IVF Live Birth Research Articles

Do aromatase inhibitors and tamoxifen impact the number of oocytes retrieved in oocyte or embryo banking cycles?

Research QuestionDoes the number of oocytes retrieved differ in oocyte/embryo banking cycles using tamoxifen versus aromatase inhibitors versus no adjuvant medications? DesignObservational cohort study of patients 18-43 years old undergoing oocyte or embryo banking cycles between 2016 and 2018 recorded in the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. ResultsAutologous fresh banking cycles from 2016-2018 (n=42,854) were analyzed in three different groups: oocyte and embryo banking cycles using aromatase inhibitors (AI, n= 2096), tamoxifen (TAM, n=58), and no adjuvant medication (NAM, n=40,700). The average age at cycle initiation was 35 and the majority of patients were nulligravid (77%) and nulliparous (92%). The number of oocytes retrieved and cryopreserved in all banking cycles was higher in the NAM group compared to the AI group (oocytes retrieved: 14.2 vs 12.6, p<.05, oocytes cryopreserved: 11.4 vs 10.3, p<.05); however, no difference in oocyte yield was observed between the AI and NAM groups in gonadotoxic treatment cycles. There was no significant difference in the number of oocytes retrieved or cryopreserved between the TAM and NAM group in all banking cycles. In the generalized linear model, the adjusted mean difference of oocytes retrieved was significantly less in the AI vs NAM group (-1.25, 95% CI: -1.7, -0.80), p <.05) in all oocyte and embryo banking cycles combined. ConclusionBanking cycles utilizing AI may compromise oocyte yield when used for non-gonadotoxic indications. Our data supports the continued use of AI for gonadotoxic treatment cycles as IVF cycle outcomes and live birth rates are comparable to those for cycles with NAM.

Predicting the pregnancy outcome: Uncovering the link between β-hCG, patient factors and live birth in IVF

ObjectiveThe objectives of the study were to correlate live birth rate with the initial level of β-hCG in all patients undergoing embryo transfer and develop a predictive model of live birth based on patients’ and assisted reproductive technology (ART) characteristics. Study designSingle-center retrospective cohort study, including a total of 7587 positive first serum β-hCG from women who performed fresh and frozen embryo transfer.Twenty-one variables related to patient characteristics and treatment modalities were analyzed by step-wise univariate analysis followed by multivariate analysis. The study included women between 18 and 45 years with a positive (>20 IU/L) serum β-hCG between January 2011 and December 2020 while it excluded cycles from donation of gametes, PGT and >3 embryos transferred simultaneously. Main results and the role of chance: Among the positive serum β-hCG measurements 5085 (67.0 %) resulted in live births. β-hCG was higher in the live birth group (691 IU/L) compared to the failed pregnancies group (304 IU/L) (p500 IU/mL provided a positive predictive value for live birth of 85.3 % (95 %CI 84.0–86.4).Failed pregnancies were more common among older maternal and paternal age. Previous abortions were more common in the failed pregnancies group (25.0 %) compared to the live birth group (19.4 %). The most common indication to treatment was male infertility, accounting for a larger portion in the live birth group (41.7 %). At multivariate analysis, the factors independently associated with live birth were: first serum β-hCG (OR 1.35, 95 %CI 1.32–1.37), maternal age (OR 0.93, 95 %CI 0.91–0.95), previous abortions (OR 0.77, 95 % CI 0.68–0.88). The number of embryos transferred showed a positive correlation below a maternal age of 39 (<35 years old OR 1.60, CI 95 % 1.32–1.94; <39 years old OR 1.27 CI 95 % 1.09–1.47). The prediction model incorporating these four variables resulted in a sensitivity and specificity with an area under the ROC curve of 0.798. Conclusion: The study confirms the importance of the first value of β-hCG and proposes a predictive model that takes into account maternal age, number of embryos transferred, and obstetric history, thereby aiding in couples’ counseling and ultimately improve patients’ care.

P-669 Not the oocyte yield but the number of embryos predicts live birth at high response: analysis of 39,136 fresh IVF/ ICSI cycles from National Database

Abstract Study question Oocyte or embryo yield- which is a better predictor of live birth (LB) in fresh cycle IVF/ ICSI? Summary answer The embryo yield is better than oocyte in predicting fresh-cycle LB and positively correlates with LB at high ovarian response when the oocytes yield doesn’t. What is known already As the LB rates plateau after a certain oocyte yield, the number of oocytes collected no longer can predict the live birth in IVF/ ICSI cycles with fresh embryo transfer.Since pregnancy outcomes also depend on the number of mature oocytes obtained, fertilisation rate and subsequent embryo development, it can be postulated that the number of total or transferrable embryos could be a better predictor of LB. Study design, size, duration Retrospective analysis of 39,136 fresh IVF/ ICSI cycles that met the inclusion criteria from the national database published by Human Fertilisation and Embryology Authority (HFEA) in the United Kingdom. We analysed 2 years of published data between January 2015 and December 2016. Participants/materials, setting, methods Only the first cycles of IVF/ ISCI that had oocyte retrieval procedure with intended fresh embryo transfer were included. Couples with any cause of infertility and female partners aged up to 44 years were included. Very few cycles with &amp;gt;25 oocytes had fresh transfer, therefore excluded. The ovarian response has been graded by 0-5, 6-10, 11-15, 16-20, 21-25 collected oocytes. Significant confounders found in univariate analysis were adjusted for in the multiple regression model. Main results and the role of chance Women’s age, method of insemination (IVF or ICSI) and number of transferred embryos and stage of transfer significantly associated with LB in univariate analysis (p &amp;lt; 0.0001 each). The oocyte yield predicted fresh-cycle LB only in low response group (0-5 oocytes), but not in higher response groups. Total number of embryos, the number of transferable embryos and embryo utilisation rate remained positively correlated with LB in all response groups. The number of transferable embryos found to be the best predictor of LB with the highest adjusted OR 1.51 (CI:1.4-1.65, p &amp;lt; 0.0001) in the lowest response (0-5 oocyte) group, that gradually declined to 1.06 (CI:1.03-1.10, p = 0.0003) in 21-25 oocytes group. Followed next by the total number of embryos with the highest adjusted OR of 1.20 (CI:1.13-1.27, p &amp;lt; 0.0001) in the lowest response (0-5 oocytes) group, down to 1.04 (CI:1.02-1.06, p = 0.0003) in the 21-25 oocytes group. The number of oocytes was the weakest in predicting LB (adjusted OR 1.07 (CI 1.02-1.12; p = 0.003) in the 0-5 oocytes group only. The inference remained the same when ICSI cycles with supposedly sperm factor was excluded. Limitations, reasons for caution Information on patient’s BMI or stimulation dose is not available in the HFEA database. However, it might have little impact in our findings, given large sample size. Ages are given in groups, so the groups taken as ordinal (dummy) variables in multiple regression analysis. Cumulative LB data were not available. Wider implications of the findings Having been influenced by both oocyte and sperm competency, the number of transferable embryos may have a stronger relation with the pregnancy outcomes than merely the oocyte number. On theory, this may be applicable for cumulative LB too, but awaiting confirmation by data evidence. Trial registration number Not applicable

#156 : Patient Decision Making and Trends in Embryo Disposal

Background and Aims: Embryo cryopreservation is common in IVF, allowing for surplus embryos to be utilised in subsequent cycles. As such, for a variety of reasons, patients may need to contend with embryo disposition decisions. This study looked at trends surrounding patient decisions to dispose of cryopreserved embryos. Method: A retrospective study was conducted on the consented embryo disposals of 230 patients between 2019 and 2023. Variables analysed included number of live births, number of embryos for disposal, embryo mosaicism, and reasons behind the decision to dispose of their embryos. The length of time between the date the consent was signed and the last IVF cycle, IVF live birth and initial contact with the clinic was also established. Results: A large proportion of patients (43.9%) did not specify why they chose to discard their embryos, however of those who did, there were three main categories (embryos reaching their expiry (27.9%), the return of mosaic PGT results (24.0%), and patients completing their family (22.5%). Of the 57 patients who chose to discard after being contacted regarding their embryo expiry, 19.3% initially chose to extend their storage before opting to discard. Surprisingly, only 62.2% of patients had at least one live birth prior to submitting their disposal consent, and waited, on average, 1.6 years from the date of their most recent live birth to discard. Furthermore, there was an average of 1.8 years between patients’ last IVF cycle and the decision to discard, with an average of 86.5 days elapsing from the point of initial contact with the clinic until the date the disposal consent was signed. Conclusion: Many patients retain their embryos in storage until their expiry, and this point of contact prompts them to make decisions regarding the disposition of their biomaterial, and the reasons behind discard decisions are not solely associated with achieving a live birth.

Prognostic value of a serum β-human chorionic gonadotropin cutoff, twelve days after fresh embryo transfer, on predicting live birth among Ugandan women

Objective: This study aimed to evaluate the prognostic value of a serum β-hCG level cutoff, 12 days after embryo transfer, on predicting live births among Ugandan women. Methods: This is a retrospective cross-sectional study. Three hundred thirty-seven fresh IVF cycles with serum β-hCG ≥5 mIU/mL, at 12 days after embryo transfer, were eligible. We abstracted participant characteristics, IVF cycle characteristics, live birth, clinical pregnancy, and ongoing pregnancy data from each eligible cycle. We utilized the Youden Index metric and the maximize_boot_metric method to link serum β-hCG levels to outcome data and determine the optimal cutoff values. Results: The optimal serum β-hCG cutoff value for predicting live birth was 437.42 mIU/mL with a corresponding sensitivity and false positive rate of 72% and 31%, respectively. The cutoffs for clinical and ongoing pregnancy were 239.58 mIU/mL and 353.66 mIU/mL, respectively. These corresponded with a sensitivity of 83% and 77%, respectively, and a false positive rate of 27% and 33%, respectively. The serum β-hCG cutoff had poor discriminatory performance for predicting live births but moderate performance for predicting clinical and ongoing pregnancies. Conclusion: A single serum β-hCG 12 days after cleavage embryo transfer has poor discriminatory performance in predicting live birth, albeit performing modestly in predicting clinical pregnancy and ongoing pregnancy among Ugandan women.

P-666 High embryo yield (and not oocyte yield) despite low ovarian stimulation dose correlates with cumulative livebirth rate in normal-high responders undergoing IVF/ICSI

Abstract Study question Does a good response i.e., high oocyte or embryo yield with low ovarian stimulation correlate with cumulative live birth outcome in IVF/ ICSI treatment? Summary answer High ovarian sensitivity to stimulation (embryos to gonadotropin dose ratio) positively predicts cumulative live birth in IVF, while oocytes to stimulation dose ratio does not. What is known already The conventional belief that the higher the number of eggs retrieved, the better for IVF outcome has been challenged. Oocyte yield fails to predict fresh-cycle live birth in presence of high ovarian response. Ovarian sensitivity index (OSI) which is an expression of inherent ovarian responsiveness to stimulation remained overlooked as a predictor of success in IVF. We explore whether attention should be on the oocyte or embryo yield as a function of ovarian stimulation (OSI) can predictor of positive outcomes in IVF. Study design, size, duration Retrospective analysis of 750 patients who underwent IVF/ ICSI treatment with ≤150 IU of gonadotropin in an antagonist protocol due to predicted normal or high response. This is a further analysis of a previously published study covering a period between 1 January 2016 to 31 Dec 2018. Participants/materials, setting, methods Multi-centre study within a group company using the same treatment protocols. Participants were normal or high responders of IVF/ ICSI, predicted poor responders (according to Bologna criteria) were excluded. All patients received ≤150 IU daily dose of gonadotropin (FSH) in an antagonist cycle. Cumulative LBR calculated. Univariate and multivariate (regression) analysis, adjusting for all significant variables were done to find the predictors of cumulative livebirth. Main results and the role of chance When the women who achieved a livebirth were compared with those who did not, there was no difference in the mean BMI (23.7 vs 23.6, p = 0.81), antral follicle counts (p = 0.33), Anti-mullerian hormone levels (p = 0,89), mean starting (149.5 vs 140.5 IU/ day, p = 0.16), and total gonadotropin doses (1360.7 vs 1342.8 IU, p = 0.62). Women’s age (33.5 vs 35.3 years, p &amp;lt; 0.0001) and the number of embryos transferred (p &amp;lt; 0.0001) had significantly correlation with LBRs. There was no difference in the mean number of oocyte (9.1 vs 8,6, p = 0.21) or oocyte yield per unit of gonadotropin (7.4 vs 6.7, p = 0.32).. The mean number of embryos (5.4 vs 4.1, p &amp;lt; 0.0001), transferable embryos (2.5 vs 1.9, p = 0.0006) and embryo yield per unit of gonadotropin (4.1 vs 3.2, p &amp;lt; 0.0001) were significantly higher in the livebirth group. After adjusting for woman’s age and the number of embryos transferred, the embryo yield (both total (p &amp;lt; 0.0001) and transferable (p = 0.01) embryos and embryo yield per gonadotropin unit (p = 0.0007) were predictors of cumulative livebirth whereas oocyte yield and oocyte number per unit of gonadotropin were not. The above findings remained the same when only IVF cycles excluding male infertility or only the cycles with a fixed 150 IU/d gonadotropin dose were analysed. Limitations, reasons for caution A moderate-sized study population. The poor responders have been excluded to minimise variations in the protocol and stimulation dose. Wider implications of the findings Our study is a proof of concept of ‘ovarian sensitivity index’ indicating the inherent ovarian responsiveness rather than the strength of stimulation determines the IVF/ICSI outcome. Embryo yield appeared to be a predictor of cumulative livebirth while oocyte yield is not, in normal and high responders of IVF. Trial registration number Not applicable

P-473 The reproductive performance of euploid blastocysts declines after each consecutive embryo transfer: The pendulum is swinging back?

Abstract Study question the impact of euploid blastocysts on reproductive performance by association between the number of previous failed IVF cycles and live birth rate per transfer Summary answer Our findings suggest a negative association between the number of previous failed IVF cycles per euploid transfers. implantation rates decreased following each consecutive FE-ET cycles What is known already In assisted reproductive technologies, implantation failure presents a challenging clinical dilemma since its underlying etiology is unknown. Implantation is a very complex process which involves a variety of factors related to the embryo, endometrium, and immune system (Fox et al. 2016). Therefore, implantation failure is also a complex pathological condition that involve both embryonic defects and/or endometrial dysfunctions (Das et al.2012). This situation poses a therapeutic dilemma. Hence implantation failure etiologies and treatments remain unresolved. which results in ongoing debate over whether embryonic chromosomal aneuploidy is a major contributor or within the endometrium itself. Study design, size, duration This observational cohort study included 387 patients undergoing euploid embryo transfer between January 2015 and until October 2022. Participants/materials, setting, methods Participants: Women with an anatomically normal uterus who underwent autologous vitrified-warmed euploid blastocyst transfer (Frozen Euploid Embryo Transfer: FE-ET) cycles were included in the study. Setting: Fertility center at a university-affiliated public hospital. Intervention(s): Trophectoderm biopsy and comprehensive preimplantation 24-chromosome analysis using Next Generation Sequencing (NGS). Main Outcome Measure(s): Cumulative outcomes from these cycles were analyzed. A logistic regression model was used to assess the differences in outcomes between the first, second, and third FE-ET. Main results and the role of chance The mean age of the patient population under investigation was 33.4 ± 5.3 years. Maternal age at oocyte retrieval was negatively associated with the mean euploidy rate per cohort of biopsied blastocysts from each patient (m-ER). The m-ER did not show any association with the number of previous failed IVF cycles (0/1-2/≥3) among different ranges of maternal age at oocyte retrieval (≤30/31-35/36-39/≥40). The transfer of the first single vitrified-warmed euploid blastocyst was associated with an implantation rate (IR) of 47%, a miscarriage rate of 17.9% and a live birth rate (LBR) of 33.9%. Miscarriage rate and LBR were sensitive to the number of previous failed IVF cycles, showing statistically significant differences between women with no previous and ≥3 failed IVF cycles (11.3% versus 27.8%, P = 0.04) and (40.7% versus 26.3%, P = 0.05) respectively. Sustained implantation rates of the first, second, and third FE-ET were 47%, 40.5%, and 30% per transfer, respectively. The sustained IR was sensitive to the number of consecutive euploid blastocyst transfers (P = 0.03). Limitations, reasons for caution The retrospective nature of the study. The data should also be verified using a multicenter approach, to increase the sample size. Wider implications of the findings After experiencing multiple unsuccessful IVF cycles, transferring euploid blastocysts leads to improved clinical outcomes, but these improvements eventually level off. Additional information beyond embryo euploidy is needed to further enhance clinical outcomes. Trial registration number not applicable

P-253 Clinical efficacy of PGT-A according to maternal age and embryo quality in blastocyst stage

Abstract Study question To establish the usefulness of PGT-A as an embryo selection tool based on the quality of the blastocyst and the age of the patient. Summary answer The euploidy rate of good quality blastocysts decreases dramatically with increasing maternal age. What is known already One of the fundamental objectives to achieve an optimal gestation rate is the selection of the embryo with the highest implantation potential. For this purpose, morphokinetics and aneuploidy detection are used. Most aneuploidies arise in maternal meiosis, and increase exponentially in women over the age of 35 years, coinciding with the rapid decline in IVF success and live birth rates in patients of advanced maternal age. Study design, size, duration In the present retrospective study, embryo quality of 321 blastocysts was evaluated from June 2020 to January 2023. They were analyzed according to the ASEBIR (2015) classification and using preimplantation genetic testing for aneuploidy (PGT-A) with next-generation sequencing (NGS). Participants/materials, setting, methods A total of 321 blastocysts were analyzed using PGT-A from which 101 were euploid. This 101 blastocysts were classified according to the morphokinetic (A or B (good quality) and C (medium quality)) and the maternal age (&amp;lt;35, 35-36, 37-38, 39-40, 41-42, 43-44 and 45 -46 years). Out of the 101 euploid blastocysts, 78 embryos were classified as A or B (good quality) and 23 as C (medium quality) according to the ASEBIR classification. Main results and the role of chance The euploidy rate of the embryos decreases as the age of the patient increases, being 73% for good quality embryos in patients under 35, 54% in patients between 35-36, 37% in patients between 37- 38, 31% in patients between 39-40, 23% in patients between 41-42, 5% in patients between 43- 44 and 0 % in patients between 45-46 years. For medium quality embryos, the euploidy rate is 58% in patients under 35, 38% in patients between 35-36, 30% in patients between 37-38, 26% in patients between 39-40, 0% in patients between 41-42, 0% in patients between 43-44 and 0% in patients between 45- 46 years. In patients under 35 years, PGT-A will improve pregnancy rates considering that it is an invasive and costly technique. In patients between 35-36 years, PGT-A is a very useful tool when embryos have C quality as well as, in patients between 37- 40, regardless of embryo quality. Furthermore, patients between 41-42 years with good quality embryos, PGT-A will decrease the abortion rates and increase the pregnancy rates. In contrast, patients with C-quality embryos should not start new cycles, as well as patients with over than 43 years due to the low probability of euploidy. Limitations, reasons for caution Studies of larger sample size and study period are required to validate our current findings. Furthermore, more information about fertilization, pregnancy, birth rate and perinatal outcomes could improve the current results. Wider implications of the findings Making the decision whether or not to use PGT-A on the day of blastocyst formation helps to choose the best strategy by individualizing each case according to the maternal age and the quality of the blastocysts. Decreasing cycle times will always be beneficial to patients and their outcomes. Trial registration number Does not apply

A comparison of perinatal outcomes following fresh blastocyst or cleavage stage embryo transfer in singletons and twins and between singleton siblings.

Are perinatal outcomes following fresh blastocyst versus fresh cleavage stage embryo transfer (ET) different in singletons, twins, and between singleton siblings? Singleton babies conceived following fresh blastocyst, versus cleavage stage, ET are less likely to be small for gestational age (SGA) or to have a congenital anomaly (a result confirmed by comparing singleton siblings), while singletons born following fresh blastocyst ET were at a higher risk of being large for gestational age (LGA) than their sibling born following fresh cleavage stage ET. Blastocyst stage transfer is now the preferred strategy in most IVF units. Previous studies have suggested that babies conceived through blastocyst transfer are at increased risk of preterm birth and LGA. A national population-based retrospective cohort study was performed using linked Human Fertilisation and Embryology Authority (HFEA) data on 130 516 IVF and ICSI livebirths occurring from 103 062 women between 2000 and 2017. We included women who had at least one singleton livebirth resulting from IVF/ICSI fresh embryo treatment, using their own eggs and partner's sperm. A linked HFEA dataset was analysed using a multilevel framework, which accommodated repeated IVF cycles resulting in livebirths in the same woman. A population-averaged robust Poisson model was used for binary outcomes and a multinomial logistic regression model was used for categorical outcomes. Unadjusted and adjusted risk ratios (aRRs) (95% CI) were calculated. There were 130 516 livebirths in 103 062 women, including 86 630 singletons, 43 886 twin births, and 5384 pairs of singleton siblings. In comparison with fresh cleavage stage ET, fresh blastocyst stage transfer in singletons was associated with a lower risk of low birthweight (aRR = 0.92; 95% CI 0.86, 0.99), lower risk of being SGA (0.83; 0.78, 0.89), and lower risk of congenital anomaly (0.79; 0.71, 0.89). This analysis did not show an increase in risk associated with preterm birth (1.00; 0.94, 1.06), high birthweight (0.99; 0.93, 1.06), LGA (0.99; 0.93, 1.05), and the chance of healthy singleton baby (1.00; 1.00, 1.02). Twins resulting from fresh blastocyst stage ET were at slightly higher risk of preterm birth (1.05; 1.02, 1.10) compared with twins conceived following fresh cleavage stage ET. There was insufficient evidence for an association with the other perinatal outcomes. Singleton siblings born following fresh blastocyst stage ET were at a higher risk of being LGA (1.57; 1.01, 2.46) and at lower risk of having a congenital anomaly (0.52; 0.28, 0.97) compared to their singleton siblings born following cleavage stage ET. There was some evidence of excess risk of preterm birth (1.42; 0.97, 2.23) associated with blastocyst stage transfer. However, we could not confirm an association between blastocyst stage ET and low birthweight (1.35; 0.81, 2.27), high birthweight (1.19; 0.80, 1.77), and the chance of being a healthy baby (0.97; 0.86, 1.09). This was an observational study where we were unable to adjust for some key confounders, such as maternal smoking status and BMI, which may change from one pregnancy to another and are not recorded in the HFEA dataset. In the largest study of its kind, our analysis of singleton siblings, corrected for unmeasured, non-time varying maternal factors, confirms the previously reported association between blastocyst transfer and LGA babies, and shows a reduced risk of congenital anomaly following blastocyst transfer. Our sibling analysis did not confirm a decreased risk of low birthweight following blastocyst transfer. Overall, absolute risks are low and there is insufficient evidence to challenge the practice of extended culture of embryos. This project is financed by an NHS Grampian Endowment Research Grant, project number 17/052. One of the authors, S.B., was the Editor in Chief of HROpen until 31 December 2022 and would have been in that role when the paper was first submitted. As an invited speaker, S.B. has received travel expenses, accommodation and honoraria from Merck, Organon, and Ferring. A.M. has received travel expenses, accommodation, and honoraria from Merck Serono, Cook Medical, Pharmasure, Gedeon Richter, and Ferring. D.J.M. is currently a HROpen Associate Editor. N/A.

O-089 The impact of sharing personalized IVF-prognoses: a randomized controlled trial

Abstract Study question Are women less likely to expect unrealistic live birth rates (i.e. 100% or &amp;gt; 2x their personalized IVF-prognosis) if gynaecologists share personalized IVF-prognoses during embryo transfer? Summary answer Sharing IVF-prognoses results in 1/3 rather than 1/2 women expecting unrealistic live birth rates (p = 0.03), but their partners do not take their IVF-prognosis into account. What is known already IVF-patients know that average IVF-success rates are only around 30%, but this does not hold them back from expecting an IVF success-rate of around 59% from their own IVF-cycle. These unrealistic expectations cause frustration among clinic staff and seem to contribute to patient’s decision to discontinue IVF. Performant prognostic models can now calculate personalized IVF-prognoses, based on clinical and laboratory factors, but the impact of these models on the expectations and wellbeing of IVF-patients had yet to be examined by an RCT. Study design, size, duration As dictated by a-priori power calculation, 160 heterosexual couples having their 2nd-5th oocyte aspiration (2019-2021) were recruited to study minimally 128 randomized couples (computer; 1:1 allocation; drop-out=20%) on the day of fresh embryo transfer. On that day the attention-control group received an embryo photo and feedback on the number of cryopreserved embryos. The intervention group additionally received their embryo quality rating and personalized IVF-prognosis (complete IVF-cycle live birth rate, Devroe et al., BMJOpen, 2020). Participants/materials, setting, methods A total of 160 of 197 (81.2%) invited couples agreed to participate and 144 were randomized (72 per group; n = 16 not randomized as no embryo for transfer on day 3 or 5). Immediately after the embryo transfer and attention-control or intervention condition, women and their partners (independently) rated their expected IVF live birth rate on a numerical rating scale (0-100%) and filled out the ‘STAI-State-Anxiety Inventory’. Analysis was according to intention to treat principles. Main results and the role of chance Randomisation succeeded in distributing the background variables equally between the attention-control group (ACG) and intervention group (IG). Couples had a mean duration of infertility of 26 months (±14.6), a median of one previous oocyte aspiration (range: 1-4) and a mean personalized IVF prognosis of 29.7 (±16.2; range 3.3–75.5). The primary hypothesis was accepted: women of the intervention group, having received their personalized IVF-prognosis, were less likely to expect an unrealistic IVF-live birth rate of 100% or of twice as high as their personalized IVF-prognosis (IG: n = 23/69 or 33.3% vs. ACG: 34/66 or 51.522%; p = 0.03). A trend in the same direction was observed in men (IG: 26/63 or 41.27% vs. ACG: 34/60 or 56.67%; p = 0.09). Focussing on the subgroup of couples with a below average prognosis (&amp;lt;30%; n = 76), in which the hypothesised effect seems most likely, confirmed the intervention effect in women (p = 0.016) and the lack thereof in men (p = 0.15). Receiving the intervention during embryo transfer affected state anxiety immediately after the embryo transfer in women (IG: 39.5±10.0 vs. 39.5±10.1; p = 0.54) nor men (IG: 37.6±9.1 vs. 37.1±7.7; p = 0.41). The vast majority of patients would advise the feedback to others, irrespective of having received their personalized prognosis (women: p = 0.9; men p = 0.4). Limitations, reasons for caution This RCT was powered for analysing the primary outcome in the entire sample, but not for the subgroup analysis. Whether the effect of sharing personalized IVF-prognoses on women's expectations translates into an effect on IVF-discontinuation, and hence cumulative success rates, is currently followed up. Wider implications of the findings Clinics are advised to offer patients their personalized IVF-prognosis as this limits the likelihood of unrealistic expectations in women, without triggering anxious reactions. The proportion of women and men with unrealistic expectations, however, remained high and men did not respond to our feedback. Trial registration number NCT04169295

Maternal hypothyroidism and its effect on placental histopathology in singleton live births resulting from in vitro fertilization treatment

We aimed to examine the impact of maternal hypothyroidism on placental pathology and perinatal outcomes in singleton live births resulting from IVF, using medical records of IVF births between 2009 and 2017 at a tertiary hospital. The primary outcomes included anatomical, inflammation, vascular malperfusion, and villous maturation placental features. Secondary outcomes included foetal, maternal, perinatal, and delivery complications. There were 1,057 live births, of which 103 (9.7%) and 954 (90.3%) were in the study and control groups, respectively. Patients in the study group were more likely to have diabetes mellitus, polycystic ovarian syndrome, gestational diabetes mellitus, and non-reassuring foetal heart rate (NRFHR) tracing during delivery. After adjustment for potential confounding factors, hypothyroidism was significantly associated with the bilobed placenta (aOR 4.1; 95% CI 1.2–14.3), retroplacental haematoma (aOR 2.4; 95% CI 1.2–4.9), decidual arteriopathy (aOR 2.0; 95% CI 1.2–4.1) and subchorionic thrombi (aOR 2.4; 95% CI 1.3–5.0). Additionally, there was a statistically significant relationship with NRFHR tracing. The incidence of acute chorioamnionitis and severe foetal inflammatory response was higher in the study group. In conclusion, the placental histopathology patterns of singleton IVF live births show that maternal hypothyroidism has a significant impact on adverse perinatal outcomes.

P-767 Cumulative live birth rate after IVF - trend over time and the impact of blastocyst culture and vitrification

Abstract Study question Has cumulative live birth rate (CLBR) improved over time and which factors are associated with such an improvement? Summary answer During 2007-2017, CLBR per oocyte aspiration increased significantly (27.0 % to 36.3 %), in parallel with an increase in blastocyst transfer and cryopreservation by vitrification. What is known already While it has been shown that live birth rate (LBR) per embryo transfer (ET) is higher for fresh blastocyst than for fresh cleavage stage embryo transfer, CLBR per oocyte aspiration, including one fresh ET and all subsequent frozen embryo transfers (FET), does not seem to differ between the two culture strategies. Study design, size, duration STUDY DESIGN, SIZE, DURATION: National register study including all oocyte aspirations performed in Sweden 2007-2017, n = 124 700. Donation cycles excluded. Participants/materials, setting, methods Data were retrieved from the Swedish National Registry of Assisted Reproduction (Q-IVF). CLBR was defined as the number of deliveries with at least one live birth resulting from one oocyte aspiration, including all fresh and/or frozen embryo transfers within one year. The delivery of a singleton, twin, or other multiples was registered as one delivery. Cryopreservation of cleavage stage embryos was performed by slow freezing and of blastocyst by vitrification. Main results and the role of chance Overall, the CLBR per oocyte aspiration increased significantly during the study period, from 27.0 % to 36.3 % (OR 1.039, 95% CI 1.035-1.043) and from 30.0 % to 43.3 % if at least one ET was performed (AOR 1.055, 95% CI 1.050-1.059). The increase in CLBR was independent of maternal age, number of oocytes retrieved and number of previous IVF live births. The CLBR for women &amp;lt; 35 years and ≥ 35 years both increased significantly, following the same pattern. During the study period a substantially increasing number of blastocyst transfers were performed, both in fresh and in FET cycles. An important contributor included in the blastocyst strategy, may be the extended culture of the total cohort of embryos, also embryos earlier discarded at early cleavage stages, in order to reach the blastocyst stage. These embryos may contribute to the total number of available blastocysts and thereby increase the chance of a live birth within that oocyte aspiration cycle. Other important predicting factors for live birth, such as number of embryos transferred, could not explain the improvement, on the contrary the single embryo transfer (SET) rate increased with time. Limitations, reasons for caution The retrospective design implicates that other confounders of importance for CLBR can not be ruled out. In addition, some FET cycles might be performed later than one year post oocyte aspiration for the last year (2017) and are thus not included in this study. Wider implications of the findings The results suggest that blastocyst transfer, particularly when used in FET cycles and in combination with vitrification, is an important contributor to the improved live birth rates over time. This gives a possibility for fewer oocyte aspirations needed to achieve a live birth and a shortened time to live birth. Trial registration number -

P–767 Cumulative live birth rate after IVF - trend over time and the impact of blastocyst culture and vitrification

Abstract Study question Has cumulative live birth rate (CLBR) improved over time and which factors are associated with such an improvement? Summary answer During 2007–2017, CLBR per oocyte aspiration increased significantly (27.0% to 36.3%), in parallel with an increase in blastocyst transfer and cryopreservation by vitrification. What is known already While it has been shown that live birth rate (LBR) per embryo transfer (ET) is higher for fresh blastocyst than for fresh cleavage stage embryo transfer, CLBR per oocyte aspiration, including one fresh ET and all subsequent frozen embryo transfers (FET), does not seem to differ between the two culture strategies. Study design, size, duration STUDY DESIGN, SIZE, DURATION: National register study including all oocyte aspirations performed in Sweden 2007–2017, n = 124 700. Donation cycles excluded. Participants/materials, setting, methods Data were retrieved from the Swedish National Registry of Assisted Reproduction (Q-IVF). CLBR was defined as the number of deliveries with at least one live birth resulting from one oocyte aspiration, including all fresh and/or frozen embryo transfers within one year. The delivery of a singleton, twin, or other multiples was registered as one delivery. Cryopreservation of cleavage stage embryos was performed by slow freezing and of blastocyst by vitrification. Main results and the role of chance Overall, the CLBR per oocyte aspiration increased significantly during the study period, from 27.0% to 36.3% (OR 1.039, 95% CI 1.035–1.043) and from 30.0% to 43.3% if at least one ET was performed (AOR 1.055, 95% CI 1.050–1.059). The increase in CLBR was independent of maternal age, number of oocytes retrieved and number of previous IVF live births. The CLBR for women &amp;lt;35 years and ≥ 35 years both increased significantly, following the same pattern. During the study period a substantially increasing number of blastocyst transfers were performed, both in fresh and in FET cycles. An important contributor included in the blastocyst strategy, may be the extended culture of the total cohort of embryos, also embryos earlier discarded at early cleavage stages, in order to reach the blastocyst stage. These embryos may contribute to the total number of available blastocysts and thereby increase the chance of a live birth within that oocyte aspiration cycle. Other important predicting factors for live birth, such as number of embryos transferred, could not explain the improvement, on the contrary the single embryo transfer (SET) rate increased with time. Limitations, reasons for caution The retrospective design implicates that other confounders of importance for CLBR can not be ruled out. In addition, some FET cycles might be performed later than one year post oocyte aspiration for the last year (2017) and are thus not included in this study. Wider implications of the findings: The results suggest that blastocyst transfer, particularly when used in FET cycles and in combination with vitrification, is an important contributor to the improved live birth rates over time. This gives a possibility for fewer oocyte aspirations needed to achieve a live birth and a shortened time to live birth. Trial registration number -

Cumulative live birth rate after IVF: trend over time and the impact of blastocyst culture and vitrification.

STUDY QUESTIONHas cumulative live birth rate (CLBR) improved over time and which factors are associated with such an improvement?SUMMARY ANSWERDuring an 11-year period, 2007–2017, CLBR per oocyte aspiration increased significantly, from 27.0% to 36.3%, in parallel with an increase in blastocyst transfer and cryopreservation by vitrification.WHAT IS KNOWN ALREADYWhile it has been shown that live birth rate (LBR) per embryo transfer (ET) is higher for fresh blastocyst than for fresh cleavage stage embryo transfer, CLBR per oocyte aspiration, including one fresh ET and all subsequent frozen embryo transfers (FET), does not seem to differ between the two culture strategies.STUDY DESIGN, SIZE, DURATIONA national register study including all oocyte aspirations performed in Sweden from 2007 to 2017 (n = 124 700 complete IVF treatment cycles) was carried out. Oocyte donation cycles were excluded.PARTICIPANTS/MATERIALS, SETTING, METHODSData were retrieved from the Swedish National Registry of Assisted Reproduction (Q-IVF) on all oocyte aspirations during the study period where autologous oocytes were used. CLBR was defined as the proportion of deliveries with at least one live birth per oocyte aspiration, including all fresh and/or frozen embryo transfers within 1 year, until one delivery with a live birth or until all embryos were used, whichever occurred first. The delivery of a singleton, twin, or other multiples was registered as one delivery. Cryopreservation of cleavage stage embryos was performed by slow freezing and of blastocyst by vitrification.MAIN RESULTS AND THE ROLE OF CHANCEIn total, 124 700 oocyte aspirations were performed (in 61 313 women), with 65 304 aspirations in women <35 years and 59 396 in women ≥ 35 years, resulting in 38 403 deliveries with live born children. Overall, the CLBR per oocyte aspiration increased significantly during the study period, from 27.0% to 36.3% (odds ratio (OR) 1.039, 95% CI 1.035–1.043) and from 30.0% to 43.3% if at least one ET was performed (adjusted OR 1.055, 95% CI 1.050–1.059). The increase in CLBR was independent of maternal age, number of oocytes retrieved and number of previous IVF live births. The CLBR for women <35 and ≥35 years both increased significantly, following the same pattern. During the study period, a substantially increasing number of blastocyst transfers was performed, both in fresh and in FET cycles. Other important predicting factors for live birth, such as number of embryos transferred, could not explain the improvement. An increased single embryo transfer rate was observed with time.LIMITATIONS, REASONS FOR CAUTIONThe retrospective design implicates that other confounders of importance for CLBR cannot be ruled out. In addition, some FET cycles might be performed later than 1 year post oocyte aspiration for the last year (2017) and are, thus, not included in this study. In addition, no data on ‘dropouts’, i.e. patients that do not continue their treatment despite having cryopreserved embryos, are available, or if this drop-out rate has changed over time.WIDER IMPLICATIONS OF THE FINDINGSThe results suggest that blastocyst transfer, particularly when used in FET cycles and in combination with vitrification, is an important contributor to the improved live birth rates over time. This gives a possibility for a lower number of oocyte aspirations needed to achieve a live birth and a shortened time to live birth.STUDY FUNDING/COMPETING INTERESTSThe study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (ALFGBG-70940) and by Hjalmar Svensson’s research foundation. None of the authors declares any conflict of interest.

2008 financial crisis versus 2020 economic fallout: how COVID-19 might influence fertility treatment and live births

Research questionThe economic and reproductive medicine response to the coronavirus disease 2019 (COVID-19) pandemic in the USA has reduced the affordability and accessibility of fertility care. What is the impact of the 2008 financial recession and the COVID-19 recession on fertility treatments and cumulative live births? DesignThe study examined annual US natality, Centers for Disease Control and Prevention IVF cycle activity and live birth data from 1999 to 2018 encompassing 3,286,349 treatment cycles, to estimate the age-stratified reduction in IVF cycles undertaken after the 2008 financial recession, with forward quantitative modelling of IVF cycle activity and cumulative live births for 2020 to 2023. ResultsThe financial recession of 2008 caused a 4-year plateau in fertility treatments with a predicted 53,026 (95% confidence interval [CI] 49,581 to 56,471) fewer IVF cycles and 16,872 (95% CI 16,713 to 17,031) fewer live births. A similar scale of economic recession would cause 67,386 (95% CI 61,686 to 73,086) fewer IVF cycles between 2020 and 2023, with women younger than 35 years overall undertaking 22,504 (95% CI 14,320 to 30,690) fewer cycles, compared with 4445 (95% CI 3144 to 5749) fewer cycles in women over the age of 40 years. This equates to overall 25,143 (95% CI 22,408 to 27,877) fewer predicted live births from IVF, of which only 490 (95% CI 381 to 601) are anticipated to occur in women over the age of 40 years. ConclusionsThe COVID-19 recession could have a profound impact on US IVF live birth rates in young women, further aggravating pre-existing declines in total fertility rates.

Preimplantation genetic testing (PGT) for copy number variants of uncertain significance (CNV- VUS) in the genomic era: to do or not to do?

To review cases of couples presented to our PGT-unit with copy number variants (CNVs) classified as variants of uncertain significance (VUS) in order to better understand their needs. Retrospective cohort study conducted in a tertiary medical-center, 2014-2019. We reviewed files of all couples applying for genetic counseling with CNVs classified as VUS. The main outcomes measured: number of VUS findings and their description, PGT-M procedures planned and performed, IVF cycles, clinical pregnancy, and live birth rates (LBR). VUS were classified according to the American-College of Medical-Genetics and Genomics classification at time of first consultation, and updated-December 2018. Twenty-four couples presented with a total of 30 VUS. Twelve couples (50%) had isolated VUS and 12 (50%) had VUS diagnosed in addition to a pathogenic mutation. Initially, nine findings (30%) were defined as VUS; eight (27%) as likely benign (b-VUS); and 13 (43%) as likely pathogenic (p-VUS). PGT-M was recommended for 17/30 CNVs (56.6%), 12 (70%) of which, isolated VUS. No couple had other indications for IVF. To date, nine couples performed PGT-M for isolated VUS; LBR per-couple-55.5%. Five couples performed PGT-M for both pathogenic findings and VUS, LBR-80%. After reviewing VUS classifications, 30% remained unchanged, 20% were more severely defined, and 50% less severely defined. The genomic era enables detection of VUS whose definition is subject to change as additional information becomes available. The uncertainty of variants' clinical significance and changes in VUS definition over time complicates genetic counseling. Revised guidelines for VUS interpretation and reevaluation of patient counseling before each pregnancy must be practiced when counseling them regarding the justification of PGT-M for their diagnosed VUS.

Sex ratio of infants born through in vitro fertilization and embryo transfer: Results of a single-institution study and literature review.

Objective:The possible effects of Assisted Reproductive Technology (ART) on sex ratio at birth are extremely significant. This study aimed to determine whether ART affects the sex ratio of infants born through in vitro fertilization and embryo transfer (IVF-ET).Materials and Methods:We ran this retrospective study on 290 singleton infants born following IVF-ET from February 2014 to August 2018 at a single institution. We compared the sex ratios of these infants with respect to insemination versus intracytoplasmic sperm injection (ICSI), early-cleavage embryo versus blastocyst transfer, fresh versus frozen-thawed embryo transfer and normal sperm versus asthenospermia.Results:There were no significant differences in the sex ratio with respect to the fertilization method, transfer time, fresh embryo or frozen-thawed embryo transfer. In addition, the multiple logistic regression analysis revealed that these factors did not significantly affect the sex ratio.Conclusions:Our study indicated that the differences in the fertilization method transfer time and sperm motility rate did not affect the sex ratio of IVF live births. However, with increasing numbers of ICSI and blastocyst transfer cycles, factors possibly affecting the sex ratio need to be further investigated.

Prioritizing IVF treatment in the post-COVID 19 era: a predictive modelling study based on UK national data.

STUDY QUESTIONCan we use prediction modelling to estimate the impact of coronavirus disease 2019 (COVID 19) related delay in starting IVF or ICSI in different groups of women?SUMMARY ANSWERYes, using a combination of three different models we can predict the impact of delaying access to treatment by 6 and 12 months on the probability of conception leading to live birth in women of different age groups with different categories of infertility.WHAT IS KNOWN ALREADYIncreased age and duration of infertility can prejudice the chances of success following IVF, but couples with unexplained infertility have a chance of conceiving naturally without treatment whilst waiting for IVF. The worldwide suspension of IVF could lead to worse outcomes in couples awaiting treatment, but it is unclear to what extent this could affect individual couples based on age and cause of infertility.STUDY DESIGN, SIZE, DURATIONA population based cohort study based on national data from all licensed clinics in the UK obtained from the Human Fertilisation and Embryology Authority Register. Linked data from 9589 women who underwent their first IVF or ICSI treatment in 2017 and consented to the use of their data for research were used to predict livebirth numbers.PARTICIPANTS/MATERIALS, SETTING, METHODSThree prediction models were used to estimate the chances of livebirth associated with immediate treatment versus a delay of 6 and 12 months in couples about to embark on IVF or ICSI.MAIN RESULTS AND THE ROLE OF CHANCEWe estimated that a 6-month delay would reduce livebirths by 0.4%, 2.4%, 5.7%, 9.5% and 11.8% in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively, while corresponding values associated with a delay of 12 months were 0.9%, 4.9%, 11.9%, 18.8% and 22.4%, respectively. In women with known causes of infertility, worst case (best case) predicted chances of livebirth after a delay of 6 months in women aged <30, 30-35, 36-37, 38-39 and 40-42 years varied between 31.6% (35.0%), 29.0% (31.6%), 23.1% (25.2%), 17.2% (19.4%) and 10.3% (12.3%) for tubal infertility and 34.3% (39.2%), 31.6% (35.3%) 25.2%(28.5%) 18.3% (21.3%), and 11.3% (14.1%) for male factor infertility. The corresponding values in those treated immediately were 31.7%, 29.8%, 24.5%, 19.0% and 11.7% for tubal factor and 34.4%, 32.4%, 26.7%, 20.2% and 12.8% in male factor infertility. In women with unexplained infertility the predicted chances of livebirth after a delay of 6 months followed by one complete IVF cycle were 41.0%, 36.6%, 29.4%, 22.4% and 15.1% in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively, compared to 34.9%, 32.5%, 26.9%, 20.7% and 13.2% in similar groups of women treated without any delay. The additional waiting period, which provided more time for spontaneous conception, was predicted to increase the relative number of babies born by 17.5%, 12.6%, 9.1%, 8.4% and 13.8%, in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively. A 12-month delay showed a similar pattern in all subgroups.LIMITATIONS, REASONS FOR CAUTIONMajor sources of uncertainty include the use of prediction models generated in different populations and the need for a number of assumptions. Although the models are validated and the bases for the assumptions are robust, it is impossible to eliminate the possibility of imprecision in our predictions. Therefore, our predicted live birth rates need to be validated in prospective studies to confirm their accuracy.WIDER IMPLICATIONS OF THE FINDINGSA delay in starting IVF reduces success rates in all couples. For the first time, we have shown that while this results in fewer babies in older women and those with a known cause of infertility, it has a less detrimental effect on couples with unexplained infertility, some of whom conceive naturally whilst waiting for treatment. Post COVID 19, clinics planning a phased return to normal clinical services should prioritise older women and those with a known cause of infertility.STUDY FUNDING/COMPETING INTEREST(S)No external funding was received for this study. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy work for ObsEva, Merck, Merck KGaA, Guerbet and iGenomics. SB is Editor-in-Chief of Human Reproduction Open. None of the other authors declare any conflicts of interest.

IMPACT OF 2008 AND COVID-19 ECONOMIC RECESSIONS ON FERTILITY TREATMENTS AND LIVE BIRTHS

The economic and reproductive medicine response to the COVID-19 pandemic in the United States has reduced the affordability and accessibility of fertility care. We sought to determine the impact of the 2008 financial and the COVID-19 recession on fertility treatments and cumulative live-births. prospective projection modeling. We examined annual US natality, CDC IVF cycle activity and live birth data from 1999 to 2018 encompassing 3,286,349 treatment cycles, to estimate the age-stratified reduction in IVF cycles undertaken after the 2008 financial recession, with forward quantitative modelling of IVF cycle activity and cumulative live-births for 2020 to 2023. The financial recession of 2008 caused a four-year plateau in fertility treatments with a predicted 53,026 (95% CI 49,581 to 56,471) fewer IVF cycles and 16,872 (95% CI 16,713 to 17,031) fewer live births. A similar scale of economic recession would cause 67,386 (95% CI: 61,686 to 73,086) fewer IVF cycles between 2020 and 2023, with women younger than 35 years overall undertaking 22,504 (95% CI 14,320 to 30,690) fewer cycles, as compared to 4,445 (95% CI 3,144 to 5749) fewer cycles in women over the age of 40 years. This equates to overall 25,143 (95% CI: 22,408 to 27,877) fewer predicted live-births from IVF, of which only 490 (95% CI 381 to 601) are anticipated to occur in women over the age of 40 years. The COVID-19 recession could have a profound impact on US IVF live-birth rates in young women, further aggravating pre-existing declines in total fertility rates.

PLANNED OOCYTE CRYOPRESERVATION (PL-OC) IN WOMEN AGE 40-45

Women 40-45, particularly if unpartnered, consider Pl-OC to preserve opportunity for a genetic child in the future. According to SART, IVF live birth rates for women >40 are <12% and cycle cancellation rates are as high as 20%. Limited data exist on Pl-OC process and outcomes in this age group, particularly for women 43+. This study aimed to identify rates of Pl-OC in women age 40-45 following appropriate evidence-based counseling. We hypothesized that women 43+ and those with lower AMH would be less likely to proceed with Pl-OC. Retrospective cohort study. All women age 40-45 presenting for a complimentary Pl-OC assessment (consisting of AMH/AFC) and physician consultation at Extend Fertility Medical Practice, a large single-center oocyte cryopreservation program from 1/1/18-5/25/20 were included. Counseling included specific evidence-based algorithms for oocyte yield based on age and AMH, as well as estimated live birth outcomes based on published aneuploidy data, and where relevant, discussion of the lack of live birth data for women 43+. Median AMH levels were calculated overall and by age, for the entire cohort and those who chose Pl-OC. Mean number of MII oocytes cryopreserved per cycle and mean number of cycles per patient were also calculated. Comparisons were made using Kruskal-Wallis, t-test, and X2 where appropriate. 474 women age 40-45 presented for complementary consultation and were included in the study. Following their consultation, 117/474 (24.6%) proceeded with Pl-OC.Tabled 1TABLE 1: Demonstrates data for the entire cohort and those who chose Pl-OC (cycling cohort)AgeTotal CohortAMHMedian±IQRCycling CohortAMHMedian±IQRFrozen MII/CycleMean±SD# of Cycles/PatientMean±SDNN(%)401561.22±1.7847 (30.2)1.80±2.217.14±5.281.77±1.21411220.75±1.6627 (22.1)1.37±2.136.61±5.982.08±1.9042870.58±1.1827 (31.0)1.01±1.707.57±5.641.33±0.6143470.58±1.046 (12.8)1.81±2.455.50±4.641.79±0.9844370.50±0.906 (16.2)0.85±1.205.07±5.091.80±0.9445250.35±0.554 (16.0)0.81±0.653.33±1.632.33±1.21Total4740.77±1.35117 (24.6)1.34±1.896.68±5.451.83±1.38Women who chose not to cycle had lower Median AMH (0.62±1.20 vs 1.34±1.89, p<0.001) and were more likely to be 43+ (OR 0.45 CI 0.25-0.80; 16/109 vs. 101/365 p=0.005) compared to those who cycled. Of those who cycled, only 8/117 (6.8%) had a cycle cancelled for poor response or 0 oocytes cryopreserved. Open table in a new tab Women who chose not to cycle had lower Median AMH (0.62±1.20 vs 1.34±1.89, p<0.001) and were more likely to be 43+ (OR 0.45 CI 0.25-0.80; 16/109 vs. 101/365 p=0.005) compared to those who cycled. Of those who cycled, only 8/117 (6.8%) had a cycle cancelled for poor response or 0 oocytes cryopreserved. With effective counseling, even in this low efficacy group, women with the highest chances of success can have the opportunity to attempt Pl-OC with a low cycle cancellation rate.