A randomized, non-inferiority trial on the DuoStim strategy in PGT-A cycles

RESEARCH QUESTION

Is the DuoStim strategy an effective alternative to two conventional ovarian stimulation cycles in poor-prognosis patients undergoing preimplantation genetic testing for aneuploidies (PGT-A) to improve euploidy rates and obtain the first euploid embryo in less time?

DESIGN

This randomized controlled trial was performed at IVI Madrid between June 2017 and December 2020 and included 80 patients with a suboptimal profile aged 38 or older undergoing PGT-A cycles. Patients were blindly randomized into two groups: 39 women underwent two ovarian stimulations in consecutive cycles (control group), whereas the double stimulation strategy was applied to 41 women (DuoStim group). The main outcome was the euploidy rate in each group. The secondary outcomes were the time it took to obtain a euploid embryo and the main cycle outcomes.

RESULTS

The baseline characteristics of the patients were similar. No differences were found between the control group and the DuoStim group in the mean days of stimulation (21.3 ± 1.6 versus 23.0 ± 1.4, P = 0.10), total gonadotrophins (4005 ± 450 versus 4245 ± 430, P = 0.43), metaphase II oocytes (8.7 ± 1.8 versus 6.8 ± 1.7, P = 0.15) or euploid embryos obtained (0.8 ± 0.4 versus 0.6 ± 0.4, P = 0.45). The euploid rate per randomized patient (ITT) was 16.1% in the control group versus 22.7% in the DuoStim group, with P-values of 0.371, and the euploidy rate per patient treated was 39.0% versus 45.7% in the control versus DuoStim groups. However, there was a significant difference in the average number of days it took to obtain a euploid blastocyst, favouring the DuoStim group (44.1 ± 2.0 versus 23.3 ± 2.8, P < 0.001).

CONCLUSIONS

The use of the DuoStim strategy in poor-prognosis patients undergoing PGT-A cycles maintains a similar euploidy rate while reducing the time required to obtain a euploid blastocyst.

P-629 A prospective, randomized, placebo-controlled pilot trial investigating telomere length dynamics and ovarian function in patients with diminished ovarian reserve (DOR) after danazol treatment

Study question

Could the administration of a synthetic steroid -danazol- for 3 months reactivate telomerase activity and lengthen telomeres in patients with DOR?

Summary answer

Danazol treatment resulted in an increase of the mean leukocyte telomeric length (TL) but did not improve fertility results after the nearest ovarian stimulation (OS).

What is known already

A primary molecular cause of aging is telomere attrition, given that the accumulation of critically short telomeres leads organ dysfunction. Telomere shortening can be counteracted by the telomerase enzyme, which is responsible for adding deoxyribonucleotides to the linear ends of chromosomes. In patients with DOR, TL in granulosa cells (GCs) is short and telomerase activity is absent, compromising their proliferative capacity. Previuos studies have shown that estrogens can activate telomerase gene transcription through estrogen-responsive elements located in the promoter of the telomerase gene. Therefore, telomere attrition could be reduced in patients with DOR upon telomerase reactivation.

Study design, size, duration

This blinded, placebo-controlled pilot trial was carried out at IVIRMA Madrid clinic between February 2020 and February 2022. The study included 12 patients with DOR (AMH&lt;2ng/ml) which were randomized to danazol or placebo. Patients had 12 visits for health supervision and in vitro fertilization (IVF) treatment. Both groups received danazol (400mg per day) or placebo for 3 months. As control group, 7 patients with normal ovarian reserve (AMH≥2ng/ml) were included.

Participants/materials, setting, methods

In both groups, blood samples were collected prior (PT) and after the treatment (AT). Luteinized GCs and blood samples were obtained during oocyte retrieval, after OS. Leukocytes were purified in Ficoll gradients and then, evaluated for TL and TRF1 levels by Quantitative Fluorescent in Situ Hybridization followed by image acquisition using high resolution confocal microscope. IVF parameters were assessed according to IVIRMA standard protocols.

Main results and the role of chance

A total of 19 women were recruited: 5 in the placebo group (39.8±2.7 years), 7 in Danazol group (41.0±3.0 years) and 7 in control group (39.5±3.0 years). The Danazol group showed a trend to higher mean TL in leukocytes after the treatment (108.2±37.4 versus 99±13.2 a.u., AT vs PT). Interestingly, the percentage of long telomeres also increased with treatment (15.5±0.0 versus 10.8±8.1 a.u., AT vs PT). In addition, there was a decrease of the percentage of critically short telomeres (15.7±0.0 versus 20.8±9.9 a.u. AT vs PT). In the placebo group, mean leukocyte TL and the percentage of long and short telomeres remained constant. These findings suggest that telomeres lengthen after Danazol treatment. The protein levels of TRF1, a shelterin involved in telomere protection, were similar in both Danazol and placebo groups. Regarding fertility, there were no differences in the number of antral follicles, total and MII oocytes, fertilization rate and blastocyst formation. The control group had, as expected, signficantly higher mean follicle number after OS when compared with Danazol (16.0±1.4 and 0.7±0.9, P &lt; 0.0001) and placebo (16.0±1.4 and 5.0±3.8, p = 0.0127) groups, and higher numbers of total oocytes retrieved (p = 0.006; control and Danazol, and p = 0.007; control and placebo).

Limitations, reasons for caution

Firstly, the number of patients included in the study is limited due to strict inclusion/exclusion criteria. Secondly, because follicle growth can take up to 150 days, danazol effects could be noticeable at later OS and not only in the first OS, which was the only one studied here.

Wider implications of the findings

Since telomeres seem to elongate in blood samples after Danazol treatment in DOR patients, we could hypothesize that this may have a positive impact for general health, including the ovaries. Thus, danazol therapy might help improving IVF outcomes, perhaps at later OS.

Trial registration number

NCT04058678

P-374 Serum progesterone levels on the of embryo transfer in replacement cycles (HRT-ET): soft capsules vs suppositories may make a difference

Study question

Are there differences in serum progesterone levels when vaginal progesterone is administered in soft capsules vs suppositories in HRT-ET?

Summary answer

Mean serum levels of progesterone in embryo replacement cycles are higher when progesterone suppositories are used instead of soft capsules.

What is known already

Serum levels of progesterone on the day of the embryo transfer has captured recent attention, as it may vary among patients and different vaginal progesterone formulations. Previous studies have suggested that natural micronized vaginal progesterone induces a comparable decidual transformation and clinical pregnancy rates to vaginal progesterone gel. However, no data exists comparing suppositories versus soft capsules.

Study design, size, duration

Prospective, observational, single center study to compare serum progesterone levels on the day of the embryo transfer in women undergoing HRT-ET and being treated with vaginal progesterone in capsules or suppositories. Also, a patient satisfaction questionnaire was given to women participating in the study to investigate patient experience. Sample size calculation estimated 50 patients per group needed for a = 0.05 and power 90%, considering standard deviation of 5.1.

Participants/materials, setting, methods

From April to October 2021, 100 patients undergoing HRT-ET were recruited. Only one type of progesterone was administered. 50 patients received soft capsules (Progeffik©, Utrogestan©) and the other half suppositories (Cyclogest©). After estradiol priming for 10-12 days and once confirmed that endometrial thickness was &gt;7mm, 400 mg vaginal progesterone was started b.i.d. Blood was drawn on the day of embryo transfer by venipuncture and progesterone levels in blood were evaluated.

Main results and the role of chance

Mean serum levels of progesterone were significantly higher when suppositories were compared with soft capsules (16.2 ± 7 vs 12.5 ± 5.2 ng/ml, p = 0.0034). According to our previous studies we considered an adequate cut-off of progesterone of 8.8 ng/ml, and patients with a suboptimal serum level of progesterone were supplemented with subcutaneous progesterone. Of those patients receiving suppositories, only 6 out 50 (12%) required subcutaneous supplementation, whereas it was needed in 12 out of 50 (24%) women receiving soft capsules. No differences were observed in pregnancy rate (70% vs 50%) or ongoing pregnancy rate (48% vs 36%).

Regarding patient satisfaction, no differences were observed in the frequency of itching, burning, leakage of medication or drowsiness between groups.

Limitations, reasons for caution

We should consider the limited sample size and the study design, not randomized, before generalizing the results observed.

Wider implications of the findings

In luteal support of frozen embryo replacement cycles, vaginal progesterone suppositories yields superior progesterone serum levels than soft capsules.

Trial registration number

Not applicable

O-111 The DuoStim strategy shortens the time to obtain an euploid embryo in poor prognosis patients: a non-inferiority, randomized controlled trial

Study question

Is there any difference in the time to obtain euploid embryos from poor prognosis patients who performed two conventional cycles versus double stimulation (DuoStim) in the same cycle?

Summary answer

DuoStim showed similar ovarian response and in vitro fertilization (IVF) laboratory outcomes while shortening the time to obtain an euploid embryo in poor prognosis patients.

What is known already

Several waves of cyclic development of antral follicles within the same menstrual cycle have been demonstrated. Likewise, it has been shown that oocytes obtained from luteal phase ovarian stimulation (OS) have similar competence than those obtained in the follicular phase OS. Often, some patients require sequential OS in order to obtain more oocytes and increase their chances to reach embryo transfer. Thus, the DuoStim strategy could be an attractive alternative to reduce the time-to-pregnancy. However, prospective data and randomized trials that validate this strategy are lacking.

Study design, size, duration

We conducted a prospective, randomized controlled trial at our institution from[MCM1] [JAGV2] January 2017 to December 2020. A total of 80 poor prognosis patients aged over 38 years undergoing PGT-A were enrolled in two groups: 39 patients did two OS in consecutive cycles (control) whereas 41 women underwent two OS in the same menstrual cycle (DuoStim).

Participants/materials, setting, methods

Poor prognosis was defined as suboptimal responders. The primary outcome was the time needed to obtain an euploid embryo. The secondary outcomes were duration of stimulation, dose of gonadotropins, oocyte maturity rate, fertilization and blastocyst formation rates. Variables were expressed as mean ± standard deviation. Statistical analyses was performed by ANOVA and Chi-square tests, as appropriate. Differences were considered significant when p-value &lt; 0.05.

Main results and the role of chance

The patients’ baseline characteristics were similar between groups. We did not find any difference in the mean days of stimulation between the control and the DuoStim group (21.3 ± 1.6 vs. 23 ± 1.4, p = 0.105), nor in the amount of gonadotropin required (4005 ± 450 vs. 4245 ± 430, p = 0.43), number of MII oocyte (8.7 ± 1.8 vs. 6.8 ± 1.7, p = 0.159), blastocyst rate (51.4% vs. 34.8%, p = 0.113) and the number of euploid embryos (0.8 ± 0.4 vs. 0.6 ± 0.4, p = 0.45). However, there was a significant difference in the average number of days until reaching an euploid blastocyst, favoring the DuoStim group (44.1 ± 2 vs. 23.3 ± 2.8, p &lt; 0.001). Comparing the follicular versus the luteal phase within the DuoStim group, the only difference detected concerns to the mean days of stimulation (10.3 ± 0.8 vs. 12.7 ± 0.9, p &lt; 0.001). We also observed a trend towards a higher fertilization (38.1% vs. 61.8%, p = 0.02) and blastulation rate (23% vs. 53%, p = 0.03) in the luteal phase of the DuoStim cycle.

Limitations, reasons for caution

The major limitation is related to the limited sample size, as it limits our power analysis (70%). On the other hand, it is one of the first randomized prospective pilot trial that compared the efficiency of performing two consecutive ovarian stimulation in different menstrual cycles with the DuoStim strategy.

Wider implications of the findings

This study clearly showed that the DuoStim protocol is not inferior to the conventional stimulation in terms of ovarian response and laboratory outcomes. Moreover, the DuoStim reduces the time to obtain an euploid embryo in poor prognosis patients, which is of great clinical utility.

Trial registration number

NCT03291821

Acceptability and adoption of clinical practice guidelines and treatment protocols on preeclampsia/eclampsia in the Dominican Republic

Objective

Estimate the acceptability and adoption by health care workers of clinical practice guidelines and treatment protocols for women with preeclampsia/eclampsia and identify the facilitating factors and barriers to their implementation.

Methods

A qualitative study was conducted, using semi-structured interviews and focus groups in five maternity hospitals. Interviews were compiled for analysis, and barriers and facilitators were characterized.

Results

Seventy health professionals (52 female and 18 male) participated, representing different levels of the health system. The majority of workers and managers were aware of the existence and content of clinical practice guidelines (CPGs) for preeclampsia/eclampsia, especially the participants with more time in the health service. With respect to facilitating factors, both medical and nursing staff were positive about continued development and implementation of high-quality CPGs. There was consensus that limitations exist, especially with respect to a lack of the necessary medicines, supplies, and equipment to meet and implement the established recommendations.

Discussion

The results of the study show the need to strengthen strategies that help close the gap between research and public policy. Studies suggest that research should focus on users, policymakers, and decisionmakers in the health system. The actors in the Dominican health system recognize the GRADE methodology as an appropriate instrument for the development and implementation of CPGs. Implementation barriers require systemic and comprehensive approaches.

[Acceptability and adoption of clinical practice guidelines and treatment protocols on preeclampsia/eclampsia in the Dominican RepublicAceitabilidade e adoção de diretrizes de prática clínica e protocolos de atenção para pré-eclâmpsia e eclâmpsia na República Dominicana]

Objetivo.

Estimar la aceptabilidad y adopción de las guías de prática clínica (GPC) y protocolos de atención a la mujer con preeclampsia-eclampsia por parte del personal prestador de los servicios de salud, e identificar los factores facilitadores y las barreras para su implementación.

Métodos.

Se desarrolló un estudio cualitativo por medio de entrevistas semiestructuradas y grupos focales en cinco maternidades. Se recopilaron las entrevistas para su análisis y se caracterizaron las barreras y facilitadores.

Resultados.

Participaron 70 profesionales de la salud (52 de sexo femenino y 18 de sexo masculino) que se desempeñan en distintos niveles del sistema de salud, participaron. La mayoría de los prestadores y gerentes conocen la existencia de las GPC de eclampsia-preeclampsia y su contenido, sobre todo los participantes con más tiempo en el servicio. Para los facilitadores, se estableció una valoración positiva entre el personal médico y de enfermería ante el proceso de continuar con la elaboración e implementación de GPC de alta calidad. Hubo consenso en cuanto a la existencia de limitaciones, sobre todo, por la falta de medicamentos, insumos y equipos requeridos, para cumplir y aplicar las recomendaciones formuladas.

Discusión.

Los resultados del estudio exponen la necesidad de fortalecer estrategias que ayuden a cerrar la brecha entre la investigación y la política pública. Estudios fundamentan la investigación en priorizar la atención a los usuarios, y los encargados de formular políticas y los tomadores de decisiones en el sistema de salud. Los actores del sistema de salud dominicano reconocen la metodología GRADE como un instrumento apropiado para la formulación e implementación de GPC. Las barreras de implementación requieren de abordajes sistémicos e integrales.

Genetic transformation of selected mature cork oak (Quercus suber L.) trees

A transformation system for selected mature cork oak (Quercus suber L.) trees using Agrobacterium tumefaciens has been established. Embryos obtained from recurrent proliferating embryogenic masses were inoculated with A. tumefaciens strains EHA105, LBA4404 or AGL1 harbouring the plasmid pBINUbiGUSint [carrying the neomycin phosphotransferase II (nptII) and beta-glucuronidase (uidA) genes]. The highest transformation efficiency (4%) was obtained when freshly isolated explants were inoculated with A. tumefaciens strain AGL1. Evidence of stable transgene integration was obtained by PCR for the nptII and uidA genes, Southern blotting and expression of the uidA gene. The transgenic embryos were germinated and successfully transferred to soil.

Vegetative propagation of Quercus suber L. by somatic embryogenesis. I. Factors affecting the induction in leaves from mature cork oak trees

Somatic embryogenesis was induced in expanding leaves from epicormic shoots forced to sprout from segments of branches collected from several hundred-year-old cork oak trees. Following a basic protocol previously defined for leaves taken from seedlings of this species, several factors were studied to improve the response. The induction frequency was significantly higher when the length of exposure to growth regulators was increased from 7 to 30 days. The combined application of NAA and BAP was essential for induction. Although both regulators had a very significant influence, their interaction was not significant, suggesting independent roles. Leaf size had a crucial effect, because beyond a certain threshold, embryogenesis could not be obtained. Embryogenic lines were maintained via repetitive embryogenesis on hormone-free medium for more than 2 years.

Vegetative propagation of Quercus suber L. by somatic embryogenesis. II. Plant regeneration from selected cork oak trees

The regeneration of somatic seedlings from selected 100-year-old cork oak trees is reported. The induction of somatic embryogenesis from leaves of epicormic shoots was significantly affected by genotype, harvesting time and their interaction. Leaves from all five selected trees produced somatic embryos when the segments of branches used as sources of epicormic shoots were collected in May. Genotype, but not the level of photosynthetically active radiation, affected the proliferation of the embryogenic lines and the number of detachable embryos that could be obtained from them. Genotype also affected several steps leading to conversion of somatic embryos, from germination to complete acclimatisation of somatic seedlings. Almost 40% of the somatic embryos from all lines germinated, showing coordinated root and shoot growth. Although the mean percentage of recovery for the whole process was low, plants could be regenerated from four of the five trees tested.

Histology of Organogenic and Embryogenic Responses in Cotyledons of Somatic Embryos of Quercus Suber L

In cork oak (Quercus suber L.), recurrent embryogenesis is produced in vitro through autoembryony without exogenous plant growth regulators (PGRs); secondary embryos appear on the embryo axis but seldom on cotyledons. Focusing mainly on the histological origin of neoformations, we investigated the influence of the embryo axis and exogenous PGRs on the embryogenic potential of somatic embryo cotyledons. Isolated cotyledons of somatic embryos became necrotic when cultured on PGR-free medium but gave secondary embryos when cultured on media containing benzyladenine and naphthaleneacetic acid. Cotyledons of cork oak somatic embryos are competent to give embryogenic responses. Isolated cotyledons without a petiole showed a lower percentage of embryogenic response than did those with a petiole. In petioles, somatic embryos arose from inner parenchyma tissues following a multicellular budding pattern. Joined to the embryo axis, cotyledons did not show morphogenic responses when cultured on PGR-free medium but revealed budlike and phylloid formations when cultured on medium with PGRs. The different morphogenic behavior displayed by somatic cotyledons indicates an influence of the embryo axis and indicates a relationship between organogenic and embryogenic regeneration pathways.

B cell participation in the recursive selection of T cell repertoires

Normal BALB/c mice produce 2,4,6-trinitrophenyl (TNP)-I-Ad specific T helper (Th) cells expressing a receptor heterodimer which share with anti-TNP antibodies an idiotope defined by the F6(51) anti-idiotypic antibody. Expression of this Th idiotype is controlled by major histocompatibility complex and immunoglobulin heavy chain-linked genes and results from antibody-dependent selection of T cell repertoires (Martinez-A. et al., Eur. J. Immunol. 1986. 16: 417). We now present evidence for the recursive nature of T----B cell repertoire selection and suggest that perinatal B cells, present in adult peritoneal cavity, operate in the early phases of this process. Thus, the Th idiotype is absent in BALB/c mice which are either suppressed from birth with anti-mu antibodies, or reconstituted with autologous bone marrow after lethal irradiation as adults. Supplementation of bone marrow reconstitution with syngeneic Thy-1-, Ly-1+ peritoneal B cells, however, selects Th cell repertoires that are undistinguishable from normal mice as to expression of the F6(51) clonotype. This effect is lost after depletion of Ly-1+ cells in the reconstituting Thy-1- peritoneal cell population. Interestingly, large in vivo "naturally" activated Ly-1- splenic B cells can also reconstitute Th idiotype expression if they are isolated from normal, but not from athymic, nude donors. However, transfer of normal large splenic T cells to adult nude mice "educates" the splenic "large B cell" compartment in these animals such that they acquire the ability to recursively select, upon transfer to bone marrow reconstituted recipients, the Th clonotype.(ABSTRACT TRUNCATED AT 250 WORDS)

A common idiotope on T cell receptors and antibodies expressed in the absence of network selection

The monoclonal antibody F6(51), directed to an idiotope of MOPC 460-like anti-1,4,6-trinitrophenl (TNP) antibodies produced in IgHa mouse strains, identifies in helper T cells from C57BL/6 (IgHb) mice with (4-hydroxy-3-nitrophenyl)acetyl (NP)-self specificity, a clonotypic determinant functionally and biochemically associated with the specific T cell receptor. The expression of this antibody-related T cell clonotype in C57BL/6 mice, although "recurrent", is independent of network selection, as shown by its presence in B mice suppressed from birth with anti-mu antibodies, and in IgH-congenic mouse strains. These results indicate aleatory cross-reactivity between T cell receptors and antibodies and command caution in network interpretations for "idiotype sharing".

Turning (Ir gene) low responders into high responders by antibody manipulation of the developing immune system

The ability of helper T cells directed against trinitrophenyl-modified syngeneic spleen cells to recognize low-hapten densities on target cells is under major histocompatibility complex-linked Ir gene control. Thus, BALB/c (H-2d) mice are low responders while H-2 congenic BALB.C3H (H-2k) mice are high responders. Immunization of adult BALB/c mice with the monoclonal antibody F6(51), directed to shared idiotopes by anti-trinitrophenyl antibodies and clonal receptors on anti-trinitrophenyl-self helper T cells, leads to the production of high titers of circulating idiotype, has no influence on helper T cell idiotypic profiles, but shifts to a high-responder phenotype the ability of helper T cells to recognize low-hapten densities. These effects on Ir gene phenotype are even more striking in untreated progenies from F6(51)-immunized BALB/c females, which are better responders than genetically high-responder BALB.C3H mice, although completely different in the expression of the F6(51)-defined clonotype. The general significance of these findings on Ir gene-directed T-cell repertoire selection is discussed, for they constitute formal evidence against antigen-presentation as a mechanism of Ir gene effects and strong support for the importance of maternal influences on the development of T-cell repertoires.