Fundamentals of human embryonic growth in vitro and the selection of high-quality embryos for transfer

New Insight of Lipiodol Flush on Pregnancy Outcomes in Women with Recurrent Implantation Failure Undergoing IVF/ICSI: a Prospective Study Based on Propensity Score Matching

Pregnancy outcomes in women with recurrent implantation failure (RIF) undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI): does treatment with lipiodol flush matter? In this propensity score-matched study, we recruited 966 RIF patients who underwent IVF/ICSI from two tertiary hospitals. These patients were divided into groups based on whether they received lipiodol flush or not. Further stratification was applied to investigate the effect of lipiodol flush on pregnancy outcomes in RIF patients with different cycle type of embryo transferred. Then, patients subjected to lipiodol flush were categorized into three groups based on the duration of the interval: short interval (≤ 3 months), moderate interval (3-6 months), and long interval (≥ 6 months). The groups were well-matched at baseline. The lipiodol flush group exhibited a significantly lower incidence of biochemical pregnancy (46.27% vs. 56.22%, p = 0.046) and live birth (25.87% vs. 37.31%, p = 0.014). Subgroup analysis for fresh embryo transfer cycles revealed no significant differences in pregnancy outcomes. Among RIF patients underwent frozen-thawed embryo transfer cycle, a statistically significant difference in the live birth rate was observed in the lipiodol flush group when compared to the control group (26.40% vs. 37.21%, p = 0.030). Analysis of different lipiodol flush intervals demonstrated a significantly lower live birth rate in the lipiodol flush group. Our results challenge the value of lipiodol use in clinical practice for the treatment of RIF.Trial registration: Chinese Clinical Trial Registry, ChiCTR1900024273. Registered 4 July 2019.

Cellular and Molecular Nature of Fragmentation of Human Embryos

Embryo fragmentation represents a phenomenon generally characterized by the presence of membrane-bound extracellular cytoplasm into the perivitelline space. Recent evidence supports the cellular and molecular heterogeneity of embryo fragments. In this narrative review, we described the different embryo fragment-like cellular structures in their morphology, molecular content, and supposed function and have reported the proposed theories on their origin over the years. We identified articles related to characterization of embryo fragmentation with a specific literature search string. The occurrence of embryo fragmentation has been related to various mechanisms, of which the most studied are apoptotic cell death, membrane compartmentalization of altered DNA, cytoskeletal disorders, and vesicle formation. These phenomena are thought to result in the extrusion of entire blastomeres, release of apoptotic bodies and other vesicles, and micronuclei formation. Different patterns of fragmentation may have different etiologies and effects on embryo competence. Removal of fragments from the embryo before embryo transfer with the aim to improve implantation potential should be reconsidered on the basis of the present observations

Solution NMR in human embryo culture media as an option for assessment of embryo implantation potential

NMR offers the potential to holistically screen hundreds of metabolites and has already proved to be a powerful technique able to provide a global picture of metabolic changes in a wide range of biological systems underlying complex and multifactorial matrixes. This review covers the literature until May 2020 centered on the early prediction of the viability of in vitro developed embryos using several analytical techniques, including NMR. Nowadays, the predominant non-invasive technique for selecting viable embryos is based on morphology, where variables associated with the rate of cleavage and blastocyst formation are evaluated by the embryologist following standardized criteria that are somewhat subjective. This morphological approach is therefore inadequate for the prediction of embryo quality, and several studies have focused on developing new non-invasive methods using molecular approaches based particularly on metabolomics. This review outlines the potential of NMR as one of these non-invasive in vitro methods based on the analysis of spent embryo culture media.

Biodynamic digital holographic speckle microscopy for oocyte and embryo metabolic evaluation

Assisted reproductive technologies seek to improve the success rate of pregnancies. Morphology scoring is a common approach to evaluate oocyte and embryo viability prior to embryo transfer in utero, but the efficacy of the method is low. We apply biodynamic imaging, based on dynamic light scattering and low-coherence digital holography, to assess the metabolic activity of oocytes and embryos. A biodynamic microscope, developed to image small and translucent biological specimens, is inserted into the bay of a commercial inverted microscope that can switch between conventional microscopy channels and biodynamic microscopy. We find intracellular Doppler spectral features that act as noninvasive proxies for embryo metabolic activity that may relate to embryo viability.

Fresh oocyte cycles yield improved embryo quality compared with frozen oocyte cycles in an egg-sharing donation programme

The objective of this study was to investigate any effect of cryopreservation of donated eggs on laboratorial and clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles. This retrospective cohort study included 320 oocyte recipients undergoing 307 vitrified and 119 fresh oocyte recipient ICSI cycles, participating in an egg-sharing donation programme, from 2015 to 2018, in a private university-affiliated in vitro fertilization (IVF) centre. A review of donor and recipient ICSI cycles was charted. A general mixed models fit by restricted maximum likelihood, followed by Bonferroni post hoc test was used to compare the means between fresh and warm oocyte donation groups and investigate the effect of cryopreservation on recipient ICSI outcome. The main outcome measure was blastocyst development rates. Fertilization rate, high-quality embryo rates on days 2 and 3, normal cleavage speed rates on days 2 and 3, and blastocyst development rate were significantly higher for the fresh oocyte donation cycles compared with warmed oocyte donation cycles. In the egg-sharing donation programme, fertilization and embryo developmental competence were reduced when vitrified oocytes from infertile couples were used for ICSI compared with fresh oocytes.

Separating the contributions of zona pellucida and cytoplasm in the viscoelastic response of human oocytes

The successful characterization of the mechanical properties of human oocytes and young embryos is of crucial relevance to reduce the risk of pregnancy arrest in in-vitro fertilization processes. Unfortunately, current study has been hindered by the lack of accuracy in describing the mechanical contributions of each structure (zona pellucida, cytoplasm) due to its high heterogeneity. In this work, we present a novel approach to model the oocyte response taking into account the effect of both zona and cytoplasm, as well as different loading conditions. The model is then applied to develop an experimental protocol capable of accurately separating the viscoelastic contribution of zona and cytoplasm by simply varying the loading condition. This new protocol has the potential to open the door to improving our understanding the mechanical properties of oocytes at different stages, and provide a quantitative predictive ability to the evaluation of oocyte quality. STATEMENT OF SIGNIFICANCE: Assisted reproductive technologies, such as in vitro fertilization, often rely on identifying high quality oocytes or female egg cells. The viscoelastic properties of these cells, such as stiffness and stress relaxation time, have been identified as potential objective indicators of cell quality. However, their characterization has proven difficult due to the structural heterogeneity of the cell and inconsistent loading conditions. This paper presents a new model that, although simple, addresses the above difficulties to provide accurate estimations of the cell's mechanical properties. Learning from this model, we then propose a novel non-invasive testing protocol to allow oocyte characterization with increased accuracy. We believe this effort would improve consistency in measurements and enhance our knowledge on the mechanics of oocytes.

Investigating the impact of the timing of blastulation on implantation: management of embryo-endometrial synchrony improves outcomes

STUDY QUESTION

Do embryos with delayed blastulation have inferior reproductive potential or poorer outcomes due in part to embryo and endometrial synchrony?

SUMMARY ANSWER

Diminished outcomes in embryos with delayed blastulation undergoing fresh embryo transfer (ET) may be attributed to a loss of embryonic-endometrial synchrony.

WHAT IS KNOWN ALREADY

Embryos that blastulate slowly have lower sustained implantation rates (SIR) than those which blastulate normally on Day 5 (D5). Traditionally this has been attributed to reduced embryo quality; however, dyssynchrony with the endometrium is also a possibility and has not been fully described. This convenient cohort composed of groups that resulted from a practice wide change in laboratory protocol allows for evaluation of embryo and endometrial synchrony as it related to blastocyst expansion.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort analysis was carried out from January 2009 to February 2013. Three cohorts were identified: D5 ET, D6 ET and frozen ET that comprised 822 patients, 763 patients and 718 patients, respectively. Each of these cohorts had slowly blastulating and normally blastulating embryos identified.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study setting was academic affiliated private practice. All first fresh or cryopreserved ETs from 2010 to 2013 were studied. Non-biopsied embryos were classified into two groups on D5: slowly blastulating (Morula-Gardner 1) or normally blastulating (Gardner 2–6). Only single ETs or transfer of two embryos within the same classification group were included. Outcomes were compared between classification groups in embryos undergoing transfer on D5, D6, or after cryopreservation. This assesses the impact of transfer timing in fresh cycles as well as isolating a pure embryonic factor in frozen ET cycles. Sustained implantation was defined as heart beat detection at discharge sonogram at 8 weeks gestation. SIR was defined as the number of embryos transferred meeting criteria for sustained implantation divided by the total number of embryos transferred.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 3391 embryos were transferred to 1966 patients. On D5, SIRs were significantly lower with slowly blastulating embryos (44% versus 64% in women <35 years of age (P < 0.001) and 18% versus 56% in women ≥35 years of age (P < 0.001)). Fresh D6 ETs also had significantly lower SIRs for embryos that were slowly blastulating on D5 (52% versus 63% in <35 years of age (P < 0.05) and 32% versus 48% in ≥35 years of age (P < 0.005)) despite continued development to full blastocysts and being morphologically equivalent at the time of ET, suggesting dyssynchrony. However, when slowly blastulating embryos underwent vitrification and then ET, they had SIRs which were equivalent to their normally blastulating counterparts (57% versus 60% in <35 years of age (P = 0.5) and 37% versus 42% in ≥35 years of age (P = 0.3)). An intraclass correlation and a generalized estimating equation corrected for patient age was performed which confirmed these findings. The normalization in cryopreserved ETs indicates that dyssynchrony may be a major adverse factor limiting outcomes with late blastulating embryos in fresh cycles.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study comprising cohorts from a convenient sample chosen due to a uniform change in embryology laboratory protocol regarding ET day, however, this was done independent of the management of embryo and endometrial synchrony. Although strict ultrasound and serum progesterone criteria were utilized to make endometrial receptivity uniform, pathologic states of pre-receptive and post-receptive endometrium cannot be ruled out.

WIDER IMPLICATIONS OF THE FINDINGS

The data surrounding embryo and endometrial synchrony should be considered in patients undergoing IVF and attention to the variations in blastulation rates can be applied to any patient undergoing extended embryo culture.

STUDY FUNDING/COMPETING INTERESTS

None.

Speckle variance OCT for depth resolved assessment of the viability of bovine embryos

The morphology of embryos produced by in vitro fertilization (IVF) is commonly used to estimate their viability. However, imaging by standard microscopy is subjective and unable to assess the embryo on a cellular scale after compaction. Optical coherence tomography is an imaging technique that can produce a depth-resolved profile of a sample and can be coupled with speckle variance (SV) to detect motion on a micron scale. In this study, day 7 post-IVF bovine embryos were observed either short-term (10 minutes) or long-term (over 18 hours) and analyzed by swept source OCT and SV to resolve their depth profile and characterize micron-scale movements potentially associated with viability. The percentage of en face images showing movement at any given time was calculated as a method to detect the vital status of the embryo. This method could be used to measure the levels of damage sustained by an embryo, for example after cryopreservation, in a rapid and non-invasive way.

A Review of The Society for Assisted Reproductive Technology Embryo Grading System and Proposed Modification

The Society for Assisted Reproductive Technology (SART) method of embryo grad- ing is unique, simple, and widely practiced, and its use has been mandatory for SART membership programs since 2010. Developed by SART in 2006, the current embryo grading system categories, "good, fair, and poor," are limited because they do not describe the best 1-2 embryos in the interest of keeping pace with the shift in clinical practice to be more selective and to transfer fewer embryos. This inspired us to conduct a review on the SART embryo grading system. In this retrospective study, the literature on evaluation of human embryo quality in gen- eral, and the SART method of evaluation in particular, were reviewed for the period of 2000 to 2014. A multifaceted search pertaining to methods of embryo grading and trans- fer using a combination of relevant terms [embryo, mammalian, embryo transfer, grade, grading, morphology, biomarkers, SART, and in vitro fertilization (IVF)] was performed. The inclusion and exclusion in this review were dictated by the aim and scope of the study. Two investigators independently assessed the studies and extracted information. A total of 61 articles were reviewed. Very few studies have evaluated the efficacy of the SART embryo grading method. The present study suggests the necessity for revision of the current SART grading system. The system, as it is now, lacks criteria for describing the cohort specific best embryo and thus is of limited use in single embryo transfer. The study foresees heightened descriptive efficiency of the SART system by implementing the proposed changes. Strengths and weaknesses of the SART embryo grading were identified. Ideas for selecting the best cohort-specific embryo have been discussed, which may trigger methodological improvement in SART and other embryo grading systems.

Softening of the mouse zona pellucida during oocyte maturation

A change in the elasticity and the resistance to dissolution of the mouse zona pellucida (ZP) was quantitatively evaluated at immature germinal vesicle (GV), mature metaphase II (MII) and fertilized pronuclear (PN) stages. Young's modulus of the ZP was measured using a micro tactile sensor (MTS), a highly sensitive resonator-based sensor for a micro scale elasticity measurement. 0.25% α-chymotrypsin was used for the ZP dissolution assay. The results of measuring the ZP elasticity and the dissolution time clearly showed that the ZP softened during oocyte maturation and the ZP hardened after fertilization. The results indicate that the amount of the zona softening can be a criterion to evaluate oocyte quality for the selection of top quality mature oocyte before in vitro fertilization (IVF) treatment.

Assisted reproductive technology and risk of congenital malformations: a meta-analysis based on cohort studies

PURPOSE

To assess the association between assisted reproductive technology (ART) and risk of congenital malformations (CM) by conducting a meta-analysis of cohort studies.

METHODS

PubMed, Google Scholar, Cochrane Libraries and Chinese database were searched through August 2014 to identify studies that met pre-stated inclusion criteria. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. Subgroup analysis was performed to explore potential heterogeneity moderators.

RESULTS

Fifty-seven studies involving 119,874 infants conceived following ART and 1,212,320 infants conceived naturally were included in the analysis. The ART-conceived infants were associated with a higher risk of CM [relative risk (RR) = 1.33; 95 % confidence interval (CI) 1.24-1.43] when compared with those conceived naturally. When data were restricted to singleton births (RR = 1.38; 95 % CI 1.30-1.47), major CM (RR = 1.47; 95 % CI 1.29-1.68), matched/adjusted studies (RR = 1.37; 95 % CI 1.27-1.47) or high quality studies (RR = 1.40; 95 % CI 1.27-1.55), the increased risk of CM still existed in ART pregnancies. Additionally, an increased risk of CM was also found when the ART twin (RR = 1.18; 95 % CI 1.06-1.32) or multiple births (RR = 1.16; 95 % CI 1.05-1.27) were separately compared with spontaneously conceived twin or multiple births. Substantial heterogeneity was observed across studies (I (2) = 68, 44, 39, and 33 % for all infants, singletons, twins and multiples, respectively). Whether confounding factors were matched or adjusted, study quality and sample size as the first three of the most relevant heterogeneity moderators have been identified. No evidence of publication bias was observed (P > 0.10).

CONCLUSIONS

The ART-conceived infants have a higher risk of CM compared with those conceived naturally. However, these estimates have to be viewed with caution because of heterogeneity.

Noninvasive embryo viability assessment by quantitation of human haptoglobin alpha-1 fragment in the in vitro fertilization culture medium: an additional tool to increase success rate

OBJECTIVE

To find new candidate molecules to assess embryo viability in a noninvasive manner.

DESIGN

Prospective, blinded study with randomized sample collection.

SETTING

University research center.

PATIENTS(S)

Ninety embryos implanted in 53 randomly selected patients (mean ± SD age, 32.3 ± 5.1 years) were analyzed.

INTERVENTION(S)

Superovulation treatment was initiated by the administration of the GnRh agonist triptorelin and individual dosages of recombinant FSH. Ovulation was induced by the injection of hCG. Oocytes were fertilized by intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Liquid chromatography coupled mass spectrometric quantification of the α-1 fragment of human haptoglobin in the culture medium.

RESULT(S)

A novel polypeptide marker was found that might be helpful to differentiate between potentially viable and nonviable embryos. This molecule was identified with tandem mass spectrometry as the α-1 fragment of human haptoglobin. Significant correlation was found in the amount of the peptide fragment and the outcome of pregnancy. In the culture media of embryos that were assigned in the biochemical assay as nonviable (according to the amount of the haptoglobin fragment), there were no pregnancies detected; this assay revealed a 100% successful selection of the nonviable embryos. In the group assigned as viable, the rate of pregnancy was 54.7%.

CONCLUSION(S)

Viability of the embryo during the IVF process is assessed by microscopic inspection, resulting in a pregnancy rate of 25%-30%. Detection and quantitation of the α-1 haptoglobin fragment of the culture medium proved to be a useful additional method for identifying nonviable embryos, increasing the success rate to 50%.

Using the Society for Assisted Reproductive Technology Clinic Outcome System morphological measures to predict live birth after assisted reproductive technology

OBJECTIVE

To model morphological assessments of embryo quality that are predictive of live birth.

DESIGN

Longitudinal cohort using cycles reported in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) between 2007 and 2011.

SETTING

Clinic-based data.

PATIENT(S)

Fresh autologous assisted reproductive technology (ART) cycles with ETs on day 3 or day 5 and morphological assessments reported (25,409 cycles with one embryo transferred and 96,093 cycles with two embryos transferred). Live-birth rates were modeled by morphological assessments using backward-stepping logistic regression for cycle 1 and over five cycles, separately for day 3 and day 5 transfers and number of embryos transferred (1 or 2). Additional models for each day of transfer also included the number of oocytes retrieved and the number of embryos cryopreserved.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live births.

RESULT(S)

Morphological assessments of grade, stage, fragmentation, and symmetry were significant for the day 3 models; grade, stage, and trophectoderm were significant in the day 5 model; inner-cell mass was significant in the models when two embryos were transferred. Number of oocytes retrieved and number of embryos cryopreserved were significant for both day 3 and day 5 models.

CONCLUSION(S)

These findings confirm the significant association between embryo quality parameters reported to SART CORS and live-birth rate after ART.

Quality evaluation of IVM embryo and imprinting genes of IVM babies

Purpose

Oxygen consumption rates of human embryos derived from in vitro matured (IVM) oocytes and controlled ovarian hyperstimulation (COH) were compared with scanning electrochemical microscopy (SECM) non-invasively in order to answer why embryos from IVM oocytes have lower developmental potential. We also analyzed the epigenetic disorders for IVM babies born in our clinic.

Methods

The oxygen consumption rate was calculated with the SECM system for different maturation stages of human oocytes, IVM and COH embryos. Blood from umbilical cords of IVM babies was collected to examine the imprinting genes.

Results

There were no significant differences in oxygen consumption of embryos at each cleavage stage between IVM and COH (range 0.26–0.56 × 10¹⁴/mol S⁻¹). There also was no abnormality found in expression of imprinting genes in IVM babies.

Conclusions

There are no differences in terms of oxygen consumption between embryos derived from IVM and COH. There was no imprinting gene disorder founded from IVM babies.

The simplified SART embryo scoring system is highly correlated to implantation and live birth in single blastocyst transfers

OBJECTIVE

Prior studies have validated the ability of the SART embryo scoring system to correlate with outcomes in cleavage stage embryo transfers. However, this scoring system has not been evaluated in blastocyst transfers. The objective of this study was to estimate the correlation between the simplified SART embryo scoring system and ART cycle outcomes in single blastocyst transfers.

MATERIALS AND METHODS

All fresh, autologous single blastocyst transfers cycles from a large ART center from 2010 were analyzed. Blastocysts were given a single grade of good, fair, or poor based upon SART criteria which combines the grading of the inner cell mass and trophectoderm. Multiple logistic regression assessed the predictive value of the SART grade on embryo implantation and live birth.

RESULTS

Seven hundred seventeen fresh, autologous single blastocyst transfers cycles were included in the analysis. The live birth rate was 52 % and included both elective and non-elective SBT. Chi square analysis showed higher live birth in good grade embryos as compared to fair (p=0.03) and poor (p=0.02). Univariate binary logistic regression analysis demonstrated SART embryo grading to be significantly correlated with both implantation and live birth (p<0.01). This significance persisted when patient age, BMI, and the stage of the blastocyst were controlled for with multiple logistic regression. In five patients with a poor blastocyst score, there were no live births.

CONCLUSION

These data demonstrate that the SART embryo scoring system is highly correlated to implantation and live birth in single blastocyst transfers. Patients with a good grade embryo are excellent candidates for a single blastocyst transfer.

Morphological systems of human embryo assessment and clinical evidence

Success rates with IVF have improved remarkably since the procedure was first established for clinical use with the first successful birth in 1978. The main goals today are to perform single-embryo transfer in order to prevent multiple pregnancies and achieve higher overall pregnancy rates. However, the ability to identify the most viable embryo in a cohort remains a challenge despite the numerous scoring systems currently in use. Clinicians still depend on developmental rate and morphological assessment using light microscopy as the first-line approach for embryo selection. Active research in the field involves developing non-invasive methods for scoring embryos and ranking them according to their ability to implant and give rise to a healthy birth. Current attention is particularly being focused on time-lapse evaluation. Available data from preliminary studies indicate that these systems are safe;prospective data now need to be collected to determine whether these methods do improve implantation rates. This review gives brief consideration to the use of morphological evaluations in assisted reproduction treatment, discusses the types of embryo scoring,digital imaging and biometric approaches currently in use and comments on future developments for embryo evaluation.

Standardization of grading embryo morphology

Standardization of morphological assessment for embryo grading system was developed and is being implemented by the Society for Assisted Reproductive Technology (SART). A recent European consensus conference of embryologists from Europe and America is working toward adopting an embryo classification system modeled similarly to that of SART which, if adopted, would produce a de facto international standard to aid cross border collaboration.

Pronuclear morphology, embryo development and chromosome constitution

The aim of the present study was to evaluate the usefulness of pronuclear patterns, according to the classifications of Tesarik and Scott, as predictors of embryo chromosome constitution. Up to 73 preimplantation genetic diagnosis/preimplantation genetic screening (PGD/PGS) cycles were analysed in this retrospective study including 17 cycles of translocation carriers and 56 PGS cycles. A total of 331 biopsied embryos were studied assessing pronuclear (PN) pattern, embryo quality and chromosome constitution. As regards to the relationship between PN pattern and embryo quality, the data obtained in this study show no correlation between both parameters. Although there were no significant differences when comparing the distribution of chromosomally normal and abnormal embryos with respect to embryo quality, such differences were observed when distinguishing between normal, aneuploid and polyploid embryos. The results show that the PN pattern using Tesarik's and Scott's classification systems is not related to the embryo developmental potential or its chromosome constitution. Therefore, in the context of a PGD/PGS programme, the PN pattern cannot be used as a tool to predict embryo quality or chromosome status.

MicroRNA expression in preimplantation mouse embryos from Ped gene positive compared to Ped gene negative mice

PURPOSE

The mouse preimplantation embryo development (Ped) gene product, Qa-2, influences the rate of preimplantation embryonic development and overall reproductive success. Here we investigated the expression pattern of two microRNAs, miR-125a and miR-125b, known to be involved in development in lower organisms, in preimplantation embryos from the two-cell, four-cell, eight-cell, morula, and blastocyst stages of development from the congenic B6.K1 (Ped negative) and B6.K2 (Ped positive) strains of mice.

METHOD

B6.K1 and B6.K2 congenic mice differ only in the absence (B6.K1) or presence (B6.K2) of the genes encoding Qa-2 protein. We analyzed the expression of miR-125a and miR-125b in B6.K1 and B6.K2 preimplantation embryos by using real-time PCR.

RESULT

We found no variability in miR-125b expression at any developmental stage in both strains. However, miR-125a expression increased during development in both strains and was ten times higher in Ped negative (B6.K1) embryos than in Ped positive (B6.K2) embryos by the blastocyst stage of development.

CONCLUSION

Our results show that the absence of the Ped gene profoundly affects the level of a miRNA (miR-125a) known to regulate early development. The implication is that miR-125a is likely involved in the regulation of timing of early development in mice.

Genetics and imaging to assess oocyte and preimplantation embryo health

Two major criteria are currently used in human assisted reproductive technologies (ART) to evaluate oocyte and preimplantation embryo health: (1) rate of preimplantation embryonic development; and (2) overall morphology. A major gene that regulates the rate of preimplantation development is the preimplantation embryo development (Ped) gene, discovered in our laboratory. In mice, presence of the Ped gene product, Qa-2 protein, results in a fast rate of preimplantation embryonic development, compared with a slow rate of preimplantation embryonic development for embryos that are lacking Qa-2 protein. Moreover, mice that express Qa-2 protein have an overall reproductive advantage that extends beyond the preimplantation period, including higher survival to birth, higher birthweight, and higher survival to weaning. Data are presented that suggest that Qa-2 increases the rate of development of early embryos by acting as a cell-signalling molecule and that phosphatidylinositol-32 kinase is involved in the cell-signalling pathway. The most likely human homologue of Qa-2 has recently been identified as human leukocyte antigen (HLA)-G. Data are presented which show that HLA-G, like Qa-2, is located in lipid rafts, implying that HLA-G also acts as a signalling molecule. In order to better evaluate the second criterion used in ART (i.e. overall morphology), a unique and innovative imaging microscope has been constructed, the Keck 3-D fusion microscope (Keck 3DFM). The Keck 3DFM combines five different microscopic modes into a single platform, allowing multi-modal imaging of the specimen. One of the modes, the quadrature tomographic microscope (QTM), creates digital images of non-stained transparent cells by measuring changes in the index of refraction. Quadrature tomographic microscope images of oocytes and preimplantation mouse embryos are presented for the first time. The digital information from the QTM images should allow the number of cells in a preimplantation embryo to be counted non-invasively. The Keck 3DFM is also being used to assess mitochondrial distribution in mouse oocytes and embryos by using the k-means clustering algorithm. Both the number of cells in preimplantation embryos and mitochondrial distribution are related to oocyte and embryo health. New imaging data obtained from the Keck 3DFM, combined with genetic and biochemical approaches, have the promise of being able to distinguish healthy from unhealthy oocytes and embryos in a non-invasive manner. The goal is to apply the information from our mouse model system to the clinic in order to identify one and only one healthy embryo for transfer back to the mother undergoing an ART procedure. This approach has the potential to increase the success rate of ART and to decrease the high, and undesirable, multiple birth rate presently associated with ART.

Respiration rates correlate with mRNA expression of G6PD and GLUT1 genes in individual bovine in vitro-produced blastocysts

Quantification of embryo respiration is a promising procedure to assess embryonic metabolism and possibly select viable embryos. At the blastocyst stage, ATP is produced by glycolysis and oxidative phosphorylation, processes that require uptake of oxygen and glucose, which is regulated by the expression of GLUT1 and G6PD. The purpose of the present study was to investigate the relationship between respiration rates and relative abundances of G6PD and GLUT1 transcripts in individual bovine blastocysts produced in vitro. Respiration rates of 104 bovine in vitro-produced blastocysts were measured individually using the nanorespirometer technology. Real-time RT-PCR was employed to determine the relative abundance of G6PD and GLUT1 mRNA in individual embryos. The mean respiration rates were similar for male and female blastocysts of the same developmental stage, but the sex ratio was skewed towards males. GLUT1 expression was down-regulated in female versus male embryos. In contrast, a approximately 1.8-fold increase in the expression of G6PD mRNA was observed in female blastocysts when compared to male blastocysts, indicating that dosage compensation for this gene had not yet occurred. Both GLUT1 and G6PD expression levels were affected by morphological quality and stage of development. Expression of GLUT1 and G6PD mRNAs was correlated with respiration rates, indicating that, in metabolically active blastocysts, uptake of oxygen and glucose are jointly increased. These findings suggest that expression of genes for oxidative phosphorylation and glycolysis are both involved in oxygen demanding ATP production.

Investigation of respiration of individual bovine embryos produced in vivo and in vitro and correlation with viability following transfer

BACKGROUND

Quantification of oxygen consumption by individual preimplantation embryos has the potential to improve embryo selection. This study investigated whether respiration rates of individual embryos are useful indicators of embryo viability. The effect of the Nanorespirometer on embryo viability was also evaluated.

METHODS

The respiration rates of individual day 7 bovine in vivo- (n=44) and in vitro-produced (n=156) embryos were measured using the Nanorespirometer. In vivo-produced embryos were individually transferred to recipients.

RESULTS

The respiration rates of in vivo-produced embryos increased with increasing morphological quality and stage of development (P < 0.05). Pregnancy rates on days 35 and 60 were 65 and 60%, respectively. The mean respiration rate did not differ significantly between embryos producing and not producing a pregnancy, but the transfer of embryos with respiration rates <0.78 nl/h, between 0.78 and 1.10 nl/h, and >1.10 nl/h resulted in 48, 100 and 25% pregnancy rate, respectively. The mean respiration rate of in vitro-produced embryos was higher than that of in vivo-produced embryos because of differences in the morphological quality and stage of development.

CONCLUSION

The Nanorespirometer does not adversely influence embryo viability, but the sample size was too small to confirm the significance of the correlation observed between respiration rates and viability.

Comparison of in-vitro outcomes from cryopreserved oocytes and sibling fresh oocytes

In Italy, the restrictive IVF law generalizes the indication for oocyte freezing for surplus oocytes in 78.5% of in-vitro assisted reproductive cycles. With a view to understanding better what the prospects for intracytoplasmic sperm injection (ICSI) on frozen-thawed oocytes might be, the consequences of freeze-thaw procedures on fertilization, cleavage rates and embryo quality obtained from frozen-thawed oocytes were studied and compared with the results obtained from sibling fresh oocytes. Eleven IVF and 29 ICSI on 76 and 169 fresh oocytes were performed and the corresponding 40 ICSI on 221 sibling frozen-thawed oocytes. There was no difference in terms of fertilization rate between fresh and sibling frozen-thawed oocytes. The cleavage rate (98.0 and 94.4% with fresh oocytes in IVF and ICSI; 77.3% with frozen-thawed oocytes in ICSI; P < 0.001) and embryo quality (grade I embryos over total embryos: 36.7 and 22.2% with fresh oocytes in IVF and ICSI; 12.1% with frozen-thawed oocytes in ICSI; respectively P < 0.001 and P < 0.05) were statistically lower after oocyte cryopreservation. The significant decrease in meiotic spindle retrieval rate before freezing (62.4%) and after thawing procedures (43.4%; P < 0.001) suggests that cryoconservation induces irreversible damage to microtubule repolymerization. The consequences of oocyte cryopreservation procedures on embryo development are reviewed.

Analysis of the sex ratio in preimplantation embryos from B6.K1 and B6.K2 Ped gene congenic mice

PURPOSE

The mouse preimplantation embryo development (Ped) gene product, Qa-2, which is the homolog of human HLA-G, influences the rate of preimplantation embryonic development and overall reproductive success. The sex ratio in preimplantation embryos from Ped gene congenic mice was examined in order to determine whether embryo sex is a confounding factor in the control of the rate of preimplantation development.

METHODS

B6.K1 (Ped slow) and B6.K2 (Ped fast) congenic mice differ only in the absence (B6.K1) or presence (B6.K2) of the genes encoding Qa-2 protein. We analyzed the sex of B6.K1 (n=221) and B6.K2 (n=260) preimplantation embryos by using Real-Time PCR with primers specific for the X and Y chromosomes.

RESULTS

We found that there was no statistically significant difference in the ratio of male to female preimplantation embryos in either strain.

CONCLUSIONS

We conclude that the sex of the embryos is not a confounding factor that affects the Ped gene control of the rate of preimplantation development. Therefore, the Ped gene is entirely responsible for mediating the faster development of B6.K2 embryos compared to B6.K1 embryos.

Fads and foibles in ART: where is the evidence?

This commentary on the scientific basis of laboratory procedures in assisted conception discusses the origins of widespread discrepancies in 'standard' laboratory techniques experienced by patients and their embryos. The lack of direct evidence from clinical laboratory trials and the reasons for this will be highlighted using some examples drawn mainly from embryo culture. Inconsistencies and grey areas in the governance framework of this unique field could usefully be eliminated and attention focused on the need for a rational approach to procedural trials and pilot studies necessarily conducted in clinical laboratories. This may help progress towards a consensus on fundamental questions for which the evidence is currently lacking.

Amino acid depletion and appearance during porcine preimplantation embryo development in vitro

Preimplantation embryos can consume and produce amino acids in a manner dependent upon the stage of development that may be predictive of subsequent viability. In order to examine these relationships in the pig, patterns of net depletion and appearance of amino acids by in vitro produced porcine preimplantation embryos were examined. Cumulus oocyte complexes derived from slaughterhouse pre-pubertal pig ovaries were matured for 40 h in defined TCM-199 medium (containing PVA) before being fertilised (Day 0) with frozen-thawed semen in Tris-based medium. After 6 h, presumptive zygotes were denuded and cultured in groups of 20, in NCSU-23 medium modified to contain 0.1 mM glutamine plus a mixture of 19 amino acids (aa) at low concentrations (0.02-0.11 mM) (NCSU-23(aa)). Groups of 2-20 embryos were removed (dependent on stage) on Day 0 (1 cell), Day 1 (two- and four-cells), Day 4 (compact morulae) and Day 6 (blastocysts) and placed in 4 mul NCSU-23aa for 24 h. After incubation, the embryos were removed and the spent media was analysed by HPLC. The net rate of amino acid depletion or appearance varied according to amino acid (P < 0.001) and, apart from serine and histidine, stage of development (P < 0.014). Glycine, isoleucine, valine, phenylalanine, tryptophan, methionine, asparagine, lysine, glutamate and aspartate consistently appeared, whereas threonine, glutamine and arginine were consistently depleted. Five types of stage-dependent trends could be observed: Type I: amino acids having high rates of net appearance on Day 0 that reached a nadir on Day 1 or 4 but subsequently increased by Day 6 (glycine, glutamate); Type II: those that exhibited lower rates of net appearance on Days 0 and 6 compared with the intermediate Days 1 and 4 (isoleucine, valine, phenylalanine, methionine, arginine); Type III: amino acids which showed a continuous fall in net appearance (asparagine, aspartate); Type IV: those that exhibited a steady fall in net depletion from Day 0 to Day 6 (glutamine, threonine); Type V: those following no discernable trend. Analysis of further embryo types indicated that presumptive polyspermic embryos on Day 0 had increased (P < 0.05) net rates of leucine, isoleucine, valine and glutamate appearance, and reduced (P < 0.05) net rates of threonine and glutamine depletion compared with normally inseminated oocytes. These data suggest that the net rates of depletion and uptake of amino acids by pig embryos vary between a) amino acids, b) the day of embryo development and, c) the type of embryos present at a given stage of development. The results also suggested that the net depletion and appearance rates of amino acids by early pig embryos might be more similar to those of the human than those of the mouse and cow.

Changing genetic world of IVF, stem cells and PGD. A. Early methods in research

Genetics proved essential to introduce IVF, preimplantation diagnosis (PGD) and embryo stem cells in the 1960s. Its small input in early years was confined to aspects such as timing follicle growth and ovulation. Modest understanding in the mid- to late 1980s, mostly on studies in mice, involved the actions of single genes and the balance between maternal and zygotic transcripts in preimplantation stages. Human IVF began after human oocytes were matured in vitro, and their meiotic chromosomes analysed. Their fertilization in vitro led to PGD and embryo stem cells. Unlike mouse embryos, most human embryos failed to implant, so the best had to be selected to improve IVF pregnancy rates. Initially, faster-growing embryos proved superior. Later, patterns of polarized nucleoli in pronuclei, the degree of blastomere fragmentation and growth of embryos in vitro to blastocysts provided excellent markers. Single cells could be isolated from embryos using micromanipulation. Stem cells from inner cell mass, a branch of IVF, differentiated into immortal stem cell lines in vitro if disaggregated. They formed virtually all body tissues in blastocysts cultured intact or when injected singly into recipient blastocysts. Later, the genetic controls of ES cell differentiation were assessed, together with factors switching them along specific differentiation pathways. Marker genes identified ES cells differentiating into various tissues.

An approach to the ethical donation of human embryos for harvest of stem cells

This paper considers embryo grading within a given infertility treatment and suggests an ethical approach to embryo donation for embryonic stem cell harvest. It is concluded that ethical considerations regarding human embryos do not necessarily preclude the use of certain embryos for biomedical research or transplantation. The argument is based on the following rationale: all embryos are not physiologically equal, some low-grade embryos will never be chosen for implantation, cells from low-grade embryos may be donated for transplantation or research, and embryonic stem cells can be harvested from low-grade embryos. This argument bears special importance at this time as embryos created by IVF are still the only source of embryonic stem cells, given the current controversy surrounding published studies of human somatic cell nuclear transfer.

Effect of fragment removal on blastocyst formation and quality of human embryos

Blastomere fragmentation is one of the most significant defects in cleaving embryos. Scientists believed that removing the fragments was a possible way to reduce their unwanted effects. This hypothesis has been tested in some studies in which the development of human fragmented embryos was followed in vivo after all fragments were removed, but little is known about the potential for in-vitro development of such embryos, which is the subject of the present study. For this purpose, 4-6 cell surplus human embryos were scored according to the degree and pattern of fragmentation into four grades, allocated into two groups of control and fragmentation removal (experimental) and cultured sequentially. At the end of day 6 of culture, in the experimental group especially in grade IV blastocyst rate, size and number of blastomeres in each blastocyst were all improved compared with those of the control group (42.3 versus 20.0%; 19,205.7 +/- 1060.3 versus 15,825.9 +/- 448.7 microm(2) and 100.14 +/- 13.48 versus 63.75 +/- 19.79 respectively, P < 0.05). In the grade IV embryos, apoptotic index was also significantly reduced after embryo fragmentation removal (3.40 +/- 0.88 versus 22.99 +/- 4.45, P < 0.05). In conclusion, fragmentation removal had a positive effect on human fragmented embryos and produced the best quality blastocysts.

Rate of cell division and weight of neonates following IVF

The present study tested the hypothesis that embryos with a lower number of cells on day 3 would be associated with infants born of lower weight. Singleton births (n = 447) were analysed to assess mean birth weight according to mean cell number in the transferred cohort. Mean birth weight increased with increasing average cell number. Each increase of one in average cell number was associated with a predicted increase in birth weight of 42.7 g (P = 0.01). This association was present only without assisted hatching, where an increase of one in average cell number was associated with a predicted increase of 79.1 g (P = 0.0005). Intracytoplasmic sperm injection was not associated with any change in birth weight. Demonstration of causality is limited because it is impossible to know which embryo in the transferred group implanted and grew into a fetus. Complete data were also lacking on some factors that influence birth weight. However, our data indicate that mean cell number on day 3 is positively associated with birth weight, but only without assisted hatching. Assisted hatching of slower-cleaving embryos may normalize birth weight distribution to that of faster-cleaving embryos.

Use of both early cleavage and day 2 mononucleation to predict embryos with high implantation potential in intracytoplasmic sperm injection cycles

OBJECTIVE

To evaluate the value of early cleavage and day 2 mononucleation as combined parameters in predicting the implantation potential of embryos.

DESIGN

Prospectively designed retrospective cohort analysis.

SETTING

Private IVF center.

PATIENT(S)

Two hundred eighty-seven ICSI cycles were evaluated in four groups according to the presence of early cleavage and mononucleation in all (ECM), some (pECM, ECpM), or none (noECnoM) of the transfer embryos.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Embryo quality and pregnancy and implantation rates.

RESULT(S)

The cycle characteristics, embryo quality, and pregnancy rates were similar when all (ECM) or some (pECM and ECpM) transfer embryos displayed these parameters. The poorest cycle characteristics and outcome were observed in the absence of both parameters (noECnoM). When early cleavage was present, a higher implantation rate was observed when all transfer embryos displayed mononucleation at day 2 (ECM) than when this was the case only in some (ECpM).

CONCLUSION(S)

Combination of early cleavage and day 2 mononucleation improves selection of embryos with high implantation potential in ICSI cycles with good prognosis.

Respiration rates of individual bovine in vitro-produced embryos measured with a novel, non-invasive and highly sensitive microsensor system

Oxygen consumption is a useful parameter for evaluating embryo quality, since it provides a valuable indication of overall metabolic activity. Over the years, several approaches have been used to measure the respiration rates of individual embryos, but a convincing method has not yet been reported. In this study, we introduce and have validated a novel high resolution microsensor technology to determine the respiration rates of individual embryos at different developmental stages. We have employed this technology to investigate the correlation between respiration rate and embryo morphology, diameter and sex. Following morphological evaluation, individual respiration rates of day 3 (n= 18) and day 7 (n= 60) bovinein vitro-produced embryos were determined. Of the measured embryos, 64 were lysed for sex diagnosis by PCR. Average respiration rates of day 7 embryos (1.30 ± 0.064 nl/h) were 3.4-fold higher than day 3 embryos (0.38 ± 0.011 nl/h). On day 7, the average respiration rate of quality 1 blastocysts was significantly higher than the respiration rates of the lower qualities. For both day 3 and day 7 embryos, respiration rates were directly influenced by embryo diameter but did not differ between sexes. These results have demonstrated that the novel microsensor technology can be used to accurately and rapidly (8 min) measure the respiration rates of individual embryos at different developmental stages. Respiration rates were only in partial agreement with embryo morphology, suggesting a slight discrepancy between these two methods in assessing embryo quality. It is likely that a combined assessment of embryo respiration and morphology would improve embryo classification and subsequent selection.

Polar body morphology and spindle imaging as predictors of oocyte quality

It has been suggested that first polar body (PBI) morphology reflects oocyte competence. Oocytes with an intact normal-sized PBI have been described as generating better day 2 embryos, higher blastocyst yield, and increased pregnancy and implantation rates. In other studies, PBI morphology was found to be unrelated to fertilization rate, embryo quality, and blastocyst formation. In a prospective analysis, the predictive value of the PBI was investigated by comparing the development of oocytes retrieved from intracytoplasmic sperm injection patients and displaying different PBI morphology, classified according to the following characteristics: normal size and smooth surface (I), fragmented (II), rough surface (III), or large size (IV). Fertilization rates were 59, 57, 64 and 60% respectively. No significant differences were found between the various groups. The proportions of high quality (grade A) day 2 embryos were also comparable among groups I-III (14, 12 and 17% respectively), while the low number of grade A embryos in group IV (two embryos) did not allow comparison with the other classes. These data do not suggest that PBI selection can contribute to identification of embryos with high developmental ability. In order to establish alternative criteria for oocyte selection, a metaphase II (MII) spindle analysis was also conducted via Polscope. In oocytes of patients of different age, spindle retardance (which reflects the high order and density of microtubules) was compared with parameters of embryo development. In aged patients, a trend was observed between low retardance and poor embryo quality, although in general the association between retardance and oocyte developmental performance did not reach statistical significance.

Predictive factors for embryo implantation potential

In spite of recent improvements in IVF, pregnancy rates have not increased significantly and one of the major problems remains the high multiple pregnancy rate. Better criteria are therefore necessary to establish the viability of a transferable embryo. Early prognosis of the developmental fate of the oocyte would help in selecting the best embryos to transfer, but non-invasive selection at the oocyte stage (extracytoplasmic and intracytoplasmic morphology) has proved to be of little prognostic value. Recently, it has been shown that follicular vascularization appears to be predictive of oocyte developmental fate, making it a good first-step approach for selection. Observation of pronuclei patterns at the zygote stage appears to offer an additional prognostic tool, correlating well with IVF outcome. Morphological evaluation of the embryo at days 2-3 remains the most used and valid method of selection, even though it is not sufficient to select embryos with the higher implantation potential. Blastocyst culture is another possible strategy for selecting the best embryos with reduced risk of aneuploidies, though not all major chromosomal aberrations are excluded by prolonged in-vitro culture. In summary, selecting the best embryo for transfer is a decision that should be based on choices made during the different stages of assisted reproductive technologies.

Combinatorial peptide library binding of mammalian spermatozoa identifies a ligand (HIPRT) in the axin protein: putative identification of a sperm surface axin binding protein and intriguing developmental implications

The identification of components in cell-cell interactions is an important research goal in reproductive and developmental biology. Such interactions are critical to gamete development, fertilization, implantation and basic development. Several proteins involved with sperm-oocyte interaction and other developmentally important phenomena have been identified. However, these are obviously only a subset of the molecular components involved in such complex cell-cell interactions. One method that has been used to identify binding partners for particular molecular targets is the use of combinatorial libraries accessible on phage surfaces. For the most part, this technique has mainly been applied to screen specific target moieties. However, in some cases whole-cell screening has been attempted. This study describes the first report of screening intact, living mammalian gametes using a proprietary whole-cell combinatorial library binding and analysis protocol. Results from the first screening protocol of mouse spermatozoa strongly identified a putative sperm-binding ligand using proprietary bioinformatic analysis. This amino acid sequence (HIPRT) precisely corresponds with a previously characterized highly conserved protein-protein interaction site in the axin protein. This sequence is found within the binding site for a known sperm surface protein, glycogen synthase kinase-3. This result not only provides proof of the utility of this technique to identify cell surface ligands in mammalian gametes, but it also suggests a potential role for spermatozoa in facilitating developmental axis formation in mammalian embryos.

Artificial Reproductive Technology Achievements for Optimizing Embryo Quality

Evaluation of morphological characteristics, to date, has been the most widely accepted method for the selection of embryos with higher developmental ability and optimization of the outcome of in vitro fertilization (IVF). Improvement in clinical results has also been pursued through attempts to generate embryos of high quality or to identify more reliable selection criteria. This work evaluates the possibility of improving embryo quality and subsequent IVF outcome in situations in which creation of supernumerary embryos is not allowed. Optimization of gamete selection and conditions of insemination, such as hormonal therapy to improve sperm quality of patients undergoing intracytoplasmic sperm injection treatment, use of power Doppler image for follicle selection, short coincubation of gametes during insemination, and use of a polscope for spindle detection, is described.

Early embryo development is an indicator of implantation potential

To maximize the chances of pregnancy during assisted reproduction treatment, it is important to be able to identify embryos with high implantation potential. Embryos which divide more quickly following insemination have been shown to produce higher pregnancy and implantation rates than those which divide later. The aim of this study was to compare the developmental potential of early cleaving embryos with those in which the pronuclear membranes had broken down at the time of scoring. Normally fertilized zygotes (n = 2447) were assessed 25-27 h post-insemination and categorized according to developmental stage (pronuclei visible, no pronuclei, or early cleavage to two cells). Pregnancy and implantation rates were assessed in cycles where embryos selected for transfer were at an equivalent stage 25-27 h post-insemination. A significantly higher implantation rate was achieved following transfer of either early cleavage embryos or those which had no pronuclei compared with embryos with intact pronuclei when assessed 25-27 h post-insemination/microinjection. The correlation between early cleavage and an improved pregnancy and implantation rate was confirmed. Scoring for the presence of early cleavage or status of pronuclei is quick and objective and provides information that may be used to discriminate between morphologically equivalent embryos at a later stage in development.

Perinatal outcome among singleton infants conceived through assisted reproductive technology in the United States

OBJECTIVE

To examine perinatal outcome among singleton infants conceived with assisted reproductive technology (ART) in the United States.

METHODS

Subjects were 62,551 infants born after ART treatments performed in 1996-2000. Secular trends in low birth weight (LBW), very low birth weight (VLBW), preterm delivery, preterm LBW, and term LBW were examined. Detailed analyses were performed for 6,377 infants conceived in 2000. Observed numbers were compared with expected using a reference population from the 2000 U.S. natality file. Adjusted risk ratios were calculated.

RESULTS

The proportion of ART singletons born LBW, VLBW, and term LBW decreased from 1996 to 2000. The proportion delivered preterm and preterm LBW remained stable. After adjustment for maternal age, parity, and race/ethnicity, singleton infants born after ART in 2000 had elevated risks for all outcomes in comparison with the general population of U.S. singletons: LBW standardized risk ratio 1.62 (95% confidence interval 1.49, 1.75), VLBW 1.79 (1.45, 2.12), preterm delivery 1.41 (1.32, 1.51), preterm LBW 1.74 (1.57, 1.90), and term LBW 1.39 (1.19, 1.59). Risk ratios for each outcome remained elevated after restriction to pregnancies with only 1 fetal heart or any of 7 other categories: parental infertility diagnosis of male factor, infertility diagnosis of tubal factor, conception using in vitro fertilization without intracytoplasmic sperm injection or assisted hatching, conception with intracytoplasmic sperm injection, conception in a treatment with extra embryos available, embryo culture for 3 days, and embryo culture for 5 days.

CONCLUSION

Singletons born after ART remain at increased risk for adverse perinatal outcomes; however, risk for term LBW declined from 1996 to 2000, whereas preterm LBW was stable.

LEVEL OF EVIDENCE

III

Transfer of early-cleaved embryos increases implantation rate in patients undergoing ovarian stimulation and ICSI–embryo transfer

The hypothesis that inspection for early cleavage improves pregnancy rate by aiding selection of the best embryos for transfer was tested in this study. Inspection for early cleavage was performed randomly in women undergoing intracytoplasmic sperm injection (ICSI) cycles. No differences were observed between early cleavage-inspected and uninspected embryos. When the hypothesis that transfer of early-cleaved (EC) embryos yields a higher pregnancy rate than transfer of late-cleaved (LC) embryos was tested using early cleavage-inspected cycles, it was found that transfer of EC embryos resulted in a higher implantation rate than transfer of LC embryos. In transfers for which all embryos were EC (100% EC), transfer of fewer embryos yielded a higher implantation rate compared with LC and uninspected cycles. These results indicate that, when inspected, early cleavage increases the implantation rate in ICSI patients.

Improvement of IVF results and optimisation of quality control by using intermittent activity

For several years the present authors' team had not been satisfied with the pregnancy rate achieved by their unit, especially in comparison with the results achieved by other teams with a similar population. A quality programme was established, and it was decided to switch from non-stop to intermittent activity. It was envisaged that this programme would provide a more realistic view of the team's activity and could also, as a secondary effect, improve its results. The team's experience of an in-series organization was presented for the management of 408 consecutive infertile couples, during 2002. The results obtained during 2002 were compared with those for two previous years. There was a significant increase (P < 0.01) in the clinical pregnancy rate per oocyte retrieval from 28.9% (2000) and 25.2% (2001) to 41% (2002) in IVF and from 23% (2000) and 26% (2001) to 38.5% (2002) in intracytoplasmic sperm injection (ICSI). A significant increase (P < 0.01) was also observed in the implantation rate, from 14.8% and 13.4% to 20% in IVF and from 12.1% and 12.9% to 23.5% in ICSI. The higher pregnancy rate was achieved without an increase in the multiple pregnancy rate. In conclusion, recent data support the hypothesis that the use of a quality management system, can, as in this case, have positive repercussions on pregnancy rates.

Experimental results on the recognition of embryos in human assisted reproduction

The recognition of embryos suitable for transfer in human assisted reproduction is important, and there is evidence that the morphology of the cells may influence the results achievable. A procedure for this recognition problem has been formulated based on morphological attributes of the images of the embryos, and it is therefore useful to compare the recognition of experts with that of a machine programme. The aim of this paper is to compare the precision in the recognition of viable embryos by a group of experts to that of a machine recognition procedure, both for a basic set of embryos and a blind set. Experts were asked to classify the images of 249 embryos transferred to 73 patients, indicated as the training set and another set of 103 embryos transferred to 35 patients called the blind set. A machine programme was used for the same classification. For all the experts the results were statistically not significantly different from independence, which means that viable embryos are not recognized as such for both data sets. Instead, the machine algorithm recognizes in a statistically significant way, the membership class for the embryos submitted. Cell morphology is important for IVF, but differences do not appear to be discernable by the senses, clinical insight, experience and/or training, while classification by machine methods provides more accurate results, which could be improved by enlarging the training set.