Faculty Bibliography

The use of planned oocyte cryopreservation for nonmedical need has been steadily increasing, especially since the experimental label on this procedure was lifted nearly 10 years ago. With this rise, patients' desires to postpone or conserve their reproductive potential have become increasingly nuanced, and the need for complex individualized counseling has grown. In addition, there are several ethical considerations, including risks, access, and patient comprehension that must be discussed with patients who are considering this procedure. In this review, we provide an in-depth discussion of these concepts, highlighting the need for individualized and comprehensive counseling that recognizes the gaps in knowledge that remains in this somewhat novel domain.

Background/UNASSIGNED:The opportunity for fertility preservation in adolescent and young adult (AYA) transmen is growing. Many AYA transmen desire future biologic children and are interested in ways to preserve fertility through oocyte cryopreservation prior to full gender affirmation, yet utilization of oocyte cryopreservation remains low. Additionally, standard practice guidelines currently do not exist for the provision of oocyte cryopreservation to AYA transmen. Our objective was to review our experience with oocyte cryopreservation in adolescent and young adult transmen in order to synthesize lessons regarding referral patterns, utilization, and oocyte cryopreservation outcomes as well as best practices to establish treatment guidance. Methods/UNASSIGNED:This is a case series of all AYA transmen (aged 10 to 25 years) who contacted, consulted or underwent oocyte cryopreservation at a single high volume New York City based academic fertility center between 2009 and 2021. Results/UNASSIGNED:Forty-four adolescent and young adult transmen made contact to the fertility center over the study period. Eighty percent (35/44) had a consultation with a Reproductive and Endocrinology specialist, with a median age of 16 years (range 10 to 24 years) at consultation. The majority were testosterone-naive (71%, 25/35), and had not pursued gender affirming surgery (86%, 30/35). Expedited initiation of testosterone remained the most commonly cited goal (86%, 30/35). Fifty-seven percent (20/35) pursued oocyte cryopreservation. Ninety-five percent (19/20) underwent successful transvaginal oocyte aspiration, with a median of 22 oocytes retrieved and 15 mature oocytes cryopreserved. There were no significant adverse events. At time of review, no patient has returned to utilize their cryopreserved oocytes. Conclusions/UNASSIGNED:Oocyte cryopreservation is a safe fertility preservation option in AYA transmen and is an important aspect of providing comprehensive transgender care. Insights from referral patterns, utilization, and oocyte cryopreservation outcomes from a single center's experience with adolescent and young adult transmen can be integrated to identify lessons learned with the goal of providing transparency surrounding the oocyte cryopreservation process, improving the education and comfort of patients and providers with fertility preservation, and easing the decision to pursue an oocyte cryopreservation cycle in parallel to gender-affirmatory care.

Objective/UNASSIGNED:To characterize activity, text sentiment, and online community characteristics regarding "fertility" on Twitter before and during the COVID-19 pandemic using social network analysis. Design/UNASSIGNED:Cross-sectional analysis. Setting/UNASSIGNED:Publicly available Twitter data. Patients/UNASSIGNED:Not applicable. Interventions/UNASSIGNED:Not applicable. Main Outcome Measures/UNASSIGNED:Number of users (vertices); edges (connections, defined as unique and total); self-loops (tweet without connection to another user); connected components (groups of users communicating back and forth frequently); maximum vertices in a connected component (largest group size); maximum and average geodesic distance (number of tweets to connect two users in the network); graph density; positive and negative sentiment tweets; and top 5 hashtags and top 5 word pairs. Results/UNASSIGNED:There were 1426 unique users and 401 groups in the pre-COVID-19 data compared to 1492 unique users and 453 groups in the during COVID-19 data. There was no difference in the number of total connections (96.8% [1381/1426] vs. 96.0% [1433/1492]) or self-loops (20.0% [286/1426] vs. 22.1% [329/1492]) before and during the COVID-19 pandemic. The percentage of unique connections per user decreased during COVID-19 (91.6% [1381/1508] pre-COVID-19 vs. 83.3% [1433/1720] during COVID-19). The average and maximum distance between users in the community increased during COVID-19 (maximum: 5 pre-COVID-19, 8 during COVID-19; average 1.95 pre-COVID-19, 2.43 during COVID-19). The percentage of positive sentiments per total number of tweets increased during COVID-19 (58.1% pre-COVID-19 [773/1331] vs. 64.3% [1198/1863] during COVID-19). The top 5 hashtags changed during COVID-19 to include COVID-19. The top word pairs changed from "family, hereditary; parents, children" to "fertility, treatment; healthcare, decisions." Conclusions/UNASSIGNED:Despite the challenge to the fertility community amidst the COVID-19 pandemic, the overall Twitter sentiment regarding fertility was more positive during than before the pandemic. Top hashtags and word pairs changed to reflect the emergence of COVID-19 and the unique healthcare decision-making challenges faced. While the character, the number of users, and the total connections remained constant, the number of unique connections and the distance between users changed to reflect more self-broadcasting and less tight connections.

Objective/UNASSIGNED:To determine if recent evolutions in laboratory protocols, including the increased use of natural cycles and the use of a hyaluronan-containing transfer medium, affected the rate of monozygotic twin (MZT) pregnancies after single frozen embryo transfer (FET). Design/UNASSIGNED:Retrospective cohort study. Setting/UNASSIGNED:Urban university-based fertility center. Patients/UNASSIGNED:Patients who underwent single FET between January 2016 and December 2018 resulting in an intrauterine pregnancy. Interventions/UNASSIGNED:Transition to a transfer protocol with a hyaluronan-containing transfer medium in July 2017. Main Outcome Measures/UNASSIGNED:Number of MZT pregnancies. Results/UNASSIGNED:There were 1,619 cycles that met the inclusion criteria and 31 (1.9%) resulted in MZT pregnancies. A hyaluronan-containing transfer medium was used in 875 (54.1%) cycles. Programmed cycles were used for 1,385 (85.5%) FETs and 234 (14.5%) cycles were natural. The mean age at FET, oocyte age, endometrial echo thickness, inner cell mass grade, trophectoderm grade, expansion, and day of blastocyst vitrification were similar between the groups. The use of a hyaluronan-containing transfer medium resulted in fewer MZTs. After controlling potential confounders with a multivariate regression, the use of the hyaluronan-containing medium still resulted in fewer MZTs. Monozygotic twins were colinear with preimplantation genetic testing (PGT), so PGT was excluded as a variable in our regression. A regression of PGT only cycles showed that the use of the hyaluronan-containing medium was still associated with a reduction in MZT pregnancies. Conclusions/UNASSIGNED:The use of a hyaluronan-containing transfer medium was associated with a lower rate of MZTs. Other clinical parameters, including cycle type, were not associated with changes in the number of MZTs. The use of PGT needs to be further investigated as a risk factor for MZTs.

OBJECTIVE:To evaluate the prevalence of coronavirus disease 2019 (COVID-19) and efficacy of a universal screening program in patients undergoing controlled ovarian stimulation (COS). DESIGN:Single-center retrospective cohort study. SETTING:Academic fertility center in an epicenter of the COVID-19 pandemic. PATIENT(S):All patients undergoing COS from June 17, 2019, to February 28, 2021. INTERVENTION(S):Universal COVID-19 screening starting June 17, 2020, with SARS-CoV-2 polymerase chain reaction testing within 5 days of oocyte retrieval, patient-reported symptom screening, and temperature monitoring. MAIN OUTCOMES MEASURE(S):The primary outcome was the number of positive COVID-19 cases in patients undergoing COS cycles. The secondary outcomes were cycle outcomes compared with before COVID-19 COS cycles, adverse outcomes in COVID-canceled cycles, and center-specific COVID-19 detection rates compared with New York City cases. RESULT(S):From June 17, 2020, to February 28, 2021, 1,696 COS cycles were initiated with only seven positive COVID-19 cases for an overall positivity rate of 0.4%. When compared with before COVID cycles from June 17, 2019, to February 28, 2020, the volume of COS cycles were higher, while the overall cycle cancelation rate was lower during COVID-19. Cycle outcomes including oocyte yield and blast utilization rates were unchanged from pre-COVID cycles. Cases of COVID-19, while very low, occurred more frequently during surges in New York City rates. CONCLUSION(S):Assisted reproductive technology can be performed during the COVID-19 pandemic utilizing frequent universal screening and safe practices with low SARS-CoV-2 positivity, low cycle cancelation rates, and positive patient outcomes.

OBJECTIVE: AO cryopreservation (cryo) is widely used, but published thaw data is scarce. We reviewed our elective AO thaws. MATERIALS AND METHODS: Pts who thawed AOs at our FC in 2004- 2020 were reviewed. Pts were excluded if AO cryo was performed for a medical reason, as research, due to no sperm or a natural disaster, with embryo cryo or for use with a gestational carrier. Outcomes included implantation (IR), spontaneous abortion (SABR) and ongoing pregnancy + live birth (LBR) rates / embryo transfer (ET). We calculated a final LBR (FLBR) defined as LBR / pt; FLBR only included pts who a) had live birth (LB) or ongoing pregnancy (OP), or b) consumed all AOs and resultant embryos. Statistics included Mann-Whitney U and Fisher's exact test.
RESULT(S): 543 pts (median age at 1st cryo 38y) underwent 800 cryos (89% our FC, 9% elsewhere, 2% both), 605 thaws and 416 ETs. Cryo used vitrification for 72%, slow freezing for 4% and both for 24% of pts. Median time from 1st cryo to 1st thaw was 4y. In total, we thawed 8511 AOs (7492 M2s). AO survival was 79%, M2 survival was 80% and 2PN fertilization was 66%. When pts returned for thaw, 25% pursued fresh ET, 73% pursued preimplantation genetic testing (PGT), and 2% pursued a combination of both. In pts who pursued fresh ET, 92% had >=1 embryo for ET. In pts who pursued PGT, 57% had >=1 euploid. 13% of pts had no useable embryos (embryos for fresh ET, PGT, cryo). 59% of pts had >=1 ET. 37% of ETs were fresh, with 2% using rush-PGT. 63% of ETs were frozen, with 97% using PGT. In non-biopsied ETs, IR was 29%, SABR was 19% and LBR was 31%. In euploid ETs, IR was 64%, SABR was 10% and LBR was 55%. In our cohort, FLBR was 38%. In total, 178 babies (11 twin, 1 triplet) and 24 OPs resulted. 176 pts have >=1 LB or OP, and 23 pts have >=2 LBs or OPs from AO thaw. 33% of pts have remaining AOs or euploid or untested embryos; 45% of these pts do not have a LB or OP from AO thaw. See table for outcomes by age.
CONCLUSION(S): AO thaw leads to a FLBR of 38%, comparable to our FC's 34% LBR per intended retrieval in pts of similar age1 . IMPACT STATEMENT: Our real thaw data may be more useful than models in pt counseling

OBJECTIVE: Current data conflicts on ART outcomes in pts with 1O. Furthermore, data is limited evaluating embryo quality in these pts. We assessed number of mature oocytes (M2s) and total oocytes retrieved, embryo quality, and embryo transfer outcomes in pts with 1O compared to 2O. MATERIALS AND METHODS: We performed a retrospective cohort study of all pts with 1O who underwent ART at one academic institution from 2012-2020. Pts were 3-to-1 matched to 2O controls by age, ART cycle type (oocyte freezing vs. embryo banking/in vitro fertilization) and number of ART cycles. Our primary outcome was number of M2s. Secondary outcomes included AMH and day 2 FSH prior to first cycle, number of retrieved oocytes, %M2s, 2PN fertilization rate, blastocyst formation rate (BFR), number of euploid embryos, euploidy rate, clinical pregnancy rate per pt (CPR), and live birth rate per pt (LBR). Subgroup analyses were performed comparing left vs. right ovary in situ and reason for loss of 1O. Mann-Whitney, Kruskal-Wallis, Fisher's exact, and Wilcoxon signed-rank tests were used for statistics; with p<0.05 considered significant.
RESULT(S): 104 pts (158 cycles) with 1O were matched to 312 pts (474 cycles) with 2O. Reasons for loss of 1O were torsion (18%), benign cyst (30%), malignant tumor (46%), and congenital absence (6%). Median pt age was 35.5y vs. 35.0y in pts with 1O vs. 2O (p=0.9). AMH was lower (median 1.1 vs 2.2, p<0.01) and day 2 FSH was higher (median 7.4 vs 6.2, p<0.01) in pts with 1O. See Table 1 for outcomes. Pts with 1O had fewer M2s and oocytes retrieved than pts with 2O; however, pts with 1O had more than half the number of M2s and oocytes retrieved than in pts with 2O (Z >5.8, p<0.01). The % M2s, 2PN fertilization rate, and BFR did not differ among groups. The median number of euploid embryos was 1.0 in each group, with a trend towards more euploids in pts with 2O (mean 2.0 vs 1.3, p<0.03). However, euploidy rate, CPR, and LBR did not differ among groups. Among 1O subgroups (left vs. right and reason for 1O), number of M2s, euploidy rate, CPR, and LBR did not differ.
CONCLUSION(S): Pts with 1O had fewer M2s and oocytes retrieved than pts with 2O; however, had more than 50% of the number of M2s and oocytes retrieved in pts with 2O, suggesting a compensatory mechanism in the solitary ovary. In pts with 1O compared to 2O, oocyte and embryo quality, euploidy rate, and embryo transfer outcomes were similar. IMPACT STATEMENT: Pts with 1O can be counseled that, while ART cycles may yield fewer M2s and oocytes, there is no decrease in embryo quality and LBR compared to pts with 2O. (Table Presented)

OBJECTIVE: The rise of the SARS-CoV-2 pandemic and temporary closures of fertility centers made the effect on POC cycles uncertain but garnered national attention1,2. We sought to assess the impact of the pandemic on POC cycles in a pandemic epicenter. MATERIALS AND METHODS: This is a retrospective cohort study of all POC cycles at an academic fertility center in New York City from 1/1/2019- 12/31/2020. Primary outcomes were number of POC patients (pts) and cycles. Secondary outcomes were pt relationship status, payment method, AMH, and cycle parameters; with subgroup analyses by age groups. We also examined the relationship between monthly number of POC cycles and national SaRS-CoV-2 cases. Statistical analyses included z-score analysis, Mann-Whitney, and Chi-squared, with p<0.05 significant.
RESULT(S): Despite a 5.5 week center closure in 2020, POC pts increased 14% and POC cycles increased 16% from 2019 to 2020 (Table), with a 32% increase seen between June-Dec, 2020 . There was a 28% increase in POC pts <37yo in 2020 (252 pts vs. 323 pts, p<0.04) and no change in pts >37yo in 2020 (p=0.9). Relationship status did not differ between years (16% partnered, 76% single, 8% unknown in 2019 vs. 16% partnered, 73% single, 11% unknown in 2020; p=0.6). Fewer patients in 2020 had insurance coverage (16% vs. 24%, p<0.001). AMH was higher in 2020 (2.3 vs. 2.1, p<0.03), but days of stimulation, oocytes retrieved, oocytes frozen, total gonadotropins, and maximum estradiol (E2) were not different (Table). While national SARS-CoV-2 cases peaked in April, July, and November 2020, monthly POC cycles at our center did not decrease with surges in SARS-CoV-2 after our center reopened in May (p=0.24). In 2020 there were 23 cycles cancelled, none due a positive SARS-CoV-2 test.
CONCLUSION(S): POC volume increased at our center in 2020, especially in young patients, despite center closures and SARS-CoV-2 surges. IMPACT STATEMENT: More young people pursued POC despite the SARS-CoV-2 pandemic. Further research is needed to understand POC pt motivations and experiences during a pandemic. (Table Presented)

OBJECTIVE: Social media is a popular way to disseminate new information and opinions, perhaps furthered by the COVID-19 pandemic and quarantine. Our objective was to analyze information and sentiments posted regarding the COVID-19 vaccine (VAX) on fertility-related social media. MATERIALS AND METHODS: The search function of Instagram (IG) and Twitter (TW) was used to identify the first fifty accounts with the following terms: fertility doctor, fertility, OBGYN, infertility, TTC, and IVF. Accounts not in English, private, no posts in >1 year, or content unrelated to search terms were excluded. Accounts were evaluated for author type and categorized as physician (PH), individual (ID), or fertility center/fertility-related organization (FCO). Account demographics including number of followers and prior baseline post activity (number of likes/number of followers) were recorded. The VAX was approved on 12/11/2020 and posts dated 12/1/2020 - 2/28/2021 were reviewed. Posts mentioningthe VAX were analyzed for content: sentiment (positive, negative, or neutral), mention of research studies (RS), national guidelines (NG), personal experience (PE), side effects (SE), reproductive related (RR) content and post activity. Statistical analysis included Chi-Squared and Fisher's exact tests, with significance set to <0.05 (*).
RESULT(S): 536 accounts were identified and 276 were included (133 IG and 143 TW). There were 104 PH accounts (45 IG, 59 TW), 91 ID accounts (62 IG, 29 TW), and 81 FCO accounts (26 IG, 55 TW). PH accounts were most associated with mention of COVID (83.7%*) and VAX (68.3%*), followed by FCO (37% COVID*, 30.9% VAX*), and ID (8.8% COVID*, 6.6% VAX*). PH was most associated with >1 VAX posts compared to FCO or ID (51.0% v 11.1% v 1.0%*). Sentiments toward the VAX were largely positive for all groups (PH 90.3%, ID 71.4%, FCO 70%), or neutral (PH 9.7%, ID 28.6%, FCO 30%), with no negative posts identified. Trends in mentions and sentiments were similar on both IG and TW platforms. PH cited NG (24.6%*) and RS (17.5%) more than ID and FCO, with most cited guidelines from ACOG, ASRM, and SMFM. ID posts were mostly PE (87.5%*) and SE (57.1%*). RR posts were most associated with FCO accounts (80%*) which included pregnancy, infertility, and breastfeeding. Sub-group analysis of IG accounts showed an increase in activity on VAX posts compared to baseline by likes (PH 4.86% v 3.76%, ID 7.5% v 6.37%, FCO 2.49% v 0.52%) as well as comments (PH 0.35% v 0.28%, ID 0.90% v 0.69%, FCO 0.10% v 0.02%).
CONCLUSION(S): Overall, the majority of posts expressed positive sentiments toward the VAX with no negative posts identified. PH were most likely to post about COVID-19, the VAX and guidelines. Few ID accounts posted but when present were about personal experiences or side effects and remained positive. IMPACT STATEMENT: There is an active conversation regarding COVID-19 and VAX information on social media, with the majority of posts expressing positive sentiment. Physicians play a large role in circulating information regarding the VAX on social media platforms, and can be influential in discussions of VAX guidelines and dispelling fertility myth