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By 2030, WHO estimates that 1.4 million reproductive-aged women will be diagnosed with cancer annually. Fortunately, cancer is no longer considered an incurable disease in many cases. From 2008-2014, 85% of women under the age of 45 years diagnosed with cancer survived. This increase in survival rate has shifted attention from focusing exclusively on preserving life to focusing on preserving quality of life after treatment. One aspect of this is preserving the ability to have a biological family. Oncofertility, the field that bridges oncology and reproductive endocrinology with the goal of preserving fertility, offers these patients hope. Though it is clear that ASCO and ASRM recognize the importance of fertility preservation as an aspect of comprehensive oncology care, there are not yet unified guidelines for oncologists and fertility specialists for treating oncofertility patients. First, we identify the need for reproductive counseling prior to cancer treatment, as many patients report that their fertility preservation concerns are not addressed adequately. We then delineate multi-modal fertility preservation options that are available and appropriate for different patients with corresponding outcomes using different treatments. We discuss the unique challenges and considerations, including ethical dilemmas, for delivering timely and comprehensive care specifically for oncofertility patients. Finally, we address the multidisciplinary team that includes oncologists, reproductive endocrinologists, surgeons as well as their staff, nurses, genetic counselors, mental health professionals, and more. Since oncofertility patient care requires the coordination of both physician teams, one set of unified guidelines will greatly improve quality of care.

Imaging is central to infertility evaluation, management, and treatment. Advancements in imaging technology have allowed for greater resolution while remaining minimally invasive. Imaging methods primarily consist of two-dimensional (2D) and three-dimensional (3D) ultrasound (US), saline infusion sonography (SIS), sonohysterosalpingography, hysterosalpingography (HSG), and magnetic resonance imaging (MRI). Computed tomography (CT) is of limited use in the management of infertility. Of the abovementioned imaging modalities, US remains the most cost-effective and convenient method for diagnosing uterine and ovarian pathologies related to infertility. US therefore plays a critical role throughout the entire process, from evaluation through treatment. SIS, sonohysterosalpingography, hysterosalpingography, and MRI provide additional information in the workup. A baseline US is performed during the patient’s follicular phase (cycle days 2–3) to identify uterine or ovarian abnormalities. The patient’s ovarian reserve can also be evaluated at this time, in conjunction with endocrine biomarkers. An HSG or SIS can then be performed between cycle days 6 and 12 to evaluate for tubal patency and uterine cavity abnormalities, respectively. MRI is used for additional evaluation as needed. Throughout the patient’s cycle, US tracks endometrial lining thickness and follicular size during controlled ovarian hyperstimulation in preparation for ovulation trigger.

Prior to menopause, approximately 20% of gynecological visits and a quarter of gynecological procedures are related to abnormal uterine bleeding. Abnormal uterine bleeding stems from a range of etiologies and can be traced back to pregnancy, anovulation, coagulation disorders, or structural pathologies of the uterus. These conditions may vary from cancerous to benign. Understanding the root cause of bleeding in addition to appropriate imaging modalities may optimize both evaluation and treatment. While the appropriate modality is determined by the condition causing the bleeding, determining the cause of the bleeding may be impossible without imaging. Transvaginal US is often the primary mode of imaging in cases of abnormal bleeding and aids in screening for endometrial hyperplasia and carcinoma that is readily accessible, cost-effective, and largely done without complications. However, magnetic resonance imaging (MRI) and hysteroscopy (HSG) offer additional visualization for a more appropriate diagnosis. More likely than not, a single patient will require more than one of these imaging modalities, and others, throughout the evaluation, diagnosis, and treatment of abnormal uterine bleeding.

An overwhelming proportion of females of reproductive age are affected by cancer annually. As the efficacy of cancer treatments increases the number of cancer survivors, it is imperative to ensure that the fertility-related needs of cancer survivors are met. Given the gonadotoxic nature of many cancer treatments, fertility preservation for patients prior to cancer treatment, Oncofertility, is a critical area of reproductive care. The establishment of an Oncofertility program requires swift and effective patient care that relies heavily on collaboration between multiple specialties, patient education, and clear treatment protocol. This specific flow of patient care can be referred to as an “Oncofertility treadmill,” given the emphasis on efficiently completing ovarian hyperstimulation cycles so that the patient may proceed with cancer treatment. We began by identifying key steps in the establishment of an Oncofertility program at a private, multisite fertility clinic, then explored the challenges that providers and patients may face, and the outcomes of Oncofertility patients undergoing ovarian hyperstimulation with the intention of oocyte cryopreservation. Oncofertility care is complex and the establishment of concrete guidelines for this Oncofertility care will greatly benefit cancer survivors.

“Mystery, Medicine, and the Magnificent Mile,” the theme for the annual Midwest Reproductive Symposium International (MRSi) in Chicago, IL, captured the attention of reproductive professionals all over the world. Each year, the conference agenda encompasses emerging technologies in assisted reproduction, updates in the management of reproductive diseases, and common challenges encountered in clinical practice. The structure of the meeting, offering a mixture of lectures, panel discussions, and interactive workshops, creates a collaborative environment for physicians, geneticists, embryologists, nurses, mental health professionals, basic scientists, business administrative professionals, reproductive endocrinology and infertility fellows, and obstetrics and gynecology residents. The goal of the MRSi meeting is to provide all reproductive professionals the opportunity to exchange ideas, foster relationships, and deliver quality patient care. As the field continues to evolve, MRSi provides an exciting venue to uncover the mysteries of reproductive medicine with enthusiasm and collaboration.

Conferences serve an essential means of learning and staying up to date in all aspects of medicine. Reproductive endocrinology and infertility is a young and constantly evolving field. The Midwest Reproductive Symposium International (MRSi) is a yearly conference held in Chicago, IL, and is one of the most intimate yet influential conferences in the fertility world. This conference is geared towards all professions and roles in the fertility world such as physicians, geneticists, nurses, allied health professionals, basic scientists, mental health professionals, business administration professionals, reproductive endocrinology and infertility fellows, and obstetrics and gynecology residents alike. The goal of MRSi is to continue to understand this revolutionary field in order to improve patient outcomes while staying up to date with the latest technology.

Our objective was to evaluate which demographic factors or assisted reproductive technologies were associated with IVF triplet gestations where one of the embryos split, resulting in a dichorionic triplet gestation. This was a case-control study of dichorionic versus trichorionic triplet gestations that underwent assisted reproductive technology over the last 5 years at our fertility center. There were 53 cases of dichorionic triamniotic triplet gestations compared to 119 trichorionic triplet controls. There were no significant demographic differences between the cases and controls. 51/53 dichorionic triplets and 86/119 trichorionic triplets were conceived through IVF, the remaining utilized intrauterine insemination. ICSI was performed in virtually all patients that underwent IVF. Of the potential risk factors studied, hatching was used in 70.6% of dichorionic compared to 89.5% of trichorionic IVF triplets (p = 0.005); embryo transfer was performed on Day 5 or 6 compared to Day 3 in 88.0% dichorionic vs 71.8% trichorionic (p = 0.028). Frozen sperm was utilized more frequently with dichorionic than with trichorionic triplets, 26.0% vs 10.9% (p < 0.011). Only 4 (7.5%) of the IVF cases underwent pre-implantation genetics. Certain assisted reproductive technologies appear to be associated with embryo splitting and a dichorionic triplet gestation. More research is needed in this area to further elucidate these findings.

Objective To gain a better understanding of factors influencing clinicians' embryo transfer practices. Design Cross-sectional survey. Setting Web-based survey conducted in December 2008 of individuals practicing IVF in centers registered with the Society for Assisted Reproductive Technology (SART). Patient(s) None. Intervention(s) None. Main Outcome Measure(s) Prevalence of clinicians reporting following embryo transfer guidelines recommended by the American Society for Reproductive Medicine (ASRM), prevalence among these clinicians to deviate from ASRM guidelines in commonly encountered clinical scenarios, and practice patterns related to single embryo transfer. Result(s) Six percent of respondents reported following their own, independent guidelines for the number of embryos to transfer after IVF. Of the 94% of respondents who reported routinely following ASRM embryo transfer guidelines, 52% would deviate from these guidelines for patient request, 51% for cycles involving the transfer of frozen embryos, and 70% for patients with previously failed IVF cycles. All respondents reported routinely discussing the risks of multiple gestations associated with standard embryo transfer practices, whereas only 34% reported routinely discussing single embryo transfer with all patients. Conclusion(s) Although the majority of clinicians responding to our survey reported following ASRM embryo transfer guidelines, at least half would deviate from these guidelines in a number of different situations.

Objective To describe the management of hydrosalpinges among Society for Reproduction Endocrinology and Infertility (SREI)/Society of Reproductive Surgeons (SRS) members. Design Cross-sectional survey of SREI/SRS members. Setting Academic and private practice–based reproductive medicine physicians. Participant(s) A total of 442 SREI and/or SRS members. Intervention(s) Internet-based survey. Main Outcome Measure(s) To understand how respondents evaluate, define, and manage hydrosalpinges. Result(s) Of 1,070 SREI and SRS members surveyed, 442 responded to all items, for a 41% response rate. Respondents represented both academic and private practice settings, and differences existed in the evaluation and management of hydrosalpinges. More than one-half (57%) perform their own hysterosalpingograms (HSGs), and 54.5% involve radiologists in their interpretation of tubal disease. Most respondents thought that a clinically significant hydrosalpinx on HSG is one that is distally occluded (80.4%) or visible on ultrasound (60%). Approximately one in four respondents remove a unilateral hydrosalpinx before controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI) and clomiphene citrate (CC)/IUI (29.3% and 22.8%, respectively), and physicians in private practice were more likely to intervene (COH: risk ratio [RR] 1.81, 95% confidence interval [CI] 1.31–2.51; CC: RR 1.98, 95% CI 1.33–2.95). Although laparoscopic salpingectomy was the preferred method of surgical management, nearly one-half responded that hysteroscopic tubal occlusion should have a role as a primary method of intervention. Conclusion(s) SREI/SRS members define a "clinically significant hydrosalpinx" consistently, and actual practice among members reflects American Society for Reproductive Medicine/SRS recommendations, with variation attributed to individual patient needs. Additionally, one in four members intervene before other infertility treatments when there is a unilateral hydrosalpinx present.

The objective of this retrospective analysis was to compare the clinical outcomes of recombinant FSH (r-FSH) with combination r-FSH plus human menopausal gonadotrophin (HMG) protocols in a large private practice using a single IVF laboratory, from 2001 to 2003. Patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) antagonist protocol using r-FSH or combination r-FSH plus HMG. When two or more follicles had attained a minimum mean diameter of 20 mm, follicular triggering was achieved with either recombinant HCG (r-HCG; Ovidrel, 250 microg s.c.) or urinary HCG (u-HCG; 10,000 IU i.m.). The main outcome measures were number of oocytes retrieved and clinical pregnancy rate. There was a lower percentage of cancelled cycles and an increased number of oocytes retrieved, mature oocytes, oocytes that fertilized, embryo that cleaved and a tendency towards higher clinical pregnancy rates in patients treated with r-FSH alone compared with those treated with r-FSH plus HMG. Patients treated with r-FSH plus HMG had lower miscarriage rates and the live birth rate was similar in both treatment groups. In conclusion, irrespective of age, using a treatment regimen consisting of a combination of HMG plus r-FSH was not beneficial compared with r-FSH alone in patients using a GnRH antagonist protocol.

Objective To compare corifollitropin alfa with recombinant FSH treatment in terms of the vital pregnancy rate in older patients undergoing IVF. Design Phase 3 randomized, double-blind, noninferiority trial. Setting Multicenter trial. Patient(s) A total of 1,390 women aged 35–42 years. Intervention(s) A single injection of 150 μg of corifollitropin alfa or daily 300 IU of recombinant FSH for the first 7 days then daily recombinant FSH until three follicles reach ≥17 mm in size. Ganirelix was started on stimulation day 5 up to and including the day of recombinant hCG administration. If available, two good quality embryos were transferred on day 3. Main Outcome Measure(s) Vital pregnancy rate (PR), number of oocytes, and live birth rate. Result(s) Vital PRs per started cycle were 23.9% in the corifollitropin alfa group and 26.9% in the recombinant FSH group, with an estimated difference (95% confidence interval) of -3.0% (−7.4 to 1.4). The mean (SD) number of recovered oocytes per started cycle was 10.7 (7.2) and 10.3 (6.8) in the corifollitropin alfa and the recombinant FSH groups, respectively, with an estimated difference of 0.5 (−0.2 to 1.2). The live birth rates per started cycle were 21.3% in the corifollitropin alfa group and 23.4% in the recombinant FSH group, with an estimated difference (95% confidence interval) −2.3% (−6.5 to 1.9). The incidence of serious adverse events was 0.4% versus 2.7% in the corifollitropin alfa and recombinant FSH groups, respectively, and of ovarian hyperstimulation syndrome (OHSS; all grades) was 1.7% in both groups. Conclusion(s) Treatment with corifollitropin alfa was proven noninferior to daily recombinant FSH with respect to vital PRs, number of oocytes retrieved, and live birth rates, and was generally well tolerated. Clinical Trial Registration Number NCT01144416.

This age-matched retrospective analysis compared the clinical outcomes of recombinant human chorionic gonadotrophin (rHCG) and urinary HCG (uHCG) in patients undergoing fresh, nondonor IVF cycles. The patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) agonist down-regulation or a GnRH antagonist protocol using recombinant FSH (rFSH) alone or in combination with human menopausal gonadotrophin. When two or more follicles had attained a mean diameter of 20 mm, follicular triggering was achieved with either Ovidrel (rHCG) 250 mug SC or uHCG 10,000 IU IM. Patients receiving rHCG were considered subjects, and they were age-matched in a 1:2 ratio to patients receiving uHCG, who were designated as controls. The main outcome measures were number of oocytes retrieved, number of mature oocytes obtained, number of oocytes fertilized and clinical pregnancy rates. A total of 273 subjects were age-matched and compared with 546 controls. Recombinant HCG had a minimal effect on the number of oocytes retrieved (13.4 versus 13.2), mature oocytes (10.5 versus 10.3) and oocytes fertilized (8.2 versus 7.8) compared with uHCG. Pregnancy (46.0 versus 45.2%) and clinical pregnancy rates (38.1 versus 36.8%) were similar for rHCG and uHCG. Recombinant HCG was as effective as uHCG for final follicular maturation in IVF cycles.

Design Carrier screening is recommended by the American Congress of Obstetricians and Gynecologists (ACOG), the American College of Medical Genetics and Genomics (ACMG), and Ashkenazi Jewish advocacy organizations. However, it is often difficult to ascertain a patient’s true ethnicity to determine the appropriate screening to offer. Consequently, several fertility centers now offer screening for the same disorders to all patients, regardless of ethnicity.

OBJECTIVE: To determine if intercycle variability in day 3 FSH (D3FSH) levels is useful in predicting IVF outcomes. DESIGN: Retrospective analysis of patients undergoing IVF from January 2004 to March 2005 in a large private practice setting. MATERIALS AND METHODS: A total of 2504 fresh, nondonor IVF cycles were available for analysis. This group encompassed a broad spectrum of patients representing typical infertility patients presenting for assisted reproduction. The patients ranged in age from 21-44 and underwent controlled ovarian hyperstimulation by standard midluteal phase GnRH agonist down regulation or GnRH antagonist protocol using recombinant FSH or FSH in combination with HMG. Adjustments were made based on individual responses, and when two or more follicles had attained a minimum mean diameter of 19-20mm, follicular triggering was achieved with hCG and oocyte retrieval was performed 36 hours later. Standard laboratory protocols were followed, including intracytoplasmic sperm injection, assisted hatching for cleavage embryos and extended culture for blastocyst transfer, as clinically appropriate. Ultrasound guided embryo transfer was performed, and all patients received luteal progesterone support. Serum hCG levels were measured 15 days after retrieval, and a clinical pregnancy was defined as the presence of a gestational sac on ultrasound. An estimate of normal intercycle D3FSH variability was derived by regressing standard deviations of replicate measurements against mean FSH in patients 35 years old with D3FSH 10. Patients were placed in the high variability category when their calculated standard deviation was significantly higher than normal. Comparisons were made between patients with normal and high D3FSH variability as well as patients with a single treatment cycle. Continuous and categorical data were analyzed by ANOVA and Chi Square tests, respectively. A value of P 0.05 was considered to be statistically significant. Results are expressed as mean SD. RESULTS: Patients with replicate cycles were older. Relative to patients with normal variability, patients with high D3FSH variability had significantly diminished ovarian responses, with fewer retrieved and mature oocytes but similar fertilization, pregnancy and clinical pregnancy rates. All patients with replicate cycles had significantly lower pregnancy outcomes than patients with single cycles.