A study of recipient related predictors of success in oocyte donation program

Assessing the effect of below-benchmark vitrified/warmed donor-oocyte survival rates in subsequent laboratory and clinical outcomes

OBJECTIVE

To assess the impact of below-benchmark (95%-100%) donor-oocyte survival rates on vitrification/warming in the laboratory and clinical outcomes of recipient cycles.

DESIGN

Retrospective cohort study.

SUBJECTS

We analyzed 12,690 vitrified-warmed donor-oocyte recipient cycles performed from 2018-2022.

EXPOSURE

All cycles analyzed used exclusively vitrified/warmed donor oocytes. The cycles were grouped according to the survival rate experienced: benchmark 95%-100%; competence 85%-95%; below competence 70%-85%; poor 50%-70%; and very poor <50%.

MAIN OUTCOME MEASURES

The primary endpoint of the study was the total usable blastocyst rate per 2 pronuclear (2PN) zygote. Secondary endpoints were the fertilization rate, the live birth rate after the first single blastocyst transfer, and the cumulative live birth rate.

RESULTS

The mean number of warmed oocytes per intracytoplasmic sperm injection (ICSI) cycle was 11.4 ± 3.2, with a mean survival rate of 89.1%. More oocytes per cycle were consumed in the lower survival groups, yet the total number of oocytes available for ICSI was smaller in the below-competence, poor, and very poor survival groups. The total usable blastocyst rate was lower in the lower survival groups (benchmark: 48.9%; competence: 47.0%, below competence: 46.0%; poor: 43.6%; and very poor: 43.6%), as well as the fertilization rates (benchmark: 76.8%; competence: 76.6%, below competence: 75.6%; poor: 74.7%; and very poor:75.5%). The adjusted relative risk (aRR) of live birth rate of the first embryo transferred was equal to the benchmark survival group in all the lower survival groups (benchmark: 40.9%; competence: aRR = 0.986, 95% confidence interval [CI]: 0.931-1.045; below-competence: aRR = 0.992, 95% CI: 0.929-1.059; poor: aRR = 1.103, 95% CI: 1.009-1.207; and very poor: aRR = 1.169, 95% CI: 0.963-1.419). The cumulative live birth rate decreased in lower survival groups compared with benchmark survival (benchmark: 79.2%; competence: aRR = 0.988, 95% CI: 0.961-1.015; below competence: aRR = 0.911, 95% CI: 0.880-0.944; poor: aRR = 0.802, 95% CI: 0.757-0.851; and very poor: aRR = 0.793, 95% CI: 0.693-0.907). The lower cumulative rates maintained in a subanalysis with equal metaphase-II available for ICSI (benchmark: 69.5%; competence: aRR = 0.909, 95% CI: 0.827-1.000; below competence: aRR = 0.942, 95% CI: 0.848-1.046; poor: aRR = 0.833, 95% CI: 0.7386-0.941; and very poor: aRR = 0.873, 95% CI: 0.695-1.097) CONCLUSION: Lower donor-oocyte cryo-survival rates have a moderate negative impact on the blastocyst utilization rate per 2PN zygote, fertilization rate, and the cumulative live birth rates of a donation cycle, even after adjusting for equal metaphase-II oocytes available for ICSI. Nonetheless, the surviving oocytes of a cohort seem to maintain a high competence level, with very similar laboratory outcomes, irrespective of the cohort's survival rates, as well as equal implantation potential of the resulting blastocysts.

Live birth rate after oocyte donation in females diagnosed with turner syndrome: a systematic review and meta-analysis

BACKGROUND

An enduring challenge for women diagnosed with Turner syndrome (TS) is infertility. Oocyte donation (OD) offers a chance of pregnancy for these patients. However, current data on pregnancy outcomes are inadequate. Hence, this systematic review aims to explore the clinical outcomes of OD in patients with TS.

METHODS

A systematic search was conducted in PubMed, Web of Sciences, Scopus, and Embase for relevant papers from 1 January 1990 to 30 November 2023. Our primary research objective is to determine the live birth rate among women with TS who have undergone in vitro fertilization (IVF) using OD for fertility purposes. Specifically, we aim to calculate the pooled live birth rates per patient and per embryo transfer (ET) cycle. For secondary outcomes, we have analyzed the rates of clinical pregnancy achievement per ET cycle and the incidence of gestational hypertensive complications per clinical pregnancy. Prevalence meta-analyses were performed using STATA 18.0 by utilizing a random-effects model and calculating the pooled rates of each outcome using a 95% confidence interval (CI).

RESULTS

A total of 14 studies encompassing 417 patients were systematically reviewed. Except for one prospective clinical trial and one prospective cohort study, all other 12 studies had a retrospective cohort design. Our meta-analysis has yielded a pooled live birth rate per patient of 40% (95% CI: 29-51%; 14 studies included) and a pooled live birth rate per ET cycle of 17% (95% CI: 13-20%; 13 studies included). Also, the pooled clinical pregnancy achievement rate per ET cycle was estimated at 31% (95% CI: 25-36%; 12 studies included). Moreover, the pooled rate of pregnancy-induced hypertensive disorders per clinical pregnancy was estimated at 12% (95% CI: 1-31%; 8 studies included). No publication bias was found across all analyses.

CONCLUSIONS

This study demonstrated promising pregnancy outcomes for OD in patients with TS. Further studies are essential to address not only the preferred techniques, but also the psychological, ethical, and societal implications of these complex procedures for these vulnerable populations.

TRIAL REGISTRATION

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration code CRD42023494273.

Ongoing pregnancy rates in single euploid frozen embryo transfers remain unaffected by female age: a retrospective study

RESEARCH QUESTION

Is female age a significant factor in the likelihood of an ongoing pregnancy in single euploid frozen embryo transfers (FET)?

DESIGN

Retrospective study of 1923 single euploid FET cycles in 1464 women, either in a natural cycle or a hormone replacement therapy cycle. The primary outcome was the ongoing pregnancy rate (OPR).

RESULTS

There were 990 (51.48%) ongoing pregnancies among 1923 included transfers. The OPR were 51.4%, 49.1%, 53.3% and 52.3% for women aged ≤35, >35-≤37, >37-≤40 and >40 years at oocyte retrieval (OCR), without a significant trend for decreasing OPR (P = 0.679). No significant differences in female age at embryo transfer (P = 0.609) and female age at OCR (P = 0.816) were found between the groups (ongoing pregnancy versus no pregnancy or miscarriage). Women who received good-quality embryos (P < 0.001), had a lower body mass index (BMI) (P < 0.001), had achieved at least one pregnancy previously (P < 0.001), and underwent natural cycle endometrial preparation (P < 0.001) were more likely to achieve an ongoing pregnancy. Multivariable regression analysis (adjusted for BMI, embryo quality and endometrial preparation) did not show a significant effect of female age at OCR on achieving an ongoing pregnancy. Compared with women aged ≤35 years, none of the age groups had significantly higher or lower OPR. A multinomial regression analysis showed that BMI, embryo quality and endometrial preparation were associated with miscarriage/no pregnancy versus ongoing pregnancy (P = 0.001, 0.001 and 0.001, respectively). Female age had no significant association with either outcome.

CONCLUSIONS

Female age in itself does not have a substantial impact on the OPR in single euploid FET cycles, but the OPR is impacted significantly by embryo quality, BMI, previous parity, and a natural cycle endometrial preparation protocol.

Maternal age at transfer following autologous oocyte cryopreservation is not associated with live birth rates

PURPOSE

Our aim was to evaluate if maternal age at transfer following autologous oocyte cryopreservation is associated with live birth rate (LBR).

METHODS

We performed a retrospective cohort study of all patients who thawed autologous oocytes and then underwent a single frozen euploid embryo transfer between 2011 and 2021 at a large urban university-affiliated fertility center. Each oocyte thaw patient was matched 2:1 to in vitro fertilization (IVF) patients who underwent single embryo transfer < 1 year after retrieval. Primary outcome was LBR. Secondary outcomes included implantation rates (IR) and spontaneous abortion rates (SABR).

RESULTS

A total of 169 oocyte thaw patients were matched to 338 IVF patients. As expected, oocyte thaw patients were older (median age 42.5 vs. 37.6 years, p < 0.001) and waited longer between retrieval and transfer than in vitro fertilization patients (median time 59 vs. 1 month, p < 0.001). In univariate analysis, implantation and LBR differed among oocyte thaw and IVF patients (p < 0.05), but SABR did not (p = 0.57). Transfer outcomes in oocyte thaw patients did not differ based on transfer age group (IR: p = 0.18; SABR: p = 0.12; LBR: p = 0.24). In a multiple logistic regression model, age at transfer was not predictive of live birth when controlling for age at retrieval, embryo morphology, and day of blastulation.

CONCLUSIONS

Maternal age at transfer after oocyte cryopreservation is not predictive of LBR; this suggests that "an aging womb" does not impair LBR after oocyte thaw and empowers patients to return for transfer when ready for childbearing.

Mechanisms of endometrial aging: lessons from natural conceptions and assisted reproductive technology cycles

Until recently, the study of age-related decline in fertility has focused primarily on the ovary; depletion of the finite pool of oocytes and increases in meiotic errors leading to oocyte aneuploidy are well-established mechanisms by which fertility declines with advancing age. Comparatively little is known about the impact of age on endometrial function. The endometrium is a complex tissue comprised of many cell types, including epithelial, stromal, vascular, immune and stem cells. The capacity of this tissue for rapid, cyclic regeneration is unique to this tissue, undergoing repeated cycles of growth and shedding (in the absence of an embryo) in response to ovarian hormones. Furthermore, the endometrium has been shown to be capable of supporting pregnancies beyond the established boundaries of the reproductive lifespan. Despite its longevity, molecular studies have established age-related changes in individual cell populations within the endometrium. Human clinical studies have attempted to isolate the effect of aging on the endometrium by analyzing pregnancies conceived with euploid, high quality embryos. In this review, we explore the existing literature on endometrial aging and its impact on pregnancy outcomes. We begin with an overview of the principles of endometrial physiology and function. We then explore the mechanisms behind endometrial aging in its individual cellular compartments. Finally, we highlight lessons about endometrial aging gleaned from rodent and human clinical studies and propose opportunities for future study to better understand the contribution of the endometrium to age-related decline in fertility.

Planned oocyte cryopreservation: the state of the ART

The objective of this review is to provide an update on planned oocyte cryopreservation. This fertility preservation method increases reproductive autonomy by allowing women to postpone childbearing whilst maintaining the option of having a biological child. Oocyte cryopreservation is no longer considered experimental, and its use has increased dramatically in recent years as more women delay childbearing for personal, professional and financial reasons. Despite increased usage, most patients who have undergone oocyte cryopreservation have not yet warmed their oocytes. Most women who cryopreserve oocytes wait years to use them, and many never use them. Studies have demonstrated that oocyte cryopreservation results in live birth rates comparable with IVF treatment using fresh oocytes, and does not pose additional safety risks to offspring. Based on current evidence, cryopreserving ≥20 mature oocytes at <38 years of age provides a 70% chance of one live birth. However, larger studies from a variety of geographic locations and centre types are needed to confirm these findings. Additional research is also needed to determine the recommended age for oocyte cryopreservation, recommended number of oocytes to cryopreserve, return and discard/non-use rates, cost-effectiveness, and how best to distribute accurate and up-to-date information to potential patients.

Impact of Indication for Oocyte and Embryo Reception on Reproductive and Obstetric Outcomes

OBJECTIVES

This study aimed to assess if the indication for oocyte reception (OR) or embryo reception (ER) impacts the reproductive and obstetric outcomes by evaluating our experience at a tertiary fertility centre and by performing a literature review on this subject. Several previous studies have reported that, in contrast to other types of fertility treatment, the indication for OR/ER seems to have little impact on the outcomes. However, the compared indication groups vary considerably between these studies, and some data indicates worse outcomes in patients who developed premature ovarian insufficiency (POI) due to Turner syndrome or treatment with chemotherapy/radiotherapy.

DESIGN

A retrospective analysis of all cases of OR/ER at a tertiary fertility centre from 2001 until 2020 was conducted. We analysed 584 cycles from 194 individual patients. A literature review on the impact of indication on reproductive or obstetric outcomes of OR/ER was performed using the following databases: PubMed/MEDLINE, Embase, and the Cochrane Library. A total of 27 studies were included and analysed.

PARTICIPANTS, SETTING, METHODS

For the retrospective analysis, patients were divided into three major indication groups: failure of autologous assisted reproductive technology, POI, and genetic disease carrier. To assess reproductive outcomes, we determined pregnancy rate, implantation rate, miscarriage rate, and live birth rate. For comparing obstetric outcomes, we reviewed the term of birth, mode of delivery, and birthweight. Outcomes were compared using Fisher's exact test, χ2 test, and one-way ANOVA utilizing the GraphPad tool.

RESULTS

There were no significant differences in reproductive and obstetric outcomes between the three major indication groups in our population, in line with the findings reported by existing literature. Data on impaired reproductive outcomes in patients with POI after chemotherapy/radiotherapy are conflicting. Obstetrically, these patients are at higher risk of preterm birth and possibly also low birthweight, especially after abdomino-pelvic or total body irradiation. For patients with POI due to Turner syndrome, most data suggest similar pregnancy rates but a higher rate of pregnancy loss, and obstetrically an increased risk of hypertensive disorders and caesarean section.

LIMITATIONS

The small number of patients in the retrospective analysis resulted in low statistical power when evaluating differences between smaller subgroups. There were some missing data on the occurrence of complications during pregnancy. Our analysis covers a period of 20 years, during which several technological innovations have also been made.

CONCLUSIONS

Our study shows that the important heterogeneity in couples treated with OR/ER does not significantly impact their reproductive or obstetric outcomes, except for POI due to Turner syndrome or treatment with chemotherapy/radiotherapy, where there seems to be an important uterine/endometrial component that cannot be entirely overcome by providing a healthy oocyte.

Unveiling uterine aging: Much more to learn

Uterine aging is an important factor that impacts fertility, reproductive health, and uterus-related diseases; however, it remains poorly explored. Functionally, these disturbances have been associated with an abnormal hormonal response in the endometrium and decreased endometrial receptivity. Based on emerging evidence, these alterations are mediated via the senescence of endometrial stem cells and impaired decidualization of endometrial stromal cells. Multiple molecular activities may participate in uterine aging, including oxidative stress, inflammation, fibrosis, DNA damage response, and cellular senescence. Over the past decade, several protective strategies targeting these biological processes have afforded promising results, including stem cell therapy, anti-aging drugs, and herbal medicines. However, the currently available evidence is fragmented and scattered. Here, we summarize the most recent findings regarding uterine aging, including functional and structural alterations and potential cellular and molecular mechanisms, and discuss potential protective interventions against uterine aging. Thereby, we hope to provide a comprehensive understanding of the pathophysiological processes and underlying mechanisms associated with uterine aging, as well as improve fecundity and reproductive outcomes in females of advanced reproductive age.

Factors affecting live birth rates in donor oocytes from commercial egg banks vs. program egg donors: an analysis of 40,485 cycles from the Society for Assisted Reproductive Technology registry in 2016-2018

OBJECTIVE

To examine the differences in live birth rates (LBRs), with single embryo transfer (SET), using oocytes from program generated egg donors vs. commercial egg bank donors and other factors affecting LBRs using donor oocytes.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 40,485 in vitro fertilization cycles using donor oocytes reported to the Society for Assisted Reproductive Technology registry in 2016-2018.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth rate and cumulative LBR for SET using donor oocytes.

RESULT(S)

Multivariate results from the first SET from 19,128 cycles, including 15,429 from program generated egg donors and 3,699 from commercial egg banks, showed, when controlling for all other variables, the following: the LBR in the first SET cycle using commercial egg banks was 53.3% compared with 55.4% using program recruited egg donors (odds ratio [OR], 0.92); a reduction in the LBR with increasing recipient age, ages 40-44 years (OR, 0.80), 45-49 years (OR, 0.77), and >49 years (OR, 0.65); a steady decline in the LBR with increases in recipient body mass index above normal; and a steady increase in the LBR in association with >16 oocytes retrieved. Double embryo transfer increased the LBR (SET, 52%, vs. double embryo transfer, 58%) but also significantly increased the multiple pregnancy LBR, with 43% twins and 0.9% triplets. Blastocyst transfer had a higher LBR than cleavage stage embryos (52.5% vs. 39.5%). Intracytoplasmic sperm injection vs. conventional insemination when using fresh oocytes from program donors had similar LBRs.

CONCLUSION(S)

When performing in vitro fertilization using donor oocytes with SET, the LBR is affected by oocyte source, recipient age, recipient body mass index, stage of embryo at transfer, and number of oocytes retrieved.

Evaluating the Contribution of Oocyte, Sperm, and Uterus in Determining the Outcome of Intracytoplasmic Sperm Injection - A Retrospective Observational Comparative Study on Intracytoplasmic Sperm Injection using Own Oocytes and Donor Oocytes

Context

Several studies have assessed the contribution of oocyte, sperm, and endometrium on the outcome of intracytoplasmic sperm injection (ICSI) separately. This study assesses the relative contribution of oocyte, sperm, and uterus in achieving clinical pregnancy (CP) through ICSI by comparing own and third-party ICSI cycles.

Aim

The aim of the study is to evaluate and compare the strength of contribution of oocyte, sperm, and uterus in achieving CP through ICSI.

Settings and Design

This retrospective observational study of ICSI cycles for 20 months including 1000 embryo transfers (ETs).

Methodology

Subjects were divided into two groups, Group 1 - ICSI with own oocytes (550 ETs) and Group 2 - ICSI with donor oocytes (450 ETs). Both the groups had 3 subgroups - a (husband sperm, transferred to self), b (donor sperm, transferred to self), c (husband sperm, transferred to a gestational surrogate). CP rate (CPR) as a major outcome was studied in the groups and subgroups.

Statistical Analysis

CPR was compared between various subgroups using Z-test and Chi-square of significance of difference between proportions. A P < 0.05 was taken as the level of statistical significance.

Results

CPR in subgroup 1a < 35 years, 1a ≥35 years, and 2a was 42.98%, 26.21%, and 40.92%, respectively (P = 0.001). CPR was compared between 2a and 2c (40.92%, 56.5%, P = 0.044) and between 2a and 2b (40.92%, 42.11%, P = 0.866). Implantation rate was highest in Group 2c (34.88%) compared to other subgroups.

Conclusion

The higher CPR in women <35 years undergoing ICSI with own oocytes than older women and a comparable CPR as that of recipients of donor oocytes suggests that age thereby oocyte quality is the strongest determining factor in achieving clinical pregnancy. Among oocyte recipients, higher CPR in surrogate uterus than patient uterus suggests that uterus/endometrium plays a considerable role, and comparable CPR between ICSI using husband sperm and donor sperm indicates that sperm quality might not play a major role in achieving CP.

Effect of Endometrial Thickness and duration of Estrogen Supplementation on In Vitro Fertilization-Intracytoplasmic Sperm Injection Outcomes in Fresh Ovum/Embryo Donation Cycles

Background:

There is no consensus regarding optimal endometrial thickness and duration of estrogen supplementation in embryo transfer cycles, at present.

Aims:

To observe the effect of endometrial thickness and/or duration of estrogen supplementation on in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcomes in fresh ovum/embryo donation cycles.

Settings and Design:

This was a retrospective observational study. The study was conducted from January 2015 to November 2017.

Subjects and Methods:

Nine hundred and fifty seven fresh blastocyst transfer cycles in the recipients of oocyte/embryo donation regardless of reproductive history and diagnosis conducted at Nova IVF Fertility, Ahmedabad, Gujarat, India. Of these, 315 women had single embryo transfer (SET), while 642 had double embryo transfer (DET). Only fresh blastocysts derived from oocytes of young donors (≤30 years) and transferred in a uniform hormone replacement therapy (HRT) cycle were included. The effect of endometrial thickness and duration of estrogen on live birth rate (LBR) and other IVF/ICSI outcomes were analyzed.

Statistical Analysis:

Univariate logistic regression.

Results:

A significant improvement in LBR was noted in the recipients with each millimeter increase in endometrial thickness starting from 6 mm after transfer of either single (odds ratio [OR] = 1.3, P = 0.003) or double (OR = 1.14, P = 0.0218) blastocysts. Lower LBR was observed in recipients having SET and who received estrogen supplementation of <10 days (OR = 0.72; P = 0.02). Implantation rate and clinical pregnancy rate also improved significantly with endometrial thickness, but there was no change in clinical abortion rate and ectopic pregnancy rate.

Conclusions:

After minimizing the possible oocyte factor by including only donor oocytes and that of COH using a uniform HRT protocol, LBR improved with each millimeter increase in endometrial thickness starting from 6 mm. Shorter duration of estrogen supplementation (<10 days) reduced the chances of live birth in recipients after transfer of a single blastocyst.

Day 5 vitrified blastocyst transfer versus day 6 vitrified blastocyst transfer in oocyte donation program

The superiority of day 5 blastocysts compared to day 6 blastocysts in fresh cycle transfers was previously demonstrated and attributed mainly to endometrial asynchrony. Data from frozen blastocysts transfers showed conflicting results, possibly due to heterogeneous patient population and embryo quality. The aim of this study was to compare clinical pregnancy rate (CPR) and live birth rate (LBR) between transfers of vitrified day 5 blastocysts and day 6 blastocysts in oocyte donation, blastocyst-only cycles. In a retrospective, multi-center study, with a single oocyte donation program, a total of 1840 frozen embryo transfers (FET’s) were analyzed, including 1180 day 5 blastocysts and 660 day 6 blastocysts transfers. Day 5 blastocyst transfers had better embryonic development and significantly higher CPRs (34.24% vs. 20.15%, P < 0.0001), higher LBRs (26.89% vs. 14.77%, P < 0.0001), less cycles to LBR (1.83 ± 0.08 vs. 2.39 ± 0.18, P = 0.003) and shorter time to LBRs (76.32 ± 8.7 vs. 123.24 ± 19.1 days, P = 0.01), compared to day 6 transfers, respectively. A multivariate stepwise logistic regression indicated, that day 5 transfer was an independent factor for CPRs (OR 1.91; 95% CI 1.43–2.54, P < 0.001) and LBRs (OR 2.26; 95% CI 1.19–4.28, P = 0.01), regardless of embryo quality, compared to day 6. In conclusion, day 5 blastocysts in oocyte donation program have significantly higher CPRs and LBRs, and present shorter time to delivery, compared to day 6 blastocysts, regardless of embryo quality.

Efficiency and efficacy of vitrification in 35 654 sibling oocytes from donation cycles

STUDY QUESTION

Is oocyte vitrification/warming as efficient and effective as using fresh oocytes in donation cycles?

SUMMARY ANSWER

IVF with vitrified donor oocytes is less efficient than using fresh oocytes, but its efficacy remains comparable to that of fresh cycles.

WHAT IS KNOWN ALREADY

Oocyte vitrification is used to preserve the reproductive potential of oocytes. A small number of randomized controlled trials carried out by experienced groups have shown that this technique provides fertilization, pregnancy, implantation and ongoing pregnancy rates comparable to those of fresh oocytes. However, large registry-based analyses have consistently reported lower live birth rates (LBRs) in cycles using vitrified oocytes. It is not clear whether this decrease may be due to the effect of vitrification per se on the oocytes or to the lower efficiency of the technique, as some of the oocytes do not survive after warming.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort analysis of 1844 cycles of oocyte donation (37 520 oocytes), each donor in the study provided enough oocytes for at least one reception cycle with fresh oocytes (2561 cycles) and one reception cycle with vitrified oocytes (2471 cycles) from the same ovarian stimulation (sibling oocytes). Overall, 35 654 oocytes were considered in the analysis. All embryo transfers (n = 5032) were carried out between 2011 and 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Differences in reproductive outcomes after the first embryo transfer were evaluated using Pearson's Chi-squared test and regression analysis adjusted for recipient's age, BMI, sperm origin and state, day of embryo transfer, morphological score and number of transferred embryos. We performed two additional sub-analyses, to test whether the efficiency and/or effectiveness of vitrification/warming impacts reproductive results. One analysis included paired cycles where the same number of fresh and vitrified oocytes were available for ICSI (SAME sub-analysis), while the second analysis included those cycles with a 100% survival rate post-warming (SAME100 sub-analysis).

MAIN RESULTS AND THE ROLE OF CHANCE

Baseline and cycle characteristics of participants were comparable between groups. Overall, fertilization rates and embryo morphological scores were significantly lower (P < 0.001) when using vitrified oocytes; moreover, vitrified oocytes also resulted in lower reproductive outcomes than sibling fresh oocytes using both unadjusted and adjusted analyses: ongoing pregnancy (32.1% versus 37.5%; P < 0.001; OR 0.88, 95% CI 0.77, 1.00) and live birth (32.1% versus 31.9%; P = 0.92; OR 1.16, 95% CI 0.90, 1.49). However, when the efficiency of warming was taken into account, reproductive outcomes in recipients became comparable: ongoing pregnancy (33.5% versus 34.1%; P = 0.82; OR 1.11, 95% CI 0.87, 1.43) and LBR (32.1% versus 32%; P = 0.97; OR 1.15, 95% CI 0.89, 1.48). Moreover, after selecting only cycles that, in addition to having the same number of oocytes available for ICSI, also had 100% post-warming survival rate in the vitrified group, reproductive outcomes were also comparable between fresh and vitrified oocytes: ongoing pregnancy (34.8% versus 32.4%; P = 0.42; OR 1.32, 95% CI 0.98, 1.77) and live birth (32.9% versus 31.0%; P = 0.52; OR 1.27, 95% CI 0.95, 1.71), indicating that reproductive outcomes of these cycles are affected by the efficiency of the vitrification/warming technique performed rather than the oocyte damage due to the fast cooling process to which oocytes are subjected.

LIMITATIONS, REASONS FOR CAUTION

An open vitrification system was used for all cases, and oocyte vitrification/warming was performed by experienced embryologists with consistently high survival rates; caution must be exerted when extrapolating our results to data obtained using other open vitrification systems, closed vitrification systems or to IVF units with survival rates <90%.

WIDER IMPLICATIONS OF THE FINDINGS

This is the largest cohort study comparing reproductive outcomes of vitrified and fresh sibling donor oocytes to date. We found that, when the number of oocytes available after warming is equal to the number of fresh oocytes, reproductive results including live birth are comparable. Consequently, the efficiency of vitrification must be taken into account to achieve the same reproductive outcomes as with fresh oocytes. We recommend implementing strict indicators of vitrification/warming efficiency in clinics and refining vitrification/warming protocols to maximize survival.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by intramural funding of Clínica EUGIN and by the Secretary for Universities and Research of the Ministry of Economy and Knowledge of the Government of Catalonia (GENCAT 2015 DI 048). The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Embryo transfer strategy and therapeutic options in infertile patients with thin endometrium: a systematic review

Human endometrium has a key role in implantation process. The measurement of endometrial thickness is the most commonly used in clinical practice. Managing patients with thin endometrium still represents a major challenge for clinicians. The objective of this systematic review was to investigate all available interventions to improve endometrial thickness (EMT) in women with history of thin endometrium undergoing fresh or frozen-thawed embryo transfers (ET). We performed a comprehensive search of relevant studies from January 1978 to February 2018. The different strategies were categorized as hormonal, vascular, and growth factor approaches and specifically analyzed according to the type of ET. Thirty-one studies were included. Overall, quality of the evidence ranged from very low to moderate, with only few randomized controlled trials that support the use of either GnRH analogues in fresh ET or sildenafil in frozen ET for enhancing endometrial growth. Besides, intensified estradiol administration is a common approach that might improve EMT in frozen ET. The present review evidences the paucity of reliable data regarding the efficiency of different interventions aiming at increasing EMT before fresh or frozen-thawed ET. Robust and high-quality randomized controlled trials are still needed before guidelines can be established.

Dehydroepiandrosterone enhances decidualization in women of advanced reproductive age

Objective

To investigate the impact of the androgen precursor dehydroepiandrosterone (DHEA) on the decidualization of human endometrial stromal cells isolated from women of advanced reproductive age.

Design

In vitro study.

Setting

University research institute.

Patient(s)

Proliferative phase primary human endometrial stromal fibroblasts (hESFs) were isolated from women of advanced reproductive age (n = 16; mean age, 44.7 ± 2.3). None of the women were receiving hormone therapy or had endometriosis.

Intervention(s)

Isolated hESFs were decidualized in vitro by incubation with P (1 μM) and cAMP (0.1 mg/mL) in the presence, or absence, of DHEA (10 nM, 100 nM).

Main Outcome Measure(s)

Secretion of androgens was assessed by ELISA. Expression of decidualization markers and endometrial receptivity markers was assessed by quantitative polymerase chain reaction and ELISA.

Result(s)

Decidualization responses were retained in hESF isolated from women of advanced reproductive age. Supplementation with DHEA increased androgen biosynthesis and concentrations of T and dihydrotestosterone were ∼3× greater after coincubation with DHEA compared with hESF stimulated with decidualization alone. Addition of DHEA to decidualized hESF increased expression of the decidualization markers IGFBP1 and PRL and the endometrial receptivity marker SPP1. DHEA enhanced secretion of IGFBP1, PRL, and SPP1 proteins maximally by day 8 of the decidualization time course concomitant with peak androgen concentrations.

Conclusion(s)

These novel results demonstrate DHEA can enhance in vitro decidualization responses of hESF from women of advanced reproductive age. Supplementation with DHEA during the receptive phase may augment endometrial function and improve pregnancy rates in natural or assisted reproductive cycles.

Regulation of androgen action during establishment of pregnancy

During the establishment of pregnancy, the ovarian-derived hormones progesterone and oestradiol regulate remodelling of the endometrium to promote an environment that is able to support and maintain a successful pregnancy. Decidualisation is characterised by differentiation of endometrial stromal cells that secrete growth factors and cytokines that regulate vascular remodelling and immune cell influx. This differentiation process is critical for reproduction, and inadequate decidualisation is implicated in the aetiology of pregnancy disorders such as foetal growth restriction and preeclampsia. In contrast to progesterone and oestradiol, the role of androgens in regulating endometrial function is poorly understood. Androgen receptors are expressed in the endometrium, and androgens are reported to regulate both the transcriptome and the secretome of endometrial stromal cells. In androgen-target tissues, circulating precursors are activated to mediate local effects, and recent studies report that steroid concentrations detected in endometrial tissue are distinct to those detected in the peripheral circulation. New evidence suggests that decidualisation results in dynamic changes in the expression of androgen biosynthetic enzymes, highlighting a role for pre-receptor regulation of androgen action during the establishment of pregnancy. These results suggest that such enzymes could be future therapeutic targets for the treatment of infertility associated with endometrial dysfunction. In conclusion, these data support the hypothesis that androgens play a beneficial role in regulating the establishment and maintenance of pregnancy. Future studies should be focussed on investigating the safety and efficacy of androgen supplementation with the potential for utilisation of novel therapeutics, such as selective androgen receptor modulators, to improve reproductive outcomes in women.

Development of A Questionnaire to Measure Attitude toward Oocyte Donation

Background

To our knowledge, there is no valid and comprehensive questionnaire that considers attitude toward oocyte donation (OD). Therefore this study has aimed to design and develop a tool entitled attitude toward donation-oocyte (ATOD-O) to measure attitude toward OD.

Materials and Methods

This methodological, qualitative research was undertaken on 15 infertile cases. In addition, we performed a literature review and search of various databases. Validity of this questionnaire was conducted by knowledgeable experts who determined indices such as relevancy, clarity, and comprehensiveness. Reliability of the questionnaire was assessed based on the opinions of experts and infertile couples referred to Royan Institute.

Results

ATOD-O was designed in 52 statements that covered various issues such as the OD process, donor and recipient characteristics, as well as family, emotional, psychological, legal, religious, and socio-economic dimensions. Results were scored as five points: 1 (strongly disagree), 2 (disagree), 3 (somewhat), 4 (agree), and 5 (strongly agree). The overall relevancy of the questionnaire was 97% and clarity was 96%. Overall comprehensiveness was 100%.

Conclusion

The findings from this preliminary validation study have indicated that ATOD-O is a valid measure for measuring and assessing attitude toward donated oocytes. This questionnaire can be used in studies regarding different groups of a society.

Antioxidant Supplementation Modulates Age-Related Placental Bed Morphology and Reproductive Outcome in Mice

The number of women who delay their first childbirth is increasing. This demographic shift is an important health issue because advanced maternal age is a risk factor for reproductive capacity loss and the occurrence of placental bed disorders that may lead to placenta abruption, preeclampsia, and placenta insufficiency. A redox imbalance status, resulting from the enhanced production of reactive oxygen species or their deficient neutralization, is proposed to occur in this setting. Thus, uterine redox status was evaluated in young (8- to 12-wk-old) and reproductively aged (38- to 42-wk-old) mice. In addition, it was hypothesized that specific dietary antioxidant supplementation would restore the balance and improve the reproductive outcome of aging female mice. To test this hypothesis, two different antioxidants, the nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitor apocynin and the superoxide dismutase mimetic 4-hydroxy-2,2,6,6-tetramethylpiperidinyloxy (TEMPOL), were added to the drinking water of female mice prior to and during pregnancy. Compared to younger females, uteri from reproductively aged nonpregnant mice exhibited areas of endometrial cystic dilation, increased level of NOX1 expression, and enhanced protein carbonylation, especially in the apical surface of the luminal epithelium. Both antioxidants decreased protein carbonylation level in the uterus of reproductively aged mice. When reproductively aged females became pregnant, the litter size was smaller and fetuses were heavier. The change was accompanied by a significant decrease in decidua thickness. Provision of apocynin significantly increased litter size and restored decidua thickness. Reproductively aged mice provided with TEMPOL did not evidence such benefits, but whereas apocynin normalized fetal birth weight, TEMPOL further increased it. These findings emphasize that uterine redox balance is important for reproductive success and suggest that age-related redox imbalance might be compensated by specific antioxidant supplementation.

Association between endometrial thickness in oocyte donation cycles and pregnancy success rates

Endometrial receptivity is a primary concern for embryo implantation success in fertility treatments. The present study was a retrospective analysis of 4070 cycles with donor oocytes and hormone-replacement therapy. Endometrial thickness was assessed once with transvaginal ultrasound. Patients were allowed to continue when endometrial thickness was ?5mm and had triple line morphology. Pregnancy rates, the number of gestational sacs and miscarriage rates were analysed in relation to endometrium status. Regression models were used to analyse associations, taking the day of embryo transfer into account. All patient parameters were homogeneous. Mean endometrial thickness was 7.24±1.66mm, the mean number of embryos transferred was 2.04±0.43, the pregnancy rate was 48.06% and sacs were present in 42.3% of cycles. There were no significant differences in pregnancy rates, number of gestational sacs and miscarriage rates for different endometrial thickness measurements. The present study is, to our knowledge, the largest study evaluating the role of endometrial thickness in oocyte donation cycles. Endometrial thickness >5mm is a reasonable parameter for determining treatment success, and once it is observed in a single ultrasonographic evaluation there is no need for subsequent monitoring and embryo transfer can be scheduled over the following 1-16 days, because the results are not compromised. This may lead to a significant reduction in time and cost in fertility clinics.

Effect of local endometrial injury on pregnancy outcomes in ovum donation cycles

OBJECTIVE

To evaluate the effect of local endometrial injury (LEI) on clinical outcomes in ovum donation recipients.

DESIGN

Retrospective cohort analysis of ovum donation cycles conducted from 2005 to 2012.

SETTING

Two private IVF centers.

PATIENT(S)

Total 737 ovum donation cycles.

INTERVENTION(S)

LEI by endometrial "scratch" with the use of a Pipelle catheter.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth rates.

RESULT(S)

No statistically significant differences were found in clinical pregnancy rates and live birth rates in cycles subjected to LEI compared with those without. Combination of LEI with fibroid uterus resulted with significantly higher clinical pregnancy rates compared with LEI in normal uterine anatomy.

CONCLUSION(S)

This is the first study done in ovum recipients who underwent LEI by a "scratch" procedure after failed implantation. Unlike most previous reports, which found improved pregnancy rates with the use of "scratch effect" or "minor endometrial injury" after repeated implantation failures in standard IVF with own eggs, we did not find any changes in implantation rates in a population of egg recipients following this procedure. In view of a possible positive effect of LEI in cycles with a previous four or more failures, prospective randomized controlled studies are warranted to better define the target population who may benefit from this intervention.

Endocrine and local control of the primate corpus luteum

The primate corpus luteum is a transient endocrine gland that differentiates from the ovulatory follicle midway through the ovarian (menstrual) cycle. Its formation and limited lifespan is critical for fertility, as luteal-derived progesterone is the essential steroid hormone required for embryo implantation and maintenance of intra-uterine pregnancy until the placenta develops. It is well-established that LH and the LH-like hormone, CG, are the vital luteotropic hormones during the menstrual cycle and early pregnancy, respectively. Recent advances, particularly through genome analyses and cellular studies, increased our understanding of various local factors and cellular processes associated with the development, maintenance and repression of the corpus luteum. These include paracrine or autocrine factors associated with angiogenesis (e.g., VEGF), and that mediate LH/CG actions (e.g., progesterone), or counteract luteotropic effects (i.e., local luteolysis; e.g., PGF2α). However, areas of mystery and controversy remain, particularly regarding the signals and events that initiate luteal regression in the non-fecund cycle. Novel approaches capable of gene "knockdown" or amplification", in vivo as well as in vitro, should identify novel or underappreciated gene products that are regulated by or modulate LH/CG actions to control the functional lifespan of the primate corpus luteum. Further advances in our understanding of luteal physiology will help to improve or control fertility for purposes ranging from preservation of endangered primate species to designing novel ovary-based contraceptives and treating ovarian disorders in women.