Research question: What are the reproductive choices and retrospective reflections of women at least 4 years after planned oocyte cryopreservation (POC)? Design: This was an internet survey, using the REDCap application, of women who underwent POC, at a single-centre university affiliated IVF unit, 4-8 years before the survey. The questionnaire addressed reproductive choices and outcomes following POC. Results: Seventy-nine women who underwent POC during 2011-2014 were invited to participate, and 70 (89%) responded. Mean age at cryopreservation was 37.1 +/- 2.4 (range 30-41) years, mean age at study participation 42.6 +/- 2.6 (range 35- 48) years, and mean time from first cryopreservation cycle to study participation 5.5 +/- 1.3 (range 4-8) years. The main retrospectively reported reason for POC was not wanting to become pregnant without a partner (59, 84%). During the followup period, 44 women (63%) attempted to conceive either naturally or by assisted reproductive technology using fresh or cryopreserved oocytes. Of those, 28 women achieved a live birth (64% of those who tried to conceive). Fourteen respondents (20% of all respondents) reported using their cryopreserved oocytes, and three (21%) achieved a birth using those oocytes. Fifteen women (34%) of those who tried to conceive used donor spermatozoa. Conclusions: The most common reasons for not using frozen oocytes were achieving pregnancy without frozen oocytes or preferring not to have a child without a partner. A considerable proportion of women who had POC and were not interested in being a single parent by choice eventually try to conceive using donor spermatozoa several years later.

Abstract Study question What are the success rates of social oocyte cryopreservation (SOC) at advanced age? Summary answer In this study, one in four women who underwent SOC above age 35 had a delivery. What is known already While SOC is gaining popularity, reports on delivery rates are limited due to low utilization rates. Study design, size, duration Retrospective data collection of all woman who underwent SOC between 2011–2018, and presented for treatment using cryopreserved oocytes until January 2021. Participants/materials, setting, methods: Review of patient records (including both IVF and antenatal/postnatal) and laboratory data in a university affiliated hospital-based IVF unit. Main results and the role of chance: A total of 448 women underwent SOC during 2011–2018. 50 (11.2%) women returned to use these oocytes until the end of January 2021. Women who returned to use their oocytes underwent cryopreservation at mean age of 38.2±2.2. 46 (92%) of participants were above 35 at time of cryopreservation. Number of oocytes cryopreserved was 11.3±9.7. Mean time from cryopreservation to thawing was 5.5±1.8years (range 1–9 years). and age at thawing was 43.4±2.1 (range 40–49). Nearly half of patients initially attempted to conceive before using their cryopreserved oocytes, mostly by ART using fresh oocytes. Mean number of oocytes thawed and oocytes survived per women was 9.7±6.2 and 6.1±4.9 respectively (post thawing survival rate 65.4±35%). Mean number of embryos transferred, at one or more attempts was 2.6±2.1 per women. Eleven women gave birth or had an ongoing pregnancy > 20 weeks at time of analysis. All deliveries resulted from cryopreservation at age 36 and older (delivery rate 23.9% per women). Limitations, reasons for caution: We report our initial experience of women who underwent SOC at a single center. Most women who returned to use their oocytes had undergone SOC at advanced age, therefore not necessarily reflecting outcome for younger patients attempting to preserve fertility using this technology. Wider implications of the findings: Considering modest success rates of SOC in our cohort, women considering SOC are advised to do so at an earlier age. Trial registration number Not applicable

Abstract Study question Do preimplantation genetic testing (PGT) pregnancies have higher pregnancy and delivery complications compared to naturally conceived (NC) pregnancies? Summary answer PGT pregnancies do not have increase pregnancy complications but do have increased post-partum complications. What is known already There is limited data about the outcome of PGT cycles regarding pregnancy complications. Previous reports show that PGT pregnancies are similar to NC pregnancies regarding birth weight and preterm delivery rate. Patients performing PGT are less likely to have infertility as a background problem, and therefore it is important to evaluate pregnancy complications in this specific population. Study design, size, duration A retrospective cohort study, between 2008–2020 in Shaare Zedek Medical center (SZMC). Demographic, background variables, treatment cycle information, and delivery data were collected from computerized hospital databases and patient files. Participants/materials, setting, methods All patients aged 18–45 that conceived following PGT treatment in the IVF unit and gave birth in SZMC were included in the study. We used two control groups: (1) women with spontaneous pregnancies (SP) who gave birth in SZMC. We used four “neighborhood control” for each PGT patient (two women delivered before and two after the case delivery). (2) pregnancies following ICSI with four neighborhood control for each. Main results and the role of chance 135 deliveries following PGT, 924 ICSI, and 4199 NC. Demographic variables were similar except PGT, and ICSI women were slightly older (30.93 ±4.33 PGT, 31.70±4.98 ICSI, 28.75±5.69 spontaneous, p < 0.01). PGT pregnancies had similar rates of placental complications (hypertensive disorder, preeclampsia (PET), placental abruption) as NC (p = 0.8), while ICSI pregnancies had significantly higher rates of gestational hypertension (p < 0.01) and abruption (p = 0.05). We found a higher rate of preterm delivery <37 weeks in both PGT and ICSI pregnancies (23.7%, 22.7%, 12.1%, p < 0.01 for PGT, ICSI, NC respectively), but only in ICSI was preterm delivery < 34 weeks increased (2.2% vs. 2.1%, p = 0.9, for PGT and NC, 4.3% for ICSI p < 0.01). Post-partum complications were more prevalent in both PGT and ICSI: longer third stage of labor (13.27±12.81, 12.58±10.08, 10.58±8.14, p < 0.05), manual lysis of placenta (6.7%, 2.3%, 1.4% p < 0.05), post-partum hemorrhage (PPH) (5.9%, 4.2%, 2.5% p = 0.02) and need for blood products (3.7%, 4.5%, 1.3% p = 0.02) for PGT, ICSI, NC respectively. The aOR for composite post-partum complications (PPH, hemoglobin drop>3 gram, revision or lysis) was 2.4, 95%CI [1.6–3.7]. We did not find any difference between fresh and frozen cycles in either placental complications, preterm delivery, or post-partum complications in the PGT group. Limitations, reasons for caution A single-center retrospective study. Included only pregnancies both conceived and delivered in SZMC. Wider implications of the findings: Physicians should be aware of PGT pregnancies as risk factors for post-partum placental complications and handle the third stage of the delivery with caution. Trial registration number 0351–18-SZMC

Introduction The new chromosomal microarray CMA technology, allows the identification of genetic defects in many disorders that would previously have escaped detection. Alongside the benefits, it exposes us to copy number variants (CNV) whose pathogenic significance is unclear "Variants of unknown significance" (VUS). In our cohort we reviewed all files of couples that applied for PGT-M at our clinic with a finding of VUS. We aimed to characterize these VUS and the cases in which PGT-M was decided upon. Materials and methods A retrospective cohort study in the Zohar Unit for PGT-M, Shaare Zedek medical center, 2014-2019. Files of all couples with a finding of VUS among those who applied for PGT-M with any CMA findings were reviewed. VUS were classified (likely pathogenic, VUS, likely benign) according to the American collage of medical genetics and Genomics classification at time of first consultation and to date (December 2018). Pathogenic variants were not included in the study. PGT-M was performed on blastromeres of throphoectoderm biopsy by PCR using surrounding polymorphic markers. For all microduplications, FISH was performed prior to the PGT-M in order to confirm the tandem location. Results Of 45 couples requesting PGT-M for CMA findings, 24 (53%) presented with VUS. VUS was an isolated finding in 54% of cases and as an additional finding to a known pathogenic mutation in 46%. The mean age of women was 29.8. Half the couples had children at the time of PGT-M consultation. 11 couples (46%) had a termination of pregnancy (TOP) due to VUS; three solely for the VUS and eight for VUS accompanying a sonographic finding in a prenatal screening. Indications for detecting the VUS were as follows- 33% amniocentesis for maternal request not otherwise indicated, 50% amniocentesis for a prenatal ultrasound finding, 25% had a CMA testing due to an affected child and another 12.5% for a CMA finding on a previously aborted fetus. Out of 30 VUS detected, 33% were defined VUS, 26% likely benign VUS and 40% likely pathogenic VUS. 19 VUS (63%) were microduplications (size ranging 31-2800Kbp) and 11 (37%) were microdeletions (size ranging 57-1200Kbp). Reviewing VUS classifications up to date- 33% remained unchanged, 20% were more severely defined and 46% were less severely defined. Based on genetic counseling, PGT-M was assigned for 17/30 CNVs (56%), 13(76.4%) of which were isolated VUS. 11/13 cases of isolated VUS were performed to date with a mean number of: 1.5 IVF cycles per couple (1-3), 8.3 embryos biopsied (1-15) and a mean of 2.9 wild type embryos per couple (0-6). Of 6 couples who had an embryo transfer at our institution there were 4 clinical pregnancies. Conclusions The genomic era allows the detection of varies VUS whose definition is submitted to changes as more information is gathered. Couples are already performing TOP and requesting PGT-M for VUS including likely benign VUS. It is thus of great importance to carefully use guidelines for the interpretation of these findings while counseling couples and determining the justification to practice PGT-M for their VUS finding.

Introduction: Prader-Willi syndrome (PWS (is caused by lack of paternally expressed imprinted genes at chromosome 15q11.2-q13. Diminished (BMD) and osteoporosis are common in PWS. The purpose of this study was to determine whether polymorphisms in genes previously shown to correlate with bone mineral density (BMD), might explain the variable expression of abnormal BMD in PWS. Material and methods: Blood samples were collected from 96 PWS individuals aged 3.5-47.9 (median 14.4) years. DNA samples were tested for 12 polymorphisms in 8 candidate genes: interleukin-1 (IL1-alfa, IL1-beta and IL1RN), CYP1A1, Low Density Lipoprotein Receptor-Related Protein 5 (LRP5), vitamin D receptor (VDR), RANK and RANKL. All patients underwent BMD measurements at the femoral neck and lumbar spine using a hologic dual energy x-ray absorptiometry (DXA) machine. Results: Abnormal BMD was defined as Z-score <-1.5. Severe reduced BMD as Z-score <-2.5. 67 subjects (70%) had abnormal BMD (youngest 3.7 years old), 25 (26%) had severely reduced BMD (youngest 6.8 years old). BMD correlated negatively with age (p<0.001) and BMI (p=0.006). BMD showed significant correlations with genotypes IL1 alpha C889T (p=0.031), Cyp1A1 C4887A (p=0.04) and VDR FOK I (ff /Ff/FF) (p=0.002); FF genotype has a protective effect. Conclusion: Individuals with PWS have low BMD/osteoporosis at a markedly younger age than the general population. The significant correlation between VDR genotypes and BMD is not specific for PWS. Recommendations including vitamin D, calcium, exercise and specific drugs which slow bone loss or build new bone and hormone replacement should be considered in PWS individuals, particularly patients with the high-risk genetic polymorphisms.

BACKGROUND Fertility treatments are responsible for the rise in high order pregnancies in recent decades and their associated complications. Reducing the number of embryos returned to the uterus will reduce the rate of high order pregnancies. OBJECTIVES To explore whether obstetric history and parity have a role in the clinician's decision making regarding the number of embryos transferred to the uterus during in vitro fertilization (IVF). METHODS In a retrospective study for the period August 2005 to March 2012, data of twin deliveries > 24 weeks were collected, including parity, mode of conception (IVF vs. spontaneous), gestational age at delivery, preeclampsia, birth weight, admission to the neonatal intensive care unit (NICU), and Apgar scores. RESULTS A total of 1651 twin deliveries > 24 weeks were record- ed, of which 959 (58%) were at term (> 37 weeks). The early preterm delivery (PTD) rate (< 32 weeks) was significantly lower with increased parity (12.6%, 8.5%, and 5.6%, in women with 0, 1, and ≥ 2 previous term deliveries, respectively). Risks for PTD (< 37 weeks), preeclampsia and NICU admission were significantly higher in primiparous women compared to those who had one or more previous term deliveries. Primiparity and preeclampsia, but not IVF, were significant risk factors for PTD. CONCLUSIONS The risk for PTD in twin pregnancies is significantly lower in women who had a previous term delivery and decreases further after two or more previous term deliveries. This finding should be considered when deciding on the number of embryos to be transferred in IV.

STUDY QUESTION:At what age does the type of hypogonadism, namely hypothalamic or primary gonadal defect, become established in men and women with Prader-Willi syndrome (PWS)? SUMMARY ANSWER:The type of hypogonadism becomes established only in late adolescence and early adulthood. WHAT IS KNOWN ALREADY:The etiology of hypogonadism in PWS is heterogeneous and the clinical expression is variable. Primary testicular failure is common in PWS men, while combinations of ovarian dysfunction and gonadotrophin deficiency are seen in women. STUDY DESIGN, SIZE, DURATION:This is a prospective study of a cohort of 106 PWS patients followed for a mean duration of 4.5 years. Serial blood samples were obtained and assayed for gonadotrophins, inhibin B, anti-Mullerian hormone (AMH), dehydroepiandrosterone sulfate (DHEAS), testosterone (males), and estradiol (females). Results were compared with normal reference values obtained from the literature. For the purpose of this study, we defined the following age groups: infants <1 year; children 1-10 years; adolescents 11-20 years and adults >20 years. PARTICIPANTS/MATERIALS, SETTING, METHODS:Study participants were 49 males (aged 2 months to 36 years) and 57 females (aged 1 month to 37 years) with genetically confirmed diagnoses of PWS (deletions 60, uniparental disomy 54, imprinting center defect 2) followed in the Israel national multidisciplinary PWS clinic. MAIN RESULTS AND THE ROLE OF CHANCE:Serum LH levels were in the normal range (1.0-6.0 mIU/ml) for 7/10 adult men, and high in 3, while FSH (normal range 1.0-6.1 mIU/ml) was elevated (34.4 ± 11.5 mIU/ml) in 6 and normal (3.5 ± 1.6 mIU/ml) in 4 men. Testosterone was low (5.7 ± 3.4 nmol/l) compared with the normal range of 12.0-34.5 nmol/l in the reference population in all men >20 years. AMH showed a normal decrease with age, despite low testosterone levels. Inhibin B was normal (241 ± 105 pg/ml) in infant boys, but low or undetectable in most adult men. Hormonal profiles were more heterogeneous in women than in men. Estradiol was consistently detectable in only 7/13 adult women. Inhibin B was low or undetectable in all PWS females although occasional samples showed levels within the normal range of 15-95 pg/ml. Vaginal bleeding was reported to occur for the first time in eight women at a median age of 20 years (13-34 years), but only one had regular monthly menses. The type of hypogonadism (primary or secondary) in PWS can be determined only after age 20 years. LIMITATIONS, REASONS FOR CAUTION:The study cohort was heterogeneous, showing variability in BMI, cognitive disability and medical treatment. WIDER IMPLICATIONS OF THE FINDINGS:Demonstration of the natural history of reproductive hormone development in PWS suggests that androgen replacement may be indicated for most PWS boys in mid-adolescence. Recommendations for hormone replacement in PWS women need to be individually tailored, serial measurements of inhibin B should be performed, and contraception should be considered in those women who may have the potential for fertility.

BRCA1/2 gene mutation which is prevalent in the Ashkenazi Jewish population is associated with an increased risk for developing breast cancer and ovarian cancer. Few recent studies, have established a commonly accepted belief suggesting that BRCA mutations are associated with low ovarian reserve and poor response to ovarian stimulation, as well as early menopause. We aimed to evaluate a possible association between carriage of BRCA1/2 mutations and low ovarian reserve, as demonstrated by ART performance of BRCA mutation carriers. Multicenter retrospective study including BRCA mutation carriers who underwent COH for IVF between 2000 and 2012. Healthy and cancer patients were compared with controls. The study group was divided into two sub-groups: (1) BRCA positive breast cancer patients, undergoing fertility preservation prior to chemotherapy, were compared with breast cancer patients whose BRCA mutation status was negative or unknown. (2) Healthy BRCA carriers, undergoing fertility treatment or IVF for PGD, were compared with male factor infertility patients and non-BRCA PGD patients. Patient’s age, cancer status, BRCA mutation status, stimulation data and ART outcomes were extracted from patients’ medical records. When more than one IVF cycle was recorded per patient, only the most favorable cycle (maximal oocytes yield) was included in analysis. Low response to COH was defined as retrieval of four or fewer oocytes per cycle. Fifty seven BRCA mutation carriers underwent 124 IVF cycles and 130 controls underwent 233 IVF cycles. A total of 187 best performed cycles were compared. Patients’ age, duration of stimulation and peak E2 levels were comparable between carriers and controls. Number of oocytes retrieved (15.00±8.06 vs. 14±8.24, p=0.44), number of 2PN embryos (9.61±5.91 vs. 8.17±5.55, p=0.077) and low response rate (8.77% versus 8.46%, p=1) were also not significantly different. An age-stratified (<28, 28-37, >37 years old) analysis indicated similar oocytes yield in each carriers subgroups and their corresponding age matched control subgroup. BRCA mutation carriers constitute a unique population of women who frequently utilize ART treatments, whether for fertility preservation prior to chemotherapy or for PGD. Contrary to previous publications described, our results provide reassuring data and confirm normal IVF performance among BRCA mutation carriers.

Myotonic dystrophy (DM) is the most common form of muscular dystrophy in adults. There are conflicting reports about its effect on female fertility. This study investigated ovarian reserve and IVF–preimplantation genetic diagnosis (PGD) outcome in women with DM1. A total of 21 women undergoing PGD for DM1 were compared with 21 age- and body mass index-matched women undergoing PGD for other diseases. Ovarian reserve markers, response to stimulation, embryo quality and clinical pregnancy and live birth rates were compared. Day-3 FSH concentration was higher, while anti-Müllerian hormone concentration and antral follicle count were lower in the DM1 group (median, range: 6.9 (1.8–11.3) versus 5.7 (1.5–10.7)IU/l; 0.9 (0.17–5.96) versus 2.68 (0.5–9.1)ng/ml; and 13 (0–63) versus 23 (8–40) follicles, respectively, all P<0.05). Total FSH dose was higher (5200 versus 2250IU, P=0.004), while the numbers of oocytes retrieved (10 versus 16, P<0.04) and metaphase-II oocytes (9 versus 12, P<0.03) were lower in the DM1 group. The number of cycles with top-quality embryos and the clinical pregnancy rate were lower in the DM1 group. In conclusion, there is evidence of diminished ovarian reserve and less favourable IVF–PGD outcome in women with DM1.Myotonic Dystrophy (DM) is the most common form of muscular dystrophy in adults. There is evidence of subfertility in males affected with the disease but conflicting reports about the effect of the disease on female fertility. The aim of our study was to investigate ovarian reserve and IVF–PGD results in women with DM. Twenty-one women undergoing preimplantation genetic diagnosis (PGD) treatment for DM were compared to 21 age- and BMI matched women undergoing PGD treatment for other diseases. The two groups were compared for antral follicle count (AFC) and serum anti-Mullerian hormone (AMH) levels (the best known markers of ovarian reserve and fertility potential), ovarian response, embryo quality and pregnancy and live birth rates. AFC and the AMH levels were statistically significant lower in the DM group. Total medication dose needed for ovarian stimulation was higher, the number of oocytes and mature oocytes retrieved, and the number of cycles with top quality embryos were lower in the DM group compared to the controls. In conclusion, there is evidence of diminished ovarian reserve, and less favorable IVF-PGD outcome in women with DM. Therefore, we recommend advising these women about the possibility of early decreasing ovarian function in order to prevent any delay in reproductive planning.

Anthropometric adjustments of bone measurements are necessary in Prader-Willi syndrome patients to correctly assess the bone status of these patients. This enables physicians to get a more accurate diagnosis of normal versus abnormal bone, allow for early and effective intervention, and achieve better therapeutic results.

Purpose Development of PGD assays for molecular disorders is based on analysis of a familial mutation together with linked polymorphic STR markers; a process which is lengthy and requires the identification of multiple informative markers prior to PGD analysis. On the other hand, whole genome amplification (WGA), in conjunction with microarray platforms, allows the use of a universal assay for the analysis of a very large number of SNP markers at once. The aim of this study was to test high throughput pre-PGD familial haplotyping for in-case blastomere analysis in order to eliminate time-consuming pre-case preparations for each family. Methods A PGD cycle was performed for a couple with paternal Charcot Marie Tooth 1A (CMT1A) using a classic multiplex nested PCR approach. Mutant embryos from the case were blindly reanalyzed, as single or multi-cell biopsies, using a multiple displacement amplification-based WGA protocol and microarray SNP analysis. In parallel, relevant genomic DNA samples from the family were also analyzed by SNP microarray. Results After applying a ‘unique informative allele’ selection algorithm to the data, this array-based assay reconfirmed the initial diagnosis in all samples. Conclusions We describe a PGD method that is both accurate and feasible during the time-frame required for embryo transfer. This strategy greatly reduces the time for pre-case haplotype preparation.