Embryo quality and developmental potential is compromised by age

Effect of cytoplasmic fragmentation on embryo development, quality, and pregnancy outcome: a systematic review of the literature

The role of cytoplasmic fragmentation in human embryo development and reproductive potential is widely recognized, albeit without standard definition nor agreed upon implication. While fragmentation is best understood to be a natural process across species, the origin of fragmentation remains incompletely understood and likely multifactorial. Several factors including embryo culture condition, gamete quality, aneuploidy, and abnormal cytokinesis seem to have important role in the etiology of cytoplasmic fragmentation. Fragmentation reduces the volume of cytoplasm and depletes embryo of essential organelles and regulatory proteins, compromising the developmental potential of the embryo. While it has been shown that degree of fragmentation and embryo implantation potential are inversely proportional, the degree, pattern, and distribution of fragmentation as it relates to pregnancy outcome is debated in the literature. This review highlights some of the challenges in analysis of fragmentation, while revealing trends in our evolving knowledge of how fragmentation may relate to functional development of the human embryos, implantation, and pregnancy outcome.

Correlation of female age with outcome of IVF in a low-resource setting

OBJECTIVE

To determine the effect of female age on pregnancy outcome after in vitro fertilization/embryo transfer (IVF-ET).

METHODS

A prospective study was conducted involving 266 women who had IVF-ET at Nisa Fertility and Genetic Center, Abuja, Nigeria. All eligible consenting women were recruited to the study. The main outcome measure was clinical pregnancy. Data were analyzed using IBM SPSS Statistics version 25. P < 0.05 at 95% confidence intervals was taken as significant.

RESULTS

A total of 266 patients were recruited and included in the study; 104 pregnancies were recorded, giving an overall pregnancy rate of 39.1%. The age range of the patient was 26-43 years (mean age 33.9 ± 2.41 years) while the mean number of embryo transfers per patient was 2.2. The clinical pregnancy rate for women aged below 30 years was 69.4% while the pregnancy rate for patients aged 30-34 years, 35-39 years, and 40-43 years was 52.6%, 24.7%, and 9.4%, respectively (P < 0.0001).

CONCLUSION

The study found that the success rate of IVF-ET decreases significantly in women aged over 34 years. Women should be counseled about the age-related risk of infertility and referred to a fertility center as early as possible.

Risk Factors of Pregnancy Failure in Infertile Patients Undergoing Assisted Reproductive Technology

Background

Infertile couples need to use assisted reproductive technology (ART) to give birth. However, pregnancy failure after ART is not uncommon. At present, the results of studies on the causes of pregnancy failure after ART are inconsistent.

Methods

A retrospective cohort study involving 715 embryo transfer cycles was conducted at the Reproductive Medicine Center of Meizhou People's Hospital, from December 2015 to June 2022. According to the pregnancy, they were divided into clinical pregnancy group and pregnancy failure group. The relationship between demographic characteristics and pregnancy status between the two groups was analyzed.

Results

The pregnancy failure rate after ART was 49.7% (355/715). There were statistically significant distribution differences of maternal age, paternal age, COH protocols, and number of embryos transferred between clinical pregnancy and pregnancy failure groups (all P<0.01). Multiple logistic regression analysis shows that high maternal age (>35 years old vs ≤35 years old: OR 2.173, 95% CI: 1.386-3.407, P=0.001), and GnRH-a short protocol (GnRH-a short protocol vs GnRH-a long protocol: OR 2.139, 95% CI: 1.127-4.058, P=0.020) may increase risk of pregnancy failure in ART pregnancies, while two embryos transferred (two embryos transferred vs one embryo transferred: OR 0.563, 95% CI: 0.377-0.839, P=0.005) may reduce risk of pregnancy failure. In addition, high maternal age, GnRH antagonist protocol, and GnRH-a short protocol may increase risk of implantation failure, while two embryos transferred may reduce risk of implantation failure. And high maternal age may increase risk of biochemical pregnancy.

Conclusion

The risk of pregnancy failure increased in ART cycles with maternal age >35 years old and GnRH-a short protocol, while reduced with two embryos transferred.

Embryo morphologic quality in relation to the metabolic and cognitive development of singletons conceived by in vitro fertilization and intracytoplasmic sperm injection: a matched cohort study

BACKGROUND

Embryos with higher morphologic quality grading may have a greater potential to achieve clinical pregnancy that leads to a live birth regardless of the type of cleavage-stage embryos or blastocysts. Few studies have investigated the impacts of embryo grading on the long-term health of the offspring.

OBJECTIVE

This pilot study aimed to examine the associations between embryo morphologic quality and the physical, metabolic, and cognitive development of singletons conceived by in vitro fertilization and intracytoplasmic sperm injection at preschool age.

STUDY DESIGN

This matched cohort study included singletons born to infertile couples who underwent fresh cleavage-stage embryo transfer cycles with good- or poor-quality embryos from 2014 to 2016 at the reproductive center of the Women's Hospital, School of Medicine, Zhejiang University. A total of 144 children, aged 4 to 6 years, participated in the follow-up assessment from 2020 to 2021, and the response rate of poor-quality embryo offspring was 39%. Singletons in the good-quality embryo group were matched with singletons in the poor-quality embryo group at a 2:1 ratio according to the fertilization method and the children's age (±1 year). We measured the offspring's height, weight, body mass index, blood pressure, thyroid hormone levels, and metabolic indicators. Neurodevelopmental assessments were performed using the Chinese version of the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition, and the Adaptive Behavior Assessment System, Second Edition. We also collected data from the medical records. A linear regression model was used to analyze the association between embryo morphologic quality and offspring health outcomes.

RESULTS

A total of 48 singletons conceived with poor-quality embryo transfer and 96 matched singletons conceived with good-quality embryo transfer were included in the final analysis. Age, sex, height, weight, body mass index, blood pressure, thyroid function, and metabolic indicators were comparable between the 2 groups. After adjustment for potential risk factors by linear regression model 1 and model 2, poor-quality embryo offspring exhibited a tendency toward higher free thyroxine levels than offspring of good-quality embryo transfers (beta, 0.22; 95% confidence interval, 0.09-0.90; beta, 0.22; 95% confidence interval, 0.09-0.91, respectively), but this difference was not clinically significant. Regarding neurodevelopmental assessments, there was no difference in the full-scale intelligence quotient based on the Wechsler Preschool and Primary Scale of Intelligence (109.96±12.42 vs 109.60±14.46; P=.88) or the general adaptive index based on the Adaptive Behavior Assessment System (108.26±11.70 vs 108.08±13.44; P=.94) between the 2 groups. The subindices of the 2 tests were also comparable. These findings remained after linear regression analysis.

CONCLUSION

At 4 to 6 years of age, singletons born from poor-quality embryo transfers have comparable metabolic and cognitive development as those born from good-quality embryo transfers using fresh cleavage-stage embryos. The results of this pilot study indicate that poor-quality embryos that can survive implantation and end in live birth are likely to have a developmental potential comparable to that of good-quality embryos.

C. elegans as a model organism to study female reproductive health

Female reproductive health has been historically understudied and underfunded. Here, we present the advantages of using a free-living nematode, Caenorhabditis elegans, as an animal system to study fundamental aspects of female reproductive health. C. elegans is a powerful high-throughput model organism that shares key genetic and physiological similarities with humans. In this review, we highlight areas of pressing medical and biological importance in the 21st century within the context of female reproductive health. These include the decline in female reproductive capacity with increasing chronological age, reproductive dysfunction arising from toxic environmental insults, and cancers of the reproductive system. C. elegans has been instrumental in uncovering mechanistic insights underlying these processes, and has been valuable for developing and testing therapeutics to combat them. Adopting a convenient model organism such as C. elegans for studying reproductive health will encourage further research into this field, and broaden opportunities for making advancements into evolutionarily conserved mechanisms that control reproductive function.

Effects of embryo density on cell number of day 3 embryos cultured in a 30-μl drop: a retrospective cohort study

For individual cultures, findings on regulating embryo density by changing the microdrop volume are contradictory. The aim of this study was to investigate the relationship between embryo density and the developmental outcome of day 3 embryos after adjusting covariates. In total, 1196 embryos from 206 couples who had undergone in vitro fertilization treatment were analyzed retrospectively. Three embryo densities were used routinely, i.e. one embryo in a drop (30 μl/embryo), two embryos in a drop (15 μl/embryo) and three embryos in a drop (10 μl/embryo). Embryo quality on day 3 was evaluated, both the cell number of day 3 embryos and the proportion of successful implantations served as endpoints. Maternal age, paternal age, antral follicles and level of anti-Müllerian hormone, type of infertility, controlled ovarian stimulation protocol, length of stimulation, number of retrieved oocytes, number of zygotes (two pronuclei) and insemination type were covariates and adjusted. After adjusting fully for all covariates, the cell number of day 3 embryos was significantly increased by 0.40 (95% CI 0.00, 0.79; P = 0.048) and 0.78 (95% CI 0.02, 1.54; P = 0.044) in the 15 μl/embryo and 10 μl/embryo group separately, compared with the 30 μl/embryo group. The proportions of implanted embryos were 42.1%, 48.7% and 0.0% in the 30 μl/embryo, 15 μl/embryo and 10 μl/embryo groups respectively. There was no statistical significance (P = 0.22) between the 30 μl/embryo group and the 15 μl/embryo group. After adjusting for confounders that were significant in univariate analysis, embryo density was still not associated with day 3 embryo implantation potential (P > 0.05). In a 30-μl microdrop, culturing embryos with an embryo density of both 15 and 10 μl/embryo increased the cell number of day 3 embryos, which did not benefit embryo implanting potential, compared with individual culture of 30 μl/embryo.

Critical Analysis of The Changes in CFM Resolution 2294/21 And Its Impacts on Assisted Human Reproduction

The Brazilian Federal Board of Medicine (CFM) issued resolution number 2294/21, which regulates human reproduction procedures in Brazil, bringing significant changes to clinical practice in assisted human reproduction, and it raised ethical, bioethical, and legal discussions between professionals and patients. This study aims to analyze these changes in different aspects, especially because some of them are controversial. Evidence-based knowledge resources were used to support the analyses of crucial points that were impacted by this change. A literature review was carried out to obtain information about guidelines and laws, as well as articles that contemplate ethical discussions on assisted reproduction. The search sites used were BVS, Pub Med, LILACS and Google Scholar. The keywords used were law, legislation, bioethics, reference guide and assisted human reproduction. Relevant official documents from the Brazilian State were also found and included in the survey. The new resolution regarding the use of assisted reproduction techniques brought important changes, with clinical implications for couples who wish to become pregnant, and there is a need for a broad discussion concerning these repercussions from clinical, ethical, bioethical, and legal points of view.

Embryo Density and Its Neutrality in Day-3 Embryo Development: A Retrospective Cohort Study

INTRODUCTION

Many studies have shown that embryo density has an impact on day-3 embryo-developmental outcomes; however, embryo density remains controversial in clinical practice. We aimed to evaluate the association between embryo density and day-3 embryo-developmental outcomes in real world with the largest sample size.

METHODS

In 2018, we identified 10941 day-3 embryos from all female patients (n = 1568) in the study. The embryos were allocated to three embryonic densities: 30 μl/embryo (individual culture), 15 μl/embryo, and 10 μl/embryo (group culture). The primary outcomes were cleaving speed, quality, and proportion of successful implantations. The generalized estimate equation (GEE) model was used both in the univariate analysis and multivariable logistic regression analyses to investigate the relationship between embryo density and embryo-developmental outcomes.

RESULTS

There were 3064, 5695, and 2182 embryos in the 30 μl/embryo group, 15 μl/embryo group, and 10 μl/embryo group, respectively. The proportions of 7-10 cell embryos were 57.2%, 56.1%, and 58.3% in three densities with no statistical significance (P=0.37), respectively. The proportions of morphologically good embryos were 20%, 20.3%, and 20% in three densities with no statistical significance (P=0.85), respectively. Proportions of implanted embryos were 37.7%, 37.1%, and 27.8% with no statistical significance (P=0.36), respectively. After adjustment for confounders, which were significant in the univariate analysis, the embryo density was still not associated with day-3 embryo-cleaving speed, day-3 embryo quality, and day-3 embryo-implanting potential (all P > 0.05).

CONCLUSION

In a 30 μl microdrop, the culturing embryos with embryo densities of 15, 10, and 30 μl/embryo (from zygotes to day 3) had similar developmental outcomes. The embryo density had no impact on day-3 embryo development.

The role of cellular senescence in female reproductive aging and the potential for senotherapeutic interventions

BACKGROUND

Advanced maternal age is associated with decreased oocyte quantity and quality as well as uterine and placental dysfunctions. These changes lead to infertility, pregnancy complications and birth defects in the offspring. As the mean age of giving birth is increasing worldwide, prevention of age-associated infertility and pregnancy complications, along with the more frequent use of ART, become extremely important. Currently, significant research is being conducted to unravel the mechanisms underlying female reproductive aging. Among the potential mechanisms involved, recent evidence has suggested a contributing role for cellular senescence, a cellular state of irreversible growth arrest characterized by a hypersecretory and pro-inflammatory phenotype. Elucidating the role of senescence in female reproductive aging holds the potential for developing novel and less invasive therapeutic measures to prevent or even reverse female reproductive aging and increase offspring wellbeing.

OBJECTIVE AND RATIONALE

The review will summarize the positive and negative implications of cellular senescence in the pathophysiology of the female reproductive organs during aging and critically explore the use of novel senotherapeutics aiming to reverse and/or eliminate their detrimental effects. The focus will be on major senescence mechanisms of the ovaries, the uterus, and the placenta, as well as the potential and risks of using senotherapies that have been discovered in recent years.

SEARCH METHODS

Data for this review were identified by searches of MEDLINE, PubMed and Google Scholar. References from relevant articles using the search terms ‘Cellular Senescence’, ‘Aging’, ‘Gestational age’, ‘Maternal Age’, ‘Anti-aging’, ‘Uterus’, ‘Pregnancy’, ‘Fertility’, ‘Infertility’, ‘Reproduction’, ‘Implant’, ‘Senolytic’, ‘Senostatic’, ‘Senotherapy’ and ‘Senotherapeutic’ where selected. A total of 182 articles published in English between 2005 and 2020 were included, 27 of which focus on potential senotherapies for reproductive aging. Exclusion criteria were inclusion of the terms ‘male’ and ‘plants’.

OUTCOMES

Aging is a major determinant of reproductive wellbeing. Cellular senescence is a basic aging mechanism, which can be exploited for therapeutic interventions. Within the last decade, several new strategies for the development and repurposing of drugs targeting senescent cells have emerged, such as modulators of the anti-inflammatory response, oxidative stress, DNA damage, and mitochondria and protein dysfunctions. Several studies of female reproductive aging and senotherapies have been discussed that show promising results for future interventions.

WIDER IMPLICATIONS

In most countries of the Organization for Economic Co-operation and Development, the average age at which women give birth is above 30 years. Currently, in countries such as the Netherlands, Australia, Spain, Finland, Germany and the UK, birth rates among 30- to 34-year-olds are now higher than in any other age groups. This review will provide new knowledge and scientific advancement on the senescence mechanisms during female reproductive aging, and benefit fundamental and clinical scientists and professionals in the areas of reproduction, cancer, immunobiology and fibrosis.

Risk Factors for Different Types of Pregnancy Losses: Analysis of 15,210 Pregnancies After Embryo Transfer

OBJECTIVE

To evaluate the risk factors for different types of pregnancy losses after embryo transfer (ET).

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine center.

PARTICIPANTS

A total of 15,210 pregnancies after fresh and frozen-thawed embryo transfer between January 2014 and June 2019.

MAIN OUTCOME MEASURES

The primary outcome was pregnancy loss (PL) throughout the entire pregnancy. Secondary outcomes were non-visualized PL, early miscarriage, late miscarriage, and stillbirth.

METHODS

The effect of patients' baseline characteristics and IVF/ICSI cycle-specific factors on the risk of PL after fresh and frozen-thawed ET was determined by multivariate logistic regression analysis.

RESULTS

Compared to women under 35 years old, those between 35 and 40 had an increased risk of early miscarriage [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.22-1.83], while those after 40 appeared to have an increased risk of both early miscarriage (OR 3.82, 95% CI 2.65-5.51) and late miscarriage (OR 2.79, 95% CI 1.64-4.77). Overweight patients were observed to have a higher risk of late miscarriage (OR 1.38, 95% CI 1.16-1.65), while obese patients showed a higher risk of both early miscarriage (OR 1.47, 95% CI 1.14-1.91) and late miscarriage (OR 1.80, 95% CI 1.33-2.44). Polycystic ovary syndrome (PCOS) was an independent risk factor for late miscarriage (OR 1.58, 95% CI 1.28-1.96), and the detrimental effect of PCOS was independent of obesity status. Women with uterine factors had a higher risk of early miscarriage (OR 1.77 (95% CI 1.32-2.38) than women without uterine factors. A negative correlation was observed between the thickness of the endometrium and PL (OR 0.95 95% CI 0.92-0.97). There was an increased risk of PL after frozen-thawed ET versus fresh ET (OR 1.12, 95% CI 1.01-1.24). Women who transferred ≥2 embryos showed lower risk of overall PL than women who transferred a single embryo, with adjusted ORs ranged from 0.57~0.94. However, women who transferred three embryos demonstrated a higher risk of late miscarriage than women who transferred a single embryo (OR 2.23, 95% CI 1.36-3.66).

CONCLUSIONS

Patients with uterine factors demonstrated higher risk of early miscarriage and stillbirth. Being overweight, PCOS, and transferring three embryos was associated with late miscarriage. Being aged 40 and over, obese, and using frozen embryo transfer was associated with early and late miscarriage.

Paternal Age Does Not Influence the Outcomes of Assisted Reproduction in Donor Oocyte Cycles

Purpose: To study effect of paternal age on pregnancy outcomes of intracytoplasmic sperm injections (ICSI).

Methods: The present study is a retrospective analysis of 153 ICSI cycles on donor oocytes. The effect of paternal age on fertilization rates, implantation rates, total pregnancy rates, number of miscarriages and live births were analyzed.

Results: 1422 donor oocytes were injected with sperm from 153 men. Linear regression analysis revealed no association between paternal age (28-54 years) and fertilization rate. No association was found between the embryo quality and paternal age. Of the 359 embryos transferred, linear regression analysis revealed no association between paternal age and implantation rate. After correcting for maternal age, binary logistic regression analysis revealed no association between total pregnancy rates (B = 0.943, CI 0.861-1.033, P = 0.205), live birth rates (B = 1.018, CI 0.896-1.158, P = 0.562) and miscarriage rates (B = 0.944, CI 0.866-1.029, P = 0.193) and paternal age.

Conclusion: Paternal age does not seem to influence outcomes in assisted reproduction.

Statistical Modelling Outcome of In Vitro Fertilization and Intracytoplasmic Sperm Injection: A Single Centre Study

BACKGROUND

Assisted reproductive techniques (ART) have been extensively used to treat infertility. Inaccurate prediction of a couple's fertility often leads to lowered self-esteem for patients seeking ART treatment and causes fertility distress.

OBJECTIVE

This prospective study aimed to statistically analyze patient data from a single reproductive medical center over a period of 18 months, and to establish mathematical models that might facilitate accurate prediction of successful pregnancy when ART are used.

METHODS

In the present study, we analyzed clinical data prospectively collected from 760 infertile patients visiting the second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University between June 1, 2016 and December 31, 2017. Various advanced statistical methods, including broken-line regression, were employed to analyze the data.

RESULTS

Age remained the most important factor affecting the outcome of IVF/ICSI. Using the broken-line regression model, the fastest clinical pregnancy declining age was between 25 and 32. Female infertility type was found to be a key predictor for the number of good-quality embryos and successful pregnancy, along with the antral follicle count (AFC), total number of embryos, recombinant follicle stimulating hormones (rFSH) dosage, estradiol (E2) on the trigger day, and total number of oocytes retrieved. rFSH dosage was also significantly associated with the number of oocytes retrieved and the number of frozen embryos.

CONCLUSION

The fastest clinical pregnancy declining age is ranged between 25 and 32, and female infertility type is evidenced as another key predictive factor for the cumulative outcome of ART.

The BlastGen study: a randomized controlled trial of blastocyst media supplemented with granulocyte-macrophage colony-stimulating factor

RESEARCH QUESTION

Does Embryogen®/BlastGen™ culture medium improve live birth rates compared with standard culture medium for women undergoing IVF and intracytoplasmic sperm injection (ICSI) with poor prognosis.

DESIGN

Randomized clinical trial. A total of 100 couples undergoing IVF/ICSI were randomly allocated to having their inseminated oocytes incubated in either Embryogen®/BlastGen™ sequential culture media or standard Cleavage/Blastocyst sequential culture media for 5 days (ClinicalTrials.gov Identifier: NCT02305420).

RESULTS

No statistically significant difference in live birth rate was found between the control group and the Embryogen®/BlastGen™ group (17 [34%] versus 11 [22%], respectively) (OR 0.55; 95% CI 0.22 to 1.32; P = 0.18). After adjustment for maternal age, body mass index and fertilization procedure, the blastulation rate reduced (40.6 ± 26.5 versus 24.6 ± 26.7; RR 0.70, CI 0.52 to 0.95; P < 0.05), and grade of the embryo transferred (OR 0.35, CI 0.16 to 0.77; P < 0.01) when Embryogen®/BlastGen™ medium was used.

CONCLUSION

A significant reduction in day-5 embryo outcome parameters was found using Embryogen®/BlastGen™ compared with standard medium, and insufficient evidence of a difference in pregnancy outcomes. Taking into consideration the small samples size, study limitations and strict inclusion criteria of this single-centre study, further research is needed to determine the efficacy of Embryogen®/BlastGen™ medium in couples undergoing IVF/ICSI.

Effects of paternal age on human embryo development in in vitro fertilization with preimplantation genetic screening

OBJECTIVE

As paternal age increases, the quality of sperm decreases due to increased DNA fragmentation and aneuploidy. Higher levels of structural chromosomal aberrations in the gametes ultimately decrease both the morphologic quality of embryos and the pregnancy rate. In this study, we investigated whether paternal age affected the euploidy rate.

Methods

This study was performed using the medical records of patients who underwent in vitro fertilization (IVF) procedures with preimplantation genetic screening (PGS) from January 2016 to August 2017 at a single center. Based on their morphological grade, embryos were categorized as good- or poor-quality blastocysts. The effects of paternal age were elucidated by adjusting for maternal age.

RESULTS

Among the 571 total blastocysts, 219 euploid blastocysts were analyzed by PGS (38.4%). When the study population was divided into four groups according to both maternal and paternal age, significant differences were only noted between groups that differed by maternal age (group 1 vs. 3, p=0.031; group 2 vs. 4, p=0.027). Further analysis revealed no significant differences in the euploidy rate among the groups according to the morphological grade of the embryos.

CONCLUSION

Paternal age did not have a significant impact on euploidy rates when PGS was performed. An additional study with a larger sample size is needed to clarify the effects of advanced paternal age on IVF outcomes.

Female subfertility

Subfertility is common and affects one in six couples, half of whom lack an explanation for their delay in conceiving. Developments in the diagnosis and treatment of subfertility over the past 50 years have been truly remarkable. Indeed, current generations of couples with subfertility are more fortunate than previous generations, as they have many more opportunities to become parents. The timely access to effective treatment for subfertility is important as many couples have a narrow window of opportunity before the age-related effects of subfertility limit the likelihood of success. Assisted reproduction can overcome the barriers to fertility caused by tubal disease and low sperm count, but little progress has been made in reducing the effect of increasing age on ovarian function. The next 5-10 years will likely see further increases in birth rates in women with subfertility, a greater awareness of lifestyle factors and a possible refinement of current assisted reproduction techniques and the development of new ones. Such progress will bring challenging questions regarding the potential benefits and harms of treatments involving germ cell manipulation, artificial gametes, genetic screening of embryos and gene editing of embryos. We hope to see a major increase in fertility awareness, access to safe and cost-effective fertility care in low-income countries and a reduction in the current disparity of access to fertility care.

Human frozen-thawed blastocyst morphokinetics observed using time-lapse cinematography reflects the number of trophectoderm cells

Recent studies reported morphokinetic indices for optimal selection of embryos in assisted reproductive technology (ART). The morphokinetics in blastocyst stage include the collapse and re-expansion rates after thawing. However, evaluation methods using these morphokinetics have not been established, mainly because the underlying molecular mechanisms remain unclarified. In this study, we focused on the relationship between these morphokinetic observation of the blastocyst behaviour and the number of cells constituting the blastocyst. We evaluated 38 surplus human frozen-thawed blastocysts using time-lapse cinematography and recorded their expansion, contraction, and hatching. A total of 28 blastocysts expanded in culture (cross-sectional area ≥ 5,000 π μm²). In comparison to the ones that did not, the expanded group presented significantly more number of inner cell mass (ICM) and trophectoderm (TE) cells, which eventually develop into the fetus and placenta, respectively (ICM: Expanded 10.2 ± 6.3 vs. Non-Expanded 6.0 ± 12.3, p < 0.05; TE: Expanded 165.7 ± 74.8 vs. Non-Expanded 57.0 ± 29.4, p < 0.05). Moreover, a positive correlation was found between the expansion rate (up to 4 h) and the number of TE cells (r = 0.558, p = 0.0021). Additionally, blastocysts that hatched had a significantly higher number of TE cells than those that did not (hatching 225.2 ± 61.2 vs. no hatching 121.1 ± 48.6, p < 0.0001). The number of TE cells per unit of cross-sectional area correlated negatively with the contraction time (r = –0.601, p = 0.0007). No correlation between the number of ICM cells and these morphokinetics was detected. In conclusion, our study demonstrates that different morphokinetics of frozen-thawed blastocysts reflect the number of TE cells. The differentiation of blastocysts containing sufficient TE cells would be beneficial for implantation and prognosis of a subsequent pregnancy. Thus, evaluation of these morphokinetics can be an effective method to screen good embryos for ART.

Influencing factors of pregnancy loss and survival probability of clinical pregnancies conceived through assisted reproductive technology

BACKGROUND

Pregnancies following assisted reproductive technology (ART) may have elevated potential risk of pregnancy loss (PL) when compared to natural conception. However, rare studies comprehensively analyzed the IVF/ICSI cycle-dependent factors for loss of clinical pregnancy. Therefore, we aimed to determine the ART subgroup-specific risks of PL throughout pregnancy and explore different risk factors for early miscarriage and late miscarriage among pregnancies conceived through ART.

METHODS

A retrospective cohort study was launched in two infertility treatment centers in Nanjing and Changzhou including 5485 IVF/ICSI embryo transfer cycles with known outcomes after clinical pregnancy by the end of 2015. Cox proportional hazards regression analysis was performed to estimate the hazard ratios and their 95% confidence intervals. The associations between survival time during pregnancy and demographics and clinical characteristics of clinical pregnancies were estimated using the Kaplan-Meier method and the Log-rank test.

RESULTS

The overall PL rate in current ART population was 12.5%. Among the 685 pregnancy loss cycles, a total of 460 ended as early miscarriage, 191 as late miscarriage. We found couples in ART pregnancies demonstrated a significantly increased risk of PL as maternal age (HR = 1.31, Ptrend < 0.001) grows. Pregnancies received controlled ovarian hyperstimulation (COH) protocol like GnRH antagonist protocol (HR = 3.49, P < 0.001) and minimal stimulation protocol (HR = 1.83, P < 0.001) had higher risk of PL than GnRH-a long protocol. Notably, in contrast to fresh cycle, women who received frozen cycle embryo had a significant increased risk of early miscarriage (P < 0.001), while frozen cycle was linked with lower risk of late miscarriage (P = 0.045). In addition, four factors (maternal age, COH protocol, cycle type and serum hCG level 14 days after transfer) had independent impact on miscarriage mainly before 12 weeks of gestational age.

CONCLUSIONS

With these findings in this study, clinicians may make it better to evaluate a patient's risk of PL based on the maternal age at the time of treatment, COH protocol, cycle type and serum hCG level 14 days after transfer and the gestational week of the fetus, and we hope that it contributes to future study on its etiology and guide the clinical prevention and treatment.

Determinants of The Grade A Embryos in Infertile Women; Zero-Inflated Regression Model

OBJECTIVES

In assisted reproductive technology, it is important to choose high quality embryos for embryo transfer. The aim of the present study was to determine the grade A embryo count and factors related to it in infertile women.

MATERIALS AND METHODS

This historical cohort study included 996 infertile women. The main outcome was the number of grade A embryos. Zero-Inflated Poisson (ZIP) regression and Zero-Inflated Negative Binomial (ZINB) regression were used to model the count data as it contained excessive zeros. Stata software, version 13 (Stata Corp, College Station, TX, USA) was used for all statistical analyses.

RESULTS

After adjusting for potential confounders, results from the ZINB model show that for each unit increase in the number 2 pronuclear (2PN) zygotes, we get an increase of 1.45 times as incidence rate ratio (95% confidence interval (CI): 1.23-1.69, P=0.001) in the expected grade A embryo count number, and for each increase in the cleavage day we get a decrease 0.35 times (95% CI: 0.20-0.61, P=0.001) in expected grade A embryo count.

CONCLUSIONS

There is a significant association between both the number of 2PN zygotes and cleavage day with the number of grade A embryos in both ZINB and ZIP regression models. The estimated coefficients are more plausible than values found in earlier studies using less relevant models.

Paternal age as an independent factor does not affect embryo quality and pregnancy outcomes of testicular sperm extraction-intracytoplasmic sperm injection in azoospermia

This study was performed to evaluate the independent influence of paternal age affecting embryo development and pregnancy using testicular sperm extraction (TESE)-intracytoplasmic sperm injection (ICSI) in obstructive azoospermia (OA) and nonobstructive azoospermia (NOA). Paternal patients were divided into the following groups: ≤30 years, 31-35 years, 36-40 years, 41-45 years and ≥46 years. There were no differences in the rates of fertilisation or embryo quality according to paternal and maternal age. However, clinical pregnancy and implantation rates were significantly lower between those ≥46 years of paternal age compared with other age groups. Fertilisation rate was higher in the OA than the NOA, while embryo quality, pregnancy and delivery results were similar. Clinical pregnancy and implantation rates were significantly lower for patients ≥46 years of paternal age compared with younger age groups. In conclusion, fertilisation using TESE in azoospermia was not affected by the independent influence of paternal age; however, as maternal age increased concomitantly with paternal age, rates of pregnancy and delivery differed between those with paternal age <41 years and ≥46 years. Therefore, paternal age ≥46 years old should be considered when applying TESE-ICSI in cases of azoospermia, and patients should be advised of the associated low pregnancy rates.

The Effect of Paternal Age on Oocyte Donation Outcomes

IMPORTANCE

In recent decades, a trend toward delayed childbearing is noted in developed countries. Whereas the effects of maternal age on fertility, pregnancy complications, and postnatal outcomes have been thoroughly explored, consequences of advanced paternal age are less well known. Oocyte donation cycles can be used as an optimal model to analyze the association between male ageing and reproductive outcomes with minimal confounding.

OBJECTIVE

The purpose of this work was to summarize the updated and relevant literature dealing with the effect of paternal age on oocyte donation outcomes.

RESULTS

According to the available evidence from oocyte donation cycles, it seems that no significant association exists between advanced paternal age and fertility. However, this evidence is based on few studies, many of which are of low quality, yielding conflicting results. In addition, the emerging evidence clearly indicates an increased risk of adverse postnatal manifestations of pregnancies conceived by older fathers, including de novo autosomal dominant disorders, impaired neurocognitive development, and increased risk of malignancy.

CONCLUSIONS AND RELEVANCE

This review may be of aid to medical practitioners in counseling couples on the risks of delayed childbearing.

Effects of maternal age on embryo quality and pregnancy outcomes using testicular sperm with intracytoplasmic sperm injection

Objective

The aim of this study was to evaluate the influence of maternal age on fertilization, embryo quality, and clinical pregnancy in patients undergoing intracytoplasmic sperm injection (ICSI) using testicular sperm from partners with azoospermia.

Methods

A total of 416 ICSI cycles using testicular spermatozoa from partners with obstructive azoospermia (OA, n=301) and non-obstructive azoospermia (NOA, n=115) were analyzed. Female patients were divided into the following age groups: 27 to 31 years, 32 to 36 years, and 37 to 41 years. The rates of fertilization, high-quality embryos, clinical pregnancy, and delivery were compared across maternal age groups between the OA and NOA groups.

Results

The rates of fertilization and high-quality embryos were not significantly different among the maternal age groups. Similarly, the clinical pregnancy and delivery rates were not significantly different. The fertilization rate was significantly higher in the OA group than in the NOA group (p<0.05). Age-group analysis revealed that the fertilization and high-quality embryo rates were significantly different between the OA and NOA groups in patients aged 27 to 31 years old, but not for the other age groups. Although the clinical pregnancy and delivery rates differed between the OA and NOA groups across all age groups, significant differences were not observed.

Conclusion

In couples using testicular sperm from male partners with azoospermia, pregnancy and delivery outcomes were not affected by maternal age. However, women older than 37 years using testicular sperm from partners with azoospermia should be advised of the increased incidence of pregnancy failure.

Age-related infertility

Oocyte number and quality decrease with advancing age. Thus, fecundity decreases as age increases, with a more rapid decline after the mid-30s. Patients more than 35 years old should receive prompt evaluation for causes of infertility after no more than 6 months of attempted conception. Patients with abnormal tests of ovarian reserve have a poorer prognosis and may need more expedited and aggressive treatment. Although oocyte donation is the best method to overcome age-related infertility, other treatment options may help women proceed quicker toward pregnancy. Patients at an advanced age should be counseled and evaluated before undergoing infertility treatments.

The effects of being overweight and obese on female reproduction: a review

Obesity is a major international problem related to many reproductive health problems including polycystic ovary syndrome (PCOS). This article reviews the evidence of being overweight and its effect on female reproduction. The fecundity of obese women is lower than normal weight women, but there is no absolute consensus about the effect of obesity on infertility treatment. The obese patient might have oocyte, hormone, metabolic and endometrial dysfunction affecting reproduction. Insulin and leptin may be some of the answers explaining anovulation during obesity leading to infertility. Moreover, the follicular glucose and lipids which are important for oocyte development also increase in the obese patient and these might have an effect on oocyte quality because studies in mice have revealed that the obesity affects follicular cell stress and oocyte lipids. Overall, obesity affects female reproduction by disturbing the general body metabolism, hormone metabolism and the follicular environment.

Assisted reproductive techniques

Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.

Do estrogen receptor alpha polymorphisms have any impact on the outcome in an ART program?

PURPOSE

To investigate two of the most studied estrogen receptor alpha polymorphisms (PvuII and XbaI) in combination, in order to evaluate their impact on an ART program outcome.

METHODS

203 normally ovulating women who underwent IVF or ICSI treatment were genotyped for PvuII and XbaI polymorphisms in ESR1 intron 1 using Real-Time PCR. The relationship between the presence of polymorphic alleles and the ovulation induction parameters and outcome was examined.

RESULTS

Women were grouped according to the number of polymorphic alleles they carried in two groups (0-2 versus 3-4 polymorphic alleles). The presence of 3 or more polymorphic alleles was associated with significantly lower E2 levels on the day of hCG administration and a significantly lower rate of good quality embryos.

CONCLUSION

There is an association between ESR1 polymorphisms and some ART parameters such as the level of E2 on the day of hCG administration and the quality of the embryos. These results underline the importance of ESR1 as a candidate gene for the prediction of ovarian response to IVF/ICSI protocols. Future research work concerning several more genes is necessary for a better evaluation of patients before entering an IVF/ICSI program.

Germ cell differentiation from pluripotent cells

Infertility is a medical condition with an increasing impact in Western societies with causes linked to toxins, genetics, and aging (primarily delay of motherhood). Within the different pathologies that can lead to infertility, poor quality or reduced quantity of gametes plays an important role. Gamete donation and therefore demand on donated sperm and eggs in fertility clinics is increasing. It is hoped that a better understanding of the conditions related to poor gamete quality may allow scientists to design rational treatments. However, to date, relatively little is known about human germ cell development in large part due to the inaccessibility of human development to molecular genetic analysis. It is hoped that pluripotent human embryonic stem cells and induced pluripotent stem cells may provide an accessible in vitro model to study germline development; these cells are able to differentiate to cells of all three primary embryonic germ layers, as well as to germ cells in vitro. We review the state of the art in germline differentiation from pluripotent stem cells.

Ceramide and its transport protein (CERT) contribute to deterioration of mitochondrial structure and function in aging oocytes

In women as well as in mice, oocytes exhibit decreased developmental potential (oocyte quality) with advanced age. Our current data implicate alterations in the levels of oocyte ceramide and associated changes in mitochondrial function and structure as being prominent elements contributing to reduced oocyte quality. Both ROS levels and ATP content were significantly reduced in aged oocytes. The decreased in ROS levels are of intrigue because it is contrary to what has been previously reported. Lowered levels of both ROS and ATP indicate diminished mitochondrial function that was accompanied by alterations in mitochondrial structure. Interestingly, developmental potential of old oocytes was improved by microinjection of mitochondria isolated from young oocytes. Co-treatment of aged oocytes with ceramide and a cytoplasmic lipid carrier (l-carnitine) improved both mitochondrial morphology and function, and totally rescued spontaneous in vitro fragmentation. In addition, ceramide localization was altered in old oocytes possibly due to downregulation of the ceramide transport protein (CERT). However, knockdown of CERT alone was not sufficient to increase young oocyte's susceptibility to death, because the sequential manipulation of ceramide levels (its chronic decrease, followed by downregulation of CERT, and finally a ceramide spike) were all necessary to replicate the aging phenotype. These results indicate that oocyte aging is due to a multiplicity of events; and that with increasing biological age, changes in levels of both ceramide and its transport protein contribute to deterioration of oocyte mitochondrial structure and function. Hence, those changes may represent potential targets to manipulate when attempting to ameliorate aging phenotypes in germ cells.

In vitro fertilisation treatment and factors affecting success

The efficacy of assisted reproductive technologies has improved significantly over the past decades. The main indications for in vitro fertilisation include tubal obstruction, severe male-factor infertility, severe endometriosis, ovulatory dysfunction, diminished ovarian reserve, and infertility of unexplained cause. In vitro fertilisation has also become an effective treatment option for couples wishing to undergo pre-implantation genetic diagnosis or screening, and for those wishing to cryopreserve their oocytes or embryos for preservation of fertility. The management of women in late reproductive age poses a major challenge; the optimum in vitro fertilisation treatment for poor responders remains elusive. The success of in vitro fertilisation treatment can be optimised by taking an individualised, patient-centered approach to controlled ovarian hyperstimulation. Key components involve selection of an appropriate controlled ovarian protocol, close-cycle monitoring, adjustment of gonadotropin dosage to avoid hyper-response, and individualised timing of human chorionic gonadotropin injection. Future directions of assisted reproductive technologies include development of non-invasive embryo selection methods, use of transcriptomics, proteomics, metabolomics, and time-lapse imaging technologies.

Low-dose aspirin for in vitro fertilization or intracytoplasmic sperm injection: a systematic review and a meta-analysis of the literature

BACKGROUND

It was hypothesized that low-dose aspirin could improve implantation rates in subsequent pregnancies in women undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Previous studies have shown inconclusive results or focused on surrogate endpoints. We therefore conducted a systematic review and meta-analysis of the literature investigating the effect of low-dose aspirin on hard outcomes, including live birth rate, pregnancy rate and miscarriage.

METHODS

MEDLINE and EMBASE databases were searched up to November 2011. Randomized controlled trials comparing low-dose aspirin with placebo/no treatment in IVF/ICSI women were included. Pooled odds ratios (ORs) and 95%confidence intervals (CIs) were calculated.

RESULTS

Seventeen studies with 6403 patients were included. The use of aspirin did not improve live birth pregnancy rate compared with placebo or no treatment (1.08; 95% CI, 0.90, 1.29). Pregnancy rates were significantly increased in patients randomized to low-dose aspirin (OR, 1.19; 95% CI, 1.01, 1.39), but miscarriage rates were not (OR, 1.18; 95% CI, 0.82, 1.68). Results of sensitivity analyses including high-quality studies did not show statistically significant differences in all considered endpoints.

CONCLUSIONS

The results of this study do not show a substantial efficacy of aspirin inwomen undergoing IVF/ICSI and do not support the use of low-dose aspirin to improve the success of IVF/ICSI in terms of pregnancy outcomes. Further high-quality studies evaluating the possible efficacy of aspirin in selected groups of patients are warranted.

Early and delayed aspects of nuclear reprogramming during cloning

The successful production of viable progeny following adult somatic cell nuclear transfer (cloning) provides exciting new opportunities for basic research for investigating early embryogenesis, for the propagation of valuable or endangered animals, for the production of genetically engineered animals, and possibly for developing therapeutically valuable stem cells. Successful cloning requires efficient reprogramming of gene expression to silence donor cell gene expression and activate an embryonic pattern of gene expression. Recent observations indicate that reprogramming may be initiated by early events that occur soon after nuclear transfer, but then continues as development progresses through cleavage and probably to gastrulation. Because reprogramming is slow and progressive, cloned embryos have dramatically altered characteristics in comparison with fertilized embryos. Events that occur early following nuclear transfer may be essential prerequisites for the later events. Additionally, the later reprogramming events may be inhibited by sub-optimum culture environments that exist because of the altered characteristics of cloned embryos. By addressing the unique requirements of cloned embryos, the entire process of reprogramming may be accelerated, thus increasing cloning efficiency.

Routine morphological scoring systems in assisted reproduction treatment fail to reflect age-related impairment of oocyte and embryo quality

Routine morphological scoring systems in assisted reproduction treatment are based on parameters that presumably correlate with the biological quality of gametes and embryos, including chromosome abnormalities. Maternal age is a key factor predicting pregnancy and live birth, and it is therefore of considerable interest to identify age-related indicators of oocyte and embryo quality in assisted reproduction treatment. The purpose of this study was to examine whether routine morphological scoring systems reflect age-related impact on oocyte and embryo quality among 4587 couples undergoing their first assisted reproduction treatment. This study assessed over 43,000 oocytes, 25,000 embryos and 7900 transferred embryos and analysed the associations among the following parameters: number of oocytes retrieved, oocyte quality, including maturity, fertilization rates, embryo quality, based on morphological features, and treatment outcome. Advanced chronological age was found to be associated with fewer oocytes retrieved, fewer embryos available for cryopreservation, as well as lower pregnancy, implantation, live birth rates and a higher miscarriage rate. No age-related correlation was found between fertilization rates, oocyte or embryo quality. Routinely-used morphological scoring systems, such as assessment of blastomere count, shape and fragmentation, fail to reflect age-related impact on oocyte and embryo quality.

Gene expression profiles of single human mature oocytes in relation to age

BACKGROUND

The development competence of human oocytes declines with increasing age. The objective of this study was to investigate the effect of age on gene expression profile in mature human oocytes.

METHODS

mRNA was isolated for whole genome gene expression microarray analysis from metaphase II (MII) oocytes donated by IVF or ICSI patients [10 women aged <36 years (younger) and five women aged 37-39 years (both inclusive) (older)] undergoing controlled ovarian stimulation. The oocytes were donated and prepared immediately after recovery from the follicle. RT-PCR on additional four younger and two older oocytes confirmed the array analysis.

RESULTS

On the basis of 15 independent replicates of single MII oocytes, 7470 genes (10 428 transcripts) were identified as present in the MII oocytes. Of these, 342 genes showed a significantly different expression level between the two age groups; notably, genes annotated to be involved in cell cycle regulation, chromosome alignment (e.g. MAD2L1 binding protein), sister chromatid separation (e.g. separase), oxidative stress and ubiquitination. The top signaling network affected by age was 'cell cycle and organism development' (e.g. SMAD2 and activin B1 receptor).

CONCLUSION

There is a substantial difference between younger and older oocytes in the transcriptional level of genes involved in central biological functions of the oocytes, thus providing information on processes that may be associated with the ageing phenomenon and possibly contributing to decreased fertility.

Retrospective analysis of 1217 IVF cycles in women aged 40 years and older

Older women comprise an increasing portion of patients entering assisted reproduction programmes. This study is a retrospective summary of the files of all patients aged 40 years and older at advent of IVF, between 1995 and 2004, in the authors' centre. In all, 381 women underwent 1217 initiated treatment cycles. Embryo transfer was performed in 62.6% of initiated cycles. Success rates declined with each year after age 40; pregnancy and delivery rates were 13.9 and 9.1% at age 40 and 2.8 and 0.7% at age 45. There were no deliveries at an older age. Logistic regression analysis showed the following factors were independently and significantly related to higher pregnancy rates: younger age, lower dose of gonadotrophins, greater number of mature follicles, endometrial thickness, and number of embryos transferred; prior pregnancy did not influence success. Retrieving more than four oocytes increased pregnancy rates in all women over 40. Transferring 3 embryos or more increased pregnancy rates in all ages, but reached statistical significance only in women aged 40-41 (P < 0.000). It is concluded that in women between 40 and 41 years of age, ovarian response is a major determinant of success, but not in women older than that. Unrealistic expectations may be avoided if accurate data are provided regarding delivery rates per year after age 40.

Gender effects on the incidence of aneuploidy in mammalian germ cells

Aneuploidy occurs in 0.3% of newborns, 4% of stillbirths, and more than 35% of all human spontaneous abortions. Human gametogenesis is uniquely and gender-specific susceptible to errors in chromosome segregation. Overall, between 1% and 4% of sperm and as many as 20% of human oocytes have been estimated by molecular cytogenetic analysis to be aneuploid. Maternal age remains the paramount aetiological factor associated with human aneuploidy. The majority of extra chromosomes in trisomic offspring appears to be of maternal origin resulting from nondisjunction of homologous chromosomes during the first meiotic division. Differences in the recombination patterns between male and female meiosis may partly account for the striking gender- and chromosome-specific differences in the genesis of human aneuploidy, especially in aged oocytes. Nondisjunction of entire chromosomes during meiosis I as well as premature separation of sister chromatids or homologues prior to meiotic anaphase can contribute to aneuploidy. During meiosis, checkpoints at meiotic prophase and the spindle checkpoint at M-phase can induce meiotic arrest and/or cell death in case of disturbances in pairing/recombination or spindle attachment of chromosomes. It has been suggested that gender differences in aneuploidy may result from more permissive checkpoints in females than males. Furthermore, age-related loss of chromosome cohesion in oocytes as a cause of aneuploidy may be female-specific. Comparative data about the susceptibility of human male and female germ cells to aneuploidy-causing chemicals is lacking. Increases of aneuploidy frequency in sperm have been shown after exposure to therapeutic drugs, occupational agents and lifestyle factors. Conversely, data on oocyte aneuploidy caused by exogenous agents is limited because of the small numbers of oocytes available for analysis combined with potential maternal age effects. The vast majority of animal studies on aneuploidy induction in germ cells represent cause and effect data. Specific studies designed to evaluate possible gender differences in induction of germ cell aneuploidy have not been found. However, the comparison of rodent data available from different laboratories suggests that oocytes are more sensitive than male germ cells when exposed to chemicals that effect the meiotic spindle. Only recently, in vitro experiments, analyses of transgenic animals and knockdown of expression of meiotic genes have started to address the molecular mechanisms underlying chromosome missegregation in mammalian germ cells whereby striking differences between genders could be shown. Such information is needed to clarify the extent and the mechanisms of gender effects, including possible differential susceptibility to environmental agents.

Low-dose aspirin for in vitro fertilization: a systematic review and meta-analysis

Despite recent advances in ovarian stimulation regimens and laboratory techniques, the pregnancy rate of assisted reproduction remains relatively low. New methods that would potentially improve implantation rates are needed. One proposed strategy involves enhancement of blood flow at the implantation site with the use of low-dose aspirin. We conducted a systematic review and meta-analysis to investigate the effect of low-dose aspirin on likelihood of pregnancy in women undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). An electronic search of the literature was conducted targeting reports published over the last 26 years. Only randomized controlled trials (RCTs) comparing aspirin with placebo or no treatment in IVF/ICSI women were included in the meta-analysis. A number of relevant outcomes including pregnancy and live birth (LB) rates were investigated. Pooled relative risk (RR) and 95% confidence interval (CI) were calculated using a random-effects model. Inter-study heterogeneity among the trials was assessed using the Cochran's Q test. Ten RCTs were identified from the literature search, six of which met the criteria for inclusion in the meta-analysis. Clinical pregnancy (CP) rate per embryo transfer (ET) was not found to be significantly different between patients who received low-dose aspirin and those who received placebo or no treatment (RR 1.09, 95% CI 0.92-1.29). None of the other outcomes, including CP per cycle, spontaneous abortion or ectopic pregnancy per CP and LB rate per cycle or ET was found to differ significantly between the compared groups. On the basis of up-to-date evidence, low-dose aspirin has no substantial positive effect on likelihood of pregnancy and, therefore, it should not be routinely recommended for women undergoing IVF/ICSI.

Cost of transferring one through five embryos per in vitro fertilization cycle from various payor perspectives

OBJECTIVE

We sought to examine the costs of transferring one through five embryos per in vitro fertilization cycle from each of three perspectives: society, the infertile couple, and the insurer.

METHODS

Data from the 2003 Assisted Reproductive Technology Report was used to create Markov decision analytic models stratified by maternal age subgroup. We modeled both total costs, cost-effectiveness (cost per live birth), and clinical outcomes: multiple births, preterm deliveries, and cerebral palsy.

RESULTS

From a societal and insurer perspective, it was least expensive to transfer one embryo. For women aged younger than 35 years, it cost society 80% more to transfer five rather than one embryo at a time (total cost 39,212 dollars compared with 21,661 dollars). For women aged older than 42 years, it cost 13% more (29,102 dollars compared with 25,723 dollars). From a parental perspective, it was least expensive to transfer between two and five embryos, depending on maternal age. One-embryo transfers markedly improved clinical outcomes. For example, two compared with one-embryo transfers for women aged younger than 35 years reduced preterm birth and cerebral palsy rates by 55% and 41%, respectively. Univariable sensitivity analysis and Monte Carlo simulation showed our results to be robust.

CONCLUSION

Transferring one embryo per cycle is the least expensive strategy from a societal perspective, especially for younger women, yet it is the most expensive option from a parental perspective. To reduce in vitro fertilization-associated multiple birth rates, public policy must address these disparate financial incentives.

Effect of dehydroepiandrosterone on oocyte and embryo yields, embryo grade and cell number in IVF

BACKGROUND

The aim of this study was to investigate the effect of treatment with dehydroepiandrosterone (DHEA) on fertility outcomes among women with diminished ovarian reserve.

MATERIALS AND METHODS

This is a case-control study in an academically affiliated private infertility centre. Twenty-five women with significantly diminished ovarian reserve had one IVF cycle before and after DHEA treatment, with otherwise identical hormonal stimulation. Women received 75 mg of DHEA daily (25 mg three times daily) for an average of 17.6 +/- 2.13 weeks. We performed a comparison of IVF outcome parameters, before and after DHEA treatment, including peak estradiol (E(2)) levels, oocyte and embryo numbers, oocyte and embryo quality and embryo transfer statistics.

RESULTS

Paired analysis of IVF cycle outcomes in 25 patients, who underwent cycles both before and after DHEA supplementation, demonstrated significant increases in fertilized oocytes (P < 0.001), normal day 3 embryos (P = 0.001), embryos transferred (P = 0.005) and average embryo scores per oocyte (P < 0.001) after DHEA treatment.

CONCLUSION

This study confirms the previously reported beneficial effects of DHEA supplementation on ovarian function in women with diminished ovarian reserve.

Chromosome abnormalities and their relationship to morphology and development of human embryos

This review covers the relationship between chromosome abnormalities, morphological abnormalities and embryonic development. The baseline of chromosome abnormalities in human embryos produced by assisted reproduction is higher than 50%, regardless of maternal age. While aneuploidy increases with maternal age, abnormalities arising post-meiotically, such as mosaicism, chaoticism, polyploidy and haploidy, have similar incidence in all age groups (about 33%). Post-meiotic abnormalities do increase with dysmorphism. The most common dysmorphisms found in cleavage-stage embryos are multinucleation, fragmentation and uneven cells, among others. All dysmorphisms are associated with an increase in post-meiotic chromosome abnormalities and a decreased implantation potential. Similarly, embryos developing slowly or with arrested development have higher incidence of post-meiotic abnormalities than normally developing ones. Chromosome studies in blastocysts indicate that mosaicism is the most common abnormality but that the load of abnormal cells decreases with increasing blastocyst quality. Regardless of blastocyst quality, more than 40% of mosaics are still chromosomally abnormal and will not implant or will spontaneously abort. Because aneuploidy is not related to cleavage stage dysmorphism and trisomies can reach blastocyst stage and beyond, morphological analysis is not enough to select against chromosome abnormalities, and thus preimplantation genetic diagnosis should be recommended in patients 35 and older.