial Intelligence Can Improve Our Understanding of the Genes Associated with Endometriosis: Natural Language Processing of the PubMed Database

Endometriosis is a disease characterized by the development of endometrial tissue outside the uterus, but its cause remains largely unknown. Numerous genes have been studied and proposed to help explain its pathogenesis. However, the large number of these candidate genes has made functional validation through experimental methodologies nearly impossible. Computational methods could provide a useful alternative for prioritizing those most likely to be susceptibility genes. Using artificial intelligence applied to text mining, this study analyzed the genes involved in the pathogenesis, development, and progression of endometriosis. The data extraction by text mining of the endometriosis-related genes in the PubMed database was based on natural language processing, and the data were filtered to remove false positives. Using data from the text mining and gene network information as input for the web-based tool, 15,207 endometriosis-related genes were ranked according to their score in the database. Characterization of the filtered gene set through gene ontology, pathway, and network analysis provided information about the numerous mechanisms hypothesized to be responsible for the establishment of ectopic endometrial tissue, as well as the migration, implantation, survival, and proliferation of ectopic endometrial cells. Finally, the human genome was scanned through various databases using filtered genes as a seed to determine novel genes that might also be involved in the pathogenesis of endometriosis but which have not yet been characterized. These genes could be promising candidates to serve as useful diagnostic biomarkers and therapeutic targets in the management of endometriosis.

Activated ovarian endothelial cells promote early follicular development and survival

Background

New data suggests that endothelial cells (ECs) elaborate essential “angiocrine factors”. The aim of this study is to investigate the role of activated ovarian endothelial cells in early in-vitro follicular development.

Methods

Mouse ovarian ECs were isolated using magnetic cell sorting or by FACS and cultured in serum free media. After a constitutive activation of the Akt pathway was initiated, early follicles (50–150 um) were mechanically isolated from 8-day-old mice and co-cultured with these activated ovarian endothelial cells (AOEC) (n = 32), gel (n = 24) or within matrigel (n = 27) in serum free media for 14 days. Follicular growth, survival and function were assessed.

Results

After 6 passages, flow cytometry showed 93% of cells grown in serum-free culture were VE-cadherin positive, CD-31 positive and CD 45 negative, matching the known EC profile. Beginning on day 4 of culture, we observed significantly higher follicular and oocyte growth rates in follicles co-cultured with AOECs compared with follicles on gel or matrigel. After 14 days of culture, 73% of primary follicles and 83% of secondary follicles co-cultured with AOEC survived, whereas the majority of follicles cultured on gel or matrigel underwent atresia.

Conclusions

This is the first report of successful isolation and culture of ovarian ECs. We suggest that co-culture with activated ovarian ECs promotes early follicular development and survival. This model is a novel platform for the in vitro maturation of early follicles and for the future exploration of endothelial-follicular communication.

Capsule

In vitro development of early follicles necessitates a complex interplay of growth factors and signals required for development. Endothelial cells (ECs) may elaborate essential “angiocrine factors” involved in organ regeneration. We demonstrate that co-culture with ovarian ECs enables culture of primary and early secondary mouse ovarian follicles.

[Do poor-responder patients benefit from increasing the daily gonadotropin dose from 300 to 450 IU during controlled ovarian hyperstimulation for IVF?]

OBJECTIVE

We aim to evaluate the IVF-ET outcome in patients receiving a high daily dose (300 IU) of gonadotropins during controlled ovarian hyperstimulation (COH) for IVF and to assess the role of increasing the daily dose to 450 IU on improving outcome.

PATIENTS AND METHODS

All consecutive women admitted to our IVF unit during an 11 year period who underwent COH consisting of daily gonadotropin dose of 300 IU were included in the study. The ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and pregnancy rate were assessed. We also evaluated the subsequent cycle, using daily gonadotropin doses of 450 IU, among those patients who did not conceive using the 300 IU daily gonadotropin dose.

RESULTS

Nine hundred and forty-nine consecutive IVF cycles were evaluated. Patients who conceived using the daily gonadotropin dose of 300 IU (n = 133, 14% pregnancy rate) had significantly longer stimulation, yielded higher numbers of oocytes retrieved, fertilization rate and number of embryos transferred, compared to those who did not conceive. Moreover, while comparing IVF cycles using daily gonadotropin doses of 300 IU to 450 IU (n = 117), no in-between group differences were observed, except for significantly higher yields of oocytes retrieved. Moreover, cycles using daily gonadotropin doses of 450 IU resulted in a 7.7 live-birth rate.

CONCLUSIONS

In poor responders undergoing COH with a daily gonadotropin dose of 300 IU, increasing the dose to 450 IU resulted in significantly higher oocyte yields and a reasonable live birth rate.

Co-administration of GnRH-agonist and hCG, for final oocyte maturation (double trigger), in patients with low proportion of mature oocytes

OBJECTIVE

Human chorionic gonadotropin (hCG) is usually used at the end of controlled ovarian hyperstimulation (COH), as a surrogate LH surge, to induce final oocyte maturation and resumption of meiosis. Recently, the co-administration of GnRH agonist and hCG for final oocyte maturation - 40 and 34 h prior to OPU, respectively (double trigger) was suggested to improve IVF outcome in patient with genuine empty follicle syndrome. In the present study, we aim to evaluate whether the double trigger might improve the proportions of metaphase-II (MII) oocytes in patients with low proportion of mature oocytes (<66%) per number oocytes retrieved.

PATIENTS AND METHODS

We compared the stimulation characteristics of 12 IVF cycles, which include the cycle with the double trigger to the same patients' previous IVF attempt, triggered with hCG-only.

RESULTS

Patients who received the double trigger (study group) had a significantly higher number of mature oocytes - MII (6.5 versus 3.6 p < 0.008), number of embryos transferred (2.4 versus 1.1 p < 0.03), a significantly higher proportions of MII oocytes per number of oocytes retrieved (69.7% versus 47.1% p < 0.03) and a higher number of top quality embryos (3.1 versus 1 p < 0.02), as compared to their previous control cycles (hCG-only trigger). Six pregnancies were recorded in the study group and none in the control group.

CONCLUSIONS

Co-administration of GnRH-agonist and hCG for final oocyte maturation, 40 and 34 h prior to OPU, respectively (double trigger) improves IVF outcome in patients with high proportion of immature oocytes.

Do poor-responder patients benefit from increasing the daily gonadotropin dose during controlled ovarian hyperstimulation for IVF?

We aim to assess the in vitro fertilization-embryo transfer (IVF-ET) outcome in patients receiving an extremely high 450 daily dose (IU) of gonadotropins during controlled ovarian hyperstimulation (COH) for IVF. Moreover, in those who failed to conceive while using 450 daily dose (IU) of gonadotropins, we aim to evaluate whether increasing the daily dose gonadotropins to 600 IU will improve IVF outcome. All consecutive women, admitted to our IVF unit and underwent COH consisting of daily gonadotropin dose of 450 IU were included. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and pregnancy rate were assessed. Nine-hundred one consecutive IVF cycles were evaluated. While there was no between-group difference in the duration of COH, patients who conceived were significantly younger, yielded higher number of oocytes retrieved and embryos transferred and had significantly lower cancellations. In a sub-analysis, including only those patients who failed to conceive while using 450 daily dose (IU) of gonadotropins, and who underwent a subsequent IVF cycle attempt with the used of 600 IU daily dose of gonadotropins, no improvements in COH characteristics or cancellation rates were observed with increasing the daily gonadotropin dose to 600 IU. To conclude, in poor responders undergoing COH with an extremely high daily gonadotropin dose (450 IU), the most important factors that predict IVF success are female age and the number of oocytes retrieved. Moreover, patients who failed to conceive on a daily gonadotropin dose of 450 IU will not benefit from increasing the dose to 600 IU and should therefore consider the options of egg donation or adoption.

Anti Müllerian Hormone (AMH) level and expression in mural and cumulus cells in relation to age

Background

Serum AMH is declining with age and is highly associated with ovarian follicular reserve and disordered folliculogenesis. However, the precise role of AMH in the process of human follicular aging has still to be determined.

Aim

This study investigates AMH level in the follicular fluid (FF) and mRNA expression pattern in cumulus and mural granulosa cells of human ovarian follicles in relation to age.

Methods

We conducted a prospective study. Sixty-eight women undergoing In vitro fertilization (IVF) treatment were enrolled in the study. We obtained FF, mural and cumulus granulosa cells from large preovulatory follicles (17-20 mm) of 21–35 years old women (n = 40) and 40–45 years old women (n = 28) during oocyte pickup.

Results

Higher level of AMH mRNA expression in cumulus cells was observed in the older age group compared to the younger (P <0.01). In accordance with AMH mRNA expression results, FF AMH protein levels were significantly higher in the older group than in the younger group (4.7 ± 1.1 ng\ml and 2.3 ± 0.2 ng\ml respectively, p < 0.002).

Conclusions

AMH is highly expressed and secreted from cumulus GCs of advanced age patients. This remarkable correlation between AMH mRNA levels in cumulus cells in respect to age suggests that AMH may be involved in follicular aging process.

Does bariatric surgery improve ovarian stimulation characteristics, oocyte yield, or embryo quality?

Background

Obesity is a major global health concern associated with multiple co-morbidities. Bariatric surgery has been considered a good treatment option in cases of morbid obesity. This preliminary study aims to investigate the effect of bariatric surgery on ovarian stimulation characteristics and IVF treatment cycle outcome.

Methods

A retrospective study that was performed in a tertiary, university-affiliated medical center and included all patients who underwent IVF treatment both before and after bariatric surgery. Data on ovarian stimulation variables of IVF treatment cycle prior and following the bariatric surgery were reviewed and compared.

Results

From January 2005 to June 2014, seven women fulfilled the inclusion criteria. After the operation, BMI was significantly reduced (mean ± SD) (43.1 ± 3.3 vs. 29.6 ± 7.33, p = 0.018), as was the number of gonadotropin ampoules required during stimulation (69.3 ± 10.5 vs. 44.5 ± 17, p = 0.043). No between-cycle differences were observed in peak estradiol level, the number of oocytes retrieved, and percentage of mature oocytes.

Conclusions

To the best of our knowledge, this preliminary case series is the first comparison of IVF cycle characteristics prior to and following bariatric surgery. The operation seems to reduce treatment costs without affecting oocyte or embryo quality. Further large studies are required to establish the surgery’s effect on IVF outcome among infertile women.

Co-administration of GnRH-agonist and hCG for final oocyte maturation (double trigger) in patients with low number of oocytes retrieved per number of preovulatory follicles--a preliminary report

Background

Recently, the co-administration of GnRH agonist and hCG for final oocyte maturation- 40 and 34 hours prior to OPU, respectively (double trigger) was suggested as the treatment of genuine empty follicle syndrome. In the present study, we aim to evaluate whether the double trigger improves the number of oocytes retrieved in patients with low (<50%) number of oocytes retrieved per number of preovulatory follicles.

Methods

In this proof of concept cohort historical study, we compared the stimulation characteristics of 8 IVF cycles, which include the double trigger to the patients’ previous IVF attempt, triggered with hCG-only.

Results

Patients who received the double trigger (study group) had a significantly higher number of oocytes retrieved, number of 2PN, number of embryos transferred and significantly higher proportions of the number of oocytes retrieved to the number of follicles >10 mm and >14 mm in diameter on day of hCG administration, with a tendency toward a higher number of TQE, as compared to their previous cycles (hCG-only trigger). Three ongoing clinical pregnancies were recorded in the study group and none in the hCG-only trigger group.

Conclusions

Co-administration of GnRH-agonist and hCG for final oocyte maturation, 40 and 34 hours prior to OPU, respectively (double trigger), is suggested as a valuable new tool in the armamentarium for treating patients with low/poor oocytes yield despite an apparently normal follicular development and E2 levels and in the presence of optimal hCG levels on the day of OPU.

Characterization of the human cumulus cell transcriptome during final follicular maturation and ovulation

Cumulus expansion and oocyte maturation are central processes in ovulation. Knowledge gained from rodent and other mammalian models has revealed some of the molecular pathways associated with these processes. However, the equivalent pathways in humans have not been thoroughly studied and remain unidentified. Compact cumulus cells (CCs) from germinal vesicle cumulus oocyte complexes (COCs) were obtained from patients undergoing in vitro maturation (IVM) procedures. Expanded CCs from metaphase 2 COC were obtained from patients undergoing IVF/ICSI. Global transcriptome profiles of the samples were obtained using state-of-the-art RNA sequencing techniques. We identified 1746 differentially expressed (DE) genes between compact and expanded CCs. Most of these genes were involved in cellular growth and proliferation, cellular movement, cell cycle, cell-to-cell signaling and interaction, extracellular matrix and steroidogenesis. Out of the DE genes, we found 89 long noncoding RNAs, of which 12 are encoded within introns of genes known to be involved in granulosa cell processes. This suggests that unique noncoding RNA transcripts may contribute to the regulation of cumulus expansion and oocyte maturation. Using global transcriptome sequencing, we were able to generate a library of genes regulated during cumulus expansion and oocyte maturation processes. Analysis of these genes allowed us to identify important new genes and noncoding RNAs potentially involved in COC maturation and cumulus expansion. These results may increase our understanding of the process of oocyte maturation and could ultimately improve the efficacy of IVM treatment.

HCG (1500IU) administration on day 3 after oocytes retrieval, following GnRH-agonist trigger for final follicular maturation, results in high sufficient mid luteal progesterone levels - a proof of concept

Background

Controlled ovarian hyperstimulation (COH) which combining GnRH antagonist co-treatment and GnRH agonist trigger with an additional 1500 IU hCG luteal rescue on day of oocytes retrieval, has become a common tool aiming to reduce severe ovarian hyperstimulation syndrome (OHSS). In the present, proof of concept study, we evaluate whether by deferring the hCG rescue bolus for 3 days, we are still able to rescue the luteal phase.

Methods

Patients undergoing the GnRH-antagonist protocol, who were considered at high risk for developing severe OHSS and received GnRH-agonist for final oocyte maturation, were included. For luteal phase support, all patients received an “intense” luteal support. Those who had no signs of early moderate OHSS on day 3 after oocytes retrieval were instructed to inject 1500 IU of HCG bolus (hCG group). Ovarian stimulation characteristics and mid luteal progesterone levels were compared between those who received the HCG bolus and those who did not.

Results

Eleven IVF cycles were evaluated, 5 in the hCG group and 6 in the intense luteal support only group. While no in-between group differences were observed in ovarian stimulation characteristics, significantly higher mid luteal progesterone levels (>127 nmol/L vs 42.1 ± 14.5 nmol/L, respectively) and a non-significant increase in pregnancy rate (40% vs 16.6%, respectively), were observed in those who receive the hCG bolus compared to those who did not.

Conclusions

hCG luteal rescue should be offered 3 days after oocytes retrieval only to those patients with no signs of early moderate OHSS. Further studies are required to elucidate the appropriate regimen of luteal HCG administration in patients undergoing final follicular maturation with GnRH-agonist.

GnRH agonist vs. hCG for triggering of ovulation--differential effects on gene expression in human granulosa cells

OBJECTIVE

To investigate the mRNA expression of genes related to steroidogenesis and OHSS in granulosa cells (GCs) of patients triggered with GnRH agonist compared to patients triggered with hCG.

DESIGN

Mural GCs were obtained at the time of oocyte retrieval and gene expression was analyzed using quantitative real time RT-PCR.

SETTINGS

Single center, case control study.

PATIENT(S)

24 women who were treated with GnRH agonist or hCG for triggering of ovulation.

INTERVENTIONS

GC collection.

MAIN OUTCOME MEASURE(S)

The expression of genes related to steroidogenesis and OHSS in mural GCs.

RESULTS

The fertilization rate was similar in the two groups. The mRNA expression of CYP19A1 (0.50 vs 1, arbitrary unit), CYP11A1 (0.6 vs. 1) and 3 beta hydroxysteroid-dehydrogenase (0.39 vs 1) was significantly lower in the GnRH group. The expression of VEGF (0.74 vs. 1) and inhibin β B (0.38 vs 1) was lower in the GnRH analog triggered group.

CONCLUSION

Expression of genes related to steroidogenesis is lower at the time of oocyte retrieval in patients triggered with GnRH agonist. The decreased expression of VEGF and inhibin β B in the GnRH agonist group can explain the mechanism of early OHSS prevention.

Ongoing pregnancy rates in women with low and extremely low AMH levels. A multivariate analysis of 769 cycles

Background

The ideal test for ovarian reserve should permit the identification of women who have no real chance of pregnancy with IVF treatments consequent upon an extremely reduced ovarian reserve. The aim of the current study was to evaluate pregnancy rates in patients with low AMH levels (0.2–1 ng/ml) and extremely low AMH levels (<0.2 ng/ml) and to determine the cumulative pregnancy rates following consecutive IVF treatments.

Methods

We conducted an historical cohort analysis at a tertiary medical center. Serum AMH levels were measured at initial clinic visit and prior to all following treatment cycles in 181 women (769 cycles) with an initial AMH level ≤1 ng/ml, undergoing IVF-ICSI. Main outcome measures were laboratory outcomes and pregnancy rates.

Results

Seventy patients undergoing 249 cycles had extremely low AMH levels (≤0.2 ng/ml), whereas 111 patients undergoing 520 cycles had low AMH levels (0.21–1.0 ng/ml). Number of oocytes retrieved per cycle, fertilized oocytes and number of transferred embryos were significantly lower in the extremely low AMH levels group compared to the low AMH levels (P<0.003). Crude ongoing pregnancy rates were 4.4% for both groups of patients. Among 48 cycles of women aged ≥42 with AMH levels of ≤0.2 ng/ml no pregnancies were observed. But, in patients with AMH levels of 0.2–1.0 ng/ml, 3 ongoing pregnancies out of 192 cycles (1.6%) were observed. However, in a multivariate regression analysis adjusted for age and cycle characteristics, no significant differences in ongoing pregnancy rates per cycle between the two groups were evident. Cumulative pregnancy rates of 20% were observed following five cycles, for both groups of patients.

Conclusions

Patients with extremely low AMH measurements have reasonable and similar pregnancy rates as patients with low AMH. Therefore, AMH should not be used as the criterion to exclude couples from performing additional IVF treatments.

Anti-Müllerian hormone (AMH) downregulation in late antral stages is impaired in PCOS patients. A study in normo-ovulatory and PCOS patients undergoing in vitro maturation (IVM) treatments

PURPOSE

To prospectively study the AMH expression and secretion pattern in mural granulosa cells (GCs) and follicular fluid (FF) from small follicles and medium follicles that were collected from normo-ovulatory (NO) and polycystic ovary syndrome (PCOS) patients undergoing in vitro maturation (IVM) treatments.

METHODS

FF AMH levels and mRNA expression of mural GCs were measured in small (≤ 10 mm) and medium size follicles (11-15 mm) obtained from IVM treatments and large size follicles (≥ 16 mm) obtained from in vitro fertilization treatments.

RESULTS

First, we show that AMH expression and protein level in the FF of NO patients were significantly higher in the small size follicles than in the medium and large size follicles (p < 0.003). We could not demonstrate these differences in PCOS patients. Second, we found significantly higher levels of AMH protein and mRNA in the large and medium (but not small) size follicles of PCOS patients compared to follicles from NO patients (p < 0.02). Finally, we observed a positive correlation between FF AMH of small and medium size follicles from NO patients and serum AMH (p < 0.03 and p < 0.0002, respectively).

CONCLUSIONS

Our data demonstrate a pathological dysregulation of AMH expression and secretion in follicles from PCOS patients and emphasize the association between the physiological downregulation of AMH and follicular antral health.

Caput succedaneum thickness in prolonged second stage of labour: a clinical evaluation

BACKGROUND

Data are scarce regarding the association between the presence of caput succedaneum and the mode of delivery.

AIMS

To evaluate the presence and clinical significance of caput succedaneum thickness in prolonged second stage of labour.

MATERIALS AND METHODS

We conducted a prospective study of women, beyond 37 weeks of gestation, during prolonged second stage of labour. Transperineal ultrasound was performed to assess the caput succedaneum thickness. The relationships between caput succedaneum thickness, feto-maternal characteristics, delivery mode and immediate post-natal outcomes were analysed.

RESULTS

Fifty-eight women, of whom 47 were nulliparas, in prolonged second stage of labour, were included in the study. The caput succedaneum thickness could be measured in all cases. Overall mean thickness was 21.9 (±4.9) mm (range 14-40 mm). No significant difference or correlation was found between caput succedaneum thickness, fetal head positions, modes of delivery, duration of second stage, head circumference or neonatal outcomes.

CONCLUSIONS

Caput succedaneum is measurable in all cases at prolonged second stage using transperineal sonography. Its presence and dimensions presented in our pilot study seem to have no implication on delivery mode and neonatal outcome.

What is the optimal threshold of serum Anti-Müllerian hormone (AMH) necessary for IVM treatments?

PURPOSE

To assesse circulating levels of Anti-Müllerian hormone (AMH) as a predictor of oocyte number and their potential to mature in vitro in both normo-ovulatory (NO) women and in women with Polycystic Ovary Syndrome (PCOS) undergoing in vitro maturation (IVM) treatments.

METHODS

We prospectively studied NO women and women diagnosed with PCOS, (age range 21-39 years) underwent IVM treatments at our center. Serum AMH levels were quantified before each cycle and correlated to oocytes number, maturation and fertilization during in vitro maturation.

RESULTS

104 NO and 30 PCOS IVM cycles were followed with retrieval of a total of 672 and 491 oocytes, respectively. In NO women, the serum AMH level positively correlated with the number of oocytes retrieved, (R = 0.6; P <0.0001) the number of M2 oocytes at 24 and 48 h (R = 0.4; P <0.01; R = 0.26 p < 0.007, respectively) and with the total number of M2 oocytes (R = 0.47; P < 0.0001). In the PCOS group, the serum AMH level positively correlated only with the number of oocytes retrieved (R = 0.43; P <0.03). Receiver operating characteristic (ROC) analyses showed that a cutoff AMH level of 1.56 (ng/ml) could identify patients with 5 or more oocytes at OPU with a sensitivity of 83 % and a specificity of 75 %. An AMH level of 1.63 (ng/ml) was the threshold for 5 or more matured oocytes (sensitivity = 81 %, specificity = 53 %).

CONCLUSIONS

Serum AMH may be used as a marker to identify candidates for IVM treatment in both NO and PCOS women.

Head progression distance in prolonged second stage of labor: relationship with mode of delivery and fetal head station

OBJECTIVE

To evaluate the clinical significance of fetal head progression distance (HPD), measured by transperineal ultrasound, during prolonged second stage of labor.

METHODS

In this prospective study, a single operator, who was blinded to the results of the digital examination, assessed using transperineal ultrasound women at ≥ 37 weeks of gestation with failure to progress in the second stage of labor. Patients had an empty urinary bladder and the examination was performed during maternal pushing. HPD was defined as the length of the line perpendicular to the infrapubic line that would connect it to the lowest part of the fetal bony skull. We analyzed associations between HPD and digital examination of fetal head station, fetomaternal characteristics, mode of delivery and perinatal outcome.

RESULTS

Sixty-five patients in prolonged second stage of labor participated in the study. The overall mean HPD was 6.50 (± 1.35; 95% CI, 6.16-6.83) cm. No correlation was found between HPD and head position or mode of delivery, but HPD was positively correlated with fetal head station and neonatal head circumference measured after delivery. Logistic regression and receiver-operating characteristics curve analysis demonstrated no significant predictive value of HPD with respect to mode of delivery.

CONCLUSION

Although HPD in prolonged second stage of labor could not predict mode of delivery, it may have a role as an ancillary tool for fetal head station assessment.

Pubic arch angle in prolonged second stage of labor: clinical significance

OBJECTIVE

To evaluate the clinical significance of the pubic arch angle (PAA) measured by transperineal ultrasound during prolonged second stage of labor.

METHODS

We evaluated prospectively 62 women ≥ 37 weeks of gestation with failure to progress in the second stage of labor. Transperineal ultrasound (transverse plane) was used to measure the pubic arch angle. Correlations with fetomaternal characteristics, mode of delivery and perinatal outcome were evaluated.

RESULTS

The mean PAA was 101.1° (± 13.1°; range, 80°-135°). We found a negative correlation with maternal age. Patients with an occipitotransverse fetal position had a significantly smaller angle compared with those with occipitoanterior positions (94.3° ± 5.5° vs. 103.2° ± 14.8°, P < 0.05), as did those with operative deliveries compared with those with spontaneous vaginal delivery (97.1° ± 11.5° vs. 110.1° ± 14.0°, P < 0.05). The prediction of operative delivery in prolonged second stage of labor by receiver-operating characteristics curve using PAA alone yielded an area under the curve of 0.75. The predicted probability for operative delivery increased as PAA decreased, with an odds ratio of 0.933 for each decrease in angle of 1°.

CONCLUSION

Our study suggests a correlation between the PAA and mode of delivery in prolonged second stage of labor. This may be used as an adjunctive parameter when considering delivery mode.

Defensive medicine among obstetricians and gynecologists in tertiary hospitals

OBJECTIVE

To describe the daily work practice under the threat of defensive medicine among obstetricians and gynecologists.

STUDY DESIGN

A prospective cross-sectional survey of obstetricians and gynecologists working at tertiary medical centers in Israel.

RESULTS

Among the 117 obstetricians and gynecologists who participated in the survey, representing 10% of the obstetricians and gynecologists registered by the Israel Medical Association, 113 (97%) felt that their daily work practice is influenced by concern about being sued for medical negligence and not only by genuine medical considerations. As a result, 102 (87%) physicians are more likely to offer the cesarean section option, even in the absence of a clear medical indication, 70 (60%) follow court rulings concerning medical practices, and 85 (73%) physicians mentioned that discussions about medical negligence court rulings are included in their departments' meetings.

CONCLUSIONS

Defensive medicine is a well-embedded phenomenon affecting the medical decision process of obstetricians and gynecologists.

Does local injury to the endometrium before IVF cycle really affect treatment outcome? Results of a randomized placebo controlled trial

AIM

To evaluate the effect of local injury to the endometrium during spontaneous menstrual cycles before in vitro fertilization (IVF) treatment on implantation and pregnancy rates in women with recurrent implantation failure (RIF).

METHODS

In a prospective randomized controlled trial (RCT), a total of 36 patients, with RIF undergoing IVF, were randomized to two groups. In 18 patients, endometrial biopsies were performed using a pipelle curette on days 9-12 and 21-24 of the menstrual cycle preceding IVF treatment. In 18 control patients, a cervical pipelle was performed.

RESULTS

The implantation rate (2.08% versus 11.11%; p = 0.1), clinical (0% versus 31.25%; p < 0.05) and live births rates (0% versus 25%; p = 0.1) were lower in the experimental group compared with controls.

CONCLUSION

Our RCT did not find any benefit from local injury to the endometrium in women with a high number of RIFs. Further studies are warranted to better define the target population of patients who may benefit from this procedure.