Chances Of Natural Conception Research Articles

ANTI-MÜLLERIAN HORMONE LEVELS ARE ASSOCIATED WITH CHANCE OF NATURAL CONCEPTION

ANTI-MÜLLERIAN HORMONE LEVELS ARE ASSOCIATED WITH CHANCE OF NATURAL CONCEPTION

P-450 Prediction models for estimating treatment independent conception in unexplained infertility – a systematic review

Abstract Study question What are the best prediction models which can estimate the chance of natural conception in couples with unexplained infertility? Summary answer The best quality clinical prediction models were those generated by Hunault et al (2004), Van Eekelen et al (2017) and McLernon et al. (2019). What is known already Although couples with unexplained infertility have a chance of natural conception, a formal estimate of prognosis is not part of routine clinical decision making in most settings. In the UK, NICE recommends IVF after two years of unexplained infertility in all couples, regardless of their individual chances of conception without treatment. This approach risks overtreatment for some whilst delaying access to IVF for others. Since the last systematic review on this topic 10 years ago, several models which aim to predict natural conception in infertile couples have been published, but few are in routine clinical use Study design, size, duration We searched OVID MEDLINE, OVID EMBASE, and OVID PsycINFO systematically for primary articles published between 1978 and 2022, reporting on the development and/or validation of models in predicting spontaneous conception, pregnancy, or live birth. No language or any other restrictions were applied. Participants/materials, setting, methods We included couples with unexplained infertility / those with no major barriers to natural conception. Women who underwent any form of fertility treatment immediately after the initial diagnostic work up were excluded. The methodological quality of the included papers was assessed using criteria within the CHARMS checklist. Risk of bias was evaluated using the PROBAST tool while discrimination and calibration results, which rate the performance of the prediction model, were also reported. Main results and the role of chance Eighteen publications reported on 23 prediction models with natural conception, pregnancy, ongoing pregnancy and live birth as outcomes. Of 11 studies involving model development, internal and external validation were reported in 4 and 2 publications respectively . Two studies published extended versions of the same model (Hunault et al, 2004) while 3 studies focussed on independent validation of existing models. The methodological rigour of the models has improved over time, as demonstrated by accuracy measures including discrimination and calibration. Three models (Hunault et al, 2004, Van Eekelen et al, 2017, and McLernon et al, 2019) had low risk of bias. The static Hunault model can be used to determine the chance of conception at a single point in time – usually at the conclusion of the initial fertility work up, whereas the Van Eekelen and McLernon models are dynamic models that can estimate chances of conception at different time points. The discriminatory ability of models ranged between 0.59-0.64 in the internal validation and external validation studies. The calibration slope for the Hunault’s static model was 0.6 to 1.0 and for the dynamic models it ranged from 0.62 to 1.01 for Van Eekelen’s model and 0.65to 1.06 for McLernon’s model. Limitations, reasons for caution The quality of prediction models which predated the CHARMS checklist and PROBAST tool could not be adequately assessed. The population with most models went beyond unexplained infertility and included other couples with a chance of natural conception e.g. mild male infertility and minimal endometriosis. Wider implications of the findings Of the 3 models which are of high quality, the Hunault model can only be used once but the Van Eekelen and McLernon models have the potential to be used more flexibly, following further external validation in different settings and larger populations. Trial registration number not applicable

A NUTTY CASE: RARE PRESENTATION OF ALLERGIC VAGINITIS

<h3>Introduction</h3> This case describes a female patient with a history of IgE-mediated anaphylaxis to peanut and tree nuts with a new complaint of vaginitis after male ejaculation during intercourse. Her symptoms resolved with targeted food elimination from her partner's diet. This case demonstrates the importance of an expanded differential for vaginitis, including allergic causes. <h3>Case Description</h3> A 28-year-old female with an atopic history presented with vaginal pain and burning after male ejaculation during intercourse, reducing her chance of natural conception. She notably tolerated intercourse both without male ejaculation and with male ejaculation while using a condom. Gynecologic testing for infectious etiologies was normal, prompting evaluation for human seminal plasma (HSP) hypersensitivity. Given her known history of IgE-mediated allergy to peanut and tree nuts, it was recommended they trial intercourse after a period of targeted food elimination for her partner. The patient was subsequently able to tolerate male ejaculation during intercourse without vaginitis symptoms. <h3>Discussion</h3> Although Type IV hypersensitivity reactions exceed Type I in most cases of allergic vaginitis, it is important to consider the numerous antigens within seminal fluid that may cause hypersensitivity. This includes not only HSP but also food allergens, posing an increased risk for reactions in patients with a history of IgE-mediated food allergy in the context of allergen exposure from the seminal fluid of their sexual partners. Furthermore, targeted food elimination from the male partner's diet may provide an effective means allowing for intercourse without subsequent hypersensitivity.

O-058 The impact of endometriosis on fertility treatment

Abstract Abstract text Endometriosis can affect natural fertility by distorting pelvic anatomy and by causing local pelvic inflammation that affects the quality of the oocytes, the function of the tubes and the sperm capacity to fertilize. Two approaches can be foreseen, either removing the disease with the aim of restoring normality (surgery) or overcoming the disease by retrieving oocytes in the ovary and allowing their fertilization in in vitro conditions (IVF). Both therapeutic approaches seem rational and wise. However, despite this apparently simple clinical scenario, management of endometriosis-related infertility has engendered long-lasting and burning debates over the last two decades and, to date, no consensus has been reached. Robust scientific evidence is scant, actually limited to the demonstration that laparoscopy modestly increases the chance of natural conception. In this debate, it is noteworthy that chances of pregnancy do not represent the unique stake. Other factors can play a role and deserves consideration. Considering the choice of fertility treatment, he most relevant are the following: 1) the impact of ovarian endometriomas and their removal on ovarian responsiveness, 2) the impact of endometriomas and endometriosis in general on oocytes quality, 3) the additional risks of oocytes retrieval in the presence of endometriosis (infections in particular) 4) the detrimental effects of endometriosis-related hydrosalpinx, 5) the impact of endometriosis on uterine motility and endometrial receptivity, 5) the confounding effect of endometriosis-associated adenomyosis. Unfortunately, for the vast majority of these concerns, evidence is not definite and physicians have to take decisions based on their clinical commonsense.

O-207 Which infertile patients mostly deserve to have a sperm DNA fragmentation index done? Findings from a cross-sectional study

Abstract Study question Current scientific guidelines do not clearly suggest which patients would benefit the most from a sperm DNA fragmentation (SDF) test. Summary answer We aimed to investigate potential predictive factors for altered SDF in a homogenous cohort of white-European men presenting for primary couple’s infertility. What is known already High SDF has been associated with reduced fertilization rates, reduced chances of natural conception and an increased risk of early pregnancy loss. Study design, size, duration Data from 478 consecutive men with normal or altered SDF were analysed. Infertility was defined according to the WHO criteria. Semen analysis, SDF (according to SCSA) and serum hormones were measured in every patient. Health significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Altered SDF was considered with a threshold of &amp;gt; 30%. Participants/materials, setting, methods Descriptive statistics compared the overall characteristics of patients with normal SDF and altered SDF. Logistic regression analysis tested potential predictors of altered SDF. ROC curve was used to test the accuracy of the model in predicting SDF alteration Main results and the role of chance Of 478 patients, 253 (57.7%) had altered SDF. Median (IQR) age and BMI of the whole cohort were 38 (35-42) years and 25.1 (23.3-27.1) kg/m2 respectively. Patients with altered SDF were older (median (IQR) age: 39 (36-43) vs. 37 (34-38) years, p &amp;lt; 0.0001), had lower sperm concentration (5 (1.1–18) vs. 17 x106/mL (6–38.8), p &amp;lt; 0.0001), testicular volume (15.1 (12 –20) vs. 16.8 (12 – 25) Prader, p = 0.0005), and total motile sperm count (TMSC) (1.8 (0.21–10.71) vs. 11.8x106 (2–37.26), p &amp;lt; 0.0001). Conversely, men with altered SDF had higher FSH (6.1 (3.85–9.7) vs. 4.8 (3.85 – 7.9) mIU/mL, p &amp;lt; 0.0001) and prolactin levels (9.8 (7.43–14.04) vs. 8.3 (6.6–11.3) pg/mL, p = 0.0004) than those with normal SDF. At multivariable logistic regression analysis, patients’ age &amp;gt;35 years (OR: 2.45, p = 0.0009), FSH &amp;gt; 8.0 mIU/mL (OR: 2.23, p &amp;lt; 0.0001) and lower TMSC (OR: 2.04, p = 0.002) were identified as indipendent predictors of altered SDF, after adjusting for testicular volume and CCI≥1. ROC curve (Figure 1) revealed that the model has a good predictive ability to identify patients with SDF alteration (AUC: 0.72, 95%CI: 0.67 - 0.77). Limitations, reasons for caution It is a retrospective analysis at a single, tertiary-referral academic centre, thus raising the possibility of selection biases. In spite of this, all patients have been consistently analysed over time with a rigorous follow-up, thus limiting potential heterogeneity in terms of data reporting Wider implications of the findings Primary infertile men older than 35 years, with high serum FSH and low TMSC at baseline are the ones who mostly deserve a SDF test over their diagnostic work-up and that would potentially benefit the most of certain treatments to improve SDF value, thus increasing chances of conceiving. Trial registration number Not applicable

Male factor infertility in the Comprehensive Procreational Health Protection Program at the University Hospital in Cracow.

Quality of semen is one of the most important factors contributing to couples' chance of natural conception. There are many confirmed or potential factors that influence semen analysis results. To estimate the incidence and analyze male factor infertility. The retrospective observational study was in the Clinical Department of Gynecological Endocrinology and Gynecology, University Hospital in Krakow. The study included men from subfertile population, aged ≥ 18 years, without prior diagnosis and obvious cause of infertility, whose initial seminograms were used to characterize the population. Seminograms of men remaining in the follow-up were used to analyze the variability of sperm parameters in relation to lifestyle modification and the use of fertility supplements containing antioxidants. Control semen tests were performed at 1-3-month intervals. The study included 870 men. In 68.5% of men, at least one abnormal sperm parameter was found and 40.7% had complex sperm abnormalities. Averaged values of sperm parameters of men from subfertile couples were within the WHO reference ranges, except for the normal morphology, whose median was 3.8%. No significant differences in the selected sperm parameters after the implementation of conservative management were observed. The percentage of pregnancies not resulting from IVF in the follow-up population was 7.7%. One semen sample is representative of an individual in the diagnostics of male infertility. Expectant management and lifestyle modification should not be proposed as first-line treatment when more effective procedures are available.

Efficacy of assisted reproductive technology after ovarian tissue transplantation in a cohort of 11 patients with or without associated infertility factors.

IVF treatment in women with grafted frozen-thawed ovarian tissue is associated with poor reproductive outcomes. The aim of this study was to evaluate the efficacy of ovarian tissue transplantation (OTT) followed by assisted reproductive technology (ART) in women with or without associated infertility factors. This is a prospective cohort study with retrospective data collection including eleven women, four of whom having an infertility factor (IF), who had undergone OTT in one university center between 2005 and 2017, followed by ART in six in vitro fertilization (IVF) centers. In total, 25 of the 85cycles initiated (29%) were canceled, resulting in 60 oocyte retrievals. Ninety-five oocytes were retrieved: 36 were abnormal or immature, 29/39 fertilized (74%) after ICSI and 13/20 (65%) after IVF. Thirty-five embryos were transferred in seven patients (5/7 patients without IF and 2/4 patients with IF). After ART, one patient with IF experienced two pregnancies, one resulting in a live birth. For all patients, pregnancy rates and live birth rates were 7.4% and 3.7% per embryo transfer, respectively. Nine pregnancies and four live births occurred after spontaneous conception in five patients without IF, none in the infertility group. This study confirms that IVF treatment in women with grafted frozen-thawed ovarian tissue is associated with poor outcomes. However, the chances of natural conception are high in women without IF. Patients with IF, without the possibility of spontaneous pregnancy, should be informed of poor reproductive outcomes after OTT followed by ART. NCT02184806.

L-carnitine and l-acetylcarnitine supplementation for idiopathic male infertility.

SummaryFifteen percent of couples are globally estimated to be infertile, with up to half of these cases attributed to male infertility. Reactive oxidative species (ROS) are known to damage sperm leading to impaired quantity and quality. Although not routinely assessed, oxidative stress is a common underlying pathology in infertile men. Antioxidants have been shown to improve semen analysis parameters by reducing ROS and facilitating repair of damage caused by oxidative stress, but it remains unclear whether they improve fertility. Carnitines are naturally occurring antioxidants in mammals and are normally abundant in the epididymal luminal fluid of men. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of carnitine supplementation for idiopathic male infertility. We searched ClinicalKey, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, PubMed and ScienceDirect for relevant studies published from 1 January 2000 to 30 April 2020. Of the articles retrieved, only eight randomised controlled trials were identified and included. Analysis showed that carnitines significantly improve total sperm motility, progressive sperm motility and sperm morphology, but without effect on sperm concentration. There was no demonstrable effect on clinical pregnancy rate in the five studies that included that outcome, although patient numbers were limited. Therefore, the use of carnitines in male infertility appears to improve some sperm parameters but without evidence of an increase in the chance of natural conception.Lay summaryAlthough male infertility affects 1:15 men, there is no obvious reason in the vast majority of cases. Reactive oxidative species (ROS) are highly active molecules containing oxygen and are natural byproducts of normal metabolism. However, high concentrations of ROS have been shown to damage sperm, which negatively impacts a couple’s ability to conceive. Carnitines are natural antioxidants found in the body that counterbalance the damaging effects of ROS. We conducted a comprehensive review of published studies to assess whether carnitine supplements are safe and effective in improving sperm quality and pregnancy rates. Our analysis shows that carnitines improve sperm swimming and production of normal-shaped sperm cells but do not affect sperm count or pregnancy rates, although there are only a few studies and scientific evidence is limited. Whilst it is possible that carnitines may benefit male infertility, more evidence is required regarding chances of pregnancy after carnitine therapy.

The stepwise development of an interactive web-based sex education programme for subfertile couples: the Pleasure & Pregnancy programme.

Can we develop a web-based sex education programme (programme running in a web browser) that addresses the needs of subfertile couples who are advised expectant management for at least 6 months? The 'Pleasure & Pregnancy' programme addresses couples' needs, is likely to improve couples' sexual functioning, and is subsequently hypothesised to improve the chance of natural pregnancy. According to professional guidelines (e.g. the Netherlands and UK) couples with unexplained subfertility and a good chance of natural pregnancy, should be advised at least 6 months of expectant management. Adherence to expectant management is challenging as couples and gynaecologist prefer a more active approach. Targeting sexuality may be useful as subfertility is a risk factor for decreased sexual functioning. A novel programme was developed according to the three steps of the Medical Research Councils' (MRC) framework. First, relevant literature was explored. Second, an interdisciplinary expert panel developed a theory (based on a systematic literature review and patient interviews) on how the chance of natural conception can be improved. Third, the expected process and outcomes were modelled. Two licenced clinical sexologists, two gynaecologists, a clinical embryologist and two midwife-researchers, all from Belgium and the Netherlands, proposed components for the sex education programme. PubMed was searched systematically for randomised controlled trials (RCTs) evaluating the proposed components in different patient populations. The needs of 12 heterosexual Dutch or Belgian couples who were advised expectant management were explored with in-depth interviews. The content and delivery characteristics of the novel programme were described in detail with the aid of 'Intervention Taxonomy'. To model the outcomes, a protocol for an RCT was designed, registered and submitted for publication. To help maintain or improve sexual functioning, mainly pleasure, and hence increase pregnancy rates, the web-based Pleasure & Pregnancy programme contains a combination of psychosexual education and couple communication, mindfulness and sensate focus exercises. Information on the biology of conception and interaction with fertility clinic staff and peers were added based on couples' needs to increase potential acceptability. This paper outlines the development phase of a sex education programme according to the MRC-framework. Whether the Pleasure & Pregnancy programme actually is acceptable, improves sexual functioning, increases pregnancy rates and is cost-effective remains to be determined. No previous interactive web-based sex education programme has aimed to increase the natural pregnancy rate of subfertile couples by targeting their sexual pleasure. The Pleasure & Pregnancy programme addresses couples' needs and its effect on sexual functioning and pregnancy rate is plausible but remains to be demonstrated by an RCT which is currently ongoing. Funding was provided by The Netherlands Organisation for Health Research and Development (ZonMw), Flanders Research Foundation and the University of Amsterdam. C.B.L. is editor-in-chief of Human Reproductionbut was blinded to all parts of the peer review process. The remaining authors have no conflict of interest to report. Not applicable.

Sperm DNA fragmentation is a necessity for modern clinical practice

According to world statistics, 15 % of married couples do not reach pregnancy within one year and seek medical help. At the same time, an important component of the complex problem of infertility, in addition to not getting pregnant, are also pregnancy losses. According to modern ideas, one of the reasons for termination of pregnancy is sperm DNA fragmentation (SDF). According to the European Association of Urology guidelines on male infertility, SDF reduces the chances of natural conception and increases the risk of pregnancy loss. In the European Society of Human Reproduction and Embryology guideline on the management of recurrent pregnancy loss, the definition of SDF is recommended in the algorithm for examining a couple after a single episode of miscarriage. The causes, mechanisms and approaches to correcting increased SDF are the subject of active research; according to PubMed, more than 2,500 papers have been published on this problem to date. Given the huge amount of factual material, the purpose of this review is to highlight the key points of etiology, pathogenesis and approaches to the correction of increased levels of SDF

Is early initiation of infertility treatment justified in women over the age of 35 years?

Natural fecundity and the success of IVF and intracytoplasmic sperm injection (ICSI) rate both decrease with age. For this reason, in women older than 35 years, it is generally recommended to start the infertility work-up after only 6 months. This assumption, however, may expose couples to over-diagnosis and over-treatment. A theoretical model aimed at assessing the effects of starting the infertility work-up after 6 rather than 12 months of trying to conceive naturally was developed. The assumptions of the model were as follows: infertile women are treated with IVF/ICSI for up to three cycles; IVF/ICSI success rate at first cycle linearly declines with age (3% per year between the ages of 35 and 45 years); the drop-out rate after the first and second cycle is 18% and 25%, respectively; the relative reduction of the success rate at second and third cycle is 16% and 26%, respectively. Early initiation of treatment moderately improved the cumulative chances of live birth resulting from a full IVF/ICSI programme. This improvement is dependent on age. Specifically, it increased from 2.0% at age 35 years to 3.0% at age 43 years. Conversely, the incremental success rate per single IVF cycle was mainly stable, varying only from 1.4% at age 35 years to 1.3% at age 43 years. In women older than 35 years, early initiation of the infertility work-up is associated with only a modest increase in the rate of success of IVF/ICSI. In most scenarios, this advantage may compare unfavourably with the chances of natural conception during the 6-month period.

Predicting the chances of having a baby with or without treatment at different time points in couples with unexplained subfertility.

Can we develop a prediction model that can estimate the chances of conception leading to live birth with and without treatment at different points in time in couples with unexplained subfertility? Yes, a dynamic model was developed that predicted the probability of conceiving under expectant management and following active treatments (in vitro fertilisation (IVF), intrauterine insemination with ovarian stimulation (IUI + SO), clomiphene) at different points in time since diagnosis. Couples with no identified cause for their subfertility continue to have a realistic chance of conceiving naturally, which makes it difficult for clinicians to decide when to intervene. Previous fertility prediction models have attempted to address this by separately estimating either the chances of natural conception or the chances of conception following certain treatments. These models only make predictions at a single point in time and are therefore inadequate for informing continued decision-making at subsequent consultations. A population-based study of 1316 couples with unexplained subfertility attending a regional clinic between 1998 and 2011. A dynamic prediction model was developed that estimates the chances of conception within 6months from the point when a diagnosis of unexplained subfertility was made. These predictions were recomputed each month to provide a dynamic assessment of the individualised chances of conception while taking account of treatment status in each month. Conception must have led to live birth and treatments included clomiphene, IUI + SO, and IVF. Predictions for natural conception were externally validated using a prospective cohort from The Netherlands. A total of 554 (42%) couples started fertility treatment within 2years of their first fertility consultation. The natural conception leading to live birth rate was 0.24 natural conceptions per couple per year. Active treatment had a higher chance of conception compared to those who remained under expectant management. This association ranged from weak with clomiphene to strong with IVF [clomiphene, hazard ratio (HR) = 1.42 (95% confidence interval, 1.05 to 1.91); IUI + SO, HR = 2.90 (2.06 to 4.08); IVF, HR = 5.09 (4.04 to 6.40)]. Female age and duration of subfertility were significant predictors, without clear interaction with the relative effect of treatment. We were unable to adjust for other potentially important predictors, e.g. measures of ovarian reserve, which were not available in the linked Grampian dataset that may have made predictions more specific. This study was conducted using single centre data meaning that it may not be generalizable to other centres. However, the model performed as well as previous models in reproductive medicine when externally validated using the Dutch cohort. For the first time, it is possible to estimate the chances of conception following expectant management and different fertility treatments over time in couples with unexplained subfertility. This information will help inform couples and their clinicians of their likely chances of success, which may help manage expectations, not only at diagnostic workup completion but also throughout their fertility journey. This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck, and Guerbet. None of the other authors declare any conflicts of interest.

Salpingostomy in the treatment of hydrosalpinx: a systematic review and meta-analysis

What is the chance of natural conception when salpingostomy is used to treat hydrosalpinx?. The natural clinical pregnancy rate following salpingostomy is 27%, in the hands of experienced surgeons who publish their results. Tubal surgery is not commonly offered for women with hydrosalpinges since the advent of assisted conception treatment. This is the first systematic review to investigate natural conception rates following salpingostomy in the treatment of hydrosalpinx. A systematic review and meta-analysis of 22 observational studies encompasses 2810 patients undergoing salpingostomy and attempting natural conception. Literature searches were conducted to retrieve observational studies which reported salpingostomy for hydrosalpinx. Databases searched included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL, with no language restriction. Only studies that focused on salpingostomy (rather than other tubal conserving surgeries) for the treatment of hydrosalpinx were included. A total of 22 studies matched the inclusion criteria. The pooled natural clinical pregnancy rate from the 22 observational studies (including 2810 patients) was 27% (95% confidence interval (CI): 25-29%) after salpingostomy was performed for hydrosalpinx. The cumulative clinical pregnancy rates were 8.7% (95% CI: 6.6-11.5%) at 6 months, 13.3% (95% CI: 10.6-16.7%) at 9 months, 20.0% (95% CI: 17.5-22.8%) at 12 months, 21.2% (95% CI: 18.6-24.1%) at 18 months and 25.5% (95% CI: 22.2-29.4%) at 24 months after salpingostomy. The pooled live birth rate (10 studies, 1469 patients) was 25% (95% CI: 22-28%) after salpingostomy was performed for hydrosalpinx. The pooled ectopic pregnancy rate (19 studies, 2662 patients) was 10% (95% CI: 9-11%). The pooled miscarriage rate (seven studies, 924 patients) was 7% (95% CI: 6-9%). The included studies scored well on the Newcastle Ottawa quality assessment scale. Strict inclusion criteria were used in the conduct of the systematic review. However, the studies included are clinically heterogeneous in many aspects including patient characteristics, surgical technique and duration of follow-up after salpingostomy. The findings of this systematic review suggest that salpingostomy is an alternative treatment strategy to tubal clipping or salpingectomy in patients presenting to fertility services with hydrosalpinx. Further prospective, large and high quality studies are needed to identify the subpopulation that would most benefit from tube conserving surgery. No external funding was either sought or obtained for this study. The authors have no competing interests to declare. N/A.

Reproductive choices and outcomes after freezing oocytes for medical reasons: a follow-up study.

What reproductive choices do women make after they have cryopreserved oocytes for medical reasons? Women who had cryopreserved oocytes for medical reasons and tried to become pregnant, either attempted natural conception or resorted to assisted reproduction with fresh oocytes. Women confronted with a risk of premature ovarian insufficiency, due to gonadotoxic therapy, ovarian surgery or genetic predisposition, have an indication to cryopreserve oocytes. Many of these women will retain ovarian function, thus will retain the possibility of natural conception. The added value of cryopreserved oocytes to reproductive outcomes is unknown as there is a lack of follow-up of women who have cryopreserved oocytes for medical reasons. This follow-up study included a cohort of 85 women who cryopreserved their oocytes for medical reasons between 2009 and 2012. Medical data from women who cryopreserved their oocytes at the Centre for Reproductive Medicine in the Academic Medical Centre in Amsterdam were extracted and self-report questionnaires were disseminated. The collected data considered demographics, outcomes of ovarian stimulation, fertility-threatening treatments, menstrual cycle changes, pregnancy attempts and outcomes and intended plans for the cryopreserved oocytes. A total of 68 women, followed up for an average 25.3 months, returned the questionnaire (response rate: 80%). None of the women had used her cryopreserved oocytes although 16 women had tried to conceive. Of these women, eight were trying to conceive naturally, five had conceived naturally within 2 months and three had conceived with assisted reproduction not requiring cryopreserved oocytes (two women with conventional IVF because of tubal pathology and endometriosis and one woman with IUI because of polycystic ovary syndrome). Three out of the eight pregnancies had resulted in live births, two resulted in miscarriages and three were ongoing. Most women (71%) intended to conceive with their cryopreserved oocytes as a last resource option. Transferability of our findings is challenged by the small sample but positively affected by our high response rate. As the time span between cryopreservation of oocytes and follow-up was short, follow-up of the cohort should be repeated in 2 years. After a mean follow-up of 2 years, none of the women with a medical reason to cryopreserve oocytes had used her oocytes. Women who were trying to conceive during follow-up were doing so without using their stored oocytes. It is unclear whether starting assisted reproduction while having cryopreserved oocytes is the most appropriate clinical decision. Our findings emphasize the relevance of taking the chances of natural conception into account in counselling women about cryopreservation of oocytes. This study was not externally funded. There are no conflicts of interest to declare.

Varicocelectomy in men with nonobstructive azoospermia: Is it beneficial?

Objectives To investigate the effect of open lymph sparing high ligation varicocelectomy in nonobstructive azoospermic men with palpable varicocele and determine predictive parameters of outcome. Methods After a standard diagnostic evaluation, a total number of 83 men with nonobstructive azoospermia (54 men with complete azoospermia and 29 with virtual azoospermia) and palpable varicocele underwent open lymph sparing high ligation varicocelectomy. Testicular core biopsy was also performed perioperatively in all patients. Varicocelectomy was performed bilaterally in 60 patients and unilaterally in 23. The outcome success was assessed in terms of improvement in semen parameters and spontaneous pregnancy. Four patients with recurrent varicocele were excluded from final data analysis. Results After a mean follow up of 7.4 months, motile sperm in the ejaculate could be identified in 27 (34.2%) nonobstructive azoospermic patients with a mean postoperative sperm count of 3.56 ± 4.8 × 106/mL (range 0.3–18.9) and a mean sperm motility of 42.24 ± 17.64% (range 24–76). No predictive parameters of postoperative improvement other than testicular histopathology could be concluded. Of these 27 patients, 2 had Sertoli-only-cell pattern, 6 had maturation arrest at spermatid stage pattern, 13 had hypospermatogenesis and 8 had normal spermatogenesis. Spontaneous pregnancy was achieved in 6 (7.7%) patients. Of these 6 patients, 2 had maturation arrest at spermatid stage pattern, 2 had hypospermatogenesis and 2 had normal spermatogenesis. No predictive parameters of spontaneous pregnancy achievement could be concluded. Conclusion High ligation varicocelectomy may offer nonobstructive azoospermic men an opportunity to have motile sperm via ejaculate and even the chance of natural conception, instead of the more bothersome assisted reproductive techniques.