Faculty Bibliography

The process of gender affirmation may have an impact on fertility. Counseling on the impact of affirmation and opportunities for fertility, future family building, and reproductive health is an important first step in the affirmation process. This article discusses the options for fertility preservation for transmen. The barriers and outcomes in this unique population are also considered. In addition, insights are provided on the future of fertility preservation and suggestions are made for how to build a comprehensive team for male transgender patients.

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.

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
Copyright

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.
Copyright

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
Copyright

Objective: To review outcomes of all STEET procedures based on PGT-A platform used to determine Ploidy status.
Design(s): Retrospective review of all STEET procedures over an 8 year period at a single center.
Material(s) and Method(s): More than 3200 STEET procedures performed over an 8 year period (2011 to 2018) at a single center were reviewed based on the PGT-A platform (NGS, aCGH or SNP) utilized. Our main outcome measures were: Implantation Rate (IR), Clinical Preg rate (FH) and Live Birth (LB) rate. Only embryos reported as euploid were included in the analysis- embryos reported as mosaic or those not yielding a result were omitted. Statistical significance was determined using contingency X² with 1 degree of freedom.
Result(s): TABLE 1. Comparison of STEET outcomes depending on PGT-A Platform [Figure presented] STEET following PGT-A via NGS resulted in a significantly higher IR compared to aCGH /SNP combined (70.1% vs 62.4%). Similarly, ongoing Pregnancy rates and LB rates were significantly improved when NGS was utilized vs aCGH or SNP. SAB rates were not significantly different between platforms but all methods reduced SAB rates compared to age matched controls without PGS (18% ) (Ref 1).
Conclusion(s): STEET results in high IR, high clinical pregnancy rates and high LB rates across all age groups. However, with advances in PGT-A platforms we can continue to improve outcomes and increase safety of ART by maximizing the potential of every ET procedure. With continuing development of PGT-A platforms and interpretation methods used to determine ploidy we can further improve outcomes and safety by transferring a single embryo with the highest implantation potential every time. Reference: Harton et al (2013) Fert & Ster Vol. 100 (6) 1695-1703.
Copyright

Objective: In the era of personalized medicine and the simultaneously increasing use of frozen embryo transfer (FET), assays 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 determined¹. We sought to examine the outcomes of euploid FETs by length of progesterone (P4) exposure at our clinic.
Design(s): Prospective cohort study of all programmed FETs of single euploid embryos between 6/1/2018 and 12/18/2018 at our center.
Material(s) and Method(s): All patients undergoing FET in the inclusion time period were asked to write down the exact time of P4 initiation and then report the start time on the day of P4 serum level check (2 days later) prior to embryo transfer. All FETs were then reviewed. Programmed FET cycles were defined as treatment of oral estradiol daily followed by either 50-75mg intramuscular P4 in oil or vaginal P4 suppository with transfer of a euploid embryo (tested by either array comparative genomic hybridization or Next Generation Sequencing). Programmed FETs with untested, mosaic or double embryo transfers, as well as natural cycles, were excluded. Cycles where exact timing data could not be determined were also excluded. Statistical analysis included ANOVA, receiver operating characteristic curve, and Spearman's Rho correlation where appropriate, with p<0.05 considered significant.
Result(s): 253 programmed STEET cycles met criteria and were included in the analysis. The average patient age at time of ET was 38.0+/-4.5 years. 3 cycles utilized an assay for endometrial receptivity for adjusted timing. The mean duration of P4 exposure was 112.8+/-2.9 hours with a range from 98.25-124.5 hours for all unadjusted cycles. Overall, 166 women had an ongoing pregnancy (OP), 25 had a spontaneous loss (SAB), 12 a biochemical pregnancy (BP) and 50 a negative pregnancy (NP) test, for a 65.6% ongoing pregnancy rate. There was no significant difference in P4 duration between outcome groups (112.8+/-3.1 OP, 112.4+/-4.4 SAB, 111.6+/-1.7 BP, 113.9+/-5.7 NP, F 1.76, df 3, p = 0.156). 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). Furthermore, there was no correlation in the day 28 serum hcg value based on the duration of P4 exposure (rs = 0.058, p = 0.399)
Conclusion(s): Duration of P4 is critical to the success of a programmed FET. At our center, duration of P4 was not associated with FET outcomes. 65.6% of cycles resulted in ongoing pregnancy with our center's standard instructions, which may vary from other centers who have equivalent euploid embryo implantation rates. With growing popularity for individualized testing, these results provide evidence for patient counseling of the high likelihood of desired outcome (ongoing pregnancy) without need for personalized testing. These results also support the need for further prospective or randomized controlled study of optimal FET cycle across clinics and protocols. References: 1. Mackens S, Santos-Ribeiro S, van de Vijver A, Racca A, Van Landuyt L, Tournaye H, Blockeel C. Frozen embryo transfer: a review on the optimal endometrial preparation and timing. Hum Reprod. 2017; 32(11):2234-2242.
Copyright