Exposure to the reproductive endocrinology subspecialty among obstetrics and gynecology residency programs

PURPOSE

Prior studies found that Ob-gyn trainees believe they have inadequate experience in the REI subspecialty. We evaluated the amount of time devoted to REI within the 4-year rotation schedule of ACGME-accredited Ob-gyn residency programs.

METHODS

A list of current Ob-gyn residency programs, both with and without REI fellowships, was created using ACOG and ACGME databases. The programs' websites were reviewed, or the program coordinator was queried to determine the length and year of REI rotation, and the career or fellowships pursued by alumni. Wilcoxon rank sum test was utilized to assess differences in total REI rotation time between REI-affiliated and non-affiliated programs. Spearman's correlation was utilized to assess the association between total REI exposure and the percentage of alumni pursuing REI fellowships.

RESULTS

Cumulative length of REI rotations throughout residency ranged from 0 to 20 weeks. Mean cumulative rotation length was greater in non-REI than in REI-affiliated programs (7.4 weeks vs. 6.1 weeks, p = 0.007). However, REI-affiliated programs had greater exposure to REI rotations during the first 2 years of residency (3.9 weeks vs 3.1 weeks, p = 0.042). Among all programs, 24% had the REI rotation in PGY-1, 61% in PGY-2, 50% in PGY-3, and 16% in PGY-4. The proportion of alumni matching in REI fellowship was significantly greater in REI-affiliated programs than non-REI affiliated programs (9.5% vs. 3.1%, p < 0.001).

CONCLUSION

Compared to non-REI affiliated programs, Ob-gyn residencies affiliated with REI fellowships spend less time throughout residency training in REI rotations while sending a greater proportion of residents to REI fellowships.

Psychological distress, vaccine, and booster acceptance in women considering or undergoing fertility treatments during the Omicron surge of the COVID-19 pandemic

OBJECTIVE

Follow-up study to evaluate perceptions of COVID-19 vaccination and booster with psychological distress during the COVID-19 pandemic and Omicron surge in women considering or undergoing fertility treatment.

MATERIALS AND METHODS

Cross-sectional anonymous survey (N = 2558) from a single academic fertility center. Five hundred forty patients completed the survey (response rate = 21.1%). Participants were randomized 1:1 to a one-page evidence-based graphic with information and benefits regarding COVID-19 vaccination. Mental health and vaccine hesitancy were assessed via the Patient Health Questionnaire Depression (PHQ-8), the Generalized Anxiety Disorder (GAD-7) scales, and the Medical Mistrust Index (MMI).

RESULTS

Majority of participants were nulliparous, fully vaccinated with a booster dose, with > 1 year of infertility and mild to moderate distress. Patients with vaccine hesitancy had higher medical mistrust scores (r = .21,  p < .001). Higher MMI scores were not associated with vaccination during pregnancy. Participants that had higher PHQ-8 and GAD-7 scores were more likely to believe the omicron variant would cause delay in fertility treatments, would have impact on fertility outcome, and were more likely exhibiting medical system distrust (p < .001). Participants who received educational material were more likely to know pregnant women with COVID-19 had increased risk of death, stillbirth, and preterm birth (p < .05).

CONCLUSION

The majority of women in this study were vaccinated and had received their booster dose but also with clinically significant levels of depression. Patients with higher levels of distress and greatest medical mistrust demonstrated a concern that the Omicron variant would delay treatment, lead to suboptimal fertility outcomes, and COVID-19 vaccination would impact risk of miscarriages.

Changing the "scope" of diagnosing endometriosis: the new frontier of noninvasive markers

Endometriosis affects 1 in 9 women, and diagnosis is often delayed using conventional laparoscopy. Noninvasive markers of endometriosis have the potential to enable earlier diagnosis, leading to more timely treatment and better surgical planning. This issue's Views and Reviews seek to summarize the current status of noninvasive markers of endometriosis. Experts in reproductive medicine with prior work in this field summarize the key literature on endometrial biomarkers, blood biomarkers, and advanced imaging, including ultrasound and magnetic resonance imaging. At present, there is no single definitive biomarker that can diagnose endometriosis with high sensitivity and specificity. Advancing endometriosis biomarkers beyond the discovery phase is challenging, and more work is needed. Clinicians who have an improved understanding of noninvasive imaging and biomarkers will be able to identify endometriosis earlier and more easily, allowing for prompt consideration of treatment options. We believe that continued research, innovation, and development will lead to improved diagnostic accuracy and guidance toward the best treatments for endometriosis-related pain and infertility.

Avi's Love-The Importance of Abortion Rights for Everyone

This essay describes a physician’s experience with terminating a wanted pregnancy and underscores the importance of access to abortion care.

Do gender differences exist in letters of recommendation for reproductive endocrinology and infertility fellowship?

OBJECTIVE(S)

To determine if gender differences exist in letters of recommendation (LORs) for reproductive endocrinology and infertility fellowship.

DESIGN

Cohort study.

SETTING

Academic medical center.

PATIENTS

A cohort of applicants to a reproductive endocrinology and infertility fellowship program at a single Midwestern academic institution in a single year.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Quantitative measures included linguistics inquiry and word count analysis, with 4 summary variables and 25 word categories, to quantify tone and themes present by gender. Performing qualitative analysis in parallel to linguistic analysis allowed for the exploration of themes not conveyed in quantitative methods alone. Qualitative measures included the frequency of code themes in LOR by applicant gender.

RESULTS

There were 272 letters from 72 applicants, 54 (76%) of which were women and 17 (24%) were men. One applicant was excluded because gender information was not specified; 269 letters were included in the quantitative linguistics and qualitative coding analysis. One hundred 10 letters (41%) were written by women and 159 (59%) by men. LOR written for men had a higher mean word count than those written for women (537 vs. 474, P=.04). Linguistics Inquiry and Word Count analysis exhibited more risk words used to describe men applicants (P=.01). When comparing word categories by letter writer gender, women letter writers more frequently used communal, affect, and home word categories whereas men writers more frequently used affiliation-related words. Qualitative analysis revealed that letters for men applicants described leadership, altruism, rapport with patients, and strong endorsements more frequently, whereas women applicants' letters more often mentioned doubt raisers and disclosures of personal life. In addition, letters for women applicants more often described candidates as drama free, not easy to "fluster," and not complainers. Furthermore, letters for women more frequently disclosed parenthood status.

CONCLUSIONS

Gender differences exist among both letter writers and applicants. Qualitative analysis revealed that women applicants were more likely to be described with doubt raisers and personal life disclosures, whereas men were more likely to be described by their altruism and with a strong endorsement. Increasing bias awareness and implementing mitigation strategies would improve gender equity in LOR.

REI clinics and fellowship training-a national snapshot to improve access to reproductive care

PURPOSE

To analyze the geographic distribution of REI fellowships and clinics across the USA and to strategize ways to improve patient access to care.

METHODS

Cross-sectional study using population data obtained from publicly available United States Census Bureau, Society for Assisted Reproductive Technology (SART), and National Resident Matching Program websites. Outcomes include the number of REI clinics, REI fellowship-trained physicians, and REI fellowship programs.

RESULTS

In 2020, there were 643 assisted reproductive technology (ART) clinics reporting to SART and 1351 fellowship-trained REI physicians. Most clinics are located in the south (n = 209); however, the northeast has the highest density of REI clinics. Out of 301,316 in vitro fertilization (IVF) cycles in the USA in 2020, northeastern states initiated the most cycles (n = 93,565), and Midwestern states initiated the fewest cycles (n = 50,000). The northeast has the most REI physicians per million women aged 20-44 years (42.4) while the Midwest has the lowest ratio (19.5). There are fewer REI physicians per million women aged 20-44 years in states with a lower proportion of patients with health insurance (r = 0.56, 95% confidence interval ([CI] 0.34-0.73) and in states with a lower average income per resident (r = 0.65, 95% CI 0.46-0.79). Most of the 49 accredited REI fellowship programs in the USA are in the northeast (n = 18), and there are fewest in the south (n = 10) and west (n = 10).

CONCLUSION

Access to REI care has large geographic disparities from a clinic, physician, and training program perspective. Creative solutions are needed to remedy this problem.

Validation of prognosis-based in vitro fertilization grant selection criteria

Objective

To validate a prognosis-based scoring system for in vitro fertilization (IVF) grant allocation.

Design

Retrospective cohort study.

Setting

A 501(c)(3) nonprofit foundation that awards donated IVF cycles and grants to those with demonstrated financial need. In contrast to lottery-based or subjective allocation systems, applications are scored according to medical prognostic criteria in addition to personal characteristics.

Patients

Grant recipients from 2015 to 2019.

Interventions

None.

Main outcome measures

Live birth rate (LBR) and cumulative LBR (CLBR) among grant recipients were compared with 2019 Society for Assisted Reproductive Technology (SART) national averages.

Results

A total of 435 applications were reviewed, with 59 grants awarded for 51 autologous IVF cycles, 6 donor oocyte cycles, and 2 gestational carrier cycles, resulting in 39 live births after initial embryo transfer (LBR 61.9%) and 43 CLBRs (CLBR 72.9%). Among autologous cycles, the mean (±SD=3.9 years) age was 31.8 years, and LBR and CLBR were 62.8% and 68.6% vs. 28.2% and 37.1% among all autologous SART cycles, respectively. A subanalysis of grant recipients aged <35 years (n=39) revealed LBR and CLBR of 66.7% and 74.4% vs. 40.7% and 47.8% among autologous SART cycles aged <35 years, respectively.

Conclusions

A scoring system incorporating medical criteria identified IVF grant applicants with a high likelihood of achieving a LB. Although most IVF grant programs select recipients through a lottery or personal characteristics, a prognosis-based scoring system should be considered to maximize LBR in a limited resource setting.

Childbearing, Infertility, and Career Trajectories Among Women in Medicine

Importance

Although women are increasingly represented within medicine, gender disparities persist in time to promotion, achievement of academic rank, and appointment to leadership positions, with no narrowing of this gap over time. Career-specific fertility and family building challenges among women physicians may contribute to ongoing disparities and academic attrition.

Objective

To evaluate delayed childbearing and infertility among women in medicine and investigate the extent to which women physicians may alter career trajectories to accommodate family building and parenthood.

Design, Setting, and Participants

This survey study was conducted among women physicians, with surveys distributed through medical society electronic mailing lists (listserves) and social media from March to August 2022.

Main Outcomes and Measures

Baseline demographic information and fertility knowledge were assessed. Descriptive data on delayed childbearing, infertility, use of assisted reproductive technology, and career alterations to accommodate parenthood were collected. Factors associated with timing of pregnancy and family building regret were assessed using Likert-type scales. Group differences in fertility knowledge, delayed childbearing, infertility, and family building regret were evaluated using χ2 analyses.

Results

A total of 1056 cisgender women (mean [SD] age, 38.3 [7.7] years) were surveyed across level of training (714 attending physicians [67.6%] and 283 residents or fellows [26.8%]), specialty (408 surgical [38.6%] and 638 nonsurgical [60.4%] specialties), and practice setting (323 academic [45.2%], 263 private [24.9%], and 222 community [21.0%] settings). Among respondents, 1036 individuals [98.1%] resided in the US. Overall, 910 respondents (86.2%) were married or partnered and 690 respondents (65.3%) had children. While 824 physicians (78.0%) correctly identified the age of precipitous fertility decline, 798 individuals (75.6%) reported delaying family building and 389 individuals (36.8%) had experienced infertility. Concerning measures taken to accommodate childbearing or parenthood, 199 women (28.8%) said they had taken extended leave, 171 women (24.8%) said they had chosen a different specialty, 325 women (47.1%) said they had reduced their work hours, 171women (24.8%) said they had changed their practice setting, and 326 women (47.2%) said they had passed up opportunities for career advancement among those with children. Additionally, 30 women with children (4.3%) had left medicine entirely.

Conclusions and Relevance

In this survey study, women physicians reported that career-related pressures influenced the timing of childbearing and led to marked alterations to career trajectories to accommodate family building and parenthood. These findings suggest that fertility and family building concerns among women in medicine may contribute to ongoing gender disparities and attrition and represent a potentially critical area for policy reform and future change.

Anxiety, attitudes, and education about fertility among medical students in the United States

BACKGROUND

As delayed family building is common among physicians, the goal of this study was to evaluate childbearing plans, anxiety related to future fertility, and interest in fertility education among medical students.

METHODS

Using convenience and snowball sampling methods, an electronic REDCap survey was distributed via social media and group messaging applications to medical students enrolled in medical schools across the United States. Answers were collected, and analysis of the descriptive statistics was performed.

RESULTS

The survey was completed by 175 participants, 72% of which were female (assigned at birth). The mean (± SD) age of participants was 24.9 ± 1.9 years. Of all participants, 78.3% desire to have children and 65.1% of these individuals plan to delay childbearing. On average, the planned age of first pregnancy is 31.0 ± 2.3 years. "Lack of time" was the greatest influence on decision regarding timing of childbearing. Of all respondents, 58.9% reported at least some anxiety related to future fertility. When females and males were compared, significantly more females (73.8%) versus males (20.4%) reported worrying about future fertility (p < 0.001). Participants reported that greater knowledge about infertility and potential treatments would help ease fertility related anxiety, and 66.9% of respondents showed interest in learning about how things such as age and lifestyle can impact fertility, preferably through medical curricula, videos, and podcasts.

CONCLUSION

A majority of the medical students in this cohort intend to have children and most plan to delay childbearing. A large percentage of female medical students reported anxiety related to future fertility, but many students showed interest in receiving fertility education. This study highlights an opportunity for medical school educators to incorporate targeted fertility education into their curriculum with the intention of decreasing anxiety and improving future reproductive success.

A SART data cost-effectiveness analysis of planned oocyte cryopreservation versus in vitro fertilization with preimplantation genetic testing for aneuploidy considering ideal family size

OBJECTIVE

To determine the cost-effectiveness of planned oocyte cryopreservation (OC) as a strategy for delayed childbearing to achieve 1 or 2 live births (LB) compared with in vitro fertilization (IVF) and preimplantation genetic testing for aneuploidy (PGT-A) at advanced reproductive age.

DESIGN

Decision tree model with sensitivity analyses using data from the Society for Assisted Reproductive Technology Clinical Outcome Reporting System and other clinical sources.

SETTING

Not applicable.

PATIENT(S)

A data-driven simulated cohort of patients desiring delayed childbearing with an ideal family size of 1 or 2 LB.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Probability of achieving ≥1 or 2 LB, average and maximum cost per patient, cost per percentage point increase in chance of LB, and population-level cost/LB.

RESULT(S)

For those desiring 1 LB, planned OC at age 33 with warming at age 43 decreased the average total cost per patient from $62,308 to $30,333 and increased the likelihood of LB from 50% to 73% when compared with no OC with up to 3 cycles of IVF/PGT-A at age 43. For those desiring 2 LB, 2 cycles of OC at age 33 and warming at age 40 yielded the lowest cost per patient and highest likelihood of achieving 2 LB ($51,250 and 77%, respectively) when compared withpursuing only 1 cycle of OC ($75,373 and 61%, respectively), no OC and IVF/PGT-A with embryo banking ($79,728 and 48%, respectively), or no OC and IVF/PGT-A without embryo banking ($79,057 and 19%, respectively). Sensitivity analyses showed that OC remained cost-effective across a wide range of ages at cryopreservation. For 1 LB, OC achieved the highest likelihood of success when pursued before age 32 and remained more effective than IVF/PGT-A when pursued before age 39, and for 2 LB, 2 cycles of OC achieved the highest likelihood of success when pursued before age 31 and remained more effective than IVF/PGT-A when pursued before age 39.

CONCLUSION(S)

Among patients planning to postpone childbearing, OC is cost-effective and increases the odds of achieving 1 or 2 LB when compared with IVF/PGT-A at a more advanced reproductive age.

Embryo transfer-the who, what, when, how, and why does it matter?

Embryo transfer is the ultimate step in the in vitro fertilization process and is the culmination of months to years of preparation. Many factors contribute to embryo transfer success before, during, and after the transfer. This series is a comprehensive review of the factors that converge to influence embryo transfer success. Robust discussion is included regarding the impact of the physician who performs the transfer, adjunct therapies used, timing of embryo transfer, endometrial receptivity, and resultant health of the pregnancy and offspring.

Data-driven commentary on SARS-CoV-2 infection, vaccination, and fertility

A recent study by Wesselink et al. (Am J Epidemiol. 2022 Jan 20;kwac011. doi: 10.1093/aje/kwac011. Online ahead of print) adds to the growing body of research finding that vaccination for coronavirus disease 2019 (COVID-19) is safe for individuals either seeking pregnancy or who are pregnant. The study's authors found no effect of COVID-19 vaccination on fecundity in a population of individuals with no known infertility who were attempting conception. The finding reinforces the messaging of the American Society for Reproductive Medicine COVID-19 Task Force, the aim of which is to provide data-driven recommendations to individuals contemplating pregnancy in the face of the COVID-19 pandemic. As safe and effective COVID-19 vaccines became available, and with an increasing number of studies showing a heightened risk of severe disease during pregnancy, an important role of the Task Force is to encourage vaccination during the preconceptual window and in early pregnancy. The Task Force supports ongoing research to address gaps in knowledge about safe and effective therapies and preventive measures for individuals contemplating pregnancy and during pregnancy. Such research will help optimize care for reproductive-age individuals in the face of current and future health crises.

Data-Driven Commentary on SARS-CoV-2 Infection, Vaccination, and Fertility

A recent study by Wesselink et al. (Am J Epidemiol. 2022;191(8):1383-1395) adds to the growing body of research finding that vaccination for coronavirus disease 2019 (COVID-19) is safe for individuals either seeking pregnancy or who are pregnant. The study's authors found no effect of COVID-19 vaccination on fecundity in a population of individuals with no known infertility who were attempting conception. The finding reinforces the messaging of the American Society for Reproductive Medicine COVID-19 Task Force, the aim of which is to provide data-driven recommendations to individuals contemplating pregnancy in the face of the COVID-19 pandemic. As safe and effective COVID-19 vaccines became available, and with an increasing number of studies showing a heightened risk of severe disease during pregnancy, an important role of the Task Force is to encourage vaccination during the preconceptual window and in early pregnancy. The Task Force supports ongoing research to address gaps in knowledge about safe and effective therapies and preventive measures for individuals contemplating pregnancy and during pregnancy. Such research will help optimize care for reproductive-age individuals in the face of current and future health crises.

Knowledge of Fertility and Perspectives About Family Planning Among Female Physicians

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Reduction of Heavy Menstrual Bleeding in Women Not Designated as Responders to Elagolix Plus Add Back Therapy for Uterine Fibroids

Objective: To assess outcomes of women with uterine fibroids (UFs) and heavy menstrual bleeding (HMB) treated with 300 mg elagolix twice daily plus add-back therapy (E2 1 mg/NETA 0.5 mg once daily) or placebo who were not considered responders in pooled analysis of two phase 3, 6-month randomized clinical trials (Elaris UF-1 and UF-2). Methods: Responders were defined as women who met both primary end point bleeding criteria (<80 mL menstrual blood loss [MBL] during the final month and ≥50% reduction in MBL from baseline to the final month) and either completed the study or discontinued due to predefined reasons. Thus, women termed nonresponders who were analyzed in this study who met neither or one bleeding end point or met both criteria but prematurely discontinued treatment because of adverse events, perceived lack of efficacy, or required surgical or interventional treatment for UFs were analyzed in this study. This post hoc analysis assessed mean changes from baseline in MBL, as well as adverse events. Results: Among 367 women receiving elagolix with add-back with observed data, 89 (24%) were not considered responders. Within this subset, 17 (19%) women met both bleeding criteria but prematurely discontinued treatment for the reasons mentioned above, while 23 (26%) met one bleeding criterion and 49 (55%) met neither bleeding criteria, regardless of discontinuation status. Among all nonresponders, a numerical trend toward greater mean reductions in MBL was observed in those receiving elagolix with add-back, compared with placebo group nonresponders. No differences in adverse events were observed between responders and nonresponders. Conclusion: Forty of 89 (45%) women with HMB and UFs who were classified as nonresponders in the UF-1 or UF-2 trials may have had a clinically meaningful response to elagolix with add-back therapy because they met at least one of the objective bleeding criteria. Clinical Trial Registration: Clinicaltrials.gov, NCT02654054 and NCT02691494. (NEJM 2020; 382:328-340) DOI: 10.1056/NEJMoa1904351.

Coronavirus disease 2019, reproductive health, and public policy: lessons learned after two years of the ongoing pandemic—the American Society for Reproductive Medicine’s Center for Policy and Leadership

Objective

To describe the experience of the ASRM COVID-19 Task Force over the past 2 years and to discuss lessons learned during the pandemic that can be applied to future public health crises.

Design

Descriptive narrative.

Subjects

None.

Intervention

Creation of the ASRM COVID-19 Task Force in March 2020.

Main Outcome Measures

None.

Results

Effective pandemic management requires a joint effort on the part of physicians, scientists, government agencies, subject area experts and funders.

Conclusion

Reproduction is a fundamental human right that should be protected at all times. Advanced preparation for future pandemics should include appointment of a standing group of experts so that a response is both informed and immediate when a public health crisis arises. This approach will help ensure that the ultimate objective – preserving the safety and well-being of patients and health care workers – is fulfilled. The recommendations put forth in this paper from the ASRM’s Center for Policy and Leadership can be used as a template to prepare for future public health threats.

Planting the seed of doubt: the diagnosis and management of mosaic embryos

This month's Views and Reviews focuses on different aspects of the diagnosis of mosaicism. The first piece was written by Treff and Marin, who discuss the methodologic challenges of preimplantation genetic testing for aneuploidies and how the diagnosis of "mosaic" has led to a significant reduction in the accuracy of such testing. The second article by Viotti et al. provides an excellent overview of outcome data from >1,000 mosaic embryo transfers. The investigators make a strong case for three categorizations of embryos: euploid, aneuploid, and mosaic, and that use of mosaic embryos will prevent the discard of embryos that may lead to live birth. The final piece in this series was written by Besser et al., who discussed the various society recommendations for genetic counseling and prenatal diagnostic testing after mosaic embryo transfer and question whether these are truly data-driven. This collection of pieces will give the reader a deeper understanding of the controversy and management of mosaic embryo transfer.

Planned oocyte cryopreservation in women with blepharophimosis-ptosis-epicanthus inversus syndrome: a case series

Objective

To describe the experiences of three women with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) who desired to pursue planned oocyte cryopreservation.

Design

Case series.

Setting

An academic institution and a private clinic.

Patient(s)

Three nulligravid women aged 23, 25, and 34 years who desired to pursue planned oocyte cryopreservation. Two women had BPES diagnosed when they were infants and one had BPES diagnosed after presenting to discuss oocyte cryopreservation.

Intervention(s)

All three women underwent ovarian stimulation. One woman underwent three oocyte retrievals.

Main Outcomes Measure(s)

Vitrification of metaphase II oocytes.

Result(s)

One woman had a total of eight metaphase II oocytes vitrified. In addition, she underwent genetic testing that confirmed type 1 BPES. The other two women, who had BPES diagnosed when they were newborns, each underwent two cycles of ovarian stimulation. Neither of these two women responded to ovarian stimulation and both cycles were cancelled before oocyte retrieval.

Conclusion(s)

BPES is a rare condition that can lead to primary ovarian insufficiency. Early identification of this condition is important to allow for timely reproductive counseling so that oocyte cryopreservation can be offered at a young age before oocyte depletion. Careful counseling is critical for these patients, because this case series demonstrated that not all women with BPES will respond to stimulation. Further, outcomes with cryopreserved oocytes have not yet been described in women with BPES.

Psychological distress and postponed fertility care during the COVID-19 pandemic

Purpose

To evaluate perceptions of delayed fertility care secondary to the COVID-19 pandemic.

Methods

This was a cross-sectional anonymous survey of N = 787/2,287 patients (response rate = 42.6%) from a single academic fertility center. Participants were randomized 1:1 to receive supplemental educational explaining the rationale behind recommendations to delay fertility treatments due to the COVID-19 pandemic. Assessment of well-being was conducted via the Personal Health Questionnaire Depression Scale, the Generalized Anxiety Disorder-7, the Ways of Coping-Revised, the Appraisal of Life Events Scale, and influence of supplemental education on agreement with ASRM COVID-19 Taskforce recommendations and associated distress.

Results

Participants in the education v. no education groups were 35.51 (SD = 4.06) and 37.24 (SD = 5.34) years old, married (90.8% v. 89.8%), had a graduate degree (53.9% v. 55.4%), > 1 year of infertility (73.4% v. 74.4%), and were nulliparous (69.0% v. 72.6%), with moderate to high distress (64.9% v. 64.2%) (ns). Distress was related to age, duration of infertility, and engagement in social support seeking and avoidant coping strategies (P < 0.001). Agreement with recommendations was related to receipt of supplemental education, history of pregnancy loss, and use of cognitive coping (P = 0.001).

Conclusion

Most participants were distressed by the delay of treatments. Supplemental education increased acceptance of recommendations but did not decrease distress. Future treatment delays should include education related to and assessment of understanding of recommendations, and inclusion of mental health professionals in patient care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10815-020-02023-x.

Novel ploidy analysis in ectopic pregnancy

Objective

To study whether a single-nucleotide polymorphism (SNP) array could be used to test tissue from ectopic pregnancy to distinguish whether ectopic pregnancies were aneuploid.

Design

Case series report.

Setting

Academic medical center.

Patients

One hundred seventy-eight women who underwent surgery for ectopic pregnancy at Northwestern Memorial Hospital between 2015 and 2018 were eligible for participation; written consent was obtained from 33 patients. Eight subjects had sufficient DNA samples and were included in the analysis. Maternal and paternal DNA samples were self-collected by buccal swab. Archived paraffin tissue containing chorionic villi from each surgically removed ectopic specimen was analyzed using SNP microarray technology to determine chromosome number and evaluate for maternal cell contamination.

Interventions

None.

Main Outcome Measures

Prevalence of aneuploidy in ectopic pregnancy specimens as well as success of SNP array technology in formalin-fixed and paraffin-embedded specimens.

Results

Subjects had a mean (±SD) age of 33.4 ± 5.4 years, body mass index of 23.4 ± 5.7 kg/m², 3.3 ± 1.8 prior pregnancies, and 1.5 ± 1.4 live births. Genetic testing revealed that all eight tested samples were euploid, 6 female and 2 male (two arr(1-22)x2, (X,Y)x1 and 6 arr(1-22, X)x2); maternal cell contamination was ruled out in all cases.

Conclusions

This study showed proof of concept for the use of routinely stored formalin-fixed, paraffin-embedded tissue blocks with DNA extraction for SNP array to detect ploidy status of ectopic pregnancy. Although all tested samples were euploid, further research is needed to gain a definitive answer to this question and better understand the mechanism that leads to ectopic implantation.

Knowledge gaps in the understanding of fertility among non-medical graduate students

Objective

To assess knowledge of female and male fertility among students enrolled in a Master of Business Administration (MBA) program.

Design

Web-based cross-sectional survey.

Setting

Academic setting.

Patient(s)

Not applicable.

Intervention(s)

None.

Main Outcome Measure(s)

Knowledge of how female and male age impacts reproduction, fecundability, and success rates with in vitro fertilization (IVF).

Result(s)

A total of 133 female and male MBA students completed the survey. Nearly 10% of participants were not aware that women are born with a fixed number of oocytes and that oocyte quantity and quality decline with age. More than 30% of participants overestimated fecundability in women aged ≥35 years, and >50% overestimated IVF success rates in women older than 40 years. Fifteen percent of participants did not know that men have stem cells in the testes, and >25% were not aware that men experience a decrease in sperm concentration and quality with age. Nearly 30% believed that a man’s age never impacts reproductive outcomes. Less than 30% of participants correctly estimated fecundability and IVF success rates based on male age.

Conclusion(s)

These data highlight important knowledge gaps in a highly educated group of MBA students, most whom desire future childbearing. Specifically, there is a lack of understanding of both male and female reproductive aging and an overestimation of treatment success. As delayed childbearing continues, particularly among those with high educational attainment, attention should be focused on introducing broad fertility education at a younger age to improve future reproductive success.

Time for sperm eg(g)alitarianism?

The demand for certainty is one which is natural to man, but is nevertheless an intellectual vice -Bertrand Russell.

Prior and novel coronaviruses, Coronavirus Disease 2019 (COVID-19), and human reproduction: what is known?

OBJECTIVE

To summarize current understanding of the effects of novel and prior coronaviruses on human reproduction, specifically male and female gametes, and in pregnancy.

DESIGN

Review of English publications in PubMed and Embase to April 6, 2020.

METHOD(S)

Articles were screened for reports including coronavirus, reproduction, pathophysiology, and pregnancy.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Reproductive outcomes, effects on gametes, pregnancy outcomes, and neonatal complications.

RESULT(S)

Seventy-nine reports formed the basis of the review. Coronavirus binding to cells involves the S1 domain of the spike protein to receptors present in reproductive tissues, including angiotensin-converting enzyme-2 (ACE2), CD26, Ezrin, and cyclophilins. Severe Acute Respiratory Syndrome Coronavirus 1 (SARS-CoV-1) may cause severe orchitis leading to germ cell destruction in males. Reports indicate decreased sperm concentration and motility for 72-90 days following Coronavirus Disease 2019 (COVID-19) infection. Gonadotropin-dependent expression of ACE2 was found in human ovaries, but it is unclear whether SARS-Coronavirus 2 (CoV-2) adversely affects female gametogenesis. Evidence suggests that COVID-19 infection has a lower maternal case fatality rate than SARS or Middle East respiratory syndrome (MERS), but anecdotal reports suggest that infected, asymptomatic women may develop respiratory symptoms postpartum. Coronavirus Disease 2019 infections in pregnancy are associated with preterm delivery. Postpartum neonatal transmission from mother to child has been reported.

CONCLUSION(S)

Coronavirus Disease 2019 infection may affect adversely some pregnant women and their offspring. Additional studies are needed to assess effects of SARS-CoV-2 infection on male and female fertility.

Elagolix Suppresses Ovulation in a Dose-Dependent Manner: Results From a 3-Month, Randomized Study in Ovulatory Women

CONTEXT

Elagolix is an oral gonadotropin-releasing hormone (GnRH) antagonist recently approved for the treatment of endometriosis-associated pain and being developed for heavy menstrual bleeding associated with uterine fibroids.

OBJECTIVE

The objective was to evaluate the effects of elagolix on ovulation and ovarian sex hormones.

DESIGN AND SETTING

This was a randomized, open-label, multicenter study.

PARTICIPANTS

Participants were healthy ovulatory women aged 18 to 40 years.

INTERVENTIONS

Elagolix was administered orally for 3 continuous 28-day dosing intervals at 100 to 200 mg once daily (QD), 100 to 300 mg twice daily (BID), and 300 mg BID plus estradiol/norethindrone acetate (E2/NETA) 1/0.5 mg QD.

MAIN OUTCOME MEASURES

The main outcomes measures were ovulation rates measured by transvaginal ultrasound, progesterone concentrations, and hormone suppression.

RESULTS

Elagolix suppressed ovulation in a dose-dependent manner. The percentage of women who ovulated was highest at 100 mg QD (78%), intermediate at 150 and 200 mg QD and 100 mg BID (47%-57%), and lowest at 200 and 300 mg BID (32% and 27%, respectively). Addition of E2/NETA to elagolix 300 mg BID further suppressed the ovulation rate to 10%. Elagolix also suppressed luteinizing hormone and follicle stimulating hormone in a dose-dependent manner, leading to dose-dependent suppression of estradiol and progesterone. Elagolix had no effect on serum biomarker of ovarian reserve, and reduced endometrial thickness compared to the screening cycle.

CONCLUSION

Women being treated with elagolix may ovulate and should use effective methods of contraception. The rate of ovulation was lowest with elagolix 300 mg BID plus E2/NETA 1/0.5 mg QD.

Embryo through the lens: from time-lapse cinematography to artificial intelligence

"Once a new technology rolls over you, if you're not part of the steamroller, you're part of the road." -Stewart Brand.