Reproductive Specialists Research Articles

Reproductive Empires and Perverse Markets: Unpacking the Paradoxical Dynamics of ART Market Expansion in Non-urban India and Beyond

The global use of assisted reproductive technologies (ARTs) to address structural infertility has burgeoned since the early 2000s. Large corporate in vitro fertilization (IVF) providers from the metropolitan north quickly identified India as a prime location for service delivery, creating satellite clinics in its metropolitan centers. Having learnt from their European masters the colonizer’s art of exporting ART services from the metropolitan core to the periphery, a leading cabal of senior Indian reproductive specialists have since created their own “reproductive empires” perfusing service provision into peri-urban and even semi-rural localities in India and equally underserved emerging markets in Africa, the Middle East, and Latin America. In this paper, we chart the contours of these new empires and explore the implications of this progressive colonization for the quality of service delivery. We argue that the vast scale of expansion has resulted in unwelcome stratification as unscrupulous providers dilute the quality of services to render them affordable to lower socioeconomic groups. Weakly formulated iterations of ART legislation have also allowed this market to thrive under chaotic and uncertain conditions. These dynamics, we argue, create perverse markets that increase, rather than reduce, patient infertility, by holding unsuspecting clients in extended regimes of indentured therapy. In unpacking the drivers of this phenomenon, we identify several key factors: the neoliberalism of health service provision in India; the privatization and corporatization of care; gendered competitiveness; and potent cultural preferences for biologically related children.

The management of haemoglobinopathies in pregnancy and childbirth

Key Content The haemoglobinopathies encompass a complex collection of red blood cell disorders that are responsible for considerable morbidity and mortality in women and their unborn children. Sickle cell disease and the thalassaemias are the commonest haemoglobinopathies encountered in UK clinical practice. A consistent standard of care will enable women with haemoglobinopathies to have a pregnancy that is as safe as possible, with good outcomes and minimal long‐term effects on their health and the health of their babies. The most effective way to deliver a consistent standard of care for these women is via the multidisciplinary team (MDT). The MDT should include a haematologist, cardiologist, maternal medicine obstetrician, specialist midwife, reproductive medicine specialist and a nurse specialist. The care of these women, within the MDT, should start with pre‐conception advice and continue through their antenatal care, intrapartum support and finally, provide postnatal considerations including contraception advice. Learning Objectives To understand the inheritance, incidence, detection and pathophysiology of the commonest haemoglobinopathies. To appreciate the role of pre‐conception advice and prenatal diagnosis in the management of women with a haemoglobinopathy. To appreciate the multidisciplinary team approach in managing women with these conditions. Ethical Issues Prenatal diagnostic techniques can be used to diagnose an affected pregnancy; however, diagnosis after conception means families must address the option of terminating the pregnancy. This requires expert counselling to minimise long‐term sequelae. The definitive prenatal tests – chorionic villus sampling and amniocentesis – are both associated with a small risk of miscarriage. Non‐invasive free fetal DNA (ffDNA) tests that will minimise the risk of testing to the developing fetus are being developed, but use of these tests will still require expert counselling both before and after a test is taken.

Reproductive Issues in Long-Term Surviving Patients following Therapy for Hodgkin's Disease in the Republic of North Macedonia: Risks of Infertility According to First-Line Treatment Regimens.

Infertility as a consequence of therapy presents a high psychosocial burden for HL patients. In the cohort of our analyzed patients, within the post-ABVD surviving patients, alterations of the spermogram were documented in a total of 6.1% of the male patients and 5.4% of the female patients developed amenorrhea. On the other hand, within the subgroup of surviving patients following BEACOPP chemotherapy, 60% of the male patients manifested defects in their spermogram, and as high as 28.6% of the female survivors reported loss of their monthly cycle. It has been reported on several occasions that even prior to treatment, the sperm of HL patients manifests poorer quality characteristics when analyzed against control specimens from healthy male donors. The analyzed results in ABVD-treated male HL patients confirm ABVD to be a safe regimen for males of all age categories, as well as for female patients under the age of thirty. In women above the age of 30, the infertility risk rate is relatively low (14%), which leaves the decision of preserving fertility to themselves. For all BEACOPP-treated female, as well as male patients, a consult with a reproductive medicine specialist is warranted prior to therapy, due to the high infertility risk, and the final decision should be made on an individual basis.

Fertility preservation in cancer patients

Introduction: Fertility preservation or oncofertility is a relatively new interdisciplinary field dealing with the preservation of female and male reproductive functions before the administration of gonadotoxic therapy. Despite recommendations from different international scientific bodies, Hungary still does not have a national fertility preservation network, patient referral is unorganised. Objective: As the first step towards establishing a national fertility preservation program, a study was designed to evaluate the Hungarian oncologists' knowledge, attitudes and practice in the field of oncofertility. Method: A national online survey was sent to the physician members of the Hungarian Society of Clinical Oncology between November 2020 and February 2021. The survey was completed by 94 physicians and the results were analysed statistically. Results: The majority of the oncologists (77%) discusses reproductive health issues before starting gonadotoxic therapy. However, almost half of these physicians do not refer patients for fertility preservation consultation or treatment. Physicians report lack of organised fertility preservation network, lack of knowledge and clinical practice guidelines as major barriers in referring their patients for fertility preservation. The majority (86%) proposes that a better col-laboration between cancer and fertility centers needs to be organized in Hungary. Conclusion: This study is the first nationwide survey to assess oncologists' attitude, knowledge and practice in the field of oncofertility in Hungary. It highlights the need for more education and increased collaboration between oncologists and reproductive specialists. This is an important step towards the establishment of a national fertility preservation network which is our ultimate goal.

Autosomal dominant pseudohypoparathyroidism type 1b due to STX16 deletion: a case presentation and literature review.

Pseudohypoparathyroidism (PHP) is a heterogeneous group of rare, genetically related, endocrine disorders, characterized by end-organ resistance to parathyroid hormone (PTH) action and other G protein-coupled receptors (GPCRs) related hormones. The clinical variants of PHP are classified according to the presence of features of Albright's hereditary osteodystrophy (AHO) and in vivo response to exogenous PTH. Autosomal dominant PHP1b is often caused by a deletion in the syntaxin-16 (STX16) gene, leading to a loss of methylation in the A/B exon of the guanine nucleotide-binding protein a-stimulating polypeptide (GNAS) complex. Herein, we present a case of a 41-year-old man with familiar PHP1b due to a maternal inherited 3-kb STX16 deletion, who was referred to us for consultation by artificial reproductive technology specialists. A bibliographic search was performed in electronic databases (PubMed and Cochrane Library) to identify similar cases. Twenty studies (case-series or reports) were eligible. These studies included collectively 120 patients; 46 patients (38.3%) presented with symptoms of hypocalcemia; 38 were asymptomatic (31.7%); data for 36 patients (30%) were unavailable. Thyroid-stimulating hormone (TSH) resistance was documented in 25 occasions (21%); growth hormone deficiency in 2 (1.7%); 3 patients shared features of the AHO (2.5%); 6 had abnormal bone mineral density test (5%). Notable is the development of tertiary hyperparathyroidism in 3 individuals (2.5%). The present review confirms the heterogeneity in the clinical spectrum of familiar PHP1b. Future research should focus on the molecular characterization of the GNAS disorders, leading to a facile diagnosis and appropriate genetic counseling.

Practices, Attitudes, and Knowledge Among Healthcare Providers and Oncologists in China Regarding Male Fertility Preservation.

ObjectiveThe purpose of this study was to help to promote a better understanding of the male fertility preservation status in China.MethodsIn this cross-sectional survey, 1,912 healthcare providers and oncologists were surveyed anonymously using 16 questions carried out at community oncology practices in China from September 2018 to April 2021. 16 questions were designed to evaluate their knowledge on male fertility preservation in cancer patients, assess the factors they considered when deciding whether to discuss male fertility preservation with their patients.ResultsAmong the 1,912 healthcare providers (42.2% male), 1,713 (89.6%) considered that patients with cancer should be recommended for fertility preservation. 1,264 (66.1%) respondents were aware of male fertility preservation, but only 248 (13.0%) respondents knew the correct institutions. Whether a healthcare provide recommended fertility preservation to their patients depended on the provider's educational background, professional qualifications, hospital grade, area, department, and age. Among the healthcare providers, the three main factors for not recommending fertility preservation for patients with cancer were lack of suitability of the patient for fertility (28.2%), lack of knowledge of fertility preservation (28.6%), and lack of knowledge concerning the institutes that provide fertility preservation (25.4%).ConclusionDespite this, healthcare providers and oncologists in China showed a positive attitude toward fertility preservation in patients with cancer. Hence, the education of physicians should include fertility preservation, with the aim of increasing their knowledge and awareness. There should be more collaboration between oncologists and reproductive medicine specialists.

The changing world of IVF: the pros and cons of new business models offering assisted reproductive technologies.

This analysis contrasts traditional not-for-profit academic with new corporate practices of reproductive medicine and offers an assessment of risks to quality of patient care with investors entering the for-profit reproductive medicine market. Large corporate enterprises may have a global impact on access to care while at the same time is putting at risk the training of the next generation of reproductive medicine specialists.

The possible effects of the Japan Society of Clinical Oncology Clinical Practice Guidelines 2017 on the practice of fertility preservation in female cancer patients in Japan.

PurposeIn 2017, the first guidelines for fertility preservation in cancer patients were published in Japan. However, the impact of the guidelines remains unknown. Therefore, the authors conducted a nationwide survey on cryopreservation procedures in the period from shortly before to after publication of the guidelines (2016–2019) and compared the results with our previous survey (2011–2015). The authors also surveyed reproductive specialists’ awareness of the guidelines and implementation problems.MethodsThe authors sent a questionnaire to 618 assisted reproductive technology facilities certified by the Japanese Society of Obstetrics and Gynecology.ResultsThe authors received responses from 395 institutions (63.8%). Among them, 144 institutions conducted cryopreservation for cancer patients (vs. 126 in 2011–2015) and performed 2537 embryo or oocyte and 178 ovarian tissue cryopreservation procedures (vs. 1085 and 122, respectively). Compared with the previous period, indications were more varied and protocols for controlled ovarian stimulation were more standardized. Reproductive specialists’ interest in oncofertility was high, but many reported three main difficulties: selecting a treatment method, storing samples in the long term, and securing the necessary human resources.ConclusionsThe practice of fertility preservation in cancer patients in Japan has been considerably affected by the first Japanese guidelines.

Japan Society of Clinical Oncology Clinical Practice Guidelines 2017 for fertility preservation in childhood, adolescent, and young adult cancer patients: part 1

In 2017, the Japan Society of Clinical Oncology (JSCO) published the JSCO Clinical Practice Guidelines 2017 for Fertility Preservation in Childhood, Adolescent, and Young Adult Cancer Patients. These were the first Japanese guidelines to address issues of oncofertility. In this field of medicine, sustained close cooperation between oncologists and reproductive specialists is essential from the diagnosis of cancer until many years after completion of cancer treatment. These JSCO guidelines were intended to guide multidisciplinary medical staff in considering the availability of fertility preservation options and to help them decide whether to provide fertility preservation to childhood, adolescent, and young adult cancer patients before treatment starts, with the ultimate goal of improving patient survivorship. The guidelines are presented as Parts 1 and 2. This article (Part 1) summarizes the goals of the guidelines and the methods used to develop them and provides an overview of fertility preservation across all oncology areas. It includes general remarks on the basic concepts surrounding fertility preservation and explanations of the impacts of cancer treatment on gonadal function by sex and treatment modality and of the options for protecting/preserving gonadal function and makes recommendations based on 4 clinical questions. Part 2 of these guidelines provides specific recommendations on fertility preservation in 8 types of cancer (gynecologic, breast, urologic, pediatric, hematologic, bone and soft tissue, brain, and digestive).

Innovations for Optimizing Fertility and Ovarian Functionality in Female Cancer Patients

The survival rates and quality of life of patients undergoing cancer treatments have significantly increased in recent years. However, these advanced treatments are known to exert a potentially gonadotoxic effect, impairing the female population of germ cells and, consequently, leading to ovarian failure through hormonal dysfunction and premature menopause. Nowadays, it is strongly recommended that oncologists discuss the risks of infertility and alternatives with each patient individually, recommending a consultation with a reproductive specialist as early as possible. In this context, remarkable progress has been made in assisted reproductive techniques aimed at fertility preservation for female patients. The main currently applied methods to avoid total loss of ovarian activity as a result of chemo or radiotherapy include oocyte, embryo, or ovarian tissue cryopreservation. This topic review summarizes the recent advances in these techniques, which have increased the chances of fertility preservation and family planning, as well as providing hope for cancer survivors. Oocyte cryopreservation followed by in vitro fertilization and embryo transfer are currently the recommended first-line fertility preservation approaches. However, for prepubertal individuals, the technique of ovarian tissue cryopreservation is advised; this is, moreover, the best method for efficient maintenance of the follicular reserve and allows future tissue transplantation, which not only restores fertility but also resumes natural ovarian hormonal activity. Recently, the discussion about the reestablishment of ovarian function in a defective tissue has raised compelling arguments, based on the theory about the presence of germ stem cells in the ovary. Despite the relevance of the results and the psychological benefits, the number of female patients diagnosed with cancer who are offered any method of fertility preservation is low. Multidisciplinary teams working jointly with oncologists and fertility specialists are essential for better outcomes regarding the wellness of patients who recover from cancer. Although further studies are needed to improve some of the available approaches, for now, comprehensive availability of oocyte/embryo or ovarian tissue freezing services is necessary worldwide to meet patient needs.

Outcomes of fertility treatment in patients with cardiac disease: a multi-centre experience

Abstract Introduction Risks of pregnancy in women with cardiac disease are well described, but data regarding the risks of assisted conception in this cohort is limited. As increasing numbers of older women seek fertility treatment, more women with congenital heart disease desire to have children of their own, and pre-implantation genetic testing (PGT) becomes more widely adopted, increasing numbers of women at risk of cardiac complications are likely to undergo fertility treatment. Aims To assess safety of fertility treatment in women with cardiac disease. Methods Multi-centre retrospective review of outcomes and complications in women with cardiac disease undergoing fertility treatment. Results 34 women with cardiac disease who underwent fertility treatment were identified, with 50 cycles undertaken. 24 patients (71%) received pre-pregnancy counselling. Four patients underwent assisted conception with PGT and two patients underwent IVF and egg collection for the purposes of surrogacy (both mWHO class III). The mean age at the start of an assisted conception cycle was 32 years. Cardiac disease was identified pre-pregnancy in 31 patients. Those diagnosed during pregnancy included a restrictive cardiomyopathy (presumed long standing), and pulmonary stenosis (PS) with an atrial septal defect (ASD). The Modified WHO (mWHO) risk category for the 34 women is seen in table 1. Those in mWHO class III include patients with mechanical valves, Fontan circulation, moderate LV systolic impairment, cyanotic heart disease due to previously undiagnosed PS and ASD, and a patient with Eisenmengers syndrome seeking surrogacy using her own eggs. Live births: 50 cycles resulted in 31 pregnancies; There were 31 live births, (including two sets of twins). One pregnancy lost a twin, and there were two first trimester miscarriages. Complications: Eight patients developed complications; four during fertility treatment and four during pregnancy (table 2). There was a correlation between higher mWHO class and higher rates of complications. No patients in mWHO class I experienced complications compared to 43% of mWHO class III. Of the 31 live births, five babies were delivered pre-term (<37/40). Conclusion The potential cardiac risks of assisted conception in patients with known cardiac disease, or older patients with risk factors for acquired cardiac disease should be considered by both reproductive medicine specialists and cardiologists before treatment commences. Formal pre-treatment / pre-pregnancy counselling is of paramount importance and should involve dialogue between both specialties and the patient to ensure all are aware of the potential risks, and action can be taken to minimise these. However, the presence of cardiac disease per se should not necessarily prevent patients accessing fertility treatment, as in many cases it can be used safely and successfully. Funding Acknowledgement Type of funding sources: None. Table 1. mWHO classificationsTable 2. Complications

Reproductive management in white-tailed deer (Odocoileus virginianus Zimmermann)

Objective: To review information related with the reproductive physiology and management of white-tailed deer for reproductive specialists and producers. Design/methodology/approach: The information presented in this document relies on the review of scientific papers and on experience gained in white-tail deer production systems. Results: White-tailed deer is a species with seasonal reproduction and one of the most important hunting species in Mexico. Currently, all reproductive biotechnologies applied to small ruminants can be used in white-tailed deer. Limitations of the study/implications: Information regard the physiology and reproductive management of white-tailed deer is limited, probably due to conditions specific to its production system. Findings/conclusions: Research and publication of information regard the physiology and reproductive management of white-tailed deer is needed.

Retained products of conception as an aetiology for endometritis.

Chronic endometritis is a controversial and complex condition encountered by reproductive specialists. In the infertile population, the prevalence of chronic endometritis has been estimated to be between 2.8- 56.8% compared to around 10% in the general population undergoing hysterectomy for benign pathology.1,2 The overwhelming prevalence of chronic endometritis in infertile women suggests that both infectious and non-infectious etiologies must be considered as causative factors.

Advisory Board on potential import substitution of follitropin alfa preparations in IVF cycles

On July 17, 2021, Advisory Board with the participation of more than 60 leading reproductive specialists and healthcare executives was held. The primary task was to discuss the real world data on the first Russian biosimilar follitropin alfa and the possibilities of import substitution of follitropin alfa drugs. The information about drug development stages, experience of usage in ovarian stimulation for artificial insemination and assisted reproductive technologies (ART), the results of the largest Russian study in reproduction "FОLLITROPIN" (2020), where biosimilar recombinant human follicle stimulating hormone (FSH) was studied in 5484 IVF cycles in real clinical practice, experience of drug use in leading ART medical centers have been provided in research reports. After discussion the Advisory Board Resolution has been developed.

YOUNGER PATIENTS ARE MORE LIKELY TO HAVE MOSAIC-ONLY EMBRYOS DUE TO THEIR LOWER LIKELIHOOD OF AGE-RELATED WHOLE CHROMOSOME ANEUPLOIDY

While embryo mosaicism is most likely a frequent biological occurrence, during ART treatment mosaicism frequencies had been thought to be influenced by embryo culture environment, sperm quality, insemination method, and/or biopsy protocol. 1 Notwithstanding these associations, mosaicism rates had been thought to be largely independent of female age.2,3 A recent study shown a statistical trend towards decreased rates of mosaicism in women of advanced age (>37 years) compared with younger groups 4. Based on these observations, our study aims to assess the rate of mosaicism across patient age in a large cohort of screened blastocysts from a single IVF center. Patients who underwent IVF from January 2020 - March 2021 were included. All embryos underwent PGT-A with FAST-SeqS. Embryos were assigned an interpretation of aneuploid, mosaic, or euploid; indeterminate/no call embryos were not included in the analysis. The PGT lab utilized for testing did not report mosaicism when present with a full aneuploidy; those embryos were assigned the interpretation of aneuploid. Thus, any embryos designated as mosaic are “mosaic-only.” Cohorts were segregated into 5 groups based on SART age groups: (A: <35; B: 35-37; C: 38-40; D: 41-42; E: ≥43 years, respectively). Frequencies of mosaicism were compared across age groups with a Chi squared analysis and a multivariate regression analysis was performed to adjust for confounding variables. A total of 7,940 embryo biopsies were analyzed. A 13.01% prevalence of mosaic-only embryos was found in the cohort (n=1,035). When analyzing these frequencies per age, younger age groups had a significant higher prevalence of mosaic-only embryos: Group A: 15.2% (n=524); B: 14.13% (n=274); C: 10.9% (n=177); D: 6.6% (n=45) and E: 5% (n=13) (p=<0.0001). After adjusting for day of biopsy and embryo grading, an increase in age was significantly associated with lower odds of isolated mosaicism (OR 1.06 CI95% 1.05-1.06). Day of biopsy, and embryonic quality were not associated with increased odds of isolated mosaicism. A sub-analysis analyzing the mosaicism levels detected with the NGS platform found no differences in frequencies of high and low level mosaicisms across age groups. With the introduction of NGS, reproductive specialists have expanded knowledge surrounding the complexities of early human genomics. Our analysis demonstrates that younger women were more likely to have mosaic embryos without concurrent full aneuploidies. Patients of advanced age are more prone to meiotic segregation abnormalities, resulting in an increased probability of experiencing full and/or complex aneuploidies. For younger patients who are less likely to have meiotic errors, any abnormal findings are more likely to be mitotic in origin, and therefore mosaic.

ANTIOXIDANT THERAPY FOR MALE INFERTILITY – 3 MONTH OR 6 MONTHS: WHICH IS BETTER?

Oxidative stress (OS) plays a pivotal role in the pathogenesis of male subfertility/infertility. Hence, oral supplementation with antioxidants (AOXs) is thought to improve sperm quality by reducing oxidative damage. Interestingly, a recent global survey of 1327 reproductive specialists from 88 countries indicated that AOXs are routinely prescribed by 85.6% of clinicians, for 3 months (43.7%) or between 3–6 months (38.6%). However, the impact of the duration of AOX therapy on reproduction is unclear. This study aims to investigate the effect of duration of AOX therapy on sperm parameters in subfertile men. We reviewed the scientific literature to include studies investigating the use of AOX therapy in male subfertility/infertility, regardless of the type of AOX or the dosage used, measuring sperm parameters before and after treatment. We statistically compared the changes in sperm parameters following AOX therapy at 3 and 6 months. Eight studies on various AOX components (vitamins C and E, L-carnitine, folic acid, Coenzyme Q10, zinc and selenium), with a total population of 278 subfertile men, were eligible for inclusion in the study. Five studies reported significant improvement in sperm concentration, motility, and morphology at 3 and 6 months compared to the base-line values. The average percentage change in parameters at 3 months vs 6 months was not statistically significant for sperm concentration (32.3% vs 53.8%, p=0.261), sperm motility (29.4 % vs 43.5%, p=0.190), progressive sperm motility (21.6% vs 36.7%, p=0.529), morphology (37.3% vs 38.9%, p=0.938). This study found no statistically significant difference in semen parameter when using AOX for 3 or 6 months. Hence, there seems to be no justification in using AOX therapy beyond 3 months in absence if no improvement in semen parameters is observed. However, studies have shown a non-statistical trend towards further improvement in semen parameters when therapy was continued for 6 months. Future studies utilizing serial measurements of oxidative stress during AOX treatment would be valuable in addressing this uncertainty.

Efficacy of three COS protocols and predictability of AMH and AFC in women with discordant ovarian reserve markers: a retrospective study on 19,239 patients

BackgroundRecent studies have consistently shown that AFC and serum AMH are good predictors of ovarian response and have shown strong correlations. However, it is not unusual for reproductive medicine specialists to encounter discordance between them. This is the first study to investigate the efficacies of the different COS protocols when the AFC and AMH levels are discordant. Based on the association between COS protocols and pregnancy outcomes, we attempt to explain the controversial results and clarify the predictive value of AMH and AFC in this context.Methods19,239 patients undergoing their first fresh in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles with GnRH antagonist protocols, GnRH-a long protocols or GnRH-a ultra-long protocols between January 1, 2016, and December 31, 2019, were enrolled and then divided into four groups in accordance with the boundaries for the AFC and serum AMH level provided by the Poseidon Classification. Our study was divided into two parts. Firstly, we retrospectively compared the effects of the three COS protocols in patients with discordant AMH and AFC. Multivariate logistic regression models were conducted in a forward manner to exclude the influence of confounding factors. Afterward, to increase comparability between Group 2 (low AMH and normal AFC) and Group 3 (normal AMH and low AFC), propensity score matching (PSM) analysis was performed based on age, BMI, the number of embryos transferred, and COS protocol. IVF intermediate and reproductive outcomes were compared between Group 2 and Group 3.ResultsFor people with low AMH and normal AFC (Group 2), the number of total oocytes, clinical pregnancy rate (CPR), live birth rate (LBR) and cumulative live birth rate (CLBR) were significantly higher in GnRH-a ultra-long protocol compared with GnRH antagonist protocol. In multivariate logistic regression models, significant associations of COS protocol with fresh LBR and CPR were found after adjusting for age, BMI, AFC, AMH and the number of embryos transferred. Whereas, in patients with normal AMH and low AFC (Group 3), the number of total oocytes, CLBR, LBR and CPR were highest in the long GnRH-a protocol although there was no statistically significant difference. After PSM, the results showed that although oocytes yield and available embryos in patients with normal AMH and low AFC were significantly higher, there was no significant difference in reproductive outcomes between Group 2 and Group 3.ConclusionsWe found that women with normal AFC and low AMH may benefit from the GnRH-a ultra-long protocol. Nevertheless, for women with normal AMH and low AFC, the long GnRH-a protocol seems to be associated with better clinical outcomes. Furthermore, after eliminating the confounding factors including the COS protocol, we found that AMH can only predict the number of oocytes but not the quality of oocytes when there was discordance between AFC and AMH.

Influence of a patient education and care program on women undergoing non-assisted reproductive technology fertility treatment.

PurposeTo determine the influence of a patient education and care program on the quality of life (QOL) of female patients undergoing non‐assisted reproductive technology (ART) fertility treatment.MethodsParticipants completed the MOS 36‐Item Short‐Form Health Survey and fertility QOL (FertiQoL) questionnaires at baseline and at 3, 6, and 12 months of treatment. The responses of patients who underwent three sessions of the program (at baseline, 3 months, and 6 months of treatment) were compared with those of patients who did not receive the program.ResultsThis study compared 69 patients who received an additional care program with 104 patients in the control group, all from 13 facilities. Treatment FertiQoL responses (p = 0.004) and treatment tolerability (p = 0.043) differed between the program and control groups at 3 months using the repeated measures mixed model. The cost of treatment per pregnancy was lower in the program group than in the control group.ConclusionThe patient education and care program provided by reproductive fertility specialists or fertility nurses during non‐ART fertility programs improves patient satisfaction.

P–604 Effectiveness comparison of antral follicular count (AFC), follicular-output-rate (FORT), follicle-to-oocyte-index (FOI), oocyte-sensitivity-index (OSI), and follicular-sensitivity-idex (FSI) for predicting clinical pregnancy rates in IVF

Abstract Study question Which is better for predicting clinical pregnancy rate : AFC, FORT, FOI, FSI, or OSI? Summary answer Both AFC and OSI can be used to predict clinical pregnancy better than FORT, FOI or FSI. What is known already AFC, FORT, FOI, OSI, FSI can be used to predict clinical pregnancy, but no study compared which one is better Study design, size, duration Retrospective study using data from medical record (2016–2018) Subjects were patients underwent IVF cycle at Aster Clinic in Hasan Sadikin Hospital Bandung. Subjects divided into 2 groups: clinically pregnant that is visible gestational sac on ultrasound (n = 83) and not pregnant (n = 148). Inclusion criteria : antagonist protocols, &amp;lt;45 years, basal follicle stimulating hormone (FSH) ≤ 12 IU/L, ICSI fertilization method, and fresh transfer cycle. Participants/materials, setting, methods AFC categorized &amp;lt; 5 and ≥ 5 (poseidon) FORT=pre-ovulatory follicles(16–20 mm) x 100 divided by AFC(2–10 mm). FOI=oocytes obtained x 100 divided by AFC. OSI=oocytes obtained x 1000 divided by total FSH dose. FSI=pre-ovulatory follicles x 100,000 divided by (AFC x total FSH dose). FORT and FSI divided using percentil 33 and 67. OSI divided into 3 groups by cut-off 1.697/IU for poor-response and 10.07/IU for hyperresponse. FOI divided into 2 groups, ≤ 50% or &amp;gt; 50% Main results and the role of chance Group of AFC ≥ 5 had a significantly higher clinical pregnancy rate than the AFC &amp;lt; 5 group (39.49% vs. 16.67% ; p = 0.009). High and moderate OSI had higher clinical pregnancy rate than low OSI (66.37% vs. 37.72% vs. 25.45% ; p = 0.038). There is a significant negative correlation between OSI and age (–0.454) or total FSH dose (–0.594). There is a significant positive correlation between OSI and AFC (0.625), the number of follicles at trigger (0.792), and oocytes (0.923). There were no significant differences in clinical pregnancy rates between the FORT, FOI, and FSI groups. Limitations, reasons for caution Limitation Retrospective study using medical record data Ultrasound measurement was done by many reproductive gynecology specialist (not 1 person) --- observer bias. Wider implications of the findings: This study found no association between FORT, FOI, FSI on clinical pregnancy. Why? FORT, FSI, FOI use measurement number of follicles at trigger and antral follicle. Differences among observers in interpreting antral follicles and number of follicles at trigger, or inaccurate measurement. No FORT, FOI, and FSI cut off values from previous study. Trial registration number Not applicable

P–464 What is the optimal ovarian stimulation (OS) protocol for women who undergo planned oocyte cryopreservation (POC)?

Abstract Study question When repeated cycles of OS for planned oocyte cryopreservation using a standard GnRH antagonist protocol are required, can OS protocol modifications improve oocyte yield? Summary answer Compared to repeating a standard GnRH antagonist protocol, switching to a long GnRH agonist protocol for POC results in a higher number of cryopreserved oocytes. What is known already The total number of cryopreserved oocytes is a key parameter of POC programs because of its association with livebirth. A substantial proportion of women embarking on POC will undergo repeated cycles of OS to reach their desired target number of vitrified oocytes. According to recent guidelines, the GnRH antagonist protocol with GnRH agonist triggering is considered the first choice protocol for POC, because of its safety profile and convenience. However, in women with normal ovarian reserve, the long GnRH agonist protocol results in a higher number of oocytes retrieved. Evidence regarding the optimal protocol for POC is limited. Study design, size, duration This is a single-centre, retrospective cohort study including 283 women who had a first cycle for POC using a standard GnRH antagonist protocol and who requested a second OS cycle to increase their total number of vitrified oocytes for later use. The choice of protocol for the second cycle was left at the discretion of the reproductive medicine specialist. All OS cycles took place between January 2009 and December 2019 in a tertiary referral hospital. Participants/materials, setting, methods After ovarian reserve testing, the first cycle OS was performed using rFSH or HPhMG in a GnRH antagonist protocol. For the second cycle, a GnRH antagonist protocol with or without antagonist pretreatment, or a long GnRH agonist protocol was prescribed. The primary outcome was the number of mature oocytes (MII) vitrified per cycle. Cycle characteristics were compared. Data were assessed by generalized estimating equation (GEE) regression analysis adjusting for covariates. Main results and the role of chance In total, 226 (79.9%) women had a GnRH antagonist protocol and 57 (20.1%) had a long GnRH agonist protocol in their second OS cycle for POC. Overall, mean age was 36.6±2.4 years. The median (CI) number of mature oocytes vitrified after the second OS cycle was significantly higher than that after the first cycle [8 (5–11) vs. 7 (4–10), p &amp;lt; 0.001]. According to GEE multivariate regression, adjusting for relevant confounders, switching from a GnRH antagonist protocol in the first cycle to a long GnRH agonist protocol in the second cycle was the only significant predictor of the number of vitrified oocytes after the subsequent cycle (coefficient 1.59, CI 0.29–2.89, p-value = 0.017). Age, AFC, initial dose and type of gonadotropins did not predict the number of vitrified oocytes. None of the women developed moderate or severe OHSS. Similarly, of 174 women who underwent their first OS cycle with a standard GnRH antagonist protocol, 133 women (76.4%) had the same protocol for their second cycle and 41 women (23.6%) an additional three-day course of GnRH antagonist pretreatment. According to GEE multivariate regression, this protocol modification did not result in more mature oocytes available for vitrification (coefficient –0.25, CI –1.86–1.36, p-value = 0.76). Limitations, reasons for caution These data should be interpreted with caution because of the retrospective design and limited sample. Although more oocytes were obtained with a long GnRH agonist protocol we have no data on livebirth in women returning to use their oocytes to support the choice for a specific OS protocol for POC. Wider implications of the findings: Although oocyte yield in the context of POC is an important parameter that may be modulated by the choice of OS protocol, the ultimate outcome measure of a successful POC program is livebirth after oocyte vitrification. Future research of oocyte parameters reflecting oocyte quality is paramount. Trial registration number Not applicable