Faculty Bibliography

PURPOSE/OBJECTIVE:To improve access to fertility care at the largest safety net hospital in New York City, fellows and residents run a reproductive endocrinology and infertility clinic that supports an ovulation induction (OI) program under attending physician supervision. Our objective was to evaluate OI pregnancy outcomes to describe the program's efficacy and guide quality improvement. METHODS:We performed a descriptive study of patients who completed at least one OI cycle from 6/1/2019 to 4/1/2023. Fellows and residents managed patient care, including the prescription of an OI agent (clomiphene citrate or letrozole), ultrasound monitoring, and trigger (human chorionic gonadotropin) followed by timed intercourse (TIC) or intrauterine insemination (IUI). Primary outcomes included the overall pregnancy rate (PR) and live birth rate (LBR). RESULTS:Two hundred twenty-eight patients were prescribed OI agents during the study period. Of these, 161 patients (70.6%) completed at least one OI cycle and were not lost to follow up. The PR and LBR per patient were 21.1% (34/161) and 11.2% (18/161). The PR and LBR per cycle were 9.0% (34/379) and 4.7% (18/379). Patients who achieved a pregnancy were younger (median 32.5 years vs. 36 years, p < 0.002), had a higher AMH (median 3.2 vs. 2.1 ng/mL, p < 0.03), and were more likely to have PCOS (35.3% vs. 18.9%, p < 0.04). Among the 228 patients ever-prescribed an OI agent, there were 22 (9.6%) patients with pregnancies that occurred without OI treatment. CONCLUSIONS:PRs from this low-resource OI program are comparable to published data, demonstrating that fellow and resident-run initiatives can be successful in bridging the gap in fertility care.

A case is reported of delayed ovarian torsion following controlled ovarian hyperstimulation and uncomplicated oocyte retrieval, further complicated by post-laparoscopic ipsilateral vulvar hematoma. A 37-year-old nulliparous woman with a history of polycystic ovary syndrome presented with clinical symptoms of ovarian torsion on post-retrieval day 8 and underwent laparoscopic detorsion. Her case was complicated by a large non-traumatic vulvar hematoma on post-laparoscopy day 1. Despite safe aspiration of follicles at oocyte retrieval and onset of menses on post-operative day 6, her ovaries' prolonged enlargement placed her at risk of delayed ovarian torsion. She had no known underlying risk factors or vascular pathology to explain the etiology of her post-laparoscopy vulvar hematoma. The patient ultimately underwent a successful single euploid embryo transfer, followed by an uncomplicated vaginal delivery of a full-term neonate. Ovarian torsion is a rare event amongst patients undergoing in vitro fertilization, with occurrence after the onset of menses even more uncommon. Clinicians should consider close post-retrieval monitoring of patients with high oocyte yield who are at risk of delayed ovarian healing. In addition, vulvar hematoma is a rare complication after laparoscopy, but patients with altered anatomy or in the setting of enlarged ovaries must be given unique consideration.

PURPOSE/OBJECTIVE:To examine assisted reproductive technology (ART) outcomes in patients with congenital complex uterine anomalies (CUA) as well as the impact of surgical repair on these outcomes. METHODS:This retrospective cohort study analyzed 46 patients with CUA who underwent 130 embryo transfer cycles at a large academic fertility center from 2000 to 2024. Outcomes were compared between patients who underwent surgical repair and those who did not. RESULTS:The overall live birth and ongoing pregnancy rate after fresh or frozen embryo transfer was 36.9% (48/130). Cesarean section was the most common mode of delivery (61.7%). Pregnancy complications occurred in 38.3% of live births. Live birth and ongoing pregnancy rates did not differ significantly between patients with and without surgical repair (32.6% vs. 39.2%, p = 0.57). CONCLUSIONS:Patients with complex uterine anomalies experience lower live birth rates compared to the center's average and face a high risk of pregnancy complications. Surgical repair of CUA does not significantly improve ART outcomes. Personalized counseling regarding goals and risks is crucial for CUA patients undergoing ART.

RESEARCH QUESTION/OBJECTIVE:What are the overall, singleton and twin live birth rates (LBR) after a double embryo transfer (DET) involving mosaic embryos? DESIGN/METHODS:This was a retrospective cohort study of DET with at least one mosaic embryo between 1 December 2016 and 1 December 2024. Each DET was assigned a prognostic score (A-F) based on the ploidy of both embryos. The primary outcome was the overall, singleton and twin LBR of good-prognosis (A and B), moderate-prognosis (C and D) and poor-prognosis (E and F) DET. Secondary outcomes were the LBR for mosaic/mosaic compared with euploid/mosaic transfers. Comparisons were also made with previously published data on euploid/euploid transfers. RESULTS:In total, there were 38 DET: 22 mosaic/mosaic and 16 euploid/mosaic. Twenty-nine (76.3%) patients had prior failed euploid transfers, and 19 (86.4%) mosaic/mosaic patients did not have any euploid embryos. The differences in overall LBR between the prognostic groups did not reach significance [65.0% (13/20) good-prognosis group versus 71.4% (5/7) moderate-prognosis group versus 45.5% (5/11) poor-prognosis group; P = 0.5]. The twin LBR was higher in the good-prognosis group (46.2%) compared with the moderate- and poor-prognosis groups (0% for both; P = 0.04). Overall [72.7% (16/22) versus 43.8% (7/16); P = 0.07], singleton [54.5% (12/22) versus 31.3% (5/11); P = 0.20] and twin [18.2% (4/22) versus 12.5% (2/16); P = 0.6] LBR were similar between mosaic/mosaic and euploid/mosaic DET. While the multiple LBR was high in both groups, it was lower for mosaic/mosaic and euploid/mosaic DET compared with euploid/euploid DET [26.1% (6/23) versus 49.8% (113/227, previously published data); P = 0.04]. CONCLUSIONS:Caution must be exercised with mosaic embryos as they can behave like euploid embryos, and DET can result in twins. DET with moderate- or poor-prognosis mosaic embryos had lower twin rates and may be reasonably considered. Larger studies are needed.

We aim to present two rare cases of ovarian torsion immediately following controlled ovarian hyperstimulation and their prolonged recovery state at an academic fertility center. Patient 1 is a 38-year-old nulligravid woman with a history of prior right oophorectomy and patient 2 is a 37-year-old nulligravid woman with a previous left oophorectomy. The main objective of our paper is to characterize the recovery time after ovarian detorsion surgery. These case reports highlight that ovarian torsion after controlled ovarian hyperstimulation may be associated with prolonged systemic symptoms including increased abdominal pain, persistent low-grade fevers, and mild leukocytosis for several weeks following laparoscopic ovarian de-torsion. A proposed mechanism for this extended inflammatory state could be due to higher levels of luteinizing hormone surge activating Phospholipase C-Protein Kinase C pathway and vascular endothelial growth factors involved in follicular growth and luteinization.

PURPOSE/OBJECTIVE:To determine factors associated with embryo disposition decisions at a large academic fertility center. METHODS:We performed a single-center retrospective cohort study of patients who made final embryo disposition (discard or donation to research) between January 1, 2020, and February 28, 2024, via electronic consent. Demographic and cycle-specific variables were collected via chart review. Chi-square and Mann-Whitney U tests were used for data analysis (p < 0.05). RESULTS:Of 1280 patients, 900 (70.3%) discarded embryos and 380 (29.7%) donated to research. Patients who donated were more likely to have a diagnosis of recurrent pregnancy loss (6.1% vs 2.4%, p < 0.002). Patients who chose to donate had transferred more embryos (2 vs 1, p < 0.033) and had transferred more euploid embryos (44.7% vs 36.6%, p < 0.007). There was no difference in total number, number of euploids, or type of embryo disposed (p = 0.24, p = 0.96, p = 0.34). There was no difference observed among those who communicated with the center (p = 0.81) or those using donor gametes (egg p = 0.34, sperm p = 0.29). An additional analysis compared patients who achieved live birth (n = 902) to those who did not (n = 378), and those who donated were more likely to have achieved live birth (32.0% vs 24.1%, p < 0.005). CONCLUSION(S)/CONCLUSIONS:At final embryo disposition, more patients discarded embryos than donated. Donators were more likely to have recurrent pregnancy loss as their reason for pursuing embryo creation, transfer more embryos across all cycles, and achieve a live birth. Discarders were more likely to have transferred untested or no embryos.

PURPOSE/OBJECTIVE:To evaluate the live birth rate (LBR) following donor frozen embryo transfer (dFET) of preimplantation genetic testing for aneuploidy (PGT-A) versus untested donor embryos, stratified by blastocyst morphologic grade (MG). METHODS:This was a retrospective cohort study of 146 patients undergoing dFET of a single euploid blastocyst from fresh or frozen oocytes using PGT-A compared to age-matched controls (1:1 ratio) who did not use PGT-A. Primary outcome was LBR. LBR was compared among cohorts, with further stratification by (1) high/low MG and (2) fresh/frozen oocyte status. Secondary outcomes included perinatal outcomes. RESULT(S)/RESULTS:Median age in both groups was 44.5 years (p = 0.98). LBR was similar among the two cohorts (PGT-A: 57.5% vs. untested: 50.0%, p = 0.20). There was similar LBR in fresh (PGT-A: 59.2% vs. untested: 50.0%, p = 0.20) and frozen (PGT-A: 47.6% vs. untested: 50.0%, p = 0.85) oocyte subgroups. When stratified by MG, we appreciated similar LBR among high-quality blastocysts (PGT-A-high: 56.5% vs. untested-high: 52.3%, p = 0.49) among the whole cohort, as well as in fresh (fresh-PGT-A-high: 58.3% vs. fresh-untested-high: 52.9%, p = 0.46) and frozen (frozen-PGT-A-high: 44.4% vs. frozen-untested-high: 51.7%, p = 0.59) subgroups. Similarly, we appreciated no difference in LBR among low-quality blastocysts (PGT-A-low: 75.0% vs. untested-low: 31.2%, p = 0.08) among the whole cohort, as well as in the fresh (fresh-PGT-A-low: 80.0% vs. fresh-untested-low: 16.1%, p = 0.08) or frozen (frozen-PGT-A-low: 66.7% vs. frozen-untested-low: 40.0%, p = 0.56) subgroups. Gestational age (37.8 weeks, p = 1.0) and infant birth weight (PGT-A: 3128.0 g vs. untested: 3150.2 g, p = 0.60) were similar. CONCLUSION(S)/CONCLUSIONS:Though limited by the small number of MG blastocysts, overall PGT-A did not improve LBR regardless of blastocyst quality from fresh and previously frozen donor oocytes. CAPSULE/UNASSIGNED:Use of PGT-A did not improve live birth rate regardless of blastocyst quality from both fresh and previously frozen donor oocytes.

PURPOSE/OBJECTIVE:To investigate the relationship between early serum hCG levels after frozen embryo transfer and fetal anomalies. METHODS:This was a case-control study at a single academic fertility center between 1/2010 and 12/2021, including all patients who underwent euploid frozen embryo transfers resulting in any fetal anomaly confirmed at the time of induced abortion > 10 weeks or any anomaly reported at delivery. Controls included patients with healthy live births matched for age and day/grade of embryo after euploid FET. The primary outcome was fetal anomaly, with comparisons made using serum hCG levels from cycle day 28 to cycle day 35 and percent change between days 28 and 35. RESULTS:Both cycle day 28 serum hCG levels and day 35 serum hCG levels were significantly lower in the anomalous group (day 28: 152 vs 177.5 mIU/mL, p < 0.04; day 35: 3033 vs 3744 mIU/mL, p < 0.05). Patients with anomalous outcomes had a significantly lower hCG to start with 5/78 (6.4%) < 50 mIU/mL, 16/78 (20.5%) 51-100 mIU/mL, and 57/78 (73.1%) > 101 mIU/mL, compared to controls 3/78 (3.8%) < 50 mIU/mL, 8/77 (10.3%) 51-100 mIU/mL, and 66/77 (85.7%) > 101 mIU/mL (p < 0.02). However, the rate of rise between day 28 and day 35 was not statistically different (1758.0% vs 2097.0%, p = 0.23). CONCLUSION/CONCLUSIONS:Patients with anomalous fetal outcomes following frozen embryo transfer had lower early serum hCG levels than controls with healthy live births, highlighting the potential utility of this serum marker to identify high-risk pregnancies in the first trimester and expedite treatment as appropriate for this rare but devastating outcome.

PURPOSE/OBJECTIVE:To assess the impact of sperm source on cumulative live birth rate (CLBR) after oocyte thaw in autologous oocyte cryopreservation (AOC) patients. METHODS:A retrospective cohort study of autologous oocyte thaw patients at an urban academic fertility center from 2006 to 2021. Patients were stratified by sperm source [partner sperm (PS) vs. donor sperm (DS)]. The primary outcome was CLBR per patient. Secondary outcomes were the oocyte survival rate and usable embryo rate. Statistics included Mann-Whitney U, Kruskal-Wallis, Fisher's exact, chi-square, two-sample t-tests, and multiple logistic regression (p < 0.05). RESULTS:A total of 653 patients were included; 455 (69.7%) used PS and 198 (30.3%) used DS. Time from the first AOC to the first thaw did not differ among DS and PS users (56.8 vs. 54.0 months, p = 0.20). PS users were younger at AOC (37.9 vs. 38.5 years, p < 0.001) and thaw (42.3 vs. 43.1 years, p < 0.001). There were equivalent overall CLBRs (39.9% PS vs. 40.6% DS, p = 0.85) and CLBRs in patients < 35 years at AOC (51.2% PS vs. 100% DS, p = 0.18), 35-37 years at AOC (45.9% PS vs. 60.4% DS, p = 0.10), 38-40 years at AOC (35.4% PS vs. 35.2% DS, p = 0.93), 41-42 years at AOC (28.9% PS vs 14.3% DS, p = 0.21), and > 43 years at AOC (12.5% PS vs 16.7% DS, p = 0.83) among PS and DS users. There were no significant differences in the oocyte survival (79% PS vs 80.5% DS, p = 0.08) or the proportion of patients with usable embryos (27.3% vs 27.8%, p = 0.70) between PS and DS groups. CONCLUSIONS:In AOC patients, CLBR, oocyte survival rate, and usable embryo rate did not differ based on sperm source.

PURPOSE/OBJECTIVE:To investigate pregnancy outcomes resulting from transfer of embryos with non-mosaic (NM) segmental aneuploid (SA) results following preimplantation genetic testing for aneuploidy (PGT-A). METHODS:All patients who underwent frozen embryo transfer (FET) of at least one embryo with a NM-SA between March 2021 and April 2024 were retrospectively reviewed. Primary outcomes included live birth rate (LBR) and results of prenatal diagnosis. Embryos with NM-SA results were also compared to those with NM whole chromosome aneuploid (WCA) and mosaic SA results. RESULTS:Out of 25 NM-SA embryos transferred, the LBR was 24%. Prenatal diagnosis by amniocentesis and/or chorionic villus sampling was performed in 3/6 pregnancies, and results were normal. Embryos with duplications produced more live births compared to those with deletions. NM-SA embryos had a significantly higher ongoing pregnancy (OP)/LBR compared to embryos with NM-WCA results and a significantly lower OP/LBR compared to embryos with mosaic SA results; however, when compared to embryos with high-level SA mosaicism > 40%, the OP/LBR was not significantly different. CONCLUSION/CONCLUSIONS:Embryos with NM-SAs can result in euploid live births, albeit at reduced rates compared to those with mosaic SAs. These data can be used to aid in patient counseling about PGT-A results and embryo transfer decisions.