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Irene Gazzo I Gazzo, IRCCS Ospedale Policlinico San Martino, Genova, Italy

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Francesca Bovis F Bovis, Department of Health Sciences, University of Genoa, Genova, Italy

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Denise Colia D Colia, Ospedale Evangelico Internazionale, Genova, Italy

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Fausta Sozzi F Sozzi, Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy

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Mauro Costa M Costa, Ospedale Evangelico Internazionale, Genova, Italy

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Paola Anserini P Anserini, Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy

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Claudia Massarotti C Massarotti, DINOGMI Department, University of Genoa, Genova, 16132, Italy

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In the registrational trials, follitropin delta was compared with a fixed dose of 150 UI of follitropin alpha/beta, finding higher chances to reach a target response of 8-14 oocytes compared to controls. For this reason, follitropin delta is marketed as particularly useful in expected hyper-responder patients. The main outcome of this study is to report if comparable results are reached in a real-life scenario with follitropin alpha/beta personalized doses, based on patients’ characteristics. This is a retrospective study performed in two public fertility centres. All first cycles from January 2020 to June 2022 with either follitropin delta (cases) or alpha/beta (controls) in patients with antiMüllerian hormone >2.5 ng/ml were compared by an inverse probability weighting approach based on propensity score. The follitropin total dose was higher in controls (1179.06 ± 344.93 vs. 1668.67 ± 555.22 IU, p<0.001). The target response of 8-14 oocytes was reached by 40.2% of cases and 40.7% of controls (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.65-1.53, p=0.98). Fewer than 8 oocytes were collected in 24.1% of cases and 22% of controls (OR 1.10, 95% CI 0.71-1.69, p=0.67); more than 14 oocytes in 35.7% of cases and 37.3% of controls (OR 0.83, 95% CI 0.54-1.28, p=0.40). Our experience did not find worse results in term of proportion of patients who reached the target response with an algorithm-chosen dose of follitropin delta compared to a personalised starting dose of follitropin alpha/beta, with follitropin delta having the advantage of objectivity. Larger numbers are needed to confirm these results.

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Leah Calvert L Calvert, The University of Newcastle Australia, Callaghan, Australia

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Jacinta H Martin J Martin, The University of Newcastle Australia, Callaghan, Australia

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Amanda L. Anderson A Anderson, The University of Newcastle, Callaghan, Australia

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Ilana R. Bernstein I Bernstein, The University of Newcastle, Callaghan, Australia

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Nathan D Burke N Burke, The University of Newcastle, Callaghan, Australia

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Geoffry N De Iuliis G De Iuliis, Biological Sciences, The University of Newcastle, Callaghan, Australia

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Andrew L. Eamens A Eamens, University of the Sunshine Coast, Sippy Downs, Australia

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Matthew D. Dun M Dun, The University of Newcastle Hunter Medical Research Institute, New Lambton, Australia

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Brett D. Turner B Turner, University of Technology Sydney, Sydney, Australia

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Shaun D. Roman S Roman, The University of Newcastle Australia, Callaghan, Australia

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Mark P Green M Green, School of BioSciences, The University of Melbourne, Melbourne, Australia

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Brett Nixon B Nixon, Biological Sciences, The University of Newcastle Australia, Callaghan, Australia

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Poly- and perfluoroalkyl substances (PFAS) are synthetic environmentally persistent chemicals. Despite the phase out of specific PFAS, their inherent stability has resulted in persistent and ubiquitous environmental contamination. PFAS bioaccumulation has been reported globally with omnipresence in most populations wherein they have been associated with a range of negative health effects; with some PFAS chemicals exhibiting strong associations with increased instances of testicular cancer and reductions in overall semen quality. To elucidate the biological basis of such effects, we employed an acute in vitro exposure model in which the spermatozoa of adult male mice were exposed to a cocktail of PFAS chemicals at environmentally relevant concentrations. We hypothesized that direct PFAS treatment of spermatozoa would induce ROS generation and compromise the functional profile and DNA integrity of exposed cells. Despite this, post-exposure functional testing revealed that short-term PFAS exposure (3 hours) did not elicit a cytotoxic effect, nor did it overtly influence the functional profile, capacitation rate or the in vitro fertilization ability of spermatozoa. PFAS treatment of spermatozoa did, however, result in a significant delay in the developmental progression of the day 4 pre-implantation embryos they sired in vitro. This developmental delay could not be attributed to a loss of sperm DNA integrity, DNA damage, or elevated levels of intracellular reactive oxygen species. When considered together, the results presented here raise the intriguing prospect that spermatozoa exposed to a short term PFAS exposure period potentially harbor an alternate stress signal that is delivered to the embryo upon fertilization.

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Yasmin Franko Clinic of Ruminants, Faculty of Veterinary Medicine, Ludwig-Maximilians-Universität München, Oberschleißheim, Germany
Gene Center, Ludwig-Maximilians-Universität München, Munich, Germany

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Marcia de Almeida Monteiro Melo Ferraz Clinic of Ruminants, Faculty of Veterinary Medicine, Ludwig-Maximilians-Universität München, Oberschleißheim, Germany
Gene Center, Ludwig-Maximilians-Universität München, Munich, Germany

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Graphical abstract

Lay summary

The decreasing rate of successful pregnancies, both naturally and through assisted conception, has led to innovations in the way eggs, sperm, and embryos are stored. Despite these advances, the use of assisted reproductive techniques to preserve endangered or rare species remains unexplored. Since the location where samples are collected and facilities are often far apart, we aim to address part of this challenge by comparing different methods to store and handle ovarian tissue before freezing. This may pave the way for further research in preserving endangered species, despite the challenges posed by the distance between sample collection sites and suitable facilities.

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Lixia He Reproductive Medicine Center, West China Second University Hospital, Sichuan University, Sichuan, China

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Junyong He Health Management Center of West China Hospital of Sichuan University, Sichuan, China

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Qianhong Ma Reproductive Medicine Center, West China Second University Hospital, Sichuan University, Sichuan, China

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Song Jin Reproductive Medicine Center, West China Second University Hospital, Sichuan University, Sichuan, China

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Yuechao Lu Reproductive Medicine Center, West China Second University Hospital, Sichuan University, Sichuan, China

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Dongmei Zhang Reproductive Medicine Center, West China Second University Hospital, Sichuan University, Sichuan, China

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Xu Liao Reproductive Medicine Center, West China Second University Hospital, Sichuan University, Sichuan, China

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We aimed to investigate the effects of the position of the transferred air bubble with the clinical pregnancy rate (PR) in frozen-thawed embryo transfer (FET) cycles. A prospective clinical study was carried out at Reproductive Medicine Center of West China Second University Hospital between June 2020 and May 2021. A total of 1159 women who underwent FET were included in this study. Transabdominal ultrasonographic guidance was used during the transfer procedure. The distance from the air bubble to endometrial cavity fundus (DAF) was measured in the freeze-frame ultrasound immediately after ET. In DAF ≤3 mm, 3–15 mm, and ≥15 mm group, the clinical PR in women transferred with cleavage embryos was 33.3% (7/21), 55.0% (153/280), and 31.3% (5/16), respectively, and the difference was statistically significant (P < 0.05). Among women transferred with blastocysts, the clinical PR was 63.0% (34/54), 68.5% (485/708), and 55.0% (44/80), respectively, and the difference was statistically significant (P < 0.05). In multivariate logistic regression model for clinical PR, the clinical PR was associated with age, embryo quality, number of embryo transferred, and endometrial thickness. DAF was an independent risk factor influencing clinical PR in blastocyst FET cycles rather than in cleavage embryo FET cycles. In conclusion, our results suggested that DAF was associated with the clinical PR and DAF between 3 mm and 15 mm is the optimal position in blastocyst FET cycles.

Lay summary

Embryo transfer is the last step in the IVF process. The position of the transferred embryo in the uterine cavity may affect the clinical pregnancy rate. The relationship between the position of the embryo in the uterine cavity at the time of transfer and the clinical pregnancy rate is disputed. In this study, the distance from the air bubble to endometrial cavity fundus measured using the freeze-frame ultrasound immediately after embryo transfer was used to indicate the position of the embryo in the uterine cavity. This study demonstrates that the position of the transferred air bubble in the uterine cavity is an independent factor on clinical pregnancy rate in blastocysts (embryos on the fifth day of fertilization) frozen-thawed embryo transfer cycles but not in cleavage embryos (embryos on the third day of fertilization) frozen-thawed embryo transfer cycles. The distance from the air bubble to endometrial cavity fundus between 3 mm and 15 mm is the optimal position in blastocyst frozen-thawed embryo transfer cycles.

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Ibrahim Banaru Abubakar I Abubakar, Department of Family Medicine, Ahmadu Bello University Teaching Hospital, Zaria, 0000, Nigeria

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Hafsat Banaru Abubakar H Abubakar, Department of Family Medicine, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria

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Nigeria has the largest population in Africa, a high fertility rate, and unmet needs for family planning. Family planning is a key strategy for sustainable development. Good knowledge of factors that determine contraceptive uptake is imperative for policy formulation. A nationally representative secondary dataset of 33,924 women aged 15–49 years who participated in the 2018 Nigeria Demographic and Health Survey was analyzed. Multivariate logistic regression was used to examine the association between various factors and the current use of modern contraceptives. The respondents' average age was 35.9 +/- 7.9 years. Overall, contraceptive prevalence was 16.6% for traditional methods and 12.2% for modern methods. Factors associated with an increase in modern contraception use were age 40–44 (aOR = 1.07, 95% CI: 0.75–1.53); being a working-class woman (aOR = 1.15, 95% CI: 0.99–1.33); living in an urban area (aOR = 1.14, 95% CI: 0.97–1.33); living in the South-West (aOR = 1.36, 95% CI: 1.03–1.79); increasing wealth (aOR = 0.78, 95% CI: 0.66–0.93);and health insurance (aOR = 1.22, 95% CI: 0.89–1. 68. Couple dynamics influencing modern contraceptive use were joint decision (aOR = 2.16, 95% CI: 1.81–2.59), self-decision on healthcare (aOR = 1.34, 95% CI: 1.06–1.70), and earning more than a partner (aOR = 1.14, 95% CI: 0.78–1.66). There are significant variations in contraceptive uptake attributable to socio-economic and political inequalities, requiring a holistic approach to mitigate barriers and improve contraceptive uptake.

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Ziting Chen Department of Animal Science, University of Illinois, Urbana-Champaign, Urbana, Illinois, USA
Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, Michigan, USA

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Matthew Dean Department of Animal Science, University of Illinois, Urbana-Champaign, Urbana, Illinois, USA

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Approximately 50% of pregnancies in humans fail, mostly before or during implantation. One factor contributing to pregnancy loss is abnormal glucose metabolism in the endometrium. Glucose contributes to preimplantation embryo development, uterine receptivity, and attachment of the embryo. Across multiple species, the epithelium stores glucose as the macromolecule glycogen at estrus. This reserve is mobilized during the preimplantation period. Glucose from circulation or glycogenolysis can be secreted into the uterine lumen for use by the embryo or metabolized via glycolysis, producing ATP for the cell. The resulting pyruvate could be converted to lactate, another important nutrient for the embryo. Fructose is an important nutrient for early embryos, and the epithelium and placenta can convert glucose to fructose via the polyol pathway. The epithelium also uses glucose to glycosylate proteins, which regulates embryo attachment. In some species, decidualization of the stroma is critical to successful implantation. Formation of the decidua requires increased glucose metabolism via the pentose phosphate pathway and glycolysis. After decidualization, the cells switch to aerobic glycolysis to produce ATP. Paradoxically, the decidua also stores large amounts of glucose as glycogen. Too little glucose or an inability to take up glucose impairs embryo development and decidualization. Conversely, too much glucose inhibits these same processes. This likely contributes to the reduced pregnancy rates associated with conditions like obesity and diabetes. Collectively, a precise control of glucose metabolism is important for several endometrial processes required to establish a successful pregnancy. The factors regulating these metabolic processes remain poorly understood.

Lay summary

Pregnancy failure soon after an egg has been fertilized is common in humans and cattle. The inner lining of the womb (endometrium) plays a role in the development and implantation of an embryo. The levels of glucose needed by the endometrium and embryo change dramatically during early pregnancy. The inner layer of tissue (epithelium) uses glucose and other nutrients to help the embryo develop and attach to the endometrium. In some species, the layer underneath the epithelium (stroma) goes through a series of major changes that alter the function of the cells and the levels of energy they require. This review discusses the way glucose is used in the epithelium and stroma to provide insights into the role this has in ongoing pregnancy.

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Alex Polyakov Faculty of Medicine and Health Sciences, University of Melbourne, Melbourne, Australia
Reproductive Biology Unit, Royal Women’s Hospital, Melbourne, Australia

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Genia Rozen Faculty of Medicine and Health Sciences, University of Melbourne, Melbourne, Australia
Reproductive Biology Unit, Royal Women’s Hospital, Melbourne, Australia

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The field of fertility preservation (FP) for oncology patients has evolved significantly in recent years, offering new possibilities for individuals with life-threatening illnesses. We commend Jones et al. for their comprehensive ethical review of offering FP to patients with poor prognoses, acknowledging the potential benefits that it may bring. ‘Poor prognosis’ in this context implies a high likelihood of death due to cancer progression. We highlight the importance of considering posthumous reproduction, involving the use of cryopreserved gametes or embryos to conceive a child after one or both partners have passed away, a topic briefly mentioned by Jones et al. Posthumous reproduction raises complex ethical, logistical, and legal questions. Distinctions between cryopreserved sperm and oocytes are discussed, with each scenario presenting unique challenges. The article also examines the complexities faced by same-sex couples in posthumous reproduction, addressing issues related to donor selection, legal parentage, and rights. Legal and regulatory aspects play a crucial role, including obtaining clear and legally valid consent, defining parental rights, navigating surrogacy laws, and addressing inheritance and estate planning. Ethical dilemmas require healthcare professionals to ensure informed decision-making, consider psychological impacts, and offer information on alternative family-building options.

Lay summary

Cancer treatments can have a negative impact on a person’s ability to have children, and some cancer survivors may end up being unable to conceive. Fortunately, there are currently available technologies that can help preserve fertility for these patients. These options include freezing eggs or sperm before starting cancer treatment. For patients who have been diagnosed with cancer and have a poor prognosis, meaning they are not likely to survive their illness, it is crucial to think about what happens to their frozen eggs and sperm in case of their death. This process of conceiving a child after someone's passing is known as ‘posthumous reproduction’. In our article, we explore the ethical, legal, and logistical challenges that the surviving partners of patients who may not live long enough to have a child with their frozen eggs or sperm might face. We pay particular attention to same-sex couples because their surviving partners often encounter more obstacles. In some countries, posthumous reproduction in these circumstances is even prohibited by law. There is a significant variation in the regulations related to posthumous reproduction, both between different countries and within individual countries. These differences need to be carefully considered when healthcare professionals counsel patients and their family members.

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Justin Sinclair NICM Health Research Institute, Western Sydney University, Sydney, Australia

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Jason Abbott School of Clinical Medicine, Medicine and Health, Division of Obstetrics and Gynaecology, UNSW, Sydney, NSW, Australia
Gynaecological Research and Clinical Research (GRACE) Unit, Royal Hospital for Women, UNSW, Sydney NSW Australia

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Antonina Mikocka-Walus School of Psychology, Faculty of Health, Deakin University, Melbourne, VIC, Australia

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Cecilia Ng School of Clinical Medicine, Medicine and Health, Division of Obstetrics and Gynaecology, UNSW, Sydney, NSW, Australia
Gynaecological Research and Clinical Research (GRACE) Unit, Royal Hospital for Women, UNSW, Sydney NSW Australia
The George Institute for Global Health, UNSW, Sydney, Australia

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Jerome Sarris NICM Health Research Institute, Western Sydney University, Sydney, Australia
Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia

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Subhadra Evans School of Psychology, Faculty of Health, Deakin University, Melbourne, VIC, Australia

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Mike Armour NICM Health Research Institute, Western Sydney University, Sydney, Australia
Translational Health Research Institute, Western Sydney University, Sydney, NSW, Australia
Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand

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Previous quantitative research has shown that cannabis use, mostly illicit, is used for symptom management amongst those with endometriosis living in Australia or New Zealand, but the drivers and barriers for use of legal, medicinal cannabis in this population are currently unclear. This study sought to investigate, via online focus groups, the perceptions, barriers, drivers, and experiences associated with cannabis use, whether legal or illicit, amongst 37 Australians and New Zealanders, aged 18–55, with a medical diagnosis of endometriosis. Previous cannabis usage was not required to participate. Discussion topics included strategies employed to manage symptoms, exploration of current medications, previous use of cannabis for pain management, and interest in using medicinal cannabis as a management strategy. Participants with moderate-to-severe symptoms of medically diagnosed endometriosis reported inadequacies with their current medical and self-management strategies and were inclined to try medicinal cannabis, both as part of their medical management and as part of a clinical trial. Barriers to medicinal cannabis adoption identified in this cohort included high costs of legal cannabis products, lack of clarity and fairness in current roadside drug testing laws and workplace drug testing policies, concern over the impact of stigma affecting familial, social and workplace life domains, and subsequent judgement and the lack of education/engagement from their medical providers regarding cannabis use. Given the interest in medicinal cannabis and the reported lack of effective symptom management, clinical trials are urgently required to determine the potential role that medicinal cannabis may play in reducing the symptoms of endometriosis.

Lay summary

Previous research has demonstrated that cannabis, either medically or illicitly obtained, is being used to manage the pain and associated symptoms of endometriosis in people across Australia and New Zealand. However, there are no clinical trials yet to determine how safe and effective medicinal cannabis might be for endometriosis symptoms. Before we design our clinical trial we wanted to get input from people in the community who have endometriosis to understand what kind of barriers there might be to both being in a clinical trial and using medicinal cannabis for their symptoms. Overall, the vast majority of participants were open to trying medicinal cannabis as a management option, driven mainly by inadequacies in their current medical and self-management strategies. Several barriers to adoption were identified, including the high costs of legal cannabis products, current drug driving laws or workplace drug testing policies, and the negative stigma around cannabis usage.

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Lewis Nancarrow Centre for Women's Health Research, Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool, UK

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Nicola Tempest Centre for Women's Health Research, Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool, UK
Liverpool Women's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK

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Suganthi Vinayagam Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool, UK

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Steven Lane Department of Biostatistics, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, University of Liverpool, UK

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Andrew J Drakeley Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool, UK
Liverpool Women's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK

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Roy Homburg Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool, UK

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Richard Russell Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool, UK
Liverpool Women's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK

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Dharani K Hapangama Centre for Women's Health Research, Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
Liverpool Women's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK

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Abstract

Embryo implantation is vital for successful conception but remains to be fully understood. Trophoblast invasion is key for implantation, with anchorage and depth of placentation determined by its extent. There is a dearth of synchronous information regarding IVF, implantation site, and trophoblastic thickness (TT). Our aim was to determine whether pregnancy implantation site and TT, had an impact on outcomes of IVF pregnancies. This prospective observational study was undertaken at a tertiary referral UK fertility unit over 14 months, collecting data on implantation site and TT from three-dimensional (3D) images of the uterus following early pregnancy scan. Of the 300 women recruited, 277 (92%) had live births, 20 (7%) miscarried, 2 (0.7%) had stillbirths, and 1 (0.3%) had a termination. Significantly more pregnancies that resulted in miscarriage (7/20, 35%) were located in the lower uterine cavity when compared to ongoing pregnancies (15/277, 5%) (P < 0.01). TT was significantly higher in ongoing pregnancies when compared with those who miscarried (7.2 mm vs 5.5 mm; P < 0.01). Implantation in the lower half of the uterine cavity and decreased TT are significantly associated with an increased rate of miscarriage. Identification of those at risk should prompt increased monitoring with the aim of supporting these pregnancies.

Lay summary

Implantation of an embryo in the womb is vital for a successful pregnancy. We wanted to find out whether findings on an ultrasound scan in early pregnancy had an impact on outcomes of IVF pregnancies. Three hundred women were recruited to the study, 277 (92%) had live births and unfortunately 20 (7%) had a miscarriage, 2 (0.7%) had stillbirths, and 1 (0.3%) had a termination. Many more of the pregnancies that miscarried implanted in the lower part of the womb. The thickness of the infiltration of the pregnancy into the womb was significantly higher in the ongoing pregnancies. We concluded that implantation in the lower half of the womb and reduced infiltration of the pregnancy seen on scan are associated with an increased rate of miscarriage. We propose that when we identify those at risk, we should increase monitoring, with the aim of supporting these pregnancies.

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