P-285 An analysis of automated morphometric measurements finds that a combination of a large blastocyst size and a short tB-tSB time interval doubles the implantation rate

Study question

Are automated blastocyst morphometric measurements combined with morphokinetic pattern associated with implantation rate?

Summary answer

Automated blastocyst morphometric measurements with morphokinetic pattern demonstrated that a larger blastocyst size and a shorter time interval tB-tSB are associated with higher implantation potential.

What is known already

Optimization of embryo selection is important for increasing implantation potential. Transfer of a high-quality blastocyst based on conventional morphological parameters has been shown to improve IVF clinical outcome. Novel parameters of blastocyst quality, including morphokinetics from time-lapse monitoring and manual analysis of morphometric parameters, have demonstrated promising results regarding implantation potential. However, manual measurement of morphometric parameters is a time-consuming task and is subjected to intra- and inter-observer variations. The introduction of automated morphometric measurements would remove subjective blastocyst analysis and further improve implantation rates.

Study design, size, duration

A nested retrospective case control analysis of 608 day-5 transferred blastocysts was conducted and included women who underwent IVF treatment in three public IVF units between 2014 and 2017.

Participants/materials, setting, methods

Automated morphometric blastocyst analysis was measured at the mean time of tEB-tPNf (85.82 h) by training a pixel-wise segmentation model (MaskRCNN) on time-lapse videos. Morphometric blastocyst parameters included the following: blastocyst size (μm), inner cell mass (ICM) size (μm), ICM to blastocyst size ratio, and ICM shape. Annotation variables included all the time intervals (hours) from time of pronuclei fading (tPNf) to the expanded blastocyst (tEB).

Main results and the role of chance

The mean blastocyst size for implanted embryos was significantly larger compared to non-implanted embryos (152.10 ±19.22μm vs 144.25±18.52μm, respectively, p < 0.001), while the mean interval times of tSB-tPNf, tB-tPNf, tEB-tPNf, tB-tSB, and tEB-tSB were significantly shorter (tSB-tPNf: 72.10±5.60h vs 73.30±5.80h, respectively, p = 0.016; tB-tPNf: 80.08±5.96h vs 82.54±5.92h, respectively, p < 0.001; tEB-tPNf: 84.95±5.43h vs 86.58±4.93h, respectively, p = 0.001; tB-tSB: 8.21±2.90h vs 9.49±3.62h, respectively, p < 0.001; and tEB-tSB: 13.50±3.00h vs 14.58±3.75h, respectively, p = 0.001). In a multivariable logistic model that measured the independent effect of ICM size, blastocyst size, tB-tSB, and woman age on implantation potential, blastocyst size was found to be positively associated with implantation potential (OR = 1.017, 95% CI 1.006-1.027, p = 0.002) while tB-tSB and woman age were found to be negatively associated (OR = 0.918, 95% CI 0.861-0.980, p = 0.010 and OR = 0.903, 95% CI 0.874-0.932, p < 0.001, respectively). Blastocyst size larger than the mean and a tB-tSB interval shorter than the mean had a 2.028 greater chance of implantation compared to blastocysts that did not meet these criteria (OR = 2.028, 95% CI 1.420-2.894, p < 0.001). In a multivariable logistic model adjusted for woman age, the chance for implantation among blastocysts meeting the aforementioned criteria was 1.7 greater (adjusted OR 1.714, 95% CI 1.182-2.485, p = 0.005). The AUC value for implantation prediction was 0.69 (p < 0.01).

Limitations, reasons for caution

The study's limitations include its retrospective nature and the absence of some patient characteristics.

Wider implications of the findings

A blastocyst selection based on the combination of automated blastocyst size measurements and manual tB-tSB time interval may double the implantation rate. The inclusion of automated morphometric measurements to the blastocyst selection algorithm may reduce intra- and inter-observer variations and should be incorporated into models for implantation prediction.

Trial registration number

0006-20-HMO

Prediction of sperm extraction in non-obstructive azoospermia patients: a machine-learning perspective

STUDY QUESTION

Can a machine-learning-based model trained in clinical and biological variables support the prediction of the presence or absence of sperm in testicular biopsy in non-obstructive azoospermia (NOA) patients?

SUMMARY ANSWER

Our machine-learning model was able to accurately predict (AUC of 0.8) the presence or absence of spermatozoa in patients with NOA.

WHAT IS KNOWN ALREADY

Patients with NOA can conceive with their own biological gametes using ICSI in combination with successful testicular sperm extraction (TESE). Testicular sperm retrieval is successful in up to 50% of men with NOA. However, to the best of our knowledge, there is no existing model that can accurately predict the success of sperm retrieval in TESE. Moreover, machine-learning has never been used for this purpose.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of 119 patients who underwent TESE in a single IVF unit between 1995 and 2017 was conducted. All patients with NOA who underwent TESE during their fertility treatments were included. The development of gradient-boosted trees (GBTs) aimed to predict the presence or absence of spermatozoa in patients with NOA. The accuracy of these GBTs was then compared to a similar multivariate logistic regression model (MvLRM).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We employed univariate and multivariate binary logistic regression models to predict the probability of successful TESE using a dataset from a retrospective cohort. In addition, we examined various ensemble machine-learning models (GBT and random forest) and evaluated their predictive performance using the leave-one-out cross-validation procedure. A cutoff value for successful/unsuccessful TESE was calculated with receiver operating characteristic (ROC) curve analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

ROC analysis resulted in an AUC of 0.807 ± 0.032 (95% CI 0.743–0.871) for the proposed GBTs and 0.75 ± 0.052 (95% CI 0.65–0.85) for the MvLRM for the prediction of presence or absence of spermatozoa in patients with NOA. The GBT approach and the MvLRM yielded a sensitivity of 91% vs. 97%, respectively, but the GBT approach has a specificity of 51% compared with 25% for the MvLRM. A total of 78 (65.3%) men with NOA experienced successful TESE. FSH, LH, testosterone, semen volume, age, BMI, ethnicity and testicular size on clinical evaluation were included in these models.

LIMITATIONS, REASONS FOR CAUTION

This study is a retrospective cohort study, with all the associated inherent biases of such studies. This model was used only for TESE, since micro-TESE is not performed at our center.

WIDER IMPLICATIONS OF THE FINDINGS

Machine-learning models may lay the foundation for a decision support system for clinicians together with their NOA patients concerning TESE. The findings of this study should be confirmed with further larger and prospective studies.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Division of Obstetrics and Gynecology, Soroka University Medical Center, there are no potential conflicts of interest for all authors.

DNA topoisomerases I and II in human mature sperm cells: characterization and unique properties

BACKGROUND

The condensed state of the human sperm's chromatin is essential for the compact structure of the spermatozoon head, which is important for the fertilization process. The enzymes DNA topoisomerases (topo I and topo II) are responsible for the topological structure of the chromatin in somatic cells. The activities and the characterization of topoisomerases in mature human sperm cells have not been previously investigated.

METHODS

Sperm cells were purified from the semen of healthy donors by standard procedures and assays measuring the activities, protein size and sensitivity to inhibitors of topoisomerases were performed.

RESULTS

Topo I and topo II DNA relaxation activities are present in nuclear extracts derived from human sperm. The sperm topo I activity is inhibited by camptothecin, similarly to the somatic enzyme. An 85 kDa sperm protein, compared with the 100 kDa somatic topo IB enzyme, reacted with anti-human topo I antibody. Sperm topo II lacks the DNA decatenation activity of the somatic enzyme and a 97 kDa protein, compared with the 170 kDa somatic topo IIalpha enzyme, was detected with anti-human topo II antibody. Sperm nuclear extracts contained inhibitors of somatic topo II decatenation activity.

CONCLUSIONS

Topoisomerase I and II activities as well as topo I and topo II proteins are present in mature human sperm cells. These enzymes possess unique properties compared with their somatic counterparts.

Relationship between age and semen parameters in men with normal sperm concentration: analysis of 6022 semen samples

This study evaluates retrospectively the relationship between age and semen parameters among men with normal sperm concentration. It was based on computerized data and performed in an Academic Fertility and IVF Unit. Six thousand and twenty-two semen samples with sperm concentrations of >or=20 x 10(6) ml(-1) were examined according to WHO criteria and analysed in relation to patients' age. For each age group, mean values +/- SD of semen volume, sperm concentration, percentage of motile spermatozoa, normal morphology, acrosome index, total sperm count/ejaculate, total motile sperm count/ejaculate and sexual abstinence duration were examined. A peak semen volume of 3.51 +/- 1.76 ml(-1) was observed at age >or=30 to <35 years and a lowest volume of 2.21 +/- 1.23 ml(-1) was observed at age >or=55 years (P<0.05). Sperm motility was found to be inversely related to age with peak motility of 44.39 +/- 20.69% at age <25 years and lowest motility of 24.76 +/- 18.27% at age >or=55 years (P<0.05). A reduction of 54% was observed for total motile sperm, between values of 103.34 +/- 107 x 10(6) at age >or=30 to <35 years and 46.68 +/- 53.73 x 10(6) (P<0.05) at age >55 years. A statistically significant and inverse relationship was observed between semen volume, sperm quality and patient age, in spite of prolonged sexual abstinence duration. Top sperm parameters were observed at age >or=30 to <35 years, while the most significant reduction in sperm parameters occurred after the age of 55 years.

Relationship between sexual abstinence duration and the acrosome index in teratozoospermic semen: analysis of 1800 semen samples

A high acrosome index (percentage of sperm with normal acrosome morphology--cutoff value > or =10%) is known to be associated with an improved fertilization rate in conventional IVF. A retrospective evaluation of the relationship between duration of sexual abstinence and acrosome index among oligozoospermic and normozoospermic semen samples with teratozoospermia was undertaken. A significant (P = 0.001) decrease in the acrosome index was observed among the normozoospermic samples (n = 1264) between the peak value of 10.2 +/- 3.6% on day 2 and 8.5 +/- 4.0% on day 5 of abstinence, while for the oligozoospermic samples (n = 536) the peak value of 8.7 +/- 3.5% was observed on day 1 and the lowest values of 6.8 +/- 3.7% (P = 0.04) on day 5 of abstinence. The results suggest that an optimal acrosome index will be obtained following a short sexual abstinence.

The use of recombinant human LH (lutropin alfa) in the late stimulation phase of assisted reproduction cycles: a double-blind, randomized, prospective study

BACKGROUND

The effect of recombinant human LH (r-hLH; lutropin alfa) in women undergoing controlled ovarian stimulation with recombinant human FSH (r-hFSH) prior to IVF was investigated.

METHODS

After down-regulation with the GnRH agonist, buserelin, 114 normo-ovulatory women (aged 18-37 years) received r-hFSH alone until the lead follicle reached a diameter of 14 mm. Patients were then randomized in a double-blind fashion to receive r-hFSH in addition to r-hLH, 75 IU s.c., or placebo daily for a maximum of 10 days prior to oocyte retrieval and IVF. The primary end-point was the number of metaphase II oocytes.

RESULTS

There were no significant differences between treatment groups for the primary end-point. Serum estradiol concentrations on the day of HCG administration were significantly higher in the group receiving r-hLH plus r-hFSH than in the group receiving r-hFSH alone (P = 0.0001), but there were no significant differences between the groups in dose and duration of r-hFSH treatment required, oocyte maturation, fertilization rate, pregnancy rate and live birth rate.

CONCLUSION

In this patient population, the addition of r-hLH during the late follicular phase of a long GnRH agonist and r-hFSH stimulation cycle provides no further benefit in terms of oocyte maturation or other end-points.

Monozygotic twins following blastocyst transfer: a report of two cases

Several studies have shown an increased risk for monozygotic twinning after fertilization treatments. We present the clinical and sonographic characteristics of two monozygotic twin cases following blastocyst transfer. It is suggested that delayed transfer of the embryo in the blastocyst stage is a contributing factor to monozygotic twinning.

Treatment outcome in women with a single ovary versus patients with two ovaries undergoing in vitro fertilization and embryo transfer (IVF/ET)

OBJECTIVE

To compare ovarian response and pregnancy rate between women with one and two ovaries undergoing in vitro fertilization and embryo transfer (IVF/ET).

STUDY DESIGN

20 IVF/ET treatment cycles in ten women with a single ovary were compared with 60 IVF/ET cycles in 47 women with two ovaries. Both groups were matched for age and treated for mechanical infertility. In both groups treatment protocol included gonadotropin releasing hormone/human menopausal gonadotropin/human chorionic gonadotropin (GnRH/hMG/hCG).

RESULTS

Effective daily dose of gonadotropins (3.7+/-0.7 vs. 3.6+/-1.0), mean 17beta-estradiol levels on day of hCG administration (1136+/-467 vs. 1343+/-776), number of retrieved oocytes (6.4+/-3.7 vs. 8.3+/-4.2) and number of embryos per transfer (3.0+/-0.7 vs 2.9+/-1.2) were not statistically different between the groups. A significantly higher pregnancy rate was observed among women with one ovary (52.9%) as compared with those with two ovaries (20.8%), (P=0.015). Multivariate logistic regression analysis demonstrated an odds ratio of 5.73 for patients with a single ovary.

CONCLUSION

Treatment outcome in patients with a single ovary undergoing IVF/ET is comparable to those with two ovaries. The unexpected significantly higher pregnancy rate observed among these patients need to be further evaluated.

Periovulatory and interleukin-1 beta-dependent up-regulation of intraovarian vascular endothelial growth factor (VEGF) in the rat: potential role for VEGF in the promotion of periovulatory angiogenesis and vascular permeability

Vascular endothelial growth factor (VEGF) is an endothelial cell mitogen and permeability factor the role of which in ovarian angiogenesis has been the subject of increasing interest. It was the objective of this communication to explore the possibility that interleukin (IL)-1 may regulate the in vitro expression of rat ovarian VEGF mRNA, as well as to study the in vivo expression of rat ovarian VEGF transcripts during follicular maturation, ovulation, and corpora lutea formation. Taken together, our findings 1) reaffirm the rat ovary as a site of VEGF expression; 2) document an in vivo increase in VEGF transcripts before ovulation; 3) disclose a marked dependence of VEGF on IL-1 beta; 4) reveal the IL-1 beta effect to be receptor mediated and dose and time dependent and to be shared by at least two growth factors--epidermal growth factor and basic fibroblastic growth factor; and 5) demonstrate a lack of VEGF effect on ovarian progesterone biosynthesis as assessed in cultured isolated granulosa cells. It is tempting to speculate that the up-regulatory effect of IL-1 beta on VEGF transcripts may be relevant to the marked angiogenesis and increased vascular permeability displayed by the hyperemic ovarian Graafian follicle during the terminal stages of follicular development. In this context, VEGF may be joined by other IL-1-dependent angiogenesis promoters such as IL-6 or transforming growth factor beta 1. Thus, IL-1-mediated VEGF induction may constitute one of several end points through which IL-1 may coordinate and perhaps amplify the ovulatory cascade.

Transcriptional and posttranscriptional regulation of intraovarian insulin-like growth factor-binding proteins by interleukin-1beta (IL-1beta): evidence for IL-1beta as an antiatretic principal

Intraovarian interleukin-1 (IL-1), a putative intermediary in the ovulatory cascade, has recently been implicated as an antiatretic agent. Given the reported antigonadotropic and thus atretogenic potential of granulosa cell-derived insulin-like growth factor-binding proteins (IGFBPs), we evaluated the ability of IL-1beta to regulate ovarian IGFBP-4 and -5, the IGFBP species elaborated by the rat granulosa cell. Treatment of whole ovarian dispersates of immature rat origin with increasing concentrations of IL-1beta for 96 h resulted in substantial and significant time-dependent inhibition of IGFBP-4 and IGFBP-5 transcripts compared with that in untreated controls. The IL-1 effect proved relatively specific in that no significant alterations in IGFBP transcripts were observed in the presence of select ovarian agonists, including transforming growth factor-alpha, tumor necrosis factor-alpha, endothelin-1, hepatocyte growth factor, keratinocyte growth factor, or basic fibroblast growth factor. The inhibitory effect of IL-1beta on ovarian IGFBP-4 and -5 expression was almost completely reversed in the presence of IL-1 receptor antagonist, suggesting mediation via a specific IL-1 receptor. The addition of actinomycin D to IL-1beta-pretreated whole ovarian dispersates produced a pattern of (IGFBP-4 and -5) messenger RNA decay indistinguishable from that noted for the untreated control group. Medium conditioned by IL-1beta-treated (but not untreated) whole ovarian dispersates displayed a marked diminution in the relative content of the IGFBP-4 and IGFBP-5 proteins (24- and 28- to 29-kDa proteins, respectively). Medium conditioned by IL-1beta-treated (but not untreated) whole ovarian dispersates proteolyzed [125I]IGFBP-5 (but not IGFBP-4) into fragments with apparent molecular masses of 18 and 14 kDa, respectively. In conclusion, our present observations demonstrate the ability of IL-1 to 1) inhibit the steady state levels of transcripts corresponding to IGFBP-4 and -5 in a time-dependent, relatively specific, and receptor-mediated fashion; 2) suppress the accumulation of the corresponding IGFBP proteins; and 3) stimulate the activity of the IGFBP-5-directed (but not IGFBP-4) endopeptidase, a posttranscriptional phenomenon. Our findings also suggest, by inference, that the IL-1beta-mediated inhibition of IGFBP-4 and -5 transcripts is due in part to a decrease in the rate of transcription of the corresponding genes and not to a change in the stability of the relevant messenger RNAs. Consequently, the ability of IL-1 to influence ovarian IGFBP economy appears multifaceted, comprising both transcriptional and posttranscriptional effects. To the extent that IGFBP-4 and -5 constitute atretogenic agents, our present findings support the view that IL-1beta may play an antiatretic role in the context of ovarian physiology.

Does transcervical intra-fallopian insemination improve pregnancy rates in cases of oligoteratoasthenozoospermia? A prospective, randomized study

The relatively low pregnancy rates (PR) after treatment of patients with oligoteratoasthenozoospermia (OTA) result in a search for different treatment modalities. The objective of this study was to assess the efficacy of transcervical intrafallopian insemination (IFI) with husband's semen in comparison to intrauterine insemination (IUI) in couples with OTA. A prospective, randomized study included 30 couples with OTA-related infertility (according to WHO criteria). The female patients underwent individually adjusted controlled ovarian stimulation by gonadotropins. Spermatozoa was prepared using the Percoll 70% technique and insemination was performed 36-40 h after human chorionic gonadotropin (HCG) administration. The Tomcat Catheter was used for IUI and the Jansen-Anderson Catheter for IFI to the fallopian tube leading to the ovary that contained more dominant follicles. The couples were divided according to sperm count, into group A (9 couples): < 10 mill ml-1 and group B (21 couples): > 10 mill ml-1. Within the groups the patients were randomly assigned for IUI or IFI treatment. Among group B couples, two pregnancies out of 15 IUI cycles (13.3% PR) and two pregnancies out of 18 IFI cycles (11.1% PR) were achieved. Group A patients completed 7 IUI and 9 IFI treatment cycles with no pregnancies observed. These data did not demonstrate a statistically significant advantage for either technique.

Influence of estrogen replacement therapy on airway reactivity

The effect of estrogen on smooth muscle in various organs is unpredictable. Little is known about the effect of estrogen on respiratory tract smooth muscle, particularly in humans. In the present study we used the histamine challenge test (HCT) to assess the effect of estrogen replacement therapy (ERT) on airway reactivity in postmenopausal women who did not suffer from respiratory disease. Thirty-six women who were undergoing treatment at the postmenopausal clinic completed the study. All participants were nonsmokers whose pulmonary function tests were normal. HCT was performed twice before the inception of ERT, and a third time 4-6 weeks after ERT was begun. None of the 36 women demonstrated a 20% decrease in FEV1 values (PC20) after inhaling histamine at a concentration of 8 mg/ml, either before or during ERT. The maximal decrease in FEV1 values in response to the maximum concentration of histamine was significantly lower during ERT compared to the pretreatment period. The average maximal decrease in FEV1 during ERT was 2.63 +/- 2.72% (mean +/- DS) compared to 5.21 +/- 4.47% and 6.57 +/- 5.28% on the 2 tests prior to therapy (p < 0.0002). We conclude that ERT has an inhibitory effect on the bronchial reactivity of respiratory smooth muscle. There is no cause for concern about increased airway reactivity as an adverse effect of this therapy.

Idiopathic dilated cardiomyopathy in pregnancy

We report a 34-year-old woman who presented at 21 weeks with cardiac failure due to idiopathic dilated cardiomyopathy. Following refusal of pregnancy termination, she was treated conservatively with good maternal and neonatal outcome.

The relationship between endogenous oestradiol and vitamin D3 metabolites in serum and follicular fluid during ovarian stimulation for in-vitro fertilization and embryo transfer

The present study was undertaken to examine the effect of circulating oestradiol on serum levels of 25-hydroxyvitamin D3 (25-OHD3), 24,25-dihydroxyvitamin D3[24,25-(OH)2D3], and 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] during gonadotrophin-induced ovarian stimulation in 10 healthy women undergoing in-vitro fertilization and embryo transfer (IVF). The presence of these metabolites in the follicular fluid was also investigated. Plasma oestradiol increased from 25 +/- 3.2 (mean +/- SE) pg/ml before initiation of treatment to 2563 +/- 328 pg/ml on the day of injection of human chorionic gonadotrophin (HCG) and 1641 +/- 299 pg/ml on the day of ovum retrieval (P < 0.01). Serum levels of 1,25-(OH)2D3 increased from 32.0 +/- 1.9 (mean +/- SE) pg/ml to 46.6 +/- 8.1 and 48.5 +/- 7.7 pg/ml (P < 0.05) on the day of HCG and ovum retrieval, respectively. No changes in blood levels of 25-OHD3 and 24,25-(OH)2D3 were found. The presence of vitamin D metabolites in follicular fluid is documented herein for the first time. All three metabolites were present in the follicular fluid but were significantly lower than in the concurrent serum (P < 0.01). A highly significant correlation was found between serum and follicular fluid levels: r = 0.787, P < 0.001 for 1,25-(OH)2D3; r = 0.738, P < 0.01 for 25-OHD3; and r = 0.751, P < 0.01 for 24,25-(OH)2D3. Our results suggest that raised levels of circulating oestradiol during gonadotrophin-induced ovarian stimulation are associated with a significant increase of serum 1,25-(OH)2D3.