Faculty Bibliography

Objective: It has been suggested that socio-demographic factors may affect access to FP opportunities¹. In one of America's most racially diverse cities, we sought to compare the racial make-up of patients with cancer (Ca) who completed FP against the overall racial diversity (including Hispanic origin) identified in the incidence of Ca in women of reproductive age in our city.
Design(s): A retrospective cohort study and cross-sectional comparison of all medical embryo banking (Em) and egg freezing (Eg) cycles from 1/2017-12/2018 at our center.
Material(s) and Method(s): All patients who completed at least one medical Em or Eg cycle were reviewed. Race was self-reported at time of consultation. A calculation of the expected incidence of Ca by race in women of reproductive age in our city was determined using the most recent Ca incidence data by race² and available city census data by race, age and gender³. Statistical analysis included chi square goodness of fit and test for independence where appropriate, with p < 0.05 considered statistically significant.
Result(s): 107 patients who completed medical FP were included. Overall, 55 (51.4%) identified as White, 3 (2.8%) as Black, 13 (12.2%) as Asian, 6 (5.6%) as Hispanic, 3 (2.8%) as other and 27 (25.2%) did not report. 40.2% of patients were diagnosed with Breast Ca, 15.0% Gynecologic Ca, 15.0% Hematologic Ca, 5.6% Neurologic Ca, 4.7% GI Ca, 4.7% Sarcoma, 3.7% Endocrine Ca, 2.8% other Ca and 7.5% tested BRCA+ with scheduled BSO. There was no significant difference in racial distribution by Ca type (p=0.255). A subgroup analysis excluding the BRCA+ patients and those races not reported by the census³ (n=69) was then performed to compare the racial distribution of patients who completed medical FP at our center with the racial distribution of women of reproductive age who were diagnosed with Ca in our city. Based on the calculated frequency of race within the incidence of Ca in women of reproductive age (42% White, 21% Black, 8.9% Asian, 2.8% Hispanic), an expected number of FP cases for each race was calculated and compared. Results show that there is a statistically significant difference between observed (O) and expected (E) cases of FP by race at our center; White 47O/29E, Black 3O/15E, Asian 13O/6E and Hispanic 6O/19E (X² 36.9, df 3, p <0.001). This FP subgroup was further analyzed by FP type [Em (n=31, 44.9%) vs Eg (n=38, 55.1%)]. A statistically significant difference in racial distribution by FP type was observed; White 66.0% Eg vs 34.0% Em, Black 33.3% Eg vs 66.7% Em, Asian 46.2% Eg vs 53.8% Em and Hispanic 0% Eg vs 100% Em (X² 10.60, df 3, p < 0.014).
Conclusion(s): There is a difference in the observed versus expected racial distribution of patients completing medical FP at our clinic, as well as a difference in the racial distribution between procedure types (Eg vs Em). Black and Hispanic patients were underrepresented in FP and White patients had a higher incidence of Eg, while non-White patients had a higher incidence of Em. Further studies are needed to determine if these differences generalize beyond our clinic and to identify modifiable factors that can improve equal opportunity to all patients. References: 1. Letourneau JM, Smith JF, Ebbel EE, Craig A, Katz PP, Cedars MI & Rosen MP. Racial, Socioeconomic, and demographic disparities in access to fertility preservation in young women diagnosed with cancer. 2. National Cancer Institute. (2019, April 9). State Cancer Profiles. Retrieved April 9, 2019, from 3. United States Census Bureau. (2018, July 1). Population estimates. Retrieved April 9, 2019, from
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Objective: Non-surgical management for patients desiring future fertility with EMCA and its' precursor, EIN, has the goal of clearance of affected tissue and reversion to normal endometrial function (1). Only approximately 15% of these patients will have a livebirth (LB) without the need for ART (2). Despite this low number, little information exists on the pregnancy outcomes for patients who will go on to utilize ART. We investigated the pregnancy outcomes for patients who underwent ET after FST.
Design(s): Retrospective cohort study of all patients who underwent ET after FST for EMCA or EIN at a single center between 1/2003 and 12/2018.
Material(s) and Method(s): An analysis of all patients and ET outcomes after FST was performed. Patients who utilized ART but did not yet return for ET were excluded. Descriptive data are presented as mean +/- SD. Observed ET outcomes were sub-grouped into 1) LB + ongoing pregnancy (OP) and 2) spontaneous abortion (SAB) + not pregnant (NP). Observed outcomes were compared to expected outcomes matched for age and type of transfer [fresh or frozen, number of embryos transferred, and with or without pre-implantation genetic testing (PGT) at our center] with a Wilcoxon Signed-Rank Test, p < 0.05 considered significant.
Result(s): 14 patients, 3 with EMCA and 11 with EIN, met criteria for inclusion for a combined total of 40 ETs. The mean age at initiation of ART following FST was 35.14 +/- 4.77 (range 28 to 44) and includes two patients, aged 40 and 44, who ultimately used donor eggs. The average BMI at diagnosis was 26.51 +/- 6.17. FSTs prior to ET included megestrol acetate (n=7), oral progesterone (n=5), levonorgestrel intrauterine device (n=1), and polypectomy (n=1). The average time from diagnosis to first ET was 1.62 years +/- 1.46. The average number of ETs per patient was 2.86 +/- 2.03, with a range of 1 to 9. Of 40 ETs, 10 transfers were fresh ETs with an average of 2.70 +/- 1.06 embryos transferred per cycle. Three ETs were untested donor eggs, each with a single embryo transferred per cycle. Thirteen were frozen untested ETs, with an average of 1.77 +/- 0.81 embryos transferred per cycle. Six patients elected to use PGT [Array Comparative Genomic Hybridization (aCGH) and Next Generation Sequencing (NGS)] for a total of 14 frozen euploid ETs, with an average of 1.69 +/- 0.97 embryos transferred per cycle. Outcomes for all ETs included 7 LB, 1 OP, 8 SAB, and 24 NP. An analysis of observed outcomes by sub-group, compared to the expected from matched controls (age, ET type and number, and PGT as described above) showed that patients with EMCA/EIN after FST had a significantly lower LB/OP rate than expected, Z = -5.04, df = 39, p < 0.01. A sub-group analysis of the 14 euploid ETs (7 single by NGS, 4 single by aCGH, 3 double by aCGH) resulted in a LB/OP rate of 21.4% compared to an expected rate of 62.8% (Z = -3.32, df = 13, p < 0.001).
Conclusion(s): Patients who have undergone FST for EMCA/EIN have significantly poorer outcomes than expected after ET. Further evaluation of the impact of the diagnosis, treatment and repeated cavity instrumentation for EMCA/EIN is necessary to create an individualized and optimized approach for this unique patient population. References: 1. ACOG Committee Opinion #631. Reaffirmed 2017. Endometrial Intraepithelial Neoplasia. 2. Gallos ID, Yap J, Rajkhowa M, et al. Regression, relapse, and live birth rates with fertility-sparing therapy for endometrial cancer and atypical complex endometrial hyperplasia: a systematic review and metaanalysis. Am J Obstet Gynecol 2012;207;266.e1-12.
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Objective: There is an inverse relationship between the use of elective oocyte donation and the understanding of long-term potential impact. We sought to assess the long-term medical and psychological health status of all elective oocyte donators (anonymous, directed, agency) at a single institution.
Design(s): Anonymous quantitative and qualitative survey.
Material(s) and Method(s): An anonymous survey was emailed to all donors with a working email who donated between 2008 - 2019 (n=161).
Result(s): 36 donors completed the survey (response rate 22.4%). The majority identified as Caucasian (77.1%). Most identified as not religious (33.3%), atheist (19.4%) or spiritual (16.7%). 44.4% reported they are currently single and 33.3% as currently married. 41.6% had at least a Bachelors degree, 38.9% a Masters and 16.7% a Doctorate. 48.6% reported half altruistic/half financial motivations, 14.3% reported pure altruism and another 14.3% purely financial. Most (54.3%) were between 25-30 years old at time of first donation. 40.0% donated between 2-5 years ago and another 34.3% 5-10 years ago. 40.0% of respondents donated once, 17.1% twice, 17.1% three times, and 25.7% 4 or more times. Most reported no post-op complications (34.3%) or minor symptoms only (51.4%). 30.6% reported at least 1 pregnancy but 57.1% hadn't tried or are not interested. Of donors reporting pregnancies, none required Assisted Reproductive Technology for conception but 13.3% reported >2 losses. Of donors with living biological children, 75% reported their children had no medical problems. 1 directed donor reported her niece has Schaff-Yang syndrome. 80% reported no update in their medical history; 2 reported new allergies, 1 epilepsy, 1 anemia, 1 collagenous colitis, 1 fibrocystic breasts, and 1 reported a keratoacanthoma removal. 1 respondent each reported a diagnosis of ovulatory dysfunction, blocked fallopian tubes, unexplained fertility and fibroids respectively. Over half of donors reported being treated for or having ever experienced symptoms of depression or anxiety. Birth control was the most reported new medication. 63.0% reported no update in their family history. 2 reported new cancers in grandmothers (breast, cervical) and 3 reported a family death (depression, colon cancer, old age). 31.3% reported they knew children were born from their oocytes and all wrote positive comments about the knowledge of livebirth. 80.6% reported that they would make the same choice to donate and 58.1% reported they would recommend donation. 62.5% would still have donated under open donation or ID disclosure models. 81.3% were interested in maintaining contact for future updates.
Conclusion(s): Most donors did not have major medical history updates. The majority felt positively about donation but also reported a high rate of depression/anxiety, which could be related. Donors felt positively about open disclosure and maintaining contact with recipients. Continued long-term follow up will help provide better counseling about the medical risks/benefits of donation. Moving toward an open disclosure may expand the psychological benefits for both donor and recipient. References: None
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PURPOSE/OBJECTIVE:To assess the experiences and psychological outcomes of oocyte donors from one fertility center. METHODS:An anonymous survey was distributed via a secure email to 161 donors who underwent oocyte donation-anonymous, directed/known, and recruited agency-between January 2008 and January 2019 at the NYU Langone Fertility Center. RESULTS:Thirty-six donors completed the survey with the majority between 2 and 10 years since donation. Respondents reported a high prevalence of psychiatric symptoms or diagnoses post-donation. The majority of donors reported positive thoughts and feelings toward their donation process as well as to the knowledge of children born from their donation. Negative comments about donation were in the minority but focused on unexpected aspects about the process or outcome. Based on qualitative analysis, thoughts about family or "family-oriented thoughts" were the most frequent theme in respondent comments. 62.5% of respondents reporting that they would be open to identity-disclosure or open donation after experiencing the process. CONCLUSIONS:Despite a high reported prevalence of psychiatric symptoms, the majority of respondents felt positively about the donation experience as well as the prospect of open donation or identity-disclosure post-donation. Further research on long-term psychological outcomes, related to all aspects of donation, is important as the counseling and informed consent of oocyte donors continues to evolve. These data will be particularly important with regard to the aspect of disclosure, both planned and unplanned, in the modern era of electronic information sharing.

Two of the many milestone developments in the field of assisted reproduction have been oocyte donation and preimplantation genetic testing for aneuploidy (PGT-A). Because it has been demonstrated that even young women produce a meaningful proportion of aneuploid embryos, screening out such abnormalities could potentially increase the efficacy of donor egg (DE) cycles. In this retrospective cohort study, we investigated the effect of PGT-A on DE cycle outcomes, including implantation rate (IR), spontaneous abortion rate (SABR), and ongoing pregnancy/live birth rate. We used fresh and frozen donor cycles not using PGT-A as comparison groups; all cases involved single embryo transfer. Data analysis revealed that PGT-A did not improve pregnancy outcome metrics in DE cycles, although there was a trend toward decreasing the SABR. There was a significant increase in IR with fresh cycles outperforming all frozen cycles. Overall, these results suggest that the benefits of performing PGT-A on embryos derived from young DEs may be limited and that there is an effect of the freezing process on pregnancy outcomes. These findings may provide useful insights into the science and practice of PGT-A across all of its applications.

Objective Improvements in oocyte cryopreservation(OC) have led to successful oocyte banking and more readily available cryopreserved donor oocytes(DO). Simultaneously, preimplantation genetic screening(PGS) has increased, even with DO. Using OC, DO, and PGS together is less common, but now occurs. Reservations include increased technological and financial cost ($1,100/oocyte). Our goal was to determine whether adding PGS increases implantation and live birth rates in DOT. Design Retrospective cohort study. Material and Methods We conducted a retrospective analysis of DOT performed 10/2004-1/2017 at a university-based fertility center. To remove bias, we conducted a sub-analysis of single embryo transfers(SET). Data was mined for: number of oocytes thawed/survived/fertilized, embryo development/transfer/implantation, and ongoing pregnancy/live birth. Mood's median and Fischer's exact tests were used for statistical analysis. Results Within the 130 non-PGS DOT (118 pts, median age:26y), 1138 oocytes (median:8/cycle) were thawed. Within the 15 PGS DOT (15 pts, median age:24y), 180 oocytes (median:11/cycle) were thawed a mean of 3 blastocysts(BL) were biopsied. Oocyte survival, 2-PN fertilization, BL formation, implantation, and ongoing pregnancy/live birth rates were not significantly different between the groups. The multiple birth rate in the non-PGS group was 6% (5/84 births). When controlling for SET, no differences were found in implantation or ongoing pregnancy/live birth rates with and without PGS (p>.1). When comparing embryo quality in the non-PGS group, a higher ongoing pregnancy/live birth rate was noted among SETs with excellent-quality Gardner's >2Bb (62% 50 births/81 transfers) when compared with SETs with poor-quality Gardner's <2Bb (35% 8 births/23 transfers p=.03). Conclusions Due to this study's small sample size, it is difficult to conclude whether PGS improves implantation/live birth rates in a young donor population. In DO cycles with excellent-quality BL for transfer, morphology alone predicts a high live birth rate. Given the financial and technological burden of PGS, larger studies are needed to determine whether the costs of PGS outweigh the benefits in DO cycles

Resident physicians' scores on the REI section of the CREOG exam are traditionally low, and nearly 40% of house staff nation-wide perceive their REI knowledge to be poor. We aimed to assess whether an interactive case-based group-learning curriculum would narrow the REI knowledge gap by improving understanding and retention of core REI concepts under the time constraints affecting residents. A three-hour case-based workshop was developed to address four primary CREOG objectives. A multiple-choice test was administered immediately before and after the intervention and 7 weeks post-workshop, to evaluate both knowledge and confidence. Following the intervention, residents self-reported increased confidence with counseling and treatment of PCOS, ovulation induction cycle monitoring, counseling and treatment of POI, and breaking bad news related to infertility (p < 0.05). The multiple-choice exam was re-administered 7 weeks post-intervention, and scores remained significantly improved compared to pre-workshop scores (p < 0.05). At that time, all residents either strongly agreed (91.7%) or agreed (8.3%) that the case-based interactive format was preferable to traditional lecture-based teaching. In conclusion, a nontraditional curriculum aimed at teaching core REI concepts to residents through interactive case-based learning can be successfully integrated into a residency curriculum, and significantly improves knowledge and confidence of critical concepts in REI.