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BACKGROUND: Future Fertility’s Violet is an artificial intelligence image analysis egg assessment tool for patients seeking elective oocyte preservation. The technology is used to identify the relative viability of mature eggs to tailor a personalized treatment plan for each patient. The software detects patterns in oocytes in order to better understand egg quality. It may be particularly impactful for older patients who are known to have problems related to egg quality, especially given the fact that they may have less opportunities to undergo multiple cycles. While we currently have methods for assessing sperm quality and embryo quality, there are very limited guidelines for determining successful oocytes. Violet is currently the only objective assessment tool for predicting egg quality. Current research suggests Violet is superior to trained embryologists by more than 20%, with 100% reproducibility . More data is needed to assess the viability of Violet to better assess the value it provides in improving IVF outcomes. OBJECTIVE: We sought to compare predictions of live birth rate between Violet and a currently utilized egg freezing predictor, which takes into account age and number of mature oocytes. MATERIALS & METHODS: A retrospective chart review was performed at a private multi-site infertility center from March 2020 to April 2022. All patients undergoing elective egg vitrification who opted to get oocyte assessment results from Violet were included, for a total of 154 patients. Patients under the age of 24 or over the age of 44 were excluded as the calculator is not recommended in those age groups. All patients underwent controlled ovarian stimulation and subsequent retrieval and mature oocyte vitrification. Likelihood of one live birth was given as a percentage by the Violet report. These results were compared to the Brigham & Women’s Hospital Egg Freezing Counseling Tool (BWH EGCT) calculator per MDCalc. An unpaired t-test was performed to compare the mean percentages. Given differences in egg quality with relation to age, we also sought to determine if there was a difference in results by age (age groups: 27-32, 33-38, and 39-44 years old). RESULTS: The probability of one live birth was assessed using Violet as well as the BWH EGCT for 154 patients. Mean AMH of patients included was 2.42. Mean age at retrieval was 36, with a range of 27-44. The mean likelihood of one live birth rate using Violet as an assessment tool was 47.60%, while the conventional method gave a mean likelihood of one live birth of 49.14% (p=0.6079). There was no significant difference in predictions by Violet versus the conventional method by age, though the results did approach signficance (p=.12 for 27-32, p=.24 for 33-38, and p=.13 for 39-44). CONCLUSIONS: This is the largest study to our knowledge assessing the viability of Violet compared to conventional methods for assessing egg quality. Our results suggest there is no significant difference between the AI oocyte assessment tool Violet and conventional methods for prediction using age and number of mature oocytes. Additionally, there is no signficant difference when comparing results by age group. This suggests that Violet is able to individually visually assess oocytes for quality and likelihood of success. Violet provides a non-invasive approach and a comprehensive breakdown of the quality of each oocyte. Though these results suggest Violet is similar to existing predictors, it adds value by determining the individual quality of each oocyte. This allows for stratification that can guide fertility decision-making. A limitation of the study is the fairly low number of patients given this is a new technology. As more patients utilize the Violet assessment tool, there will be greater numbers of oocytes that undergo thaw, insemination, and transfer. This will provider greater data regarding fertilization, blastocyst development, and ultimately live birth rate. Though this technology is still in its relative infancy, there is an exciting future ahead for artificial intelligence in assessing oocyte quality and predicting IVF success.

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.