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Objective To determine optimal infertility therapy in women at the end of their reproductive potential. Design Randomized clinical trial. Setting Academic medical centers and private infertility center in a state with mandated insurance coverage. Patients Couples with ≥ 6 months of unexplained infertility; female partner aged 38–42. Interventions Randomized to treatment with 2 cycles of clomiphene citrate (CC) and intrauterine insemination (IUI), follicle stimulating hormone (FSH)/IUI, or immediate IVF, followed by IVF if not pregnant. Main Outcome Measures Proportion with a clinically recognized pregnancy, number of treatment cycles, and time to conception after 2 treatment cycles and at the end of treatment. Results 154 couples were randomized to receive CC/IUI (N=51), FSH/IUI (N=52), or immediate IVF (N=51); 140 (90.9%) couples initiated treatment. Cumulative clinical pregnancy rates per couple after the first 2 cycles of CC/IUI, FSH/IUI, or immediate IVF were 21.6%, 17.3%, and 49.0%, respectively. After all treatment, 71.4% (110/154) of couples conceived a clinically recognized pregnancy and 46.1% delivered at least one live-born baby. 84.2% of all live born infants resulting from treatment were achieved from IVF. There were 36% fewer treatment cycles in the IVF arm compared to either COH/IUI arm and couples conceived a pregnancy leading to a live birth after fewer treatment cycles. Conclusions An RCT to compare treatment initiated with 2 cycles of COH/IUI to immediate IVF in older women with unexplained infertility demonstrated superior pregnancy rates with fewer treatment cycles in the immediate IVF group.

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Objective To systematically review the reporting of race/ethnicity in SART Clinic Outcome Reporting System (CORS) publications. Design Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology of literature published in PUBMED on race/ethnicity that includes data from SART CORS. Setting Systematic review was performed on behalf of the ASRM Health Disparities Special Interest Group. Population IVF cycles reported to SART Exposure Race/ethnicity Main Outcome Measure Any outcomes reported in SART CORS Results Seven publications were identified that assessed racial/ethnic disparities in IVF outcomes using SART data. All reported a racial/ethnic disparity. However, over 35% of cycles were excluded from analysis because of missing race/ethnicity data. Conclusions Review of current publications of SART data suggests significant racial/ethnic disparities in IVF outcomes. However, the potential for selection bias limits confidence in these findings given that fewer than 65% of SART reported cycles include race/ethnicity. Our understanding of how race/ethnicity influences ART outcome could be greatly improved if information on race/ethnicity was available for all reported cycles.

The data suggest that FMR1 premutations and intermediate alleles are increased in women with occult POI. Thus, FMR1 testing should be performed in these women as some will have fragileX-associated POI. Although the FMR1 repeat lengths were longer in women with occult POI, the data do not support the use of a repeat length cutoff to predict occult POI.

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Synopsis Sexuality is an important component in the lives of menopausal women. The addition of phosphodiesterase type 5 inhibitors for the treatment of male erectile dysfunction in combination with longer life expectancy has impacted attitudes and expectations to maintain sexual functioning. Despite the importance of sexual function in menopausal women, sexual dysfunction increases with age. Age-related decline in sexual function may significantly reduce quality of life, making recognition of sexual dysfunction by physicians important for getting menopausal women effective care. Sexual dysfunction can result from multiple etiologies including psychosocial factors, medication side effects, vulvovaginal atrophy, chronic illness, or hypoactive sexual desire disorder (HSDD). Discovering the etiology and identifying modifiable factors of the sexual function will help define appropriate treatment.

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