The effects of fertilization mode, embryo morphology at day 3, and female age on blastocyst formation and the clinical outcomes

Independent predictors and thresholds of in vitro fertilization outcomes in patients with diminished ovarian reserve

This study aimed to identify the independent predictors of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcomes among patients with diminished ovarian reserve (DOR), focusing on factors that predict the retrieval of oocytes (cumulus-oocyte complexes [COC]), day 3 (D3) available cleavage-stage embryos, clinical pregnancy during the IVF/ICSI fresh embryo transfer cycle, and viable blastocyst formation. We retrospectively analyzed 1,403 IVF/ICSI cycles involving 1,039 patients diagnosed with DOR, of which 441 cycles underwent fresh embryo transfer. Patients were categorized into groups based on their IVF/ICSI outcomes, which included oocyte retrieval, obtaining D3-available cleavage-stage embryos, clinical pregnancies, and viable blastocyst formation. Univariate and multivariate logistic regression analyses were performed to identify factors influencing IVF/ICSI outcomes. The predictive model incorporated the receiver operating characteristic curve to evaluate the predictive performance of the identified factors for IVF/ICSI outcomes. Anti-Mullerian hormone (AMH) was identified as a more effective independent predictor for oocyte retrieval than antral follicle count (AFC) and basal follicle-stimulating hormone (FSH), whereas AFC demonstrated superior predictive accuracy for obtaining D3-available cleavage-stage embryos, with prediction thresholds of 0.345 ng/mL and 3.5, respectively. D3 top-quality cleavage-stage embryos were a more reliable independent predictor of clinical pregnancy than age for patients aged below 40 years, whereas age showed greater predictive reliability in those aged 40 years or above. Additionally, D3-available cleavage-stage embryos were the sole predictor of viable blastocyst formation. In conclusion, AMH and AFC were more reliable than basal FSH at predicting the retrieval of oocytes and D3-available cleavage-stage embryos. Acquiring a D3 top-quality cleavage-stage embryo suggests potential for clinical pregnancy, but for patients aged 40 years or older, even access to such embryos does not mitigate the significant effects of age on clinical pregnancy outcomes. If none of the three to four D3 available cleavage-stage embryos are of top quality, culturing them to the blastocyst stage may improve clinical outcomes by yielding viable blastocysts.

Pregnancy outcomes in freeze-all versus fresh embryo transfer cycles of women with adenomyosis and endometriosis: a systemic review and meta-analysis

Background

Endometriosis (EMS) and adenomyosis have adverse effects on women's fertility. In vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are effective treatments for these diseases. Research has shown that different embryo transfer strategies in IVF/ICSI can influence gestational outcomes. This systematic review and meta-analysis aimed to evaluate the impact of freeze-all embryo transfer (FET) versus fresh embryo transfer (ET) strategies in IVF/ICSI cycles for infertile women with EMS and adenomyosis.

Method

A comprehensive search was conducted across PubMed, EMBASE, MEDLINE, Web of Science, Google Scholar, and Chinese databases to identify studies examining different embryo transfer strategies in IVF/ICSI cycles among patients with EMS and adenomyosis. The outcomes analyzed included rates of implantation, clinical pregnancy, miscarriage, and live birth. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects or fixed-effects models.

Results

In patients with EMS, the results demonstrated that the FET strategy yielded higher clinical pregnancy (OR: 1.25; 95% CI: 1.11, 1.40), live birth rates (OR: 1.31; 95% CI: 1.15, 1.49), and implantation rates (OR: 1.27; 95% CI: 1.05, 1.54) compared to the fresh ET strategy. The miscarriage rate (OR: 0.89; 95% CI: 0.52, 1.52) and the ectopic pregnancy rate (OR: 0.51; 95% CI: 0.24, 1.07) were comparable between groups. For the group of women with adenomyosis, the IVF/ICSI outcomes were comparable between the FET and fresh ET strategies.

Conclusion

In IVF/ICSI, the FET strategy has been associated with more favorable reproductive outcomes compared to the fresh ET strategy in women with EMS. Whereas in women with adenomyosis, pregnancy outcomes were comparable between the FET and fresh ET groups.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024563268, identifier CRD42024563268.

Influence of parental age on chromosomal abnormalities in PGT-A embryos: exponentially increasing in the mother and completely null in the father

PURPOSE

To study the influence of parental age on aneuploidy rates (AR) in PGT-A cycles and on the recurrence rate.

METHODS

A total of 16,029 PGT-A cycles were studied over a 9-year period. The median age was 40.0 [37.0; 41.0] in women and 40.0 [37.0; 43.0] in men. In 48.3%, the biopsy was performed on day 3 embryos (D3E) and in 51.7% on blastocysts (79.5% using NGS).

RESULTS

In women, the AR was almost constant at < 50% until the age of 35 but increased steadily to reach > 90% at 44. The AR pattern varied according to embryo stage and was considerably higher in D3E, with a steeper curve. A U-pattern was observed in D3E, whereas this was not seen in blastocysts. In the blastocysts analyzed using NGS, trisomy 21 increased sixfold (from < 1% at < 30 to nearly 5% in women aged 40), whereas trisomies 13 and 18 increased their frequency twofold. After 3 biopsied blastocysts studied using NGS, 100% of women aged ≤ 30 had at least 1 euploid embryo, vs 96% aged 31-35, almost 80% aged 36-40, 50% aged 41-45, and 33% aged 46-50. In terms of the man's age, the non-adjusted analysis revealed a correlation with AR. However, after correcting for the woman's age, no correlation was observed. The man's age was not associated with any of the aneuploidies potentially resulting in a newborn.

CONCLUSIONS

Carrying out PGT-A systematically in IVF cycles from the age of 38-39 is highly recommended. Advanced paternal age does not carry an increased risk of aneuploidy for the embryo and does not in itself constitute an indication for PGT-A.

'Blame it on my youth': when very young age of oocyte donors appears to be associated with poorer embryo development

RESEARCH QUESTION

Is the age of oocyte donors associated with usable and top-quality blastocyst rates?

DESIGN

Retrospective cross-sectional study (January 2016-October 2022) of 1738 oocyte recipient cycles with culture to blastocyst stage. Cycles were categorized according to the age of oocyte donors (Group I, <20 years; Group II, 20-25 years; Group III, ≥26 years). Usable and top-quality blastocyst rates were compared using chi-squared test. For the multivariable analysis, a generalized logistic mixed model was applied to estimate the odds for every endpoint. The probabilities of obtaining one usable blastocyst and one top-quality blastocyst based on the number of inseminated oocytes were estimated.

RESULTS

The usable blastocyst rate was 42.8%, and this differed significantly with the age of the oocyte donor: 33.2% for Group I, 42.9% for Group II, and 43.5% for Group III (P < 0.001). When adjusting for covariates, the usable blastocyst rate remained significantly lower for Group I compared with Group III (OR 0.65, 95% CI 0.49-0.86). The top-quality blastocyst rate was 56.7%, and this did not differ significantly with the age of the oocyte donor (P = 0.565). In order to have the same 90% likelihood of obtaining at least one usable blastocyst as the reference group (Group III), two more oocytes (six versus four) are required when the oocyte donor is aged <20 years. Similarly, three more oocytes (12 versus nine) are needed to have the same 90% chance of obtaining at least one top-quality blastocyst.

CONCLUSIONS

In comparison with oocyte donors aged ≥26 years, those aged <20 years have a significantly lower usable blastocyst rate but a comparable top-quality blastocyst rate. These findings allow for adjustment of the number of oocytes assigned to recipients based on the age of the donor to ensure comparable outcomes across age groups while preventing the creation of too many supernumerary embryos.

Influencing factors and effects of low oocyte retrieval in patients with polycystic ovary syndrome undergoing in-vitro fertilization

OBJECTIVE

To investigate influencing factors and effects of low oocyte retrieval in patients with polycystic ovary syndrome (PCOS) undergoing in-vitro fertilization (IVF).

METHODS

In total, 720 patients with PCOS undergoing IVF were enrolled in this retrospective study from January 2017 to December 2022. The oocyte retrieval rate (ORR) was defined as the ratio of the number of oocytes retrieved to the number of follicles ≥ 12 mm in diameter on the trigger day. Using 1 standard deviation from the mean ORR as the boundary value, patients were divided into low and normal ORR groups. Patient characteristics, stimulation protocols, serum hormone levels, oocyte maturity, embryo developmental quality, and pregnancy outcomes of fresh transfer cycles were analysed.

RESULTS

ORR ranged from 0.06 to 2.69, with a mean value of 1.02. Compared with the normal ORR group (ORR ≥ 0.65), patients in the low ORR group (ORR < 0.65) had a higher body mass index; higher antral follicle count (AFC); more days of gonadotrophin stimulation; and lower serum oestradiol (E2) level, lower progesterone level and lower E2 level/follicle (≥12 mm) on the trigger day. Multivariate logistic regression analysis showed AFC [adjusted odds ratio (aOR) 1.05, 95 % confidence interval (CI) 1.0120-1.0940], E2 level/follicle (≥12 mm) (aOR 0.99, 95 % CI 0.9888-0.9972) and progesterone level (aOR 0.41, 95 % CI 0.2402-0.6649) on the trigger day were significantly associated with low ORR. Receiver operator characteristic curve analyses revealed that serum E2 level/follicle (≥12 mm) had an area under the curve of 0.7036 (95 % CI 0.65-0.76; p < 0.01). The cut-off value was 169.2 pg/ml, with sensitivity of 65 % and specificity of 65 %, for predicting low ORR. Low ORR was associated with fewer top-quality embryos and more cycles with no embryos available for transfer. The rates of metaphase II oocytes, top-quality embryos, clinical pregnancy and live birth did not differ between the two groups.

CONCLUSION

Serum E2 level/follicle (≥12 mm) on the trigger day may be used as a predictive factor for low ORR in patients with PCOS. Low ORR may not affect oocyte and embryo developmental potential under appropriate ovarian stimulation management, but likely increases the risk of no embryos being available for transfer.

Lessons learned from 64,071 embryos subjected to PGT for aneuploidies: results, recurrence pattern and indications analysis

RESEARCH QUESTION

What is the influence of biological, technical and clinical factors on embryo outcomes in preimplantation genetic testing for aneuploidies (PGT-A) and what is the recurrence pattern?

DESIGN

This retrospective study included 64,071 embryos undergoing PGT-A in the same laboratory between 2011 and 2019. Biopsies were performed at the day 3 embryo stage (48.32%) or blastocyst stage (51.70%). Advanced maternal age (AMA) was the main indication (65.62%).

RESULTS

The aneuploidy rate was 67.75%, higher in women aged over 35 years than in women aged 35 years or less (71.76% versus 47.44%), and higher in day 3 embryo versus blastocyst biopsies (77.51% versus 58.62%). The trisomy:monosomy ratio was 1.01 for blastocysts versus 0.84 for day 3 embryos. Trisomy 21 was present in 4.9% of embryos. In aneuploid embryos, the probability of having one or more involved chromosomes followed a decreasing exponential pattern. The probability of an embryo being euploid was constant at around 30% (40% in blastocysts, 20% in day 3 embryos). The cumulative probability of having one or more euploid embryos after 10 biopsied embryos was 94.79% in blastocysts and 80.61% in day 3 embryos. AMA was associated with a much higher aneuploidy rate than all other indications, which among them had similar aneuploidy rate and chromosomal involvement.

CONCLUSIONS

There is a considerably lower aneuploidy rate in blastocysts than day 3 embryos, which is most notable for monosomies. While AMA shows an increased aneuploidy rate and a specific chromosomal pattern of involvement, the remaining indications showed a similar aneuploidy rate and chromosomal pattern. Even after producing many consecutive aneuploid embryos, the possibility of obtaining a euploid embryo is not negligible.

Predictive Factors for the Formation of Viable Embryos in Subfertile Patients with Diminished Ovarian Reserve: A Clinical Prediction Study

This study aims to construct and validate a nomogram for predicting blastocyst formation in patients with diminished ovarian reserve (DOR) during in vitro fertilization (IVF) procedures. A retrospective analysis was conducted on 445 DOR patients who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) at the Reproductive Center of Yulin Maternal and Child Health Hospital from January 2019 to January 2023. A total of 1016 embryos were cultured for blastocyst formation, of which 487 were usable blastocysts and 529 did not form usable blastocysts. The embryos were randomly divided into a training set (711 embryos) and a validation set (305 embryos). Relevant factors were initially identified through univariate logistic regression analysis based on the training set, followed by multivariate logistic regression analysis to establish a nomogram model. The prediction model was then calibrated and validated. Multivariate stepwise forward logistic regression analysis showed that female age, normal fertilization status, embryo grade on D2, and embryo grade on D3 were independent predictors of blastocyst formation in DOR patients. The Hosmer-Lemeshow test indicated no statistical difference between the predicted probabilities of blastocyst formation and actual blastocyst formation (P > 0.05). These results suggest that female age, normal fertilization status, embryo grade on D2, and embryo grade on D3 are independent predictors of blastocyst formation in DOR patients. The clinical prediction nomogram constructed from these factors has good predictive value and clinical utility and can provide a basis for clinical prognosis, intervention, and the formulation of individualized medical plans.

Impacts of different culture times on pregnancy outcomes after thawing of cleavage stage embryos

OBJECTIVE

This study assessed the impacts of in vitro culture times of cleavage embryos on clinical pregnancy outcomes.

METHODS

This retrospective cohort study was performed at the Reproductive Medicine Department of Hainan Modern Women and Children's Hospital in China between January 2018 and December 2022. Patients who first underwent frozen embryo transfer with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles on day 3 were included. According to the time of embryo culture after thawing, the embryos were divided into long-term culture group(18-20 h) and short-term culture group (2-4 h). The clinical pregnancy rate was regarded as he primary outcome. To minimize confounding factors and reduce selection bias, the propensity score matching was used to balance the effects of known confounding factors and to reduce selection bias. Stratified analyses and multiple logistic regression analyses were used to evaluate the risk factors affecting the clinical pregnancy outcomes after matching.

RESULTS

General characteristics between two groups were comparable after matching. In the long-term culture group, 266/381 (69.81%) embryos had more than 10 blastomeres, and 75/381 (19.68%) reached the morula stage. After overnight culture, the implantation rate (27.97% vs. 14.28%, P = 0.018) and clinical pregnancy rate (38.46% vs. 22.5%, P = 0.05) were increased in the group with proliferating blastomeres. The long-term culture group trended to have a higher clinical pregnancy rate compared with the short-term culture group (35.74% vs. 29.79%). No statistical differences in clinical pregnancy outcomes between the two groups were observed after matching, including the rates of implantation (25.46% vs23.98%), miscarriages (25% vs. 22.85%), ongoing pregnancy rate (76.2% vs. 77.15%) and live birth rate (26.8% vs. 22.98%). Stratified analyses were performed according to the age of the patients. After matching, there were no significant differences in the clinical pregnancy, implantation and miscarriage rates between the two groups for patients > 35 or ≤ 35 years of age. Subgroup analyses were performed according to the quality of the transferred embryos. There were no significant differences in the clinical outcomes, between two groups after embryos transferred with the same quality. Multivariate Logistic regression analysis was used to evaluate the influencing factors of clinical pregnancy outcomes after matching. Culture time was not found to be an independent predictor for clinical pregnancy [OR 0.742, 95%CI 0.487 ~ 1.13; P = 0.165]. The age of oocyte retrieval [OR 0.906, 95%CI 0.865 ~ 0.949; P <0.001] and the number of high-quality embryos transferred [OR 1.787, 95%CI 1.256 ~ 2.543; P = 0.001] were independent factors affecting clinical pregnancy outcomes.

CONCLUSIONS

In vitro 18-20 h culture of embryos with either good-or non-good-quality will not adversely affect the clinical pregnancy.

Association between transferred embryos and multiple pregnancy/live birth rate in frozen embryo transfer cycles: A retrospective study

Background

Physicians need an appropriate embryo transfer strategy to address the challenge of reducing multiple birth rates, while maintaining the couples' live birth rate during assisted reproductive technology.

Methods

We included 10,060 frozen embryo transfer cycles from January 2015 to March 2020 in reproductive medical center of Ruijin hospital, Shanghai, China. Patients were grouped according to the number and grade of cleavage-stage embryo or blastocysts transferred. Live birth rate and multiple live birth rate were compared among groups of women of different ages. Multivariable logistic regression models were used to estimate the risk of multiple live birth using different combinations of transferred embryos.

Results

The transfer of double good-quality embryos was an independent predictor for multiple birth in women aged <30 years and those aged 36-39 years [<30 years: aOR =1.54 (95% CI: 1.14-2.06, P < 0.01); 36-39 years: aOR =1.84 (95% CI: 1.0-3.4, P < 0.01)]. Further, for women aged <36 years, the transfer of good-quality + poor-quality blastocysts was an independent predictor for multiple birth rate [<30 years: aOR=2.46 (95% CI: 1.45-4.18, P < 0.01); 31-35 years: aOR =4.45 (95% CI: 1.97-10.06, P < 0.01)].

Conclusions

Single-good-quality blastocyst transfer is recommended for women of all ages. When good-quality cleavage embryos are available, the choice of single or double embryo transfer with good- or average-quality embryo should depend on the age of women. Double embryo transfer with the highest possible grade of embryos is recommended for women aged ≥40 years.

The serum follicle stimulating hormone-to-luteinizing hormone ratios can predict assisted reproductive technology outcomes in women undergoing gonadotropin releasing hormone antagonist protocol

BACKGROUND

The basal follicle stimulating hormone (FSH)/luteinizing hormone (LH) ratio is a useful predictor of ovarian response. In this study, we investigated whether the FSH/LH ratios during the entire controlled ovarian stimulation (COS) can be used as effective predictors of outcomes in women undergoing in vitro fertilization (IVF) treatment using the gonadotropin releasing hormone antagonist (GnRH-ant) protocol.

METHODS

A total of 1,681 women undergoing their first GnRH-ant protocol were enrolled in this retrospective cohort study. A Poisson regression model was used to analyze the association between the FSH/LH ratios during COS and embryological outcomes. Receiver operating characteristic analysis was performed to determine the optimal cutoff values for poor responders (≤ 5 oocytes) or poor reproductive potential (≤ 3 available embryos). A nomogram model was constructed to provide a tool for predicting the cycle outcomes of individual IVF treatments.

RESULTS

The FSH/LH ratios (at the basal day, stimulation day 6 (SD6) and trigger day) were significantly correlated with the embryological outcomes. The basal FSH/LH ratio was the most reliable predictor of poor responders with a cutoff value of 1.875 (area under the curve (AUC) = 72.3%, P < 0.05), or of poor reproductive potential with a cutoff value of 2.515 (AUC = 66.3%, P < 0.05). The SD6 FSH/LH ratio predicted poor reproductive potential with a cutoff value of 4.14 (AUC = 63.8%, P < 0.05). The trigger day FSH/LH ratio predicted poor responders with a cutoff value of 9.665 (AUC = 63.1%, P < 0.05). The basal FSH/LH ratio, combined with the SD6 and trigger day FSH/LH ratios, slightly increased these AUC values and improved the prediction sensitivity. The nomogram provides a reliable model with which to assess the risk of poor response or poor reproductive potential directly based on the combined indicators.

CONCLUSIONS

FSH/LH ratios are useful predictors of poor ovarian response or reproductive potential throughout the entire COS with the GnRH antagonist protocol. Our findings also provide insights into the potential for LH supplementation and regimen adjustment during COS to achieve improved outcomes.

The influence of day 3 embryo cell number on the clinical pregnancy and live birth rates of day 5 single blastocyst transfer from frozen embryo transfer cycles

BACKGROUND

To evaluate the influence of day 3 embryo cell number on the clinical pregnancy and live birth rates of day 5 single blastocyst transfer in frozen embryo transfer (FET) cycles.

METHODS

Our retrospective study included 3761 day 5 single blastocyst FET cycles between January 2015 and December 2019. These FET cycles were divided into three groups according to the day 3 embryo cell number: 939 cycles in the < 8-cell group, 1224 cycles in the 8-cell group and 1598 cycles in the > 8-cell group. The clinical pregnancy and live birth rates were compared among the three groups.

RESULTS

The clinical pregnancy rate of day 5 single blastocyst transfer in FET cycles increased significantly as the day 3 embryo cell number increased (52.2%, 61.4% and 66.8%, P < 0.001). Similarly, the live birth rate increased significantly as the day 3 embryo cell number increased (42.7%, 49.8% and 54.9%, P < 0.001). The results of the subgroup analysis showed that the clinical pregnancy and live birth rates were not significantly different among the three groups when good-quality blastocysts were transferred. The clinical pregnancy and live birth rates increased significantly as the day 3 embryo cell number increased when fair- and poor-quality blastocysts were transferred.

CONCLUSION

The day 3 embryo cell number needs to be considered when day 5 single blastocyst transfer is performed in FET cycles, especially when fair- and poor-quality blastocysts are used for transfer. The transfer of a day 5 single blastocyst derived from an embryo with faster development on day 3 may shorten the time to achieving a live birth.

Does the cell number of 0PN embryos on day 3 affect pregnancy and neonatal outcomes following single blastocyst transfer?

Background

0PN zygotes have a low cleavage rate, and the clinical outcomes of cleavage-stage embryo transfers are unsatisfactory. Blastocyst culturing is used to screen 0PN embryos, but whether the cell number of 0PN embryos on day 3 affects the clinical outcomes following single blastocyst transfer is unknown and would be helpful in evaluating the clinical value of these embryos.

Methods

This retrospective study compared 46,804 0PN zygotes, 242 0PN frozen-thawed single blastocyst transfers, and 92 corresponding 0PN singletons with 232,441 2PN zygotes, 3563 2PN frozen-thawed single blastocyst transfers, and 1250 2PN singletons from January 2015 to October 2019 at a tertiary-care academic medical centre. The 0PN and 2PN embryos were divided into two groups: the group with < 6 cells on day 3 and that with ≥ 6 cells. Embryo development, subsequent pregnancy and neonatal outcomes were compared between the two groups.

Results

The cleavage and available blastocyst rates of the 0PN zygotes were much lower than those of the 2PN zygotes (25.9% vs. 97.4%, P < 0.001; 13.9% vs. 23.4%, P < 0.001). In the < 6 cells group, the available blastocyst rate of the cleaved 0PN embryos was significantly lower than that of the 2PN embryos (2.5% vs. 12.7%, P < 0.001). However, in the ≥ 6 cells group, the available blastocyst rate of the 0PN cleaved embryos significantly improved, although it was slightly lower than that of the 2PN embryos (33.9% vs. 35.7%, P = 0.014). Importantly, compared to those of the 2PN single blastocyst transfers, the clinical pregnancy rate, live birth rate, Z-score and malformation rate of the 0PN single blastocyst transfers were not significantly different in either the < 6 cells group (30.4% vs. 39.8%, P = 0.362; 30.4% vs. 31.3%, P = 0.932; 0.89 ± 0.90 vs. 0.42 ± 1.02, P = 0.161; 0% vs. 2.6%, P = 1.000) or the ≥ 6 cells group (50.7% vs. 46.6%, P = 0.246; 39.7% vs. 38.3%, P = 0.677; 0.50 ± 1.23 vs. 0.47 ± 1.11, P = 0.861; 2.4% vs. 1.8%, P = 1.000).

Conclusions

The cell number on day 3 of 0PN embryos affected the subsequent formation of blastocysts but did not influence the subsequent pregnancy and neonatal outcomes of 0PN single blastocyst transfers, which may be beneficial to clinicians counselling patients on the clinical value of 0PN embryos.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04492-7.

Developmental Potential of embryos does not Impact Pregnancy Outcomes, but it Affects Live Birth Rates in Frozen Blastocyst Transfer Cycles

OBJECTIVE

This study aimed to determine whether or not developmental potential impacts clinical outcomes, when good grade blastocysts from Days 5 and 6 were transferred in frozen embryo transfer (FET) cycles.

METHODS

654 women, including 460 (70.33%) on Day 5 and 194 (29.66%) on Day 6 were analyzed, in which 905 Day-5 and 274 Day-6 blastocysts were transferred. Only grade AA, AB, BA, BB quality and expansion grade between 3-6 (Gardner grading system) blastocysts survived and were included.

RESULTS

The implantation rate was higher, 41.9% (379/905) in normal Day-5 compared to delayed Day-6 blastocyst transfers - 36.5% (100/274), but not significant (p=0.1). The clinical pregnancy rate was similar and not significant (p=0.4) in normal Day-5 (32.4%), compared to delayed Day-6 (35%). Miscarriage rates were higher in normal Day-5 (13.3%) compared to delayed Day-6 (6.3%) blastocyst transfers but were not significant (p=0.06). On the other hand, the biochemical pregnancy rate was significantly higher (p=0.001) in the delayed Day-6 blastocysts (16.7%) transfer group compared to patients with normal Day-5 (2.4%) blastocyst transfers. Two patients had ectopic pregnancies from the delayed Day-6 blastocyst transfer group. Live-Birth rates were significantly higher in Day-5 blastocysts compared to Day-6 (p=0.03).

CONCLUSIONS

The developmental potential of embryos should not be considered a negative influence on pregnancy outcomes, especially good grade blastocysts vitrified on Days 5 and 6. Fully expanded blastocysts on Day-5 are considered similar in terms of outcomes to delayed Day-6 blastocysts; however, live-birth rates are significantly higher in Day-5 blastocysts.

Predictive value of the number of frozen blastocysts in live birth rates of the transferred fresh embryos

Background

Blastocyst development by extended culture in vitro allows the embryos to ‘select’ themselves, thus successful growth to the blastocyst stage is a reflection of the developmental competence of cleavage stage embryos in a cohort. The study aims to determine whether the number of frozen blastocysts is associated with live birth rates of the transferred fresh embryos.

Method

The retrospective study included 8676 cycles of first fresh embryo transfer from January 2016 to June 2019 at a fertility center of a university hospital. The patients with ≥ 10 oocytes retrieved were divided into three groups according to the number of frozen blastocysts: 0 (group 1), 1–2 (group 2), and ≥ 3 (group 3). The primary outcome measure was the live birth. The secondary outcome measures included clinical pregnancy rates and implantation rates. Logistic regression analysis was also performed.

Results

Live birth rates in patients with ≥ 3 and 1–2 frozen blastocysts were 47.6% and 46.1%, respectively, which were significantly higher than that in patients without blastocyst (36.0%). The clinical pregnancy rate in group 3 was 65.1%, which was also significantly higher than the other two groups (47.0% and 59.2%). The implantation rates were 35.5%, 47.6%, and 56.0% in the three groups, respectively (P < 0.001). Compared with groups of frozen blastocysts, 0 frozen blastocyst yielded a lower rate of live birth (the adjusted odds ratio: 0.526, 95% CI: 0.469, 0.612).

Conclusion

In patients with optimal ovarian response that retrieved ≥ 10 oocytes, fresh embryos transfer followed by having blastocysts frozen is a strong indicator of pregnancy achievement, but the number of frozen blastocysts (if not = 0) has limited value in predicting live birth rates.

GnRH Antagonist Protocol With Cessation of Cetrorelix on Trigger Day Improves Embryological Outcomes for Patients With Sufficient Ovarian Reserve

OBJECTIVE

To evaluate the efficiency and validity of cessation of cetrorelix on trigger day during gonadotropin releasing hormone antagonist (GnRH-ant)-controlled ovarian stimulation of in vitro fertilization (IVF) cycles.

METHODS

In this retrospective study, a total of 1271 patients undergoing initial IVF cycles following the GnRH-ant protocol were enrolled; 832 patients received cetrorelix on trigger day (Group A) and 439 patients ceased cetrorelix on trigger day (Group B). We compared demographic characteristics, embryological and clinical outcomes between the two groups. A Poisson regression model was used to identify factors that significantly affected embryological outcomes. Patients were further divided into subgroups according to anti-Mullerian hormone (AMH) and age, to assess associations between ceasing cetrorelix on trigger day and embryological outcomes.

RESULTS

There was a significant improvement on embryological outcomes in patients who ceased cetrorelix on trigger day, and there were no significant differences in clinical outcomes or preovulation rates between the two groups. Furthermore, for patients with 1.1 ≤ AMH ≤ 4.7 ng/ml, all embryological outcomes were significantly higher in Group B compared with Group A. For patients with AMH > 4.7 ng/ml, the number of oocytes retrieved, fertilization rate (2PN) of IVF cycles and proportion of day 3 good quality embryos were all significantly higher in Group B. For patients with age < 35 years, all the embryological outcomes, besides the number of available embryos, were significantly higher in Group B than in Group A. There were no differences in embryological outcomes between the two groups when patients were stratified based on age > 35 years or AMH < 1.1 ng/ml.

CONCLUSION

GnRH-ant protocol with cessation of cetrorelix on trigger day improved embryological outcomes for young patients or patients with sufficient ovarian reserve, and was effective at preventing preovulation.

A visualized clinical model predicting good quality blastocyst development in the first IVF/ICSI cycle

RESEARCH QUESTION

Is it possible to establish a visualized clinical model predicting good quality blastocyst (GQB) formation for patients in their first IVF/intracytoplasmic sperm injection (ICSI) cycle?

DESIGN

A total of 4783 patients in their first IVF/ICSI cycle between January 2015 and December 2019 were retrospectively included and randomly divided into the training set (n = 3826) and the testing set (n = 957) in an 8:2 ratio. The least absolute shrinkage and selection operator (LASSO) regression was adopted to select the most critical predictors for GQB formation to construct a visualized nomogram model based on the data of patients in the training set. Receiver operating characteristic and calibration curves were used to evaluate the predictive accuracy and discriminative ability. The performance of the model was also validated on independent data from patients treated in the testing set.

RESULTS

Maternal age, maternal serum anti-Müllerian hormone (MsAMH) concentration and the number of oocytes retrieved were highlighted as critical predictors of GQB development and were incorporated into the nomogram model. Based on the area under the curve (AUC) values, the predictive ability for ≥1, ≥3 and ≥5 GQB were 0.831, 0.734 and 0.748, respectively. The calibration curve also showed high concordance between the observed and predicted results. The AUC for predicting ≥1, ≥3 and ≥5 GQB in the testing set were 0.805, 0.695 and 0.707, respectively, which were similar to those for the training set.

CONCLUSIONS

The visualized nomogram model provides great predictive value for GQB development in patients in their first IVF/ICSI cycle and can be used to improve clinical counselling.

Predictors of blastocyst formation rate in elective day 5 transfer cycle

This study aimed to investigate the factors affecting blastocyst formation rate. One hundred and seven fresh in vitro fertilisation (IVF) and elective day 5 blastocyst transfer cycles were selected. Univariate and multivariate analyses revealed that intracytoplasmic sperm injection (ICSI) (r = -.236, p = .014 vs. p = .005) was advantageous for blastocyst formation. In addition, the number of mature oocytes (r = -.274, p = .004 vs. p = .002) was a significant factor associated with blastocyst and good-quality blastocyst formation rates (p = .021, r = -.389). Both blastocyst and good-quality blastocyst formation rates were significantly higher with ICSI than with conventional insemination (65.0 ± 24.5% vs. 50.0 ± 21.2%, p = .012; 43.1 ± 22.8% vs. 30.9 ± 19.8%, p = .038, respectively). The number of mature oocytes appears to be the most important predictor of blastocyst formation rate. Additionally, ICSI fertilisation is superior to conventional insemination in terms of blastocyst formation rate.IMPACT STATEMENTWhat is already known on this subject? There are many advantages of blastocyst transfer cycle over cleavage transfer cycle, but there are no known routine selection criteria for the timing of embryo transfer. To date, the number of blastomeres, number of retrieved oocytes, quality of embryos and fertilisation method have been suggested as the important factors involved in blastocyst formation. However, the number of studies on this issue is limited, and some studies have shown conflicting results.What do the results of this study add? This study showed that the number of mature oocytes and ICSI fertilisation are the significant factors associated with blastocyst formation rate in elective day 5 transfer cycle.What are the implications of these findings for clinical practice and/or further research? This paper demonstrated that the number of mature oocytes and the fertilisation method should be considered before embryo transfer. Consideration of these factors would be meaningful in selecting patients who will be suitable for extended culture up to day 5.

The association of AGO1 (rs595961G>A, rs636832A>G) and AGO2 (rs11996715C>A, rs2292779C>G, rs4961280C>A) polymorphisms and risk of recurrent implantation failure

Recurrent implantation failure (RIF) is a common reproductive clinical condition treated by fertility specialists at in vitro fertilization (IVF) clinics. Several factors affect embryo implantation including the age of the female, the quality of embryos and the sperm, genetics, immunologic factors. Here, we investigated the association of Argonaute 1 (AGO1) and Argonaute 2 (AGO2) polymorphisms and RIF. We collected blood samples from 167 patients with RIF and 211 controls. Genetic polymorphisms were detected by polymerase chain reaction (PCR) – restriction fragment length polymorphism analysis and real-time PCR. We found that the AGO2 rs4961280C>A polymorphism (adjusted odds ratio [AOR] = 1.984; P = 0.023) was significantly associated with RIF. Furthermore, in RIF patients with three or more consecutive implantation failure, the AGO2 rs4961280C>A CA genotype (AOR = 2.133; P = 0.013) and dominant model (AOR = 2.272; P = 0.006) were both significantly associated with prevalence of RIF. An analysis of variance revealed that patients with the AGO2 rs2292779C>G genotypes (CC: 6.52 ± 2.55; CG: 7.46 ± 3.02; GG: 8.42 ± 2.74; P = 0.044) and the dominant model (CC: 6.52 ± 2.55; CG+GG: 7.70 ± 2.97; P = 0.029) exhibited significantly increased white blood cell levels. Furthermore, patients with the AGO1 rs595961G>A dominant model (GG: 36.81 ± 8.69; GA+AA: 31.58 ± 9.17; P = 0.006) and the AGO2 rs4961280C>A recessive model (CC+CA: 35.42 ± 8.77; AA: 22.00 ± 4.24; P = 0.035) exhibited a significantly decreased number of CD4⁺ helper T cells. Our study showed that AGO1 and AGO2 polymorphisms are associated with the prevalence of RIF. Hence, the results suggest that variations in AGO1 and AGO2 genotypes may be useful clinical biomarkers for the development and prognosis of RIF.

Increased pregnancy outcome after day 5 versus day 6 transfers of human vitrified-warmed blastocysts

Vitrification is a highly efficient technique for the cryopreservation of the human embryo. The effect of delayed blastulation may be responsible for implantation failures and negatively affects in vitro fertilization (IVF) outcomes. The current literature displays discordant results; some studies have announced higher pregnancy rates after day 5 (D5) transfer compared with day 6 (D6) transfer, while others have shown equivalent outcomes. In the present study an investigation into the clinical implications of delayed blastulation (D5 versus D6) was carried out. We performed a retrospective study comparing clinical pregnancies and implantation rates following warmed single blastocyst transfer (WSBT). All patients coming for a programmed warmed transfer at Edinburgh Assisted Conception Programme, EFREC, Royal Infirmary of Edinburgh, were included in this study and divided in two groups according to the day of blastocyst vitrification: D5 (n = 1563) and D6 (n = 517). The overall survival rate was 95.0% (1976/2080) with no significant difference between the D5 and D6 groups: 95.3% (1489/1563) and 94.2% (487/517) respectively. WSBT of D6 blastocysts resulted in a lower implantation and clinical pregnancy compared with D5 embryos. The implantation rate (IPR) and clinical pregnancy rate (CPR) were respectively 49.4% and 42.6% for the D5 and 37.4% and 32.2% for the D6 embryos, which was statistically significant. The multiple pregnancy rate was 1.32% (1.14% for D5 vs 1.84% for D6). Although the transfer of D6 vitrified-warmed blastocyst remains a reasonable option, priority to a D5 embryo would reduce the time to successful pregnancy.

A comparison of the survival and implantation rates of blastocysts that were vitrified on post-fertilization day five, six and seven

The goal of this retrospective cohort study was to compare survival, implantation, clinical and ongoing pregnancy rates between blastocysts that were vitrified on post-fertilization days 5, 6 and 7. Before vitrification, blastocysts were evaluated in terms of morphology and blastocyst expansion, inner cell mass and trophectoderm quality. They were thawed and transfered in a subsequent artificial cycle. Embryo implantation rates were 39%, 25% and 25% for blastocysts that were vitrified on days 5, 6, and 7, respectively (p = 0.006). Clinical and ongoing pregnancy rates were 19%, 12%, 13% (p = 0.100) and 9%, 7%, 12% (p = 0.99) for days 5, 6 and 7 blastocysts, respectively. Day 5 blastocysts had significantly higher full-collapsing score after assisted-hatching compared to days 6 and 7 blastocysts (p = 0.014). As blastocyst quality increased, implantation and clinical pregnancy rates increased in all groups and both parameters were statistically significantly higher on day 5 blastocysts than on days 6 or 7 (p = 0.001). It was clearly found that good quality blastocysts obtained on day 5 have higher implantation and clinical pregnancy rates than 6th and 7th day cryopreserved embryos. There were no statistically significant differences between the cryopreserved embryos on days 6 and 7 regarding the implantation, clinic and ongoing pregnancy rates.

A predictive model for high-quality blastocyst based on blastomere number, fragmentation, and symmetry

PURPOSE

The aim of this study was to create a predictive model for high-quality blastocyst progression based on the traditional morphology parameters of embryos.

METHODS

A total of 1564 embryos from 234 women underwent conventional in vitro fertilization and were involved in the present study. High-quality blastocysts were defined as having a grade of at least 3BB, and all embryos were divided based on the development of high-quality blastocysts (group HQ) or the failure to develop high-quality blastocysts (group NHQ). A retrospective analysis of day-3 embryo parameters, focused on blastomere number, fragmentation, the presence of a vacuole, symmetry, and the presence of multinucleated blastomeres was conducted.

RESULTS

All parameters were related to high-quality blastocysts (p < 0001) in t tests, chi-square tests, or Fisher tests. The individual scores for all parameters were determined according to their distributions and corresponding rates of forming high-quality blastocysts. Parameters are indicated by s_bn (blastomere number), s_f (fragmentation), s_pv (presence of a vacuole), s_s (symmetry), and s_MNB (multinucleated blastomeres). Subsequently, univariate and multivariate logistic regression analyses were conducted to explore their relationship. In the multivariate logistic regression analysis, a predictive model was constructed, and a parameter Hc was created based on the s_bn, s_f, and s_s parameters and their corresponding odds ratios. The value of Hc in group HQ was significantly higher than that in group NHQ. A receiver operating characteristic curve was used to test the effectiveness of the model. An area under the curve of 0.790, with a 95% confidence interval of 0.766-0.813, was calculated. A dataset was used to validate the predictive utility of the model. Moreover, another dataset was used to ensure that the model can be applied to predict the implantation of day-3 embryos.

CONCLUSIONS

A predictive model for high-quality blastocysts was created based on blastomere number, fragmentation, and symmetry. This model provides novel information on the selection of potential embryos.

The day of embryo transfer affects delivery rate, birth weights, female-to-male ratio, and monozygotic twin rate

OBJECTIVE

To compare the reproductive outcomes between the transfer of cleavage-stage embryos and blastocysts in two different age groups of patients. The reproductive capacity of women decreases by age. This decrease in capacity is directly related to a lower ovarian reserve and errors in the meiotic spindle of the oocyte, which increase chromosomal abnormalities and the formation of aneuploidy embryos with lower chances of implantation.

MATERIALS AND METHODS

A total of 1400 intracytoplasmic sperm injection cycles were analyzed. The study patients were divided into two age groups [aged < 36 years (Group I) and aged ≧ 36 years (Group II)]. The groups were subdivided according to the day of embryo transfer (ET)-Day 3 (ET3) and Day 5 (ET5).

RESULTS

In both age groups, transfer of blastocysts resulted in a higher clinical pregnancy rate and deliveries. An increased twin birth rate was observed in patients who were younger than 36 years on both transfer days compared with those who were older than 36 years of age. There was an elevated percentage of newborn males on ET5 in both age groups. Monozygotic twinning (MZT) rate was observed only among younger patients (<36 years of age), specifically on ET5 compared with ET3. There was no significant difference in the mean birth weight of singleton and twins between the ET3 and ET5 subgroups in the younger group of patients except for the triplets who were significantly heavier in the ET5 group compared with the older group (≧36 years of age) where significant difference was found only on the mean birth weight of singleton.

CONCLUSION

The study suggests that if a blastocyst can be obtained in patients of advanced age (≧36 years), it improves their baby take-home rates. Younger patients (aged < 36 years) should undergo elective single blastocyst transfers to reduce multiple pregnancy rates.

Ultrastructure of cytoplasmic fragments in human cleavage stage embryos

PURPOSE

The goal of this study was to evaluate the ultrastructure of cytoplasmic fragments along with the effect of cytoplasmic fragment and perivitelline space coarse granulation removal (cosmetic microsurgery) from embryos before embryo transfer on ART outcomes.

METHODS

One hundred and fifty intracytoplasmic sperm injection cycles with male factor infertility were included in this prospective study. Patients were divided into three groups of case (n = 50), sham (n = 50), and control (n = 50). Embryos with 10-50 % fragmentation were included in this study. Cosmetic microsurgery and zona assisted hatching were only performed in case and sham groups respectively. Extracted fragments were evaluated ultrastructurally by transmission electron microscopy (TEM). Rates of clinical pregnancy, live birth, miscarriage, multiple pregnancies, and congenital anomaly in the three groups were also compared.

RESULTS

Micrographs from TEM showed that mitochondria were the most abundant structures found in the fragments along with mitochondria-vesicle complexes, Golgi apparatus, primary lysosomes, and vacuoles. There were no significant differences in demographic characteristics, laboratory and clinical data, or embryo morphological features between the groups. The rate of clinical pregnancy in control, sham, and case groups had no significant differences (24, 18, and 18 %, respectively). The rates of live birth, miscarriage, multiple pregnancy, and congenital anomaly were also similar between the different groups.

CONCLUSIONS

Our data demonstrated that cosmetic microsurgery on preimplantation embryos had no beneficial effect on ART outcomes in unselected groups of patients. As mitochondria are the most abundant organelles found in cytoplasmic fragments, fragment removal should be performed with more caution in embryos with moderate fragmentation.