Fertility and Sterility On Air - Live from ASRM 2024: Part 2

Fertility and Sterility On Air brings you the best of ASRM 2024! In Part 2, our hosts bring you: home semen testing with Dan Greenberg (0:40), state insurance mandates for fertility coverage with Adeola Adeyeye (7:13), resource utilization difference between programmed and natural transfers with Ben Peipert (12:23), patient perspectives on embryo donation with Deb Roberts (21:37), corpus lutea and preeclampsia risk after embryo transfer with David Huang (35:02), exercise during stimulation with Maren Shapiro (40:57), combination of letrozole and clomiphene with Rachel Mejia and Jessica Kresowik (49:07), the impact of Alabama's personhood bill with David Monroe (54:06), and embryo quality and polygenic risk with Jordan O'Donnell (58:40).

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Welcome to Fertility and Sterility On Air, the podcast where you can stay current on the latest global research in the field of reproductive medicine. This podcast brings you an overview of this month's journal, in-depth discussion with authors, and other special features. FNS On Air is brought to you by Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine, and is hosted by Dr. Kurt Barnhart, Editor-in-Chief, Dr. Eve Feinberg, Editorial Editor, Dr. Micah Hill, Media Editor, and Dr. Pietro Bortoletto, Interactive Associate-in-Chief.

Welcome to another episode of Fertility and Sterility On Air. I'm Micah Hill, the Media Editor for FNS On Air, and I am here live at ASRM, and I'm with Dan Greenberg. He's a fifth-year urology resident at Northwestern University.

He has some very interesting data on a randomized controlled trial of home semen testing for prospective father, semen analysis results, and three-month follow-up. Dan, this is such a cool idea, if we can do our semen test collection from home and just send it on. So, why was this important to study? Why did you think this was something you were interested in? Yeah, so first of all, thank you so much for having us on air and allowing us to speak on our work.

It's a pleasure to be here at ASRM. So, you know, the initial impetus for the study is, as you said, that there's a significant rise in these direct-to-consumer, DTC is the acronym that you'll hear, DTC products for male fertility in the male fertility space. And we really wanted to see how home semen testing can affect fathers that we were calling early stages of family building.

That was including men that are within six months of trying or planning to start trying to conceive within the next year. And so we wanted to see, are these men, A, is it feasible to do at home? Are they wanting to do this at home? And if they do complete the home semen testing, does this help them to either understand their fertility status or possibly want to seek care earlier in this process? And was it that feasibility aspect that made you decide to study this in men who didn't really have a definition or a diagnosis of infertility, but wanted to get pregnant potentially? Yeah, I think the reason for studying the early family, or early stages, excuse me, is we see anecdotally a lot of men coming in who are already in their mid to late 30s, who've been in a relationship for a number of years, who have been trying for a number of years, and have not yet sought or helped with a fertility specialist. And so if we get these men at a younger stage, at an earlier phase of their family building, can we potentially provide them early services and help them in their fertility journey? That's fantastic.

And so just so it's clear to our audience, this isn't a cohort study. You actually randomize these men to these two arms, the traditional collection versus the home collection. Yeah, so we recruited men online using researchmatch.com. And then in the later phases of the trial, to increase recruitment, we actually had in-person flyers that we put up.

And absolutely, we did a prospective randomized clinical trial. If they were randomized to the home semen testing arm, we sent them a home semen testing kit, and then asked them to also fill out a 10-question questionnaire about their experience with the home testing as well. Okay.

And just from a practical standpoint, so I know when we, sometimes we have men collect at home, but still bring it into the clinic. What's the shelf life on this from the instructions? How easy is it? Do you put it in the cup and put it in the mail? And how does that part of it work? Yeah, so the whole testing is done at home, and they generate what they call a YO score. It's the YO home semen testing kit.

And that gives them a score between 10 to 90, which is really related to modal sperm concentration, which they've shown is one of the best predictors of fertility status. Gotcha. And so these men will get a number 10 through 90, 10, 20, increments of 10.

That's really based on large-scale predictive values of what their percentile is within the general population. So this is primarily giving total modal sperm as the output, probably the most important thing for us. Exactly.

Excellent. Okay. So sounds like a fascinating study.

What'd you find? So we assessed first their primary outcome was really, did this improve their overall well-being as well as their fertility-related quality of life? And so we used the WHO-5 Well-Being Index. As well as the FertiQL, which are both scaled zero to 100. And we assessed both cohorts, the home semen testing, as well as what we call standard of care, which is men who did not receive the home semen testing.

And we assessed them at baseline, three months, six months, and then 12 months into the trial. And right now we actually have a majority of men with three-month data, as well as some with six-month data. Unfortunately, we did not show, or maybe not unfortunately, but we did not show an increase or a decrease in either of those indices between the two cohorts.

However, we did, obviously, a subgroup analysis of the home semen testing cohort. And we found that the vast majority of men, we're talking in the 80 to 90 percent, thought this was easy to perform. It was easy to interpret.

It allowed them kind of a baseline to discuss their fertility status. And really 86% of them would actually recommend this to other men in their same scenario, in the early stages of family building. So I think that is really the primary driver of what we're finding with this, is that if offered, men are willing to undergo this test at home.

They think that it's valuable to their fertility journey. And this should be considered in the algorithm for treatment of male infertility, or even just evaluation of a male undergoing the process. Yeah.

So that was one of my next questions is, so do you think this is ideal for just men who are deciding to start to try to become pregnant with their partner? Or do you think this is of value to men who actually have proven infertility? They've been trying for 12 months, and they haven't been able to conceive yet with their partner. I think it can go to both of those populations, and even one step further. Well, I don't know if we really need to even wait till a man is starting his fertility journey.

Right. Why can this not be offered to the man in their young 20s who's interested in learning about their fertility status and where they may stand? Sounds a lot like some of the testing that are currently offered to women, but I think this is one area in health where maybe men actually lag behind the female population. Yeah.

I mean, obviously the female population, they're seeing their general practitioners at a much higher rate, their OBGYNs at a much higher rate. Right. And us men, we're not as good about that.

We don't like going to the doctor. Yeah. So a lot of times, you know, their first touch or their first interaction with the healthcare system since they've been a pediatric patient is when they're coming to a male fertility specialist with these concerns.

Yeah. So for you personally, what's the next step? You've done this amazing RCT, you're going to obviously publish it. What do you think is the follow-up study? Where are you taking this? Well, we're still at the interim analysis.

I'm really interested to see what our 12-month data looks like because that questionnaire we're going to send out that also evaluates, did you achieve pregnancy? Did you seek care with a fertility specialist and when? Did you require assisted reproductive technology in your journey? Okay. And you know, that's going to be really telling, I think, to how we implement this moving forward. All right.

Fantastic. Thank you very much for sharing this with us and congratulations on this amazing study and good luck with pursuing your reproductive urology fellowship. We're glad to have you in the field.

Thank you so much again for having me. Glad to have you. Hi, it's Molly Kornfield here with Kate Devine and we have the privilege of interviewing Adeola Adeyeye about her wonderful abstract today.

It's really nice to meet you, how are you doing today? I'm doing great. Nice to meet you both as well and thank you so much for this opportunity. Well, thank you so much for being here.

Yes. Well, we loved reading your abstract and seeing what you've been up to. Can you tell us a little bit about what your research question was and how you went about answering it? Sure.

Sure thing. So this kind of started in 2009 where the World Health Organization kind of advocated for fertility by sharing the fact that infertility is a disease and that kind of helped to push forward the treatment of this disorder as well. So we took a look at insurance mandates in the United States and we actually saw that less than 50% of the states have insurance mandates that encourage insurances to cover fertility treatments.

So we took a look and we discovered that actually there's more, there's a lot of room for advocacy to encourage more states to help cover fertility care. Great. And I saw you also had this discrimination piece.

Can you tell me more about what you, what were you looking at for that? Yeah. The biggest part of the study was taking a look to see if insurance mandates actually cover patients against discrimination for different parts of their identity, such as race, ethnicity, ancestry, disease. And we saw that only two mandates in the United States, which were New York and Washington DC actually explicitly in their policy protect patients against that.

How are some ways that you see that these mandates not having these protections in place can impact patients? Can you give us an example? Absolutely. There are some states that actually encourages group policies or religious centers and influences them to cover fertility care. However, the states that don't have these coverages, patients who work and have a group policy or they work with any affiliate of a religious center do not have these coverages.

So those are some of the ways. I see. Well, you know, we get excited when there's new coverage added in new states.

We all know that a new insurance mandate SB729 was just passed in California with 9 million additional lives hopefully covered. So that's, that's exciting. What do you see as the next steps in terms of both advocacy and research on this topic? Yeah.

So overall in the United States, there are 22 mandates. 23 now. Yeah.

Oh yes. 23 now. That's less than 50% of the states.

So in the future, I do see that getting better and improved and more states kind of joining in that. I'm excited. Yeah, that's great.

And you know, the other thing that I think is really important to highlight is that all mandates are not created equal. Correct. Even separate and apart from discrimination protections.

They cover very, very different things. So can you speak a little bit to that? You know, what did you observe in terms of the way in which these mandates run the gamut? Yeah. So some states have mandates to help support fertility preservation and some states don't.

Some states have mandates to help support IVF treatments and others don't. So I think it's important that we have kind of like an overall standard of mandates as well. So somebody living in one state wouldn't have more or better opportunities than somebody living in another state.

I'd be interested in, so last year around this time, our ASRM expanded definition of infertility came out, which I think really expanded infertility to encompass and care for many of our LGBTQ patients who cannot conceive because of partners and all those indications. So I'd be really interested if that helped in a lot of these states and help prevent discrimination. I love your proposal in your impact statement that we really just need a federal mandate for both fertility care and to prevent discrimination in fertility care.

But we're kind of just fighting away little by little at this point. We all know that our advocacy team and ASRM is working so hard to help expand access. So all the data we can get from studies like yours help them and you know they've recently released a scorecard that's highly useful for folks to kind of understand where things are at in their state.

So thanks for all the work you're doing and thanks so much for being with us today. Thank you so much for having me. Congratulations on your abstract.

Thank you. And we're back. This is Eve Feinberg.

I am pleased to be back with... Hi, I'm Ben Peipert. I'm one of the second year fellows at the University of Pennsylvania. Great.

Welcome, Ben. Today we're discussing your abstract differences in resource utilization between programmed and natural frozen embryo transfers at a single academic fertility practice. I think this is something that we talk about all the time in our practice.

Our lab is often expressing some frustration at the number of natural cycle FETs that we do and the unpredictability and the timing. So I'm assuming that's at least partly why you chose to do this work, but why don't you tell us a little bit more? Yeah, sure. So first of all, thank you for having me.

I'm really excited to share this work. Obviously there's both a lot of discussion presently happening both about the logistics of natural frozen embryo transfers as well as the risks and benefits as it pertains to both outcomes for patients and the development of preeclampsia, spectrum disorders, and pregnancy. So our team thought it would be helpful for us to look at some of the resource utilization around natural and programmed frozen embryo transfers.

So when you... Just to back up a little bit because I know how we do natural cycles in our center, but my understanding is that there's a lot of nuanced differences between centers. So when you do a programmed, walk us through just very briefly when you do a programmed cycle, what that means in terms of monitoring visits and how do you do your natural cycle FETs in terms of monitoring? Absolutely. That's a super important point.

So as far as our programmed cycles go, most of our patients do start on Lupron for a period of time before starting their cycles. They then start with oral esterase to prepare the endometrial lining. We have them come in for a laboratory visit and an ultrasound to check the lining, determine the thickness, make sure it's trilaminar, and at that point we'll map them and then start them on progesterone and oil to time them appropriately for their embryo transfer.

Yeah. And so in terms of visits, do you do like a luteal check? Do you ensure that they're luteal or do you overlap OCPs with Lupron? So we overlap OCPs with Lupron at our center for most of our patients. So then it sounds like two visits, maybe a baseline after the onset of menses once they've started Lupron and then that final lining check.

Exactly. So it's almost always at least two ultrasound visits, so that baseline and the lining check, but then we also do pre-frozen embryo transfer labs just to make sure that the estrogen and progesterone are appropriate for transfer. And when do you do those pre-labs? We do them the day before the transfer.

So in that setting, that would not count towards the way that we measured our monitoring visits, but it is an extra laboratory visit for those patients. Okay. And then for a natural cycle frozen embryo transfer, how do you do those? So that's a great point.

It varies a lot. At our center, most commonly though, we're doing unstimulated natural frozen embryo transfers, meaning the patients call with their period, they have a baseline scan and their labs are drawn, and then we let them develop a follicle on their own. And then when the follicle is of an appropriate size with appropriate estrogen level, we'll trigger them.

So- So you bring them in for monitoring during their natural cycle- We do. To try to capture that pre-ovulatory follicle. Exactly.

So in general, do you bring them in on day 12, on day 10? When do you start bringing them in and how many visits do they usually have before you deem that it's adequate? Right. So they come in for their baseline and then they'll usually come in empirically on day 10 or 12, depending on their cycle length. And so again, the goal is to time it just right so you're catching them and you maybe only need two ultrasound visits.

But I would say that that's the ideal, and it's more commonly three or four. A lot of the times you're just waiting for the optimal lining, the labs, all things to match up. And so you have this repetitive monitoring visit that happens towards the end, right before trigger.

In some cases- And then once you trigger them, do you transfer a week later or do you alter your timing based on their individual rise in progesterone levels? So if we are triggering them, then they have not had their own endogenous rise in LH, for example, in progesterone. And so then yes, we're timing it out a week afterwards and we're using vaginal progesterone for alluvial support. Sometimes patients decide to ovulate on their own.

And in that case, then we're waiting for follicular collapse and then timing, the day of collapse for us is day zero and they're having the transfer on day five. Okay. All right.

So what did you find in your study? Yeah. So we found that, we looked at the cycles, all frozen embryo transfer cycles for the past two years at our center. We looked at the natural frozen embryo transfers that did not use any form of ovarian stimulation.

So we did have 25 cycles that use letrozole for stimulation, and we excluded those because those were very different than the majority of our cycles. So we ultimately ended up with 540 natural frozen embryo transfers and 1,042 programmed frozen embryo transfers. There were some differences in terms of the baseline characteristics of the populations, but it wasn't major.

The natural FET patients were slightly younger, had slightly lower AMH values, but they weren't clinically meaningfully different. The biggest difference was obviously that the diagnosis of ovulatory dysfunction was much lower in a natural frozen embryo transfer group, because that wouldn't make sense for us. What we found is that on average, the natural frozen embryo transfers required one and a half more monitoring visits, and the cancellation rate was higher as well.

So we're talking about the difference of monitoring visits being 3.6 on average for our natural frozen embryo transfers and 2.1 on average for the programmed. With respect to cancellation rates, it was higher for the natural frozen embryo transfers with 14.1% canceling as opposed to 9.8% for the programmed frozen embryo transfers, usually being canceled either for failure to develop a follicle or issues with lining development as we see with both types of frozen embryo transfers. And then finally, we looked at the weekend transfer rate, and obviously it was much higher with the natural frozen embryo transfers.

We do try to avoid the weekend, but we're not a practice that uses, for example, I've heard some people talking about using antagonists to try to avoid the weekend for these natural frozen embryo transfers. That is not something that we're doing. And so 15% of our transfers are happening on the weekend for natural frozen embryo transfers as opposed to almost zero for programmed.

And then cost differences. My understanding is you saw a cost difference between the natural and the program cycles. Yeah.

So we calculated based on our package pricing and the codes that were being billed. We looked at the cost of the lab tests as well as the blood draws and the ultrasound visits, totaled that up and equated that to one monitoring visit. So each additional monitoring visit costs $363.

So on average, the natural frozen embryo transfers cost $545 more. And so if we just did all natural instead of program frozen embryo transfers during our study interval, we would have spent an extra $283,000 to do the natural cycles just for monitoring alone. Yeah.

I mean, I think, and I think it's a wonderful study and I'm so glad you did it. My only critique of it is when you're doing your program cycles, you're using an entire Lupron kit, which is also a couple hundred dollars too. And so I think it's not an entirely fair cost differential because you have to take the medication cost into account.

It is. And that's been a good conversation that we've had during the poster presentation at ASRM. So that's been very helpful in terms of helping to shape the future direction of this research.

We really took a clinic perspective. And so I think whenever you do cost effectiveness, you have to keep that perspective in mind. And it's, it's a choice about whose perspective do you want to take? And I think certainly thinking about the patient perspective is essential because they're, they're the driver for a lot of the choice in protocol oftentimes because they have, they have strong preferences.

Lots of people don't want to use progesterone in oil and lots of people want the, or the idea of a natural frozen embryo transfer is appealing. Yeah. So I totally agree.

And it's something that I think we talk about almost every day in our practice. And I think that there is a huge difference in workflow between the natural cycles and the program cycles with the program cycles being so much easier, but is that really what's better for the patient? And I think also is that better, what's, is that better for the clinic staff and for the embryology staff? And I think that all of those factors are competing, but this is a fantastic poster. And I really commend you guys on doing this and really diving in and looking at those differences and teasing them out so beautifully.

So thank you. Thank you for sharing your work with us. Thanks, Dr. Feinberg.

This is Eve Feinberg. I'm back and today I'm joined by Deb Roberts. Welcome, Deb.

Thanks for having me, Eve. I'm so glad to be here. I'm Deb Roberts.

I'm founder and CEO of Embryo Connections and Embryo Donation Concierge and Embrace Embryo Donation, which is a not-for-profit education platform for embryo donation. Amazing. And the title of your abstract that we're going to be talking today is Embryo Donation Motivations, Barriers, and Interests Among Individuals During Surplus Embryos, which is fascinating.

So what I'd love to hear is how you thought about the project and some of the background information on embryo donation that led you to study this. Absolutely. There's not a lot of research out there, so we really wanted to create a study that was expansive, meaning that we were reaching the general population that have embryos in storage.

We also talked to recipients. We talked to people who are going through their IVF cycle at the same time. And we did that because we really wanted to understand in today's climate what people thought about their embryos in storage and the idea of embryo donation, what that meant to them, what were their needs, their fears, what were the requirements for them to want to donate, and what that looked like for them in the future in terms of interaction and engagement with their donor concierge children.

I commend you on doing it because, as you said, there's really not a lot of data out there. And I think that especially there's not a lot of data with regard to the idea of embryo donation. And for our listeners, I think people know I'm really particular about language, that embryo, quote, adoption is a religious perspective and personifies the embryo, whereas embryo donation is really the scientifically and medically correct term to use.

And some of the research, admittedly, that's been published has been more in that religious bend to it. And so I think having a medical and this secular perspective is incredibly important. So how did you conduct your study? So it was a two-part study.

I guess we can say three parts. First, we did a lot of research to understand what was out there already. What had people already studied? And it was pretty outdated.

And to your point, there was some faith-based approach to it. There was also research that was focused on a specific clinic that didn't even include embryo donation as an option for their patients. So I don't think the study was very credible in that way.

So we started with qualitative. We did that in 2023. And we talked to groups of three or four donors and three or four intended parents at a time about what their concerns were and what their needs were around embryo donation and their awareness.

We then took that information and put together a 75-question survey and reached out to, we got 344 completes through Ipsos, which is an independent research agency. And the value of using them is that they could reach out a wide range of people who had embryos stored or who were going through their IVF. Yeah.

So the people that you sent the questionnaire to weren't necessarily people that were going to donate their embryos, correct? Or were they people who just simply had embryos stored and maybe had not made a final disposition? Right. That was actually really important that it wasn't just the population of people who had reached out saying they were interested in embryo donation. We actually wanted to talk to people simply who had embryos in storage or who were actively in their IVF cycles.

Yeah. And so tell me a little bit about what you found with the results of that survey. It was really interesting.

First thing we found was that 86% of those who had embryos in storage were considering or actively considering embryo donation as an option for their embryos. Yeah. As a clinician, I think that's very surprising.

It is something that I speak with most of my patients about in terms of disposition. And it doesn't seem to be a popular one. Although admittedly, I'm usually seeing patients as they are still pursuing treatment, I don't often get the chance to speak with them once their family has been completed.

Right. I mean, that is interesting. And what we know is that when people have a child, once there's a child that comes from those embryos, those embryos take on a different, just a different value, right? They're no longer embryos.

They become siblings of their children. And so there's a lot of meaning that goes with that. And so when we're talking to these storage clients who no longer have access to their physicians and nurses, right? They're not connecting with them on a regular basis.

They have all these ideas, but they weren't thinking about it back when they were pursuing IVF. Right. And I think we generally talk about, there's so much to cover in these IVF consults.

We talk about fresh versus frozen, risks of IVF, PGT versus not PGT, embryo banking versus not embryo banking. Embryo disposition does not often, there's not a lot of time that's dedicated to it. So I'm actually fascinated that 86 or those patients who finished, completed their family, had surplus embryos and 86% were considering embryo donation.

Right. 86% said that they were considering embryo donation with their embryos. And note that this was before the Dobbs decision, right? And so this really didn't have a legal or political lens to it.

Right. This was people who were saying, I get my storage bill and I'm thinking about what to do with my embryos. And so that's really great news.

What's interesting is that of the remaining group, those were people who were either familiar with it, but didn't really, they knew of it, but they weren't really familiar with it, or they just didn't know about it at all. And we, when we asked them, would you, if you learned more about it, they said, if they learned more about it, that 83% of those would actually consider embryo donation as an option. Yeah, that's amazing.

And then you dove in a little bit to what some of the barriers are for embryo donation. Can you speak to that? Some of the perceptions and barriers that patients felt? Yes. One of, some of their biggest concerns were around how embryos are donated.

So they did not feel comfortable donating anonymously because they do feel like those embryos are siblings of their children. And so that they feel like they, they need to have control over those embryos. And so that was a very big piece is that they feel responsible.

And so they, they, they feared donating to a program where they would never know what happened to their embryos or that they couldn't control where they went or how many families got them. So their concerns were really around that, um, that idea. Yes.

Yeah. That's interesting. Yes.

And then, and I guess, you know, we don't do anonymous embryo donation or de-identified embryo donation in our practice. We, we only do, um, known where we can have some element of, um, known factors in this. How common is de-identified embryo donation in this country? Do you know? Well, I would say that it's, it's becoming less common with agencies, right? I think agencies are the first ones to say we can handle, we can handle open donations, right? And so that the idea of open can any be anywhere from high engagement, open to, um, even donor ID disclosure, which allows for interaction at some point, it's harder for, for clinics.

So I would say within clinic programs, it's very common, but only 15% of clinics actually have an embryo donation program. And so, um, we, you know, we're talking about small numbers here, but of those 15%, most of them are, are not open. They're de-identified.

Okay. That's interesting. So what do you, what did you take as the big take-home point from this? If you were to say this research, if you could distill it down into two or three points, what would you say about the findings of this study? That, that our storage clients are very eager to donate their embryos when they feel that they can control the disposition of those embryos.

So when they feel like they can know, um, they can decide who they're donating to, and they can have interaction that they can have a long-term interaction, because what they want is for their children to be able to have access to their, these donor conceived children who are full genetic siblings, and that those donor conceived people have access to their roots. It seems like the donors really understand that. And what I find very fascinating is that because we talk to intended parents as well, I think there's fear in the industry that intended parents don't want that.

But in fact, um, this, a very similar percentage of intended parents want a line of communication. They want openness, um, because they also know the research. They, they're hearing how important it is for children to be able to have access to their roots.

Yeah, I think that was my biggest question of it is what do, what do the intended parents want and how important is it for the intended parents to have that same openness and that same connection? So I, I actually think that's surprising just in some of the conversations that I've had with my own patients who often fear, uh, and one of, when we talk about egg donation versus embryo donation, um, I've had a lot of patients who have gone more purposely towards egg donation because they didn't want that attachment to full genetic siblings that are out there. So I, I think, you know, there's a lot of different options for everyone, but I, I think embryo donation is an amazing, uh, it's an amazing option for so many couples. And I do feel like research on both sides, like this one, where you looked at the intended parents and you looked at the embryo donors.

I think that's, that's informative. Yeah. And I want to get to that point because I think it's important.

Intended parents want less engagement than donors, right? Donors are very eager to say, let's be high engagement. Let's have them grow up like cousins so they know each other from a very young age. And we find more donors lean that direction, but there's that middle ground of semi-open to low engagement, open either the adults are communicating and waiting for children to lead when they want to know one another.

Um, but it, it's a little bit less engagement and semi-open where they're communicating through a portal. Our intended parents like those options because they do fear intrusion. They, they're mourning the loss of their own genetics.

And then the idea that somebody might be, um, intruding on their parents, parenting. Yeah. That's, that's what I hear in my clinic all the time.

I think to me, that's probably the largest region reason that I see parents choosing oocyte donation. And even in, even in situations where there's poor egg and poor sperm or, um, single parents or LGBTQ couples, they still will choose oocyte and sperm donation because of that perceived fear of intrusion. Yes.

And what's interesting is that that's actually why we developed the embrace embryo donation website, the platform. We wanted to, we wanted them to hear from donors and donor conceived people about what it means to be open. I would say that our population tends to be more ready for openness, but if they could be educated that the donors actually don't want to intrude at all, right? The donors are coming from a very different lens, which is we want, we want to give this gift to you.

We want you to have your children and raise your children the way you want to. We want to make sure that they're going to a good home and their definition of a good home is different for everybody, right? But the idea is they just want to make sure their children are loved, that these children are loved. That is really ultimately from our research, the number one thing they want to make sure that the children are loved and that those children have access when they want information, right? That those offspring have information.

So once intended parents can embrace that idea, it becomes much more easy to accept openness. And that's why we see that semi-open to low engagement open, where they say, I know we want that line of communication, but we want to put up a little bit of a barrier, just a little bit. Yeah.

And I think that strikes a really nice, happy medium. So I just want to thank you for coming on the podcast and congratulations on doing this excellent work. And I look forward to seeing more.

I'm excited to read the manuscript. Hope you'll publish it in Fertility and Sterility. And it was really nice talking to you.

Yes. Thank you. We're very much looking forward to getting that published so that everybody can read it.

Thank you so much. We're here in Denver at ASRM. I'm Kate Devine and I'm here with Molly.

Molly, do you want to tell us a little bit about how the conference has been going for you? Oh, it's going great. Molly Kornfield here. We're having a lot of fun, lots of recording, lots of great abstracts.

We're enjoying the science here today. And we're so fortunate to have with us Dr. Huang from UCSF. Dr. Huang presented his research yesterday in the prize paper session.

David, welcome. Tell us about your work. Thank you for having me today.

I appreciate this platform. Our work at this year's ASRM conference is to look specifically at whether or not the way we do ART and the different regimen may affect maternal risk and particularly hypertensive disorders of pregnancy and preeclampsia. Wow.

Well, that's certainly a hot topic. We know lots of research is ongoing and we're all anxiously awaiting the results of the NAPRO trial. Tell us how did you evaluate this and what did you find? Yeah.

So a lot of the prior studies were limited by a retrospective approach, but also it's hard to adjust for underlying parental factors on top of the number of corpus lutea as well as the ART regimen. So we looked at it prospectively of 540 pregnancies in women who conceived with or without ART, but all diagnosed with infertility and they conceived via different methods. Unfortunately, we did not see a difference by the number of corpus lutea when you adjust for parental factors.

So what do you think the outcome of the NAPRO study is going to be? Well, I'm still very excited and UCSF were also a part of the NAPRO study as well. And I think it's based on really good biological plausibility of the roles that scientists have found for relaxin. I feel like I'm still hopeful that we could still see a difference.

But the main reason why we wanted to share our results first is because we wanted to wait until high quality data comes out before we impose potential risks and stress associated with natural cycle FET for our patients. Yeah, I think reading this was really interesting and somewhat surprising. And I think when I've looked at the retrospective studies showing a big difference between natural and program cycles, there are a lot of flaws in them and a lot of confounders.

And so there is strength of the prospective study design here. Do you guys think you are powered to find, could there still be a slight difference and we're just underpowered to see that in this study? Yeah, I think that's certainly a limitation of a prospective and it's always a push pull between a large registry database where you lose some granularity and accuracy versus a prospective but some of the results that we didn't show today, we did see a difference. So it's large enough to detect some other obstetric complications but not preeclampsia specifically.

But that's why and the NaPro study, I believe each arm is about 300 or so pregnancies as well. So it's getting close to there. So I know that you also had a strength of your study, which was that while all the patients were infertile, some of them did conceive naturally.

So tell us about that. We all worry and stay up at night wondering by doing ART for patients, are we sometimes doing some harm? So in patients who are able to conceive naturally in your study or who were able to conceive naturally, did they have a lower risk for obstetrical outcomes than those that needed either a fresh IVF transfer, a frozen transfer or that being in a natural or a program cycle? Yeah, that is the whole origin of why I wanted to do academic REI is to look at this topic, which impacts all of our patients' lives aside from getting pregnant. The patients who got pregnant on their own who have infertility and we're about to hopefully publish this soon.

So keep an eye out, but we did see that for most of the obstetric complications, ART did not add an additional risk on top of the underlying infertility diagnosis. However, we did see that potentially placentation is still affected and particular ART treatment parameters are major predictors of that too. Wow.

Well, really important work. What are your next steps? What do you plan to do with these data going forward and is the enrollment ongoing? Yeah, I think the enrollment is currently halted and unfortunately was impacted by COVID-19. But I am certainly biased and I looked into this because I do feel like it's something in the intrauterine environment that we're impacting during this periconception black box.

And my next steps are to look at it locally in the endometrium using various transcriptomic and hopefully proteomic approaches in correlation with the obstetric outcomes that we see in real life and hopefully draw some associations or conclusions from that. Fantastic. Well, I look forward to seeing that work as well and not wanting to digress too much, but what kind of a model are you looking at those pathways in? So I'm actually using patients that were generously donated by our patients who we do endometrial biopsies on for various reasons and just picking the appropriate time frame, the appropriate groups to look at to better understand how exactly we modulate the uterine environment as REIs and what potential impact that can have for the initial placentation process.

Got it. So it's a culture system using human endometrium. Or I'm using specifically single nucleus sequencing of the human endometrium during the window of implantation.

Awesome. Awesome. That's such exciting work.

Thank you so much for being with us today. Congratulations on your paper. Thank you so much.

Hi, Maren. I'm joined by Maren Shapiro. Maren, where are you at right now? I'm at University of California, San Francisco, Center for Reproductive Health.

Thank you so much for joining me. I'm honored to be here. Thanks for having me.

So we're going to talk about your abstract titled Physical Activity During Fertility Care or PACE, a randomized control trial of exercise during ovarian stimulation. This one is near and dear to me as somebody who's a chronic exerciser, runner who did IVF. I will tell you personally, one of the hardest parts of going through fertility treatment for me was not exercising and being sedentary.

So I read your abstract with interest and I'd love to hear you talk a little bit about why you designed it and what it is and how you did your trial. Yeah. I mean, people like you were really why we designed this.

We heard time and time again from patients that not being able to exercise was a huge stressor for them in this already very stressful process. And I think in fertility, in pregnancy, we put so many restrictions on women just because we don't have good data to say, let's be conservative. Don't do this thing because we don't know what it's going to do.

And myself, my partners, we felt like exercise was one of those things that didn't really have the data behind it. And I would think that universally practices tell patients do not exercise while going through ovarian stimulation for IVF. I think that's a pretty common thing that we all tell patients.

Yeah. I mean, that's what we told our patients and doing a quick Google search online of different practices, it's clear that most practices do say that as well. And I think we think theoretically that the risk is ovarian torsion, that if we exercise, then the ovary is heavy and it's at risk for cutting off its own blood supply.

Yes. That is the theoretical concern. Now, there haven't been any studies that have actually shown that exercise increases the risk of torsion.

Admittedly, it's a really hard thing to study because torsion only happens pretty less than one in a thousand cycles. So to study that is really difficult. But anecdotally, I mean, I don't know about you, most of the cases of torsion that I've seen were people asleep in bed at night.

They get up in the middle of the night to use the bathroom and they call in excruciating pain. That is exactly what we see. So I think it's pretty random.

And even if exercise does increase risk a little bit, it's still such a rare outcome. If there are benefits to exercise, I think our patients should be allowed to make that risk benefit decision themselves. Yeah, I agree.

So tell me a little bit. So you randomize patients to exercise versus no exercise, correct? Correct. And what was the time period? Was this over a year? How many patients did you enroll? We really wanted it to be during stimulation because that's when the recommendations are.

And so we randomized people at the time of their baseline ultrasound to either standard of care. So we asked them to cut back or not exercise at all or allowed them to exercise. And we didn't tell them what kind of exercise they had to do.

We just said, you can exercise. We would like you to try and meet the health and human services, healthy people goals of greater than 75 minutes of vigorous exercise a week or greater than 150 minutes of moderate exercise per week. And we asked them to maintain that activity level through their egg retrieval.

And then after their egg retrieval, they could do whatever they wanted. So it really was just during the period of stimulation. Okay.

And so how compliant were the patients who were exercising? Were they actually exercising most days of their stimulation or what sorts of activity did you see? Yeah, that's a great question. So we did have patients wear Apple watches during the study. We are still going through that data.

So I don't have the information on compliance, but we will have that for the manuscript. But I think really one thing that we also were interested in is purely removing that restriction. And I think allowing people to exercise in and of itself was an intervention, right? Whether or not they actually followed what they were asking.

Right. And you looked at stress levels as one of your primary interventions. That was our primary outcome.

Yeah. And so what did you, go ahead, tell us a little bit about what you found. So we did find that, so stress levels were comparable in the two groups at baseline, but at the end of stimulation, those who were allowed to exercise actually had a decrease in stress compared to those who were asked not to exercise who had an increase in stress.

And the change was statistically significant. But I think more interestingly, we did a subgroup analysis because we hypothesized that someone who exercises like you at baseline a lot and who's asked not to exercise is very different from someone who doesn't exercise who's asked to exercise. Exactly.

I feel like if you take patients who don't exercise and you tell them you can exercise, they may or may not follow through with it, which is where I was asking you about compliance. But if you take somebody like a six day a week exerciser or a seven day a week exerciser and you tell us not to exercise, it's very stressful. Yes.

And so in our subgroup analysis, and I will say the majority of our patients in San Francisco are very active. So I'd say three quarters of our patients were active at baseline. But in our subgroup analysis, based on baseline activity level, we did not see, we actually saw an increase in stress across the board in those who did not exercise at baseline.

And there was no difference between the exercise and the no exercise group. And then in those who were active at baseline, our initial findings held true. So we saw a decrease in stress in those who were allowed to exercise and an increase in stress in those who were not allowed to exercise.

Any complicate, did you see, and I'm not surprised by that at all. And I think it's great. I think it's fantastic that you did a trial, you used rigorous measures to assess stress at baseline, to assess stress after egg retrieval.

But I guess my question is, did you see any complications in the patients who exercised? We did not. So we saw, I mean, I think the biggest complication that everyone worries about is torsion. We had zero cases of torsion in either group.

Now, as we mentioned, torsion is hard to study. We were not powered by any means to find a difference in torsion, but I find it really reassuring that in over a hundred people who were allowed to exercise, no one had torsion. So I think you can say to your patients, but I use this data to tell my patients now is torsion is still really rare.

Even if you do exercise, use this to make the decision for yourself. Yeah. And I think that's great.

Did your practice change patterns after this study? Yeah. So we, you know, it's a work in progress. I think it's hard to shift what people say, but we're moving towards removing exercise restrictions from our standard paperwork for patients.

I know I don't tell people not to exercise. A lot of my partners don't have anything. Yeah.

I think I'm going to try it. I think I'm going to tell people they can exercise. And I tell people to do what feels comfortable for them, right? Like if you need a doctor to tell you, sit on your couch for two weeks, even by all means, go for that.

That's fine. But if it's really stressful for you not to exercise, then do what feels comfortable. Listen to your body.

I don't think like a Peloton ride for 10 minutes is really going to hurt you that much. Right. Right.

Yeah. I guess the only thing that gives me pause is two weeks ago after I had already selected this abstract for presentation, we had a patient who's on anticoagulation. She did a Lupron trigger and her husband's a personal trainer.

They had a vigorous workout session after she got her period, which is when we tell patients that their restrictions are lifted. And she came in with a hemoperitoneum. Wow.

That's shocking. Well, we don't know whether or not it's from the exercise, whether it's because she's anticoagulated, but her hemoperitoneum was six days after egg retrieval. And the timing of it was coincident with her exercise.

She worked out and then she developed incredibly sharp shoulder pain and lost consciousness two hours after they finished exercising. That's alarming. We only went through egg retrieval.

So after egg retrieval, we allowed them to do what they felt most comfortable with. Yeah. But I still think that the data are compelling enough to say that restricting exercise increases stress, allowing patients to exercise will decrease their stress during an already stressful process.

And when we look at things like torsion, I truly think that this is compelling to say that it's not going to increase your risk of torsion. Thank you so much. Congratulations.

And thank you for being on the podcast. Thank you. It's my pleasure.

Welcome back to Fertility and Sterility on Air. We're live from ASRM 2024 in Denver. I'm Micah Hill, the media editor, and I've got an all-star team here from the University of Iowa.

We're joined by Rachel Mejia and Jessica Kresowik. We're talking about an RCT of combined letrozole and clomiphene versus letrozole monotherapy for women with anovulation. Welcome, Rachel.

Welcome, Jessica. Good to see you. Thank you.

So tell us, why did you decide to do this study? Why was this a question you felt was important enough to put to an actual clinical trial and all of the work that that takes? Yes, absolutely. I mean, we really wanted to try to find another option for women with anovulation in this PCOS population as they be very challenging to treat and sometimes are not responsive to letrozole alone. And so we were really just searching for something that, you know, was relatively cost-effective option for patients before having to move to gonadotropins or IVF, which can have more costs and risks.

Yeah. So obviously clinical trial, generally pretty simple from a study design standpoint, not simple from an execution standpoint. Is there anything we should know from a study design? Like how did you do it? What were the key things that went into the trial itself? Yeah.

So this was three cycles with escalation of doses if they did not ovulate. Okay. And one arm was started at 2.5 of letrozole and another arm was 2.5 and 50 of clomiphene.

Okay. And so if they didn't ovulate, then that group, whichever group they were in was escalated to five and up to three cycles to 7.5. Okay. 50-50 allocation into each arm? Yes.

One-to-one ratio and the allocation scheme was generated by a statistician, which was blinded by, to the researchers. Okay. And it was stratified by clinical site when there was four clinical sites, age and BMI.

Okay. So some stratification. And I assume there wasn't a placebo for the clomiphene? There was not.

Okay. Fantastic. So everyone's dying to know, what did you find? So we found that per patient that both groups have very high ovulatory rates when looking at all the cycles and greater than 90% in both groups.

But when we looked at it by per treatment cycle, the ovulation rate was significantly increased in the combination group compared to letrozole alone. Okay. By how much? 72 to 84.

Okay. So 10 to 12% absolute difference in the per cycle ovulatory rate. So in theory, in a big enough trial over enough cycles, that should be a difference.

Did you look at downstream from ovulation? Did you look at implantation, clinical pregnancy, any of those other outcomes? We did. We're still collecting the live birth and the miscarriage, but the pregnancy rate in the letrozole group was around 27% and in the combination group was around 33%. So a slight trend towards the higher, but we were not empowered to detect a difference in pregnancy rate.

Gotcha. Gotcha. So when I read this study, it really brought me back to the great RNN studies, looking at this patient population.

And as you said in your introduction, sort of inexpensive low intervention ways to help these patients get pregnant. So how was this funded and tell us about that? Yeah. So we're really grateful for the funding that we received from both ASRM research grant, as well as the Society for Reproductive Investigation and Bayer research grant to help fund the study.

That's fantastic. So Jessica, just tell me big picture, what was your take-home point from doing the study and from the results? Absolutely. I would say the other thing that she didn't mention about the results are that this combination seemed to have worked better in patients with higher BMIs.

Okay. And so, you know, you say, well, yeah, it seems at least equivalent. And she also didn't talk about the fact that it was well-tolerated, but we didn't have a higher rate of multiples.

So important things to make us feel like it's a safe treatment and something that a lot of times people may be taking retrozole by the time they get to us. So we have something else to offer. Something to edge before saying IVF.

And, you know, I think it's just important to be, like I said, looking for alternatives to really invasive treatments and ovarian drilling. There are other things out there, but this is super easy and well-tolerated. That's fantastic.

My favorite part about this study is it's an inexpensive intervention and it's just one of those elegant, simple RCTs that's easy to understand and the outcomes actually matter. And I think it's important that ASRM is stepping in the gap to try to fund important research like this now that some of that RNN dollars and NIH dollars have dried up a little bit. Absolutely.

It's very appreciated. Yeah. Well, congratulations.

Thank you for sharing it with our listeners. We hope you submit this and publish it in Fertility and Sterility. We would love to read it there.

Thank you. Welcome back to Fertility and Sterility on Air. I'm Micah Hill, the media editor of FNS, and we are live at ASRM 2024 in Denver.

And I'm very excited to have Naval Medical Officer David Monroe with me. We're talking about the impact of embryo personhood status on IVF in Alabama. This is a cost-effectiveness analysis after the decision the Alabama Supreme Court made this year.

So, David, this is a fascinating topic, one I think all of our listeners want to hear about. Tell us why did you decide to do this study? What did you think was important about this? Absolutely. Thank you so much for having me.

It's such an honor to be here. You know, whenever we see something, whether it's an on-off switch that happens with a policy, that immediately starts our brain turning of possible cost-effectiveness analysis. So in this case where you had a statewide issue that caused the total lack of IVF accessibility immediately when the Supreme Court decision happened, that really got our gears turning, and we thought it was a really interesting opportunity to look at the policy impacts.

I love this idea. This is something I've thought about a lot, and some of my fellows are working on as well. So how did you decide to approach this from a methodologic standpoint? How did you design this study design? Absolutely.

It's a very complicated thing to study, as you're aware. We started by just building our model using the software that we had, and we just started with the initial path of there's one strategy where you have total access to IVF, and then another strategy where you had no access to IVF, and we looked at it starting from that point. And then we included three IVF cycles, up to three IVF cycles.

So after the first IVF cycle, if you weren't going up to three IVF cycles. And then the main difference between the two strategies was that if IVF wasn't accessible, there's some portion of women who would travel out of state to try to get IVF. And that's what we really tried to capture, because that's a huge generator of cost for that arm if IVF is not accessible.

Right. So you essentially used a decision tree analysis, went down those arms, and you used actual numbers from Alabama to model the cost on this, from the actual number of patients who were in clinics. Is that correct? Yes, we did.

Okay. Well, this is fantastic. Tell me what you found.

We're dying to know. Yeah, absolutely. So what was interesting was that it was actually cost-saving in our analysis to not have IVF services, which, you know, sounds jarring at first, but when you factor in the cost of IVF services, you factor in the cost of pregnancy.

So many more people were getting IVF services and getting pregnant, and then all the ensuing costs of delivery, and in the arm where IVF was accessible, versus in the arm where it wasn't accessible, there's a smaller portion of people who were able to achieve IVF, and that reduced costs. But if, I guess, if we used an analogy, if a state banned cancer care, they would save money. Exactly.

But there would be health repercussions as a result of that. That's exactly what we found. The quality of life was significantly reduced in a situation where Alabamans were not able to get IVF.

The impact of being infertile and then not being able to get infertility care to the extent that they needed, and then the utility of having to travel out of state, you know, the impact of having to take off work, having to find child care, having to get a hotel for the period of time when you're out of state and trying to get fertility care, that was all factored in as well. So quality of life was significantly reduced if we did not allow people to have IVF. Yeah, that's fascinating.

Is there anything else in the results that you think are important for the readership or next steps from a sort of advocacy standpoint? Yeah, absolutely. I think what was most interesting to me from our outcomes, what we looked at was we included what number of people would not end up with either a genetic or adopted child. Because that's really, you know, that's really the patient-centered outcome that we care about, that patients care about.

And we found that 580 fewer people would end up with either a genetic or an adopted child. And so that's significant. You know, people are not going to be ending up with the offspring that they're looking for.

Wow. That's a sobering thought. And that's just numbers from one of the smaller states in the U.S. You could imagine if that spread, what those numbers would look like.

Exactly. Well, I think this is fascinating data. I think this is helpful from an advocacy standpoint for us to use as we advocate to these legislatures across these states and to the U.S. Congress.

Absolutely. Well, congratulations. Thank you, sir, for doing this.

And thank you for your service. And we hope you publish this in Fertility and Sterility. I hope so, too.

Thank you so much for the opportunity. It's been great. Our pleasure.

Hi, it's Molly and Kate back again. And we are so excited to be interviewing Jordan O'Donnell, whose abstract is Evaluating Human Blastocyst Morphology and Polygenic Disease Risk Scores. Thanks for being here, Jordan.

Hi, thank you so much for having me. And where are you located? Where is your research out of? So it's out of Genomic Prediction, the company, but I actually collaborated with them for my thesis at UCL. So I actually live in the U.K. and it was kind of a UCL Genomics and Genomic Prediction collaboration.

Great. So can you tell us what was your clinical question? What were you trying to answer and how did you design your study to address that question? Yeah, so we based it off of the assumption that morphology-based embryo selection would be equivalent to random selection in terms of polygenic disease reduction. So our study question was to actually try and prove this assumption that has always been made.

So what we did was we collected our data from a single PGT center that had the data, the morphology data, and clinic-provided Gardner scores for all of the embryos. So we basically conducted our study based off of this data and tried to filter the data and see what outcomes we would get from it. So just to clarify, and sounds like a really exciting study, and I certainly have always assumed that morphology did not predict risk for disease in offspring.

So it's a great question. We want to confirm these beliefs that we hold. So you essentially looked at the morphologic grade of the embryo and associated it with the polygenic risk score, correct, and assessed whether there was any correlation? Yep, that's exactly right.

So we actually had to find a way to standardize the Gardner grades first because they came from numerous IVF clinics that have different ways and different Gardner grading systems. So we categorized the data into three variables in order to make it suitable for computational analysis, and then we compared it to the polygenic risk scores. Awesome.

So what were the three variables? So we categorized them into variables of high, medium, and low, where the low morphology clusters correlated to poor graded embryos, and the high cluster corresponded to the better graded embryos. And how are the polygenic risk score categories categorized as well? So we used a composite PRS algorithm that was developed in-house called the EHS, or the embryo health score, and that combines the risk predictors for multiple diseases, and it's run individually for each ancestry. So the aim of it is to, of course, like, simultaneously reduce the risk of multiple diseases.

So higher EHS values corresponds to better overall genetic health, or individuals at a lower risk of developing these diseases. Gotcha. And how did your standardized morphologic grading take into account the two-affected arm versus the inner cell mass versus both? I know from your presentation that you had some updated data, even since the abstract in the abstract book.

Yes. Yeah, no, that's a great question. So for this morphology clustering system, I worked with a team of embryologists, and we assumed equal weight between trifecta term quality and ICM quality due to papers that we read.

And, you know, of course, there's different papers that say they have different impacts on outcomes and everything. So we had to assume equal weight as we saw happen with other grading systems as well. Okay.

So not to steal the punchline here, but tell us, what did you find? Yes. So I think to most people's surprise, we actually found an inverse correlation between conventional morphology-based embryo selection and polygenic disease reduction. So we found that embryos graded with poorer morphology actually had higher overall genetic health values.

Higher overall genetic health values being correlated with more future clinical disease as how you would interpret the PDT score? So meaning that they were at a lesser risk of developing polygenic diseases. Wow. That's certainly surprising.

And was that true when you looked at the trifecta term and the inner cell mass together and separately? Yep. So we first analyzed all of them together and saw that it was the combined, the overall effect that was statistically significant. And then we looked at the individual embryo categories as well and found that the trifecta term development and the expansion status followed the same pattern of, you know, poor developed corresponding to a less risk of developing these diseases.

Individually, they were not statistically significant, but it was their combined effect that we found was with the bigger sample size. Gotcha. Okay.

Well, so at the end of the day, this is important work and it is also correlating one test with another test. So ultimately what we want to know about is the actual health of the child. Do you have any clinical data on how these embryos where we've correlated the trifecta term and inner cell mass with the polygenic risk score actually behave in terms of the health of the child? Yes, that's a great question.

Thank you. So of course, we don't have that data yet on clinical outcomes. The main point of PGTP was to, you know, provide more information of how to select the embryos and provide genetic counseling to make sure that the patients understand what the risk scores actually mean.

But for future studies, we are definitely looking into, you know, clinical outcomes, pregnancy outcomes, and how we can correlate the two of those. It even begs the question of testing characteristics and whether the polygenic risk production test is somehow affected by the type of biopsy or the expansion that you can take with a poor quality versus a better quality embryo. So definitely more research needed there to figure out that correlation a little better.

Yeah, we also looked at sample quality as well and see how to see how that was correlated, if that had any effect on the results that we were seeing, because, of course, we also weren't expecting these results. So we wanted to see, you know, could it have been sample quality? What could have led us to this? And we did find that poor sample quality had like correlated to poor morphology as well. So the higher polygenic risk scores.

Yeah, so the fact that we saw this inverse results kind of showed that our data results were strong enough to overcome that. Understood. One final question.

I know that there are some iterations of polygenic risk scoring that actually separate out individual diseases. Did you look at that at all? Were there any diseases that seemed more or less risk scores for those diseases, I should say, that seemed more or less correlated with morphology? Yes. Yeah, that's a great question as well.

So we did look at that. It was outside the scope of this particular study, especially in the case of a master's thesis. But we did look at it, and we're going to continue to evaluate it.

But we did find some specific diseases, such as coronary artery disease, type 2 diabetes. Those had a stronger impact on the poor developed morphology, actually. So we did look individually at each of the diseases.

Gotcha. So what do you think? If you have a strong family history for coronary artery disease, should you transfer your lowest morphology euploid? That's an interesting question. Yeah, I think, I mean, again, just to highlight the importance of genetic counseling, because that is, of course, it's up to the patient, right? If that's what they strongly believe that they want to be screening for, as long as they know what is coming out of it.

And it's just so such new research. It's just a preliminary study. So very hard to say, but... Yeah, I think that's a really important point.

Fascinating research and clinical data are forthcoming. Yep, yep, exactly. Thank you so much, Jordan.

Thank you. Thank you so much. I enjoyed this time.

Congratulations. This concludes our episode of Fertility and Sterility On Air, brought to you by the Fertility and Sterility Family of Journals in conjunction with the American Society for Reproductive Medicine. This podcast was developed by Fertility and Sterility and the American Society for Reproductive Medicine as an educational resource in service to its members and other practicing clinicians.

While the podcast reflects the views of the authors and the hosts, it is not intended to be the only approved standard of practice or to direct an exclusive course of treatment. The opinions expressed are those of the discussants and do not reflect Fertility and Sterility or the American Society for Reproductive Medicine.