PROBLEM:The interleukin-17 (IL-17) family includes pro-inflammatory cytokines IL-17A-F with important roles in mucosal defence, barrier integrity and tissue regeneration. IL-17A can be dysregulated in fertility complications, including pre-eclampsia, endometriosis and miscarriage. Because mammalian subclasses (eutherian, metatherian, and prototherian) have different related reproductive strategies, IL-17 genes and proteins were investigated in the three mammalian classes to explore their involvement in female fertility. METHOD OF STUDY:Gene and protein sequences for IL-17s are found in eutherian, metatherian and prototherian mammals. Through synteny and multiple sequence protein alignment, the relationships among mammalian IL-17s were inferred. Publicly available datasets of early pregnancy stages and female fertility in therian mammals were collected and analysed to retrieve information on IL-17 expression. RESULTS:Synteny mapping and phylogenetic analyses allowed the classification of mammalian IL-17 family orthologs of human IL-17. Despite differences in their primary amino acid sequence, metatherian and prototherian IL-17s share the same tertiary structure as human IL-17s, suggesting similar functions. The analysis of available datasets for female fertility in therian mammals shows up-regulation of IL-17A and IL-17D during placentation. IL-17B and IL-17D are also found to be over-expressed in human fertility complication datasets, such as endometriosis or recurrent implantation failure. CONCLUSIONS:The conservation of the IL-17 gene and protein across mammals suggests similar functions in all the analysed species. Despite significant differences, the upregulation of IL-17 expression is associated with the establishment of pregnancy in eutherian and metatherian mammals. The dysregulation of IL-17s in human reproductive disorders suggests them as a potential therapeutic target.

Objectives Global access to assisted reproductive technologies (ART) remains highly inequitable. Until recently, access to ART in Ireland was solely available through private fertility clinics. Publicly funded ART was introduced in September 2023 but eligibility requires patients to meet strict access criteria that include referral by their primary care general practitioner (GP) to the local fertility service. Previous studies report that fertility training amongst doctors, including GPs, is variable and an obstetrics and gynaecology (O&G) rotation is not mandatory for GP trainees in Ireland. This study aimed to investigate GPs’ knowledge of fertility investigations and management, as well as attitudes towards publicly funded ART access criteria. Study Design A cross-sectional online survey was distributed to GPs working in Ireland between September 2023 and January 2024. The survey questionnaire explored attitudes to, and knowledge of, ART including the publicly funded access criteria. Responses to free-text questions were qualitatively analysed using content analysis. Results The study had 154 respondents, representing approximately 4 % of GPs in Ireland. Three quarters (n = 120, 78 %) of respondents were female, 68 % (n = 105) had completed an O&G training rotation and 72 % (n = 111) had further O&G qualifications. However, 69 % (n = 107) reported that they had no training in subfertility investigation and management, and 34 % (n = 53) were not aware of the access criteria for publicly funded ART prior to completing the survey. Almost all GPs (97 %, n = 149) felt that they would benefit from more education on fertility. Qualitative content analysis generated two themes regarding publicly funded ART: (i) the access criteria are too restrictive and (ii) the workload for GPs will increase. Conclusions GPs in Ireland are now being tasked with managing infertility and fertility treatment referrals, but most have not been provided with sufficient training. Our study shows that GPs in Ireland desire broader access criteria for publicly funded ART and better fertility training and education for their own clinical practice.

STUDY QUESTION: Does receptor for advanced glycation end products (RAGE) on the surface membrane of the sperm cell function as a biomarker of low-quality sperm? SUMMARY ANSWER: Membrane-bound RAGE at a cellular level directly correlates with low sperm motility, high cell permeability, decreased mitochondrial function, DNA fragmentation, and higher levels of apoptosis. WHAT IS KNOWN ALREADY: RAGE has previously been measured by ELISA in low-quality sperm in diabetic men and has been shown to correlate with DNA fragmentation (terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay). STUDY DESIGN, SIZE, DURATION: Semen samples were recovered from 60 non-obese, non-diabetic and non-smoking subjects, washed with fresh media, and analysed directly or purified further by differential gradient centrifugation (DGC) or fractionated by direct swim-up before being analysed for sperm motility and molecular health parameters, including cell membrane permeability, cell death, mitochondrial membrane potential, DNA fragmentation, and RAGE protein expression. PARTICIPANTS/MATERIALS, SETTING, METHODS: Sperm motility assessments were carried out by computer-assisted sperm analysis (CASA) on 1000 spermatozoa for washed samples and 300 spermatozoa for purified samples. Molecular sperm health parameters were evaluated using flow cytometry with the use of the following markers: DAPI for cell membrane permeability, Annexin V/ DAPI for cell death (apoptosis and necrosis), MitoTracker (R) Red CMXRos for mitochondrial membrane potential, TUNEL assay for DNA fragmentation and 8-hydroxy-2-deoxyguanosine for identification of oxidative damage to sperm DNA, and contrasted to membrane- bound RAGE expression levels, which were evaluated using an anti-RAGE monoclonal mouse antibody. MAIN RESULTS AND THE ROLE OF CHANCE: RAGE protein was shown to be present on the acrosomal and equatorial regions of sperm, with the levels of membrane bound receptor strongly correlating with poor sperm health across all parameters tested; motility (R2 = 0.5441, P <0.0001) and mitochondrial membrane potential (R2 = 0.6181, P <0.0001) being of particular note. The analysis was performed at a single cell level thereby removing confounding complications from soluble forms of the RAGE protein that can be found in seminal plasma. The expression of the RAGE protein was shown to be stable over time and its levels are therefore not subject to variation in sample handling or preparation time. LARGE SCALE DATA: N/A. LIMITATIONS, REASONS FOR CAUTION: Inclusion criteria for this study were non-diabetic, non-obese and non-smoking participants to assess the distribution of RAGE expression in the general population, thereby excluding disease conditions that may increase RAGE expression in sperm or contribute to low sperm quality. The study does not address how RAGE expression may be affected in other patient subpopulations or disease states associated with male infertility. Sperm analysis by flow cytometry is not amenable to the study of males with a low sperm count. WIDER IMPLICATIONS OF THE FINDINGS: Results of this study suggest that RAGE expression is a molecular maker of sperm cell health, which may be used for improvements in assisted reproduction through the removal of RAGE expressing sperm and facilitate in the diagnoses of unexplained infertility through its use as a biomarker of male infertility.

Objective: Effect of the pandemic, and associated disruption of reproductive services, on mental wellbeing of those whose fertility journey was disrupted during the first phase of COVID-19 Design: Web- based cross- sectional study Setting: Not for profit fertility clinic Population: Fertility patients Methods: Web- based cross- sectional study of fertility patients who had an appointment over a 7 week period Main Outcome Measures: Effect of the pandemic on mental wellbeing of those whose fertility journey was disrupted Results: 135 responses were received giving a response rate of 16.3%. 117 responses were analysed following exclusion of incomplete responses. The mean well- being score in our population was 45.03 + 0.796 (n=117), significantly lower than the published average WEMWBS score (P<0.0001). When a gender-based analysis was performed, female fertility patients had a lower score during the period under observation compared to the published average WEMWBS scores (Female: 49.6 + 0.34, n=644 vs 44.4 + 0.88, n=99, P< 0.0001; Male: 50 + 0.43, n=4429 vs 47.3 + 1.81, n=26, P=0.136). There was no significant difference in average well-being score in the 30-39yr category compared to the over 40yr group (44.9 + 0.97 vs 45.0 + 1.39). Participants with children scored higher than those without (46.8 + 1.19 (n=38) vs 44.1 + 1.02 (n=79)). Conclusions: Increased levels of depression and anxiety coupled with added uncertainty of clinic closures and disruption to services have led to a statistically significant lower WEMWBS scores in the fertility population.

Expedited development of SARS-CoV-2 vaccines led to public concerns regarding impacts of the novel vaccine on gametes in patients seeking assisted reproduction. In cases of an acute intermittent illness or fever in men, it is often advised to postpone ART treatments so that efforts can be made to enhance wellbeing and improve sperm parameters. However, it is unknown whether sperm parameters are altered in the acute (24-72 hour) phase following COVID-19 vaccination. We performed a longitudinal cohort study of 17 normospermic male patients attending a fertility clinic for semen analysis. Semen and matched peripheral blood samples were collected prior to vaccination, within 46 + 18.9 hours of vaccine course completion (acute) and at 88.4 + 12 days (3 months) post-vaccination. No overall change from baseline was seen in symptoms, mean volume, pH, sperm concentration, motility, morphology or DNA damage in the acute or long phase. Seminal plasma was found to be negative for anti-SARS-CoV2 Spike antibody detection, and MCP-1 levels showed an acute but transient elevation post-vaccine, while IL-8 was marginally increased 3 months after completion of vaccination. A modest, positive correlation was noted between serum levels of the anti-inflammatory cytokine IL-10 and self-reported symptoms post-vaccine. Our findings are reassuring in that no significant adverse effect of vaccination was noted and provide evidence to support the current recommendations of reproductive medicine organisations regarding timing of vaccination during fertility treatment.

Endometriosis is a chronic systemic disease, which results in endometrial-type tissue growing outside the uterus, and affects approximately 10% of reproductive-aged women worldwide. Its aetiology is poorly understood, and there is currently no long-term cure. Development and persistence of the disease depend on several coexisting factors including the vaginal microbiome. However, the role played by this important entity in endometriosis and its systemic involvement is not fully understood. Here, we investigated the vaginal microbiota, the serum and urine glycome, and antibody glycosylation in endometriosis patients. We reveal an endometriosis-specific vaginal microbiota in patients, being distinct from that present in a control group. Endometriosis patients were typified by a loss of the dominant Lactobacillus species, i.e. Lactobacillus iners, increased bacterial diversity and the presence of species such as Anaerococcus senegalensis, Prevotella jejuni, Porphyromonas bennonis and Anaerococcus octavius. The presence of trigalactosylated and triantennary serum glycans and urine core fucosylated mono-antennary glycans from IgG correlated with the vaginal presence of the bacterium A. senegalensis in endometriosis patients. Urine glycans did not differ in endometriosis, but urine IgG identified four novel sulfated glycans differing from serum IgG indicating functional relevance. Our findings contribute to understanding the relationships between the vaginal microbiota and the serum and urine glycome on the one hand, and endometriosis on the other. Further functional studies are warranted.

OBJECTIVE:Legislation and policies regarding assisted human reproduction (AHR) vary widely across nations and societies. As one of only 5 European countries which currently lacks legislation, Ireland now has a unique opportunity to learn from other jurisdictions and introduce AHR law that is reflective of the ongoing myriad developments in this complex field. Draft legislation, initially published in 2017, was revised in 2022 with strong political commitment to enacting in the same year. This study sought to ascertain the views of fertility patients (service users) to the proposed AHR legislation in its current format, prior to its implementation.STUDY DESIGN:A survey questionnaire, previously designed to investigate the attitudes and perceptions of healthcare professionals (HCPs) towards a broad range of issues contained within the draft AHR Bill, was adapted for a patient/service user population. The survey link was distributed via secure email to all patients that had a doctor consult at our fertility clinic in 2020-2021.RESULTS:The survey link was sent to 4420 patients/service users, of whom 1044 (23.6%) responded. A majority had experienced AHR treatment. Service users indicated strong support for AHR regulation and for access to all AHR techniques for all patients, irrespective of relationship or gender status. A majority of respondents disagreed with aspects of the draft bill regarding mandatory counselling, the timing of assignment of parentage in surrogacy, the exclusion of international surrogacy and the exclusion of men from posthumous AHR. Interestingly, the fertility patient cohort were more liberal in their views and opinions regarding AHR than the Irish HCPs previously surveyed.CONCLUSION:This study demonstrates the views of a large group of AHR patients/service users towards proposed AHR legislation. Many of their views concur with but others differ from those of the drafters of the legislation and from those of healthcare professionals. Consideration of the views of all these groups and a collaborative approach would help ensure that Ireland has AHR legislation that is inclusive and fit for purpose in the 21st century.

Objective: Ireland is one of 5 European countries which currently lacks specific legislation on Assisted Human Reproduction (AHR). Draft legislation was introduced in 2017 and revised in 2022 with a view to enacting legislation this year (2022). This study sought to ascertain the views of healthcare professionals to proposed AHR legislation, prior to the implementation of that legislation.Study design: A survey questionnaire based on all clinically relevant aspects of the Irish draft AHR Bill 2017 was distributed to relevant healthcare professionals using an online platform.Results: Over 200 healthcare personnel indicated strong support for the availability of AHR techniques, access to treatment for all patient populations regardless of relationship or gender status, and appropriate legislation and regulation in the field. Views of respondents are at variance with several proposals surrounding surrogacy, with 84 % favouring a pre-birth order to assign parentage from birth, rather than the proposed birth order 6 weeks after birth. The majority also support legislation around international surrogacy. Contrary to the draft Bill, re-spondents believe that men, as well as women, should be able to use posthumously any stored gametes or embryos belonging to the deceased partner or the couple. While the majority favour altruistic gamete donation, respondents support more generous compensation for donors, such as compensation for time lost at work.Conclusion: This study has uniquely ascertained the views of healthcare professionals to imminent AHR legis-lation. It is hoped that the results will help inform the national legislation as it nears completion. Similar studies could help other countries, and policy bodies such as ESHRE to frame good legislation in this extremely speci-alised and complex field.

The effects of COVID-19 on fertility services became evident in early 2020. Fertility treatments were initially suspended following advice from international fertility governing bodies. We performed a web-based study to investigate the attitudes of male and female fertility patients in Ireland, for risk mitigation strategies and pregnancy advice during the first wave of COVID-19. Despite international recommendations and uncertainty regarding COVID-19 and pregnancy, over two thirds of patients continued trying to conceive, while awaiting recommencement of fertility services. When services resumed, the majority were keen to continue fertility treatment. They were agreeable to telemedicine in place of face-to-face consultations. They felt that privacy was maintained and were comfortable signing consent forms via video link. Large numbers, however, strongly disagreed with the no-partner policy for embryo transfer and early pregnancy scanning, highlighting the importance of partner support. Patients felt strongly that fertility treatments should be classified as essential services and that every effort should be made to continue treatments in future pandemics. These results highlight the importance of maintaining fertility services, while adapting to new practices that may be required. The primary concern of the infertility population is the desire for pregnancy and parenthood. This innate human need trumps concerns regarding COVID-19 for the majority of those affected.

TPS2679 Background: Anti-PD-1/PD-L1/CTLA4 agents have revolutionized the treatment landscape of many cancer types, resulting in durable responses. With recent approvals in the adjuvant setting, the long-term consequences of immune checkpoint inhibitors (ICIs) such as the impact on fertility are of increasing clinical relevance. The impact of ICI therapy on fertility is poorly understood. Based on published data, we hypothesize that patient fertility may be affected by ICIs via several mechanisms, including: endocrine dysfunction, direct impact on gametogenesis, or autoantibody formation. Methods: We designeda prospective, multi-center translational study that aims to identify the effects of ICIs on fertility. We aim to recruit 88 patients over 3-4 years. Participants of child-bearing age as defined by study protocol who are due to start ICIs for any solid tumour malignancy, will be eligible. The primary endpoint of the study is a change in anti-Müllerian hormone level and antral follicle count in females, and a change in sperm concentration, motility, morphology in males measured before and serially during ICI therapy (up to 24 months). Secondary endpoints include analysis of FSH, LH, testosterone levels, the proportion of patients with a persistent change in any one reproductive parameter as assessed at follow-up visits, frequency of oligo/amenorrhoea in females and immunologic changes in seminal fluid in males. Conclusions: ICIs have led to a significant improvement in the long-term survival in selected patients with cancer. This study will elucidate the effects of ICIs on both male and female fertility over time, and provide useful information to guide patients and their care teams regarding long-term effects of ICIs on fertility. Recruitment is ongoing.

Endometriosis is a chronic inflammatory gynaecological disease characterized by the growth of endometrial tissue outside the uterine cavity. There are currently no definitive non-invasive diagnostic tools. Glycosylation is the most common posttranslational modification of proteins and altered glycosylation has been found in many diseases, including chronic inflammatory conditions and cancer. Sialylation and galactosylation on serum IgG have previously been found to be altered in endometriosis and serum sialylation changed after Zoladex (Goserelin Acetate) therapy. Using IgG and whole serum glycoproteins, we investigated N -glycosylation in two clinical cohorts of women with and without endometriosis. PNGase F-digested serum samples were fluorescently labelled and N -glycans were profiled by ultra-performance liquid chromatography. Clinical data was collected to link glycomic findings with metabolic and hormonal profiles. Total serum glycoprotein and IgG glycosylation differed in patients with endometriosis compared to control cases. The most significantly altered was glycan peak 3 from IgG, containing bisected biantennary glycans, which was decreased in the endometriosis cohorts (p = 0.0000005–0.018). In conclusion, this is the first pilot study to identify changes in N -glycans from whole serum glycoproteins associated with endometriosis. A larger validation study is now warranted and such studies should include the follow-up of surgically and pharmacologically treated patients.

Aims The expedited development of multiple COVID-19 vaccines has raised concerns for some, with vaccine hesitancy described in many populations. A U.S. study assessing fertility patients attitudes towards the COVID -19 vaccine revealed that over half were unsure, or would not accept the vaccine if offered. Only 7.4% of participants in this study were male. We therefore sought to assess the perspective of male fertility patients towards COVID-19 vaccination. Methods Men with a fertility appointment were invited to complete an anonymous 21-item questionnaire. Results Willingness to accept the COVID-19 vaccination was influenced by stage of fertility journey. Overall, 76% (n=102) of participants were willing to receive the COVID-19 vaccine. Men with a pregnant partner were most likely to accept or have already accepted the vaccine (97%, 30/31). Conclusion Although concerns around COVID-19 vaccines persist, this study demonstrates the growing rate of acceptance and engagement among the male fertility population.

The management of endometriomas in women wishing to preserve their fertility is complex. While surgery can help to achieve pregnancy in some, it may also have a detrimental effect on a woman's ovarian reserve. The present article reviews the impact of endometriomas on fertility and the different management approaches that should be considered in women who wish to preserve their fertility. This study also reviews the role of assisted reproduction in the setting of endometriomas, and the evolving role of oocyte cryopreservation for this benign but progressive disease. Using evidence from the latest guidelines and major publications, we emphasize the need to consider the woman's future fertility when navigating the diverse range of management strategies available, and outline an evidence-based framework to help facilitate fertility-friendly discussion, counseling and management of this complex disease.

Traditionally, the assessment of endometrial receptivity at transvaginal ultrasound scan has been based on the thickness and the morphological appearance of the endometrium. The objective of this study was to prospectively evaluate endometrial thickness (ET), endometrial morphology and uterine artery Doppler parameters prior to assisted reproduction treatment (ART) in the prediction of pregnancy outcome. This was a prospective cohort study. ET, morphology and uterine artery Doppler (UtAD) pulsatility index (PI) and resistance index (RI) were measured in the mid-luteal stage of the menstrual cycle ultrasonographically, timed with urinary luteinizing hormone testing. A total of 50 women were included in the analysis. The clinical pregnancy rate (CPR) per embryo transfer was 42.0% (n = 21/50). Twenty nine women (58.0%) had an unsuccessful outcome. There were no differences in mean +/- SD endometrial thickness (ET) (10.0 +/- 1.8 mm vs. 10.5 +/- 2.4; p = 0.43), or endometrial morphology (100% (n = 21) vs 100% (n = 29); p = 1.00) between the pregnant and not pregnant groups. Similarly, there were no differences in mean +/- SD UtAD PI (2.17 +/- 0.83 vs. 2.07 +/- 0.81; p = 0.67 or mean +/- SD UtAD RI (0.84 +/- 0.10 vs. 0.81 +/- 0.10; p = 0.30). Ultrasonographic endometrial assessment did not differentiate between those who would have a subsequent clinical pregnancy.

The intestinal mucosa exists in a state of "physiologic hypoxia,"where oxygen tensions are markedly lower than those in other tissues. Intestinal epithelial cells (IECs) have evolved to maintain homeostasis in this austere environment through oxygen-sensitive transcription factors, including hypoxia-inducible factors (HIFs). Using an unbiased chromatin immunoprecipitation (ChIP) screen for HIF-1 targets, we identify auto-phagy as a major pathway induced by hypoxia in IECs. One important function of autophagy is to defend against intracellular pathogens, termed "xenophagy."Analysis reveals that HIF is a central regulator of auto-phagy and that in vitro infection of IECs with Salmonella Typhimurium results in induction of HIF transcrip-tional activity that tracks with the clearance of intracellular Salmonella. Work in vivo demonstrates that IEC-specific deletion of HIF compromises xenophagy and exacerbates bacterial dissemination. These re-sults reveal that the interaction between hypoxia, HIF, and xenophagy is an essential innate immune compo-nent for the control of intracellular pathogens.

Background: Endometriosis is a chronic gynaecological disease whose aetiology is still unknown. Despite its prevalence among women of reproductive age, the pathology of the disease has not yet been elucidated and only symptomatic treatment is available. Endometriosis has high latency and diagnostic methods are both limited and invasive. Aim of review: The aim of this review is to summarise minimally invasive or non-invasive diagnostic methods for endometriosis and their diagnostic efficiencies. Furthermore, we discuss the identification and diagnostic potential of novel disease biomarkers of microbial or glycan origin. Key scientific concepts of review: Great efforts have been made to develop minimally invasive or non-invasive diagnostic methods in endometriosis. The problem with most potential biomarker candidates is that they have high accuracy only in cases of severe disease. Therefore, it is necessary to examine other potential biomarkers more closely. Associations between gastrointestinal and genital tract microbial health and endometriosis have been identified. For instance, irritable bowel syndrome is more common in women with endometriosis, and hormonal imbalance has a negative impact on the microbiome of both the genital tract and the gastrointestinal system. Further interrogation of these associations may have potential diagnostic significance and may identify novel therapeutic avenues. Glycomics may also be a potent source of biomarkers of endometriosis, with a number of glyco-biomarkers already approved by the FDA. Endometriosis-associated microbial and glycomic profiles may represent viable targets for development of innovative diagnostics in this debilitating disease.

Key content Continued advances in oncology treatments have led to better survival rates for children and young adults with cancer. An important ‘late effect’ of cancer treatment is the loss of fertility. Although many survivors of childhood cancers go on to conceive without difficulty, the potential loss of fertility is a concern for children and young adults with cancer, their parents and caregivers. We review current options for fertility preservation (FP) for prepubertal and postpubertal girls and boys, including oocyte cryopreservation, ovarian tissue cryopreservation, sperm cryopreservation and testicular tissue cryopreservation. Learning objectives To understand the different FP methods available for children and adolescents, the barriers to FP and ethical and psychological considerations To raise awareness of the importance of early discussions about FP with patients who are at risk of infertility from their cancer treatment. Ethical Issues Autotransplantation of ovarian tissue in survivors of haematological malignancies, particularly leukaemia, carries a strong risk of re‐introducing the malignancy and should be avoided. Clinicians must consider suitability of the patient for FP, taking into account emotional maturity, patient and parent desire for FP and the physical fitness of the patient, including their immunosuppressive state.