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Introduction: Fertility declines with increasing age, especially in women. In recent decades women’s age at the birth of their first child has risen markedly in many countries, and an increasing number of women do not establish a family until their late-twenties to mid-thirties. Although there can be various reasons that couples experience fertility problems, advanced maternal age is the most frequent cause for difficulties with achieving pregnancy. Objective: In this meta-synthesis, we investigated reflections on timing of motherhood in women who have not yet had children. Methods: A systematic literature search of six electronic databases and manual searches of reference lists identified eight qualitative studies published between 2011 and 2018 that focused on women’s reflections on timing of motherhood. The studies were assessed with the Critical Assessment Skills Programme (CASP) quality appraisal tool. The results were synthesized using Noblit and Hare’s meta-ethnographic approach as described by Malterud. Findings: An overall theme of ‘Timing of motherhood’ and four overlapping subthemes were identified: Making a life-changing decision, The right time, Fear of regret, and Plan B. The dilemmas associated with timing of motherhood leave women of reproductive age balancing their priorities and values against a biological deadline for having children naturally or through assisted reproductive technology. Conclusions: Women of reproductive age are aware that they must make a life-changing decision as to if or when to have children, but they consider having children at ‘the right time’ to be important. Simultaneously, while some women are reluctant to have children for various reasons, they express fear that waiting too long could result in their regretting not having children later in life. Although women of reproductive age express concern about their ability to achieve pregnancy, they have limited focus on the medical risks associated with postponing motherhoo

Aim To evaluate the effects of offering a clinic-driven lifestyle intervention programme in the waiting time before fertility treatment to women and men with obesity (body mass index [BMI] ≥ 30 kg/m2). Methods This prospective intervention study was conducted at a public Danish fertility clinic. All consecutive patients, both women and men, referred to the clinic between May 2020 and March 2021 with a BMI ≥ 30 kg/m2 were offered a 6-month lifestyle intervention programme consisting of monthly motivational dialogues and counselling with a certified nutritionist nurse. Weight loss maintenance was evaluated at a 1-year follow-up visit conducted 6-months after completion of the programme. The primary outcomes were absolute weight loss (kg) and relative weight loss (percent compared with weight at inclusion) upon completing the 6-month programme and at the 1-year follow-up. Secondary outcome measures were effects on biochemical metabolic markers. Results Forty-five participants were enroled in the study, of which 38 completed the 6-months lifestyle intervention programme and 33 participated in the 1-year follow-up. The participants' mean weight loss was 5.4 kg (95% confidence interval [CI]: 3.3, 7.5) after the 6-month programme (30 of 38 participants lost weight) and 4.4 kg (95% CI: 1.4, 7.3) at the 1-year follow-up compared with baseline. Previously undiagnosed metabolic conditions were revealed in 61% of the participants, including four cases (11%) of undiagnosed diabetes mellitus type 2. Conclusion A clinic-driven lifestyle intervention programme offered to patients with obesity in the waiting time for fertility treatment can successfully reduce weight in a high number of patients with stable results at 1-year follow-ups. Metabolic conditions, including diabetes mellitus type 2, are likely underdiagnosed in this group of patients, but further studies are needed., Aim To evaluate the effects of offering a clinic-driven lifestyle intervention programme in the waiting time before fertility treatment to women and men with obesity (body mass index [BMI] ≥ 30 kg/m2). Methods This prospective intervention study was conducted at a public Danish fertility clinic. All consecutive patients, both women and men, referred to the clinic between May 2020 and March 2021 with a BMI ≥ 30 kg/m2 were offered a 6-month lifestyle intervention programme consisting of monthly motivational dialogues and counselling with a certified nutritionist nurse. Weight loss maintenance was evaluated at a 1-year follow-up visit conducted 6-months after completion of the programme. The primary outcomes were absolute weight loss (kg) and relative weight loss (percent compared with weight at inclusion) upon completing the 6-month programme and at the 1-year follow-up. Secondary outcome measures were effects on biochemical metabolic markers. Results Forty-five participants were enroled in the study, of which 38 completed the 6-months lifestyle intervention programme and 33 participated in the 1-year follow-up. The participants' mean weight loss was 5.4 kg (95% confidence interval [CI]: 3.3, 7.5) after the 6-month programme (30 of 38 participants lost weight) and 4.4 kg (95% CI: 1.4, 7.3) at the 1-year follow-up compared with baseline. Previously undiagnosed metabolic conditions were revealed in 61% of the participants, including four cases (11%) of undiagnosed diabetes mellitus type 2. Conclusion A clinic-driven lifestyle intervention programme offered to patients with obesity in the waiting time for fertility treatment can successfully reduce weight in a high number of patients with stable results at 1-year follow-ups. Metabolic conditions, including diabetes mellitus type 2, are likely underdiagnosed in this group of patients, but further studies are needed.

STUDY QUESTION Does adjuvant letrozole in ovarian stimulation for IVF decrease the uterine peristalsis frequency (UPF) prior to fresh embryo transfer (ET)? SUMMARY ANSWER Adjuvant letrozole in ovarian stimulation for IVF does not reduce the UPF significantly prior to fresh ET. WHAT IS KNOWN ALREADY Throughout the cycle, uterine peristalsis aids spermatozoa transport to the fallopian tube and may affect implantation. At fresh ET, UPF is negatively correlated with implantation and clinical pregnancy rates and is believed to be modulated by oestradiol and progesterone. High levels of oestradiol, from multiple follicular development, in ovarian stimulation have been reported to increase UPF, whereas progesterone is considered to be an utero-relaxant. The influence of androgens is unclear. Co-treatment with letrozole during gonadotropin ovarian stimulation limits the supra-physiological oestradiol rise and may therefore reduce UPF prior to fresh ET. STUDY DESIGN, SIZE, DURATION This study was carried out on subjects participating in a single-centre double-blinded randomized controlled trial of the impact of letrozole on follicle development and endocrine profiles, and investigated the impact of adjuvant letrozole in ovarian stimulation for IVF on UPF prior to fresh ET and the correlations of UPF with endocrine markers. Between 2016 and 2017, 39 women expected to be normal responders were randomized to co-treatment with letrozole or placebo. Of these, 33 women completed this element of the study. The study was carried out according to the Helsinki Declaration and the ICH-Good-Clinical-Practice. PARTICIPANTS/MATERIALS, SETTING, METHODS Eligible women were randomized 1:1 to adjuvant treatment with letrozole 5 mg/day or placebo in an antagonist protocol using a fixed dose of recombinant (r) FSH 150 IU/day. Final maturation was triggered with hCG 6500 IU and luteal support with vaginal progesterone was administered from the day following oocyte aspiration. Less than 1 h pr

OBJECTIVE: To investigate whether treatment with proprietary lactobacilli-loaded vaginal capsules improves an unfavorable vaginal microbiome diagnosed using a commercially available test and algorithm.DESIGN: A randomized, double-blinded, placebo-controlled study was conducted in 74 women prior to undergoing fertility treatment at a single university fertility clinic between April 2019 and February 2021. The women were randomly assigned in a 1:1 ratio to receive one vaginal capsule per day for 10 days containing either a culture of more than 10 8 CFU of Lactobacillus gasseri and more than 10 8 CFU Lactobacillus rhamnosus (lactobacilli group) or no active ingredient (placebo group). Vaginal swabs for microbiota analysis were taken at enrollment, after treatment and in the cycle following treatment. PARTICIPANTS AND METHODS: Women aged 18-40 years who prior to fertility treatment were diagnosed with an unfavorable vaginal microbiota, characterized by either a low relative load of Lactobacillus or a high proportion of disrupting bacteria using the criteria of the IS-pro™ diagnostic system (ARTPred, Amsterdam, the Netherlands), were enrolled in the study. The primary outcome measure was the proportion of women with improvement of the vaginal microbiota after intervention. RESULTS: The vaginal microbiota improved after intervention in 34.2% of all participants (lactobacilli group 28.9%, placebo group 40.0%), with no significant difference in the improvement rate between the lactobacilli and placebo groups, RR = 0.72 (95% CI 0.38-1.38).CONCLUSION: This study indicates that administering vaginal probiotics may not be an effective means of modulating the vaginal microbiome for clinical purposes in an infertile population. However, a spontaneous improvement rate of 34.2% over a period of one to three months, confirming the dynamic nature of the vaginal microbiota, indicates that a strategy of postponing further IVF treatment to await microbiota

This study explored women's lived experience of making fertility decisions six years after attending the Fertility Assessment and Counselling (FAC) clinic in Copenhagen, Denmark, which is a personalised fertility awareness intervention. We conducted a qualitative interview study with 24 women who attended the FAC clinic 6 years earlier. Interviews were semi-structured and broadly examined the women's perceptions and experience of the intervention during follow-up. Data was analysed using a phenomenological framework and themes were identified related to women's experience of making fertility decisions after attending the FAC clinic. The overarching theme regarding the women's lived experience of making fertility decisions after attending the FAC clinic was: Fertility decisions were guided by the 'family clock'. There were four themes: (i) Deciding to 'get started' by attending the FAC clinic; (ii) Sense of making informed and empowered decisions; (iii) Influence of partner status on fertility decisions; and (iv) Decisions dictated by circumstance over preference and knowledge. At follow-up, the majority (21 women, 88%) had become parents. More than half of the women said that they had not achieved their desired family size. Consideration of women's 'family clock' is necessary in personalised fertility awareness interventions to enable women to achieve their family goals.

Background: Social media platforms provide new possibilities within health research. With Facebook being the largest social network in the world, it constitutes a potential platform for recruitment and data collection from women of reproductive age. Women in Denmark and in other Western countries postpone motherhood and risk infertility due to their advanced age when they try to conceive. To date, no study has explored Danish women’s reflections on the timing of motherhood within a social media setting. Objective: The aim of this study was to explore the challenges and opportunities of using Facebook as a platform for qualitative health research in Danish women of reproductive age. Methods: This study was a qualitative study based on 3 online focus groups on Facebook with 26 Danish women of reproductive age discussing the timing of motherhood in January 2020. Results: Conducting online focus groups on Facebook was successful in this study as the web-based approach was found suitable for developing qualitative data with women of reproductive age and made recruitment easy and free of charge. All participants found participating in an online focus group to be a positive experience. More than half of the women participating in the online focus groups found it advantageous to meet on Facebook instead of meeting face-to-face. Conclusions: Conducting online focus groups on Facebook is a suitable method to access qualitative data from women of reproductive age. Participants were positive toward being a part of an online focus group. Online focus groups on social media have the potential to give women of reproductive age a voice in the debate of motherhood.

Research question: What is the prevalence of disrupted markers of endometrial function among women experiencing recurrent implantation failure (RIF), and does the prevalence differ from a control cohort? Design: Prospective controlled cohort study. In total, 86 women with a history of RIF and 37 women starting their first fertility treatment were recruited for this study. Endometrial and blood profiling were carried out in a hormone-substituted cycle using oestradiol and progesterone. Endometrial biopsies were analysed by histology, immune cell profiling, and the endometrial receptivity array (ERA®) test (Igenomix, Valencia, Spain). The vaginal microbiome was analysed using a NGS-based technology (ArtPRED, Amsterdam, the Netherlands). Blood tests included oestradiol, progesterone, prolactin, thyroid-stimulating hormone, vitamin D and anti-phospholipid antibody levels. Results: Patients who had experienced RIF produced a range of test abnormalities. Compared with controls, women with RIF had a higher prevalence of chronic endometritis (24% versus 6%), a lower vitamin D level and a borderline lower progesterone level. Women who had experienced RIF had a more favourable vaginal microbiome compared with controls. Although the RIF cohort was older than the controls (mean age 33.8 years versus 30.2 years), no differences between the groups were observed in immune cell profiling and the ERA test. Conclusion: These data demonstrate that a single test or treatment for the endometrial factor in RIF is unlikely to be clinically effective. Diagnosing the endometrium in women with RIF permits targeted rather than blind interventions. Relative vitamin D deficiency, lower mid-luteal progesterone and chronic endometritis are ready targets for treatment. Understanding the role and treatment of an unfavourable vaginal microbiome in RIF needs further investigation.

Introduction Despite the high number of frozen embryo transfer (FET) cycles being conducted (190 000 cycles/year) in Europe, the timing of blastocyst transfer and the use of luteal phase progesterone support in modified natural cycle FET (mNC-FET) in assisted reproductive technologies are controversial. In mNC-FET, the timing of blastocyst warming and transfer is determined according to the time of implantation in a natural cycle, aiming to reach blastocyst endometrial synchronicity. However, the optimal day of blastocyst transfer following ovulation trigger is not determined. In addition, the value of luteal phase support to maintain the endometrium remains uncertain. Thus, there is a need to identify the optimal timing of blastocyst warming and transfer and the effect of luteal phase support in a randomised controlled trial design. The aim of this randomised controlled trial is to investigate if progesterone supplementation from the early luteal phase until gestational age 8 weeks is superior to no progesterone supplementation and to assess if blastocyst warming and transfer 6 days after ovulation trigger is superior to 7 days after ovulation trigger in mNC-FET with live birth rates as the primary outcome. Methods and analysis Multicentre, randomised, controlled, single-blinded trial including 604 normo-ovulatory women aged 18-41 years undergoing mNC-FET with a high-quality blastocyst originating from their first to third in vitro fertilisation/intracytoplasmic sperm injection cycle. Participants are randomised (1:1:1:1) to either luteal phase progesterone or no luteal phase progesterone and to blastocyst warming and transfer on day 6 or 7 after human chorionic gonadotropin trigger. Only single blastocyst transfers will be performed. Ethics and dissemination The study is approved by the Danish Committee on Health Research Ethics (H-18025839), the Danish Medicines Agency (2018061319) and the Danish Data Protection Agency (VD-2018-381). The results of the study w

INTRODUCTION: The Fertility Assessment and Counselling (FAC) Clinic was initiated to provide women information about their current fertility status to prevent infertility and smaller families than desired. The aim was to study the predictive value of a risk assessment score based on known fertility risk factors in terms of time to pregnancy.MATERIAL AND METHODS: Prospective cohort study of the first 570 women attending the FAC Clinic from 2011 to 2013 at Rigshospitalet, Denmark. A consultation included: risk assessment score sheet with items on infertility risk factors, anti Müllerian hormone and ultrasound. The risk score was categorized as low, medium or high. After two years an email-based questionnaire was distributed regarding subsequent pregnancies.RESULTS: The follow up questionnaire was answered by 519 women (91.1%). The mean age was 35 years and 38% were single at inclusion. The majority (67.8%, 352/519) tried to conceive within two years after attending the FAC Clinic. At follow up 73.6% (259/352) had achieved a pregnancy, 21% (74/352) were still trying and 5.4% (19/352) had given up. Two thirds (65%) with only low risk scores conceived spontaneously within 12 months, while this figure was only 32% for women with at least one high risk score (n=82). Accordingly, presence of at least one high risk score reduced the odds of achieving a pregnancy within 12 months by 75% (OR 0.25, 95%CI; 0.12-0.52).CONCLUSION: The new FAC Clinic concept seems usable and offers a tool for fertility experts to guide women on how to fulfil their reproductive life-plan. This article is protected by copyright. All rights reserved.

The Fertility Assessment and Counselling Clinic was initiated in 2011 as an analogue to the family planning clinics in the 1970s, but with a pro-fertility aim. The idea was to provide individual assessment of fertility risk factors, ovarian reserve and sperm concentration to help women and men to fulfil their reproductive life plan. Fertility screening on an individual level is a new concept, and the Fertility Assessment and Counselling Clinic is the first of its kind. The aim of the clinic is to reduce the need for fertility treatments and to prevent involuntary childlessness.

Objective: To audit the clinical management preceding peripartum hysterectomy and evaluate if peripartum hysterectomies are potentially avoidable and by which means. Material and Methods: We developed a structured audit form based on explicit criteria for the minimal mandatory management of the specific types of pregnancy and delivery complications leading to peripartum hysterectomy. We evaluated medical records of the 50 Danish women with peripartum hysterectomy identified in the Nordic Obstetric Surveillance Study 2009-2012 and made short narratives of all cases. Results: The most frequent indication for hysterectomy was hemorrhage. The two main initial causes were abnormally invasive placenta (26%) and lacerations (26%). Primary atony was third and occurred in 20%. Before hysterectomy another 26% had secondary atony following complications such as lacerations, retained placental tissue or coagulation defects. Of the 50 cases, 24% were assessed to be avoidable and 30% potentially avoidable. Hysterectomy following primary and secondary atony was assessed to be avoidable in 4/10 and 4/13 cases, respectively. Early sufficient suturing of lacerations and uterine ruptures, as well as a more widespread use of intrauterine balloons alone or in combination with uterine compression sutures (the sandwich model), could presumably have prevented about one fourth of the peripartum hysterectomies. Conclusion: More than 50% of peripartum hysterectomies seem to be avoidable by simple measures. In order to minimize the number of unnecessary peripartum hysterectomies, obstetricians and anesthesiologists should investigate individual cases by structured clinical audit, and disseminate and discuss the results for educational purposes. An international collaboration is warranted to strengthen our recommendations and reveal if they are generally applicable.

OBJECTIVE: To study treatment modalities for cesarean scar pregnancies (CSPs), focusing on efficacy and complications in relation to study quality.DESIGN: Systematic review.SETTING: Not applicable.PATIENT(S): A total of 2,037 women with CSP.INTERVENTION(S): Review of MEDLINE, EMBASE, and Cochrane Library to find studies including five or more women. Data were extracted on primary treatment modality/efficacy, complications, and future fertility. The level of evidence was categorized according to Oxford Centre for Evidence-based Medicine guidelines. Quality was assessed using The Cochrane Collaboration's Risk of Bias Tools for Randomized Controlled Trials and the modified Delphi techniques for case series. Meta-analysis was impossible owing to multifarious treatments.MAIN OUTCOME MEASURE(S): Successful first-line treatment. Complications were hysterectomy, laparotomy, bleeding >1,000 mL, or blood transfusion.RESULT(S): Fifty-two studies were included: four randomized, controlled trials and 48 case series. Fifteen of the 52 analyzed studies were scored as high quality. Treatment modalities were condensed to 14 different approaches. Combining study quality, level of evidence, efficacy, and safety, five approaches for treating CSP are recommended, depending on availability, severity of patient symptoms, and surgical skills: [1] resection through a transvaginal approach, [2] laparoscopy, [3] uterine artery embolization in combination with dilatation and curettage and hysteroscopy, [4] uterine artery embolization in combination with dilatation and curettage, and [5] hysteroscopy.CONCLUSION(S): This review recommends treatment options for CSP in clinical practice, based on efficacy and safety. The literature supports an interventional rather than medical approach. Present recommendations are primarily based on case series. Multicenter, well-designed studies are needed to draw definite conclusions on how to treat CSP.

This study aimed to explore attitudes towards family formation in single or cohabiting childless women of advanced age. The design comprised semi-structured qualitative interviews of 20 women aged 34–39 years attending the Fertility Assessment and Counselling Clinic, Rigshospitalet, Copenhagen. A sample of 10 single women and 10 cohabiting women was chosen with equal distribution of postgraduate education length. Data were analysed using content analysis following the method of Graneheim and Lundman and consolidated criteria for reporting qualitative research (COREQ). The general attitude towards family formation was characterized by a fear of the consequences of choosing motherhood on one hand, and a ‘ticking biological clock’ and a wish to establish a nuclear family on the other. The women idealized the perception of perfect mothering in terms of uncompromising expectations of child rearing and showed an increasing awareness of solo motherhood as a possible solution to advanced age, the wish of a child and single status compared to earlier studies. Our study contributes to knowledge and understanding of personal considerations related to childbearing in nullipara women in their mid- to late 30s and may be useful in a fertility assessment and counselling setting.

During the 1970s new contraceptive options developed and legal abortions became accessible. Family planning clinics targeting young women and men provided advice and assistance on contraception. Today, delayed childbearing, low total fertility rates and increasing use of social oocyte freezing create a need for pro-fertility initiatives. Three years ago we established a new separate unit: The Fertility Assessment and Counselling (FAC) clinic. The FAC clinic offers free individual counselling based on a clinical assessment including measurement of serum anti-Müllerian hormone and ovarian and pelvic sonography in women, sperm analysis in men, and a review of reproductive risk factors in both sexes. The FAC clinic includes a research programme with the goal to improve prediction and protection of fertility. Our first proposition is that clinics for individual assessment and counselling need to be established, as there is a strong unmet demand among women and men to obtain: (i) knowledge of fertility status, (ii) knowledge of reproductive lifespan (women) and (iii) pro-fertility advice. Addressing these issues is often more challenging than treating infertile patients. Therefore, we propose that fertility assessment and counselling should be developed by specialists in reproductive medicine. There are two main areas of concern: As our current knowledge on reproductive risk factors is primarily based on data from infertile patients, the first concern is how precisely we are able to forecast future reproductive problems. Predictive parameters from infertile couples, such as duration of infertility, are not applicable, diagnostic factors like tubal patency are unavailable and other parameters may be unsuitable when applied to the general population. Therefore, strict validation of reproductive forecasting in women and men from the general population is crucial. The second main concern is that we may turn clients into patients. Screening including reproductive forecasting m

Placenta percreta is a rare life-threatening obstetrical condition, often resulting in severe haemorrhage and hysterectomy. The incidence seems to be increasing, probably secondary to the increase in caesarean section rates. We present a protocol for an elective multidisciplinary approach with proactive management to reduce haemorrhage and allow appropriate surgery, which imply a low maternal and fetal morbidity as well as maintained fertility.

Rarely, but with increasing frequency, we detect pregnancies within the uterine scar of a prior Caesarean section. These ectopic pregnancies entail a risk of severe bleeding and uterine rupture, and thus constitute a threat to the pregnant woman's life, underlining the necessity of awareness about these complications. Vaginal bleeding and/or mild to moderate lower abdominal pain are symptoms seen in half of the women. The diagnosis is made by sonography and criteria for these are listed. We here present the most recent studies on treatment strategies, follow-up and future fertility.