Faculty Bibliography

OBJECTIVE: POC is underutilized by Black women and persons of color1 . We sought to describe the opinions and attitudes toward POC among BOGs and their experiences in counseling patients of color. MATERIALS AND METHODS: An anonymous survey was distributed to BOGs via separate listservs belonging to a BOG organization and a historically Black college/university in April 2021. The survey included 30 demographic and qualitative questions pertaining to personal family building goals, fertility preservation, and patient counseling experiences. Analyses included descriptive statistics and chi square test to compare answers across demographic, professional and subspecialty groups using SPSS (v25) with p<0.05 considered significant.
RESULT(S): Of the 136 potential participants, the response rate was 49% (n=67). The majority of respondents were female (93%) and heterosexual (93%). The mean age was 34.2 years. Attendings (ATT), fellows (FEL) and residents (RES) represented 47%, 17% and 36% of respondents, respectively. Fifty-four percent of ATTs were generalists. Subspecialties represented by ATTs and FELs included Maternal Fetal Medicine (24%), Minimally Invasive Gynecology (2%), Reproductive Endocrinology and Infertility (14%), and Urogynecology (8%). Sixty-six percent of subjects did not currently have children and 20% did not want children. Sixty-eight percent felt the need to postpone family building due to medical training, most commonly citing career plans (88%) and financial concerns (60%). Of the 41% who had tried to conceive in the past, 9% required fertility treatment. Nineteen percent had already undergone POC or planned to in the future. Most (70%) felt that all women planning to undergo residency +/- fellowship training should consider POC. Fifty-six percent reported receiving some form of education on POC and 22% felt ''very comfortable'' counseling patients on POC. Fifty-six percent had recommended POC to patients in the past. When asked to exclude cost, the most common reported personal barriers for POC were time (31%) and fear/stigma (22%) and the most common barriers for their patients of color were knowledge (41%) and fear/stigma (25%). Those <35 years were more likely to not have a child (p <0.01) and more likely to feel the need to postpone family building due to their medical training (p<0.01). RES and FELs were more likely to agree that all women planning medical training should consider POC (p<0.03). Generalist ATTs who had not undergone POC trended toward having more regret compared to subspecialists (p=0.05).
CONCLUSION(S): Medical careers can have an unfavorable impact on family building and our results highlight this effect in Black women and persons of color. Most BOGs think trainees may benefit from POC. Improved education and access to POC could support personalized reproductive planning. IMPACT STATEMENT: Considering the underutilization of POC among Black women1 and the increase in infertility among female physicians2 , a better understanding of the mitigating factors is important in order to develop culturally appropriate counseling and educational interventions for women of color

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

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: OC is widely used for fertility preservation. Many models predict the live birth (LB) rate of OC, but real-world data is lacking. We reviewed our LBs from OC to develop an OC counseling tool based on real outcomes. MATERIALS AND METHODS: We reviewed patients (pts) who thawed autologous oocytes (AOs) at our academic fertility center from 2004-2020. We included pts who: 1) had a LB or ongoing pregnancy (OP) >12 weeks at last contact, or 2) consumed all AOs and resultant embryos. Pts were excluded if they transferred AOs or resultant embryos to another center or if OC was performed for a medical reason, as research, due to no sperm or a natural disaster, combined with embryos or for use with a gestational carrier. We calculated OP + LB rate (LBR) based on number of AOs and metaphase II oocytes (M2s) thawed. Data were stratified by age (<38y vs. >=38y). For pts who underwent OC at <38y and >=38y, a weighted age was calculated (for each OC cycle, #AOs thawed was multiplied by age at OC; the sum of these numbers was then divided by total #AOs thawed). Statistics included Fisher's exact test (p<0.05 significant).
RESULT(S): We included 462 pts (median age at 1st OC 38.5y). Weighted ages were used for 21 pts (5%). Our pts underwent 650 OCs (90% our center, 9% elsewhere, 1% both), 512 thaws and 385 embryo transfers. OC involved vitrification for 72%, slow freezing for 4% and both for 24% of pts. A total of 7050 AOs and 6178 M2s were thawed. 38% of pts (n=176) have >=1 LB or OP from AO thaw. See table for outcomes. Pts who thawed 0-10 AOs had a lower LBR than pts who thawed 11-20, 21-30, or >30 AOs (p<=0.03). Pts who thawed 0-10 M2s had a lower LBR than pts who thawed 11-20 or 21- 30 M2s (p<=0.02). LBR was not significantly different between pts who thawed 11-20, 21-30, or >30 AOs or M2s.
CONCLUSION(S): Pts who thawed 0-10 AOs had a lower LBR (27%) than pts who thawed >10 AOs (LBR >= 43%), and pts who thawed 0-10 M2s had a lower LBR (30%) than pts who thawed > 10 M2s (LBR >= 42%), but LBR was not different with >10 thawed AOs. IMPACT STATEMENT: Our real-world OC outcomes are not consistent with LBRs in published models. These results provide more realistic expectations about OC outcomes and may help pts decide how many AOs to freeze

CONTEXT/BACKGROUND:Postpartum depression (PPD) is a serious psychiatric disorder. While causes remain poorly understood, perinatal sex hormone fluctuations are an important factor, and allopregnanolone in particular has emerged as a key determinant. While synthetic environmental chemicals such as bisphenols and phthalates are known to affect sex hormones, no studies have measured allopregnanolone and the consequences of these hormonal changes on PPD have not been interrogated. OBJECTIVE:To investigate associations of repeated measures of urinary bisphenols and phthalates in early- and mid-pregnancy with serum pregnenolone, progesterone, allopregnanolone, and pregnanolone concentrations in mid-pregnancy and PPD symptoms at four months postpartum. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION/UNASSIGNED:Prospective cohort study of 139 pregnant women recruited between 2016-18. Bisphenols and phthalates were measured in early- and mid-pregnancy urine samples. Serum sex steroid hormone concentrations were measured in mid-pregnancy. PPD was assessed at 4 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multiple informant models were fit using generalized estimating equations. MAIN OUTCOME MEASURES/METHODS:Serum levels of allopregnanolone, progesterone, pregnanolone, and pregnenolone were examined as log-transformed continuous variables. PPD symptoms were examined as continuous EPDS scores and dichotomously with scores ≥10 defined as PPD. RESULTS:Di-n-octyl phthalate (DnOP) and diisononyl phthalate (DiNP) metabolites were associated with reduced progesterone concentrations. Log-unit increases in ∑DnOP and ∑DiNP predicted 8.1% (95% Confidence Interval (CI): -15.2%, -0.4%) and 7.7% (95% CI: -13.3%, -1.7%) lower progesterone, respectively. ∑DnOP was associated with increased odds of PPD (odds ratio=1.48 (95% CI: 1.04, 2.11)). CONCLUSIONS:Endocrine disrupting chemicals may influence hormonal shifts during pregnancy as well as contribute to PPD.

OBJECTIVE:To evaluate the outcomes of planned oocyte cryopreservation patients most likely to have a final disposition. DESIGN/METHODS:Retrospective cohort study of all patients who underwent at least 1 cycle of planned oocyte cryopreservation between Jan 2005 and December 2009. SETTING/METHODS:Large urban University-affiliated fertility center PATIENT(S): All patients who underwent ≥1 cycle of planned oocyte cryopreservation in the study period. INTERVENTION(S)/METHODS:None MAIN OUTCOME MEASURE(S): Primary outcome was the disposition of oocytes at 10-15 years. Secondary outcomes included thaw/warming types, laboratory outcomes, and live birth rates. Outcomes and variables treated per patient. RESULT(S)/RESULTS:A total of 231 patients with 280 cycles were included. The mean age at the first retrieval was 38.2 years (range 23-45). A total of 3,250 oocytes were retrieved, with an average of 10 metaphase II frozen/retrieval. To date, the oocytes of 88 patients (38.1%) have been thawed/warmed, 109 (47.2%) remain in storage, 27 (11.7%) have been discarded, and 7 (3.0%) have been transported elsewhere. The return rate (patients who thawed/warmed oocytes) was similar by Society for Assisted Reproductive Technology age group. The mean age of patients discarding oocytes was 47.4 years (range, 40-57). Of the 88 patients who thawed/warmed oocytes, the mean age at the time of thaw/warming was 43.9 years (range, 38-50) with a mean of 5.9 years frozen (range, 1-12). Nine patients (10.2%) thawed/warmed for secondary infertility. A total of 62.5% of patients created embryos with a partner, and 37.5% used donor sperm. On average, 14.3 oocytes were thawed/warmed per patient, with 74.2% survival (range, 0%-100%) and a mean fertilization rate of 68.8% of surviving oocytes. Of 88 patients, 39 (44.3%) planned a fresh embryo transfer (ET); 36 of 39 patients had at least 1 embryo for fresh ET, and 11 had a total of 14 infants. Forty-nine of 88 patients (55.7%) planned for preimplantation genetic testing for aneuploidy, with a mean of 4.2 embryos biopsied (range, 0-14) and a euploidy rate of 28.9%. Of the 49 patients, 17 (34.7%) had all aneuploidy or no embryos biopsied. Twenty-four patients underwent a total of 36 single euploid ET with 18 live births from 16 patients. Notably, 8 PGT-A patients had a euploid embryo but no ET, affecting the future cumulative pregnancy rate. Overall, 80 patients with thaw/warming embryos had a final outcome. Of these, 20 had nothing for ET (arrested/aneuploid), and of the 60 who had ≥1 ET, 27 had a total of 32 infants, with a live birth rate of 33.8% (27/80). CONCLUSION(S)/CONCLUSIONS:We report the final outcomes of patients most likely to have returned, which is useful for patient counseling: a utilization rate of 38.1% and a no-use rate of 58.9%, similar across age groups. Further studies with larger cohorts as well as epidemiologic comparisons to patients currently cryopreserving are needed.

Objective/UNASSIGNED:To determine the impact of endometrial thickness on live birth outcomes and obstetric complication rate after hormone-replaced frozen embryo transfer. Design/UNASSIGNED:Retrospective cohort study. Setting/UNASSIGNED:Large, urban, academic fertility center. Patients/UNASSIGNED:All patients with a singleton live birth after single euploid embryo transfer (by array comparative genomic hybridization or next-generation sequencing) in a hormone-replaced frozen embryo transfer cycle between January 2017 and December 2018 were reviewed. Interventions/UNASSIGNED:None. Main Outcome measures/UNASSIGNED:The primary outcomes were birth weight and obstetric complication rate. Results/UNASSIGNED:A total of 492 patients were included. The median endometrial thickness was 8.60 mm (range, 6.0-20.0). The median gestational age at live birth was 39.4 weeks with a median birth weight of 3,345.2 g. Endometrial thickness was significantly correlated with birth weight. When patients were dichotomized into groups (those with an endometrial thickness of <7 mm and those with an endometrial thickness of >7 mm), neonates born from endometria with a thickness of <7 mm were born earlier (37.3 vs. 39.4 weeks and born with lower birth weights (2,749.9 vs. 3,345.2 g). It should be noted that only seven patients had an endometrium measuring <7 mm. Moreover, 7.1% (n = 35) of patients had an obstetric complication. Endometrial thickness was not significantly associated with obstetric complications, even with adjustments for age and medical history. Conclusions/UNASSIGNED:Endometrial thickness may be a valuable predictor of placental health and birth weight. Further study is required to examine the relationship with individual obstetric complications, as our study may not have been powered to observe differences in obstetric complication rate, as well as the relationship between endometrial thickness and outcomes in natural frozen embryo transfer cycles.

PURPOSE/OBJECTIVE:To characterize the demographic differences between infertile/sub-fertile women who utilized infertility services vs. those that do not. METHODS:A retrospective analysis of cross-sectional data obtained during the 2011-2013, 2013-2015, and 2015-2017 cycles of National Survey for Family Growth from interviews administered in home for randomly selected participants by a National Center of Health Statistics (NCHS) surveyor was used to analyze married, divorced, or women with long-term partners who reported difficulty having biological children (sub-fertile/infertile women). Demographic differences such as formal marital status, education, race, and religion were compared between women who presented for infertility care vs. those that did not. The primary outcome measure was presenting for infertility evaluation and subsequently utilizing infertility services. Healthcare utilization trends such as having a usual place of care and insurance status were also included as exposures of interest in the analysis. RESULTS:Of the 12,456 women included in the analysis 1770 (15.3%) had used infertility services and 1011 (8.3%) said it would be difficult for them to have a child but had not accessed infertility services. On univariate analysis, compared to women who used infertility services, untreated women had lower average household incomes (295.3 vs. 229.8% of the federal poverty line respectively). Untreated women also had lower levels of education and were more likely to be divorced or never have married. In terms of health status, unevaluated women were less likely to have a usual place for healthcare (87.3%) as compared to women presenting for fertility care (91.9%) (p = 0.004). When examining insurance status, 23.3% of unevaluated women were uninsured as compared to 8.3% of evaluated women. On multivariate analysis, infertile women without insurance were at 0.37 odds of utilizing infertility care compared to women with insurance. CONCLUSIONS:Demographic factors are associated with the utilization of infertility care. Insurance status is a significant predictor of whether or not infertile women will access treatment. Data from the three most recent NSFG surveys along with prior analyses demonstrate the need for expanded insurance coverage in order to address the socioeconomic disparities between infertile women who are accessing services vs. those that are not.

PURPOSE/OBJECTIVE:In the era of personalized medicine and the increased use of frozen embryo transfer (FET), assay of the endometrium's receptivity prior to transfer has gained popularity, especially among patients. However, the optimal timing for single thawed euploid embryo transfers (STEET) in a programmed FET has yet to be determined Mackens et al. (Hum Reprod. 32(11):2234-42, 2017). We sought to examine the outcomes of euploid FETs by length of progesterone (P4) exposure. METHODS:Prospective cohort study of programmed FETs of single euploid embryos between June 1, 2018, and December, 18, 2018, at our center. Subjects reported the exact start time for initiating progesterone. The transfer time was noted to calculate the primary independent variable, duration of progesterone exposure. Statistical analysis included ANOVA and Spearman's rho correlation, with p < 0.05 considered significant. RESULTS:Inclusion criteria were met for 253 programmed STEET cycles in the analysis. There was no significant difference in P4 duration when comparing outcome groups (112.8 ± 3.1 ongoing pregnancy (OP), 112.4 ± 4.4 spontaneous abortion (SAB), 111.6 ± 1.7 biochemical pregnancy (BP), 113.9 ± 5.7 no pregnancy (NP), F 1.76, df 3, p = 0.16). An ROC curve assessing the ability of P4 duration to predict ongoing pregnancy (OP) had an area under the curve of 0.467 (p = 0.38). CONCLUSION/CONCLUSIONS:Duration of P4 was not associated with outcome. Of the cycles, 65.6% resulted in ongoing pregnancy with our center's instructions resulting in an average progesterone exposure of 112.8 h, with a range of 98.3-123.7 h. With growing popularity for individualized testing, these results provide evidence for patient counseling of the high likelihood of ongoing pregnancy without personalized testing.