High initial β-hCG predicts IVF outcomes accurately and precludes the need for repeated measurements

This study evaluated β-human chorionic gonadotropin (hCG) changes during the early period of pregnancy in an attempt to predict successful pregnancy outcomes in ART. It determined the median values of the β-hCG and the 2-day β-hCG increments of clinical vs biochemical pregnancies. The results of fresh day 3 embryo, frozen day 3 embryo, and frozen day 5 embryo transfers were evaluated. The cutoff values of β-hCG and the 2-day increments predicting clinical pregnancy and delivery were determined. All women who underwent embryo transfer and had a singleton pregnancy from January 2017 to December 2019 were included. As expected, clinical pregnancies had higher initial median β-hCG values compared to biochemical pregnancies (fresh day 3 (400 vs 73 mIU/mL), frozen day 3 (600 vs 268.5 mIU/mL) and frozen day 5 (937 vs 317 mIU/mL)). Nonetheless, the abortion rate was significantly lower in the group with β-hCG above the cutoff values in fresh (141 mIU/mL) and frozen (354.5 mIU/mL) cleavage stage transfers (17.2% vs 44%, P < 0.001 and 18.5% vs 38%, P = 0.003, respectively). Blastocyst transfers resulted in higher median initial β-hCG compared to cleavage embryo transfers (937 vs 600 mIU/mL), and the initial β-hCG values from frozen cleavage embryos were higher compared to fresh cleavage embryos (600 vs 400 mIU/mL). Earlier implantation in frozen cycles may be caused by freezing-thawing procedures. Moreover, in fresh cycles, negative effects of the hormonal milieu of fresh cycles may delay implantation. These results indicate that high initial β-hCG and high 2-day β-hCG increments demonstrated better outcomes, including more clinical pregnancies and fewer abortions.

Cleavage Patterns of 9600 Embryos: The Importance of Irregular Cleavage

This prospective, observational study investigated the incidence of irregular cleavage (IRC) among human embryos and its influence on IVF treatment outcomes. It included 1001 women who underwent 1976 assisted reproduction treatments during 2016-2021 in a single IVF clinic. Embryo morphokinetics were analyzed and evaluated for the association between IRC and women's characteristics, treatment characteristics, and pregnancy outcomes. The incidence of IRC was 17.5% (1689/9632 embryos). Of these, 85% of the embryos had one IRC, 15% had multiple IRC and 35% of IRC events occurred during the embryo's first cell cycle. IRC embryos were found to correlate with male factor (p = 0.01) and higher ICSI rate (p = 0.01). Age, BMI, parity, basal FSH level, stimulation protocol, and number of retrieved oocytes did not differ between groups. Embryos with early IRC or more than one IRC had lower blastulation rates (p = 0.01 for each). Fresh cycles with IRC embryos had a lower clinical pregnancy rate (p = 0.01) and embryos with early IRC had a lower live birth rate (p = 0.04) compared to embryos without IRC. Frozen transfer cycles of blastocyst embryos, with or without IRC, had comparable results. In conclusion, the number of abnormal cleavage events and their timing are important factors in the prognosis of the developing human embryo.

Ovulatory-cycle frozen embryo transfer: spontaneous or triggered ovulation and the impact of LH elevation at hCG triggering

The effect of the luteinizing hormone (LH) elevation before the human chorionic gonadotropin (hCG) trigger in ovulatory frozen-thawed embryo transfer (Ovu-FET) cycles has not been determined. We aimed to investigate whether triggering ovulation in Ovu-FET cycles affects the live birth rate (LBR), and the contribution of elevated LH at the time of hCG trigger. This retrospective study included Ovu-FET cycles performed in our center from August 2016 to April 2021. Modified Ovu-FET (hCG trigger) and true Ovu-FET (without hCG trigger) were compared. The modified group was divided according to whether hCG was administered, before or after LH increased to > 15 IU/L and was twice the baseline value. The modified (n = 100) and true (n = 246) Ovu-FET groups and both subgroups of the modified Ovu-FET, those who were triggered before (n = 67) or after (n = 33) LH elevation, had comparable characteristics at baseline. Comparison of true vs. modified Ovu-FET outcomes revealed similar LBR (35.4% vs. 32.0%; P = 0.62), respectively. LBR were similar between the modified Ovu-FET subgroups regardless of the hCG trigger timing (31.3% before vs. 33.3% after LH elevation; P = 0.84). In conclusion, LBR of Ovu-FET were not affected by hCG trigger or whether LH was elevated at the time of hCG trigger. These results add reassurance regarding hCG triggering even after LH elevation.

Non-invasive evaluation of embryos using mid-infrared attenuated total reflection spectrometry of incubation medium: a preliminary study

RESEARCH QUESTION

Can mid-infrared attenuated total reflection (MIR ATR) spectroscopy combined with machine learning methods be used as an additional tool to predict embryo quality and IVF treatment outcomes?

DESIGN

Spent culture media was collected and analysed. MIR ATR absorbance spectra were measured using an ALPHA II spectrometer equipped with an attenuated total reflection (ATR) spectrometry accessory. Patient and treatment data and results were collected and analysed in combination with machine learning techniques to identify possible correlations. The main outcome measures were to define the characteristics of absorbance spectra of spent culture media and to distinguish the difference in absorbance between top- and low-quality embryos, day 3 and day 5 embryos and implanting embryos versus non-implanting embryos.

RESULTS

Spent culture media of 227 embryos was collected and analysed. Absorbance peaks in the culture media were different between day 3 and day 5 embryos. Moreover, significant differences in P-values, spanning from 0.014 to 0.044 in absorbance peaks for day 3 embryos and 0.024 up to 0.04 for day 5 embryos, were seen between implanting and non-implanting embryos. Machine learning techniques offered a pregnancy prediction value of 84.6% for day 3 embryos.

CONCLUSIONS

MIR ATR may offer an additional parameter for better selection of embryos based on the spectrometric absorbance and secretions of metabolites in the culture media.

The Impact of Lifestyle on Sperm Function, Telomere Length, and IVF Outcomes

Many risk factors can potentially influence sperm quality. Telomeres confer stability on the chromosome and their dysfunction has been implicated in conditions such as cancer, aging, and lifestyle. The impact of lifestyle on sperm cell telomeres is unclear. The objectives of this study were to evaluate the impact of lifestyle behaviors on telomere length in sperm and to follow the correlation with pregnancy outcomes in patients undergoing in vitro fertilization (IVF). In this prospective observational study, sperm was analyzed for telomere length (TL). Men were asked to report lifestyle behaviors including occupation (physical or sedentary), smoking duration and amount, physical activity, dietary habits, and where they keep their cellular phone (bag, pants, or shirt pocket). Correlations among semen analysis, TL, men's habits, and embryo quality and pregnancy outcomes were evaluated. Among 34 patients recruited, 12 had longer TL and 13 shorter TL. Sperm motility was negatively correlated with TL (Pearson correlation = -.588, p = .002). Smoking adversely affected native sperm motility (53% motility in nonsmokers vs. 37% in smokers; p = .006). However, there was no significant impact on TL. The group with longer telomeres demonstrated significant association with healthy diet (10/12 vs. 6/13; p = .05) and a trend toward more sports activity, weekly (16/84 vs. 7/91; p = .04) compared with the shorter telomeres group. This study suggests that lifestyle, healthy diet, and sports activity are associated with long telomeres in sperm. Sperm quality is also influenced by patients' habits. The study strongly recommends maintaining a healthy lifestyle to preserve general health and fertility.

Does mRNA SARS-CoV-2 vaccine in the follicular fluid impact follicle and oocyte performance in IVF treatments?

Problem

The COVID‐19 pandemic has many clinical manifestations. Rapid vaccine development raised concerns and speculations about future fertility outcomes and vaccine safety. We evaluated the effect of Pfizer‐BioNTech mRNA SARS‐CoV‐2 vaccine on IVF treatment, oocyte and embryo quality, and pregnancy outcomes.

Method of study

This prospective, observational cohort study was conducted in a referral IVF Unit, 3/2021‐5/2021. We aimed to recruit all women undergoing IVF/ICSI cycles from 3/1–4/30/2021, 2‐8 weeks after the second vaccination, and to analyze 50–60 samples in the 2‐month period. Patients were categorized according to serum antibody levels: positive for spike (S), positive for nucleotide (N), or negative for both. On the day of ovum pick‐up, follicular fluid and blood samples were analyzed for anti‐nucleotide (anti‐N) antibodies, and anti‐spike (anti‐S) antibodies, hormonal profile, C‐reactive protein (CRP) and other metabolic parameters.

Results

Of 59 women enrolled, 37 reported being vaccinated and 22 were not. We found 97% correlation between anti‐S and anti‐N in the blood and the follicular fluid. Follicular fluid was analyzed based on antibody categorization. All IVF treatment parameters in the follicular fluids and serum were comparable, except CRP was significantly elevated among patients with anti‐N antibodies (2.29 [1.42–6.08] vs. 4.11 [1.62–5.75] vs. 1.44 [.36–8.33]; p < .001). Pregnancy outcomes were comparable (44% vs. 33% vs. 50%; p = .97).

Conclusion

mRNA SARS‐CoV‐2 vaccine did not appear to affect treatment outcomes or ovarian reserves in the subsequent IVF cycle.

Male genome influences embryonic development as early as pronuclear stage

BACKGROUND

Impaired paternal genome expression may cause poor embryonic development after in vitro fertilization (IVF).

OBJECTIVE

To evaluate the expression of male infertility on embryo morphokinetics using a time-lapse incubator and its impact on IVF cycles.

MATERIALS AND METHODS

This retrospective cohort study followed patients from January 2017 to August 2019. Patients were divided according to the cause of infertility to male factor (study group) and unexplained infertility (control group) and further subdivided according to the severity of male infertility.

RESULTS

A cohort of 462 patients who underwent IVF cycles, with a total of 3,252 embryos was evaluated. Intracytoplasmic sperm injection (ICSI) was conducted more often in the study group compared to the control group (94% vs. 47%, p < 0.0001) and more embryos were discarded (47% vs. 43%, p = 0.016). Treatment outcomes were comparable in both groups regardless of the severity of male infertility. T3-T5 had a significant impact on embryo quality and more transfer and freeze compared to discard. Maternal age, number of aspirated oocytes, BMI, protocol used, and faster time to T3, T6 were significant in increasing chances of achieving pregnancy.

CONCLUSION

The paternal genome may have an earlier impact on embryo development than previously surmised and may also account for faster morphokinetics. Faster embryo cleavage in male infertility IVF-ICSI cycles may contribute to outcomes comparable to other causes of infertility, in terms of embryo quality and clinical pregnancy rate, despite lower sperm quality, even in cases of severe Oligo-terato-Astheno spermia (OTA).

P–748 Diode laser hysteroscopic metroplasty for dysmorphic uterus: a pilot study

Study question

Whether diode laser hysteroscopic metroplasty for dysmorphic uterus is a safe and efficacious procedure and its effect on reproductive outcomes.

Summary answer

Diode laser hysteroscopic metroplasty is a safe and effective procedure for infertile women with dysmorphic uterus with comparable results to those reported in the literature.

What is known already

A T-shaped uterine anomaly is categorized by the ESHRE/ESGE consensus as dysmorphic uterus class U1a, characterized by an abnormal hypoplastic uterine cavity. A Y-shaped uterus is a dysmorphic uterus with a fundal subseptum. Dysmorphic uteri are associated with infertility, recurrent implantation failure (RIF), recurrent pregnancy loss (RPL), and adverse pregnancy outcomes. According to several studies, it seems that hysteroscopic metroplasty may improve the chances of conception and live birth. Previous studies described the procedure using bipolar systems, monopolar needle or scissors. The purpose is to achieve a uterine cavity of normal shape and volume by cutting the thickened lateral walls.

Study design, size, duration

This was a retrospective pilot study with a prospective follow-up. We retrospectively evaluated all cases operated between February 2018 to February 2020, at Hillel Yaffe Medical Center, Hadera, Israel. Reproductive outcomes for women who underwent the procedure were followed until September 2020. Pregnancies that were ongoing on September 2020 were followed until January 31st 2021.

Participants/materials, setting, methods

Nulliparous women with a diagnosis of infertility or RPL, who were diagnosed with dysmorphic uterus by three-dimensional ultrasound (3D-US) and underwent diode laser hysteroscopic metroplasty were included. All the metroplasties were done in one tertiary center by the same specialist. Reproductive outcomes were evaluated retrospectively and prospectively for a total follow-up time of 32 months. Reproductive performances before and after metroplasty were compared where possible.

Main results and the role of chance

Twenty-five women underwent diode laser hysteroscopic metroplasty for dysmorphic uterus in our institute. No perforations, excessive bleeding, or other complications were encountered during the procedures. Follow-up hysteroscopy and 3D-US were satisfactory in all cases 2 months after the metroplasty. A total of 15 nulliparous women returned to fertility treatments afterwards, among whom 9 conceived (60% pregnancy rate). Their infertility period before the procedure was 56.6 ± 36.1 months. The duration between the metroplasty to pregnancy was 5.2 ± 3.5 months. The rate of deliveries and ongoing pregnancies (pregnancies beyond 20 weeks of gestation) was 78% (7/9), with five successful liveborn deliveries and two ongoing pregnancies. All deliveries were between 36–37 weeks. The 10 women who were not treated by our infertility unit were contacted, among whom 6 discontinued their attempt to conceive. The other 4 conceived; three of them spontaneously. Among those 4 women,the rate of deliveries and ongoing pregnancies was 75%, with one term delivery and two ongoing pregnancies.

Limitations, reasons for caution

First, we included both T-shaped and Y-shaped uteri as both represent close versions of dysmorphic uteri, but in fact they differ. The subseptum might interfere with reproduction in a different mechanism. Second, the small and heterogeneous sample as well as the short duration of follow-up limit the conclusions.

Wider implications of the findings: We present the first application of diode laser in hysteroscopic metroplasty for dysmorphic uteri. This technique seems promising and our results are comparable with other series using different cutting devices. Only larger controlled trials with a longer follow-up can confirm the safety, efficacy, and impact on reproductive outcomes

Trial registration number

Not applicable

P–190 Can pregnancy be predicted according to mean infra-red attenuated total reflectance (MIR-ATR) spectrometry of incubation medium of embryos in IVF?: A proof of concept

Study question

Can MIR-ATR spectrometry of embryo incubation medium be used to predict embryo quality and IVF treatment results.

Summary answer

MIR-ATR spectrometry is able to distinguish between good and poor embryo quality and may improve the prediction of pregnancy based on better embryo selection.

What is known already

Infra Red (IR) spectra enable to determine if certain chemical functional components are present in a molecule. Attenuated total reflection (ATR) spectroscopy is a well established, simple and rapid technique for objective classification of biological samples. ATR spectrometry was investigated and confirmed to serve as an additional diagnostic tool in oral and gynecologic cancer. Currently, embryo quality is assessed based on morphokinetics parameters from Time-laps incubator and/or final embryo’s grading

Study design, size, duration

Culture media of 227 embryos on cleavage stage and blastocyst stage were collected and analysed between January 1st, 2018 and December 31st 2020.

Participants/materials, setting, methods

The incubation medium liquid of embryos cultured in Time-lapse incubator were collected after transferring the embryos to their final destination. Infra-Red (IR) absorbance spectra was measured. Nominal resolution was 4 cm–1, wavenumber range was from 600 cm–1 to 5000 cm–1 and each absorbance spectrum was normalized to the height of amide I band at ∼1650cm–1. Machine learning techniques utilized to build discrimination models for the absorbance data. Results were correlated with clinical and pregnancy results.

Main results and the role of chance

This preliminary study demonstrates that ATR spectrometry differs in media of : Day 3 embryos compared to day 5 embryos, top quality compared to poor quality embryos and implanting embryos comparing to non-implanting embryos. We found that MIR-ATR spectrometry might predict pregnancy in accuracy rates of 85%. MIR-ATR spectrometry of incubation medium can be used as an additional tool for selection of embryos for transfer.

Limitations, reasons for caution

Additional study and collection of larger number of culture Media is requested to validate MIR-ATR spectrometry as an additional tool in clinical set up in IVF units and laboratories.

Wider implications of the findings: MIR-ATR spectrometry can be used in the future as an additional tool for selection of embryos and prediction of cycles outcomes.

Trial registration number

NCT03317418

P-748 Diode laser hysteroscopic metroplasty for dysmorphic uterus: a pilot study

Study question

Whether diode laser hysteroscopic metroplasty for dysmorphic uterus is a safe and efficacious procedure and its effect on reproductive outcomes.

Summary answer

Diode laser hysteroscopic metroplasty is a safe and effective procedure for infertile women with dysmorphic uterus with comparable results to those reported in the literature.

What is known already

A T-shaped uterine anomaly is categorized by the ESHRE/ESGE consensus as dysmorphic uterus class U1a, characterized by an abnormal hypoplastic uterine cavity. A Y-shaped uterus is a dysmorphic uterus with a fundal subseptum. Dysmorphic uteri are associated with infertility, recurrent implantation failure (RIF), recurrent pregnancy loss (RPL), and adverse pregnancy outcomes. According to several studies, it seems that hysteroscopic metroplasty may improve the chances of conception and live birth. Previous studies described the procedure using bipolar systems, monopolar needle or scissors. The purpose is to achieve a uterine cavity of normal shape and volume by cutting the thickened lateral walls.

Study design, size, duration

This was a retrospective pilot study with a prospective follow-up. We retrospectively evaluated all cases operated between February 2018 to February 2020, at Hillel Yaffe Medical Center, Hadera, Israel. Reproductive outcomes for women who underwent the procedure were followed until September 2020. Pregnancies that were ongoing on September 2020 were followed until January 31st 2021.

Participants/materials, setting, methods

Nulliparous women with a diagnosis of infertility or RPL, who were diagnosed with dysmorphic uterus by three-dimensional ultrasound (3D-US) and underwent diode laser hysteroscopic metroplasty were included. All the metroplasties were done in one tertiary center by the same specialist. Reproductive outcomes were evaluated retrospectively and prospectively for a total follow-up time of 32 months. Reproductive performances before and after metroplasty were compared where possible.

Main results and the role of chance

Twenty-five women underwent diode laser hysteroscopic metroplasty for dysmorphic uterus in our institute. No perforations, excessive bleeding, or other complications were encountered during the procedures. Follow-up hysteroscopy and 3D-US were satisfactory in all cases 2 months after the metroplasty. A total of 15 nulliparous women returned to fertility treatments afterwards, among whom 9 conceived (60% pregnancy rate). Their infertility period before the procedure was 56.6 ± 36.1 months. The duration between the metroplasty to pregnancy was 5.2 ± 3.5 months. The rate of deliveries and ongoing pregnancies (pregnancies beyond 20 weeks of gestation) was 78% (7/9), with five successful liveborn deliveries and two ongoing pregnancies. All deliveries were between 36-37 weeks. The 10 women who were not treated by our infertility unit were contacted, among whom 6 discontinued their attempt to conceive. The other 4 conceived; three of them spontaneously. Among those 4 women,the rate of deliveries and ongoing pregnancies was 75%, with one term delivery and two ongoing pregnancies.

Limitations, reasons for caution

First, we included both T-shaped and Y-shaped uteri as both represent close versions of dysmorphic uteri, but in fact they differ. The subseptum might interfere with reproduction in a different mechanism. Second, the small and heterogeneous sample as well as the short duration of follow-up limit the conclusions.

Wider implications of the findings

We present the first application of diode laser in hysteroscopic metroplasty for dysmorphic uteri. This technique seems promising and our results are comparable with other series using different cutting devices. Only larger controlled trials with a longer follow-up can confirm the safety, efficacy, and impact on reproductive outcomes.

Trial registration number

Not Applicable

P–337 Mid-Infrared spectroscopy as a real time diagnostic tool for chronic endometritis

Study question

Can we develop a real-time diagnostic tool for chronic endometritis (CE) by using attenuated total reflection-Fourier transform infrared (ATR-FTIR) spectroscopy to evaluate biopsies obtained during hysteroscopy?

Summary answer

A discrimination model based on the absorbance data was developed by machine learning techniques, differentiating between positive and negative CE histopathology with 97% accuracy.

What is known already

CE is diagnosed in approximately 15% of infertile women who undergo in vitro fertilization (IVF), in 42% of women with recurrent implantation failure (RIF), and in 57.8% of women with RPL. Diagnosis is done by endometrial biopsy, and the presence of plasma cells in the endometrial stroma is the generally accepted histological diagnostic criterion. However, the histological detection of CE is time-consuming and difficult. ATR-FTIR spectroscopy is a non-destructive method that can provide valuable information on biochemical changes that occur during pathological processes, such as inflammation and cancer.

Study design, size, duration

We performed a prospective study in which fresh biopsies of endometrium were obtained during standard hysteroscopies. Each biopsy was examined by the spectrophotometer and afterward by histopathological analysis in which multiple myeloma oncogene 1 (MUM–1) staining for plasma cells, a marker of CE, was performed. We planned to investigate 80 samples to develop a discrimination model, and another 40 samples for validation of the model. The study was planned to last two years.

Participants/materials, setting, methods

Women that underwent hysteroscopy as a part of infertility evaluation were recruited. The hysteroscopies and the biopsy evaluation were performed at the same center. A cut-off of 8 MUM–1 positive cells per 10 high power fields (HPF) was set. We compared the spectroscopy analysis of the positive CE group (≥8) and the negative CE group (&lt;8). Machine learning technique was utilized to build discrimination models. Data analysis was performed using Matlab and Unscrambler software packages.

Main results and the role of chance

We present preliminary results for our study. Forty-two women were recruited from January 2020 until November 2020. Of the 42 measured spectra, three were discarded due to high measurement noise. Of the 39 biopsies, 33 had MUM–1&lt;8 (CE negative group) and 6 had MUM–1≥8 (CE positive group). Measured spectra of tissue smears from CE negative and positive groups differed from each other in the spectral range of 850–990 [cm–1] (p &lt; 0.05). This wavenumber can be associated with the C-H in-plane bend in the alkene group (CnH2n). A discriminant model was developed between the groups using the Principal Component Analysis and Linear Discriminant Analysis techniques. The accuracy obtained by the model was 97%.

We divided the 39 hysteroscopies based on the CE signs into 2 groups: “Negative hysteroscopic-CE” and “Positive hysteroscopic-CE”. Positive hysteroscopic signs were micropolyps, strawberry pattern, hyperemia, punctuation, or pale endometrium. Twenty-three samples were taken in the Negative group and 16 samples were taken in the Positive group. However, measured spectra of tissue smears from negative and positive hysteroscopy groups were not significantly different. The correlation coefficient between hysteroscopy groups and MUM–1 score was r = 0.29, meaning that the characteristic signs of CE in hysteroscopy were not correlated to the histopathology.

Limitations, reasons for caution

First, these are preliminary results and we need to investigate more samples to validate our model. Second, diagnostic criteria for CE are diverse in the literature and we chose 8 MUM–1 positive cells in 10 HPF, a criterion which may not be accepted by all experts in the field.

Wider implications of the findings: ATR-FTIR spectroscopy is highly sensitive to molecular changes and has been utilized as a diagnostic tool in a variety of clinical studies. While histopathological results take about two weeks, ATR-FTIR spectroscopy might give us the possibility to diagnose CE in real-time, allowing an immediate initiation of the appropriate treatment.

Trial registration number

ClinicalTrials.gov Identifier: NCT04197167

Diode Laser Hysteroscopic Metroplasty for Dysmorphic Uterus: a Pilot Study

This paper aims to study the efficacy and safety of diode laser hysteroscopic metroplasty for dysmorphic uterus and the impact on reproductive outcomes. This is a retrospective, single-center pilot study with prospective follow-up. The study was performed at a university-affiliated, tertiary hospital. From February 2018 to February 2020, all nulliparous women with a 3D ultrasound diagnosis of T-shaped or Y-shaped dysmorphic uterus and diagnosis of infertility, recurrent implantation failure, or recurrent pregnancy losses were referred for hysteroscopic metroplasty. Diode laser hysteroscopic metroplasty was performed under general anesthesia in an ambulatory setting. Main outcome measures included operative time, complications, hysteroscopic appearance of the cavity in a follow-up hysteroscopy, and reproductive outcomes in terms of pregnancy and live birth. A total of 25 infertile women with mean duration of infertility of 56.6 ± 36.1 months underwent hysteroscopic metroplasty. No complications were reported, and subsequent 3D ultrasound and follow-up hysteroscopic appearance were satisfactory in all cases. Maximum follow-up was 32 months (mean ± standard deviation 11.5 ± 9.2 months). Fifteen nulliparous women returned for fertility treatments in our institute, among whom nine conceived (60% pregnancy rate). The rate of deliveries and ongoing pregnancies (pregnancies beyond 24 weeks of gestation) was 78% (7/9), with six successful liveborn deliveries at 36-38 weeks and one ongoing pregnancy. One had spontaneous abortion at week 19 and one had a spontaneous abortion at week 7. Hysteroscopic metroplasty in an ambulatory setting, using diode laser, is a safe and effective procedure, improving reproductive outcomes in cases of T-shaped or Y-shaped uterus.

Embryonic Development in Relation to Maternal Age and Conception Probability

Data regarding association between early embryo development and maternal age is limited and inconclusive. This study has two aims: to evaluate differences in the cleavage stage of embryos in young versus advanced maternal age (AMA) women. To compare the early embryonic development of embryos that result in pregnancy versus no pregnancy. A retrospective study of early embryonic development which was recorded and analyzed using time-lapse imaging was conducted. The kinetic markers of time to pronuclei fading (tPNf) and appearance of two to eight cells (t2-t8) were assessed. For embryos cultured to blastocyst, times to morula (tM), start of blastulation (tSB) cavitated, and expanded blastocyst (tB, tEB) were also recorded. A total of 2021 oocytes from 364 intracytoplasmic sperm injection (ICSI) cycles were evaluated, of which 1223 (60.5%) were derived from young patients and 798 (39.5%) from those of AMA. The mean time points to t3, t4, t5, t6, tSB, tB, and tEB were significantly shorter for embryos derived from younger women, as compared to older women (p < 0.05). Overall, women who conceived presented a faster embryonic development, for both age groups. The mean time points of t2 and t8 were significantly shorter in patients who conceived versus not conceived (p < 0.05). We concluded that older women's age is associated with delayed embryonic development. Embryos that yielded pregnancy cleaved faster compared to those which did not, in both age groups. Thus, when considering which embryo to transfer to women of AMA, selecting the faster-developing embryos may improve the chances of conception.

Ovulatory-Based FET Cycles May Achieve Higher Pregnancy Rates in the General Population and among Anovulatory Women

This study evaluated which endometrial preparation protocol in frozen embryo transfer (FET) cycles provides the best results for polycystic ovarian syndrome (PCOS) patients and the general population. This retrospective study of 634 FET cycles was conducted 2016-2018. Cycles were divided into Group A: Artificial endometrial preparations for FET (aFET; n = 348), Group B: Ovulatory cycle (n = 286) to compare two methods of endometrial preparation for FET. Artificial endometrial preparation with exogenous estrogen and progesterone versus natural ovulation cycles, modified natural cycles using hCG for the final triggering and letrozole-induced ovulation with hCG. Anovulatory patients were analyzed separately. Anovulatory PCOS patients had significantly higher pregnancy rates with letrozole treatment compared with aFET cycles (44% vs. 22.5%; p = 0.044). For the entire cohort, ovulatory cycles and aFET were similar in terms of patient characteristics, demographics, infertility causes, treatment protocols and number of embryos transferred. Although the mean ESHRE score of the transferred embryos was higher in the aFET group, we found higher clinical pregnancy rate in the ovulatory cycle FET (41.3% vs. 27.3%, p < 0.0001). A better pregnancy rate was found after ovulatory cycle FET. In the ovulatory cycles, the outcome of letrozole-induced and non-induced cycles were comparable. PCOS patients, as well as the general population, may benefit from ovulation induced FET cycles, with significantly better outcomes in FET in ovulatory cycles.

More is not always better-lower estradiol to mature oocyte ratio improved IVF outcomes

AIM

To find a cut-off ratio of estradiol/metaphase II oocyte (E2/M2) ratio and to evaluate the correlation with patients' characteristics, embryo morphokinetics using EmbryoScope™ and IVF cycle outcomes.

MATERIAL AND METHODS

For this retrospective cohort study, records of all fresh cycles that were cultured and scored by EmbryoScope™ were evaluated. The peak E2/M2 ratio was calculated on the day of human chorionic gonadotropin (hCG) administration and correlated to embryo morphokinetic quality and cycle outcomes. A receiver operating characteristics analysis was calculated for the E2/M2 ratio and clinical pregnancy rates.

RESULTS

A total of 2461 oocytes were collected from 319 patients. Receiver operating characteristics analysis revealed a cutoff of 204 as a discriminative point to predict clinical pregnancy with a sensitivity of 69.5% and specificity of 62.1% (P < 0.001). E2/M2 > 204 group were older, had higher E2 concentration, fewer M2 oocytes despite elevated gonadotrophin doses. E2/M2 ratio ≤ 204 was correlated with higher fertilization rate, better embryo quality, higher pregnancy and live birth rates, and more frozen embryos.

CONCLUSION

E2/M2 ratio < 204 yielded the best probability to achieve good quality embryos with good morphokinetic scores and better pregnancy outcomes and may be used to predict IVF cycle outcomes. Advanced maternal age and low ovarian response received higher concentrations of gonadotrophins, which resulted in higher E2/M2 ratio. Milder stimulation to those patients may improve their cycle outcomes.

Degenerative Oocytes in the Aspirated Cohort Are Not Due to the Aspirating Needle: a Prospective Randomized Pilot Study with Sibling Oocytes

The aim of this study is to compare two different needles (17G vs. 20-17G variable diameter) used for OPU and to assess whether the different stress forces along the needle affect the presence of degenerative oocytes, oocyte quality, and embryo morphokinetics. Prospective, randomized study enrolled women undergoing in vitro fertilization (IVF) intracytoplasmic sperm injection (ICSI) from August 2016 through August 2018 in an IVF unit at a tertiary care medical center. Ovaries were randomly aspirated using either a 20-17G needle or a 17G needle. The embryologist was blinded to the aspirating needle and sibling oocytes were separated according to needle used for fertilization and further evaluation. Oocytes were scored negatively if one of the following parameters was abnormal immediately after OPU: polar body shape, zona pellucida, cytoplasm, perivitelline space, or vacuoles. The presence of degenerative oocytes was noted at OPU. A total of 580 oocytes from 43 women were evaluated, 293 in the 17G needle group and 287 in the 20-17G group. Oocyte scoring was comparable between the two different needles (- 1.99 ± 1.9 vs. - 1.88 ± 1.69; P = 0.13), as were embryo quality and pregnancy rate. Cohorts with degenerative oocytes had lower oocyte scores (- 2.11 ± 1.81 vs. - 1.60 ± 1.50; P = 0.001) and poorer performance and fertilization rates (62.5% vs. 78.5%; P < 0.001) than did cohorts with no degenerative oocytes. Cycles with degenerative oocytes in the cohort at OPU demonstrated poorer oocyte quality and decreased fertilization, regardless of the needle used. 1.5.2016 NIH number NCT02749773.

Comparable Outcomes Using Oral Dydrogesterone Vs. Micronized Vaginal Progesterone in Frozen Embryo Transfer: a Retrospective Cohort Study

This retrospective study was conducted to determine whether using oral dydrogesterone (DYD) instead of micronized vaginal progesterone (MVP) in frozen embryo transfer (FET) cycles affects pregnancy outcomes. Women undergoing autologous FET in an academic fertility center were evaluated. Uses of 10 mg TID oral DYD or MVP for patients treated in FET cycles (artificial and ovulatory cycle, separately) were compared. The main outcome measure was live birth rates in each group. The study analyzed 599 cycles that occurred from January 2018 through December 2019. Chemical and clinical pregnancy rates were comparable between DYD vs. MVP groups (41.6% vs. 38.1%; P = 0.44 and 36.7% vs. 31.4%; P = 0.18, respectively). The ongoing pregnancy and delivery rates (29% vs. 22%, P = 0.06), as well as abortion rate (12.3% vs. 15.8%, P = 0.2), were comparable between the two groups. In a case-control sub-analysis of artificial FET cycles, we found comparable results between the two modes of luteal support. Similarly, results were comparable in ovulatory cycles using these medications for luteal support. Chemical and clinical pregnancy rates were comparable with DYD vs. MVP, in artificial FET (33.7% vs. 34.8%; P = 0.89 and 27.7% vs. 27.5%; P = 1), and in ovulatory FET (46.5% vs. 43.9%; P = 0.71 and 42.3% vs. 38.2%; P = 0.53), respectively. Our results indicate that in FET, pregnancy outcomes with oral DYD were not inferior to those with MVP.

Degenerated oocyte in the cohort adversely affects IVF outcome

The presence of Degenerated Oocyte (DEG) was mostly described after intracytoplasmic sperm injection (ICSI), with fewer reports on DEG at the time of ovum pick-up (OPU). This study aims to assess morphokinetics of embryos cultured in a time-lapse incubator and compare cohorts with and without DEG at OPU. In a retrospective cohort study from January 1, 2016 until September 31, 2017 a total of 399 IVF/ICSI cycles and 2980 embryos were evaluated. In 81 of 399 cycles at least one DEG oocyte was observed at the time of OPU. The remaining 318 cycles with no DEG oocyte were compared as a control group. In the DEG group, significantly more oocytes were collected per patient (12.9 ± 7.2 vs. 10.1 ± 6.1. P < 0.001). Fertilization rate, pregnancy and clinical pregnancy rates were comparable between the two groups, however, the morphokinetics and developmental scores of the embryos were significantly worse in the DEG group, (KID 3.4 ± 1.6 vs. 3.2 ± 1.6 P = 0.002 and ESHRE 1.5 ± 1.1 vs. 1.4 ± 1.0 P = 0.046). Significantly more patients achieved top-quality embryos in the NON DEG group (58.8% vs. 53.0%, P = 0.03), however, comparable delivery rate was achieved in both groups. In the DEG group, the frequency of DEG oocyte per cycle was negatively correlated with pregnancy rate. GnRH agonist protocol and the 17-20G needle used for OPU were significant predictors for the presence of DEG oocyte at OPU. In conclusions DEG oocyte may negatively affect IVF outcome, however, younger patients, and significantly more oocytes collected in the DEG group compensate for the IVF results.

Obesity results with smaller oocyte in in vitro fertilization/intracytoplasmic sperm injection cycles-a prospective study

BACKGROUND

Obesity is associated with several fertility disorders. This prospective cohort study was designed to evaluate the effect of body mass index (BMI) (kg/m2) on oocyte diameter and treatment.

METHODS

Women undergoing in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) were enrolled in the study. They were divided into two groups according to BMI: obese (BMI > 30) and normal weight (BMI < 25). Mature oocytes were evaluated according to total diameter, zona pellucida, and oolema diameters.

RESULTS

A total of 387 oocytes were obtained from the 46 women who participated. Significantly more mature oocytes (M2) were retrieved from normal weight patients compare to obese women (15.1 ± 6.8 vs. 9.7 ± 3.9, respectively, P < 0.001). Oocytes from women in the obese group were significantly smaller than those in the normal weight group, including oocyte diameter (157.9 ± 7.9 vs. 164.3 ± 5.1 μm, P < 0.0001), oolema diameter (110.3 ± 4.5 vs. 113.5 ± 3.5 μm, P < 0.0001), and zona pellucida thickness (17.9 ± 2.6 vs. 19.0 ± 2.4 μm, P < 0.000), respectively. Multivariate logistic regression analysis, including oolema diameter, female age, BMI, number of M2 oocytes, and zona pellucida, was conducted to predict pregnancy. Small oolema diameter in obese patient adversely correlated with pregnancy. Larger oolema diameter was positively associated with the probability of pregnancy in the obese group as well as thinner zona pellucida.

CONCLUSION

Obesity is associated with smaller oocytes, which adversely affect fertility outcomes.

TRIAL REGISTRATION

NIH number NCT01672931.

Can we alter pregnancy outcome by adjusting progesterone treatment at mid-luteal phase: a randomized controlled trial

Our study aimed to determine whether mid-luteal serum P concentrations can serve as a predictive factor for in vitro fertilization (IVF) outcomes and whether increasing P dosage for patients with low levels at mid-luteal phase may improve pregnancy rates. It was a prospective, randomized controlled study. A total of 146 patients undergoing IVF treatment were prospectively enrolled and received routine luteal phase support (LPS) regimen of Endometrin® (progesterone) 200 mg/day. Serum P levels were measured 7 days after embryo transfer (ET). Considering a cutoff level of 15 ng/ml on this day, patients with higher levels continued the same dosage until pregnancy test (control group). Patients with lower levels were randomly allocated to continue Endometrin® 200 mg/day (Group A) or to increase Endometrin® dosage to 300 mg/day (Group B). The Main Outcome Measures were pregnancy rates. Both biochemical and clinical pregnancy and live birth rates were comparable between all groups regardless of P level on day 7 of luteal phase and regardless of dose adjustment. ROC analysis determined that mid-luteal P levels of 17 ng/ml can be a better predictor of cycle outcome. In conclusion raising the P dose at mid-luteal phase to 300 mg daily did not improve cycle outcomes.

Comparison between stimulation with highly purified hMG or recombinant FSH in patients undergoing IVF with GnRH antagonist protocol

PURPOSE

Highly purified Human Menopausal Gonadotropins (hp-hMG) and recombinant FSH (rFSH) are widely used in assisted reproductive technology (ART). The aim of this study was to compare ART results of the two preparations in GnRH antagonist cycles.

METHODS

In this retrospective cohort study, IVF antagonist cycles performed from 2011 through 2013 were reviewed. There were 508 antagonist cycles: 320 stimulated with rFSH and 188 with hp-hMG. For every hp-hMG, two rFSH were matched for patient's age and infertility diagnosis. Subgroup analysis of patients younger and older than 35 was done as well.

RESULTS

Both treatments were resulted in comparable pregnancy and live birth rates. However, cumulative pregnancy rates were higher for the rFSH group. In the matching analysis, the rFSH group had more mature oocytes and more embryos while using lower doses of gonadotropins. Pregnancy, cumulative pregnancy rates, and live birth rates were comparable. In the subgroup analysis, young patients in the rFSH group had better cycle outcomes compared with those in the hp-hMG group.

CONCLUSION

In antagonist protocol, different gonadotropin products are equally effective. The choice of one or the other should depend on the availability, convenience of use, and cost.

Late follicular progesterone to estradiol ratio is not influenced by protocols or gonadotropins used

OBJECTIVE

Increased progesterone level during follicular phase seemed to be associated with decreased pregnancy rate.

STUDY DESIGN AND METHODS

A prospective cohort study, 1.1.2012 - 31.8.13. The Progesterone (P) and Progesterone/Estrogen (P/E2) level on ovulation induction day were compared between the protocols and the different gonadotropins used. Roc analysis was calculated to determine the cutoff of P/E2 to predict delivery rates. P/E2 ratio was calculated as PX1000/e2 level.

MAIN RESULTS

One hundred thirty-nine patients were enrolled to the study. No difference in the P level at hCG stimulation day between different protocols, however, E2 and P/E2 ratio were significantly lower in the long protocol compare with antagonist protocol 1757.7 ± 923.2 vs. 1342.9 ± 1223; P = 0.003 and 0.48 ± 0.31 vs. 0.83 ± 0.87; P = 0.038). The endometrium was significantly thicker in the long group compare with short and antagonist. Significantly more top-quality embryos (TOP) were achieved in the antagonist group. Comparable results between the types of gonadotropins used in regards with cycle characteristics and pregnancy and delivery rates. The P/E2 ratio which can predict live birth rate was found to be 0.45, AUC = 0.632, p = 0.02 and 95 % CI 0.525-0.738 and a significantly higher pregnancy and delivery rates at a P/E2 bellow 0.45.

CONCLUSION

Endometrial receptivity is determined by the complex interactions of E2 and P.

Human milk beyond one year post-partum: lower content of protein, calcium, and saturated very long-chain fatty acids

Maternal milk feeding for more than 1 year is encouraged by many health care authorities. We demonstrate that human milk beyond 1 year of lactation had a small but significantly lower concentration of protein, calcium, and long-chain saturated fatty acids compared with human milk at 3 months after delivery.