Faculty Bibliography

BACKGROUND:On March 17, 2020 an expert ASRM task force recommended the temporary suspension of new, non-urgent fertility treatments during an ongoing world-wide pandemic of Covid-19. We surveyed at the time of resumption of fertility care the psychological experience and coping strategies of patients pausing their care due to Covid-19 and examined which factors were associated and predictive of resilience, anxiety, stress and hopefulness. METHODS:Cross sectional cohort patient survey using an anonymous, self-reported, single time, web-based, HIPPA compliant platform (REDCap). Survey sampled two Northeast academic fertility practices (Yale Medicine Fertility Center in CT and Montefiore's Institute for Reproductive Medicine and Health in NY). Data from multiple choice and open response questions collected demographic, reproductive history, experience and attitudes about Covid-19, prior infertility treatment, sense of hopefulness and stress, coping strategies for mitigating stress and two validated psychological surveys to assess anxiety (six-item short-form State Trait Anxiety Inventory (STAl-6)) and resilience (10-item Connor-Davidson Resilience Scale, (CD-RISC-10). RESULTS:Seven hundred thirty-four patients were sent invitations to participate. Two hundred fourteen of 734 (29.2%) completed the survey. Patients reported their fertility journey had been delayed a mean of 10 weeks while 60% had been actively trying to conceive > 1.5 years. The top 5 ranked coping skills from a choice of 19 were establishing a daily routine, going outside regularly, exercising, maintaining social connection via phone, social media or Zoom and continuing to work. Having a history of anxiety (p < 0.0001) and having received oral medication as prior infertility treatment (p < 0.0001) were associated with lower resilience. Increased hopefulness about having a child at the time of completing the survey (p < 0.0001) and higher resilience scores (p < 0.0001) were associated with decreased anxiety. Higher reported stress scores (p < 0.0001) were associated with increased anxiety. Multiple multivariate regression showed being non-Hispanic black (p = 0.035) to be predictive of more resilience while variables predictive of less resilience were being a full-time homemaker (p = 0.03), having received oral medication as prior infertility treatment (p = 0.003) and having higher scores on the STAI-6 (< 0.0001). CONCLUSIONS:Prior to and in anticipation of further pauses in treatment the clinical staff should consider pretreatment screening for psychological distress and provide referral sources. In addition, utilization of a patient centered approach to care should be employed.

OBJECTIVE: To determine if attempts to maximize oocyte yield during ovarian stimulation translates into improved outcome of in vitro fertilization (IVF) cycles. DESIGN: Retrospective study. SETTING: Academic tertiary care IVF center. PATIENT(S): 806 de-identified nondonor IVF cycles. INTERVENTION(S): Evaluation of fresh nondonor IVF cycles (n = 806) for the period January 1, 1999, to December 30, 2001. MAIN OUTCOME MEASURE(S): Cycle cancellation, clinical pregnancy, spontaneous miscarriage, and live birth after IVF. RESULT(S): Advancing age, independent of ovarian reserve status (reflected by early follicular phase FSH and estradiol) augured a worse prognosis for all outcomes. Higher gonadotropin use lowered cycle cancellations but was associated with a statistically significantly reduced likelihood of clinical pregnancy and live birth and a trend toward a higher likelihood for spontaneous miscarriage after IVF. CONCLUSION(S): Our data add to the accruing literature suggesting adverse influences of excess gonadotropin use on IVF outcomes. Although an aggressive approach to controlled ovarian hyperstimulation results in a statistically significant reduction in cycle cancellations, the excessive use of gonadotropins detrimentally influences live birth after IVF

OBJECTIVE: To investigate the predictors of postthaw blastomere survival and the relationship of blastomere survival to the outcome of frozen-thawed embryo transfer (FET) cycles. DESIGN: Retrospective study. SETTING: An IVF unit in a tertiary care facility. PATIENT(S): Infertile women undergoing FET cycles with embryos cryopreserved on day 3 postinsemination. INTERVENTION(S): FET cycles. MAIN OUTCOME MEASURE(S): Embryo survival postthaw, pregnancy (PR), clinical pregnancy, and implantation rates. RESULT(S): A significant impact of postthaw blastomere survival on the outcome of FET cycles was noted. The thawed embryos in the low survival tertile resulted in significantly impaired implantation rate, clinical pregnancy rate, and PR compared to embryos in the high survival tertile. An inverse association was noted between serum P levels on the day of hCG administration and postthaw blastomere survival. CONCLUSION(S): We have demonstrated that postthaw blastomere survival is predictive of success of FET cycles. The relationship of poor postthaw embryo survival in the setting of elevated P is novel and not hitherto described

PURPOSE: To compare two GnRHa flare protocols among poor responders undergoing IVF-ET and to evaluate if a Day 6 estradiol level can predict outcome. METHODS: Retrospective analyses of GnRHa flare IVF cycles among poor responders. Group A ('miniflare,' N = 36) 40 microg GnRHa s.c. b.i.d. from Day 3; Group B ('standard flare,' N = 24) 1 mg GnRHa on Days 2-3; 0.5 mg GnRHa from Day 4. ROC analysis was performed to find a Day 6 estradiol value that is predictive of cycle outcome. RESULTS: With the standard flare, patients required less gonadotropins and tended to have fewer cancellations and higher pregnancy rates. A Day 6 estradiol level < or = 75 pg/mL was predictive of cycle cancellation, but not of pregnancy outcome. CONCLUSIONS: Standard GnRHa flare offers some advantages over the miniflare. Day 6 estradiol < or = 75 pg/mL is predictive of cycle cancellation. When the estradiol level is low on Day 6 (no flare), early cancellation should be considered

PURPOSE: To evaluate and compare the use of OCP with GnRHa for hypothalamic-pituitary suppression in poor responder IVF patients. METHODS: Retrospective analysis of IVF-ET cycles of poor responders. Hypothalamic-pituitary suppression with OCP (Group I, n = 29) or GnRHa (Group II, n = 52), followed by stimulation with gonadotropin, oocyte retrieval, and embryo transfer. Baseline characteristics and cycle outcomes were compared. RESULTS: 73 women underwent 81 cycles from 1/1/1999 to 1/1/2000. Baseline characteristics were similar. 31/81 (38%) cycles were cancelled (Group I, 14/29 (48%) vs. Group II, 17/52 (33%), NS). Cycle outcomes including amount of gonadotropin, number of eggs retrieved, number of embryos transferred, and embryo quality were similar. Patients in Group I required fewer days of stimulation to reach oocyte retrieval. Pregnancy outcomes were similar in the two groups. CONCLUSION: Our retrospective analysis revealed no improvement in IVF cycle outcomes in poor responders who received OCPs to achieve hypothalamic-pituitary suppression instead of GnRHa