The sex ratio of singleton offspring in assisted-conception pregnancies

Nonpronuclear- and Monopronuclear-derived Blastocysts Do Not Impair Subsequent Perinatal and Maternal Outcomes

CONTEXT

The routine clinical practice is to prioritize the transfer of blastocysts derived from 2 pronuclei (2PN) embryos if they are available. For women who only have blastocysts resulting from nonpronuclear (0PN) and monopronuclear (1PN) embryos, whether to transfer these embryos or discard them has been an ongoing debate over the years.

OBJECTIVE

To investigate the perinatal and obstetric outcomes following the transfer of vitrified-warmed single blastocysts derived from 0PN and 1PN zygotes.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated in vitro fertilization center.

PATIENT(S)

This study included singletons born to women who had undergone 0PN and 1PN vitrified-warmed single blastocyst transfers, compared to those resulting from 2PN vitrified-warmed single blastocyst transfers from 2012 to 2021.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Perinatal and obstetric outcomes.

RESULT(S)

A total of 7284 women were included in the final analysis. Of these, 386, 316, and 6582 cycles resulted from 0PN-, 1PN-, and 2PN-derived blastocysts transfer, respectively. The rates of clinical pregnancy, miscarriage, and live birth were similar across the study cohorts in both unadjusted and adjusted analyses. When comparing the 0PN and 2PN groups, no differences were found in birth outcomes after adjusting for confounders. Similarly, maternal complications and mode of delivery were comparable between these 2 study cohorts. Birth parameters were also similar between the 1PN and 2PN blastocyst groups, except for more male births in the 1PN cohort. Furthermore, a comparison between the 1PN and 2PN groups did not reveal any significant differences in maternal outcomes.

CONCLUSION

The current study showed that the transfer of 0PN and 1PN blastocysts did not compromise reproductive outcomes or increase maternal and perinatal complications. This information is valuable for clinicians to counsel couples effectively and guide them in making informed decisions.

The Effect of Assisted Reproductive Technologies on Human Sex Ratios

BACKGROUND

Modern assisted reproductive technology (ART), including pre-implantation genetic testing for aneuploidy (PGT-A), has opened new avenues in understanding early embryonic events and has simultaneously raised questions about the impact of ART itself on sex ratios.

AIMS

The primary aim was to investigate whether patient demographic characteristics, ovarian stimulation protocols or laboratory characteristics in ART influence sex ratios. The secondary aim was to relate the blastocyst sex ratio (BSR) to the corresponding secondary sex ratio (SSR) in our patient cohort.

MATERIALS AND METHODS

We conducted a retrospective single-centre cohort study on consecutive PGT-A cycles from January 2019 to February 2022. We analysed demographic data, stimulation protocols, laboratory characteristics and pregnancy outcomes.

RESULTS

The euploidy rate was 45.1% (2608/5777), BSR 1.07 and euploid BSR 1.03. There was no statistical difference in the ploidy status of XX and XY blastocysts and on multivariate logistic regression analysis, there was no association between euploidy and BSR or any other variables examined, including female age and stimulation protocol. The SSR was 1.02 (1294 embryo transfers) with no statistical difference in biochemical pregnancy (p = 0.41), clinical pregnancy (p = 0.56), miscarriage (p = 0.65) or live birth rates (p = 0.40) based on embryo sex.

CONCLUSIONS

Our study indicates that the euploid BSR is not skewed by sex, and there is no relationship between BSR and euploidy, patient characteristics or stimulation protocols. Pregnancy outcomes did not vary by sex, and the SSR was consistent with the SSR of the general Australian population at birth.

The TLI system can help day-3 single cleavage embryo transfer to obtain comparative clinical outcomes to day-4 or day-5

The aim was to explore whether the time-lapse imaging system can help day-3 single cleavage embryo transfer to obtain comparative clinical outcomes to day-4 or 5. The data of 1237 patients who underwent single embryo transfer from January 1, 2018, to September 30, 2020, in our reproductive medicine centre were retrospectively analysed. They were divided into the day-3 single cleavage-stage embryo transfer (SCT) group (n = 357), day-4 single morula transfer (SMT) group (n = 129) and day-5 single blastocyst transfer (SBT) group (n = 751) according to the different embryo transfer stage. The clinical and perinatal outcomes of the three groups were analysed and compared. The clinical pregnancy rates of the patients in the day-3 SCT group, day-4 SMT group and day-5 SBT group were 68.07, 70.54 and 72.04%, respectively. The live birth rates were 56.86, 61.24 and 60.99%, respectively. The monozygotic twin (MZT) rate in the day-3 SCT group was significantly lower than that in the day-5 SBT group (P = 0.049). Regarding perinatal outcomes, only the secondary sex ratio had a significant difference (P < 0.05). After age stratification, no improvement was found in the pregnancy outcomes of patients >35 years of age receiving blastocyst transfer. Our findings suggest that for patients with multiple high-quality embryos on day-3, prolonging the culture time can improve the pregnancy outcome to some extent, but it will bring risks. For centres that have established morphodynamic models, day-3 SCT can also achieve an ideal pregnancy outcome and reduce the rate of monozygotic twins and sex ratio.

Pregnancy outcomes of monochorionic diamniotic and dichorionic diamniotic twin pregnancies conceived by assisted reproductive technology and conceived naturally: a study based on chorionic comparison

OBJECTIVE

To evaluate monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin pregnancies conceived by assisted reproductive technology (ART) and conceived naturally.

METHODS

We retrospectively analyzed the data on twin pregnancies conceived by ART from January 2015 to January 2022,and compared pregnancy outcomes of MCDA and DCDA twins conceived by ART with those of MCDA and DCDA twins conceived naturally, pregnancy outcomes between MCDA and DCDA twins conceived by ART, and pregnancy outcomes of DCT and TCT pregnancies reduced to DCDA pregnancies with those of DCDA pregnancies conceived naturally.

RESULT

MCDA pregnancies conceived by ART accounted for 4.21% of the total pregnancies conceived by ART and 43.81% of the total MCDA pregnancies. DCDA pregnancies conceived by ART accounted for 95.79% of the total pregnancies conceived by ART and 93.26% of the total DCDA pregnancies. Women with MCDA pregnancies conceived by ART had a higher premature delivery rate, lower neonatal weights, a higher placenta previa rate, and a lower twin survival rate than those with MCDA pregnancies conceived naturally (all p < 0.05). Women with DCDA pregnancies conceived naturally had lower rates of preterm birth, higher neonatal weights, and higher twin survival rates than women with DCDA pregnancies conceived by ART and those with DCT and TCT pregnancies reduced to DCDA pregnancies (all p < 0.05).

CONCLUSION

Our study confirms that the pregnancy outcomes of MCDA pregnancies conceived by ART are worse than those of MCDA pregnancies conceived naturally. Similarly, the pregnancy outcomes of naturally-conceived DCDA pregnancies are better than those of DCDA pregnancies conceived by ART and DCT and TCT pregnancies reduced to DCDA pregnancies.

Sex ratio shift after frozen single blastocyst transfer in relation to blastocyst morphology parameters

The sex ratio shift was observed in peoples who underwent ART treatment. Moreover, there is limited evidence on differences in sex ratio between single frozen-thawed blastocyst morphology, insemination type and transfer days. So further research is needed in this area with regard to factors possibly affecting the sex ratio. Retrospective study based on multicenter including two large assisted reproduction centers in Shanghai and Wuhan in China. A total of 6361 singleton delivery offspring after frozen-thawed blastocyst transfer. Propensity score weighting and logistic regression models were used to estimate the associations between blastocyst morphology grading and child sex ratio. The main outcome measures is singleton sex ratio. In our study, the primary outcome measure was sex ratio which was calculated as the proportion of male newborns among all live births. Higher quality blastocysts resulted in a higher sex ratio than single poor-quality frozen-thawed blastocyst transfer. Among the three blastocyst morphological parameters of trophectoderm (TE), Grade A and B were significantly associated with a higher sex ratio than Grade C. The similar trend was observed in both IVF and ICSI treated subgroups. As compared with expansion (4 + 3), expansion degree 6 achieved a higher sex ratio in overall populations and IVF treated subgroup. Transferring blastocysts of day 6 had the highest sex ratio both in IVF group and ICSI group. A 6.95% higher sex ratio in transferring blastocysts of day 5 in IVF group than those in ICSI group. No significant association between inner cell mass degree and sex ratio was observed. However, as compared with IVF treatment, all morphology parameters achieved the similar or the biased sex ratio favoring female in ICSI treated subgroup. Quality of blastocysts was positively associated with sex ratio. TE score and expansion degree rather than ICM were significantly associated with sex ratio at birth. ICSI treatment promotes the biased sex ratio favoring female.

Assisted reproductive technology induces different secondary sex ratio: parental and embryonic impacts

BACKGROUND

Assisted reproduction technology (ART) has advanced significantly, raising concerns regarding its impact on the secondary sex ratio (SSR), which is the sex ratio at birth in offspring. This study aimed to explore factors affecting SSR in singletons, singletons from twin gestation, and twins from twin gestation within the context of ART.

METHODS

A retrospective analysis was conducted on data from 8335 births involving 6,223 couples undergoing ART. Binary logistic regression assessed relationships between parental and embryonic factors and SSR in singletons and singletons from twin gestation. Multinomial logistic regression models were utilized to identify factors influencing SSR in twins from twin gestation.

RESULTS

Secondary infertility (OR = 1.164, 95% CI: 1.009-1.342), advanced paternal age (OR = 1.261, 95% CI: 1.038-1.534), and blastocyst embryo transfer (OR = 1.339, 95% CI: 1.030-1.742) were associated with an increased SSR, while frozen embryo transfer (FET) showed a negative association with SSR (OR = 0.738, 95% CI: 0.597-0.912) in singletons. A longer duration of gonadotropin (Gn) usage reduced SSR in singletons (OR = 0.961, 95% CI: 0.932-0.990) and singletons from twin gestation (OR = 0.906, 95% CI: 0.838-0.980). In singletons from twin gestation, male-induced infertility (OR = 2.208, 95% CI: 1.120-4.348) and higher Gn dosage (OR = 1.250, 95% CI: 1.010-1.548) were significantly associated with an increased SSR. Women aged > 35 years and intracytoplasmic sperm injection (ICSI) were associated with lower SSR (OR = 0.539, 95% CI: 0.293-0.990 and OR = 0.331, 95% CI: 0.158-0.690, respectively). In twins from twin gestation, paternal age exceeded maternal age (OR = 0.682, 95% CI: 0.492-0.945) and higher Gn dosage (OR = 0.837, 95% CI: 0.715-0.980) were associated with a higher proportion of male twins. Cleavage stage transfer (OR = 1.754, 95% CI: 1.133-2.716) resulted in a higher percentage of boy-girl twins compared to blastocyst transfer.

CONCLUSION

This study demonstrates the complex interplay of various factors in determining the SSR in ART, highlighting the importance of considering infertility type, paternal age, fertilization method, embryo transfer stage, and Gn use duration when assessing SSR. Nevertheless, further research with a large sample size is necessary to confirm and expand upon the findings of this study.

Effect of blastocyst quality on human sex ratio at birth in a single blastocyst frozen thawed embryo transfer cycle

RESEARCH QUESTION

To determine whether blastocyst quality affects the sex ratio at birth through a single blastocyst frozen - thawed embryo transfer (SBFET) cycle.

DESIGN

In this retrospective analysis, we examined 3,041 singleton infants born following SBFET between 2017 and 2020 at a single institution. We compared the sex ratios of these infants with respect to the blastocyst quality, embryo growth rate, and morphology.

RESULTS

The main outcomes of this study were that the sex ratio (M/F) at birth of SBFET was 1.24. Mothers >40 years old had a considerably lower sex ratio than mothers <40 years old (0.39 vs. 1.23-1.28, p < .05). Transplanting high-quality blastocysts significantly increased the proportion of boys born (1.29 vs. 0.88, p < .05). There were no significant differences in the sex ratio with respect to the inner cell mass (ICM) score and expansion degree. Additionally, a high trophoblastic cell (TE) score resulted in a significantly higher sex ratio than the TE score with C (1.62 vs. 1.15 vs. 0.85, p < .001). Multivariable logistic regression analysis was performed to determine which variables were significant factors affecting sex ratio, and the outcomes were consistent with previous findings.

CONCLUSIONS

Our study indicated that high-quality, especially good TE score, had a higher chance of resulting in a male infant than a female infant.

Factors affecting male-to-female ratio at birth in frozen-thawed embryo transfer cycles: a large retrospective cohort study

Background

ICSI (intracytoplasmic sperm injection) leads to a reduced male-to-female ratio at birth, whereas blastocyst transfer results in an increased male-to-female ratio. However, limited knowledge exists regarding the impact of these factors on the live birth rate for each gender. This study aimed to investigate the influence of patient characteristics and treatment parameters on the live birth rate for each gender, as well as the ultimate male-to-female ratio at birth in frozen-thawed embryo transfer (FET) cycles.

Method

This retrospective cohort study involved a total of 28,376 FET cycles and 9,217 subsequent deliveries, spanning from January 2003 to December 2015. The study consisted of two parts. First, logistic regression models were constructed to determine the factors influencing the male-to-female ratio among babies born after FET. Second, we aimed to investigate the mechanisms underlying this sex ratio imbalance by analyzing data from all transfer cycles. Generalized estimated equations were employed to assess the impact of risk factors on rates of male and female live births separately.

Results

ICSI resulted in a lower proportion of male offspring compared to in vitro fertilization (IVF) (50.1% vs. 53.7%, aOR: 0.87, 95% CI: 0.80-0.96). Conversely, blastocyst transfer yielded a higher proportion of male offspring than cleavage-stage embryo transfer (58.7% vs. 51.6%, aOR: 1.32, 95% CI: 1.17-1.48). Analysis of all cycles indicated that ICSI resulted in a reduced likelihood of male live birth in comparison to IVF (19.8% vs. 21.6%, aOR: 0.90, 95% CI: 0.83-0.97). However, the transfer of blastocysts rather than cleavage-stage embryos not only increased the chance of male live birth (26.9% vs. 20.2%, aOR: 1.70, 95% CI:1.56-1.85) but also facilitated female live birth (20.3% vs. 19.3%, aOR: 1.26, 95% CI: 1.15-1.39).

Conclusion

ICSI was associated with a reduction in the male-to-female sex ratio and a lower rate of male live births, while blastocyst transfer was associated with an increased male-to-female sex ratio at birth and a higher rate of male live births.

Sex ratio imbalance following blastocyst transfer is associated with ICSI but not with IVF: an analysis of 14,892 single embryo transfer cycles

PURPOSE

Assisted reproductive technology (ART) has an impact on secondary sex ratio (SSR), which is seemed to be elevated after blastocyst transfer (BT) but decreased following ICSI procedure. We aim to assess whether the higher SSR associated with BT could be influenced by fertilization method used.

METHODS

All consecutive IVF/ICSI cycles (fresh and frozen) involving single embryo transfer (SET) resulting in a live birth between 2015 and 2019 were retrospective analyzed. Logistic regression was used to model the effect on the SSR of maternal and specific ART characteristics.

RESULTS

Six thousand nine hundred twenty-two women were included with the crude SSR of 54.8%. The impact of BT on SSR is influenced by the fertilization method used. After adjustment for potential confounders, the SSR in the ICSI BT group was significantly higher when compared to ICSI cleavage-stage embryo SET (aOR 1.24; 95% CI 1.10-1.40, P < 0.001). However, this effect was not detected among SBT with IVF treatment (aOR 1.04; 95% CI 0.97-1.12, P = 0.260). Assessing blastocyst morphological parameters, high trophectoderm quality was significantly associated with elevated SSR (aOR 1.76, 95% CI 1.34-2.31 [A vs. C], and aOR 1.28, 95% CI 1.14-1.44 [B vs. C]). No significant difference was shown in expansion, inner cell mass, or days of blastocyst formation between male and female blastocysts.

CONCLUSIONS

The impact of BT on SSR could be influenced by the fertilization method used. The higher SSR was observed after BT with ICSI procedures but not with IVF. Interpretation of the findings is limited by the potential for selection and confounding bias.

Sex ratio of infants born through in vitro fertilization and embryo transfer: Results of a single-institution study and literature review

Objective:

The possible effects of Assisted Reproductive Technology (ART) on sex ratio at birth are extremely significant. This study aimed to determine whether ART affects the sex ratio of infants born through in vitro fertilization and embryo transfer (IVF-ET).

Materials and Methods:

We ran this retrospective study on 290 singleton infants born following IVF-ET from February 2014 to August 2018 at a single institution. We compared the sex ratios of these infants with respect to insemination versus intracytoplasmic sperm injection (ICSI), early-cleavage embryo versus blastocyst transfer, fresh versus frozen-thawed embryo transfer and normal sperm versus asthenospermia.

Results:

There were no significant differences in the sex ratio with respect to the fertilization method, transfer time, fresh embryo or frozen-thawed embryo transfer. In addition, the multiple logistic regression analysis revealed that these factors did not significantly affect the sex ratio.

Conclusions:

Our study indicated that the differences in the fertilization method transfer time and sperm motility rate did not affect the sex ratio of IVF live births. However, with increasing numbers of ICSI and blastocyst transfer cycles, factors possibly affecting the sex ratio need to be further investigated.

Obstetrical outcomes of ART pregnancies in patients with male factor infertility

PURPOSE

Pregnancies conceived by in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are associated with an increased incidence of obstetrical and neonatal complications. With the growing rate of male factor infertility, which is unique by not involving the maternal milieu, we aimed to assess whether obstetrical outcomes differed between IVF/ICSI pregnancies due to male factor infertility and those not due to male factor infertility.

METHODS

A retrospective cohort study of women receiving IVF/ICSI treatments at a single hospital over a five-year period was involved in the study. Inclusion criteria were women with a viable pregnancy that delivered at the same hospital. Pregnancies were divided into male factor only related and non-male factor-related infertility. The groups were compared for several maternal and neonatal complications.

RESULTS

In total, 225 patients met the study criteria, with 94 and 131 pregnancies belonging to the male factor and non-male factor groups, respectively. Demographic and clinical characteristics were comparable, except for younger maternal age and higher incidence of twin pregnancies in the male factor group. A sub-analysis for singleton pregnancies revealed a less likelihood of cesarean delivery, preterm birth, and male gender offspring in the male factor group (p < 0.05). These differences were not observed in the sub-analysis for twin pregnancies. Other outcome measures were similar in both groups, both for singleton and twin pregnancies.

CONCLUSION

Singleton IVF pregnancies due to male factor infertility are associated with a reduced incidence of some adverse outcomes, likely due to lack of underlying maternal medical conditions or laboratory conditions related to ICSI. Our findings require validation by further studies on larger samples.

Increased male live-birth rates after blastocyst-stage frozen-thawed embryo transfers compared with cleavage-stage frozen-thawed embryo transfers: a SART registry study

Objective

To investigate whether there is a difference in live-birth gender rates in blastocyst-stage frozen-thawed embryo transfers (FETs) compared with those in cleavage-stage FETs.

Design

Retrospective cohort study.

Setting

Academic medical center.

Patient(s)

All women with recorded live births who underwent FET at either the blastocyst or cleavage stage, reported to the Society for Assisted Reproductive Technology during 2004–2013.

Intervention(s)

None.

Main Outcome Measure(s)

The primary outcome was live-birth gender rates. Demographic criteria were also collected. The chi-square analyses were used for bivariate associations, and multiple logistic regression models were used for adjusted associations, with all two-sided P<.05 considered statistically significant.

Result(s)

A statistically significant increase was noted in the number of live male births after blastocyst-stage FET compared with that after cleavage-stage FET (51.9% vs. 50.5%). After controlling for potential confounders including age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03, 1.08), body mass index (OR, 1.08; 95% CI, 1.04, 1.12), and male factor infertility (OR, 1.06; 95% CI, 1.03, 1.08), the increase in male live births after blastocyst-stage FET remained statistically significant.

Conclusion(s)

In patients undergoing FETs, blastocyst-stage transfers are associated with higher male gender live-birth rates compared with cleavage-stage transfers.

Associated factors of secondary sex ratio of offspring in assisted reproductive technology: a cross-sectional study in Jilin Province, China

Background

The aim of this study was to determine the secondary sex ratio (SSR) of offspring in assisted reproduction technology (ART) in Jilin Province, China, and to analyse the influencing factors associated with SSR.

Methods

A cross-sectional study of 3833 babies including singletons and twins born to 2990 couples treated by ART between May 2011 and December 2018 was performed.

Results

The main outcomes of this study were that the SSR of ART babies in Jilin Province was 50.64% and the SSR was associated with fertilization methods (p < 0.05). Comparing to in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI) (OR = 0.808, 95%CI: 0.681–0.958) decreased the percentage of male babies.

Conclusions

This study suggests that the SSR of ART births in Jilin Province was lower than the normal level and ICSI had a significant effect on SSR. Though we need more samples to study in the future, we still need to think about the impact of ICSI on SSR in ART.

ALWAYS ICSI? A SWOT analysis

PURPOSE

Intracytroplasmatic sperm injection (ICSI) is a common procedure used to improve reproductive results, even among couples without male factor infertility. However, the evidence available is still uncertain on the possible advantages and deficiencies that this procedure may have in patients with no formal indication for ICSI.

METHODS

A SWOT (strengths, weaknesses, opportunities, threats) analysis examines the possible advantages and deficiencies of performing ICSI in these patients with no formal indication.

RESULTS

The evidence suggests that ICSI is not justified for non-male factor infertile couples requiring in vitro conception. One of the major strengths associated to the procedure is the virtual elimination of cases further complicated by total fertilization failure and a combination between IVF and ICSI on sibling oocytes has been advised in the literature. Greater technical difficulties, higher costs and performing an unnecessary invasive technique in some cases represent some of the weaknesses of the procedure, and questions regarding safety issues should not be ruled out.

CONCLUSION

Despite the widespread use of ICSI in patients without a formal diagnosis of male factor infertility, evidence demonstrating its effectiveness in this population is still lacking. Additional large and well-designed randomized controlled trials are needed to clarify definitive indications for ICSI in non-male factor infertility.

Secondary sex ratio in assisted reproduction: an analysis of 1 376 454 treatment cycles performed in the UK

STUDY QUESTION

Does ART impact the secondary sex ratio (SSR) when compared to natural conception?

SUMMARY ANSWER

IVF and ICSI as well as the stage of embryo transfer does impact the overall SSR.

WHAT IS KNOWN ALREADY

The World Health Organization quotes SSR for natural conception to range between 103 and 110 males per 100 female births.

STUDY DESIGN SIZE DURATION

A total of 1 376 454 ART cycles were identified, of which 1 002 698 (72.8%) cycles involved IVF or ICSI. Of these, 863 859 (85.2%) were fresh cycles and 124 654 (12.4%) were frozen cycles. Missing data were identified in 14 185 (1.4%) cycles.

PARTICIPANTS/MATERIALS SETTING METHODS

All cycles recorded in the anonymized UK Human Fertilisation and Embryology Authority (HFEA) registry database between 1991 and 2016 were analysed. All singleton live births were included, and multiple births were excluded to avoid duplication.

MAIN RESULTS AND THE ROLE OF CHANCE

The overall live birth rate per cycle for all IVF and ICSI treatments was 26.2% (n = 262 961), and the singleton live birth rate per cycle was 17.1% (n = 171 399). The overall SSR for this study was 104.0 males per 100 female births (binomial exact 95% CI: 103.1-105.0) for all IVF and ICSI cycles performed in the UK recorded through the HFEA. This was comparable to the overall SSR for England and Wales at 105.3 males per 100 female births (95% CI: 105.2-105.4) from 1991 to 2016 obtained from the Office of National Statistics database. Male predominance was seen with conventional insemination in fresh IVF treatment cycles (SSR 110.0 males per 100 female births; 95% CI: 108.6-111.5) when compared to micro-injection in fresh ICSI treatment cycles (SSR 97.8 males per 100 female births; 95% CI: 96.5-99.2; odds ratio (OR) 1.16, 95% CI 1.12-1.19, P < 0.0001), as well as with blastocyst stage embryo transfers (SSR 104.8 males per 100 female births; 95% CI: 103.5-106.2) when compared to a cleavage stage embryo transfer (SSR 101.2 males per 100 female births; 95% CI: 99.3-103.1; OR 1.03, 95% CI 1.01-1.06, P = 0.011) for all fertilization methods.

LIMITATIONS REASONS FOR CAUTION

The quality of the data relies on the reporting system. Furthermore, success rates through ART have improved since 1991, with an increased number of blastocyst stage embryo transfers.

WIDER IMPLICATIONS OF THE FINDINGS

This is the largest study to date evaluating the impact of ART on SSR. The results demonstrate that, overall, ART does have an impact on the SSR when assessed according to the method of fertilization (ICSI increased female births while IVF increased males). However, given the ratio of IVF to ICSI cycles at present with 60% of cycles from IVF and 40% from ICSI, the overall SSR for ART closely reflects the population SSR for, largely, natural conceptions in England and Wales.

STUDY FUNDING/COMPETING INTERESTS

The study received no funding. C.M.B. is a member of the independent data monitoring group for a clinical endometriosis trial by ObsEva. He is on the scientific advisory board for Myovant and medical advisory board for Flo Health. He has received research grants from Bayer AG, MDNA Life Sciences, Volition Rx and Roche Diagnostics as well as from Wellbeing of Women, Medical Research Council UK, the NIH, the UK National Institute for Health Research and the European Union. He is the current Chair of the Endometriosis Guideline Development Group for ESHRE and was a co-opted member of the Endometriosis Guideline Group by the UK National Institute for Health and Care Excellence (NICE). I.G. has received research grants from Wellbeing of Women, the European Union and Finox.

TRIAL REGISTRATION NUMBER

Not applicable.

Trends and correlates of the sex distribution among U.S. assisted reproductive technology births

OBJECTIVE

To assess national trends in the sex distribution of live-born infants in the assisted reproductive technology (ART) and general population and to identify factors correlated with offspring sex.

DESIGN

Retrospective cohort study.

SETTING

Fertility treatment centers.

PATIENTS

All live-born infants included in the National Vital Statistics System and resulting from ART cycles reported to the National ART Surveillance System during 2006-14.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Trends in the proportion of male infants in the general population and proportion of males from fresh ART cycles among all ART live-born infants and singletons after single ET.

RESULT(S)

There were 214,274 live-born infants resulting from fresh ART cycles; 53.5% (5,492/10,266) of infants resulting from PGD/PGS cycles were male, as compared with 50.6% (103,228/204,008) in the non-PGD/PGS group. Among non-PGD/PGS cycles, blastocyst transfer was positively associated with male infants (adjusted risk ratio [aRR] = 1.03; 95% confidence interval [CI], 1.02-1.04). Intracytoplasmic sperm injection was negatively associated with male infants (aRR = 0.94; 95% CI, 0.93-0.95) and for singletons after single ET (aRR = 0.93; 95% CI, 0.90-0.95), as was transfer of two embryos (aRR 0.98; 95% CI, 0.97-0.99) or three or more embryos (aRR = 0.98; 95% CI, 0.96-0.99) among all live births from cycles without PGD/PGS use.

CONCLUSION(S)

The proportion of male live-born infants among ART population did not change during 2006-14, ranging from 50.5% to 51.2%. Factors such as blastocyst transfer, intracytoplasmic sperm injection use, embryo stage, and number of embryos transferred may be associated with infant sex; further investigation is needed to understand possible underlying causes.

Blastocyst culture and transfer in clinically assisted reproduction: a committee opinion

The purposes of this Practice Committee Opinion, which replaces the 2013 ASRM Practice Committee Opinion of the same name (Fertil Steril 2013; 99:667-72), are to review the literature regarding the clinical application of blastocyst transfer and identify the potential risks and laboratory issues related to the use of this technology. This document does not apply to patients undergoing blastocyst culture and transfer for preimplantation genetic testing.

The use of intracytoplasmic sperm injection is associated with a shift in the secondary sex ratio

RESEARCH QUESTION

What is the association between assisted reproductive technologies and human sex ratio as a proportion of male offspring at birth.

DESIGN

A total of 59,628 singleton deliveries resulting from IVF, intracytoplasmic sperm injection (ICSI) and intrauterine insemination (IUI) or ovulation induction from 101 IVF clinics in Germany, that had been documented in a national German IVF registry, were analysed. Sex ratio after assisted reproductive technology was also compared with the sex ratio reported in the birth records of the German Federal Statistical Office.

RESULTS

The sex ratio was 50.0% (95% CI 49.5% to 50.5%) for ICSI, 52.2% (95% CI 51.5% to 52.9%) for IVF, 52.2% (95% CI 50.9% to 53.5%) for IUI or ovulation induction and 51.3% in the national birth records, respectively. Significant differences existed across the three treatment groups (P = 6.86 × 10^-7) as well as in pairwise comparisons between ICSI versus IVF (P = 6.88 × 10^-7) and ICSI versus IUI or ovulation induction (P = 0.003). No difference existed between the groups IUI or ovulation induction versus IVF. Same results were also present after stratification by maternal age: IVF versus ICSI (P = 6.433 × 10^-7), ICSI versus IUI or ovulation induction (P = 0.003), and IVF versus IUI or ovulation induction (non-significant). Compared with the national birth records, ICSI is associated with a lower sex ratio compared with the reference group (P < 0.001), whereas IVF is associated with a higher sex ratio (P = 0.015).

CONCLUSIONS

The use of ICSI is associated with an equal proportion of sexes at birth, which is not the case for IVF, IUI or ovulation induction, or natural conception. This phenomenon is not influenced by maternal age.

Human semen quality and the secondary sex ratio

The aim of this study was to evaluate the association between semen quality and the secondary sex ratio (SSR), defined as the ratio of male to female live births. Our study cohort comprised 227 male partners who were enrolled prior to conception in Michigan and Texas between 2005 and 2009, and prospectively followed through delivery of a singleton birth. The male partners provided a baseline and a follow-up semen sample a month apart. Semen analysis was conducted to assess 27 parameters including five general characteristics, six sperm head measures, 14 morphology measures, and two sperm chromatin stability assay measures. Modified Poisson regression models with a robust error variance were used to estimate the relative risk (RR) and 95% confidence interval (95% CI) of a male birth for each semen parameter, after adjusting for potential confounders. Of the 27 semen parameters, only the percentage of bicephalic sperm was significantly associated with the SSR (2^ndvs 1^st quartile, RR, 0.65, 95% CI, 0.45–0.95, P = 0.03; 4^thvs 1^st quartile, RR, 0.61, 95% CI, 0.38–1.00, P < 0.05 before rounding to two decimal places), suggestive of a higher percentage of bicephalic sperm being associated with an excess of female births. Given the exploratory design of the present study, this preconception cohort study suggests no clear signal that human semen quality is associated with offspring sex determination.

The sex ratio of singleton and twin delivery offspring in assisted reproductive technology in China

In order to evaluate the impact of assisted reproductive technology (ART) procedure and individual factors on the sex ratio of singletons and twins at birth after in vitro fertilization (IVF) and intra-cytoplasmic sperm injection (ICSI) treatment in China. We conducted a retrospective cohort study including patients undergoing their first cycle of IVF or ICSI with autologous oocytes from 2001 to 2015. A total of 7410 babies were born from 5832 women with 7410 live birth. The secondary sex ratio (SSR) in singletons was significantly higher than twins (53.97% vs. 50.89%, P = 0.009). The largest disparity was observed in 'thawed blastocyst embryos ICSI' subgroup that SSR was 59.84% in singletons and 42.45% in twins (P = 0.013). Blastocyst transfer was positively associated with elevated SSR when compared to cleavage stage embryos in singletons (Odds Ratio [OR] = 1.17, P < 0.001). In addition, paternal age was significantly associated with SSR (OR = 0.75, P = 0.014). While the decrease of SSR was significantly associated with ICSI when compared to IVF (OR = 0.61, P = 0.046) in twins. Blastocyst transfer increases SSR in comparing with cleavage stage embryos in singletons, while the use of ICSI reduces SSR in twins. Our findings offered important complement for better understanding the underlying determinant of SSR in ART offspring.

Effect of semen quality on human sex ratio in in vitro fertilization and intracytoplasmic sperm injection: an analysis of 27,158 singleton infants born after fresh single-embryo transfer

OBJECTIVE

To evaluate the effect of semen quality on human sex ratio in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 27,158 singleton infants born between 2007 and 2012 after fresh single-embryo transfer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Proportion of male infants among liveborn infants.

RESULT(S)

There were 14,996 infants born after IVF, 12,164 infants born after ICSI with ejaculated sperm, and 646 infants born after ICSI with nonejaculated sperm. The sex ratio of IVF was 53.1% (95% confidence interval [CI], 52.3-53.9); the sex ratio of ICSI with ejaculated and nonejaculated sperm demonstrated as statistically significant reduction (48.2%; 95% CI, 47.3-49.1 and 47.7%; 95% CI, 43.8-51.6, respectively). In IVF, lower sperm motility, including asthenozoospermia (sperm motility <40%), was associated with a statistically significantly lower sex ratio compared with normal sperm (51.0%; 95% CI, 48.6-53.3 vs. 53.4%; 95% CI, 52.5-54.3). In ICSI with ejaculated sperm, there was no association between sperm motility and sex ratio. Sperm concentration was not associated with sex ratio in both IVF and ICSI.

CONCLUSION(S)

In IVF, lower sperm motility was associated with a statistically significant reduction in sex ratio; ICSI with either ejaculated or nonejaculated sperm was associated with a statistically significant reduction in sex ratio regardless of semen quality.

Why we should not select the faster embryo: lessons from mice and cattle

Many studies have shown that in vitro culture can negatively impact preimplantation development. This necessitates some selection criteria for identifying the best-suited embryos for transfer. That said, embryo selection after in vitro culture remains a subjective process in most mammalian species, including cows, mice and humans. General consensus in the field is that embryos that develop in a timely manner have the highest developmental competence and viability after transfer. Herein lies the key question: what is a timely manner? With emerging data in bovine and mouse supporting increased developmental competency in embryos with moderate rates of development, it is time to question whether the fastest developing embryos are the best embryos for transfer in the human clinic. This is especially relevant to epigenetic gene regulation, including genomic imprinting, where faster developing embryos exhibit loss of imprinted methylation, as well as to sex selection bias, where faster developmental rates of male embryos may lead to biased embryo transfer and, in turn, biased sex ratios. In this review, we explore evidence surrounding the question of developmental timing as it relates to bovine embryo quality, mouse embryo quality and genomic imprint maintenance, and embryo sex.

Live birth sex ratio after in vitro fertilization and embryo transfer in China--an analysis of 121,247 babies from 18 centers

In order to study the impact of procedures of IVF/ICSI technology on sex ratio in China, we conducted this multi-center retrospective study including 121,247 babies born to 93,895 women in China. There were 62,700 male babies and 58,477 female babies, making the sex ratio being 51.8% (Male: Female  = 107∶100). In univariate logistic regression analysis, sex ratio was imbalance toward females of 50.3% when ICSI was preformed compared to 47.7% when IVF was used (P<0.01). The sex ratio in IVF/ICSI babies was significantly higher toward males in transfers of blastocyst (54.9%) and thawed embryo (52.4%) when compared with transfers of cleavage stage embryo (51.4%) and fresh embryo (51.5%), respectively. Multiple delivery was not associated with sex ratio. However, in multivariable logistic regression analysis after controlling for related factors, only ICSI (adjusted OR = 0.90, 95%CI: 0.88–0.93; P<0.01) and blastocyst transfer (adjusted OR = 1.14, 95% CI: 1.09–1.20; P<0.01) were associated with sex ratio in IVF/ICSI babies. In conclusion, the live birth sex ratio in IVF/ICSI babies was influenced by the use of ICSI, which may decrease the percentage of male offspring, or the use of blastocyst transfer, which may increase the percentage of male offspring.

Changes in sex ratio from fertilization to birth in assisted-reproductive-treatment cycles

BACKGROUND

In Western gender-neutral countries, the sex ratio at birth is estimated to be approximately 1.06. This ratio is lower than the estimated sex ratio at fertilization which ranges from 1.07 to 1.70 depending on the figures of sex ratio at birth and differential embryo/fetal mortality rates taken into account to perform these estimations. Likewise, little is known about the sex ratio at implantation in natural and assisted-reproduction-treatment (ART) cycles. In this bioessay, we aim to estimate the sex ratio at fertilization and implantation using data from embryos generated by standard in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in preimplantation genetic diagnosis cycles. Thereafter, we compare sex ratios at implantation and birth in cleavage- and blastocyst-stage-transfer cycles to propose molecular mechanisms accounting for differences in post-implantation male and female mortality and thereby variations in sex ratios at birth in ART cycles.

METHODS

A literature review based on publications up to December 2013 identified by PubMed database searches.

RESULTS

Sex ratio at both fertilization and implantation is estimated to be between 1.29 and 1.50 in IVF cycles and 1.07 in ICSI cycles. Compared with the estimated sex ratio at implantation, sex ratio at birth is lower in IVF cycles (1.03 after cleavage-stage transfer and 1.25 after blastocyst-stage transfer) but similar and close to unity in ICSI cycles (0.95 after cleavage-stage transfer and 1.04 after blastocyst-stage transfer).

CONCLUSIONS

In-vitro-culture-induced precocious X-chromosome inactivation together with ICSI-induced decrease in number of trophectoderm cells in female blastocysts may account for preferential female mortality at early post-implantation stages and thereby variations in sex ratios at birth in ART cycles.

Effects of assisted reproductive technologies on human sex ratio at birth

OBJECTIVE

To investigate the effect of assisted reproductive technology (ART) treatments on the sex ratio of babies born.

DESIGN

Assessment of direct effects of assisted conception through retrospective data analysis on the progeny sex ratio of treated women in the United Kingdom.

SETTING

The study uses the anonymized register of the Human Fertilisation and Embryology Authority.

PATIENT(S)

A total of 106,066 babies of known gender born to 76,994 treated mothers and 85,511 treatment cycles between 2000 and 2010 in the United Kingdom.

INTERVENTION(S)

Intrauterine insemination, IVF, or intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Sex ratio of babies born.

RESULT(S)

Intrauterine insemination, IVF, and ICSI lead to different sex ratios, highest after IVF (proportion male = mean 0.521 ± confidence interval 0.0056) and lowest under ICSI embryo transfer (0.493 ± 0.0031). In addition, for both ICSI and IVF, transferring embryos at a later stage (blastocyst) results in approximately 6% more males than after early cleavage-stage ET.

CONCLUSION(S)

Because the cumulative number of IVF babies born is increasing significantly in Britain and elsewhere, more research is needed into the causes of gender bias after ART and into the public health impact of such gender bias of offspring born observed on the rest of the population.

Sex ratio at birth is associated with first-trimester maternal thyrotropin in women receiving levothyroxine

BACKGROUND

The sex ratio at birth (male out of total alive newborns) is historically established at 0.515 and is influenced by numerous factors. It is not known, however, whether it is influenced by maternal thyroid conditions. Our aim was to analyze its association with maternal thyroid autoimmunity and first-trimester thyrotropin (TSH).

METHODS

We performed a retrospective cohort study at a tertiary care center. We studied 167 women who had received pregestational treatment with levothyroxine for hypothyroidism or differentiated thyroid carcinoma and gave birth to live infants. Women with secondary/tertiary hypothyroidism, pregestational diabetes mellitus, or multiple pregnancies were excluded. Autoimmunity was defined as present/absent, and mean first-trimester TSH was tested both as a quantitative variable and using six predefined categories. The outcome measure was sex ratio at birth.

RESULTS

The sex ratio at birth was 0.485, not significantly different from expected. Maternal characteristics were similar in mothers of female and male newborns with the exception of mean first-trimester TSH, which was higher in pregnancies of female fetuses (3.27 vs. 2.52 mUI/L, p<0.025). Newborn sex differed across predefined TSH categories (p<0.021, with a sex ratio of 0.200 [95% confidence interval 0.00-0.402] for TSH ≥10 mUI/L). A multiple logistic regression analysis to predict newborn male sex confirmed maternal mean first-trimester TSH as the single predictor (odds ratio 0.900 [95% confidence interval 0.823-0.984], p<0.020).

CONCLUSIONS

In women under pregestational treatment with levothyroxine, mean maternal first-trimester TSH is negatively associated with sex ratio at birth. This association has not been previously described.

Female sex bias in human embryonic stem cell lines

The factors limiting the rather inefficient derivation of human embryonic stem cells (HESCs) are not fully understood. The aim of this study was to analyze the sex ratio in our 42 preimplantation genetic diagnosis (PGD)-HESC lines, in an attempt to verify its affect on the establishment of HESC lines. The ratio between male and female PGD-derived cell lines was compared. We found a significant increase in female cell lines (76%). This finding was further confirmed by a meta-analysis for combining the results of all PGD-derived HESC lines published to date (148) and all normal karyotyped HESC lines derived from spare in vitro fertilization embryos worldwide (397). Further, gender determination of embryos demonstrated that this difference originates from the actual derivation process rather than from unequal representation of male and female embryos. It can therefore be concluded that the clear-cut tendency for female preponderance is attributed to suboptimal culture conditions rather than from a true gender imbalance in embryos used for derivation of HESC lines. We propose a mechanism in which aberrant X chromosome inactivation and/or overexpression of critical metabolic X-linked genes might explain this sex dimorphism.

Comparison of early pregnancy and neonatal outcomes after frozen and fresh embryo transfer in ART cycles

PURPOSE

frozen embryo transfer (FET) has no clear negative impact on neonatal outcome compared with fresh embryo transfer (ET) and appears to result in similar or even better neonatal outcome. The objective of this study was to compare early pregnancy outcome and neonatal health of children born after FET and fresh ET.

METHODS

in this study early pregnancy and neonatal outcomes after FET (n = 200) and fresh ET (n = 500) were compared.

RESULTS

for early pregnancy, biochemical pregnancy was comparable between FET and fresh ET groups. Spontaneous abortion was significantly higher in FET (14.5%) than fresh ET group (9%). Neonatal outcome was comparable between both groups except for lower live birth rate in FET (55%) versus fresh ET group (66%).

CONCLUSION

FET has similar neonatal outcome in terms of prematurity, low birth weight, stillbirth, neonatal death and major malformation compared with fresh ET.

The effect on human sex ratio at birth by assisted reproductive technology (ART) procedures--an assessment of babies born following single embryo transfers, Australia and New Zealand, 2002-2006

OBJECTIVE

To assess the effect on the human sex ratio at birth by assisted reproductive technology (ART) procedures.

DESIGN

Retrospective population-based study.

SETTING

Fertility clinics in Australia and New Zealand.

POPULATION

The study included 13,368 babies by 13,165 women who had a single embryo transfer (SET) between 2002 and 2006.

METHODS

Logistic regression was used to model the effect on the sex ratio at birth of ART characteristics [in vitro fertilisation (IVF) or intracytoplasmic sperm insemination (ICSI) SET, cleavage-stage or blastocyst SET, and fresh or thawed SET] and biological characteristics (woman's and partner's age and cause of infertility).

MAIN OUTCOME MEASURES

Proportion of male births.

RESULTS

The crude sex ratio at birth was 51.3%. Individual ART procedures had a significant effect on the sex ratio at birth. More males were born following IVF SET (53.0%) than ICSI SET (50.0%), and following blastocyst SET (54.1%) than cleavage-stage SET (49.9%). For a specific ART regimen, IVF blastocyst SET produced more males (56.1%) and ICSI cleavage-stage SET produced fewer males (48.7%).

CONCLUSIONS

The change in the sex ratio at birth of SET babies is associated with the ART regimen. The mechanism of these effects remains unclear. Fertility clinics and patients should be aware of the bias in the sex ratio at birth when using ART procedures.

Can mammalian mothers influence the sex of their offspring peri-conceptually?

Although controversial, growing evidence from evolutionary biology suggests that the mammalian mother may have a role in influencing the sex of her offspring. However, there is competing information on the molecular mechanisms by which such influence could be manifested. The new initiatives are based on hypotheses from evolutionary biology: the 'good condition' hypothesis, which suggests that post conception, higher levels of maternal glucose may differentially promote the development of male embryos; and the 'maternal dominance' hypothesis, which proposes that before conception, higher follicular testosterone may influence the development of the ovum so that it emerges already adapted to receive an X- or a Y-chromosome-bearing spermatozoon. Now, it seems these hypothesised mechanisms could be operating in synchrony, each complementing and reinforcing the other. On the other hand, there are continuing problems in identifying a precise sequence of mechanisms as evidenced from research in sperm-sorting. Research on high-fat diets and the sex ratio in polytocous species may indicate important differences in proximate mechanisms for sex allocation between polytocous and monotocous mammals.