Can educational games, as an active teaching method, improve medical students’ knowledge of reproductive endocrinology and infertility (REI)? Active teaching with educational games improves students’ broad knowledge, and this paper shows how games that are aligned with learning aims can enrich a seminar. Medical education is dominated by seminars and lectures, where students are often passive listeners. Active teaching methods, including educational games, engage students in the learning process through various exercises and tasks designed to trigger task-focused effort. Active teaching has been shown to improve substantially student attainment in university science classes. It was a retrospective comparative posttest-only study assessing the effect of traditional seminar or gamified seminar as interventions throughout 5 semesters. The seminar on infertility work-up, anovulation and early pregnancy complications was part of the gynecology curriculum for medical students. Identical seminars lasting 2.5 hrs were held 8 times during each semester for 16-20 students each time. Personal data was not processed and ethics committee approval was not needed. The seminars were held at a university hospital. For 2 semesters, students had traditional seminars with mini-lectures and case discussions. For 3 semesters, the same topics were taught using team-based educational games. Mid-semester, students filled out multiple choice test on broad knowledge in REI. Test scores of students who had already had the seminar (exposed) were compared to those who had not yet had the seminar (control). The effect size was expressed as Cohen’s d. Students who attended the traditional seminar achieved similar scores on broad knowledge test in REI compared to respective control students (Cohen’s d = 0.05, 95%CI -0.58 to 0.68, n = 71). Students who had the seminar with educational games achieved higher scores than respective controls (Cohen’s d = 0.47, 95%CI 0.21 to 0.71, n = 253). The effect of games on knowledge was comparable to the previously reported impact of active learning methods in university science education (effect size ∼ 0.47). The team-based games included trivia in infertility pathophysiology; game of clinical resource allocation about investigation of anovulatory infertility; boxed escape-room game about early pregnancy complications. The games were closely aligned with learning aims of the seminar without distracting non-clinical game elements. The students were de-briefed after sessions to highlight learning content, address uncertainties and provide feed-back. Students reported high levels of satisfaction (90% A on A-E scale) with the seminar. The design of this study cannot rule out that confounding factors unrelated to gamification, such as learners’ prior knowledge or advance preparation for the test, explain the observed effects on learning. Seminars of reproductive endocrinology at academic medical centers can be enriched with active teaching methods including educational games, which may improve students’ satisfaction and learning outcomes. The practical examples here can be readily implemented for small and mid-sized classes (4-40 students), and require few easily sourceable props. No

How safely can OncoFertBot, a conversational AI assistant augmenting its responses with oncofertility guidelines, assist clinical decision making? Responses by OncoFertBot were comparable to GPT4, but variable quality and some potentially harmful responses indicate need for further improvement of clinical reasoning. Oncofertility is a highly specialised area with mounting interest due to the demand for procreation and rising survival amongst reproductive aged cancer survivors. The clinical guidelines in oncofertility are complex, comprehensive, fragmented but also redundant, which may reduce accessibility to non-specialists and clinical application. Conversational AI assistants (chatbots) respond to user queries using large language models (LLM) that were trained on vast datasets. In retrieval-augmented generation (RAG) mode, the responses by LLM are modified by a specific set of documents to augment information drawn from generic training data, which allow LLMs to use domain-specific information, such as specialised clinical guidelines. We compared responses by OncoFertBot, a RAG-powered assistant based on GPT4, to responses by the generic GPT4 assistant. Twenty-five clinical scenarios of varying complexity were selected from a compendium of anonymised and abridged referrals received by our oncofertility centre. The scenarios were further condensed (word counts:28-168) and presented individually to the 2 chatbots as single queries. The responses were independently evaluated by two oncofertility specialists. The study was conducted between September 2024 and January 2025. At a tertiary university hospital, we created OncoFertBot by giving specific instructions (prompts) to GPT4 in the ‘file search’ mode, letting it access 28 oncofertility guidelines in full-text through a vector store. The generic GPT4 chatbot received identical prompts but lacked access to the guidelines. Two blinded evaluators scored responses on scale of 1-5 for factual accuracy, completeness of information, relevance and potential for harm. Descriptive statistics, Cohen’s kappa and Pearson’s correlation coefficient were calculated. Responses by OncoFertBot to 25 clinical scenarios were comparable to responses by the generic GPT4, including mean factual correctness (4.08 versus 4.14, p = 0.60), completeness of information (3.92 versus 4.20, p = 0.85), relevance of information (4.24 versus 4.20, p = 0.44) and potential for harm (1.68 versus 1.62, p = 0.39). OncoFertBot gave factually incorrect information (score <3) in 1 scenario (1/25, 4%), incomplete information (4/25, 16%) and irrelevant information (2/25, 8%). OncoFertBot received perfect scores in all the areas assessed in 5/25 (20%) scenarios, similar to the generic GPT4 (6/25, 24%). OncoFertBot and generic GPT4 gave potentially harmful advice (score for harm >3) to the same two scenarios (2/25, 8%), which concerned hormone stimulation for oocyte cryopreservation in breast cancer and hormone stimulation at low BMI. The generic GPT4 gave potentially harmful responses to three additional scenarios (3/25, 12%) when OncoFertBot responded safely, whereas OncoFertBot gave potentially harmful responses to three other scenarios (3/25, 12%), which received safe advice by the generic GPT4. Potential harm score was related to low factual correctness (r2=0.43) and low relevance score (r2=0.53). It was not related to the word counts of the chatbot queries. The two evaluators had fair to moderate agreement on the chatbot responses (Cohen’s kappa 0.29-0.62). The chatbots were not used to their full capabilities as conversational agents, as only a single response was collected without follow-up questions. Factual accuracy may have improved as conversation developed. Case summaries were complex with vocabulary of medical jargon, which may have influenced the quality of responses. Pending further development, the oncofertility assistant may reduce telephone and email workloads, and supplement clinical education. Training on task-specific data with medical jargon and corpus of validated questions-answers would augment its knowledge base. Implementation of criteria for instruction prompts and chatbot queries may improve response quality. No

Abstract STUDY QUESTION Do expectant parents experience increased anxiety and depression during pregnancies conceived through ART compared to spontaneous conception? SUMMARY ANSWER Among all expectant parents in the sample, those who conceived through ART reported overall lower levels of anxiety and depression in pregnancy compared to expectant parents who conceived spontaneously, while in the subsample of parents who conceived both through ART and spontaneous conception, expectant mothers experienced increased anxiety and depression in early pregnancy following ART compared to spontaneous conception. WHAT IS KNOWN ALREADY Previous research on expectant parents’ psychosocial adjustment in response to ART has found mixed results, with some studies suggesting ART is associated with increased anxiety and depression, and other studies suggesting improved mental health or no relationship. Mixed findings may relate to the use of cross-sectional designs that do not account for confounding differences between groups, or variability in the timing of assessment. STUDY DESIGN, SIZE, DURATION This prospective cohort study used data from the Norwegian Mother, Father and Child Cohort Study (MoBa), which includes 2960 pregnant women who underwent ART and 108 183 women who conceived spontaneously. Of these, a subsample of expectant parents had two consecutive pregnancies with one pregnancy resulting from ART and one conceived spontaneously (n = 286 women, n = 211 partners). Women self-reported their composite symptoms of anxiety and depression at two timepoints during each pregnancy (gestational weeks 17 and 30). Their partners self-reported composite symptoms of anxiety and depression at 17 weeks gestation during each pregnancy. Couples reported their relationship satisfaction at 17 weeks gestation. MAIN RESULTS AND THE ROLE OF CHANGE Using a conventional full-cohort analysis we found that ART was associated with less total anxiety and depression and greater relationship satisfaction, compared to spontaneous conception among both women and men. However, in the subsample of parents who experienced both ART and spontaneous pregnancies, ART was associated with increased levels of maternal anxiety and depression at gestational age 17 weeks (M = 1.19), compared to spontaneous pregnancies (M = 1.15), 95% CI of the mean difference 0.006, 0.074. At 30 weeks gestation, anxiety and depression were similar across both types of pregnancies. Expectant fathers reported similar levels of anxiety and depression at 17 weeks gestation during both pregnancies. Among women relationship satisfaction was higher following ART conception than spontaneous conception. LIMITATIONS, REASONS FOR CAUTION There is potential for selection effects in the sample, as women who have conceived through both ART and spontaneous conception in their first two pregnancies are rare. In addition, several factors that may be important predictors of mental health in this context, such as previous miscarriages and long-term infertility, were not assessed in the current study. WIDER IMPLICATIONS OF THE FINDINGS Our findings indicate that previous discrepancies in the literature may be related to inherent differences between the groups of parents receiving reproductive treatment and those who do not. This study addresses that limitation by prospectively comparing different types of pregnancies within the same expectant parents. Earlier inconsistencies may also relate to variations in gestational age when anxiety and depression were assessed. By examining symptoms at two timepoints in each pregnancy, we were able to examine the relation between gestational age and symptoms of anxiety and depression. STUDY FUNDING/COMPETING INTEREST(S) The MoBa is supported by the Norwegian Ministry of Health and the Norwegian Research Council/FUGE (grant number 151918/S10). This work was also supported by the Research Council of Norway grant number 288083 and 301004. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A.

Endometriosis-associated infertility is a common indication for in vitro fertilisation (IVF) treatment. There is great controversy regarding the outcome of IVF in such patients. Possibly inferior results compared with other indications for IVF are likely based on reduced oocyte and embryo quality and not adverse endometrial receptivity. Such knowledge is based on IVF crossover studies with donor oocytes and patient’s own oocytes to women with and without endometriosis. Embryos that are frozen and later thawed for transfer to the uterus are selected among the best embryos in a fresh cycle. Transfer of such embryos is as successful in endometriosis as in other causes of infertility whatever endometrial preparation is used. Thus, long-term suppression of endometriosis with GnRH agonists in frozen embryo transfer is unnecessary and may possibly be harmful due to induction of endometritis.

Menopause represents the definite end of a woman’s reproductive life and the onset of a persistent hypoestrogenic state. This postmenopausal period will for most women last several decades. Although mean menopausal age seems to have increased somewhat during the last century, there is a significant individual variation in age at natural menopause. With efficient contraception, women of reproductive age can now, to some extent, choose when they want to have children. As a consequence of this and other sociodemographic changes, age at first birth has increased significantly over the last 50 years. It is well documented that long before a woman enters the menopausal transition and subsequent menopause, fertility declines and finally ceases. Being able to predict when a woman will enter menopause would therefore, from a reproductive perspective, be of major interest. Several sociodemographic, morphometric, and endocrine factors are associated with age at menopause or time to menopause. Unfortunately the sensitivity and specificity of these in predicting time to or age at menopause are low. Therefore, with the exception of anti‐Müllerian hormone measurements, either alone or in combination with chronological age close to menopause, there are as of now no reliable ways of predicting when a woman will enter menopause.

IntroductionBreast cancer susceptibility gene (BRCA) mutation carriers are recommended to undergo early oophorectomy to prevent ovarian cancer. Premature loss of ovarian hormones may increase the risk of cardiovascular disease. Because women with preventive oophorectomy are mainly young and healthy, they rarely undergo specialized cardiological surveillance. We compared the risk of cardiovascular disease in women after preventive oophorectomy with reference women.MethodsIn an historical cohort study, we included 134 women aged ≤52 years after preventive oophorectomy and 268 age matched premenopausal reference women, aged 52 years or less, from the general population, excluding participants with diabetes or cardiovascular disease. The Norwegian risk assessment tool (NORRISK 2) was used to estimate 10 year cardiovascular risk. This algorithm was validated in a large Norwegian population and is based on age, smoking, systolic blood pressure, total and high density lipoprotein cholesterol, antihypertensive medication, and family history of cardiovascular disease. We also examined cardiometabolic factors (levels of triglycerides and high sensitivity C reactive protein, as well as body mass index and waist circumference) not included in the NORRISK 2 calculation.ResultsMedian age in the preventive oophorectomy and reference groups were 47 (range 33–52) and 46 (31–52) years, respectively. Mean time since surgery in the preventive oophorectomy group was 4.2 years (standard deviation (SD) 2.8). Ten year cardiovascular risk was similar in women after preventive oophorectomy and reference women (mean 1.15% (SD 1.00) vs 1.25 (1.09), respectively, p=0.4). Women in the preventive oophorectomy group had a lower body mass index (24.7 kg/m2 (4.0) vs 26.2 (4.8), p=0.003) and waist circumference (86 cm vs 89, p=0.006). The overall cardiovascular risk estimation was comparable among hormone therapy users and non-users, but hormone therapy users had lower total cholesterol and waist circumference.DiscussionWomen who underwent preventive oophorectomy had a similar risk of cardiovascular disease as population based reference women, estimated according to risk factors easily measured in general practice. Cardiometabolic risks were not increased in the preventive oophorectomy group.

RESEARCH QUESTION:Does a successful spontaneous pregnancy in the years close to natural menopause depend on age at menopause?DESIGN:This was a retrospective population-based study of 4157 parous postmenopausal women in Norway, born during the years 1925-1940. Data were obtained by two self-administered questionnaires in the HUNT2 Survey (1995-1997). We calculated the proportions of women who gave birth within 5 years and within 10 years prior to menopause both among all women, and according to categories of age at menopause.RESULTS:Overall, 2.7% (114/4157) of all women gave birth within 5 years, and 11.7% (487/4157) gave birth within 10 years, prior to menopause. Among women with menopause before the age of 45 years, 23.5% (81/344) gave birth within 5 years, and 55.5% (191/344) gave birth within 10 years, before menopause. Among the women with menopause at the age of 55 years or older, no women (0/474) gave birth within 5 years, and 0.2% (1/474) gave birth within 10 years, prior to menopause.CONCLUSIONS:More than half of the women with menopause before the age of 45 years gave birth within the 10 years before natural menopause, whereas virtually no women with menopause at the age of 55 years or older did. Thus, the length of the sterile interval before natural menopause may vary by age at menopause.

BackgroundLocal treatment for cervical intraepithelial neoplasia (CIN) by Loop Electrosurgical Excision Procedure (LEEP) has been correlated with reproductive morbidity, while the cervicovaginal microbiota is also known to affect the risk of preterm delivery. CIN and treatment by LEEP might change the cervical microbiota. The main aim of this study was to describe the cervical microbiota before and after LEEP and assess its associaton with cone depth and HPV persistence. Further, we aimed to compare the microbiota to references with normal cervical cytology.MethodsBetween 2005 and 2007, we prospectively identified 89 women planned for LEEP in a Norwegian hospital and recruited 100 references with a normal cervical cytology. Endocervical swabs were collected prior to treatment and at six (n=77) and 12months (n=72) post LEEP for bacterial culture and PCR, and post LEEP for DNA testing for human papillomavirus (HPV). We compared the cervical microbiota composition before and after treatment and between women planned for LEEP vs references.ResultsThere was a reduction in the number of non-Lactobacillus bacterial species six and 12months after LEEP compared to before treatment and a tendency towards a concomitant increase in Lactobacillus. No association between the detection of cervical bacteria, HPV persistence or cone depth was found.Women planned for LEEP carried significantly more Bacteroides spp., Gardnerella vaginalis, Mycoplasma hominis and Ureaplasma parvum as well as a greater number of bacterial species than the references.ConclusionsLocal excisional treatment appears to alter the cervical microbiota towards a less diverse microbiota. Women with CIN have a more diverse cervical microbiota compared to women with normal cervical cytology.

ObjectivesTo identify predictors of disease among a few factors commonly associated with endometriosis and if successful, to combine these to develop a prediction model to aid primary care physicians in early identification of women at high risk of developing endometriosis.DesignCross-sectional anonymous postal questionnaire study.SettingWomen aged 18–45 years recruited from the Norwegian Endometriosis Association and a random sample of women residing in Oslo, Norway.Participants157 women with and 156 women without endometriosis.Main outcome measuresLogistic and least absolute shrinkage and selection operator (LASSO) regression analyses were performed with endometriosis as dependent variable. Predictors were identified and combined to develop a prediction model. The predictive ability of the model was evaluated by calculating the area under the receiver operating characteristic curve (AUC) and positive predictive values (PPVs) and negative predictive values (NPVs). To take into account the likelihood of skewed representativeness of the patient sample towards high symptom burden, we considered the hypothetical prevalences of endometriosis in the general population 0.1%, 0.5%, 1% and 2%.ResultsThe predictorsabsenteeism from school due to dysmenorrheaandfamily history of endometriosisdemonstrated the strongest association with disease. The model based on logistic regression (AUC 0.83) included these two predictors only, while the model based on LASSO regression (AUC 0.85) included two more:severe dysmenorrhea in adolescenceanduse of painkillers due to dysmenorrhea in adolescence. For the prevalences 0.1%, 0.5%, 1% and 2%, both models ascertained endometriosis with PPV equal to 2.0%, 9.4%, 17.2% and 29.6%, respectively. NPV was at least 98% for all values considered.ConclusionsExternal validation is needed before model implementation. Meanwhile, endometriosis should be considered a differential diagnosis in women with frequent absenteeism from school or work due to painful menstruations and positive family history of endometriosis.

The objective of this narrative review was to suggest a rational order of treatment choices in anovulatory women with polycystic ovary syndrome (PCOS), for whom a multitude of treatment options exist. In obese/overweight women with PCOS the importance of weight reduction should be stressed. Inositol, a dietary supplement with a documented effect on ovulation and without adverse effects in the doses recommended, may be suggested. Additional first-line medical alternatives include insulin sensitizers, selective estrogen receptor modulators, and aromatase inhibitors. Of these, the aromatase inhibitor letrozole and the combination of clomiphene citrate and metformin have the highest rates of ovulation and live birth. Second-line treatments are ovarian electrocautery and low-dose follicle-stimulating hormone stimulation. Controlled ovarian stimulation with in vitro fertilization, should be considered the last option as it carries a significant risk of ovarian hyperstimulation syndrome in patients with PCOS.

Research question: Are maternal concentrations of human chorionic gonadotropin (HCG) on a fixed day after embryo transfer associated with duration of pregnancy? Design: A follow-up study of 1917 singleton pregnancies after IVF was performed. Embryos were cultured for 2 days and maternal HCG concentration quantified on day 12 after embryo transfer. Duration of pregnancy was obtained from the Medical Birth Registry of Norway. Association of HCG concentration (log2-transformed) with duration of pregnancy was estimated as hazard ratios (HR) with 95% confidence intervals (CI) by applying Cox regression proportional hazard models, where time to delivery for pregnancies shortened because of planned Caesarean delivery or induction of labour was treated as censored. Results: The estimated median duration of pregnancy from embryo transfer was 266 days (95% CI 266-267 days). Maternal concentration of HCG on day 12 after embryo transfer varied from 1 to 588 IU/l (median 117 IU/l). Duration of pregnancy decreased by increasing HCG concentration, significantly in pregnancies delivered at full term (1257-270 days after embryo transfer; HR 1.127, 95% CI 1.026-1.238, P = 0.012). For each doubling of HCG concentration on day 12 after embryo transfer, duration of pregnancy was shortened by 0.51 days. Adjustment for maternal age, prepregnancy body mass index, being a first-time mother and number of embryos transferred did not change the association. Conclusion: High maternal HCG concentration on a fixed day after embryo transfer is likely to indicate early embryo implantation. After embryo transfer, pregnancies with early implantation are shorter than pregnancies with late implantation. (C) 2018 The Authors. Published by Elsevier Ltd on behalf of Reproductive Healthcare Ltd.

BAKGRUNN:Kryopreservering av ovarialvev som fertilitetsbevarende metode tilbys prepubertale jenter og kvinner i reproduktiv alder med høy risiko for å utvikle prematur ovarialsvikt i forbindelse med medisinsk eller kirurgisk behandling. I denne studien ønsket vi å kartlegge fertilitet og prematur ovarialsvikt hos kvinner som har fått gjort kryopreservering av ovarialvev i forbindelse med kreftbehandling.MATERIALE OG METODE:Et spørreskjema ble i 2014 sendt til 94 kvinner over 18 år som i perioden 2004-12 hadde fått kryopreservert ovarialvev i forbindelse med behandling for en malign tilstand. Skjemaet inneholdt spørsmål om menstruasjonsfrekvens, prevensjonsbruk, fertilitet, fremtidig barneønske og sannsynlighet for at de ville benytte ovarialvevet senere. Av de 77 kvinnene som returnerte spørreskjemaet, ble 74 kvinner inkludert i studien.RESULTATER:Totalt 20 av 74 kvinner (27 %) hadde prematur ovarialsvikt definert som opphør av ovarialfunksjonen før 40 års alder. Risikoen var lavest hos kvinner behandlet for brystkreft (5 %) og høyest hos kvinner behandlet for leukemi (75 %). Størst risiko for prematur ovarialsvikt fant man i pasientgruppene som hadde gjennomgått stamcelletransplantasjon, strålebehandling mot helkropp og/eller abdomen og bekken. Til sammen hadde 22 kvinner født 31 barn etter kreftbehandlingen, hvorav to etter reimplantasjon av ovarialvev.FORTOLKNING:Risikoen for å utvikle prematur ovarialsvikt er avhengig av pasientens kreftdiagnose. Hvilke fertilitetsbevarende tiltak som anbefales, bør differensieres avhengig av pasienten kreftdiagnose og planlagt behandling.

The objective of this narrative review was to suggest a rational order of treatment choices in anovulatory women with polycystic ovary syndrome (PCOS), for whom a multitude of treatment options exist. In obese/overweight women with PCOS the importance of weight reduction should be stressed. Inositol, a dietary supplement with a documented effect on ovulation and without adverse effects in the doses recommended, may be suggested. Additional first-line medical alternatives include insulin sensitizers, selective estrogen receptor modulators, and aromatase inhibitors. Of these, the aromatase inhibitor letrozole and the combination of clomiphene citrate and metformin have the highest rates of ovulation and live birth. Second-line treatments are ovarian electrocautery and low-dose follicle-stimulating hormone stimulation. Controlled ovarian stimulation with in vitro fertilization, should be considered the last option as it carries a significant risk of ovarian hyperstimulation syndrome in patients with PCOS.

INTRODUCTION:The Endometriosis Health Profile-30 is a disease-specific patient-reported outcome measure of health-related quality of life. Cross-cultural validation of the Endometriosis Health Profile-30 has been performed for several translated versions. The aim of this study was to evaluate the measurement properties of a Norwegian version Endometriosis Health Profile-30. METHODS:This study was designed as a cross-sectional anonymous postal questionnaire study. A total of 157 women with endometriosis were included during a period from 2012 to 2013. Women aged 18-45 years were recruited from the Norwegian Endometriosis Association. Principal components analysis with varimax rotation was used to assess construct validity. Short Form-36 was used to determine convergent validity. Cronbach's alpha was used to measure internal consistency. Intraclass correlation coefficients and paired t-tests were used to evaluate test-retest reliability. Floor and ceiling effects were estimated. RESULTS:Factor analysis resulted in a three and five-factor model for the core and modular questionnaire, respectively. Factor analysis could not support construct validity of the scales self-image and treatment. The Norwegian version Endometriosis Health Profile-30 demonstrated acceptable internal consistency and test-retest reliability, except for the scale relationship with children. Floor effects were observed for the scales self-image (20.1%), work life (33.9%), relationship with children (34.2%), and medical profession (20.5%). CONCLUSION:The construct self-image does not seem to be measured appropriately by the Norwegian version Endometriosis Health Profile-30, suggesting a lack of cross-cultural validity of the Endometriosis Health Profile-30. With multinational studies increasing, adequate translation, cross-cultural adaptation, and cross-cultural validation of instruments are essential to ensure equivalence in languages and cultures other than the original.

INTRODUCTION:Women with endometriosis have reduced health-related quality of life (HRQoL). However, comparisons to the general population and other patient groups are lacking. MATERIAL AND METHODS:The present cross-sectional questionnaire study included 157 women with endometriosis, 156 women from the general population, and 837 women with rheumatoid arthritis (RA). During a period from 2012 to 2013, women aged 18-45 years were recruited from the Norwegian Endometriosis Association and from a random sample of women residing in Oslo, Norway. HRQoL data from women with RA were included from a survey conducted in 2009 among patients of the Oslo Rheumatoid Arthritis Register. The Short Form-36 (SF-36) questionnaire was used to measure HRQoL. RESULTS:Compared with the control group, the endometriosis group had significantly reduced mean scores for all SF-36 scales. The difference was largest for the scale bodily pain with a mean score of 47.6 in the endometriosis group vs 81.5 in the control group. Compared with the RA group, the endometriosis group had significantly reduced mean scores for the three SF-36 scales vitality, social functioning, and mental health. The mean scores of these scales in the endometriosis group were 33.4, 62.7, and 66.3, respectively, vs 42.7, 68.8, and 72.6 in the RA group. CONCLUSIONS:Women with moderate to severe endometriosis seem to have overall impaired HRQoL compared with women from the general population, and poorer mental HRQoL compared with women with RA.

Abstract Endometriosis is a common condition in women of reproductive age. In addition to pain, endometriosis may also reduce fertility. The causes of infertility in women with endometriosis may range from anatomical distortions due to adhesions and fibrosis to endocrine abnormalities and immunological disturbances. In some cases, the various pathophysiological derangements seem to interact by mechanisms so far not fully understood. Whether surgery should be offered as a treatment option in endometriosis-associated infertility has become controversial, partly due to its modest or undocumented effect. Medical or hormonal treatment alone has little or no effect and should only be used in conjunction with assisted reproductive technology (ART). Of the various methods of ART, intrauterine insemination, due to its simplicity, can be recommended in women with minimal or mild peritoneal endometriosis, even though insemination may yield lower success rate than in women without endometriosis. In vitro fertilization (IVF) is an effective treatment option in less advanced disease stages, and the success rates are similar to the results in other causes of infertility. However, women with more advanced stages of endometriosis have lower success rates with IVF. This article is protected by copyright. All rights reserved.

Objective: We investigated the association of human chorionic gonadotrophin (hCG) concentrations on a fixed day in very early pregnancy with development of hyperemesis gravidarum. Study design: This retrospective cohort study included 3107 singleton and 1265 twin pregnancies after in vitro fertilization treated at Department of Reproductive Medicine, Rikshospitalet, Oslo University Hospital, Norway in the period 1996-2013. Maternal serum hCG concentrations was measured on day 12 after embryo transfer. Information about development of hyperemesis gravidarum was obtained by individual linkage to the Medical Birth Registry of Norway. We studied hCG concentrations in very early pregnancy according to development of hyperemesis gravidarum, in singleton and twin pregnancies separately. We estimated the odds ratios for hyperemesis gravidarum with 95% confidence intervals according to quartiles of hCG concentrations. Results: In twin pregnancies as compared to singleton pregnancies, we found higher mean maternal hCG concentrations (219 IU/L versus 130 IU/L, p < 0.001 Student's t-test) and higher prevalence of hyperemesis gravidarum (2.7% versus 1.4%, p = 0.002 chi-squared test). However, both in singleton and in twin pregnancies, we found no significant difference in mean hCG concentrations between women who developed hyperemesis gravidarum and women who did not (Singletons: 122 IU/L versus 130 IU/L, p = 0.504. Twins: 234 IU/L versus 219 IU/L, p = 0.417 Student's t-test). We found no significant differences in odds ratios for developing hyperemesis gravidarum according to quartiles of hCG concentrations. Conclusions: We found no association of maternal hCG concentrations on a fixed day in early pregnancy with development of hyperemesis gravidarum. (C) 2017 Elsevier B.V. All rights reserved.

Endometriosis is a common condition in women of reproductive age. In addition to pain, endometriosis may also reduce fertility. The causes of infertility in women with endometriosis may range from anatomical distortions due to adhesions and fibrosis to endocrine abnormalities and immunological disturbances. In some cases, the various pathophysiological disturbances seem to interact through mechanisms so far not fully understood. Whether surgery should be offered as a treatment option in endometriosis-associated infertility has become controversial, partly due to its modest or undocumented effect. Medical or hormonal treatment alone has little or no effect and should only be used in conjunction with assisted reproductive technology (ART). Of the various methods of ART, intrauterine insemination, due to its simplicity, can be recommended in women with minimal or mild peritoneal endometriosis, even though insemination may yield a lower success rate than in women without endometriosis. In vitro fertilization (IVF) is an effective treatment option in less-advanced disease stages, and the success rates are similar to the results in other causes of infertility. However, women with more advanced stages of endometriosis have lower success rates with IVF.

The aim of this study is to report the current status of ovarian tissue cryopreservation among alternatives for fertility preservation in the Nordic countries. A questionnaire was sent to 14 Nordic academic reproductive centers with established fertility preservation programs. It covered fertility preservation cases performed up to December 2014, standard procedures for ovarian tissue cryopreservation and oocyte cryopreservation and reproductive outcomes following ovarian tissue transplantation. Among the Nordic countries, Denmark and Norway practice ovarian tissue cryopreservation as a clinical treatment (822 and 164 cases, respectively) and their programs are centralized. In Sweden (457 cases), ovarian tissue cryopreservation is practiced at five of six centers and in Finland at all five centers (145 cases). Nearly all considered ovarian tissue cryopreservation to be experimental. In Iceland, embryo cryopreservation is the only option for fertility preservation. Most centers use slow-freezing methods for ovarian tissue cryopreservation. Most patients selected for ovarian tissue cryopreservation were newly diagnosed with cancer and the tissue was predominantly retrieved laparoscopically by unilateral oophorectomy. Only minor complications were reported. In total, 46 women have undergone ovarian tissue transplantation aiming at recovering fertility, 17 healthy children have been born and several additional pregnancies are currently ongoing. Whenever patients’ clinical condition is permissive, oocyte cryopreservation after hormonal stimulation is preferred for fertility preservation. Between 2012 and 2014, a smaller proportion of females have undergone fertility preservation in the Nordic centers, in comparison to males (1:3). Overall, ovarian tissue cryopreservation was reported to be safe. Slow freezing methods are still preferred. Promising results of recovery of fertility have been reported in Nordic countries that have initiated ovarian tissue transplantation procedures.