INTRODUCTION:Pregnancy in women with inflammatory bowel disease (IBD) is common, and active disease remains a key driver of adverse maternal and fetal outcomes. Maintaining remission throughout pregnancy is therefore essential, however clinicians lack reliable, minimally invasive tools to monitor disease activity and stratify pregnancy-related risk. AREAS COVERED:This expert review critically addresses the current evidence on blood-based biomarkers for pregnancy in women with IBD. We discuss the impact of maternal disease activity on pregnancy outcomes, the bidirectional relationship between pregnancy and IBD disease course, and the potential contribution of placental dysfunction and oxidative stress to adverse outcomes. Established and emerging biomarkers, including fecal calprotectin, inflammatory, angiogenesis-, and oxidative stress-related biomarkers, are evaluated. We further outline methodological challenges, limitations of single biomarkers, and unmet needs in validation and clinical translation. EXPERT OPINION:We emphasize that the persistent focus on isolated biomarkers is unlikely to meet the complexity of pregnancy in patients with IBD. Instead, we propose that integrative multi-omics approaches capturing interacting biological processes represent a more conceptually sensible path forward. While rigorous prospective validation and standardization are essential before clinical implementation, such strategies hold promise for more personalized risk stratification and monitoring of pregnant patients with IBD.

Objective:To evaluate long-term pregnancy outcomes in young women with breast cancer after ovarian stimulation for fertility preservation, with the addition of tamoxifen or letrozole to standard stimulation vs. no addition. Design:Follow-up study of the STIM-RCT, which was a multicentre randomized open-label trial (NTR4108), and the STIM-cohort study. Subjects:Women, aged 18-43 years, previously diagnosed with breast cancer who opted for fertility preservation through ovarian stimulation. All surviving women were eligible for follow-up (N = 216) and received an online questionnaire; 141 women from the STIM-RCT and 75 from the STIM-cohort. Exposure:Women receiving ovarian stimulation with the addition of tamoxifen, letrozole, or no addition. Main outcome measures:Natural conception, conception through assisted reproductive technology (ART), pregnancy rates, and live birth rates. Results:Out of 95 STIM-RCT responders, 36 (38%) received the addition of tamoxifen, 32 (34%) received letrozole, and 27 (28%) no addition (mean follow-up 7 years). Forty-four women became pregnant at least once after cancer treatment, and overall 7 women (7%) used their cryopreserved oocytes or embryos. In total, 63 pregnancies followed, of which 48 (76%) were conceived naturally, i.e., unassisted. Compared with standard ovarian stimulation, adding tamoxifen or letrozole resulted in comparable pregnancy rates in women who had at least one pregnancy after cancer treatment (tamoxifen vs. standard relative risk [RR], 0.92; 95% confidence interval [CI], 0.54-1.58; letrozole vs. standard RR, 0.84; 95% CI, 0.48-1.50), and live birth rates thereafter (tamoxifen vs. standard RR, 0.81; 95% CI, 0.54-1.22; letrozole vs. standard RR, 0.82; 95% CI, 0.53-1.26). In the STIM-cohort, 20 women became pregnant at least once, leading to a total of 30 pregnancies, of which 90% were conceived naturally. One woman used her cryopreserved embryos. Conclusion:After 7 years of follow-up, most women conceived naturally after cancer treatment, and 8 women used their cryopreserved oocytes or embryos. We found no evidence for a difference in pregnancy rates when adding tamoxifen or letrozole to standard ovarian stimulation compared with no addition.

RATIONALE:Intrauterine insemination (IUI) is widely used as a first-line treatment for subfertile couples with favourable prognostic factors, yet pregnancy rates vary considerably. The optimal method for timing IUI - whether through different monitoring strategies or ovulation triggering techniques in natural or stimulated cycles - remains uncertain. This review explores which timing approaches and methods of ovulation monitoring and triggering lead to the best outcomes, including live birth and clinical pregnancy. It updates a Cochrane review last published in 2014. OBJECTIVES:To evaluate the effectiveness of different methods of synchronisation of insemination with ovulation on live birth or ongoing pregnancy, in natural and stimulated cycles for IUI in subfertile couples. SEARCH METHODS:We used the Cochrane Gynaecology and Fertility Group specialised register, CENTRAL, MEDLINE, and two other databases, along with reference checking, citation searching, handsearching of conference abstracts, and contact with study authors to identify the studies included in the review. The latest search date was October 2023. ELIGIBILITY CRITERIA:We included randomised controlled trials (RCTs) comparing timing methods in natural or stimulated cycles, and different ovulation triggering methods. These included: varying the time interval between ovulation triggering and insemination, luteinising hormone (LH) detection in urine, LH detection in blood, basal body temperature charts, ultrasound detection of ovulation, human chorionic gonadotropin (hCG) administration, a combination of LH detection and hCG administration, gonadotropin-releasing hormone (GnRH) agonist administration, and other trigger administrations. OUTCOMES:Critical outcome: live birth or ongoing pregnancy rate per couple. Important outcomes (all are rate per couple): clinical pregnancy; multiple pregnancy; miscarriage; ovarian hyperstimulation syndrome; tubal pregnancy. RISK OF BIAS:We used the Cochrane Collaboration's original tool to assess the risk of bias in the included RCTs. SYNTHESIS METHODS:After the search, we screened the trials, extracted the data, and assessed the risk of bias and trustworthiness of the included studies. We synthesised results for each outcome using meta-analysis where possible. We expressed results for each included study as Mantel-Haenszel odds ratios (OR) with 95% confidence intervals (CI). We used GRADE to assess the certainty of the evidence for each outcome. INCLUDED STUDIES:This review update includes 42 studies: 18 from the 2014 version, plus 24 studies newly identified in the updated search. SYNTHESIS OF RESULTS:Of the 42 included studies (a total of 6603 couples), we included seven in the primary meta-analyses (1917 couples) and 12 in the sensitivity meta-analyses (2143 couples). The certainty of the evidence was low for most comparisons. The main limitation of the evidence was serious imprecision. Of the seven studies included in the primary analyses, two compared the optimum time interval from hCG injection to IUI for live birth or ongoing pregnancy rate, comparing different time frames ranging from 0 to 48 hours. We categorised the time frames into three groups: (i) 0 to 33 hours; (ii) 34 to 40 hours; and (iii) more than 40 hours. We compared 0 to 33 hours versus 34 to 40 hours, and 34 to 40 hours versus more than 40 hours. Results were too imprecise to be informative in both comparisons (0 to 33 hours versus 34 to 40 hours: OR 1.42, 95% CI 0.90 to 2.23; 1 study, 374 couples; 34 to 40 hours versus more than 40 hours: OR 0.45, 95% CI 0.15 to 1.33; 1 study, 107 couples). We included one study in the primary analysis for each of the following comparisons: hCG versus LH surge; recombinant hCG versus urinary hCG; and hCG alone versus hCG plus follicle-stimulating hormone (FSH). It is unclear whether there might be a difference in live birth or ongoing pregnancy rates in the first two comparisons: hCG versus LH surge: OR 1.08, 95% CI 0.50 to 2.37; 1 study, 392 couples; low-certainty evidence; recombinant hCG versus urinary hCG: OR 1.13, 95% CI 0.49 to 2.63; 1 study, 125 couples; low-certainty evidence. However, live birth or ongoing pregnancy rates may be lower with hCG alone compared to hCG plus FSH (OR 0.35, 95% CI 0.13 to 0.95; 1 study, 108 couples; low-certainty evidence). We found no clear evidence of a difference between any of the groups in clinical pregnancy rate or adverse events (multiple pregnancy rate, miscarriage rate, tubal pregnancy rate). However, all results were of low-certainty evidence. None of the studies included in the primary analyses reported on ovarian hyperstimulation syndrome. AUTHORS' CONCLUSIONS:There is insufficient evidence to determine whether there is any difference in effectiveness between different methods of synchronisation of ovulation and insemination. FUNDING:This Cochrane review had no dedicated funding. REGISTRATION:First review update (2014): doi.org/10.1002/14651858.CD006942.pub3 Review (2010): doi.org/10.1002/14651858.CD006942.pub2 Protocol (2008): doi.org/10.1002/14651858.CD006942.

BACKGROUND:Women with anorectal malformations (ARM) may experience fertility problems and complications during childbirth due to these congenital anomalies and the corrective surgeries they underwent in their childhood. We aim to investigate the outcomes regarding fertility, pregnancy, and childbirth in relation to the type of ARM and the type of treatment these patients underwent in a Dutch cohort. METHODS:We performed a prospectively designed cross-sectional study. We included 37 women with rectoperineal fistulas, rectovestibular fistulas, or cloacal fistulas. Information regarding the type of ARM, type of treatment, and presence of genital malformations (consisting of Mullerian anomalies and anomalies of the external genitals) was collected from the medical records. Two questionnaires collected information on the menstrual cycle, fertility, pregnancies, and obstetric history. RESULTS:Thirty-seven women, of whom 18 were diagnosed with rectoperineal fistula, 14 with rectovestibular fistula, and 4 with cloaca (median age 28, range 19-61 years), completed the questionnaires; 10 conceived successfully, five had tried to conceive unsuccessfully, and 22 had not attempted pregnancy. Of the 10 women who conceived successfully, 24 pregnancies were reported, of which 22 were natural conceptions, 15 resulted in live births, five in a miscarriage, two women were pregnant when completing the questionnaires, and the outcome of two pregnancies was not reported. Of the 15 live births, 12 children were carried to term, while three were born preterm. Except for one woman, deliveries were by Cesarean section. Pregnancies were reported in all three types of ARM irrespective of a Mullerian or external genital anomaly. CONCLUSIONS:Women with anorectal malformations can become pregnant irrespective of the type of ARM and the presence of a Mullerian or external genital anomaly. Of the women who attempted pregnancies, 67 % conceived successfully, and almost all women conceived spontaneously and carried to full term. Our findings regarding fertility and obstetrical outcomes for this patient group are promising. LEVEL OF EVIDENCE:II. TYPE OF STUDY:Prospectively designed, cross-sectional study.

OBJECTIVE:To develop a core outcome set for male infertility trials. DESIGN:A two-round Delphi survey and consensus development workshop were undertaken with healthcare professionals, researchers and clinicians globally. SUBJECTS:334 participants from 39 countries participated in the Delphi Survey, while 44 participants from 21 countries participated in the consensus development workshop. EXPOSURE:NA MAIN OUTCOME MEASURES: The core outcome set for male infertility trials has been developed by the inclusion of specific male-factor outcomes in addition to the general infertility core outcome set which focuses on female-factor outcomes. RESULTS:The outcomes identified include assessment of semen using the World Health Organisation recommendations for semen analysis; viable intrauterine pregnancy confirmed by ultrasound (accounting for singleton, twin and higher multiple pregnancies); pregnancy loss (accounting for ectopic pregnancy, miscarriage, stillbirth and termination of pregnancy); live birth; gestational age at delivery; birthweight; neonatal mortality; and major congenital anomaly. Although not a requirement as part of the core outcome set, other outcomes were identified as potentially useful in certain study settings. CONCLUSION:Embedding the core outcome set within RCTs and systematic reviews should ensure the comprehensive selection, collection and reporting of core outcomes, which are inconsistently reported at present. Research funding bodies, the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) statement, and over 80 specialty journals, including the Cochrane Gynaecology and Fertility Group, Fertility and Sterility and Human Reproduction, have committed to implementing this core outcome set for male infertility trials. TRIAL REGISTRATION NUMBER:Core Outcome Measures in Effectiveness Trials (COMET) initiative registration No: 1586. Available at www.comet-initiative.org/Studies/Details/1586.

STUDY QUESTION What is the risk of endometrial cancer after long-term follow-up in women treated with ART between 1983 and 2001 compared with women in the general population and subfertile women who did not undergo ART?SUMMARY ANSWER The risk of endometrial cancer is not increased in women who underwent ART in the Netherlands between 1983 and 2001, neither compared with women from the general population nor compared with subfertile women not treated with ART.WHAT IS KNOWN ALREADY Concerns have been raised that subfertility treatment may be associated with increased risk of endometrial cancer. However, published studies show inconsistent results regarding the effects of ovarian stimulation and specific subfertility diagnoses on endometrial cancer risk.STUDY DESIGN, SIZE, DURATION A nationwide historic cohort study (the OMEGA-cohort) was conducted to examine the risk of cancer in women after ovarian stimulation for ART. The OMEGA-cohort comprises 30 625 women who received ovarian stimulation for ART (ART group) in 1983-2000 and 9988 subfertile women not treated with ART (non-ART group). After a median follow-up of 24 years, endometrial cancer incidence was ascertained through linkage with the Netherlands Cancer Registry. Endometrial cancer risk in the cohort was compared with that in the general population using person-years analyses, and between the ART group and non-ART group using multivariable Cox regression analyses.PARTICIPANTS/MATERIALS, SETTING, METHODS Detailed ART-treatment data were obtained from the medical records and complete information on parity and age at first birth was obtained through linkage with the Personal Records Database. Information on hysterectomy and endometriosis was collected through linkage with the Dutch Nationwide Pathology Databank (Palga). Data about lifestyle factors, including BMI, were obtained through a self-administered questionnaire.MAIN RESULTS AND THE ROLE OF CHANCE After a median follow-up duration of 24 years, 137 endometrial cancers were diagnosed. Endometrial cancer risk after ART was not significantly increased compared with that in the general population (standardized incidence ratio = 1.19; 95% CI = 0.97-1.44) nor compared with that in the non-ART group (multivariably adjusted hazard ratio = 1.11; 95% CI = 0.74-1.67). Risk of endometrial cancer did not increase with longer follow-up or with more ART cycles, and the risk within the cohort, did not vary by cause of subfertility (male, tubal, unexplained, and other). Irrespective of ART treatment, endometrial cancer risk was increased in obese women and women with endometriosis, but decreased among parous women and women who used oral contraceptives.LIMITATIONS, REASONS FOR CAUTION Although the findings of the study are reassuring, the median age of the women at the end of follow-up (median age 56 years) was still rather young. Therefore, there is a need for at least 10-15 additional follow-up years to draw definitive conclusions. In addition, other large studies are needed to investigate the risk of endometrial cancer in women who underwent ART.WIDER IMPLICATIONS OF THE FINDINGS The results of this study contribute to knowledge about long-term health after ART treatment, which is valuable to subfertile couples, considering or undergoing fertility treatments, and their healthcare providers. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by a grant from the Dutch Cancer Society (NKI 2006-3631) and a departmental grant from the Department of Obstetrics and Gynecology of Erasmus Medical Center, Rotterdam, the Netherlands (2011-019). Ma.S. is Associate Editor of Human Reproduction Open; A.W.vd.B.-D received support for attending meetings and/or travel from the Dutch Cancer Society; C.B.L. is Editor-in-Chief of Human Reproduction; A.E.P.C. is Associate Editor of Human Reproduction Update, received royalties from Uptodate Hyperthecosis, and participated at the Data Safety Monitoring Board of the DSMB POEM Study; F.B. has received research support from Merck, honoraria or consultation fees from Merck Healthcare KGaA, Bensis Healthcare, CooperSurgical, and participated in an advisory board for Merck and Ferring; J.L. has received research support from Ferring, Merck, and Roche Diagnostics, consulting fees and honoraria from Ferring, participated on a Data Safety Monitoring Board or Advisory Board of the LOCI trial, is President of the AE-PCOS society, and Member of the ASRM Integrity Committee; J.M.J.S. has received honoraria from Ferring and Merck, support for attending meetings and/or travel from Ferring, Merck, and Good Life, and participated in the advisory board of Merck; L.L.v.L. received support for attending meetings and/or travel from Olympus Medical Expert training; M.M.v.R. received support for attending meetings and/or travel from Ferring; M.G. declares departmental research and educational grants from Ferring (location VUmc), unrelated to the presented work. The other authors declare no competing interests.TRIAL REGISTRATION NUMBER N/A.

What are long-term breast cancer survival rates of women who received standard ovarian hyperstimulation with addition of tamoxifen or letrozole? No differences were observed in long term breast cancer survival rates after ovarian stimulation with addition of tamoxifen or letrozole compared to standard stimulation alone. Previous studies found no differences in survival after ovarian stimulation with addition of tamoxifen or letrozole in women with breast cancer. However, most studies were prospective or retrospective cohort studies with a relatively short follow-up time, and many of these studies did not have matching criteria between study population and control groups. There is lack of prospective long-term follow-up studies, with regards to differences in survival rates. This is a 5-10 year follow-up study of the STIM-RCT, which was a multicenter randomized trial (NTR4108), and the STIM-cohort. The STIM-RCT evaluated oocyte yield by adding tamoxifen or letrozole to standard ovarian stimulation in women with breast cancer. The STIM-cohort was added to retrieve more data, and included women who did not want to participate in the trial. Subsequently, a digital questionnaire was sent between January 2023 and September 2024. Women with breast cancer included in the STIM-RCT and STIM-cohort were eligible for follow-up. Women included were aged 18-43 years. Questions addressed women’s wellbeing and whether they finished their cancer treatment, amongst others. Primary outcomes were overall survival and breast cancer free interval. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were calculated for the STIM-RCT only. Due to differences in ovarian stimulation protocols and missing data in the STIM-cohort, data are provided descriptively. In total 237 women were included in the study, and 220 received the questionnaire. The STIM-RCT included 154 women, of whom 13 (8%) are deceased and 141 received the questionnaire. Complete follow-up data is available of 108 women (70%), of whom 37 women received tamoxifen, 36 women received letrozole, and 35 women received standard stimulation. Median follow-up time was 7 years (range 5 months – 10 years). Mortality rates were 1 (3%) in the tamoxifen group, 4 (11%) in the letrozole group and 8 (23%) in the standard stimulation group. The STIM-RCT follow-up showed no significant differences in overall survival when comparing tamoxifen or letrozole with standard stimulation (HR = 0.19; p = 0.14; 95%CI 0.02-1.70, HR = 0.36; p = 0.24; 95%CI 0.06-1.98, respectively). Furthermore, no significant differences were found in breast cancer free interval (HR = 0.45; p = 0.12; 95%CI 0.16-1.22, HR = 0.38; p = 0.07; 95%CI 0.13-1.07, respectively). The STIM-cohort consisted of 83 women, of whom 79 received the questionnaire and 34 (43%) completed it. Median follow-up time was 7 years (range 2-9 years). The mortality rate was 3 (8%). Due to differences in protocols, survival analyses could not be performed for the STIM-cohort. Our study was too small to prove or disprove differences on safety issues like overall survival and breast cancer free interval between the various stimulation protocols. Furthermore, this study might be limited by selective inclusion, as women who experienced remission could be more likely to fill out the questionnaire. This is the first study performing a long term follow-up of a RCT after ovarian stimulation with addition of tamoxifen or letrozole. Up until now, no differences have been found in survival rates in this population. More long term follow-up studies are still needed to finalize conclusions on this topic. No

Is ovarian inflammation, as reflected by the composite biomarker GlycA in follicular fluid, associated with outcomes in modified natural cycle IVF? A higher inflammatory load in follicular fluid (FF) was associated with lower odds of achieving top-quality embryos, positive pregnancy tests, ongoing pregnancies, and live births. Fertility and assisted reproductive technology (ART) success are seemingly reduced in conditions of systemic inflammation, but conceivably local ovarian inflammation is more critical in this context. Smaller-scale studies linking cytokines in FF to ART success were inconclusive, possibly due to inherent physiological and experimental variabilities. The composite inflammation biomarker GlycA may offer superior performance and a broader representation of inflammation in FF. Derived from nuclear magnetic resonance (NMR) spectra, GlycA reflects levels and glycosylation states of acute-phase proteins, all also expressed locally by granulosa cells. To the best of our knowledge, GlycA has not been measured in FF. This single-center retrospective cohort study (n = 367 cycles from 204 patients) collected FF and plasma samples from ovulatory women undergoing MNC-IVF between 2013-2017. Only samples from cycles in which one oocyte was obtained were included, assuring that GlycA levels could be related to the characteristics of the transferred embryo. GlycA was measured by NMR spectroscopy in (i) all FF samples and (ii) n = 20 plasma samples matched to the FF to compare local and systemic concentrations. The association between FF GlycA levels and oocyte maturation, oocyte fertilization, embryo fragmentation, embryo quality, and pregnancy were analyzed using multilevel generalized estimating equations (GEE) with 50µmol/l GlycA as unit and adjustment for patient and cycle characteristics as well as potential confounders. A total of 235 embryos were transferred two days after oocyte retrieval, resulting in 66 positive pregnancy tests and subsequently 37 live births. In all patients with available plasma samples GlycA levels were consistently lower in FF than plasma (283 ± 52 vs. 361 ± 50 µmol/l, p<.001). GlycA concentrations in FF correlated positively with BMI (r=.408, p = <.001), but not with age and duration of subfertility. Interestingly, a higher inflammatory load in FF, as reflected by GlycA, was associated with a decreased odds ratios for the oocytes developing into a top-quality embryo (odds ratio [OR] 0.71, 95%CI [0.56-0.89], p=.004), a positive pregnancy test (OR 0.73 [0.56-0.95], p=.017), an ongoing pregnancy (OR 0.69 [0.52-0.92], p=.013) and a live birth (OR 0.49 [0.29-0.84], p=.01). This is a single-center study conducted in a resource-rich, high-socioeconomic healthcare environment with a predominantly Caucasian population. Further, exclusively ovulatory patients undergoing MNC-IVF were included. Thus, extrapolation to other respective settings requires further validation. Further research into the relationship between ovarian inflammation and infertility seems warranted, with a focus on identifying and characterizing causative pathways amenable to therapeutic intervention. Such advancements may pave the way for novel targeted anti-inflammatory therapies with the potential to improve infertility and ART success rates. No

Objective: We determined (1) if 11-oxygenated androgens better identify polycystic ovary syndrome (PCOS) diagnosis in women with obesity compared to total or free testosterone (T) and free androgen index; (2) how biochemical hyperandrogenism and metabolic factors cluster in a cohort of women with infertility and obesity. Methods: Women with obesity and PCOS comprised the study group (N = 132). Ovulatory women with obesity and idiopathic, tubal or male factor infertility were the control group (N = 83). Steroid hormones were measured by means of liquid chromatography tandem mass spectrometry. Receiver operating characteristic curves and principal component analysis were used. Results: Women with obesity and PCOS had higher 11-ketotestosterone (11 KT) (1.22 nmol/L [0.84; 1.65] vs 1.05 [0.78; 1.35], P = .04) compared to controls, but not 11b-hydroxyandrostenedione 4.30 [2.87; 5.92] vs 4.06 [3.22; 5.73], P = .44). 11-ketotestosterone (area under the curve: 0.59) did not better discriminate PCOS in women with obesity compared to: total T (0.84), free T (0.91), and free androgen index (0.85). We identified 4 principal components (PCs) in the PCOS group (72.1% explained variance): (1) insulin resistance status; (2) blood pressure; (3) obesity; (4) androgen status and 4 PCs in the control group (68.7% explained variance) with variables representing metabolism being dispersed in component 2, 3, and 4. Conclusions: Eleven-oxygenated androgens do not aid in the diagnosis of PCOS in women with obesity. Insulin resistance is the strongest PC in the PCOS group. There is no major dominant characteristic that defines obese non-PCOS women. (c) 2024 AACE. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

For many people, including health care providers, endometriosis is an unknown disease. It can present in many different ways, making it difficult to diagnose. As a result the diagnosis is often missed and the right treatment cannot be started. This delay can lead to a huge reduction in the quality of life. Based on three cases of endometriosis we show you when to think about this disease. In the cases we describe the most common symptoms of endometriosis are mentioned: pelvic pain, dysmenorrhea and, dyspareunia. It is important to ask a patient with pelvic pain or subfertility about these complaints. If endometriosis is suspected on the basis of these or other complaints, empirical hormonal treatment can be offered to patients who are not trying to conceive at that time.

Cumulus granulosa cells (cGCs) and mural granulosa cells (mGCs), although derived from the same precursors, are anatomically and functionally heterogeneous. They are critical for female fertility by supporting oocyte competence and follicular development. There are various techniques used to investigate the role of free radicals in mGCs and cCGs. Yet, temporospatial resolution remains a challenge. We used a quantum sensing approach to study free radical generation at nanoscale in cGCs and mGCs isolated from women undergoing oocyte retrieval during in vitro fertilization (IVF). Cells were incubated with bare fluorescent nanodiamonds (FNDs) or mitochondria targeted FNDs to detect free radicals in the cytoplasm and mitochondria. After inducing oxidative stress with menadione, we continued to detect free radical generation for 30 min. We observed an increase in free radical generation in cGCs and mGCs from 10 min on. Although cytoplasmic and mitochondrial free radical levels are indistinguishable in the physiological state in both cGCs and mGCs, the free radical changes measured in mitochondria were significantly larger in both cell types, suggesting mitochondria are sites of free radical generation. Furthermore, we observed later occurrence and a smaller percentage of cytoplasmic free radical change in cGCs, indicating that cGCs may be more resistant to oxidative stress.

BACKGROUND:The growing field of assisted reproductive techniques, including frozen-thawed embryo transfer (FET), should lead the way to the best sustainable health care without compromising pregnancy chances. Correct timing of FET is crucial to allow implantation of the thawed embryo. Nowadays, timing based on hospital-controlled monitoring of ovulation in the natural cycle of a woman is the preferred strategy because of the assumption of favourable fertility prospects. However, home-based monitoring is a simple method to prevent patient travel and any associated environmental concerns. We compared ongoing pregnancy rates after home-based monitoring versus hospital-controlled monitoring with ovulation triggering. METHODS:This open-label, multicentre, randomised, non-inferiority trial was undertaken in 23 hospitals and clinics in the Netherlands. Women aged between 18 and 44 years with a regular ovulatory menstrual cycle were randomly assigned in a 1:1 ratio via a web-based randomisation program to home-based monitoring or hospital-controlled monitoring. Those who analysed the data were masked to the groups; those collecting the data were not. All endpoints were analysed by intention to treat and per protocol. Non-inferiority was established when the lower limit of the 90% CI exceeded -4%. This study was registered at the Dutch Trial Register (Trial NL6414). FINDINGS:1464 women were randomly assigned between April 10, 2018, and April 13, 2022, with 732 allocated to home-based monitoring and 732 to hospital-controlled monitoring. Ongoing pregnancy occurred in 152 (20·8%) of 732 in the home-based monitoring group and in 153 (20·9%) of 732 in the hospital-controlled monitoring group (risk ratio [RR] 0·99 [90% CI 0·81 to 1·22]; risk difference [RD] -0·14 [90% CI -3·63 to 3·36]). The per-protocol analysis confirmed non-inferiority (152 [21·0%] of 725 vs 153 [21·0%] of 727; RR 1·00 (90% CI 0·81 to 1·23); RD -0·08 [90% CI -3·60 to 3·44]). INTERPRETATION:Home-based monitoring of ovulation is non-inferior to hospital-controlled monitoring of ovulation to time FET. FUNDING:The Dutch Organisation for Health Research and Development.

A possible biological mechanism for unexplained male infertility is due to the effect of oxidative stress (OS), defined by the imbalance of reactive oxygen species (ROS) production, and the capacity of the antioxidant defence system to counteract it. In physiological concentrations, ROS and especially free radicals play an essential role in sperm maturation and fertilization, while an overabundance could lead to OS-induced damage to spermatozoa. To date, there are no direct detection techniques available that can measure the total amount of free radicals real time and identify where and when free radicals are generated. This study applies a quantum sensing technique using fluorescent nanodiamonds (FNDs), called T1 relaxometry, which is uniquely sensitive and specific for free radicals allowing measurements of the current radical load for nanoscale detection in living cells and body fluids. This proof-of-principle study investigates if we can use this technique to detect the free radical generation in human whole and separated, using density gradient centrifugation, semen. This method could be potentially used as new diagnostic measure for unexplained infertility or to track the effect of therapeutic interventions such as lifestyle changes. We adapted the existing relaxometry technique to measure free radicals in semen. The measured relaxation time (T1 time) was correlated to sperm concentration and progressive motility. Additionally, we explored the influence of the oxidative trigger hydrogen peroxide and the antioxidant glutathione on the free radical concentration measured. No significant correlations were found, which indicates that measurements in more proximity of the sperm cell are required to use relaxometry as a potential diagnostic tool for unexplained male infertility.

In assisted reproductive technology (ART) research, live birth has been generally accepted as an important outcome, if not the most important one. However, it has been reported inconsistently in the literature and solely focusing on live birth can lead to misinterpretation of research findings. In this review, we provide an overview on the definitions of live birth, including various denominators and numerators use. We present a series of real clinical examples in ART research to demonstrate the impact of variations in live birth on research findings and the importance of other outcomes, including multiple pregnancy, pregnancy loss, time to pregnancy leading to live birth, other short and long term maternal and offspring health outcomes and cost effectiveness measures. We suggest that outcome choices in ART research should be tailored for the research questions. A holistic outcome assessment beyond live birth would provide a full picture to address research questions in ART in terms of effectiveness and safety, and thus facilitate evidence-based decision making.

We thank Dr Nayana Tara Vasireddy and colleagues (1) for their observations regarding our published research (2). We welcome the opportunity to further discuss our findings. With regard to the first comment, it has been shown that overt hyperor hypothyroid states affect semen quality negatively (3, 4). In our study, some of the participants were overtly hypothyroid upon semen cryopreservation affecting their semen quality negatively. This is shown by the lower sperm quality of the overt hypothyroid patients upon semen cryopreservation in our study. The effect of subclinical hyperor hyperthyroidism on semen quality has not been well researched or documented. Upon study evaluation, the thyroid-stimulating hormone (TSH) and thyroxine levels of the participants indeed show that participants experienced subclinical hyperthyroidism. This is expected, as most of these participants are in follow-up for their thyroid carcinoma. One can speculate that semen quality would increase if participants became euthyroid. However, current results already show that reproduction is not greatly affected in these participants, indicating that this increase in semen quality parameters would not be clinically relevant. In addition, we found no significant correlations between TSH values and semen quality parameters in additional analysis (data not shown) in our current participants, indicating that TSH levels in the current subclinical hyperthyroid participants did not affect their semen quality. As for the second remark, it is known that permanent hypoparathyroidism affects 2% of the patients undergoing total thyroidectomy (5, 6). Unfortunately, we do not have information on the parathyroid status of the current participants. Therefore, we are not able to evaluate the effect of calcium levels or PTH levels on semen quality.