The effect of laser-assisted hatching on pregnancy outcomes of cryopreserved-thawed embryo transfer: a meta-analysis of randomized controlled trials

Hyperelastic models for the human zona pellucida and their implications on shear modulus estimation in the clinical practice

It has long been speculated that the mechanical properties of the human oocyte can be an indicator for oocyte viability. Recent studies have demonstrated that embryo implantation rates, following Intra-Cytoplasmic Sperm Injection (ICSI) procedures, may be increased if the shear modulus value of the oocyte Zona Pellucida (ZP) is taken into consideration during embryo transfer. The shear modulus was determined by an iterative oocyte specific finite element (FE) analysis based on the clinical ICSI data. Nevertheless, the results obtained from the computational analysis may depend on the choice of the constitutive model used for the ZP. In the current study, three different hyper-elastic strain energy density functions (SEDF's) are considered. The Neo-Hookean (NH), Mooney-Rivlin (MR) and Ogden models (OG) were used to determine the ZP shear modulus from ICSI clinical data. The sensitivity of each SEDF in extracting the oocyte specific shear modulus is examined, for the first time. It is demonstrated that the NH and MR models are more sensitive than the OG model for determining the ZP shear modulus from clinical ICSI data. It is also demonstrated that the accuracy of ZP shear modulus identification process greatly depends on the value of suction pressure applied during the ICSI procedure.

Clinical and neonatal outcomes of complete zona pellucida removal by laser-assisted hatching after single vitrified-warmed blastocyst transfer

Laser-assisted hatching (LAH) is a widely used and unavoidable technique in assisted reproductive technology after frozen embryo transfer (FET). We aimed to investigate the safety and efficacy of completely ZP (zona pellucida) removed by an assisted laser group compared to an intact group after FET. This retrospective study involved 320 SVBT  single vitrified-warmed blastocyst transfers of 213 patients who underwent clomiphene citrate (CC) based minimal stimulation protocol. This study compared 160 SVBT with ZP that were completely removed using laser-assisted (laser beams of 10-15, a wavelength of 1.48 μm, and duration of 1.8-2.2 ms) to 160 cases of intact SVBT. Fisher's exact test, chi-squared test, and logistic regression are used for statistical analysis. The women's age, cause of infertility, BMI, transferred embryo day, insemination methods, and blastocyst grade were not significantly different between two groups. The implantation rate (66.2% vs. 51.2%, P < 0.01), the clinical pregnancy rate (CPR, 52.5% vs. 39.3%, P = 0.01), and the live birth rate (LBR, 43.7% vs. 29.3%, P < 0.01) were significantly higher in the completely ZP removed than the intact group. In logistic regression analysis, the laser-assisted hatching group showed about 2 times higher implantation rate and CPR and LBR than the control group. But miscarriage, gestational weeks, gender, birth weight, and twin births were insignificant between two groups. Our study suggests ZP free embryo transfer by assisted laser is more effective and safer than intact embryo transfer.

Diagnosis and management of infertility: NICE-adapted guidelines from the Italian Society of Human Reproduction

In Italy the fertility rate is very low, and an increasing number of patients are infertile and require treatments. The Italian Law concerning the safety of patient care, and the professional liability of health professionals, indicates that health professionals must comply with the recommendations set out in the guidelines developed by public and private bodies and institutions, as well as scientific societies and technical-scientific associations of the health professions, except for specific cases. Unfortunately, no guideline for the diagnosis and the management of infertility is currently available in Italy. In 2019, the Italian Society of Human Reproduction pointed out the need to produce Italian guidelines and subsequently approved the establishment of a multidisciplinary and multiprofessional working group (MMWG) to develop such a guideline. The MMWG was representative of 5 scientific societies, one national federation of professional orders, 3 citizens' and patients' associations, 5 professions (including lawyer, biologist, doctor, midwife, and psychologist), and 3 medical specialties (including medical genetics, obstetrics and gynecology, and urology). The MMWG chose to adapt a high-quality guideline to the Italian context instead of developing one from scratch. Using the Italian version of the Appraisal of Guidelines for Research and Evaluation II scoring system, the National Institute of Clinical Excellence guidelines were selected and adapted to the Italian context. The document was improved upon by incorporating comments and suggestions where needed. This study presents the process of adaptation and discusses the pros and cons of the often-neglected choice of adapting rather than developing new guidelines.

Stem-Cell-Derived Extracellular Vesicles: Unlocking New Possibilities for Treating Diminished Ovarian Reserve and Premature Ovarian Insufficiency

Despite advancements in assisted reproductive technology (ART), achieving successful pregnancy rates remains challenging. Diminished ovarian reserve and premature ovarian insufficiency hinder IVF success-about 20% of in vitro fertilization (IVF) patients face a poor prognosis due to a low response, leading to higher cancellations and reduced birth rates. In an attempt to address the issue of premature ovarian insufficiency (POI), we conducted systematic PubMed and Web of Science research, using keywords "stem cells", "extracellular vesicles", "premature ovarian insufficiency", "diminished ovarian reserve" and "exosomes". Amid the complex ovarian dynamics and challenges like POI, stem cell therapy and particularly the use of extracellular vesicles (EVs), a great potential is shown. EVs trigger paracrine mechanisms via microRNAs and bioactive molecules, suppressing apoptosis, stimulating angiogenesis and activating latent regenerative potential. Key microRNAs influence estrogen secretion, proliferation and apoptosis resistance. Extracellular vesicles present a lot of possibilities for treating infertility, and understanding their molecular mechanisms is crucial for maximizing EVs' therapeutic potential in addressing ovarian disorders and promoting reproductive health.

Oocyte and embryo cryopreservation in assisted reproductive technology: past achievements and current challenges

Cryopreservation has revolutionized the treatment of infertility and fertility preservation. This review summarizes the milestones that paved the way to the current routinary clinical implementation of this game-changing practice in assisted reproductive technology. Still, evidence to support "the best practice" in cryopreservation is controversial and several protocol adaptations exist that were described and compared here, such as cumulus-intact vs. cumulus-free oocyte cryopreservation, artificial collapse, assisted hatching, closed vs. open carriers, and others. A last matter of concern is whether cryostorage duration may impact oocyte/embryo competence, but the current body of evidence in this regard is reassuring. From social and clinical perspectives, oocyte and embryo cryopreservation has evolved from an afterthought when assisted reproduction was intended for immediate pregnancy with supernumerary embryos of secondary interest to its current purpose, which primarily is to preserve fertility long-term and more comprehensively allow for family planning. However, the initial consenting process, which still is geared to short-term fertility care, may no longer be relevant when the individuals that initially preserved the tissues have completed their reproductive journey. A more encompassing counseling model is required to address changing patient values over time.

Laser-assisted hatching improves pregnancy outcomes in frozen-thawed embryo transfer cycles of cleavage-stage embryos: a large retrospective cohort study with propensity score matching

INTRODUCTION

Laser-assisted hatching (LAH) is a commonly used adjunct technique; however, its effectiveness has not been fully established.

OBJECTIVE

We evaluated the effects of LAH on pregnancy outcomes in frozen-thawed embryo transfer (FET) cycles of cleavage-stage embryos.

MATERIALS AND METHODS

This retrospective study involved 5779 FET cycles performed at the Reproductive and Genetic Center in the Affiliated Hospital of Shandong University of Traditional Chinese Medicine between January 2016 and December 2020. After propensity score matching, 3535 FET cycles were included, out of which 1238 were subjected to LAH while the remaining 2297 cycles were non-LAH (NLAH). The primary outcomes were clinical pregnancy rate (CPR) and live birth rate (LBR) while secondary outcomes included implantation rate (IR), biochemical pregnancy rate (BPR), ectopic pregnancy rate (EPR), pregnancy loss rate (PLR), multiple pregnancy rate (MPL), and monozygotic twinning rate (MTR). Logistic regression analysis was conducted to adjust for possible confounders. Subgroup analysis was also performed based on the endometrial preparation regimen.

RESULTS

The LAH group exhibited a higher LBR, compared to the NLAH group (34.9% vs. 31.4%, OR = 1.185, 95% CI = 1.023, 1.374, P = 0.024). Additionally, the LAH group showed a decreasing trend in PLR and EPR; however, differences were insignificant (P = 0.078, P = 0.063 respectively). Differences in IR (24.6% vs. 24.3%), BPR (41.8% vs. 40.4%), CPR (40.7% vs. 38.3%), MPR (14.1% vs. 17.3%), and MTR (1.4% vs. 1.1%) were insignificant. Subgroup analysis revealed that LAH may be more conducive for pregnancy outcomes in hormone replacement cycles.

CONCLUSIONS

In summary, LAH has an increased chance of achieving live births. However, further prospective studies should be performed to confirm our findings.

Management of recurrent implantation failure: British Fertility Society policy and practice guideline

Recurrent implantation failure (RIF) is defined as the absence of a positive pregnancy test after three consecutive transfers of good quality embryos. There remains significant variation in clinical practice in the management of RIF. This British Fertility Society (BFS) Policy and Practice guideline analyses the evidence for investigations and therapies that are employed in RIF and provides recommendations for clinical practice and for further research. Evidence for investigations of sperm and egg quality, uterine and adnexal factors, immunological factors and thrombophilia, endocrine conditions and genetic factors and for associated therapies have been evaluated. This guideline has been devised to assist reproductive medicine specialists and patients in making shared decisions concerning management of RIF. Finally, suggestions for research towards improving understanding and management of RIF have also been provided.

The Impact of Assisted Hatching on Monozygotic Twinning is Related to Female Age and Insemination Method: A New Perspective

Whether assisted hatching (AH) is associated with a higher incidence of monozygotic twinning (MZT) in women undergoing assisted reproductive technology remains controversial; the aim of the study was to demonstrate the relationship between AH and MZT. A total of 8900 clinical pregnancies were selected among embryo transfer cycles from January 2011 to October 2019. Women receiving day (D) 3 embryos were divided into groups A-C: group A (n = 1651) and group B (n = 1045) included women aged ≤37 or ≥38 years, respectively, with zona pellucida (ZP) thinning; group C (n = 3865) included women aged ≤37 years without AH. Women aged ≤37 years who underwent blastocyst transfer and/or blastocyst ZP breaching were included in group D (n = 2339). The incidence of MZT was compared among groups A, B and C, and between groups C and D. The incidence of MZT in group B (2.2%) was significantly higher than in group A (1.0%), especially following intracytoplasmic sperm injection (ICSI), while the incidence of MZT in group A (1.0%) was significantly lower than in group C (2.2%). The MZT rate with in vitro fertilization was higher in group D (2.8%) than in group C (2.2%), but the MZT rate following ICSI was not significantly different between the two groups. ZP thinning of D3 embryos may increase the risk of MZT in older women (≥38 years), but decrease it in younger women (≤37 years). ZP breaching may be useful to reduce the incidence of MZT in ICSI-generated blastocysts.

The Current Practice of Assisted Hatching for Embryos in Fertility Centres: a General Survey

At present, there is no standardised protocol for assisted hatching (AH) and the field is beset with contradictory data. We hypothesised that such contradiction may be related to inconsistencies in clinical practice. This study aimed to investigate the application, preferences, and variations of AH in current clinical practice prior to embryo transfer (AHpET) and biopsy (AHpBP). An online voluntary survey, consisted of 25 questions regarding different aspects of AH, was circulated amongst different fertility centres via newsletters between October 2019 and March 2020. One-hundred twenty-nine different fertility centres participated in the survey. AHpBP was widely used (90.6% [48/53]) amongst these centres, especially for trophectoderm biopsy (92.2% [47/51]). In contrast, only 64.6% (73/113) of centres administrated AHpET; the application of AHpET was even lower in UK-based centres (36.6% [15/41]). Although laser pulses have become the predominant technique for AH, significant variation existed in the precise strategy. Zona pellucida (ZP) drilling was the main method for AHpBP, whilst both ZP drilling and ZP thinning were applied equally for AHpET. Furthermore, the ZP manipulation varied widely with regards to the size of the ZP opening and the extension of ZP thinning. This is the first representative survey relating to the current practice of AH. Laser-assisted AH is used extensively, especially for AHpBP. However, there is significant disparity in clinical practice across different centres. Future research should aim to create a standardised protocol for AH to help reduce the evident variation in clinical practice and investigate the true value of AH.

Comparison of the impact of laser-assisted hatching on fresh cleavage and blastocyst embryo transfer and association with pregnancy outcomes

Objective:

Assisted hatching (AH) techniques can improve live birth (LB) and clinical pregnancy (CP) rates. Since there are limited data regarding this subject, we investigated the impact of laser-assisted hatching (LAH) on fresh embryo transfer (ET) and association with pregnancy outcomes in unselected patient population.

Materials and Methods:

This retrospective study included the fresh ETs performed at our center between April 2010 and April 2019. Among 3.782 fresh ETs, 3.286 underwent LAH (n=1.583 at cleavage stage and n=1.703 at blastocyst stage) while 496 underwent non-assisted hatching (NAH) (n=213 at cleavage stage and n=283 at blastocyst stage). The ETs were performed at the blastocyst or cleavage stages, and single or double embryos were transferred. LB rate was the primary outcome, while secondary outcomes were the pregnancy test, monozygotic twinning (MZT), and CP rates.

Results:

The LAH and NAH groups showed similar LB, pregnancy test, CP, and MZT rates at cleavage and blastocyst stages. On the other hand, LAH significantly affected LB rates at the blastocyst stage (20.6% at blastocyst stage vs. 16% at the cleavage stage, p=0.001).

Conclusion:

In conclusion, LAH does not improve reproductive outcomes of fresh blastocyst-stage and cleavage-stage ETs. However, LAH significant impacts LB rates in the blastocyst stage than the cleavage stage.

The role of assisted hatching in in vitro fertilization: a guideline

There is moderate evidence that assisted hatching does not significantly improve live birth rates in fresh assisted reproductive technology cycles and insufficient evidence for the benefit of assisted hatching in patients with poor prognosis or undergoing frozen embryo transfer cycles. This document replaces the document of the same name published in 2014.

Live birth from a blastocyst derived from a conjoined oocyte in a frozen embryo transfer cycle: a case report and a literature review

The significance of conjoined oocytes in the clinical in vitro fertilization (IVF) laboratory setting has been questionable due to the extremely limited data available. This issue is discussed by presenting one case for conjoined oocyte observed in the program of the assisted reproduction and by including a review of corresponding literature. This report describes a successful clinical pregnancy with subsequent live birth from a conjoined oocyte. To our knowledge, there are only three reported cases of successful live birth from conjoined oocytes, but this is the first case of live birth from a blastocyst derived from a conjoined oocyte fertilized using intracytoplasmic sperm injection (ICSI) in a frozen embryo transfer cycle. Moreover, this study reports the first time that live birth of a conjoined oocyte is achieved without removing the degenerated immature oocyte prior to transfer. It demonstrates that the degenerated immature oocyte has no adverse effect on subsequent embryo development and pregnancy outcome. In addition, we reviewed the literature to evaluate the origin, incidence, safety, and significance of conjoined oocytes in reproductive health. We further confirm previous reports that demonstrate that a mature oocyte from conjoined-oocyte complexes can be fertilized by standard IVF or ICSI and lead to the development of a blastocyst, subsequent pregnancy, and live birth.

The efficacy of add-ons: selected IVF "add-on" procedures and future directions

Since the advent of ART, technology has continuously evolved to improve embryology and pregnancy outcomes. However, not all technologies that are integrated into practice have convincing evidence of clinical effectiveness, and they often increase the financial burden of fertility care. We discuss here a selection of commonly utilized IVF "add-ons" and discuss the existing evidence for their utility. The procedures included in this review are time-lapse imaging of embryos, assisted hatching, EmbryoGlue, sperm DNA testing, egg activation with calcium ionophore, endometrial receptivity array, and physiological intracytoplasmic sperm injection (PICSI). While there is rather limited supporting evidence for nearly all IVF add-ons that we reviewed, there is strong demand from patients, physicians, and the biotechnology industry to continue further research and development in this arena. We propose that all add-on procedures should provide true efficacy for the patient, and reproductive endocrinologists should inform patients of the costs and benefits of utilizing various technologies before they undergo treatment. In the future, add-ons that show clear evidence of efficacy and justifiable cost should be incorporated into routine practice, while others that do not meet these criteria should be phased out entirely.

Common practices among consistently high-performing in vitro fertilization programs in the United States: 10-year update

OBJECTIVE

To evaluate similarities and differences in clinical and laboratory practices among high-performing fertility clinics.

DESIGN

Cross-sectional questionnaire study of selected programs.

SETTING

Academic and private fertility practices performing in vitro fertilization (IVF).

PATIENT(S)

Not applicable.

INTERVENTION(S)

A comprehensive survey was conducted of 13 IVF programs performing at least 100 cycles a year and having high cumulative singleton delivery rates for 2 years.

MAIN OUTCOME MEASURE(S)

Clinical and laboratory IVF practices.

RESULT(S)

Although many areas of clinical practice varied among top programs, some commonalities were observed. All programs used a combination of follicle-stimulating hormone and luteinizing hormone for IVF stimulation, intramuscular progesterone in frozen embryo transfer cycles, ultrasound-guided embryo transfers, and a required semen analysis before starting the IVF cycle. Common laboratory practices included vitrification of embryos at the blastocyst stage, air quality control with positive air pressure and high-efficiency particulate air filtration, use of incubator gas filters, working on heated microscope stages, and incubating embryos in a low-oxygen environment, most often in benchtop incubators.

CONCLUSION(S)

Some areas of consistency in clinical and laboratory practices were noted among high-performing IVF programs that are likely contributing to their success. High-performing programs focused on singleton deliveries. As the field of IVF is rapidly evolving, it is imperative that we share best practices in an effort to improve outcomes from all clinics for the good of our patients.

Laser-assisted selection of immotile spermatozoa has no effect on obstetric and neonatal outcomes of TESA-ICSI pregnancies

BACKGROUND

Azoospermic patients have benefited from both epididymal and testicular spermatozoa intracytoplasmic sperm injection (ICSI) treatment and lasers have been used to identify viable, immotile spermatozoa before the procedure. There are limited studies on the safety of laser-assisted selection of immotile spermatozoa. The aim of this study was to investigate the impact of laser-assisted selection of immotile spermatozoa on the obstetric and neonatal outcomes after ICSI.

METHODS

A retrospective comparative study was conducted on outcomes of ICSI cycles with testicular spermatozoa from June 2014 to June 2018. Of 132 cycles, 33 were allocated to the test group and oocytes were injected with immotile spermatozoa selected by laser, 99 cycles were allocated as control group.

RESULTS

Compared with the control group, no significant differences were found in the pregnancy, implantation, miscarriage and live birth rates in the test group in either fresh or frozen transfer cycles. The cumulative live birth rate in the test group was 69.70%, which was slightly higher than in the control group (60.61%), but this was not statistically different. There were no differences in the average gestational age, premature birth rate, neonatal birth weight, and the malformation rate between the test and control groups (P > 0.05). In addition, the obstetric outcome between the two groups were not different (P > 0.05).

CONCLUSIONS

No negative effect on perinatal and neonatal outcomes was seen by using laser-assisted selection of immotile spermatozoa for TESA-ICSI. This study endorses the use of laser-assisted selection of viable spermatozoa for ICSI cycles.

Site specificity of blastocyst hatching significantly influences pregnancy outcomes in mice

Blastocysts hatch from the zona pellucida (ZP) to enable implantation into the uterine endometrial epithelium, but little is known regarding the effect of hatching sites on pregnancy outcomes. Murine hatching embryos were categorized into five groups based on initial trophectoderm projection (TEP)/ZP position corresponding to the inner cell mass center. In blastocysts (3.5 dpc) post-12 hours in vitro culture, TEP rates of A-site (44.4%) and B-site (38.6%) embryos were higher than those of C-site (12.5%) and D-site (3.1%) embryos, while the O-site (1.4%) was the lowest (P < .05). Post-ET A-site (55.6%) and B-site (65.6%) birth rates were higher than those of C-site embryos (21.3%) and controls (P < .05). Furthermore, live birth rate of B-site embryos remained higher than C-site embryos (68.8% vs 31.3%; P < .05) when both were transferred into the same recipients. Different TEP site blastocysts exhibited different implantation competences: the implantation rate of C-site embryos was lower than that of both A- and B-site groups (67.7% vs 84.3% and 83.2%, respectively; P < .05) at 2 days post-ET. C-site embryos also had a distinctly higher ratio of developmental defects (47.5%) than A- and B-site embryos (22.5% and 14.6%, respectively), with implantation failure mainly associated with poor birth rate, a finding corroborated by differential gene expression analysis such as LIF, LIFR, and S100a9. Surprisingly, acidified Tyrode's solution (AAH)-treated B-site blastocysts had a significantly increased birth rate (77.1%) than C-site (55.3%) and controls (43.4%). Site specificity and differential gene expression during embryo hatching can be applied in ART screening. More importantly, assisted hatching by AAH is effective and feasible for improving pregnancy and term development, particularly at the B-site, for humans and in animal husbandry.

Assisted hatching on assisted conception (in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI))

BACKGROUND

Failure of implantation and conception may result from inability of the blastocyst to escape from its outer coat, which is known as the zona pellucida. Artificial disruption of this coat is known as assisted hatching and has been proposed as a method for improving the success of assisted conception by facilitating embryo implantation.

OBJECTIVES

To determine effects of assisted hatching (AH) of embryos derived from assisted conception on live birth and multiple pregnancy rates.  SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility Group Specialised Register (until May 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; until May 2020), in the Cochrane Library; MEDLINE (1966 to May 2020); and Embase (1980 to May 2020). We also searched trial registers for ongoing and registered trials (http://www.clinicaltrials.gov - a service of the US National Institutes of Health; http://www.who.int/trialsearch/Default.aspx - The World Health Organization International Trials Registry Platform search portal) (May 2020).

SELECTION CRITERIA

Two review authors identified and independently screened trials. We included randomised controlled trials (RCTs) of AH (mechanical, chemical, or laser disruption of the zona pellucida before embryo replacement) versus no AH that reported live birth or clinical pregnancy data.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Two review authors independently performed quality assessments and data extraction.

MAIN RESULTS

We included 39 RCTs (7249 women). All reported clinical pregnancy data, including 2486 clinical pregnancies. Only 14 studies reported live birth data, with 834 live birth events. The quality of evidence ranged from very low to low. The main limitations were serious risk of bias associated with poor reporting of study methods, inconsistency, imprecision, and publication bias. Five trials are currently ongoing. We are uncertain whether assisted hatching improved live birth rates compared to no assisted hatching (odds ratio (OR) 1.09, 95% confidence interval (CI) 0.92 to 1.29; 14 RCTs, N = 2849; I² = 20%; low-quality evidence). This analysis suggests that if the live birth rate in women not using assisted hatching is about 28%, the rate in those using assisted hatching will be between 27% and 34%. Analysis of multiple pregnancy rates per woman showed that in women who were randomised to AH compared with women randomised to no AH, there may have been a slight increase in multiple pregnancy rates (OR 1.38, 95% CI 1.13 to 1.68; 18 RCTs, N = 4308; I² = 48%; low-quality evidence). This suggests that if the multiple pregnancy rate in women not using assisted hatching is about 9%, the rate in those using assisted hatching will be between 10% and 14%. When all of the included studies (39) are pooled, the clinical pregnancy rate in women who underwent AH may improve slightly in comparison to no AH (OR 1.20, 95% CI 1.09 to 1.33; 39 RCTs, N = 7249; I² = 55%; low-quality evidence). However, when a random-effects model is used due to high heterogeneity, there may be little to no difference in clinical pregnancy rate (P = 0.04). All 14 RCTs that reported live birth rates also reported clinical pregnancy rates, and analysis of these studies illustrates that AH may make little to no difference in clinical pregnancy rates when compared to no AH (OR 1.07, 95% CI 0.92 to 1.25; 14 RCTs, N = 2848; I² = 45%). We are uncertain about whether AH affects miscarriage rates due to the quality of the evidence (OR 1.13, 95% CI 0.82 to 1.56; 17 RCTs, N = 2810; I² = 0%; very low-quality evidence).

AUTHORS' CONCLUSIONS

This update suggests that we are uncertain of the effects of assisted hatching (AH) on live birth rates. AH may lead to increased risk of multiple pregnancy. The risks of complications associated with multiple pregnancy may be increased without evidence to demonstrate an increase in live birth rate, warranting careful consideration of the routine use of AH for couples undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). AH may offer a slightly increased chance of achieving a clinical pregnancy, but data quality was of low grade. We are uncertain about whether AH influences miscarriage rates.

IVF add-ons in Australia and New Zealand: A systematic assessment of IVF clinic websites

BACKGROUND

In vitro fertilisation (IVF) 'add-ons' are extra (non-essential) procedures, techniques or medicines, which usually claim to increase the chance of a successful IVF outcome. Use of IVF add-ons is believed to be widespread in many settings; however, information about add-on availability in Australasia is lacking.

AIMS

To understand which add-ons are advertised on Australasian IVF clinic websites, and what is the evidence for their benefit.

MATERIALS AND METHODS

A systematic assessment of website content was undertaken between December 2019-April 2020, capturing IVF add-ons advertised, including costs, claims of benefit, statements of risk or limitations, and evidence of effectiveness for improving live birth and pregnancy. A literature review assessed the strength and quality of evidence for each add-on.

RESULTS

Of the 40 included IVF clinics websites, 31 (78%) listed one or more IVF add-ons. A total of 21 different add-ons or add-on groups were identified, the most common being preimplantation genetic testing for aneuploidies (offered by 63% of clinics), time-lapse systems (33%) and assisted hatching (28%). In most cases (77%), descriptions of the IVF add-ons were accompanied by claims of benefit. Most claims (90%) were not quantified and very few referenced scientific publications to support the claims (9.8%). None of the add-ons were supported by high-quality evidence of benefit for pregnancy or live birth rates. The cost of IVF add-ons varied from $0 to $3700 (AUD/NZD).

CONCLUSIONS

There is widespread advertising of add-ons on IVF clinic websites, which report benefits for add-ons that are not supported by high-quality evidence.

Definition and Multiple Factors of Recurrent Spontaneous Abortion

Recurrent spontaneous abortion (RSA) is usually defined as three or more spontaneous abortions prior to 20-28 weeks gestation. RSA affects approximately 2-5% of all women of childbearing age, and it brings tremendous psychological and psychiatric trauma to the women and also results in economic burden. The causes could be female age, anatomical and chromosomal abnormalities, genetic, endocrinological, placental anomalies, infection, smoking and alcohol consumption, psychological factor, exposure to environmental factors such as heavy metal, environment pollution, and radiation.

Strategies to reduce multiple pregnancies during medically assisted reproduction

Multiple birth rates after fertility treatment are still high in many countries. Multiple births are associated with increased rates of preterm birth and low birth weight babies, in turn increasing the risk of severe morbidity for the children. The multiple birth rates vary in different countries between 2% and 3% and up to 30% in some settings. Elective single-embryo transfer, particularly in combination with frozen-embryo transfer and milder stimulation in ovulation induction/intrauterine insemination, to avoid multifollicular development is an effective strategy to decrease the multiple birth rates while still achieving acceptable live-birth rates. Although this procedure is used successfully in many countries, it ought to be implemented broadly to improve the health of the children. One at a time should be the normal routine.

ALADDIN study: does assisted hatching of vitrified/warmed blastocysts improve live birth rate? Protocol for a multicentric randomised controlled trial

INTRODUCTION

Recent data suggest a higher clinical pregnancy rate performing assisted hatching (AH) on previously cryopreserved embryos but fail to demonstrate significant effects on live birth rate. However, current evidence is based on studies with a small sample size and may hide a type II error. Moreover, poor attention has been given to the specific effect of AH on frozen/thawed blastocysts. To shed light on this topic, we developed the present protocol for a randomised trial to investigate the benefits of the laser-mediated partial removal of the zona pellucida in vitrified/warmed blastocysts.

METHODS AND ANALYSIS

The pArtiaL zonA pelluciDa removal by assisteD hatchINg of blastocysts (ALADDIN) study is a multicentric prospective comparative study with a parallel randomised controlled design aiming to investigate whether AH performed on warmed blastocysts before embryo transfer can improve live birth rate. Women allocated to the control group will undergo embryo transfer of blastocysts not previously subjected to AH. Two infertility units will be involved in the study. Enrolment of patients will last 18 months with quarterly monitoring and the entire study is foreseen to be closed in 36 months. Secondary outcomes include: proportion of transferred blastocysts/thawed blastocyst, morphological features of blastocysts before embryo transfer, implantation, biochemical pregnancy, clinical pregnancy (ultrasound visible gestational sac), miscarriage, multiple pregnancy, preterm birth (<37 weeks of gestation), obstetrical and neonatal complications and congenital anomaly rates.

ETHICS AND DISSEMINATION

This protocol received a favourable ethical opinion from the Ethical Committee of IRCCS San Raffaele Scientific Institute and the Ethical Committee Area 2 Milan. Each participant will provide written consent to participate and remain encoded during the study. The trial results will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT03623659; Pre-results.

Expansion and herniation: evaluation of the best pregnancy rate predictor after quarter laser assisted hatching in frozen blastocyst transfers

Objective

To assess the recovery of thawed blastocysts submitted to quarter laser assisted hatching and examine potential correlations between the procedure and pregnancy rates.

Methods

This cross-sectional study included only single-blastocyst transfers performed from July 2017 to December 2018. A total of 765 blastocysts were thawed and immediately submitted to quarter laser assisted hatching in the zona pellucida; they were subsequently incubated for three hours until transfer time, at which time they were examined for collapse or expansion; expanded blastocysts were further evaluated for herniation. The Chi-square test was used in statistical analysis.

Results

627 blastocysts expanded (81.9%) and yielded a pregnancy rate of 40% (251/627). 138 blastocysts collapsed after thawing (18.0%) and yielded a pregnancy rate of 25.4% (35/138) (p=0.001). Additional analysis of the subgroup of expanded blastocysts revealed that the 385 herniated blastocysts (61.4%) yielded a pregnancy rate of 43.9% (169/385). The remaining 242 non-herniated blastocysts (38.6%) yielded a pregnancy rate of 33.9% (82/242) (p=0.013). Statistical significance was attributed to events with a p<0.05.

Conclusion

Quarter laser assisted hatching is a safe, valid, and relatively easy-to-use procedure for thawed blastocysts. Blastocysts that expanded and herniated after quarter laser assisted hatching presented statistically superior results.

Minimally Invasive Cell-Free Human Embryo Aneuploidy Testing (miPGT-A) Utilizing Combined Spent Embryo Culture Medium and Blastocoel Fluid -Towards Development of a Clinical Assay

Preimplantation genetic testing for aneuploidies (PGT-A) using trophectoderm (TE) biopsy samples is labour intensive, invasive, and subject to sampling bias. In this study, we report on the efficacy and factors affecting accuracy of a technique we pioneered for minimally invasive preimplantation genetic testing for aneuploidy (miPGT-A). Our technique uses cell-free embryonic DNA (cfeDNA) in spent embryo culture medium (SEM) combined with blastocoel fluid (BF) to increase the amount of assayable cfeDNA. We compared miPGT-A results (n = 145 embryos) with standard PGT-A analysis of the corresponding trophectoderm biopsy. We found that accuracy of miPGT was not related to blastocyst morphological grade. The overall concordance rate per sample for euploidy/aneuploidy status between miPGT-A and TE biopsy samples was 88/90 (97.8%), and was not different between good 47/48 (97.9%) and moderate/low quality blastocysts 41/42 (97.9%) (p > 0.05). Importantly, we also discovered that for cfeDNA analysis, the SurePlex whole genome amplification (WGA) kit can be utilized without an additional cell lysis/extraction DNA step; this efficiency likely reduces the risk of maternal contamination. Regarding origin of embryonic cfeDNA, the average amount of miPGT-A WGA-DNA we obtained from blastocysts with different morphological grades, as well as the size miPGT-A WGA-DNA fragments, suggest that it is unlikely that apoptosis and necrosis are only mechanisms of DNA release from the inner cell mass (ICM) and TE into BF and SEM.

Higher implantation and live birth rates with laser zona pellucida breaching than thinning in single frozen-thawed blastocyst transfer

While zona pellucida (ZP) breaching of day-3 frozen blastocysts embryos can increase the blastocyst hatching rate, compared with ZP thinning, the pregnancy and implantation rates are similar. The aim of this study was to compare pregnancy outcomes and the risks associated with frozen-thawed blastocysts between laser ZP breaching and laser ZP thinning. For the thinning group, ZP of thawed blastocyst was thinned to a length of 30-40 μm using laser between January 2013 and October 2015. On the other hand, for the breaching group, thawed blastocysts were breached with a 60-80 μm hole in the ZP using laser between November 2015 and April 2018. The implantation rate of ZP breaching (72.7%) was higher than that of ZP thinning (61.8%). In single frozen blastocyst transfer, the implantation rate, clinical pregnancy rate, and live birth rate of ZP breaching (73.9%, 73.9%, 61.8%, respectively) were significantly higher than those of ZP thinning (60.9%, 60.9%, 46.7%, respectively). The abortion rate, preterm birth rate, congenital malformation, birth defects, and birth weight did not significantly differ between the two groups. In conclusion, laser assisted hatching during single frozen blastocyst transfer using ZP breaching exhibit higher implantation, pregnancy, and live birth rates compared with ZP thinning. No significant differences were observed between the two assisted hatching methods in terms of adverse effects on pregnancy and newborns.

Assisted Hatching in Couples with Advanced Maternal Age: A Systematic Review and Meta-analysis

This systematic review aimed to evaluate the efficacy and safety of assisted hatching (AH) performed in couples with advanced maternal age. We searched for randomized controlled trials (RCTs) in electronic databases, including MEDLINE, EMBASE and CENTRAL (from inception to January 2018); in addition, we hand-searched the reference lists of included studies and similar reviews. We included RCTs comparing AH versus no treatment (control). The meta-analysis was performed by RevMan 5.3 software. The search retrieved 943 records and 8 RCTs were included, comprising 870 cycles (n=440 for AH, and n=430 for control). There was no significant difference in the rates of live birth (RR 0.88, 95% CI 0.65 to 1.18, 3 RCTs, n=427, I²=0%), clinical pregnancy (RR 1.00, 95% CI 0.83 to 1.19, 8 RCTs, n=870, I²=22%), implantation (RR 1.07, 95% CI 0.83 to 1.39, 4 RCTs, n=1359, I²=0%), miscarriage (RR 1.13, 95% CI 0.66 to 1.94, 2 RCTs, n=116, I²=0%) and multiple pregnancy (RR 0.89, 95% CI 0.31 to 2.52, 1 RCT, n=97, I²=not applicable) between the treatment group and control group. No reasonable conclusions could be drawn regarding reproductive outcomes after AH in patients with advanced maternal age due to the small sample pooled in meta-analyses. Studies of high methodological quality and with adequate power are necessary to further investigate the value of AH in assisted conception of those patients.

Revisiting embryo assisted hatching approaches: a systematic review of the current protocols

Zona pellucida (ZP) manipulation, termed "assisted hatching" (AH), has been introduced in order to favor embryo hatching and ultimately improve assisted reproductive technology success but with poor proofs of safety and biological plausibility. We herein provide a systematic review of clinical outcomes following the application of different methods of ZP manipulation on fresh or frozen/thawed embryos at different developmental stages in different groups of patients. Out of the 69 papers that compared the clinical outcomes deriving from hatched versus non-hatched embryos, only 11 considered blastocysts while the rest referred to cleavage stage embryos. The ZP thinning of fresh embryos either by chemical or laser approach was shown to provide very limited benefit in terms of clinical outcomes. Better results were observed with procedures implying a higher degree of zona manipulation, including zona removal. Studies comparing the mechanical or chemical procedures to those laser-mediated consistently reported a superiority of the latter ones over the former. Literature is consistent for a benefit of ZP breaching in thawed blastocysts. This review provides the current knowledge on the AH procedure in order to improve its efficacy in the appropriate context. Embryologists might benefit from the approaches presented herein in order to improve Assisted Reproduction Technologies (ART) outcomes.