Taking a closer look at the key performance indicators in an assisted reproductive technology laboratory: a guide for reproductive professionals

Over the years, laboratories performing assisted reproductive technologies have been tasked with a growing number of procedures of increased complexity. New technologies, including hardware and software innovations, are constantly evolving, and being evaluated as potential tools to improve laboratory and clinical outcomes. The ART laboratory plays a crucial role in fertility treatments and, therefore, it is often under intense scrutiny with regards to performance and success rates. As the reproductive medicine field strives to deliver improved clinical outcomes to patients, IVF clinics - including the ART laboratories - are required to monitor their performance and seek improvement in the many different aspects related to patient care. Key Performance Indicators (KPIs) and benchmarking are important tools to support performance monitoring and quality improvement processes. The concept and potential benefits of KPI utilization is generally accepted. However, its adoption poses some challenges that may discourage ART practices from pursuing it as part of their Quality Management Systems (QMS). Properly selecting and using KPIs will allow laboratories to successfully manage their performance and set up realistic target goals to consistently deliver high rates. Existing literature can guide reproductive medicine professionals to embark on their journey to successfully select, implement, and manage KPI and benchmarking as part of their ART programs. This article discusses the concept and essentials of KPI and benchmarking applied to the ART laboratory, as well as potential challenges and how to overcome them.

Oocyte quality and embryo selection strategies: a review for the embryologists, by the embryologists

With the advance of assisted reproduction techniques, and the trend towards blastocyst culture and single embryo transfer, gamete and embryo assessment have gained greater importance in ART treatment. Embryo quality depends mainly on gamete quality and culture conditions. Oocyte maturity identification is necessary in order to plan fertilization timing. Mature oocytes at the metaphase II stage show a higher fertilization rate compared to immature oocytes. Morphology assessment is a critical yet challenging task that may serve as a good prognostic tool for future development and implantation potential if done effectively. Various grading systems have been suggested to assess embryos at pronuclear, cleavage, and blastocyst stages. By identifying the embryo with the highest implantation potential, it is possible to reduce the number of embryos transferred without compromising the chances of a successful pregnancy. Apart from the conventional morphology assessment, there are several invasive or non-invasive methods for embryo selection such as preimplantation genetic testing, morphokinetics, proteomics, metabolomics, oxygen consumption, and measurement of oxidative stress in culture medium. Morphokinetics is a method based on time-lapse technology and continuous monitoring of embryos. In this review, we aim to describe and compare the most effective and widely used methods for gamete and embryo assessment as well as embryo selection.

An expert commentary on essential equipment, supplies and culture media in the ART laboratory

The ART laboratory is a complex system designed to sustain the fertilization, survival, and culture of the preimplantation embryo to the blastocyst stage. ART outcomes depend on numerous factors, among which are the equipment, supplies and culture media used. The number and type of incubators also may affect ART results. While large incubators may be more suitable for media equilibration, bench-top incubators may provide better embryo culture conditions in separate or smaller chambers and may be coupled with time-lapse systems that allow continuous embryo monitoring. Microscopes are essential for observation, assessment, and micromanipulation. Workstations provide a controlled environment for gamete and embryo handling and their quantity should be adjusted according to the number of ART cycles treated in order to provide a steady and efficient workflow. Continuous maintenance, quality control and monitoring of equipment is essential and quality control devices such as the thermometer, and pH-meter are necessary to maintain optimal culture conditions. Tracking, appropriate delivery and storage conditions, and quality control of all consumables is recommended so that the adequate quantity and quality is available for use. Embryo culture media have evolved: preimplantation embryos are cultured either by sequential media or single-step media that can be used for interrupted or uninterrupted culture. There is currently no sufficient evidence that any individual commercially-available culture system is better than others in terms of embryo viability. In this review, we aim to analyse the various parameters that should be taken into account when choosing the essential equipment, consumables and culture media systems that will create optimal culture conditions and provide the most effective patient treatment.

Optimizing embryological aspects of oocyte retrieval, oocyte denudation, and embryo loading for transfer: a state of the art review

Oocyte retrieval, oocyte denudation, and embryo transfer are crucial processes during assisted reproduction (ART). Air quality in the ART laboratory, temperature, pH of the media used and the time interval between oocyte retrieval and insemination are all critical factors. Anesthesia is required for oocyte retrieval, however evidence regarding the potential impact of different methods (general anesthesia, conscious sedation, and local anesthesia) on the clinical outcomes is unclear. The optimal timing of oocyte denudation following retrieval has not been established. Regarding the mechanical denudation process, there is a lack of evidence to demonstrate the safest minimum inner diameter of denuding pipettes used to complete the removal of granulosa cells surrounding the oocytes. During embryo transfer, many clinics worldwide flush the catheter before embryo loading, in an attempt to potentially rinse off any toxic agents; however, there is insufficient evidence to show that flushing the embryo transfer catheter before loading increases the success of ART outcome. Considering the serious gaps in knowledge in ART practice, the aim of this review is to provide an updated overview of the current knowledge regarding the various steps and techniques involved in oocyte retrieval, oocyte denudation, and embryo loading for transfer.

HIV-associated wasting prevalence in the era of modern antiretroviral therapy

OBJECTIVE

To understand the prevalence of HIV-associated wasting (HIVAW) in the United States.

DESIGN

Medical and pharmacy claims study using IBM MarketScan Commercial, Medicare Supplemental and Medicaid Databases.

METHODS

Study period: July 2012-September 2018 (first HIV diagnosis claim = HIV index date). People with HIV (PWH) were excluded if they were aged less than 18 years, had any malignancy claim or had less than 6 months of enrollment data pre or post-HIV index date. HIVAW was defined by proxy using claims for weight loss-related diagnoses, appetite stimulant/nontestosterone anabolic agents or enteral/parenteral nutrition. Prevalence was reported cumulatively, by insurance type and antiretroviral therapy (ART) pharmacy claims (defined as ≥1 pharmacy claim of any ART within 12 months post-HIV index date). Statistical analysis assessed factors potentially associated with HIVAW.

RESULTS

The study population comprised 42 587 PWH (64.6% male, mean age 44 years, 67.5% on Medicaid, 63.9% on ART). Cumulative HIVAW prevalence (2012-2018) was 18.3% (n = 7804) for all PWH (17.9% on ART, 19.1% not on ART). HIVAW prevalence by payer was 7.5% for Commercial and Medicare Supplemental and 23.5% for Medicaid. The strongest associations with the likelihood of meeting the definition of HIVAW were for individuals with Medicaid and hospitalization(s) post-HIV index date; race and ART status were not associated.

CONCLUSIONS

Findings suggest HIVAW remains prevalent in PWH. ART use was not found to be associated with HIVAW. HIVAW was highest among those with Medicaid coverage or any hospitalization(s). Further research is needed to better understand additional factors associated with and contributing to HIVAW.