Faculty Bibliography

Objective: Several patient populations prefer to avoid TV monitoring for comfort or to prevent dysphoria. The purpose of this study is to compare TA and TV ultrasound as a means of determining cycle trigger timing and predicting oocyte maturity based on scans performed during ART cycles in this patient population.
Material(s) and Method(s): This was a retrospective cohort study of 59 patients who underwent >= 1 ART cycle at a single academic center. The study group consisted of patients who preferred TA monitoring based on any of 3 following inclusion criteria: 1) if they were virginal, 2) identified as transgender or 3) had a diagnosis of vaginismus. The control group included patients within this cohort that had no preference for TA imaging and thus underwent exclusive TV imaging. Demographics and variables included age, body mass index (BMI), antral follicle count (AFC) and anti-mullerian hormone (AMH), day 2 estradiol (D2 E2) and follicle-stimulating hormone (FSH) levels, # scans per cycle, # stimulation days per cycle, estimated # follicles and follicle sizes at trigger, # eggs retrieved, and oocyte maturity rate. Primary outcomes were 1) % difference between estimated # follicles at trigger and # oocytes retrieved, 2) # oocytes retrieved, and 3) % maturity. Secondary outcomes included % difference between AFC and # oocytes retrieved. Kolmogorov-Smirnov test was used to determine normality with independent sample t-tests and Mann Whitney U-Tests were used where appropriate with p<0.05 considered significant.
Result(s): 59 patients (n=18 TA; n= 41 TV) were included in the analysis. 27.1% (n=9 TA; 7 TV) were virginal, 50.8% (6 TA; 24 TV) had vaginismus and 37.3% (10 TA; 12 TV) identified as transgender. Some patients met 2 criteria (virginal + vaginismus, transgender + virginal, or transgender + vaginismus). Patients in the TA group were significantly younger than those in the TV group (26.2 TA v 37.8 years TV, p<0.001). Median BMI (22.4 TA v 23.7 kg/m² TV, p=0.26) and AMH (2.9 TA v 2.7 ng/mL TV, p=0.99) were similar. There was no statistical significance in mean AFC (12.8 +/- 9.2 TA, 13.6 +/- 8.2 TV, p=0.18). Patients in both groups had similar median D2 E2 (32.0 TA v 41.1 TV pg/mL, p=0.23) and FSH (5.6 TA v 7.2 mIU/mL TV, p=0.23), # scans per cycle (5 TA v 5 TV, p=0.88), and # stimulation days (11 TA v 11 TV, p=0.74). The TA group had higher mean E2 at trigger (3488.5 +/- 1087.0 TA, 2566.1 +/- 1416.1 pg/mL TV, p<0.002). There was no significant difference between estimated # follicles at trigger and # oocytes retrieved (17.7 +/- 31.4% TA, 6.7 +/- 38.0% TV; p= 0.29). Mean # oocytes (21.3 +/- 10.8 TA, 15.9 +/- 8.8 TV, p= 0.05) and median % mature oocytes (0.89 TA, 0.83 TV; p= 0.12) were also similar. Median % difference between AFC and # oocytes retrieved was not significantly different (0.68 TA, 0.82 TV; p= 0.18).
Conclusion(s): TA and TV imaging do not differ in their ability to predict FP cycle characteristics, oocytes retrieved or oocyte maturity rate. TA imaging may offer an acceptable alternative for patients uncomfortable with TV imaging during FP. Impact Statement: TA monitoring for oocyte cryopreservation does not adversely affect oocyte yield in patients with preference against TV imaging.
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Objective: Infertility affects >100 million people worldwide; improving FC access is essential, especially for low socioeconomic and minority groups. In NYC's public hospital system, patients (pts) are referred to a fellow-led reproductive endocrinology and infertility (REI) clinic that provides consults, work-ups and ultrasound-monitored controlled ovarian hyperstimulation and ovulation induction (OI). REI referrals (REF) are in high demand limiting appointment (appt) availability¹ with new pts waiting >5 months. We developed a QIP to identify pts for OI counseling and initiation in GYN clinic.
Material(s) and Method(s): REI fellows screened all REFs, and scheduled eligible pts in GYN. QIP criteria: age <38 years (y); anti-Mullerian hormone (AMH) >2ng/mL; normal prolactin, thyroid function and hemoglobin A1C; no known reproductive issues/comorbidities requiring high risk obstetrics; <3 prior OI cycles. Eligible pts received early follicular letrozole 2.5mg for 5 days (d) in GYN and were then followed in REI's OI program. Non-eligible pts were scheduled in REI. To assess effectiveness, we retrospectively compared all REF outcomes from PRE-(3/1/21-5/31/21) to POST-(9/1/21-11/30/21) QIP as of 2/14/22. A transition period (6/1/21-8/31/21) was excluded. Primary outcome was time from REF to scheduled appt. Secondary outcomes included time from REF to OI prescription/cycle start. Statistics included Mann-Whitney, Chi-square, Fischer's exact and Two-sample t tests (p<0.05 significant).
Result(s): PRE (n=121) and POST (n=102) REFs had similar median ages [36 (interquartile range (IQR): 32-39) PRE vs 35y (IQR: 31-40) POST, p=0.73], ethnic/racial identity [56.2% (68/121) PRE vs 53.9% (55/102) POST Hispanic (p=0.79); 34.7% (42/121) PRE vs 30.4% (31/102) POST Black (p=0.59)], and rates of no prior FC [88.4% (107/121) PRE vs 93.1% (95/102) POST, p=0.15]. QIP identified pts for GYN who were younger [median age 29 (IQR: 27-33) vs 38y (IQR: 33-41), p<0.01], had higher AMHs [median 3.065 (IQR: 2.315-4.883) vs 1.230 ng/mL (IQR: 0.513-3.630), p<0.01], and had fewer comorbidities [100% (19/19) vs 72.5% (50/69), p<0.01] compared to REI. After QIP implementation, median time from REF to scheduled appt decreased from PRE 151 (IQR: 125-173) to POST 98d (IQR: 73-137) (p<0.01). For pts seen in clinic thus far, median time from REF to OI prescription decreased from 150 (IQR: 122-173) to 82d (IQR: 63-119) (p<0.01) and to 1st follicle check from 202 (IQR: 159-221) to 107d (IQR: 98-115) (p<0.04). In the POST cohort, 86.3% (88/102) of REFs had visits scheduled, with 21.6% (19/88) in GYN and 78.4% (69/88) in REI. OI was started at initial visit for 61.5% (8/13) of GYN pts vs 25.8% (8/31) of REI pts (p<0.04). 38.5% (5/13) of GYN pts met criteria for QIP, but were pending >1 blood test, while 51.6% (16/31) of REI pts were pending further work-up.
Conclusion(s): Our QIP expedited FC for all pts by reducing the time from REF to scheduled fertility appt by 35% (median of 53d) and to OI prescription/cycle start by nearly 45% (medians of 68d/95d). Impact Statement: Similar OI pathways could improve access to FC for underserved populations in broader practice settings. REFERENCES: 1 Blakemore JK, Maxwell SM, Hodes-Wertz B, Goldman KN. Access to infertility care in a low-resource setting: bridging the gap through resident and fellow education in a New York City public hospital. J Assist Reprod Genet. 2020 Jul;37(7):1545-1552.
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Objective: The use of GnRH-a trigger in antagonist controlled ovarian hyperstimulation (COH) cycles has increased due to its enhanced safety profile. However, response, as measured by the serum LH level post trigger, vary considerably^1-6. We investigated the impact of serum LH response to GnRH-a trigger in antagonist COH cycles on oocyte yield, oocyte maturity, blastocyst formation, PGT-A and pregnancy outcomes.
Material(s) and Method(s): This is a retrospective cohort study in a single university-based fertility center of all GnRH-antagonist COH cycles utilizing GnRH-a alone or in combination with 1000u of human chorionic gonadotropin (hCG) for trigger from 2017 to 2020. An optimal response to GnRH-a trigger was defined as LH >= 40 mIU/mL and suboptimal response was defined as LH < 40 mIU/mL on the morning after trigger. Subanalyses with responses of LH >= 15 mIU/mL and LH < 15 mIU/mL were also performed. Primary outcomes included oocyte yield, oocyte maturity rate, blastocyst formation rate, euploidy rate, aneuploidy rate and simple mosaic rate. Secondary outcomes included biochemical pregnancy rate (BPR), spontaneous abortion rate (SABR) and ongoing/pregnancy live birth rate (OP/LBR). Primary and secondary outcomes were also stratified by age, race and BMI. Descriptive statistics (median +/- range for continuous variables), Mann Whitey U and Fisher's Exact tests were performed accordingly with p<0.05 defined as significant.
Result(s): This study included 3,833 retrieval cycles with 1,435 single thawed euploid embryo transfers (STEET) among 2,618 patients. Ten percent (351/3446) of retrieval cycles had suboptimal and 90% (3446/3833) had optimal response to GnRH-a trigger. There was no difference in median oocyte yield (16 vs 17 oocytes per cycle, p=0.92), or oocyte maturity (77% vs 76%, p=0.43), fertilization (76% vs 77%, p=0.48) and blastocyst formation (51% vs 52%, p=0.88) rates by response. There were no significant differences in the rate of euploidy (35% vs 39%, p=0.55), aneuploidy (51% vs 47%, p=0.56) and simple mosaic (11% vs 11%, p=1) between groups. Seven percent (102/1435) of STEETs utilized embryos from a cycle with suboptimal response and 93% (1333/1435) from optimal response to GnRH trigger. There were no significant differences in BPR [19/44 (14%) vs 164/1907 (9%), p=0.2], SABR [11/144 (8%) vs 152/1907 (8%), p=1] and OP/LBR [85/144 (59%) vs 1127/1907 (59%), p=1]. No differences in pregnancy outcomes were found in the subanalyses of LH >= and < 15 mIU/mL and when data were stratified by SART age ranges, race and BMI.
Conclusion(s): A suboptimal response to GnRH-a trigger (LH < 40) is not associated with lower oocyte yield, oocyte maturity rate, blastocyst rate, euploidy rate or worse pregnancy outcomes compared to an optimal response (LH >= 40). Additional studies with larger cohorts are needed to further investigate these findings and with different thresholds of response. Impact Statement: A suboptimal LH response to GnRH-a trigger may not predict poor cycle outcomes. Providers should not hesitate to use GnRH-a trigger, especially in patients with identifiable risk factors for ovarian hyperstimulation syndrome (OHSS)⁷. Support: None.
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Objective: When counseling patients regarding the use of PGT-A, it is unclear whether ploidy rates among INF pts who undergo PGT-A are comparable to FT pts¹. Our objective was to evaluate PGT-A outcomes in FT compared to INF pts.
Material(s) and Method(s): This is a retrospective cohort study of the first IVF cycle of all FT pts (pts without a diagnosis of infertility) who underwent PGT-A at one academic center from 2016-2021. Pts were 3-to-1 matched by age and # of oocytes retrieved to the first cycle of INF controls. Primary outcome was euploidy rate, defined as #euploids per #biopsied blastocysts. Secondary outcomes were % mature oocytes (M2), 2PN fertilization rate, blastocyst formation rate (BFR), and # of euploid, aneuploid, and mosaic embryos. BMI, AMH, day 2 FSH and E2, total gonadotropin (GND) dose, and stimulation days were compared. Subgroup analyses compared % mosaic, aneuploid, and no diagnosis embryos. Statistical analysis included Mann-Whitney U, Fisher's exact, Chi squared tests, and multiple linear regression (p<0.05 significant).
Result(s): 283 FT pts (reason for PGT-A: 64% embryo banking, 36% single gene disorders) were matched to 849 INF pts. Median age, AMH, and day 2 E2 were equivalent among groups (p>0.1). In FT pts, median day 2 FSH was higher (6.9 vs. 6.5, p<0.01) and median BMI was lower (22.1 vs. 22.5, p<0.05). FT pts received higher median doses of GNDs (3450 vs. 3150 IUs, p<0.01), but had similar median stimulation days (p=0.19). Median number of oocytes retrieved, M2s retrieved, and biopsied blastocysts did not differ among groups (p>0.29); nor did %M2s or BFR (p>0.06). 2PN fertilization was higher in FT pts (77.7 vs. 76.2%, p<0.05). See Table for PGT-A outcomes. Euploidy rate was higher in FT pts; among non-euploid embryos, INF pts had lower aneuploidy and higher mosaicism rates. The % of pts with >1 euploid embryo was similar in both groups. A multiple linear regression model continued to show the relationship between % euploid in FT vs. INF groups, while controlling for other significant covariates (BMI, total GNDs used, day 2 FSH, and 2PN fertilization rate).
Conclusion(s): FT pts had higher euploidy rates than INF pts, suggesting that infertility is associated with a lower euploidy rate. However, among non-euploid embryos, FT pts had higher aneuploidy and lower mosaicism rates compared to INF pts. An equivalent % of FT and INF pts yielded >1 euploid embryo. Impact Statement: FT pts undergoing PGT-A can be counseled that they may have a higher euploidy rate, but INF pts are just as likely to yield >1 euploid embryo. [Formula presented] Support: No financial support to disclose. REFERENCES: Kort JD, McCoy RC, Demko Z, Lathi RB. Are blastocyst aneuploidy rates different between fertile and infertile populations?. J Assist Reprod Genet. 2018;35(3):403-408.
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Objective: Patients with 5 or fewer follicles during IVF face a difficult choice: should they cancel the cycle or proceed to retrieval? Limited data exist to guide this decision. This study evaluates LBRs for retrievals with <=5 follicles at trigger.
Material(s) and Method(s): This retrospective cohort study from an academic fertility center reviewed all IVF cycles yielding <=10 oocytes from 2016-2020. Cycles were included if <=5 follicles measuring >=14 mm were verified at trigger. The primary outcome was rate of ongoing pregnancy or live birth per retrieval (LBR) after fresh or frozen transfer. Secondary outcomes were number of oocytes, mature oocytes (M2s), 2 pronuclear zygotes (2PNs), blastocysts for transfer or biopsy and euploid blastocysts (if preimplantation genetic testing for aneuploidy (PGT) was used). Statistics included Chi-squared, Fisher's exact and Kruskal Wallis tests (p<0.05 significant).
Result(s): 1502 cycles (900 with PGT) from 972 patients were included. Median age was 40 years (y) (range: 26-48). See table for outcomes. Mean oocytes, M2s, 2PNs, blastocysts and euploids differed by follicle number (FN) (p<0.001). Across all ages, there were differences in LBR associated with FN (p<0.001). For patients <35y, LBR did not differ by FN. In the 35-37y group, LBR with 2, 3 or 4 follicles was lower than LBR with 5 (p<0.01). In the 38-40y group, LBR with 3 follicles was lower than LBR with 4 or 5 (p<0.02). In the 41-42y group, LBR with 2 or 3 follicles was lower than LBR with 5 (p<0.02). In the >42y group, LBR with 4 follicles was lower than LBR with 5 (p<0.03). There were no other differences in LBR by FN.
Conclusion(s): We provide clear, specific outcomes for patients with <=5 follicles at trigger. As expected, LBR is higher with more follicles. Our data can guide patients with <=5 follicles as they weigh the emotional, physical and financial costs of retrieval. Impact Statement: Our results can help patients with 5 or fewer follicles decide whether to cancel or proceed to retrieval. Patients with <=3 follicles can be counseled that LBR is likely less than 20% if 35-40 years old and likely 5% or less if 41 years or older. [Formula presented]
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PURPOSE/OBJECTIVE:To assess assisted reproductive technology (ART) outcomes in patients with one ovary compared to two ovaries. METHODS:We performed a retrospective cohort study of all patients with one ovary who underwent ≥ 1 ART cycle between 2012 and 2020 at a large university-affiliated fertility center. Patients were 3-to-1 matched with two ovary controls during the same period. Primary outcome was metaphase II oocytes (MIIs) retrieved per cycle. Secondary outcomes included ovarian reserve markers, laboratory outcomes, and live birth rates (LBRs). RESULTS:A total of 104 one ovary patients (158 cycles; median age 35.5 years) were matched to 312 two ovary patients (474 cycles; median age 35.0 years). In one ovary patients, anti-Mullerian hormone was lower (median 1.1 vs. 2.2, p < 0.01) and day 2 follicle-stimulating hormone was higher (median 7.4 vs. 6.2, p < 0.01). One ovary patients yielded median 7.5 MIIs and 10 oocytes per cycle, fewer than two ovary patients (11.0 and 14.5, respectively; p < 0.01). However, one ovary patients had ≥ 50% the MII and oocyte yield of two ovary patients (Z > 5.8, p < 0.01). Fertilization and blastocyst formation rates, euploidy rate, and rate of ≥ 1 embryo for transfer were equivalent between groups (p > 0.40). Among the one and two ovary groups, LBRs per transfer (45.8% vs. 46.6%, p = 1.00) and per patient who underwent transfer (68.3% vs. 73.9%, p = 0.55) were equivalent. CONCLUSION/CONCLUSIONS:One ovary patients yielded fewer MIIs and oocytes than two ovary patients, but had ≥ 50% the yield of two ovary patients, suggesting a compensatory mechanism in oocyte yield in the solitary ovary. One and two ovary patients had equivalent LBRs.

OBJECTIVE:To review the outcomes of patients who underwent autologous oocyte thaw after planned oocyte cryopreservation. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Large urban university-affiliated fertility center. PATIENT(S)/METHODS:All patients who underwent ≥1 autologous oocyte thaw before December 31, 2020. INTERVENTION(S)/METHODS:None. MAIN OUTCOME MEASURE(S)/METHODS:The primary outcome was the final live birth rate (FLBR) per patient, and only patients who had a live birth (LB) or consumed all remaining inventory (cryopreserved oocytes and resultant euploid/untested/no result embryos) were included. The secondary outcomes were laboratory outcomes and LB rates per transfer. RESULT(S)/RESULTS:A total of 543 patients underwent 800 oocyte cryopreservations, 605 thaws, and 436 transfers. The median age at the first cryopreservation was 38.3 years. The median time between the first cryopreservation and thaw was 4.2 years. The median numbers of oocytes and metaphase II oocytes (M2s) thawed per patient were 14 and 12, respectively. Overall survival of all thawed oocytes was 79%. Of all patients, 61% underwent ≥1 transfer. Among euploid (n = 262) and nonbiopsied (n = 158) transfers, the LB rates per transfer were 55% and 31%, respectively. The FLBR per patient was 39%. Age at cryopreservation and the number of M2s thawed were predictive of LB; the FLBR per patient was >50% for patients aged <38 years at cryopreservation or who thawed ≥20 M2s. A total of 173 patients (32%) have remaining inventory. CONCLUSION(S)/CONCLUSIONS:Autologous oocyte thaw resulted in a 39% FLBR per patient, which is comparable with age-matched in vitro fertilization outcomes. Studies with larger cohorts are necessary.

The objective of this study was to describe the opinions and attitudes toward planned oocyte cryopreservation (POC) among Black Obstetrician Gynecologists (BOG) and their experiences in counseling patients of color. A web-based, cross-sectional survey was distributed to BOGs. The survey consisted of questions pertaining to personal family building goals, fertility preservation, education and patient counseling experiences regarding POC. Of the 136 potential participants, the response rate was 50% (n = 68). Sixty-six percent of respondents felt the need to postpone childbearing due to medical training and 19% had already undergone POC or planned to in the future. A majority (70%) felt that all women planning to undergo medical training should consider POC, and a subgroup analysis showed this was more likely to be reported within BOG trainees (p < 0.01). Fifty-seven percent received education on POC and 25% felt "very comfortable" counseling patients on POC. Those age < 35 years were more likely to feel the need to postpone family building due to their medical training (p < 0.01). Generalist attendings who had not undergone POC were significantly more likely to report regret, compared to subspecialists (p < 0.03). Medical careers may have an unfavorable impact on family building, and our results highlight this effect in Black women. A better understanding of the mitigating factors is needed to develop culturally appropriate counseling and educational interventions for Black women and other women of color.

PURPOSE/OBJECTIVE:Characterize outcomes among adolescents and young adults (AYAs) with sex chromosome disorders (SCDs) after oocyte cryopreservation (OC) consultation. METHODS:Retrospective case series of all AYA (< 25 years) patients with SCDs seen for OC consultation from 2011 to 2019 at a large, urban, academic fertility center. All AYA patients with an SCD seen for OC consult in the study time period were reviewed and included. Data collected included patient age, SCD type, number of patients who attempted OC, number of cycles attempted, and cycle outcomes. RESULTS:Twenty-two patients were included: 9 with Turner syndrome, 12 with mosaic Turner syndrome, and 1 with 47,XXX. Mean age at consult was 14.7 ± 3.5 years. Fourteen patients elected for OC: 5 with Turner syndrome, 8 with mosaic Turner syndrome, and 1 47,XXX who pursued 31 OC cycles total. Of those 14 patients, 10 underwent retrieval, 9 froze oocytes, and 8 froze mature (MII) oocytes. Seven patients underwent > 1 cycle and 7 had ≥ 1 cancelation. 3/3 patients who pursued cycles after 1st cancelation never got to retrieval. Age, SCD type, and baseline FSH did not predict ability to freeze MIIs. One patient returned after OC and attempted 4 ovulation induction cycles and 2 IVF cycles; all were canceled for low response. CONCLUSIONS:AYA patients with SCDs have a high risk of poor response and cycle cancelation but the majority froze MIIs. Thus, setting expectations is important. A larger sample size is needed to evaluate possible clinical predictors of success.

PURPOSE/OBJECTIVE:To determine whether sociodemographic differences exist among female patients accessing fertility services post-cancer diagnosis in a representative sample of the United States population. METHODS:All women ages 15-45 with a history of cancer who responded to the National Survey for Family Growth (NSFG) from 2011 to 2017 were included. The population was then stratified into 2 groups, defined as those who did and did not seek infertility services. The demographic characteristics of age, legal marital status, education, race, religion, insurance status, access to healthcare, and self-perceived health were compared between the two groups. The primary outcome measure was the utilization of fertility services. The complex sample analysis using the provided sample weights required by the NSFG survey design was used. RESULTS:Five hundred forty-five women reported a history of cancer and were included in this study. Forty-three (7.89%) pursued fertility services after their cancer diagnosis. Using the NSFG sample weights, this equates to a population of 161,500.7 female cancer survivors in the USA who did utilize fertility services and 1,811,955.3 women who did not. Using multivariable analysis, household income, marital status, and race were significantly associated with women utilizing fertility services following a cancer diagnosis. CONCLUSIONS:In this nationally representative cohort of reproductive age women diagnosed with cancer, there are marital, socioeconomic, and racial differences between those who utilized fertility services and those who did not. This difference did not appear to be due to insurance coverage, access to healthcare, or perceived health status.