The impact of semen parameters on ICSI and pregnancy outcomes in egg recipient cycles with PGT-A

BACKGROUND

The egg donation model offers an opportunity to isolate the male factor and evaluate its impact on IVF-intracytoplasmic sperm injection and pregnancy outcomes.

OBJECTIVE

To study the effect of non-obstructive azoospermia on intracytoplasmic sperm injection and pregnancy outcomes compared with severe oligozoospermia and mild-to-moderate oligozoospermia in egg recipient cycles.

MATERIALS AND METHODS

This is a retrospective longitudinal cohort study, including 1594 patients who underwent intracytoplasmic sperm injection in egg recipient cycles with preimplantation genetic testing for aneuploidies. The cohort was divided into three groups: couples with non-obstructive azoospermia accounting for 479 patients (30%); couples with severe oligozoospermia (sperm number <5 × 106 /mL), accounting for 442 patients (27.8%); couples with mild-to-moderate oligozoospermia, with sperm number >5 × 106 and <15 × 106 /mL, accounting for 673 patients (42.2%).

RESULTS

The fertilisation rate was significantly reduced in the non-obstructive azoospermia group as compared with the severe oligozoospermia and the mild-to-moderate oligozoospermia group: 30.3% versus 63% and 77.3% (p < 0.05). Logistic regression analysis adjusted for confounders highlighted non-obstructive azoospermia as a negative predictor of obtaining a euploid blastocyst both per injected oocyte and per obtained blastocyst. The miscarriage rate in the non-obstructive azoospermia group was 11.8%; higher than the severe oligozoospermia and mild-to-moderate oligozoospermia groups (7% and 2.7%) (p < 0.05). The live birth rate per embryo transfer (ET) was significantly lower in the non-obstructive azoospermia group compared with the severe oligozoospermia and the mild-to-moderate oligozoospermia group (20.4% vs. 30.3% and 35.4%, p < 0.05). The risk of preterm labour was significantly higher in the non-obstructive azoospermia group, compared with the severe oligozoospermia and mild-to-moderate oligozoospermia group (55.1% vs. 46.8% and 16.1%, p < 0.001), and this difference was observed in both singleton and twin pregnancies.

DISCUSSION AND CONCLUSION

In our retrospective comparative study, non-obstructive azoospermia significantly affects early embryonic potential and live birth rates per cycle and per embryo transfer. It is also associated with higher risk of preterm birth. Future prospective multi-centre studies are needed to highlight the effect of sperm quality on ART and pregnancy outcomes.

P-184 The effect of oocyte vitrification accounting for both open and closed systems on embryo developmental arrest rate. A systematic review and network meta-analysis

Study question

To investigate the effect of oocyte vitrification on embryo developmental arrest rate accounting for both open and closed systems.

Summary answer

Open and closed vitrification systems are equally associated with a statistically significant higher embryo developmental arrest rate per MII oocyte vitrified compared to fresh oocytes.

What is known already

Oocyte cryopreservation has increased in popularity as it enhances women’s reproductive autonomy. Numerous studies have been published evaluating its effectiveness. However, the majority of published evidence commonly include comparisons with the now considered as “outdated” method of slow freezing. Additionally, data principally report on fertilization rates and clinical outcomes. It may be timely and essential to focus strictly on the effect of oocyte vitrification on the developmental potential of the embryo. Further to this, data are lacking on whether employing an open or closed vitrification system may affect the outcome of vitrification.

Study design, size, duration

A systematic search of the literature was performed in the databases Pubmed/Medline, Embase, and Cochrane Central Library limited to articles published in English up to October 2021. Only studies employing vitrification were included in this meta-analysis. A total of 17 published prospective studies were eligible. The population consists of oocytes that were either vitrified or fresh and subjected to ICSI. A network meta-analysis was performed comparing the type of vitrification system employed and fresh oocytes.

Participants/materials, setting, methods

The primary outcome measure was developmental arrest rate per MII oocyte vitrified prior to reaching cleavage or blastocyst stage. The secondary outcome measures were fertilization rate per MII oocyte vitrified and developmental arrest rate per 2PN zygote. Further to this, a subgroup analysis was performed according to the stage of developmental arrest. To rank the efficiency between the fresh oocytes and the oocytes vitrified employing the open and closed system, the P-Score was employed.

Main results and the role of chance

The seventeen studies reporting on the effect of oocyte vitrification on embryo developmental arrest per MII oocyte vitrified, presented with high heterogeneity I2=81%. Vitrified oocytes employing either the open or closed vitrification system presented with a statistically higher embryo developmental arrest rate when compared to fresh oocytes (open-systems:RR:1.16; 95%CI:1.07-1.26; closed-systems:RR:1.19 95%CI:1.06-1.34). No statistically significant difference was observed between the two vitrification systems (open vs closed:RR:0.99;95%CI:0.89-1.10). Subgroup analysis was performed according to the developmental stage of embryo arrest. Similarly to the pooled results, when subgrouping for embryos arresting prior to the cleavage stage, a statistically significant difference on developmental arrest was identified when vitrifying (open-systems:RR:1.44; 95%CI:1.18-1.77; closed-systems:RR:1.51 95%CI:1.12-2.04; 8 studies). However, when subgrouping for embryos arresting prior to the blastocyst stage, no statistically significant difference on developmental arrest was observed when vitrifying (open-systems:RR:1.06; 95%CI:0.98-1.15; closed systems:RR:1.10 95%CI:0.98-1.24; 9 studies). Fertilization rate was significantly lower for vitrified oocytes compared to fresh (open-systems:RR:0.86; 95%CI:0.79-0.93; closed-systems:RR:0.81 95%CI:0.72-0.92), while no statistically significant difference was observed between the two vitrification systems (open vs closed:RR:1.04; 95%CI:0.93-1.16). When comparing developmental arrest rate per 2PN zygote no statistically significant difference was detected between vitrification versus fresh (open-systems:RR:1.01; 95%CI:0.87-1.17; closed-systems:RR:0.98 95%CI:0.78-1.22), or between the two vitrification systems (open vs closed:RR:1.03;95%CI:0.82-1.30).

Limitations, reasons for caution

The limited number of studies included along with the heterogeneity identified present as limitations of this study. Further studies and especially Randomized Controlled Trials should be conducted in order to evaluate possible effects of oocyte vitrification on embryo development.

Wider implications of the findings

Oocyte vitrification results to higher developmental arrest rates per oocyte vitrified but not per 2PN zygote. Both vitrification systems perform equally in affecting developmental arrest. The differential expression of miRNAs and cytokinesis-related genes are identified by this systematic review as potential pathways influencing developmental potential following oocyte vitrification.

Trial registration number

Not applicable

P-570 Prokineticin-1 follicular fluid levels are strongly associated with diminished ovarian reserve and poor ovarian response: A prospective observational study

Study question

Are Prokineticin-1 (PROK1) follicular fluid (FF) levels associated with poor ovarian response (POR) as well as with other well-known biomarkers associated with ovarian reserve status?

Summary answer

Poor responders present with increased PROK1 FF levels. Also, PROK1 FF levels are negatively correlated with anti-müllerian hormone (AMH) levels and number of oocytes retrieved.

What is known already

Prokineticin-1 is an angiogenic factor with pleiotropic properties. Considering its role in reproduction, PROK1 mediates significant angiogenic functions in the fetal-maternal interface. Thus, alterations in PROK1 expression and/or function lead to placenta-derived pregnancy complications. Recently published studies also indicate that PROK1 is associated with ovarian function and oocyte competence. However, limited data associating PROK1 with POR are published. This study uniquely investigates possible associations between PROK1 FF levels in POR cases, with stimulation outcome, as well as with FF levels of other factors related to ovarian functionality, namely VEGF, bone morphogenetic protein 15 (BMP-15) and Pigment Epithelium Derived Factor (PEDF).

Study design, size, duration

This prospective-observational study was collaboratively conducted between November 2020 and July 2021 at Genesis Athens Clinic and at the University of Athens Medical School. A total of 64 patients undergoing IVF treatment were enrolled. The study group comprised of 32 POR patients defined according to the Bologna criteria. The control group consisted of 32 normal responder women undergoing IVF due to tubal factor and/or mild male factor infertility. Patients with other infertility aetiologies were excluded.

Participants/materials, setting, methods

Participants in both groups received the standard short GnRH-antagonist protocol. Prior to ovarian stimulation, participants were subjected to basic infertility investigation, including antral follicle count and AMH levels evaluation. The FF samples were collected as part of the oocyte retrieval process, then centrifuged and stored at -80 °C till analysis. Follicular fluid levels of PROK1, VEGF, BMP-15 and PEDF were evaluated via ELISA employing commercially available kits. Statistical analysis was performed employing R Programming Language.

Main results and the role of chance

Significantly higher PROK1 (3229.63 ± 2372.66 vs 1945.95 ± 1408.01 pg/ml; P-value&lt;0.0001), VEGF (2309.63 ± 412.49 vs 2013.22 ± 330.16 pg/ml; P-value=0.006) and lower BMP-15 (434.13 ± 106.38 vs 532.5 ± 108.26 pg/ml; P-value=0.001) levels were recorded in the POR group. No difference was observed regarding PEDF levels (7.43 ± 1.95 vs 8.23 ± 2.54 ng/ml; P-value=0.2). However, the POR group presented with lower PEDF/VEGF ratio (3.33 ± 1.08 vs 4.18 ± 1.41; P-value=0.02), indicating a reduced antioxidant capacity. PROK1 levels were negatively correlated with AMH (P-value=0.04), number of oocytes retrieved (P-value=0.001) and number of MII oocytes (P-value=0.005). BMP-15 was positively correlated with number of oocytes retrieved (P-value&lt;0.001), number of MII oocytes (P-value=0.002), number of normally fertilized zygotes (P-value=0.007), number of cleavage stage embryos (P-value=0.03) and number of blastocysts (P-value=0.04). VEGF was negatively correlated with AMH (P-value=0.004) and number of oocytes retrieved (P-value=0.03). These correlations remained significant when adjusting for ovarian response status. PROK1 levels, with a cut-off value of 2854.25 pg/ml, were able to predict ovarian response status with an area under the curve at 0.64. Sensitivity was 0.55, specificity was 0.88, and accuracy was 0.71. The positive and negative predictive values were 81.82% and 66.67%, respectively.

Limitations, reasons for caution

Limitations of our study refer to the limited size of the studied population, as well as to the lack of data considering pregnancy outcomes. Moreover, molecular data with regards to the possible role of PROK1 on POR pathogenesis are required. Future studies are needed to verify the results presented herein.

Wider implications of the findings

Data presented herein indicate that PROK1 FF levels are strongly associated with diminished ovarian reserve and POR. Considering that FF-PROK1 presents with a similar profile with FF-VEGF, we can form the hypothesis that the compromised angiogenesis observed in POR patients leads to PROK1 and VEGF increase via a negative-feedback-loop.

Trial registration number

Not applicable

P-183 Effect of oxygen levels, temperature, and interruptive evaluation practices during embryo culture on embryo developmental arrest. A systematic review and network meta-analysis

Study question

Do different culture conditions and practices, regarding oxygen levels, temperature, and culture interruption for evaluation purposes, effect embryo developmental arrest?

Summary answer

Ultra-low oxygen levels at 2-3.5%, a temperature below 37oC, and more than one interruption during culture are associated with a higher developmental arrest rate.

What is known already

Literature indicates that embryo culture microenvironment differs among laboratories. According to data, oxygen levels range between 2%-20%, while the optimal temperature during embryo culture, ranging from 36oC-37oC, has not yet been validated. What is more, interrupting embryo culture to evaluate morphology disrupts the stable conditions of the incubator’s microenvironment, while various models of interruptive evaluation practices have been reported on time-points and assessment frequency. Data are lacking on the extent that oxygen levels, temperature and morphology evaluation practices affect the embryos’ developmental potential. Interestingly, reporting on optimal culture conditions and embryo evaluation practices still appears to be timely and essential.

Study design, size, duration

A systematic search of the literature was performed in Pubmed/Medline, Embase, and Cochrane Central Library up to October 2021. Seventeen published prospective studies were included in the three arms of this network meta-analysis. The outcome measure was developmental arrest rate prior to the blastocyst stage. To rank oxygen levels and interruption times, the P-Score was employed. Molecular pathways implicated in developmental arrest associated with each examined parameter were investigated as part of the systematic review.

Participants/materials, setting, methods

A network meta-analysis was performed regarding oxygen levels, temperature, and culture interruption practices for evaluation purposes. The population consisted of preimplantation embryos. Atmospheric conditions (20% O2), low-oxygen levels (5% O2) and ultra-low oxygen levels (2-3.5% O2), along with temperature below or at 37oC were compared. Finally, no interruptions (time-lapse microscopy), one interruption (fertilization evaluation), 2 and 3 interruptions for morphological evaluation were compared. The estimated network effect comprises of direct and indirect effects.

Main results and the role of chance

Eight studies reporting on the effect of different oxygen levels, presented with high heterogeneity I2=88%. No statistically significant difference was observed between atmospheric and low-oxygen level regarding arrest rate (RR:1.07; 95%CI:0.88-1.30). A significantly higher developmental arrest rate was observed in ultra-low oxygen levels versus low (RR:1.29; 95%CI:1.02-1.64). No statistically significant difference was observed between ultra-low oxygen levels and atmospheric conditions (RR:1.21; 95%CI:0.89-1.63). The optimal oxygen levels are low (P-Score=0.87), followed by atmospheric conditions (P-Score=0.57) and ultra-low (P-Score=0.06). Three studies reporting on the effect of different temperatures presented with low heterogeneity I2=30%. Temperature below 37oC presented with a statistically significant higher developmental arrest rate (RR:1.10; 95%CI:1.03-1.17). Six studies reporting on the effect of interruptive evaluation practices showed high heterogeneity I2=84%. Uninterrupted culture presented with no statistically significant difference with the other groups (1-interruption vs Uninterrupted: RR:0.93; 95%CI:0.78-1.12; 2-interruptions vs Uninterrupted: RR:1.08; 95%CI:0.91-1.28; 3-interruptions vs Uninterrupted: RR:1.11; 95%CI:0.92-1.34). A single-interruption presented with marginally no statistically significant difference when compared to two-interruptions (RR:0.87; 95%CI:0.74-1.02), however presented with a lower developmental arrest rate when compared to three-interruptions (RR:0.84; 95%CI:0.71-0.99). Two versus three-interruptions indicated no difference (RR:0.97; 95%CI:0.82-1.14). The optimal interruptive evaluation practice is one (P-Score=0.90) followed by uninterrupted (P-Score=0.63), two-interruptions (P-Score=0.30) and three-interruptions (P-Score=0.16).

Limitations, reasons for caution

The limited number of studies included and the heterogeneity are limitations of this study. The different number of studies and embryos included in each comparison group, along with the fact that randomization was not performed in all studies, present as reasons for caution when interpreting the results of this study.

Wider implications of the findings

Oxygen levels at 5%, 37oC temperature, and single or no-interruption embryo evaluation practices reduce developmental arrest rate. This systematic review indicates potential pathways implicated in developmental arrest as follows: oxygen tension influencing histone modifications, temperature influencing regulatory proteins’ activity, and stress-related cytokines’ differential expression when culture is interrupted multiple times.

Trial registration number

Not applicable

O-122 Reporting on the value of Artificial Intelligence in predicting the optimal embryo for transfer: A systematic review and meta-analysis

Study question

Are Artificial Intelligence (AI) based models effective in robustly predicting in vitro fertilization (IVF) outcome by assessing embryo quality?

Summary answer

The majority of the AI-based models could provide an accurate prediction regarding live birth, clinical pregnancy, clinical pregnancy with fetal heartbeat and embryo ploidy status.

What is known already

Precision and consistency in embryo quality evaluation are of paramount importance regarding the outcome of an IVF cycle. Numerous embryo grading and evaluation systems, employing morphological and morphokinetical assessment, have been proposed but without reaching a consensus yet. The main limitation of the aforementioned assessment systems is that they depend on human evaluation, which may be subject to subjectivity and interobserver variation. Thus, automated prediction models may be essential to optimize objectivity and reliability of embryo grading. Artificial neural network models may process microscopy images or time-lapse videos as input to predict the embryos’ potential competency.

Study design, size, duration

A systematic review and meta-analysis including 18 published studies. The population consists of preimplantation embryos suitable for embryo transfer in IVF/ICSI cycles following employment of an AI-based prediction model. The outcome measures are prediction of live birth, clinical pregnancy, clinical pregnancy with heartbeat and ploidy status.

Participants/materials, setting, methods

A systematic search of the literature was performed in the databases of Pubmed/Medline, Embase, and Cochrane Central Library limited to articles published in English up to August 2021. The initial search yielded a total of 694 studies with 97 of them being duplicates and other 579 being excluded on the grounds of not fulfilling inclusion criteria. Following full-text screening and citation mining a total of 18 studies were identified to be eligible for inclusion.

Main results and the role of chance

Four studies reported on prediction of live birth. The sensitivity was 70.6% (95%C.I.: 38.1-90.4%) and specificity was 90.6% (95%C.I.:79.3-96.1%).  The Area Under the Curve (AUC) of the Summary Receiver Operating Characteristics (SROC) curve was 0.905, while the partial AUC (pAUC) was 0.755. Employing the Bayesian approach, the total Observed:Expected ratio (O:E) was 1.12 (95%CI: 0.26–2.37; 95%PI:0.02-6.54). Ten studies reported on prediction of clinical pregnancy. The sensitivity and the specificity were 71% (95%C.I.: 58.1-81.2%) and 62.5% (95%C.I.: 47.4-75.5%) respectively. The AUC was 0.716, while pAUC was 0.693. Moreover, the total O:E ratio was 0.92 (95%CI: 0.61–1.28; 95%PI:0.13-2.43). Eight studies reported on prediction of clinical pregnancy with fetal heartbeat the sensitivity was 75.2% (95%C.I.: 66.8-82%) and the specificity was 55.3% (95%C.I.: 41.2-68.7%). The AUC was 0.722, while the pAUC was 0.774. The O:E ratio was 0.77 (95%CI: 0.54 – 1.05; 95%PI: 0.21-1.62). Four studies reported on the ploidy status of the embryo. The sensitivity and specificity were 59.4% (95%C.I.: 45.0-73.1%) and 79.2% (95%C.I.: 70.1-86.1%) respectively. The AUC was 0.751 and the pAUC was 0.585. The total O:E ratio was 0.86 (95%CI: 0.42 – 1.27; 95%PI: 0.03-1.83).

Limitations, reasons for caution

The limited number of studies fulfilling inclusion criteria, along with the different designs applied when developing AI models which may lead to increased heterogeneity, stand as limitations. Inclusion of women regardless of their age presents as another limitation, as advanced maternal age has been associated with diminished IVF outcomes.

Wider implications of the findings

Albeit, our findings support that AI is a highly promising tool in the era of personalized medicine providing precise predictions it does not appear to considerably surpass human prediction capabilities. More studies and more collaborations between the developers are of paramount importance prior to AI becoming the gold standard.

Trial registration number

Not applicable

O-249 The impact of semen parameters on ICSI and pregnancy outcomes in egg recipient cycles with PGT-A

Study question

To assess the effect of male factor on ICSI and pregnancy outcomes in egg recipient cycles combined with preimplantation aneuploidy testing

Summary answer

In egg donor cycles where sperm was obtained from azoospermic men there was a significant effect on ART and clinical outcomes.

What is known already

The increased incidence of chromosomal problems in men with azoospermia and its correlation with chromosomally abnormal embryos and with adverse pregnancy outcomes has been shown by multiple studies. Nevertheless, few studies in the literature outline the impact of non-obstructive azoospermia in the subgroup of couples who opt to use donated eggs.

The egg donation model offers an opportunity to isolate the male factor and evaluate its impact on IVF-ICSI and pregnancy outcomes.

The aim of our study was to study the effect of non-obstructive azoospermia(NOA) on ICSI outcomes compared with oligoasthenozoospermia(OATS) and moderate male factor(MMF) infertility, from ART parameters to clinical outcomes.

Study design, size, duration

This is a retrospective longitudinal cohort study involving 1,594 ICSI cycles using donor eggs performed between January 2016 and May 2020.

The cohort was divided into three groups according to the male partner’s sperm parameters: couples with NOA accounting for 479 cycles (30%); couples with OAT-S (sperm number &lt;5 x 106/ml), accounting for 442 cycles (27.8%); couples with moderate male factor, with sperm number &gt;_5 x 106/ml and &lt;15 x 106/ml, accounting for 673 cycles (42.2%).

Participants/materials, setting, methods

Participants:

Subfertile couples who opted to use donor eggs. Donor eggs were utilized, due to history of severe female infertility, including low ovarian reserve, poor response to ovarian stimulation, repeated IVF failures or premature ovarian failure.

Setting:

Private IVF Unit

Intervention:

ICSI with ejaculated/surgically retrieved sperm, blastocyst culture, PGT-A and frozen-thawed euploid embryo transfer.

Outcomes:

The primary outcomes were live birth, fertilization, blastocyst development and euploidy rates; the secondary outcomes were clinical pregnancy, miscarriage rates, preterm labour and SGA.

Main results and the role of chance

The fertilization rate was significantly reduced in the NOA group as compared to the OATS and the MMF group: 30.3% versus 63% and 77.3%. Logistic regression analysis adjusted for confounders highlighted NOA as a negative predictor of obtaining an euploid blastocyst per inseminated oocyte. When the analysis was performed per obtained blastocyst, no correlation between male factor and euploidy rate was observed.

The clinical pregnancy rates were similar in the MMF and OATS group, but significantly lower in the NOA group (38.2% versus 36.3% and 29.5% respectively). The miscarriage rate in the NOA group was 11.8%; higher than the OATS and MMF group (7% and 2.7%). The live birth rate per ET was significantly lower in the NOA group compared to the OATS and the MMF group (20.4% vs 30.3% and 35.4%,p&lt;0.05). The live birth rate was significantly lower in the OATS group compared to the MMF group(p &lt; 0.05).

The risk of preterm labour was significantly higher in the NOA group, compared to the OATS and MMF group (55.1% versus 46.8 and 16.1%,p&lt;0.001) and a higher number of babies born with a birth weight &lt;2.5kg came from the NOA group, compared to the OATS and MMF group (34% versus 19.8% and 12.2%, p &lt; 0.001).

Limitations, reasons for caution

The present study is limited by its retrospective design and the fact that the confounding factors of advanced maternal age, endometrial ageing and uterine factors cannot be fully evaluated. However, the study was controlled for female and male partner's age. Neonatal outcomes were not available.

Wider implications of the findings

Non-obstructive azoospermia can impair early embryonic potential and reduce live birth rates. Our study also shows an association between NOA and preterm birth. Future research should focus on prospective collection of data and long-term follow up of babies born by fathers with non-obstructive azoospermia.

Trial registration number

Not applicable

P-012 Investigating the potential role of microRNAs as biomarkers in idiopathic non-obstructive azoospermia: A systematic review and in-silico analysis of the affected pathways

Study question

Is there an association between microRNA profiles in seminal plasma and microRNAs profiles in testicular tissue samples obtained from idiopathic non-obstructive azoospermia (NOA) patients?

Summary answer

This study identified common alterations in microRNA profiles and gene expression patterns between seminal plasma and testicular tissue samples obtained from NOA patients.

What is known already

Despite the significant advances in the field of reproductive medicine the exact infertility aetiology remains unidentified regarding 30-40% of infertile men. This fact highlights the need for more accurate and sensitive diagnostic tools and biomarkers, especially regarding the most severe cases of male infertility, such as idiopathic NOA patients. It has been voiced that microRNA profiling of seminal plasma and testicular tissue samples obtained from idiopathic NOA patients could be a powerful tool towards better understanding the underlined pathogenesis and towards developing novel diagnostic and individualized biomarkers. However, a collective analysis of these data has not been performed hitherto.

Study design, size, duration

A systematic review was performed in PubMed/Medline and Embase up to November 2020. Search strategy included a combination of keywords, namely non-coding RNA OR small non-coding RNA OR microRNA AND non-obstructive azoospermia. Following study selection, original data on altered microRNAs were analyzed aiming to underline differences between microRNA expression profiles in seminal plasma and testicular tissue samples of idiopathic NOA cases. Following this, in-silico analysis was performed to detect commonly affected gene expression pathways.

Participants/materials, setting, methods

Only full-length original retrospective or prospective human studies were included. Strict inclusion-exclusion criteria were applied. The studied population consisted of idiopathic NOA patients, while the control groups consisted of men with normal semen analysis. In-silico analysis was performed employing a combination of bioinformatic tools, namely the DIANA-TarBase, microT-CDS, the GTEx repository and the KEGG database. Statistical analysis was performed using the R-package-limma. The statistically significant threshold indicating altered gene pathways was set at 0.01 P-value.

Main results and the role of chance

Five studies were considered eligible, including 382 NOA cases and 412 controls (Finocchi et al., 2020; Song et al., 2017; Wu et al., 2013; Wu et al., 2012; Wang et al., 2011). Two studies co-evaluated the profile of microRNAs in both seminal plasma and testicular tissue samples (Wu et al., 2013; Wu et al., 2012), one study evaluated only testicular tissue (Song et al., 2017) and the other two only seminal plasma (Finocchi et al., 2020 and Wang et al., 2011). Data extraction revealed a total of 14 differentially expressed microRNAs between NOA patients and controls. The following microRNAs were found to be up-regulated in both seminal plasma and testicular tissue samples of NOA cases: hsa-miR-141-3p, hsa-miR-429, hsa-miR-7-1-3p, hsa-miR-19b-3p and hsa-let-7a-5p. The hsa-miR-188-3p was found to be down-regulated in testicular tissue samples. Finally, the following microRNAs were also downregulated only in seminal plasma: hsa-miR-34c-5p, hsa-miR-122-5p, hsa-miR-181a-5p, hsa-miR-146b-5p, hsa-miR-374b-5p, hsa-miR-509-5p, hsa-miR-513a-5p and hsa-miR-34b-3p. Despite the limited number of common microRNAs between seminal plasma and testicular tissue samples, in-silico analysis revealed 34 statistically significant dysregulated gene pathways, regarding both seminal plasma and testicular tissue samples, indicating that idiopathic NOA patients are sharing several common altered molecular mechanisms involved in NOA pathogenesis.

Limitations, reasons for caution

The limited number of the included studies as well as the small size population characterizing the great majority of them, constitute the main limitations of this systematic review. Moreover, great heterogeneity was observed among the studies regarding the molecular methods employed for microRNA profiling.

Wider implications of the findings

These collective findings indicate that microRNA profiling in seminal plasma could indeed be raised as a powerful non-invasive tool towards better understanding and diagnosing idiopathic NOA. Larger well-controlled studies employing state-of-the-art microRNAome techniques are needed to validate these conclusions. Moreover, the molecular network of targeted gene pathways also merits investigation.

Trial registration number

Not Applicable

P-571 The newly developed highly sensitive reagent GL13 indicates extensively increased cellular senescence in the follicular fluid of poor responder patients: A prospective observational study

Study question

Do women of diminished ovarian reserve and poor ovarian response (POR) present with increased lipofuscin follicular fluid (FF) levels, indicating increased ovarian cellular senescence?

Summary answer

Poor responders present with a six-fold increased lipofuscin FF levels indicating extensive senescence in POR ovaries. Lipofuscin may be a new sensitive biomarker for POR.

What is known already

Lipofuscin is a nondegradable substrate of metabolism accumulating in cells due to impaired mitochondrial/lysosome/proteasome function, upon stress or damage. It is well-documented that lipofuscin constitutes a highly sensitive biomarker of cellular aging and senescence. Recently, a novel reagent (GL13) coupled by a hybrid histochemical–immunohistochemical method were developed for detecting and measuring soluble lipofuscin levels in biological fluids, ascertaining high sensitivity and specificity. Data indicate that lipofuscin levels are associated with oocyte competence and age-related infertility. However, hitherto no data has been published indicating the value of lipofuscin FF levels as a biomarker towards accurately predicting ovarian reserve and response.

Study design, size, duration

This prospective observational study was collaboratively conducted between November 2020 and September 2021 at the Athens University Medical School and at Genesis Athens Clinic. A total of 32 patients undergoing IVF treatment were enrolled. The study group comprised of 16 POR patients defined according to the Bologna criteria. The control group consisted of 16 normal responder women undergoing IVF due to tubal factor or/and mild male factor infertility. Patients with other infertility aetiologies were excluded.

Participants/materials, setting, methods

Participants in both groups received the standard short GnRH-antagonist protocol. The FF samples were collected as part of the oocyte retrieval process. Lipid and protein parts of lipofuscin were isolated from FF samples and stained with GL13. The complex of lipofuscin-GL13 was labeled with an anti-biotin HRP conjugated antibody and detected employing a chemiluminescence reaction. Luminescence was measured and signal intensity was corresponding to lipofuscin concentration. Statistical analysis was performed employing R Programming Language.

Main results and the role of chance

Poor responders presented with a statistically significant six-fold higher lipofuscin FF levels in comparison to the normal responder group (869.21 ± 501.87 vs 146.6 ± 107.64 RLU; P-value &lt;0.0001). Lipofuscin levels were negatively correlated with AFC (Spearman’s Rho: -0.68; P-value &lt;0.0001), AMH levels (Rho: -0.61; P-value =0.0002), estradiol levels on triggering day (Rho: -0.68; P-value &lt;0.0001), number of oocytes retrieved (Rho: -0.54; P-value =0.001), number of mature metaphase II (MII) oocytes obtained (Rho: -0.58; P-value =0.0008), number of normally fertilized (2PN) zygotes (Rho: -0.51; P-value =0.003), number of cleavage stage embryos (Rho: -0.48; P-value =0.005) and number of blastocyst stage embryos (Rho: -0.41; P-value =0.02). These correlations remained statistically significant when adjusting for ovarian stimulation response status. No association was established between Lipofuscin levels and embryo quality neither on Day 3 nor on Day 5. Lipofuscin levels, with a cut-off value at 294, were able to predict ovarian stimulation response status with an area under the curve (AUC) at 0.96. The sensitivity was 0.875, the specificity was 0.938 and the accuracy was 0.906. The positive predictive value was 88.24% and the negative predictive value was 93.33%.

Limitations, reasons for caution

Limitations of our study refer to the limited size of the studied population, as well as to the lack of data referring to pregnancy outcomes. Moreover, molecular data with regards to the possible mechanisms leading to the observed increased senescence are required. Future studies are needed to verify these findings.

Wider implications of the findings

Data presented herein indicates, for the first time in literature, that lipofuscin FF levels measured via the GL13 method may be a promising and sensitive tool for predicting POR and stimulation outcome. Lipofuscin could further serve as a valuable novel biomarker indicating ovarian senescence, ovarian reserve status and oocyte competence.

Trial registration number

Not Applicable

The impact of maternal age on gene expression during the GV to MII transition in euploid human oocytes

STUDY QUESTION

Are there age-related differences in gene expression during the germinal vesicle (GV) to metaphase II (MII) stage transition in euploid human oocytes?

SUMMARY ANSWER

A decrease in mitochondrial-related transcripts from GV to MII oocytes was observed, with a much greater reduction in MII oocytes with advanced age.

WHAT IS KNOWN ALREADY

Early embryonic development is dependent on maternal transcripts accumulated and stored within the oocyte during oogenesis. Transcriptional activity of the oocyte, which dictates its ultimate developmental potential, may be influenced by age and explain the reduced competence of advanced maternal age (AMA) oocytes compared with the young maternal age (YMA). Gene expression has been studied in human and animal oocytes; however, RNA sequencing could provide further insights into the transcriptome profiling of GV and in vivo matured MII euploid oocytes of YMA and AMA patients.

STUDY DESIGN, SIZE, DURATION

Fifteen women treated for infertility in a single IVF unit agreed to participate in this study. Five GV and 5 MII oocytes from 6, 21-26 years old women (YMA cohort) and 5 GV and 6 MII oocytes from 6, 41-44 years old women (AMA cohort) undergoing IVF treatment were donated. The samples were collected within a time frame of 4 months. RNA was isolated and deep sequenced at the single-cell level. All donors provided either GV or MII oocytes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cumulus dissection from donated oocytes was performed 38 h after hCG injection, denuded oocytes were inserted into lysis buffer supplemented with RNase inhibitor. The samples were stored at -80°C until further use. Isolated RNA from GV and MII oocytes underwent library preparation using an oligo deoxy-thymidine (dT) priming approach (SMART-Seq v4 Ultra Low Input RNA assay; Takara Bio, Japan) and Nextera XT DNA library preparation assay (Illumina, USA) followed by deep sequencing. Data processing, quality assessment and bioinformatics analysis were performed using source-software, mainly including FastQC, HISAT2, StringTie and edgeR, along with functional annotation analysis, while scploid R package was employed to determine the ploidy status.

MAIN RESULTS AND THE ROLE OF CHANCE

Following deep sequencing of single GV and MII oocytes in both YMA and AMA cohorts, several hundred transcripts were found to be expressed at significantly different levels. When YMA and AMA MII oocyte transcriptomes were compared, the most significant of these were related to mitochondrial structure and function, including biological processes, mitochondrial respiratory chain complex I assembly and mitochondrial translational termination (false discovery rate (FDR) 6.0E-10 to 1.2E-7). These results indicate a higher energy potential of the YMA MII cohort that is reduced with ageing. Other biological processes that were significantly higher in the YMA MII cohort included transcripts involved in the translation process (FDR 1.9E-2). Lack of these transcripts could lead to inappropriate protein synthesis prior to or upon fertilisation of the AMA MII oocytes.

LARGE SCALE DATA

The RNA sequencing data were deposited in the Gene Expression Omnibus (https://www.ncbi.nlm.nih.gov/geo), under the accession number: GSE164371.

LIMITATIONS, REASONS FOR CAUTION

The relatively small sample size could be a reason for caution. However, the RNA sequencing results showed homogeneous clustering with low intra-group variation and five to six biological replicates derived from at least three different women per group minimised the potential impact of the sample size.

WIDER IMPLICATIONS OF THE FINDINGS

Understanding the effects of ageing on the oocyte transcriptome could highlight the mechanisms involved in GV to MII transition and identify biomarkers that characterise good MII oocyte quality. This knowledge has the potential to guide IVF regimes for AMA patients.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Medical Research Council (MRC Grant number MR/K020501/1).

P–676 Mild stimulation followed by embryo accumulation via vitrification appears to be beneficial for managing poor ovarian response: A retrospective cohort study including 610 patients

Study question

Could embryo accumulation employing mild stimulation cycles prove beneficial for managing patients presenting with poor ovarian response (POR)?

Summary answer

Embryo accumulation may be an efficient POR management strategy, enabling a higher number and quality cohort of embryos, ultimately improving success results.

What is known already

It is widely accepted that POR constitutes a challenging condition. The limited oocyte yield associated with POR detrimentally impacts in vitro fertilization (IVF) success rates. Moreover, the documented heterogeneity among POR patients compromises our efforts to successfully address POR, despite the advances noted regarding stimulation protocols employed today. Considering the aforementioned, embryo accumulation following consecutive stimulation cycles has emerged as an alternative management strategy towards increasing the number of available embryos prior to embryo transfer (ET), mimicking normoresponding conditions. However, only few studies have been so far conducted and the need for further data is underlined.

Study design, size, duration

A single-center retrospective study was conducted in the Centre of Human Reproduction, Genesis-Athens Clinic from January 2015-December 2019. Only patients presenting with POR according to Bologna criteria were included. In total, 610 POR patients were considered eligible and were divided in three groups namely, mild stimulation-fresh ET (150 IUs of gonadotropins) (MILDF), mild stimulation employing embryo accumulation (MILDA), and natural cycle employing embryo accumulation (NATA). Respective comparisons on embryology and pregnancy data are provided.

Participants/materials, setting, methods

Resulting embryos from the MILDF, MILDA, and NATA groups were cultured up to the cleavage stage and categorized into three groups according to quality, namely top (grade 1), good (grade 2–3) and poor (grade 4–5) (Veeck, 1999). Top and good quality embryos were considered eligible for ET/vitrification. The banking scenario entailed accumulation of at least three embryos, including at least one top quality embryo. Embryo transfers included up to two cleavage stage embryos.

Main results and the role of chance

Comparing MILDF and MILDA groups, a higher number of available oocytes and embryos was observed in MILDA (2.36±1.15 vs 6.58±1.11; 1.72±1.02 vs 3.51±0.61, P-value&lt;0.001). However, a mean number of 3.90±1.56 oocyte retrievals were required to conclude MILDA compared to MILDF which was concluded following a single oocyte retrieval (P-value&lt;0.001). Cancellation-rate was significantly lower in the MILDA compared to MILDF group (0% vs 18.93%, P-value &lt;0.001). A higher proportion of top quality embryos were transferred in the MILDA group (66.58% vs 43.67%, P-value&lt;0.001). The MILDA group presented with higher positive-HCG (27.89% vs 23.30%, P-value=0.302), clinical-pregnancy (22.11% vs 17.96%, P-value=0.316) and live-birth rates (16.84% vs 14.08%, P-value=0.487). However, these differences were not significant. Comparing MILDA and NATA groups, the MILDA presented with a lower number of required oocyte retrievals and a higher number of oocytes per oocyte retrieval compared with NATA (3.90±1.56 vs 7.15±1.80; 1.95±0.74 vs 0.89±0.20, P-value&lt;0.001). Moreover, the MILDA presented with a higher mean number of resulting embryos (5.20±0.78 vs 4.82±0.88, P-value&lt;0.001). No difference was observed regarding the proportion of the resulting top quality embryos. The MILDA group presented with slightly higher clinical-pregnancy (22.11% vs 20.09%, P-value=0.628) and live-birth (16.84% vs 14.02%, P-value=0.490) rates, however these differences were not significant.

Limitations, reasons for caution

The retrospective nature of the study constitutes a major limitation. Considering that numerous confounders are inevitable when retrospective data is analyzed, authors employed strict eligibility criteria in an effort to reduce bias. Statistical analysis revealed a well-controlled population, considering that general patients’ characteristics did not differ between the three groups.

Wider implications of the findings: Embryo accumulation may constitute an efficient management strategy for POR, as more embryos of better quality are available for ET compared to fresh-IVF-ET. Mild stimulation should be preferred for embryo accumulation instead of natural cycles, as less oocyte retrievals are required. Future studies should be conducted to verify these conclusions.

Trial registration number

Not applicable

P–674 Development of a predictive model indicating the population of poor responders benefiting from luteal phase oocyte retrieval

Study question

Can successful implementation of luteal phase oocyte retrieval (LuPOR) following conventional follicular phase oocyte retrieval (FoPOR) be predicted for poor ovarian response (POR) patients?

Summary answer

Antral follicle count (AFC), number of small follicles recorded in FoPOR, and estradiol (E2) levels on FoPOR and LuPOR trigger days, predict successful LuPOR application.

What is known already

A second follicular wave in the same menstrual cycle was first observed in domestic animals such as horses and cattle and thenceforth in women. The second follicular wave has been introduced as an encouraging means towards optimizing the context of in vitro fertilization (IVF) success rates for infertile women and especially for POR patients. Double ovarian stimulation coupled with two oocyte retrievals in the same menstrual cycle has been proposed, and encouraging results have been reported. However, the high heterogeneity characterizing POR patients dictates that studies should focus on factors indicating efficient LuPOR application.

Study design, size, duration

This retrospective observational study included 1688 women diagnosed with POR, undergoing natural IVF cycles between 2012–2020 including two oocyte retrievals in the same menstrual cycle. Patients’ age, body mass index (BMI), number of previous POR incidences, basal hormonal levels, AFC, E2 evaluated on both trigger days and number of small follicles (8–13 mm) were evaluated on their predictive power regarding retrieval of at least one MII oocyte following LuPOR, being regarded as successful LuPOR implementation.

Participants/materials, setting, methods

A diagnosis of POR according to Bologna criteria served as the inclusion criterion for this single center study. All other infertility etiologies were excluded. Patient dataset was stratified according to age in quantiles. A random 20% of each quantile was employed to validate the model. The remaining 80% was employed to develop this model. The predictive value was determined employing the Area Under the Curve (AUC) of the Receiver Operating Characteristics, employing Youden’s index.

Main results and the role of chance

Patients’ age, BMI, number of previous failed IVF attempts, basal levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin and progesterone failed to be predictive of a successful LuPOR as the AUC was below 0.6. AFC with a threshold value of 4.47, was found to be predictive of an effective LuPOR with an AUC of 0.86, sensitivity 0.8, specificity 0.75, and accuracy 0.79. E2 levels evaluated on the FoPOR trigger day, with a threshold value of 232.66 pg/ml, were similarly predictive of an effective LuPOR presenting with an AUC 0.86, specificity 0.75, sensitivity 0.86 and accuracy 0.82. Similarly, E2 evaluated on the LuPOR trigger day, with a threshold value of 200.89 pg/ml, presented with an AUC 0.89, specificity 0.85, sensitivity 0.95 and accuracy 0.92. The number of small follicles during FoPOR also appeared to be predictive of the presence of at least one MII oocyte during LuPOR, with a threshold value of 2.94. The AUC was 0.82, specificity 0.75, sensitivity 0.76 and accuracy 0.75. When combining the above characteristics into a single predictive model the AUC was 0.88, specificity 0.73, sensitivity 0.94 and accuracy 0.89. The positive and negative predictive value of the model were 93.5% and 46.8%, respectively.

Limitations, reasons for caution

Employment of natural cycles may present as a limitation when examining the value of this study, as the cut-off values reported herein may be altered when stimulation is employed. Since internal validation may be confounded by the fact that this was a single center study, external validation is required.

Wider implications of the findings: The clinical end-point of this study reporting back to the practitioner, is the development of a predictive model identifying the optimal POR population for whom LuPOR practice is valuable. The high positive predictive value of this model may assist clinicians in identifying poor responders who will benefit from this approach.

Trial registration number

Not applicable

Discarding IVF embryos: reporting on global practices

PURPOSE

To provide a global scale report on a representative sample of the clinical embryology community depicting the practice of discarding supernumerary IVF embryos.

METHODS

A web-based questionnaire titled "Anonymous questionnaire on embryo disposal practices" was designed in order to ensure anonymous participation of practicing clinical embryologists around the world.

RESULTS

During a data collection period of 8 months, 703 filled-in questionnaires from 65 countries were acquired. According to the data acquired, the majority of practitioners, dispose of embryos by placing them directly in a trash can strictly dedicated for embryo disposal for both fresh and frozen cycles (39% and 36.7% respectively). Moreover, 66.4% of practitioners discard the embryos separately-case by case-at different time points during the day. Over half of embryologists (54%) wait until day 6 to discard the surplus embryos, while 65.5% do not implement a specially allocated incubator space as a designated waiting area prior to disposal. The majority of 63.1% reported that this is a witnessed procedure. The vast majority of embryologists (93%) do not employ different protocols for different groups of patients. Nonetheless, 17.8% reported the request to perform a ceremony for these embryos. Assessing the embryologists' perspective, 59.5% of participants stated that the embryology practice would benefit from a universally accepted and practiced protocol.

CONCLUSION(S)

This study uniquely provides insight into global embryo disposal practices and trends. Results highlight the divergence between reported practices, while indicating the significance on standardization of practice, with embryologists acknowledging the need for a universally accepted protocol implementation.

PGD for reciprocal and Robertsonian translocations using array comparative genomic hybridization

BACKGROUND

Fluorescence in situ hybridization (FISH) is the most widely used method for detecting unbalanced chromosome rearrangements in preimplantation embryos but it is known to have several technical limitations. We describe the clinical application of a molecular-based assay, array comparative genomic hybridization (array-CGH), to simultaneously screen for unbalanced translocation derivatives and aneuploidy of all 24 chromosomes.

METHODS

Cell biopsy was carried out on cleavage-stage embryos (Day 3). Single cells were first lysed and DNA amplified by whole-genome amplification (WGA). WGA products were then processed by array-CGH using 24sure + arrays, BlueGnome. Balanced/normal euploid embryos were then selected for transfer on Day 5 of the same cycle.

RESULTS

Twenty-eight consecutive cycles of preimplantation genetic diagnosis were carried out for 24 couples carrying 18 different balanced translocations. Overall, 187/200 (93.5%) embryos were successfully diagnosed. Embryos suitable for transfer were identified in 17 cycles (60.7%), with transfer of 22 embryos (mean 1.3 ± 0.5). Twelve couples achieved a clinical pregnancy (70.6% per embryo transfer), with a total of 14 embryos implanted (63.6% per transferred embryo). Three patients delivered three healthy babies, during writing, the other pregnancies (two twins and seven singletons) are ongoing beyond 20 weeks of gestation.

CONCLUSIONS

The data obtained demonstrate that array-CGH can detect chromosome imbalances in embryos, also providing the added benefit of simultaneous aneuploidy screening of all 24 chromosomes. Array-CGH has the potential to overcome several inherent limitations of FISH-based tests, providing improvements in terms of test performance, automation, sensitivity and reliability.

Retrotransposon RNA expression and evidence for retrotransposition events in human oocytes

Although human diseases of retrotransposition-derived etiology have been documented, retrotransposon RNA expression and the occurrence of retrotransposition events in the human oocyte are not studied. We investigated the RNA expression of L1 and HERV-K10 retrotransposons in human oocytes by RT-PCR analysis with designed primers. Using denucleated germinal vesicles (GVs), we detected RT-PCR products of expressed L1, HERV-K10 and, unexpectedly, SINE-R, VNTR and Alu (SVA) retrotransposons. Their transcript specificities were identified as such following RNA-FISH and their origin by cloning and sequence alignment analyses. Assessing the expression level in comparison with somatic cells by densitometry analysis, we found that although in normal lymphocytes and transformed HeLa cells their profile was in an order of L1 > HERV-K10 > SVA, remarkably this was reversed in oocytes. To investigate whether de novo retrotransposition events occur and reverse transcriptases are expressed in the human oocyte, we introduced in GVs either a retrotransposition active human L1 or mouse reverse transcriptase deficient-VL30 retrotransposon tagged with an EGFP-based retrotransposition cassette. Interestingly, in both the cases, we observed EGFP-positive oocytes, associated with an abnormal morphology for L1 and granulation for VL30, and the retrotransposition events were confirmed by PCR. Our results: (i) show that L1, HERV-K10 and SVA retrotransposons are transcriptionally expressed and (ii) provide evidence, for the first time, for retrotransposition events occurring in the human oocyte. These findings suggest that both, network of retrotransposon transcripts and controlled retrotranspositions, might serve important functions required for oocyte development and fertilization while the uncontrolled ones might explain the onset of genetic disorders.

Conception and pregnancy outcome in a patient with 11-bp deletion of the steroidogenic acute regulatory protein gene

OBJECTIVE

To report the pregnancy outcome of a patient with congenital lipoid adrenal hyperplasia (CLAH) due to an 11-bp deletion of the steroidogenic acute regulatory protein (StAR) gene.

DESIGN

Case report.

SETTING

University-based pediatric endocrinology unit and private IVF clinic.

PATIENT(S)

A 24-year-old woman homozygous for a StAR gene deletion, married to a man heterozygous for the same molecular defect.

INTERVENTION(S)

Ovarian stimulation, oocyte retrieval followed by IVF, blastomere biopsy, preimplantation genetic diagnosis, and additional estrogen support until placental function initiation.

MAIN OUTCOME MEASURE(S)

Normal pregnancy outcome and delivery of a healthy newborn.

RESULT(S)

A female patient with CLAH gave birth to a normal newborn after IVF and preimplantation genetic diagnosis.

CONCLUSION(S)

Pregnancy is feasible in patients with StAR gene mutations, provided that extra estrogens are offered until placental function ensues.

Novel strategy with potential to identify developmentally competent IVF blastocysts

BACKGROUND

Currently there are no markers fully predictive of developmental competence of human IVF embryos. The present study investigated a novel strategy involving blastocyst biopsy and DNA fingerprinting to link developmental competence with gene expression patterns.

METHODS

Patient's blastocysts were biopsied to remove 8-20 trophectoderm (TE) cells for molecular analysis prior to transfer. Biopsy samples were amplified and gene expression was evaluated using microarrays. Sibling TE biopsies and cells from resulting offspring were subjected to DNA fingerprinting to identify which blastocyst(s) in the transfer cohort developed to term.

RESULTS

Blastocyst biopsy did not appear to impair developmental competence. Comparative microarray analysis of cDNA from pooled 'viable' and 'non-viable' TE samples identified over 7000 transcripts expressed exclusively in 'viable' blastocysts. The most significant of these included transcripts involved in cell adhesion and cell communication, key processes that have been associated with mammalian implantation. DNA fingerprinting of three cohorts of sibling blastocysts identified those blastocyst(s) that produced term pregnancies.

CONCLUSIONS

The combination of blastocyst biopsy, microarray gene expression profiling and DNA fingerprinting is a powerful tool to identify diagnostic markers of competence to develop to term. This strategy may be used to develop a rapid diagnostic assay or for refining existing criteria for the selection of the single most viable blastocyst among a cohort developing in vitro.

Blastocyst biopsy versus cleavage stage biopsy and blastocyst transfer for preimplantation genetic diagnosis of beta-thalassaemia: a pilot study

BACKGROUND

Trophectoderm biopsy at the blastocyst stage is an emerging approach in preimplantation genetic diagnosis (PGD). This study aimed to compare genotyping success and implantation rates in PGD cycles for beta-thalassaemia following biopsy at the cleavage versus the blastocyst stage, with transfer of blastocysts.

METHODS

This pilot study included 20 cycles: Group A: 10 cycles, day 3 blastomere biopsy, day 5 transfer; Group B: 10 cycles, day 5 trophectoderm biopsy, day 6 transfer. Standard-assisted reproduction and laser biopsy procedures were used. Biopsied cells were genotyped using real-time PCR multiplexed with fluorescent microsatellite analysis.

RESULTS

In Group A, 131 fertilized eggs developed to 101 embryos suitable for single blastomere biopsy; 76/101 blastomeres were diagnosed (75.2%), 30 unaffected blastocysts were transferred resulting in six pregnancies (eight fetal hearts, 26.7% implantation rate). In Group B, 128 fertilized eggs developed to 53 blastocysts for trophectoderm biopsy (four to five cells), with 50/53 blastocysts diagnosed (94.3%), 21 unaffected blastocysts transferred and 6 pregnancies initiated (10 fetal hearts, 47.6% implantation rate). Overall, nine pregnancies reached >10 weeks gestation and were confirmed unaffected by prenatal diagnosis, with 12 healthy babies born.

CONCLUSIONS

This pilot study suggests that trophectoderm biopsy and blastocyst transfer may be more advantageous than cleavage stage biopsy with respect to outcome of PGD for monogenic diseases.

Blastocyst biopsy versus cleavage stage biopsy and blastocyst transfer for preimplantation genetic diagnosis of β-thalassaemia: a pilot study

BACKGROUND

Trophectoderm biopsy at the blastocyst stage is an emerging approach in preimplantation genetic diagnosis (PGD). This study aimed to compare genotyping success and implantation rates in PGD cycles for beta-thalassaemia following biopsy at the cleavage versus the blastocyst stage, with transfer of blastocysts.

METHODS

This pilot study included 20 cycles: Group A: 10 cycles, day 3 blastomere biopsy, day 5 transfer; Group B: 10 cycles, day 5 trophectoderm biopsy, day 6 transfer. Standard-assisted reproduction and laser biopsy procedures were used. Biopsied cells were genotyped using real-time PCR multiplexed with fluorescent microsatellite analysis.

RESULTS

In Group A, 131 fertilized eggs developed to 101 embryos suitable for single blastomere biopsy; 76/101 blastomeres were diagnosed (75.2%), 30 unaffected blastocysts were transferred resulting in six pregnancies (eight fetal hearts, 26.7% implantation rate). In Group B, 128 fertilized eggs developed to 53 blastocysts for trophectoderm biopsy (four to five cells), with 50/53 blastocysts diagnosed (94.3%), 21 unaffected blastocysts transferred and 6 pregnancies initiated (10 fetal hearts, 47.6% implantation rate). Overall, nine pregnancies reached >10 weeks gestation and were confirmed unaffected by prenatal diagnosis, with 12 healthy babies born.

CONCLUSIONS

This pilot study suggests that trophectoderm biopsy and blastocyst transfer may be more advantageous than cleavage stage biopsy with respect to outcome of PGD for monogenic diseases.

Birth of a healthy infant following trophectoderm biopsy from blastocysts for PGD of beta-thalassaemia major

PGD is a well accepted reproductive choice for couples at genetic risk and involves the diagnosis and transfer of unaffected IVF embryos. PGD for monogenetic diseases is most commonly accomplished by the biopsy of one or two blastomeres from cleavage stage embryos, followed by PCR-based protocols. However, PCR-based DNA analysis of one or two cells is subject to several problems, including total PCR failure, or failure of one allele to amplify. Trophectoderm biopsy at the blastocyst stage enables the removal of more than two cells for diagnosis while being non-invasive to the inner cell mass which is destined for fetal development. The aim of this study was to develop a safe, reliable technique for the biopsy of trophectoderm cells from human blastocysts. This case report demonstrates that removal of trophectoderm cells prior to blastocyst transfer is compatible with implantation and development to term. Here we report successful PGD for beta-thalassaemia following trophectoderm cell biopsy from blastocysts and the birth of a healthy infant.

Blastocyst versus early cleavage embryo transfer: a retrospective analysis of 4,165 transfers

PURPOSE

To compare the clinical outcomes after the transfer of blastocysts versus early cleavage embryos in assisted reproduction technologies (ART).

METHODS

A retrospective analysis of all the ovarian stimulation-in vitro fertilization-embryo transfer cycles performed at the Centre for Human Reproduction, Athens, Greece, between June 1997 and December 2001.

RESULTS

The number of blastocysts transferred per ET was significantly lower compared to that of all early cleavage embryos. The implantation rate of blastocysts was significantly higher compared to that of all other modes of transfer. Clinical pregnancy rate after the transfer of blastocysts was significantly increased compared to that after transfer of any early cleavage embryo. The viable pregnancy rate after the transfer of blastocysts was significantly increased only compared to that after the transfer of day-2 embryos. There were no significant differences regarding the multiple gestation rates among the various modes of transfer.

CONCLUSION

The use of blastocysts in ART is beneficial when compared to that of day-2 embryos and at least comparable to that of day-3 embryos. Blastocyst culture and transfer remains a favourable and promising option in ART.

Triplet pregnancy after oocyte donation in women 46 years of age and older: three case reports

PURPOSE

Presentation of three triplet pregnancies achieved in women 46 years of age and older with the use of donated oocytes.

MATERIAL & METHODS

Two healthy perimenopausal women 46 and 48 years old and one healthy menopausal woman 48 years old, requesting fertility options. All of them followed oocyte donation programs resulting in triplet pregnancy. Maternal as well as perinatal complications, mode of delivery and birth weight are reported.

RESULTS

Three triplet pregnancies were achieved using donated oocytes. Prenatal diagnosis was reassuring. Preterm rupture of membranes, preterm labor and gestational diabetes complicated the pregnancies. Cesarean section was the mode of delivery for all the cases giving birth to nine healthy neonates weighing between 1,130 and 2,450 g. No postpartum complications were encountered.

CONCLUSIONS

Triplet pregnancies achieved with the use of donated oocytes at a very advanced maternal age represent high-risk obstetrical cases. Cautious prenatal evaluation of maternal health and intensive antenatal surveillance are imperative principles allowing the most favorable outcome of these pregnancies.

Empty follicle syndrome associated with ovarian torsion in an in vitro fertilization program

We report a very rare case of ovarian torsion following controlled ovarian stimulation for in vitro fertilization in which no oocytes were obtained at the time of ovum retrieval from the left torsed ovary. The patient was a 33-year-old nulligravida female undergoing controlled ovarian stimulation. On day 14, the patient complained of lower left abdominal pain with nausea. Transvaginal oocyte retrieval from the right ovary was performed. The patient subsequently underwent laparoscopy 6 hours following oocyte retrieval. A portion of the left ovary was observed. The ovary was detorsed at the time of laparoscopy followed by peritoneal lavage.

Clinical pregnancy in a woman of 45 years after gamete intrafallopian transfer (GIFT)

Clinical pregnancy in women over 44 years is rare in assisted reproductive technology (ART). A case of a 45-year-old woman with clinical pregnancy after GIFT is described.

The successful use of hatched blastocysts in assisted reproductive technology

This retrospective study was undertaken to determine the value of blastocyst culture and transfer as a tool in assisted reproductive technology. Six hundred and fifty-five cycles in patients undergoing IVF treatment for infertility were involved. All patients were aged < 40 years. Day-2 embryos were transferred to 427 (group 1) and day-6 embryos (blastocysts) were transferred to 228 patients (group 2). Pronucleate oocytes obtained from IVF were cultured in vitro for 2 or 6 days. One to five embryos were transferred. A total of 10,146 oocytes were retrieved, 6,105 oocytes were fertilized, 2,222 embryos were transferred and 197 clinical pregnancies were achieved in all groups. Blastocystes were transferred to almost 90% of group 2 patients. The pregnancy rate per cycle and implantation rate per transferred embryo was 42.1% and 19.4%, respectively, in the blastocyst group compared to 23.6% and 8.6%, respectively, when embryos were transferred on day 2. Even though in the blastocyst group there was an increased number of oocytes fertilized at the same time there was a significant reduction in the number of embryos being replaced (3.2 vs 3.8). This study demonstrate that transfer of blastocysts increases the success of IVF when compared with day-2 transfers and reduces the number of embryos to be transferred.

Cryopreservation of embryos, blastocysts, and pregnancy rates of blastocysts derived from frozen-thawed embryos and frozen-thawed blastocysts

PURPOSE

To evaluate the development of cryopreserved embryos when thawed and subsequently cultured to the blastocyst stage in comparison to transferring cryopreserved blastocysts.

METHODS

In this retrospective clinical study, we have evaluated 170 cycles in patients undergoing IVF treatment for infertility. Cryopreserved embryos were thawed and were subsequently cultured and transferred at the blastocyst stage. Cryopreserved blastocysts (Day 6) were thawed and transferred immediately.

RESULTS

Five hundred and sixty embryos and 444 blastocysts have been thawed. In the embryos group, the survival rate was 89% while in the blastocyst group the survival rate was 56%. In the embryos group the blastocyst development rate was 24.5%. The implantation rate in the embryos group was 20.6% per group blastocyst transferred compared to 5.3% in the blastocyst group.

CONCLUSIONS

The ability of cryopreserved embryos to develop to blastocysts and their implantation potential does not seem to be greatly affected by the cryopreservation procedure.

Influence of advanced age on the blastocyst development rate and pregnancy rate in assisted reproductive technology

OBJECTIVE

To evaluate the percentage of blastocysts developing, the pregnancy rate, the implantation rate, and the abortion rate in women >40 years of age using a cell-free culture system for the development of viable human blastocysts.

DESIGN

Retrospective clinical study.

SETTING

Private IVF units.

PATIENT(S)

Two hundred ninety-three cycles in patients undergoing IVF treatment for infertility. Sixty-two cycles were in patients > or =40 years of age, and 231 cycles were in patients <40 years of age.

INTERVENTION(S)

Pronucleate oocytes obtained from IVF were cultured in vitro for 5-6 days. One to four embryos were transferred.

MAIN OUTCOME MEASURE(S)

Blastocyst development rate, pregnancy rate, implantation rate, and abortion rate.

RESULT(S)

From 293 cycles, 3,115 pronucleate oocytes were cultured, producing 1,175 blastocysts. In the women >40 years of age, the blastocyst development rate was 22.2%, and in the younger group, the rate was 40.5%. The pregnancy rate and implantation rate in the > or =40-year age group were 21.1% and 8.9%, respectively; corresponding rates in the younger group were 44.6% and 19.9%. The abortion rate was increased for the > or =40-year age group (25% versus 13.3%).

CONCLUSION(S)

Success rates for the development of viable human blastocysts, pregnancy, and implantation decline significantly in women > or =40 years old.

Prospective study of a modified gonadotropin-releasing hormone agonist long protocol in an in vitro fertilization program

OBJECTIVE

To determine if pituitary suppression is still maintained if GnRH agonist (GnRH-a) is discontinued as gonadotropin stimulation is begun in a long protocol.

DESIGN

Prospective, randomized study.

SETTING

An outpatient IVF-GIFT program.

PATIENTS

One hundred seventy-three patients entering an IVF-GIFT program.

INTERVENTIONS

Gonadotropin-releasing hormone agonist in long protocol was either discontinued or continued as gonadotropin stimulation was begun.

MAIN OUTCOME MEASURES

Luteinizing hormone (LH), E2, and P levels, egg numbers, fertilization rate, number of embryos transferred, day of gonadotropin stimulation, and pregnancy rates (PRs).

RESULTS

Pituitary suppression was maintained although GnRH-a was discontinued as gonadotropin stimulation was begun. No spontaneous LH surge was seen, and PRs were increased in the IVF patients.

CONCLUSION

This study indicates that the advantages gained from use of GnRH-a in the long protocol are not compromised by its early discontinuation.

Oocyte donation in menopausal women aged over 40 years

In order to investigate the pregnancy potential of menopausal women over 40 years of age by use of donor eggs, we retrospectively analysed the results of our ovum donation programme. Forty-one clinical pregnancies were established in 134 recipient cycles. The recipients were divided into three age groups (40-43, 44-47 and > or = 48 years) in order to investigate the implantation rate with respect to age. The 30.6% pregnancy rate per embryo transfer cycle and 9.7% implantation rate per embryo appeared to be constant in all age groups studied. Fourteen pregnancies ended in miscarriage, there was one ectopic pregnancy and 25 healthy babies have been delivered. The oldest woman to deliver was 54 years of age. This report highlights the question of age limit for application of the new reproductive technologies, and especially of oocyte donation.