Risk of ectopic pregnancy lowest with transfer of single frozen blastocyst

Number of embryos transferred could possibly be associated with angular pregnancy in in vitro fertilization-embryo transfer

OBJECTIVE

The probability of embryo implantation in an abnormal location is significantly higher in assisted reproductive technology (ART) than in natural pregnancies. Angular pregnancy is an eccentric intrauterine pregnancy with embryo implantation in the lateral superior angle of the uterine cavity. Cycle-level factors associated with angular pregnancy in patients conceived with ART needed to be explored.

METHODS

A total of 11 336 clinical pregnancies cycles were included. Angular pregnancy rate was compared among groups according to the type of embryos transferred. Among them, 53 cases of angular pregnancy and 159 cases of normal intrauterine pregnancy were screened out using propensity score matching. Risk factors of angular pregnancy were explored.

RESULTS

The angular pregnancy rate was 0.31% (14/4572) in the day 5 blastocyst transfer group, 0.58% (39/6764) in non-day 5 embryo transfer group, with 0.55% (29/5280) in day 3 embryo transfer and 0.67% (10/1484) in the day 6 blastocyst group, respectively. A multifactor regression analysis was performed and indicated that the number of embryos transferred was significantly associated with angular pregnancy (P = 0.031, OR, 2.23, 95% CI: 1.09-4.68).

CONCLUSION

Multiple embryo transfer could possibly be associated with an increased incidence of angular pregnancy in patients conceived with ART.

ESHRE Guideline Group on the Number of Embryos to Transfer, Alteri A, Arroyo G, Baccino G, Craciunas L, De Geyter C, Ebner T, Koleva M, Kordic K, Mcheik S, Mertes H, Pavicic Baldani D, Rodriguez-Wallberg KA, Rugescu I, Santos-Ribeiro S, Tilleman K, Woodward B, Vermeulen N, Veleva Z. ESHRE guideline: number of embryos to transfer during IVF/ICSI†

STUDY QUESTION

Which clinical and embryological factors should be considered to apply double embryo transfer (DET) instead of elective single embryo transfer (eSET)?

SUMMARY ANSWER

No clinical or embryological factor per se justifies a recommendation of DET instead of eSET in IVF/ICSI.

WHAT IS KNOWN ALREADY

DET is correlated with a higher rate of multiple pregnancy, leading to a subsequent increase in complications for both mother and babies. These complications include preterm birth, low birthweight, and other perinatal adverse outcomes. To mitigate the risks associated with multiple pregnancy, eSET is recommended by international and national professional organizations as the preferred approach in ART.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for development and update of ESHRE guidelines. Literature searches were performed in PUBMED/MEDLINE and Cochrane databases, and relevant papers published up to May 2023, written in English, were included. Live birth rate, cumulative live birth rate, and multiple pregnancy rate were considered as critical outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the collected evidence, recommendations were discussed until a consensus was reached within the Guideline Development Group (GDG). A stakeholder review was organized after the guideline draft was finalized. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 35 recommendations on the medical and non-medical risks associated with multiple pregnancies and on the clinical and embryological factors to be considered when deciding on the number of embryos to transfer. These recommendations include 25 evidence-based recommendations, of which 24 were formulated as strong recommendations and one as conditional, and 10 good practice points. Of the evidence-based recommendations, seven (28%) were supported by moderate-quality evidence. The remaining recommendations were supported by low (three recommendations; 12%), or very low-quality evidence (15 recommendations; 60%). Owing to the lack of evidence-based research, the guideline also clearly mentions recommendations for future studies.

LIMITATIONS, REASONS FOR CAUTION

The guideline assessed different factors one by one based on existing evidence. However, in real life, clinicians' decisions are based on several prognostic factors related to each patient's case. Furthermore, the evidence from randomized controlled trials is too scarce to formulate high-quality evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides health professionals with clear advice on best practice in the decision-making process during IVF/ICSI, based on the best evidence currently available, and recommendations on relevant information that should be communicated to patients. In addition, a list of research recommendations is provided to stimulate further studies in the field.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, the literature searches, and the dissemination of the guideline. The guideline group members did not receive payment. DPB declared receiving honoraria for lectures from Merck, Ferring, and Gedeon Richter. She is a member of ESHRE EXCO, and the Mediterranean Society for reproductive medicine and the president of the Croatian Society for Gynaecological Endocrinology and Reproductive Medicine. CDG is the past Chair of the ESHRE EIM Consortium and a paid deputy member of the Editorial board of Human Reproduction. IR declared receiving reimbursement from ESHRE and EDCD for attending meetings. She holds an unpaid leadership role in OBBCSSR, ECDC Sohonet, and AER. KAR-W declared receiving grants for clinical researchers and funding provision to the institution from the Swedish Cancer Society (200170F), the Senior Clinical Investigator Award, Radiumhemmets Forskningsfonder (Dnr: 201313), Stockholm County Council FoU (FoUI-953912) and Karolinska Institutet (Dnr 2020-01963), NovoNordisk, Merck and Ferring Pharmaceuticals. She received consulting fees from the Swedish Ministry of Health and Welfare. She received honoraria from Roche, Pfizer, and Organon for chairmanship and lectures. She received support from Organon for attending meetings. She participated in advisory boards for Merck, Nordic countries, and Ferring. She declared receiving time-lapse equipment and grants with payment to institution for pre-clinical research from Merck pharmaceuticals and from Ferring. SS-R received research funding from Roche Diagnostics, Organon/MSD, Theramex, and Gedeo-Richter. He received consulting fees from Organon/MSD, Ferring Pharmaceuticals, and Merck Serono. He declared receiving honoraria for lectures from Ferring Pharmaceuticals, Besins, Organon/MSD, Theramex, and Gedeon Richter. He received support for attending Gedeon Richter meetings and participated in the Data Safety Monitoring Board of the T-TRANSPORT trial. He is the Deputy of ESHRE SQART special interest group. He holds stock options in IVI Lisboa and received equipment and other services from Roche Diagnostics and Ferring Pharmaceuticals. KT declared receiving payment for honoraria for giving lectures from Merck Serono and Organon. She is member of the safety advisory board of EDQM. She holds a leadership role in the ICCBBA board of directors. ZV received reimbursement from ESHRE for attending meetings. She also received research grants from ESHRE and Juhani Aaltonen Foundation. She is the coordinator of EHSRE SQART special interest group. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (full disclaimer available at https://www.eshre.eu/Guidelines-and-Legal).

Management of ectopic pregnancy after in vitro fertilization/intracytoplasmic sperm injection and embryo transfer: a case series and mini-review

Background

Ectopic pregnancy (EP), reflecting a fertilized ovum implanted outside the normal uterine cavity, represents a frequent cause of morbidity and possibly mortality in women of reproductive age.

Objective

To summarize the diagnosis and treatment of EP after in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET).

Methods

The medical records of patients who were diagnosed with EP after embryo transfer from 2017 to 2019, in a tertiary hospital were reviewed.

Results

Of the 24 cases analyzed, 21 (87.5%) had fallopian tube involvement, while 2 (8.3%) and 1 (4.2%) had cornual and cervical pregnancies, respectively. Clinical manifestations included vaginal bleeding (58.3%) and lower abdominal pain (16.7%); 9 (42.9%) cases had no symptoms. One cornual pregnancy was misdiagnosed as acute appendicitis and later correctly diagnosed by laparoscopic exploration. There were 2 cases of multiple-site EP and 2 of heterotopic pregnancy, including one with an intrauterine pregnancy with double chorionic and four amniotic sacs and right tubal ampullary pregnancy. Five of the 21 cases with fallopian tube involvement received conservative treatment, while the remaining 16 underwent surgeries, including laparoscopic ipsilateral salpingostomy and ipsilateral salpingectomy.

Discussion

Ectopic pregnancy after embryo transfer, mainly involving the fallopian tube, is very complex and is with diverse manifestations. Even with the pregnancy sac observed in the uterus, the pelvic cavity should be scanned thoroughly after embryo transfer.

Establishment of a prediction model for the impact of endometrial thickness on the day of embryo transfer on ectopic pregnancy in frozen-thawed embryo transfer cycle

Objective

This study aims to investigate the factors affecting the ectopic pregnancy (EP) rate in the frozen-thawed embryo transfer (FET) cycle.

Methods

This study retrospectively analyzed 5606 FET cycles, including 5496 cycles resulting in intrauterine pregnancy and 110 cycles resulting in EP. Smooth curve fitting and piece-wise linear regression were utilized to evaluate a non-linear association between endometrial thickness (EMT) and EP. Multiple logistic regression analysis was used to study the effect of EMT on the embryo transfer (ET) day and other indexes on EP rate after adjusting for confounding factors. A nomographic prediction model was employed to predict EP occurrence. The predictive efficacy of the model was assessed using the area under the receiver operating characteristic (ROC) curve (AUC), utilizing the bootstrap sampling method for internal validation.

Results

After accounting for the confounding factors, the segmented linear regression analysis indicated that the EMT inflection point was 9 mm; the EP rate significantly decreased by 28% with each additional millimeter of EMT up to 9 mm (odds ratio (OR) = 0.72; 95% confidence interval (CI), 0.53-0.99; P = 0.0412) while insignificantly decreased when the EMT was greater than 9 mm (OR = 0.91; 95% CI, 0.76-1.08; P = 0.2487). Multivariate logistic regression analysis revealed that after adjusting for confounders, EP risk significantly increased in the number of previous EPs ≥ 1 (OR = 2.29; 95% CI, 1.26-4.16; P = 0.0064) and tubal factor infertility (OR = 3.86; 95% CI, 2.06-7.24; P < 0.0001). Conversely, EP risk was significantly reduced by the increased EMT (OR = 0.84; 95% CI, 0.74-0.96; P = 0.0078) and the blastocyst transfer (OR = 0.45; 95% CI, 0.27-0.76; P = 0.0027). These variables were used as independent variables in a nomogram prediction model, resulting in an AUC of 0.685. The nomination models were internally verified using self-sampling (bootstrap sampling resampling times = 500). This validation yielded an AUC of 0.689, with a sensitivity of 0.6915 and a specificity of 0.5790. The internal validation indicated minimal fluctuations in the AUC, signifying a relatively stable model.

Conclusion

Undergoing EMT on the day of ET poses a separate EP risk in the FET cycle; to mitigate the EP incidence, the EMT should exceed 9 mm before ET. Furthermore, previous EPs and tubal factor infertility were additional factors independently increasing EP risk. Furthermore, implementing blastocyst transfer demonstrated that EP incidence was significantly reduced. Utilizing a nomogram predicting system enables EP risk evaluation before ET for individual patients, establishing a basis for devising clinical strategies for ET.

Normal and Abnormal Appearances of the Ovaries during Assisted Reproduction: Multimodality Imaging Review

Infertility is a common diagnosis that prompts many couples and individuals to seek assisted reproductive technology (ART) for assistance with conception. These technologies have become increasingly used in the United States in the past several decades, with 326 468 ART cycles performed in 2020, resulting in 75 023 live births. This ubiquity of ART also increases the likelihood that radiologists will encounter both normal and abnormal imaging findings associated with these treatments. Thus, radiologists of all subspecialties should be familiar with the multimodality appearance of the ovaries and pelvis in patients undergoing ART treatments. Furthermore, it is imperative that radiologists understand the appearance expected during different stages of the ART process. During stimulated ovulatory cycles, it is normal and expected for the ovaries to appear enlarged and to contain numerous cystic follicles, often with a small to moderate volume of pelvic free fluid. After oocyte retrieval, hemorrhagic ovarian follicles and a small to moderate volume of blood products in the cul-de-sac can be expected to be seen. Multiple nonemergency and emergency complications are related to ART, many of which can be seen at imaging. The most encountered emergency complications of ART include ovarian hyperstimulation syndrome, ectopic pregnancy, heterotopic pregnancy, multiple gestations, ovarian torsion, and procedural complications related to oocyte retrieval. These complications have important clinical implications, thus necessitating accurate and timely detection by the radiologist and the clinical team. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Body mass index impacts ectopic pregnancy during in vitro fertilization: an analysis of 42,362 clinical pregnancy cycles

PURPOSE

This large, single-center, retrospective cohort study was aimed to explore the effect of female body mass index (BMI) on ectopic pregnancy (EP) following fresh and frozen-thawed embryo transfers (ET).

METHODS

A total of 27,600 pregnancies after fresh ET and 14,762 pregnancies after frozen-thawed ET were included between January 2010 to June 2022. Women were divided into three groups based on BMI according to the Working Group on Obesity in China (WGOC), International Life Sciences Institute (ILSI): underweight (BMI < 18.5 kg/m2), normal weight (BMI, 18.5-23.9 kg/m2), and overweight or obesity (≥ 24 kg/m2). Compare EP rates among BMI categories in fresh and frozen-thawed ET cycles respectively. Multivariate logistic regression analyses were used to investigate the association between female BMI and EP.

RESULTS

The overall EP rates in fresh, and frozen thawed transfer cycles were 2.43% (672/27,600) and 2.82% (417/14,762), respectively. In fresh ET cycles, underweight women yielded a significantly higher EP rate than those with normal and excess weight (3.29% vs. 2.29% vs. 2.54%, P = 0.029). But EP rates did not differ among the three BMI groups (2.72% vs. 2.76% vs. 2.96%, P = 0.782) in frozen-thawed ET cycles. In fresh ET cycles, after adjusting for potential confounding factors, no significant association was found between female BMI and EP occurrence (adjusted OR: 0.98, 95% CI 0.70-1.37, P = 0.894, for BMI 18.5-23.9 kg/m2; adjusted OR: 0.89, 95% CI 0.75-1.06, P = 0.205, for BMI ≥ 24 kg/m2. Reference = BMI < 18.5 kg/m2).

CONCLUSION(S)

Female BMI did not affect the occurrence of ectopic pregnancy in either fresh or frozen-thawed embryo transfer cycles.

An endometrium of type C along with an endometrial thickness of < 8 mm are risk factors for ectopic pregnancy after stimulated cycles with fresh embryo transfer

BACKGROUND

The study investigated whether specific ultrasonographically observed endometrial features (including endometrium type and thickness) were linked to ectopic pregnancy after stimulated cycles with fresh embryo transfer.

METHOD

Of 6246 pregnancy cycles after fresh embryo transfer, 6076 resulted in intrauterine pregnancy and 170 in ectopic pregnancy. The primary outcome of the study was ectopic pregnancy, with the main variables being endometrium type and endometrial thickness. Univariate and subsequent multiple-stepwise logistic regression analyses were used to identify the risk factors of ectopic pregnancy.

RESULTS

1. Compared with patients with an endometrial thickness ≥ 8 mm, the adjusted odds ratio for those with an endometrial thickness < 8 mm was 3.368 (P < 0.001). The adjusted odds ratio for women with a type-C endometrium was 1.897 (P = 0.019) compared with non-type C. 2. A larger dose of gonadotropin used during controlled ovarian hyperstimulation was a protective factor against ectopic pregnancy (P = 0.008). 3. The GnRH antagonist protocol (P = 0.007) was a risk factor for ectopic pregnancy, compared with the use of GnRH agonists.

CONCLUSION

(1) An endometrial thickness < 8 mm coupled with a type C endometrium significantly increased the risk of ectopic pregnancy after fresh embryo transfer. (2) A thin endometrial thickness and a type C endometrium could be further related to an abnormal endometrial receptivity/peristaltic wave. (3) Patients at a high risk of ectopic pregnancy should therefore be given special attention, with early diagnosis during the peri-transplantation period may assist in the prevention of ectopic pregnancy.

Freeze-all embryos during treatment with assisted reproduction: Health economic aspects

Assisted reproductive technologies are evolving, with the most recent example being the introduction of the freeze-all policy during which a fresh embryo transfer does not take place and all embryos of good quality are cryopreserved to be used in future frozen embryo transfers. As the freeze-all policy is becoming more prevalent, it is important to review the economic aspects of this approach, along with considerations of efficacy and safety, and the role of emerging freeze-all-specific ovarian stimulation strategies. Based on the available evidence, the freeze-all policy presents distinct clinical advantages, particularly for high responders. Available health economic evaluations are limited. Two good-quality cost-effectiveness analyses based on randomized controlled trials suggest that the freeze-all strategy is unlikely to be cost-effective in non-polycystic ovarian syndrome (non-PCOS), normally responding patients. However, the cost-effectiveness of the freeze-all strategy in different populations of patients and in different settings has not been evaluated, nor has the clinical and economic efficacy of modern freeze-all-specific ovarian stimulation protocols that are likely to simplify treatment and make it more affordable for patients. Economic evaluations that incorporate good practice health technology assessment (HTA) methods are needed to compare freeze-all with conventional embryo transfer strategies. Furthermore, future research should address the unique limitation of traditional HTA methods in valuing a life conceived through fertility treatment.

Ectopic pregnancy risk factors in infertile patients: a 10-year single center experience

The present retrospective study included both intrauterine insemination and in vitro assisted reproductive technologies (ART) procedures performed from January 2009 to December 2018 at a tertiary-care Fertility Centre. The purpose was to assess the incidence of ectopic pregnancy (EP) in infertile population who undergoes ART and to identify any risk factor impacting the occurrence of EP after ART. Among 27,376 cycles, 7352 pregnancies were achieved, of which 132 were EPs, the 1.80% (95% CI 1.5-2.1) of all pregnancies. In fresh embryo transfer cycles, a history of prior pelvic adhesions showed the greatest impact on the incidence of EP (aOR 2.49 95% CI 1.53-4.07 p < 0.001). Other factors associated with EP incidence were also identified, such as female age, basal FSH, the transfer of blastocyst embryos and difficulties during the embryo transfer procedure. In frozen embryo transfer cycles, the only factor influencing the incidence of EP was anti Müllerian hormone (AMH) serum concentration (aOR 0.81 95% CI 0.65-1.00, p = 0.048). To conclude, the incidence of EP observed was comparable to that reported after natural conception. On the other hand, pre-existing risk factors, traditionally more common in infertile population, appeared to influence the incidence of EP and should thus be modified if possible.

Pregnancy outcomes following in vitro fertilization treatment in women with previous recurrent ectopic pregnancy

Objectives

The aim of this study was to investigate the impact of a history of recurrent ectopic pregnancy (EP) on pregnancy outcomes of subsequent in vitro fertilization (IVF) treatment.

Methods

A retrospective cohort study involving 457 women with a history of recurrent EP (REP group), 912 women with a history of single EP (SEP group), and 1169 women with a history of intrauterine pregnancy (IUP group) as the control group, was conducted. IVF outcomes were compared for each cohort.

Results

The incidence of EP in the REP group after IVF treatment was significantly lower than those in the SEP group (2.4% vs. 6.8%, P = 0.011), and similar to those in the IUP group (2.4% vs. 2.1%, P = 0.830). No significant differences were observed in the clinical pregnancy rate, miscarriage rate, and live birth rate among the three groups. There was no statistically significant difference in the recurrent EP rate between the salpingectomy and salpingostomy treatments. Adjusting for maternal and treatment factors did not influence live birth rates for women with previous REP compared with women with previous SEP and those with IUP. The odds of EP were 82.2% lower (OR 0.178, 95% CI 0.042–0.762; P = 0.020) in women who had blastocyst transfer compared with cleavage embryo transfer in the SEP group. The odds of EP were over six times (OR 6.260, 95% CI 1.255–31.220; P = 0.025) in women who underwent double embryo transfer as opposed to single embryo transfer in the IUP group.

Conclusion

Our results indicate that women with previous recurrent EP have a lower risk of EP after IVF in comparison with women with previous single EP. Previous EP has no significant adverse effect on the main IVF outcomes. The salpingostomy and salpingectomy treatments of EP do not significantly affect the incidence of recurrent EP after IVF.

Heterotopic cervical pregnancy: Case report and literature review

Cervical pregnancy (CP) is a rare form of ectopic pregnancy (EP) in which the embryo implants and grows inside the endocervical canal. Heterotopic cervical pregnancy is an even rare form of EP, in which at least two embryos are simultaneously implanted in different sites and only one in the uterine cavity. Although many treatment approaches are available, the ideal management remains unclear. Here, we describe two cases of CP caused by assisted reproductive technologies (ART). One case underwent fertilization with intracytoplasmic sperm injection (ICSI) for male factor infertility, and the other was frozen–thawed embryo transfer (FET) following conventional in vitro fertilization (IVF). Both cases were successfully treated with ultrasound‐guided cervical pregnancy aspiration, and intrauterine pregnancies were effectively protected. To the best of our knowledge, these two were rare case reports use aspiration without additional methods and intrauterine pregnancy achieved live birth.

An Endometrial Thickness < 8 mm Was Associated With a Significantly Increased Risk of EP After Freeze-Thaw Transfer: An Analysis of 5,960 Pregnancy Cycles

INTRODUCTION

Endometrium characteristics that are most likely to induce ectopic pregnancy were investigated on the basis of the data of 5,960 pregnant freeze-thaw cycles.

METHODS

A total of 5,960 pregnancy cycles after freeze-thaw embryos transfer were included, with the number of intrauterine and ectopic pregnancies being 5,777 and 183, respectively. Ectopic pregnancy was the primary outcome. Endometrial thickness was the main measured variable. The risk factors of ectopic pregnancy were eventually determined based on univariate analysis and subsequent multiple-stepwise logistic regression analysis.

RESULTS

1. After adjusting for confounders, endometrial thickness could independently predict ectopic pregnancy. The adjusted odd ratios for women with endometrial thickness in the ranges of < 8 mm, 8-9.9 mm, and 10-11.9 mm were 3.270 [95% confidence interval (CI), 1.113-9.605, P = 0.031], 2.758 (95% CI, 0.987-7.707, P = 0.053), and 1.456 (95% CI, 0.502-4.225, P = 0.489), respectively, when compared with those having an endometrial thickness of 12-13.9 mm. 2. Endometrial type and preparation protocol were however not identified as risk factors for ectopic pregnancy.

DISCUSSION

1. After freeze-thaw embryo transfer, risks of ectopic pregnancy were significantly higher when the endometrial thickness was < 8 mm. 2. A thin endometrial thickness could be linked with abnormal endometrial peristaltic waves or abnormal endometrial receptivity. 3. Adequate attention should therefore be paid to patients with a thin endometrial thickness to prevent EP or to achieve early diagnosis during the peri-transplantation period.

The role of endometrial thickness in predicting ectopic pregnancy after in vitro fertilization and the establishment of a prediction model

OBJECTIVE

To explore the risk factors of ectopic pregnancy after in vitro fertilization.

METHODS

This retrospective cohort study was conducted at the Reproductive Medical Center of the Third Affiliated Hospital of Zhengzhou University from January 2016 to April 2020. Univariate and multivariate analysis were used to analyze the related factors affecting the occurrence of ectopic pregnancy (EP) and to construct a nomographic prediction model for the incidence of ectopic pregnancy.

RESULTS

A total of 12,766 cycles of 10109 patients were included, comprising 214 cases of EP and 12,552 cases of intrauterine pregnancy (IUP). Multivariate logistic regression analysis showed that the tubal factor was associated with a 2-fold increased risk for EP (aOR = 2.72, 95% CI: 1.69-4.39, P < 0.0001). A stratified analysis showed that women with an endometrial thickness (EMT) between 7.6 to 12.1mm (aOR = 0.57, 95%CI: 0.36-0.90, P = 0.0153) and >12.1mm (aOR = 0.42, 95%CI: 0.24-0.74, P = 0.0026) had a significant reduction of the risk of EP compared to women with an EMT of <7.6mm. Compared to cleavage stage transfer, blastocyst transfer can reduce the risk of ectopic pregnancy (aOR = 0.36, 95%CI: 0.26-0.50, P < 0.0001). The saturation model (full mode) establishes a nomographic prediction model with an AUC = 0.68 and a sensitivity and specificity of 0.67and 0.64, respectively. The nomination model was internally verified by self-sampling method (bootstrap sampling resampling times = 500). The resulting AUC = 0.68 (sensitivity: 0.65; specificity: 0.65) showed that the model was relatively stable.

CONCLUSIONS

Our findings indicate that EMT is inversely proportional to the risk of EP. Embryo stage, number of embryos transferred were also significantly associated with EP rate. A simple nomogram for the predicting the risk of EP was established in order to reduce the occurrence of EP.

The incidence of ectopic/heterotopic pregnancies after blastocyst-stage frozen-thawed embryo transfers compared with that after cleavage-stage: a Society for Assisted Reproductive Technologies Clinical Outcomes Reporting System study

OBJECTIVE

To investigate whether there is a difference in the ectopic/heterotopic pregnancy rate of blastocyst-stage frozen-thawed embryo transfers (FETs) compared with that of cleavage-stage FETs.

DESIGN

A retrospective cohort study.

SETTING

Not applicable.

PATIENTS

Women undergoing autologous FETs at either the blastocyst stage (n = 118,572) or the cleavage stage (n = 117,619), as reported to the Society for Assisted Reproductive Technology from 2004 to 2013.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Pregnancy outcomes, specifically ectopic pregnancy rates and heterotopic pregnancy rates.

RESULTS

Among those who became pregnant, there was a significantly lower incidence of ectopic/heterotopic pregnancies in blastocyst-stage FETs versus that in cleavage-stage FETs (0.8% vs. 1.1%). The differences in ectopic/heterotopic pregnancy rates remained statistically significant after controlling for confounders such as tubal factor infertility and number of embryos transferred.

CONCLUSIONS

Blastocyst-stage FET was associated with a lower ectopic/heterotopic pregnancy rate compared with cleavage-stage FET.

The rising incidence of heterotopic pregnancy: Current perspectives and associations with in-vitro fertilization

Heterotopic pregnancy is the simultaneous occurrence of an intrauterine and ectopic pregnancy. This study aims to review the current literature regarding heterotopic pregnancy with a focus on its diagnosis and associations with in-vitro fertilization (IVF). Studies have shown that ovarian hyperstimulation syndrome and multiple embryo transfer during IVF are associated with an increased risk of heterotopic pregnancy. Tubal abnormalities such as pelvic inflammatory disease and previous tubal or abdomino-pelvic surgery have also been identified as risk factors. Diagnosis is challenging as the falsely reassuring presence of an intrauterine fetus frequently delays early intervention. Treatment should be individualised, but is often prompt surgical intervention, and focuses on terminating the ectopic pregnancy while minimizing harm to the mother and intrauterine fetus.

ESHRE Clinic PI Working Group, Vlaisavljevic V, Apter S, Capalbo A, D'Angelo A, Gianaroli L, Griesinger G, Kolibianakis EM, Lainas G, Mardesic T, Motrenko T, Pelkonen S, Romualdi D, Vermeulen N, Tilleman K. The Maribor consensus: report of an expert meeting on the development of performance indicators for clinical practice in ART

STUDY QUESTION

Is it possible to define a set of performance indicators (PIs) for clinical work in ART, which can create competency profiles for clinicians and for specific clinical process steps?

SUMMARY ANSWER

The current paper recommends six PIs to be used for monitoring clinical work in ovarian stimulation for ART, embryo transfer, and pregnancy achievement: cycle cancellation rate (before oocyte pick-up (OPU)) (%CCR), rate of cycles with moderate/severe ovarian hyperstimulation syndrome (OHSS) (%mosOHSS), the proportion of mature (MII) oocytes at ICSI (%MII), complication rate after OPU (%CoOPU), clinical pregnancy rate (%CPR), and multiple pregnancy rate (%MPR).

WHAT IS KNOWN ALREADY

PIs are objective measures for evaluating critical healthcare domains. In 2017, ART laboratory key PIs (KPIs) were defined.

STUDY DESIGN SIZE DURATION

A list of possible indicators was defined by a working group. The value and limitations of each indicator were confirmed through assessing published data and acceptability was evaluated through an online survey among members of ESHRE, mostly clinicians, of the special interest group Reproductive Endocrinology.

PARTICIPANTS/MATERIALS SETTING METHODS

The online survey was open for 5 weeks and 222 replies were received. Statements (indicators, indicator definitions, or general statements) were considered accepted when ≥70% of the responders agreed (agreed or strongly agreed). There was only one round to seek levels of agreement between the stakeholders.Indicators that were accepted by the survey responders were included in the final list of indicators. Statements reaching less than 70% were not included in the final list but were discussed in the paper.

MAIN RESULTS AND THE ROLE OF CHANCE

Cycle cancellation rate (before OPU) and the rate of cycles with moderate/severe OHSS, calculated on the number of started cycles, were defined as relevant PIs for monitoring ovarian stimulation. For monitoring ovarian response, trigger and OPU, the proportion of MII oocytes at ICSI and complication rate after OPU were listed as PIs: the latter PI was defined as the number of complications (any) that require an (additional) medical intervention or hospital admission (apart from OHSS) over the number of OPUs performed. Finally, clinical pregnancy rate and multiple pregnancy rate were considered relevant PIs for embryo transfer and pregnancy. The defined PIs should be calculated every 6 months or per 100 cycles, whichever comes first. Clinical pregnancy rate and multiple pregnancy rate should be monitored more frequently (every 3 months or per 50 cycles). Live birth rate (LBR) is a generally accepted and an important parameter for measuring ART success. However, LBR is affected by many factors, even apart from ART, and it cannot be adequately used to monitor clinical practice. In addition to monitoring performance in general, PIs are essential for managing the performance of staff over time, and more specifically the gap between expected performance and actual performance measured. Individual clinics should determine which indicators are key to the success in their organisation based on their patient population, protocols, and procedures, and as such, which are their KPIs.

LIMITATIONS REASONS FOR CAUTION

The consensus values are based on data found in the literature and suggestions of experts. When calculated and compared to the competence/benchmark limits, prudent interpretation is necessary taking into account the specific clinical practice of each individual centre.

WIDER IMPLICATIONS OF THE FINDINGS

The defined PIs complement the earlier defined indicators for the ART laboratory. Together, both sets of indicators aim to enhance the overall quality of the ART practice and are an essential part of the total quality management. PIs are important for education and can be applied during clinical subspecialty.

STUDY FUNDING/COMPETING INTERESTS

This paper was developed and funded by ESHRE, covering expenses associated with meetings, literature searches, and dissemination. The writing group members did not receive payment.Dr G.G. reports personal fees from Merck, MSD, Ferring, Theramex, Finox, Gedeon-Richter, Abbott, Biosilu, ReprodWissen, Obseva, PregLem, and Guerbet, outside the submitted work. Dr A.D. reports personal fees from Cook, outside the submitted work; Dr S.A. reports starting a new employment in May 2020 at Vitrolife. Previously, she has been part of the Nordic Embryology Academic Team, with meetings were sponsored by Gedeon Richter. The other authors have no conflicts of interest to declare.

DISCLAIMER

This document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation.The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.Furthermore, ESHREs recommendations do not constitute or imply the endorsement, recommendation, or favouring of any of the included technologies by ESHRE.

Factors associated with the incidence of ectopic pregnancy in women undergoing assisted reproductive treatment

Background

Ectopic pregnancy (EP) is a common complication in women undergoing assisted reproductive treatment, but the underlying causes for this remain unclear. This study aimed to explore factors affecting the incidence of EP in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

Methods

This was a retrospective study on the incidence of EP in IVF/ICSI cycles between January 1, 2013 and December 31, 2017. Patient age, infertility diagnosis (tubal factor or not), primary or secondary infertility, type of cycle (frozen-thawed or fresh), type of embryo(s) transferred (cleavage embryo or blastocyst), number of embryos transferred (one, two, or three), previous history of EP, and endometrial combined thickness were analyzed to explore their relationships with the incidence of EP. Based on clinical typing results, the patients were divided into an EP group or a non-EP group. Categorical variables were analyzed using Chi-squared test or Fisher exact test. Logistic regression analysis was performed to explore their associations with the incidence of EP.

Results

The percentage of patients with primary infertility in EP group was significantly lower than that in non-EP group (31.3% vs. 46.7%, χ² = 26.032, P < 0.001). The percentage of patients with tubal infertility in EP group was also significantly higher than that in non-EP group (89.2% vs. 63.6%, χ² = 77.410, P < 0.001). The percentages of patients with transfer of cleavage-stage embryo or blastocyst (91.4% vs. 84.4%, χ² = 10.132, P = 0.001) and different endometrial combined thickness (ECT) (χ² = 18.373, P < 0.001) differed significantly between EP and non-EP groups. For patients who had a previous history of one to four EPs, the percentage of patients undergoing transfer of a cleavage-stage embryo was significantly higher in EP group than that in non-EP group (92.2% vs. 77.6%, χ² = 13.737, P < 0.001). In multivariate logistic regression analysis, tubal infertility was strongly associated with EP (adjusted odds ratio: 3.995, 95% confidence interval: 2.706–5.897, P < 0.001).

Conclusions

In IVF/ICSI cycles, transfer of a blastocyst-stage embryo, especially for patients with a previous history of EP, reduced the rate of EP. Tubal infertility was strongly associated with EP.

Abnormal Elevation of Anti-Mullerian Hormone and Androgen Levels Presenting as Granulosa Cell Tumor

We report a rare subtype of adult cystic granulosa cell tumor (AGCT) characterized by elevated anti-Mullerian hormone and hyperandrogenism. A 35-year-old woman with primary infertility, hyperandrogenism, and irregular menses who was previously diagnosed with polycystic ovarian syndrome was diagnosed with AGCT based on histopathological examination and FOXL2 genetic test after laparoscopy. Due to fertility aspirations, she underwent controlled ovarian stimulation followed by embryo cryopreservation before salpingo-oophorectomy, and two embryos were frozen-thawed and transferred after surgery. A healthy female infant was delivered at 40 weeks’ gestation. Cystic granulosa cell tumors should be considered a differential diagnosis in patients with persistent ovarian cysts and hyperandrogenism. Younger patients with AGCT with fertility goals should consider active assisted reproduction measures to preserve fertility before treatment for AGCT.

Ovarian stimulation increases the risk of ectopic pregnancy for fresh embryo transfers: an analysis of 68,851 clinical pregnancies from the Japanese Assisted Reproductive Technology registry

OBJECTIVE

To evaluate the risk of ectopic pregnancies (EPs) for fresh cycles according to different ovarian stimulation protocols.

DESIGN

Registry-based retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 68,851 clinical pregnancies after fresh single embryo transfer between 2007 and 2015.

INTERVENTION (S)

None MAIN OUTCOME MEASURE(S): Ectopic pregnancies. Odds ratios and 95% confidence intervals for EPs were calculated by using generalized estimating equations adjusted for potential maternal and treatment characteristics.

RESULT(S)

Among 68,851 clinical pregnancies, 1,049 (1.46%) cases of EP were reported. Compared with natural cycles, all ovarian stimulation protocols were associated with a significantly increased risk of EP. Ovarian stimulation with clomiphene (CC) demonstrated the highest odds ratios for EPs. Significant associations between ovarian stimulation protocols and EP compared with natural cycles were prominent when the number of retrieved oocytes was low (1-3) to moderate (4-7), but there were no significant associations when the number of retrieved oocytes was high (≥8).

CONCLUSION(S)

Ovarian stimulation protocols were significantly associated with an increased risk of EP. In particular, ovarian stimulation with CC had the highest risk of EP compared with other stimulation protocols. Further studies are essential to investigate possible confounding factors for different ovarian stimulation protocols, especially CC, and the risk of EP.

Perinatal and obstetric outcomes in singleton pregnancies following fresh versus cryopreserved blastocyst transfer: a meta-analysis

The transfer of cryopreserved blastocysts is increasing in IVF centres. However, little is known about the perinatal and obstetric outcomes of this procedure. In an attempt to further elucidate these issues, a systematic review and meta-analysis was conducted to compare cryopreserved transfer with fresh blastocyst embryo transfer. The results show that the risk of both preterm (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80-0.99, P = 0.04) and low birthweight births (OR 0.82, 95% CI 0.68-0.99, P = 0.04) was significantly lower after cryopreserved blastocyst transfer than after fresh blastocyst transfer. The rate of large for gestational age births was significantly higher (OR 1.68, 95% CI 1.55-1.82, P < 0.00001) and the rate of small for gestational age births significantly lower (OR 0.59, 95% CI 0.54-0.65, P < 0.00001) after cryopreserved blastocyst transfer. The transfer of cryopreserved blastocysts was associated with a significantly lower risk of placental abruption (OR 0.58, 95% CI 0.40-0.83, P = 0.003) but a significantly higher risk of Caesarean section (OR 1.21, 95% CI 1.01-1.43, P = 0.03). In conclusion, the perinatal and obstetric outcomes associated with the transfer of cryopreserved blastocysts differ from those associated with fresh blastocyst transfer.

Randomized, assessor-blinded trial comparing highly purified human menotropin and recombinant follicle-stimulating hormone in high responders undergoing intracytoplasmic sperm injection

OBJECTIVE

To evaluate the efficacy and safety of highly purified human menotropin (HP-hMG) and recombinant follicle-stimulating hormone (rFSH) for controlled ovarian stimulation in a population of patients predicted to be high responders.

DESIGN

Randomized, open-label, assessor-blinded, parallel-group, noninferiority trial.

SETTING

Fertility centers.

PATIENT(S)

A total of 620 women with serum antimüllerian hormone (AMH) ≥5 ng/mL.

INTERVENTION(S)

Controlled ovarian stimulation with HP-hMG or rFSH in a GnRH antagonist assisted reproductive technology (ART) cycle. Fresh transfer of a single blastocyst was performed unless ovarian response was excessive, in which all embryos were cryopreserved. Subjects could undergo subsequent frozen blastocyst transfer within 6 months of randomization.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate (OPR) after fresh transfer (primary endpoint), as well as cumulative live birth, ovarian hyperstimulation syndrome (OHSS), and pregnancy loss rates.

RESULTS

OPR/cycle start after fresh transfer was 35.5% with HP-hMG and 30.7% with rFSH (difference: 4.7%, 95% CI -2.7%, 12.1%); noninferiority was established. Compared to rFSH, HP-hMG was associated with significantly lower OHSS (21.4% vs. 9.7% respectively; difference: -11.7%, 95% CI -17.3%, -6.1%) and cumulative early pregnancy loss rates (25.5% vs. 14.5% respectively; difference: -11.0%, 95% CI -18.8%, -3.14%). Despite 43 more transfers in the rFSH group, cumulative live birth rates were similar with HP-hMG and rFSH at 50.6% and 51.5% respectively (difference: -0.8%, 95% CI -8.7%, 7.1%).

CONCLUSION(S)

In high responders, HP-hMG provided comparable efficacy to rFSH with fewer adverse events, including pregnancy loss, suggesting its optimized risk/benefit profile in this population.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02554279 (clinicaltrials.gov).

Low body mass index is associated with ectopic pregnancy following assisted reproductive techniques: a retrospective study

OBJECTIVE

To investigate the association between body mass index (BMI) and ectopic pregnancy (EP) following embryo transfer (ET).

DESIGN

Retrospective cohort study.

SETTING

University-affiliated hospital.

POPULATION

A total of 16 378 pregnancies derived from either fresh ET or frozen-thawed ET between January 2008 and December 2017.

METHODS

We used the generalised estimating equation (GEE) to analyse the association between BMI categories and EP, as one woman may contribute to more than one pregnancy. Generalised additive models were also used to demonstrate the non-linear association. Models were adjusted for age, parity, gravidity, previous history of ectopic pregnancy, duration of infertility, polycystic ovary syndrome, endometriosis, diagnosis of tubal problems, ovarian reserve markers, ovarian stimulation parameters, insemination protocol, endometrial thickness and embryo transfer policies.

MAIN OUTCOME MEASURES

Ectopic pregnancy.

RESULTS

According to the WHO criteria, the number of cycles with low (<18.5 kg/m² ), normal (18.5-24.9 kg/m² ) and high (≥25 kg/m² ) BMI were 2155, 13 447 and 776, respectively. In comparison with the normal BMI group, the rate of EP was significantly increased in the low BMI group (2.92% versus 2.02%, relative risk 1.45, 95% CI 1.11-1.90), but not in the high BMI group (2.84%, relative risk 1.41, 95% CI 0.92-2.20). Adjusted for confounding factors, the odds ratio for EP comparing low BMI versus normal BMI was 1.61 (95% CI 1.19-2.16) and that comparing high BMI versus normal BMI was 1.12 (95% CI 0.72-1.76).

CONCLUSIONS

Low BMI is associated with an increased risk of EP.

TWEETABLE ABSTRACT

The ectopic pregnancy rate after embryo transfer for lean women is higher than that for women of normal weight.

Hormonal Effects in Reproductive Technology with Focus on Diminished Ovarian Reserve

Modern use of reproductive technologies has revolutionized the treatment of infertile couples. Strategies to improve ovarian function in cases of diminished ovarian reserve are perhaps the least understood area in this field and will be the chief focus of this chapter.

Suboptimal endometrial-embryonal synchronization is a risk factor for ectopic pregnancy in assisted reproduction techniques

RESEARCH QUESTION

What are the main risk factors associated with ectopic pregnancy and what is the true incidence of ectopic pregnancies in an IVF programme?

DESIGN

Retrospective single-centre study of 12,429 blastocyst transfers (8182 fresh and 4247 frozen embryo transfers) conducted between January 2010 and December 2017. IVF outcome was analysed, and ectopic pregnancy risk evaluated according to patient's characteristics and assisted reproductive technology treatment factors.

RESULTS

Of 5061 patients reporting a positive pregnancy test, 43 were diagnosed with ectopic pregnancy (0.85%). Neither female age (36.7 versus 35.8 years), body mass index, quality of transfer nor stimulation protocol affected the ectopic pregnancy rate, but history of previous ectopic pregnancy (OR 3.26; P = 0.0080), tubal surgery, or both (OR 6.20; P < 0.0001) did. The incidence of ectopic pregnancy was increased in women with uterine malformations (OR 3.85; P = 0.0052), uterine pathologies (OR 5.35; P = 0.0001), uterine surgeries (OR 2.29; P = 0.0154) or sub-optimal endometrial build-up (OR 4.46 to 5.31; P < 0.0001). Transfer of slow-developing blastocysts (expressed by expansion) significantly increased the risk of ectopic pregnancy (OR 2.59; P = 0.0102).

CONCLUSIONS

Unfavourable uterine environment, including uterine pathologies, uterine or tubal surgery and suboptimal endometrial build-up were related to ectopic pregnancy. Low expansion grade of blastocysts was identified as an additional putative risk factor for ectopic pregnancy, indicating the importance of proper embryonal-maternal synchronization. The overall ectopic pregnancy rate after blastocyst transfer was low, comparable with reported ectopic pregnancy rates in spontaneous conceptions. Proper evaluation of tubal and uterine pathologies, optimizing endometrial preparation and the transfer of expanded blastocysts in a frozen embryo transfer cycle, might be beneficial.

Risk Factors of Recurrent Ectopic Pregnancy in Patients Treated With in vitro Fertilization Cycles: A Matched Case-Control Study

Objective: To study the risk factors for recurrent ectopic pregnancy (REP) in patients undergoing in vitro fertilization (IVF). Methods: This was a 1:4 matched case-control study that enrolled 227 REP patients and 908 matched intrauterine pregnancy (IUP) patients from the assisted reproductive technology (ART) center of the First Affiliated Hospital of Zhengzhou University from January 2012 to November 2019. Univariate analysis was carried out between the two groups for the occurrence of REP. Multivariate logistic regression analysis was used to explore the risk factors of REP after IVF. Results: The results of univariate analysis showed that there were significant differences in previous treatment of EP, stage of embryo and the number of embryos transferred between the two groups (all P < 0.05). The other factors did not have a significant effect on the probability of developing REP. Multivariate logistic regression analysis showed that after adjusting for confounders, previous treatment of EP, type of embryos transferred and stage of embryo were related to the occurrence of REP (all P < 0.05). Conclusion: Conservative treatment, frozen-thawed embryo transfer and cleavage embryo transfer were independent risk factors for REP after ART treatment.

Effect of endometrial thickness on ectopic pregnancy in frozen embryo transfer cycles: an analysis including 17,244 pregnancy cycles

OBJECTIVE

To investigate whether endometrial thickness (EMT) influences the incidence of ectopic pregnancy (EP) in frozen embryo transfer (FET) cycles.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary-care medical center.

PATIENT(S)

A total of 16,556 patients were enrolled between January 2010 and December 2017, comprising 16,701 intrauterine, 488 ectopic, and 45 heterotopic pregnancy cycles after FET.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

EP was the primary outcome. EMT was the main measured variable. Data were analyzed with the binary logistic general estimating equations model to calculate the adjusted odds ratio (aOR) for EP.

RESULT(S)

After adjusting for confounders, EMT remained statistically significant as an independent risk factor for EP. Compared with women with an EMT of ≥14 mm, the aORs for women with EMT in the ranges 7-7.9, 8-9.9, and 10-11.9 mm were 2.70 (95% confidence interval [CI], 1.65-4.40), 2.06 (95% CI, 1.33-3.20), and 1.66 (95% CI, 1.07-2.58), respectively. Hormone replacement treatment for endometrial preparation during FET increased the risk of EP after adjustment for confounding variables.

CONCLUSION(S)

EMT is inversely proportional to EP rate in FET cycles and is therefore a potential quantitative marker of endometrial receptivity and uterine contractibility in an FET cycle. The predictive validity of EMT value must be evaluated in further studies.

Cumulative live birth rates following a 'freeze-all' strategy: a population-based study

STUDY QUESTION

What is the cumulative live birth rate following a 'freeze-all' strategy compared with a 'fresh-transfer' strategy?

SUMMARY ANSWER

The 'freeze-all' strategy resulted in a similar cumulative live birth rate as the 'fresh-transfer' strategy among high responders (>15 oocytes retrieved) but did not benefit normal (10-15 oocytes) and suboptimal responders (<10 oocytes).

WHAT IS KNOWN ALREADY

Frozen-thawed embryo transfer is associated with a decreased risk of adverse obstetric and perinatal outcomes compared with fresh embryo transfer. It is unclear whether the 'freeze-all' strategy should be offered to all women undergoing ART treatment.

STUDY DESIGN SIZE DURATION

A population-based retrospective cohort study using data collected by the Victorian Assisted Reproductive Treatment Authority. This study included 14 331 women undergoing their first stimulated ART cycle with at least one oocyte fertilised between 1 July 2009 and 30 June 2014 in Victoria, Australia. Demographic characteristics, type of ART procedures and resulting pregnancy and birth outcomes were recorded for the stimulated cycle and associated thaw cycles until 30 June 2016, or until a live birth was achieved, or until all embryos from the stimulated cycle had been used.

PARTICIPANTS/MATERIALS SETTING METHODS

Women were grouped by whether they had undergone the 'freeze-all' strategy (n = 1028) where all embryos were cryopreserved for future transfer, or the 'fresh-transfer' strategy (n = 13 303) where selected embryo(s) were transferred in the stimulated cycle, and remaining embryo(s) were cryopreserved for future use. A discrete-time survival model was used to evaluate the cumulative live birth rate following 'freeze-all' and 'fresh-transfer' strategy.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1028 women undergoing 'freeze-all' strategy and 13 303 women undergoing 'fresh-transfer' strategy had 1788 and 22 334 embryo transfer cycles resulting in 452 and 5126 live births, respectively. Most women (61.3%) in the 'freeze-all' group had more than 15 oocytes retrieved in the stimulated cycle compared with 18.1% of women in the 'fresh-transfer' group (P < 0.001). For high responders (>15 oocytes), the cumulative live birth rate in the 'freeze-all' group was similar to the 'fresh-transfer' group (56.8% vs. 56.2%, adjusted hazard ratio (AHR) 0.90, 95% CI 0.77-1.04). However, the likelihood of a live birth was lower in the 'freeze-all' group compared with the 'fresh-transfer' group among normal responders (10-15 oocytes) (33.2% vs. 46.3%, AHR 0.62, 95% CI 0.46-0.83) and suboptimal responders (<10 oocytes) (14.6% vs. 28.0%, AHR 0.67, 95% CI 0.14-1.01). During the minimum follow-up time of 2 years, 34.1%, 24.4% and 8.4% of suboptimal, normal and high responders, respectively, in the 'freeze-all' group did not return for any embryo transfer after the stimulated cycle, whereas all women in the 'fresh-transfer' group had at least one embryo transferred in the stimulated cycle.

LIMITATIONS REASONS FOR CAUTION

A limitation of this population-based study is the lack of information available on clinic-specific protocols for the 'freeze-all' strategy and the potential impact of these on outcomes. Data were not available on whether the 'freeze-all' strategy was used to prevent ovarian hyperstimulation syndrome (OHSS).

WIDER IMPLICATIONS OF THE FINDINGS

This study presents population-based evidence on clinical efficacy associated with a 'freeze-all' and 'fresh-transfer' strategy. The 'freeze-all' strategy may benefit some subgroups of patients, including women who are high responders and those who are at risk of OHSS, but should not be offered universally. Clinicians should consider the potential impact of electively deferring embryo transfer on treatment discontinuation in choosing the optimal embryo transfer strategy for couples undergoing ART treatment.

STUDY FUNDING/COMPETING INTERESTS

No specific funding was received to undertake this study. There is no conflict of interest, except that M.B. is a shareholder in Genea Ltd.

Frozen blastocyst transfer reduces incidence of ectopic pregnancy compared with fresh blastocyst transfer: a meta-analysis

BACKGROUND

Ectopic pregnancy (EP) is the main cause of maternal death during early pregnancy. Blastocyst transfer (BT) reduces EP rates compared with cleavage stage embryo transfer (ET), and frozen ET reduces EP rates compared with fresh ET. However, data comparing the EP rate of fresh BT and frozen BT are limited. The objective of this meta-analysis was to determine whether frozen BT decreases the EP rate compared with fresh BT.

MATERIALS AND METHODS

PUBMED, EMBASE, and Cochrane Library databases were searched for papers with no limitation on language and publication year. A systemic literature search identified 14 studies which met the inclusion criteria for further analysis. EP rate is our only outcome measure. All statistical analyses were carried out using RevMan software [version 5.3]. Random effects models were chosen to calculate the odds ratio (OR).

RESULTS

Fourteen retrospective studies (n = 251,762 cycles) were finally analyzed, including 154,214 and 97,548 cycles undergoing fresh and frozen BT, respectively. Compared with fresh BT, the frozen BT was associated with an decrease in EP rate [OR = 1.79; 95% confidence interval (CI) = 1.37-2.34, heterogeneity was 71%], the EP rate was 1.74% (2683/154,214 pregnancies) for fresh BT and 0.97% (949/97,548 pregnancies) for frozen BT. The number of embryos transferred in subgroup analysis found that the incidence of EP in frozen BT is lower than fresh BT (OR = 1.62; 95% CI = 1.38-1.91), the EP rate was 1.2% (206/16,610 pregnancies) for one fresh BT and 0.8% (153/19,569 pregnancies) for one frozen BT, also the EP rate was 1.9% (78/4043 pregnancies) for two fresh BT and 1.1% (19/1790 pregnancies) for two frozen BT.

CONCLUSIONS

Our meta-analysis found that frozen BT was associated with an decrease in EP rate compared with fresh BT in IVF/ICSI patients. We also found that a single frozen BT is the better choice as a method to reduce the incidence of EP.

Cornual Suture at the Time of Laparoscopic Salpingectomy Reduces the Incidence of Interstitial Pregnancy after In Vitro Fertilization

STUDY OBJECTIVE

To investigate the effect of cornual suture at the time of laparoscopic salpingectomy on the incidence of interstitial pregnancy (IP) after in vitro fertilization (IVF).

DESIGN

Single-center, retrospective review (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Patients with hydrosalpinx who were treated with salpingectomy before IVF-embryo transfer and managed in our center were included in this study.

INTERVENTIONS

A total of 542 patients who underwent laparoscopic salpingectomy from April 2011 to March 2014 comprised group A. A total of 502 patients who underwent cornual suture at the time of laparoscopic salpingectomy from April 2014 to February 2016 comprised group B.

MEASUREMENTS AND MAIN RESULTS

The overall IP rate was significantly lower in group B (7/293, 2.39%) than in group A (27/373, 7.24%; p < .05). The intrauterine pregnancy and ongoing pregnancy/live birth rates were significantly higher in group B than in group A (both p < .05). All 34 patients with IP underwent laparoscopic cornuostomy and cornual repair. Seven of 11 patients with combined interstitial and intrauterine pregnancies carried the intrauterine pregnancy to term and delivered via cesarean section, whereas 4 patients underwent inevitable miscarriage. IP rupture occurred in 8 of 34 patients at a mean of 23.43 ± 2.77 days after embryo transfer. The earliest time of rupture was on day 20 after embryo transfer.

CONCLUSION

An optimized salpingectomy technique plays an important role in pretreatment before embryo transfer in patients with hydrosalpinx. Cornual suture at the time of salpingectomy helps reduce the risk of IP.

Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles and frozen-thawed cycles

PURPOSE

The purpose of this study was to determine the heterotopic pregnancy rate using fresh versus frozen-thawed embryo transfers and factors associated with heterotopic pregnancy (HP). Management and clinical outcomes after heterotopic pregnancy were also evaluated.

METHODS

In this retrospective cohort study, we included 12,484 women who had clinical pregnancies after in vitro fertilization treatment at our fertility center between 2012 and 2017. Patients received fresh day 3 embryos (F-D3 group), fresh day 5 blastocysts (F-D5 group), frozen-thawed day 3 embryos (T-D3 group), or frozen-thawed day 5 or 6 blastocysts (T-D5/6 groups) transfers. The primary outcome measure was the occurrence of heterotopic pregnancy. Factors associated with heterotopic pregnancy were analyzed using logistic regression.

RESULTS

The heterotopic pregnancy rates were 0.58% in the F-D3, 0.39% in F-D5, 0.56% in T-D3, and 0.33% in T-D5/6 groups, but no differences were found between groups. The risk factors of HP included a history of previous ectopic pregnancy (odds ratio [OR] 5.805, 95% CI 4.578-9.553, P = 0.016) and pelvic inflammation diseases (OR 1.129, 95% CI 1.021-3.178, P = 0.047). Salpingectomy was performed in 62.9% patients either through laparoscopy or through laparotomy. The early abortion rate and late abortion rate were 29.03% and 1.61%, respectively. In total, 66.13% of the patients had a live birth, either a singleton (90.24%) or twins (9.76%).

CONCLUSION

No significant difference in the incidence of heterotopic pregnancy in fresh IVF cycles vs. frozen-thawed cycles could be demonstrated in a large cohort of patients. The risk factors of HP included history of ectopic pregnancy and PID. The clinical outcome after heterotopic pregnancy appears to be favorable.

A universal freeze all strategy: why it is not warranted

PURPOSE OF REVIEW

There's some preclinical evidence of an adverse effect of multifollicular growth on endometrial function in assisted reproductive technology cycles. Universal elective frozen embryo transfer (eFET) in an unstimulated cycle is being promoted as a panacea, regardless of patient, and cycle characteristics. We review the clinical evidence on the effectiveness and safety of eFETs.

RECENT FINDINGS

Randomized controlled trials (RCTs) comparing fresh and eFET yield contradictory results in terms of live birth rates. RCTs mainly involve women with an excessive response to ovarian stimulation. Studies including women with a normal or low ovarian response are either patient/physician preference or retrospective studies, prone to bias. Yet, they yield contradictory results as well. Overall, eFET seems to have limited potential to improve effectiveness of assisted reproductive technology, which could be limited to hyper-responders. Other suggested advantages of eFET include better obstetric and perinatal outcome. However, recent studies show that frozen embryo transfers can be associated with serious complications including hypertensive disorders during pregnancy, placenta accreta, or increased perinatal mortality.

SUMMARY

The evidence behind advantages of eFET is of low quality. As such, switching to a universal eFET strategy does not seem justified. New RCTs including women from different strata of ovarian response are needed.

Heterotopic Quadruplet Pregnancy After ICSI Conception

Background

Heterotopic pregnancy (HP) is a condition characterized by the coexistence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest forms of HP. Ectopic pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube.

Case Presentation

This article reports a case of quadruplet heterotopic pregnancy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12 + 6 weeks and successful outcome of intrauterine twin pregnancy.

Oocyte, embryo and blastocyst cryopreservation in ART: systematic review and meta-analysis comparing slow-freezing versus vitrification to produce evidence for the development of global guidance

BACKGROUND

Successful cryopreservation of oocytes and embryos is essential not only to maximize the safety and efficacy of ovarian stimulation cycles in an IVF treatment, but also to enable fertility preservation. Two cryopreservation methods are routinely used: slow-freezing or vitrification. Slow-freezing allows for freezing to occur at a sufficiently slow rate to permit adequate cellular dehydration while minimizing intracellular ice formation. Vitrification allows the solidification of the cell(s) and of the extracellular milieu into a glass-like state without the formation of ice.

OBJECTIVE AND RATIONALE

The objective of our study was to provide a systematic review and meta-analysis of clinical outcomes following slow-freezing/thawing versus vitrification/warming of oocytes and embryos and to inform the development of World Health Organization guidance on the most effective cryopreservation method.

SEARCH METHODS

A Medline search was performed from 1966 to 1 August 2016 using the following search terms: (Oocyte(s) [tiab] OR (Pronuclear[tiab] OR Embryo[tiab] OR Blastocyst[tiab]) AND (vitrification[tiab] OR freezing[tiab] OR freeze[tiab]) AND (pregnancy[tiab] OR birth[tiab] OR clinical[tiab]). Queries were limited to those involving humans. RCTs and cohort studies that were published in full-length were considered eligible. Each reference was reviewed for relevance and only primary evidence and relevant articles from the bibliographies of included articles were considered. References were included if they reported cryosurvival rate, clinical pregnancy rate (CPR), live-birth rate (LBR) or delivery rate for slow-frozen or vitrified human oocytes or embryos. A meta-analysis was performed using a random effects model to calculate relative risk ratios (RR) and 95% CI.

OUTCOMES

One RCT study comparing slow-freezing versus vitrification of oocytes was included. Vitrification was associated with increased ongoing CPR per cycle (RR = 2.81, 95% CI: 1.05-7.51; P = 0.039; 48 and 30 cycles, respectively, per transfer (RR = 1.81, 95% CI 0.71-4.67; P = 0.214; 47 and 19 transfers) and per warmed/thawed oocyte (RR = 1.14, 95% CI: 1.02-1.28; P = 0.018; 260 and 238 oocytes). One RCT comparing vitrification versus fresh oocytes was analysed. In vitrification and fresh cycles, respectively, no evidence for a difference in ongoing CPR per randomized woman (RR = 1.03, 95% CI: 0.87-1.21; P = 0.744, 300 women in each group), per cycle (RR = 1.01, 95% CI: 0.86-1.18; P = 0.934; 267 versus 259 cycles) and per oocyte utilized (RR = 1.02, 95% CI: 0.82-1.26; P = 0.873; 3286 versus 3185 oocytes) was reported. Findings were consistent with relevant cohort studies. Of the seven RCTs on embryo cryopreservation identified, three met the inclusion criteria (638 warming/thawing cycles at cleavage and blastocyst stage), none of which involved pronuclear-stage embryos. A higher CPR per cycle was noted with embryo vitrification compared with slow-freezing, though this was of borderline statistical significance (RR = 1.89, 95% CI: 1.00-3.59; P = 0.051; three RCTs; I2 = 71.9%). LBR per cycle was reported by one RCT performed with cleavage-stage embryos and was higher for vitrification (RR = 2.28; 95% CI: 1.17-4.44; P =  0.016; 216 cycles; one RCT). A secondary analysis was performed focusing on embryo cryosurvival rate. Pooled data from seven RCTs (3615 embryos) revealed a significant improvement in embryo cryosurvival following vitrification as compared with slow-freezing (RR = 1.59, 95% CI: 1.30-1.93; P < 0.001; I2 = 93%).

WIDER IMPLICATIONS

Data from available RCTs suggest that vitrification/warming is superior to slow-freezing/thawing with regard to clinical outcomes (low quality of the evidence) and cryosurvival rates (moderate quality of the evidence) for oocytes, cleavage-stage embryos and blastocysts. The results were confirmed by cohort studies. The improvements obtained with the introduction of vitrification have several important clinical implications in ART. Based on this evidence, in particular regarding cryosurvival rates, laboratories that continue to use slow-freezing should consider transitioning to the use of vitrification for cryopreservation.

Reduced Ectopic Pregnancy Rate on Day 5 Embryo Transfer Compared with Day 3: A Meta-Analysis

OBJECTIVE

To compare the risk of ectopic pregnancy (EP) after embryo transfer on day 3(D3-ET) and day 5(D5-ET).

DESIGN

Meta-analysis.

PATIENTS

Women with pregnancy resulting from in vitro undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

RESULT(S)

Twenty-two studies were identified through research conducted using the PubMed, Embase, and Cochrane databases and ClinicalTrials.gov. All studies were conducted prior to October 2016. Adding the reproductive data from our center, a total of 143 643 pregnancies were reviewed(D3-ET: n = 62027,D5-ET:n = 81616). A lower EP rate was found in women undergoing D5-ET than in those undergoing D3-ET [relative risk (RR), 0.67;95% confidence interval (CI), 0.54-0.85;143643 pregnancies in 23 studies; I2 = 67%]. These results were validated in subgroups of fresh embryo-transfer (Fre-ET) cycles [RR, 0.78; 95%CI, 0.69-0.88; 91 871 pregnancies in 21 studies; I2 = 29%] and frozen-thawed embryo-transfer (Fro-ET) cycles [RR, 0.43; 95%CI, 0.36-0.51; 51 772 pregnancies in 10 studies; I2 = 33%]. After separating out the randomized controlled trials (RCTs), a significant difference was found in the retrospective studies in both subgroups [both Fre-ET (RR,0.78;95% CI 0.69-0.88);91182 pregnancies in 14 studies; I2 = 45%] and Fro-ET(RR,0.43;95% CI 0.36-0.51; 51751pregnancies in 9 studies;I2 = 33%)], while the RCTs showed no statistical significance for Fre-ET cycles[RR,0.86;95% CI 0.32-2.26); 689 pregnancies in 7 studies; I2 = 0%].

CONCLUSION(S)

The present study indicates that D5-ET reduces the risk for EP in cycles that use IVF or ICSI, compared with D3-ET. It suggests that D5-ET may be a better choice for decreasing the EP rate in assisted reproductive technology. Further high-quality randomized controlled trials are anticipated.

Clinical predictors of failing one dose of methotrexate for ectopic pregnancy after in vitro fertilization

PURPOSE

The aim of this study is to investigate the clinical predictors of failure of a single dose of methotrexate (MTX) for management of ectopic pregnancy after in vitro fertilization (IVF).

METHODS

A retrospective cohort study was performed of women who conceived ectopic pregnancies following fresh or frozen IVF cycles at an academic infertility clinic between 2007 and 2014, and received intramuscular MTX (50 mg/m²). Successful single-dose MTX treatment was defined as a serum beta-human chorionic gonadotropin (hCG) decline ≥15% between days 4 and 7 post-treatment. Logistic regression models adjusted for oocyte age, number of embryos transferred, and prior ectopic pregnancy were used to estimate the adjusted odds ratio (OR) (95% confidence interval [CI]) of failing one dose of MTX.

RESULTS

Sixty-four patients with ectopic pregnancies after IVF were included. Forty required only one dose of MTX (62.5%), while 15 required additional MTX alone (up to four total doses, 23.4%), and 9 required surgery (14.1%). By multivariable logistic regression, the highest tertiles of serum hCG at peak (≥499 IU/L, OR = 9.73, CI 1.88-50.25) and at first MTX administration (≥342 IU/L, OR = 4.74, CI 1.11-20.26), fewer embryos transferred (OR = 0.37 per each additional embryo transferred, CI 0.19-0.74), and adnexal mass by ultrasound (OR = 3.65, CI 1.10-12.11) were each correlated with greater odds of requiring additional MTX and/or surgery.

CONCLUSION

This is the first study to report that in women with ectopic pregnancies after IVF, higher hCG-though well below treatment failure thresholds previously described in spontaneous pregnancies-fewer embryos transferred, and adnexal masses are associated with greater odds of failing one dose of MTX. These findings can be used to counsel IVF patients regarding the likelihood of success with single-dose MTX.

Risk of adverse pregnancy and perinatal outcomes after high technology infertility treatment: a comprehensive systematic review

In the literature, there is growing evidence that subfertile patients who conceived after infertility treatments have an increased risk of pregnancy and perinatal complications and this is particularly true for patients who conceived through use of high technology infertility treatments. Moreover, high technology infertility treatments include many concomitant clinical and biological risk factors. This review aims to summarize in a systematic fashion the current evidence regarding the relative effect of the different procedures for high technology infertility treatments on the risk of adverse pregnancy and perinatal outcome. A literature search up to August 2016 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science and Google Scholar and an evidence-based hierarchy was used to determine which articles to include and analyze. Data on prepregnancy maternal factors, low technology interventions, specific procedures for male factor, ovarian tissue/ovary and uterus transplantation, and chromosomal abnormalities and malformations of the offspring were excluded. The available evidences were analyzed assessing the level and the quality of evidence according to the Oxford Centre for Evidence-Based Medicine guidelines and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. Current review highlights that every single procedure of high technology infertility treatments can play a crucial role in increasing the risk of pregnancy and perinatal complications. Due to the suboptimal level and quality of the current evidence, further well-designed studies are needed.

A direct healthcare cost analysis of the cryopreserved versus fresh transfer policy at the blastocyst stage

A cost analysis covering direct healthcare costs relating to IVF freeze-all policy was conducted. Normal- and high- responder patients treated with a freeze-all policy (n = 63) compared with fresh transfer IVF (n = 189) matched by age, body mass index, duration and cause of infertility, predictive factors for IVF (number of oocytes used for fertilization) and study period, according to a 1:3 ratio were included. Total costs per patient (€6952 versus €6863) and mean costs per live birth were similar between the freeze-all strategy (€13,101, 95% CI 10,686 to 17,041) and fresh transfer IVF (€15,279, 95% CI 13,212 to 18,030). A mean per live birth cost-saving of €2178 (95% CI -1810 to 6165) resulted in a freeze-all strategy owing to fewer embryo transfer procedures (1.29 ± 0.5 versus 1.41 ± 0.7); differences were not significant. Sensitivity analysis revealed that the freeze-all strategy remained cost-effective until the live birth rate is either higher or only slightly lower (≥-0.59%) in the freeze-all group compared with fresh cycles. A freeze-all policy does not increase costs compared with fresh transfer, owing to negligible additional expenses, i.e. vitrification, endometrial priming and monitoring, against fewer embryo transfer procedures required to achieve pregnancy.

Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: A case-control study

OBJECTIVES

Ectopic pregnancy (EP) occurs in 2% to 5.6% of pregnancies achieved by assisted reproductive technology (ART). EP treatment options include medical treatment by uses of methotrexate (MTX) systemic injection. The objective of this study was to compare MTX treatment effectiveness for EP occurring spontaneously or following ART.

METHODS

A case-control study performed in the department of obstetrics and gynecology at a tertiary health care center in France. Twenty EP achieved by ART (ART group) and 60 spontaneous EP (SEP group) received MTX treatment between January 2002 and May 2012. The main outcome measures were MTX treatment failure rates, number of MTX injections administered and recovery time.

RESULTS

MTX treatment failure rates observed in ART and SEP groups were similar (3/20 [15%] versus 10/60 [17%]: OR=0.88 [0.22-3.58]). Mean duration of recovery time in patients with successful MTX treatment did not differ between ART and SEP groups (33±14 days versus 28±13 days, P=0.39). A second MTX injection was required more frequently in ART group than in SEP group (10/20 [50%] versus 10/60 [17%]: OR=5 [1.65-15.15]).

CONCLUSIONS

It is concluded that MTX treatment is equally effective for spontaneous EP and EP achieved by ART, two injections of MTX being more frequently required in case of ART.

Segmented ART - The new era in ART?

Currently up to 4% of infants born in developing countries are conceived through assisted reproductive technology (ART). Even though most of these conceptions occur and progress without complications, ART procedures and processes may increase iatrogenesis through complications in - and after conception. We herein review and discuss the clinically and scientific implications and evidence of iatrogenesis, and show how the evolution in ART technologies and procedures has led to the current presumption that frozen embryo transfer might be a more optimal strategy than fresh embryo transfer, in terms of not only reproduction, but also of maternal and fetal outcomes. There is increasing scientific evidence to support the notion that controlled ovarian stimulation could induce significant changes to the endocrine profile of a reproductive cycle, especially to the reproductively important early luteal phase. These changes may not only have a negative effect on implantation and early placentation, but also on the mother, the fetus, and the infant. The overt consequences of controlled ovarian stimulation include ovarian hyperstimulation syndrome, reduced embryo implantation, increased ectopic pregnancy, and altered placentation and fetal growth. The cumulative scientific evidence from this review suggests that GnRHa trigger in segmented ART might constitute the future routine treatment regimen for IVF patients, providing a safe, effective, and patient friendly treatment.