In vitro fertilization outcome based on the detailed early luteal phase trajectory of hormones: a prospective cohort study

BACKGROUND

Ovarian stimulation and the use of human chorionic gonadotropin (hCG) for triggering oocyte maturation in women undergoing in vitro fertilisation (IVF) introduces several differences in luteal phase hormone levels compared with natural cycles that may negatively impact on endometrial receptivity and pregnancy rates after fresh embryo transfer. Exogenous luteal phase support is given to overcome these issues. The suitability of a pragmatic approach to luteal phase support is not known due to a lack of data on early phase luteal hormone levels and their association with fertility outcomes during IVF with fresh embryo transfer. This study determined early luteal phase profiles of serum progesterone, 17-hydroxyprogesterone and hCG, and associations between hormone levels/hormone level profile after hCG trigger and the live birth rate in women undergoing IVF with fresh embryo transfer.

METHODS

This prospective single center, cohort study was conducted in Vietnam from January 2021 to December 2022. Women aged 18-38 years with normal ovarian reserve and undergoing controlled ovarian stimulation using a gonadotropin-releasing hormone antagonist protocol were included. Serum hormone levels were determined before trigger, at 12, 24 and 36 h after hCG, and daily from 1 to 6 days after oocyte pick-up. Serum hormone level profiles were classified as lower or upper. The primary outcome was live birth rate based on early luteal phase hormone level profile.

RESULTS

Ninety-five women were enrolled. Live birth occurred in 19/69 women (27.5%) with a lower progesterone profile and 13/22 (59.1%) with an upper progesterone profile (risk ratio [RR] 2.15; 95% confidence interval [CI] 1.28-3.60), and in 6/31 (19.4%) versus 26/60 (43.3%) with a lower versus upper serum 17-hydroxyprogesterone profile (RR 2.24; 95% CI 1.03-4.86). Nearly 20% of women had peak progesterone concentration on or before day 3 after oocyte pick-up, and this was associated with significantly lower chances of having a life birth.

CONCLUSIONS

These data show the importance of proper corpus luteum function with sufficient progesterone/17-hydroxyprogesterone production for achievement of pregnancy and to maximize the chance of live birth during IVF.

TRIAL REGISTRATION

NCT04693624 ( www.

CLINICALTRIALS

gov ).

Epigenetic variation in neonatal tissues in infants conceived using capacitation-in vitro maturation vs. in vitro fertilization

OBJECTIVE

To investigate alterations of the global DNA methylation profile in placenta, cord blood, and neonatal buccal smears in infants conceived using in vitro maturation (IVM) with a prematuration step (capacitation-IVM [CAPA-IVM]) vs. in vitro fertilization (IVF).

DESIGN

Analysis of data from the offspring of participants in a randomized controlled trial.

SETTING

Private clinic.

PATIENTS

Forty-six women with polycystic ovary syndrome and/or high antral follicle count and their offspring (58 newborns).

INTERVENTION(S)

Women with polycystic ovary syndrome and/or a high antral follicle count participating in the clinical trial were randomized to undergo CAPA-IVM or conventional IVF.

MAIN OUTCOME MEASURE(S)

At delivery, biological samples including cord blood, placental tissue, and a neonatal buccal smear were collected. Genome-wide DNA methylation was determined using the Illumina Infinium MethylationEPIC BeadChip. Variability in methylation was also considered, and mean variances for the two treatment categories were compared.

RESULTS

In neonatal buccal smears, there were no significant differences between the CAPA-IVM and conventional IVF groups on the basis of the CpG probe after linear regression analysis using a significant cut-off of false-discovery rate <0.05 and |Δβ|≥0.05. In cord blood, only one CpG site showed a significant gain of methylation in the CAPA-IVM group. In the placenta, CAPA-IVM was significantly associated with changes in methylation at five CpG sites. Significantly more variable DNA methylation was found in five probes in the placenta, 54 in cord blood, and two in buccal smears after IVM of oocytes. In cord blood samples, 20 CpG sites had more variable methylation in the conventional IVF vs. IVM group. Isolated CpG sites showing differences in methylation in cord blood were not associated with changes in gene expression of the overlapping genes.

CONCLUSION(S)

Capacitation-IVM appeared to be associated with only a small amount of epigenetic variation in cord blood, placental tissue, and neonate buccal smears.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03405701 (www.

CLINICALTRIALS

gov).

Heat-stable spores of carotenoid-producing Bacillus marisflavi and non-pigmented Bacillus subtilis cooperatively promote growth, quality, and gut microbiota of white-leg shrimp

We evaluated the benefits of heat-stable carotenoid-producing Bacillus marisflavi SH8 spores individually and in combination with non-pigmented Bacillus subtilis SH23 spores on growth, colour change, nutritional content, innate immunity, and gut microbiota of white-leg shrimp. White-leg shrimp (Litopenaeus vannamei; n = 30 per tank; 2 tanks per group) were provided feed without (control group) or with SH8, SH23, or mixed spores (total, 1 × 106 cfu/g pellet) for 28 d. The SH8 and SH8-23 combination groups had significantly higher specific growth rates (9.6 and 11.0%), improved red-colour score (4 scores), astaxanthin concentration (1.8- and 2.3-fold), lipid contents (30 and 50%), and superoxidase dismutase activity (8.5 and 12.3%) than that of the control group. Analysis of shrimp's gut microbiome using 16S rRNA metagenome sequencing revealed increased abundance of four useful species and reduced abundance of four harmful species in the combination group than in the control group. Heat-stable Bacillus spore combination improved growth parameters, nutrient content, red-colour score, live counts, and abundance of useful bacteria in the gut of L. vannamei. This is the first study to show the benefits of combining highly heat-stable pigmented and non-pigmented Bacillus spores and their possible mechanisms in a shrimp model.

Thyroid Peroxidase Antibodies in Infertile Women with Polycystic Ovary Syndrome

To compare the rate of positive thyroid peroxidase antibodies (TPO Ab) between women with different polycystic ovary syndrome (PCOS) phenotypes and women without PCOS. This is a retrospective cohort study. Women with PCOS at My Duc Hospital between June 1, 2020, and March 27, 2021, were matched with non-PCOS women by age. TPO Ab (cut-off: 34 IU/mL) and thyroid-stimulating hormone (TSH) levels were measured as markers of Hashimoto thyroiditis and thyroid function, respectively. One thousand eight hundred eight infertile women were included, 904 with PCOS (mean age 29.0 ± 3.58 years) and 904 without PCOS (29.1 ± 3.4 years; controls). Women with PCOS had a higher body mass index (22.8 ± 3.84 vs. 19.9 ± 2.23 kg/m2, p < 0.001), but most were not overweight/obese. Rates of positive TPO Ab in women with versus without PCOS were 8.2% and 8.4%, respectively (p = 0.932). Rates of positive TPO Ab in patients with PCOS phenotype A, B, C, or D were not statistically different (7.5%, 2.9%, 20.0%, and 7.8%, respectively). Median TSH concentrations were similar in the PCOS and control groups (1.84 mIU/L vs. 1.78 mIU/L, respectively; p = 0.194). Based on a linear regression model, there was no correlation between either BMI or the estradiol to progesterone ratio and TPO Ab status. In a large population of infertile women with PCOS who were mostly lean patients, rates of positive TPO Ab across all four PCOS phenotypes did not differ significantly from those in women without PCOS. These findings did not support the hypothesis that PCOS is a risk factor for Hashimoto thyroiditis.

Endocrine Responses to Triptorelin in Healthy Women, Women With Polycystic Ovary Syndrome, and Women With Hypothalamic Amenorrhea

CONTEXT

Limited data exist regarding whether the endocrine response to the gonadotropin-releasing hormone receptor agonist (GnRHa) triptorelin differs in women with polycystic ovary syndrome (PCOS) compared with healthy women or those with hypothalamic amenorrhea (HA).

OBJECTIVE

We compared the gonadotropin response to triptorelin in healthy women, women with PCOS, or those with HA without ovarian stimulation, and in women with or without polycystic ovaries undergoing oocyte donation cycles after ovarian stimulation.

METHODS

The change in serum gonadotropin levels was determined in (1) a prospective single-blinded placebo-controlled study to determine the endocrine profile of triptorelin (0.2 mg) or saline-placebo in healthy women, women with PCOS, and those with HA, without ovarian stimulation; and (2) a retrospective analysis from a dose-finding randomized controlled trial of triptorelin (0.2-0.4 mg) in oocyte donation cycles after ovarian stimulation.

RESULTS

In Study 1, triptorelin induced an increase in serum luteinizing hormone (LH) of similar amplitude in all women (mean peak LH: healthy, 52.3; PCOS, 46.2; HA, 41.3 IU/L). The AUC of change in serum follicle-stimulating hormone (FSH) was attenuated in women with PCOS compared with healthy women and women with HA (median AUC of change in serum FSH: PCOS, 127.2; healthy, 253.8; HA, 326.7 IU.h/L; P = 0.0005). In Study 2, FSH levels 4 hours after triptorelin were reduced in women with at least one polycystic morphology ovary (n = 60) vs normal morphology ovaries (n = 91) (34.0 vs 42.3 IU/L; P = 0.0003). Serum anti-Müllerian hormone (AMH) was negatively associated with the increase in FSH after triptorelin, both with and without ovarian stimulation.

CONCLUSION

FSH response to triptorelin was attenuated in women with polycystic ovaries, both with and without ovarian stimulation, and was negatively related to AMH levels.

Cumulative live birth rate after oocyte in vitro maturation with a pre-maturation step in women with polycystic ovary syndrome or high antral follicle count

PURPOSE

This study evaluated the 24-month cumulative live birth rate (CLBR) for women with polycystic ovary syndrome (PCOS) or high antral follicle count (AFC) who underwent oocyte in vitro maturation (IVM) with pre-maturation step (CAPA-IVM).

METHODS

This multicenter, retrospective study was performed at IVFMD, My Duc Hospital, and IVFMD Phu Nhuan, My Duc Phu Nhuan Hospital from 1 January 2017 to 31 December 2019. All women with PCOS or high AFC treated with a CAPA-IVM cycle were included. Cumulative live birth was defined as at least one live birth resulting from the initiated CAPA-IVM cycle. Where a woman did not return for embryo transfer, outcomes were followed up until 24 months from the day of oocyte aspiration. Logistic regression was performed to identify factors predicting the CLBR.

RESULTS

Data from 374 women were analyzed, 368 of whom had embryos for transfer (98.4%), and six had no embryos for transfer (1.6%). The oocyte maturation rate was 63.2%. The median number of frozen embryos was 4 [quartile 1, 2; quartile 3, 6]. Cumulative clinical pregnancy and ongoing pregnancy rates were 60.4% and 43.6%, respectively. At 24 months after starting CAPA-IVM treatment, the CLBR was 38.5%. Multivariate analysis showed that patient age and number of frozen embryos were significant predictors of cumulative live birth after CAPA-IVM.

CONCLUSIONS

CAPA-IVM could be considered as an alternative to in vitro fertilization for the management of infertility in women with PCOS or a high AFC who require assisted reproductive technology.

Development of children born to women with twin pregnancies treated with cervical pessary or vaginal progesterone: Follow-up of a randomized controlled trial

INTRODUCTION

Preterm birth is the most common cause of neonatal morbidity and mortality. Women with twin pregnancies and a short cervical length are at high risk for preterm birth. Vaginal progesterone and cervical pessary have been proposed as potential strategies to reduce preterm birth in this high-risk population. Therefore, we aimed to compare the effectiveness of cervical pessary and vaginal progesterone in improving developmental outcomes of children born to women with twin pregnancies and mid-trimester short cervical length.

MATERIAL AND METHODS

This was a follow-up study (NCT04295187) of all children at 24 months of age, born from women treated with cervical pessary or progesterone to prevent preterm birth in a randomized controlled trial (NCT02623881). We used a validated Vietnamese version of Ages & Stages Third Edition Questionnaires (ASQ-3) and a red flag questionnaire. In surviving children, we compared the mean ASQ-3 scores, abnormal ASQ-3 scores, the number of children with any abnormal ASQ-3 scores and red flag signs between the two groups. We reported the composite outcome of perinatal death or survival with any abnormal ASQ-3 score in offspring. These outcomes were also calculated in a subgroup of women with a cervical length ≤28 mm (<25th percentile).

RESULTS

In the original randomized controlled trial, we randomized 300 women to pessary or progesterone. After counting the number of perinatal deaths and lost to follow-up, 82.8% parents in the pessary group and 82.5% parents in progesterone group returned the questionnaire. The mean ASQ-3 scores of the five skills and red flag signs did not differ significantly between the two groups. However, the percentage of children having abnormal ASQ-3 scores in fine motor skills was significantly lower in the progesterone group (6.1% vs 1.3%, P = 0.01). There were no significant differences in the composite outcome of perinatal death or survival with any abnormal ASQ-3 score in unselected women and in those with cervical length ≤28 mm.

CONCLUSIONS

Cervical pessary and vaginal progesterone may have comparable effects on developmental outcomes in children at ≥24 months of age, born to women with twin pregnancies and short cervical length. However, this finding could be likely due to a lack of study power.

Pediatric Cardiology Fellowship Standards for Training in Exercise Medicine and Curriculum Outline

Over the past 2 decades, fundamentals of exercise medicine, including clinical exercise testing, assessment and promotion of physical activity, exercise prescription, and supervised exercise training/rehabilitation programming have demonstrated considerable clinical value in the management of children and adolescents with congenital and acquired heart disease. Although the principles of exercise medicine have become an integral component in pediatric cardiology, there are no standardized training recommendations for exercise physiology during pediatric cardiology fellowship at this time. Thus, the Pediatric Cardiology Exercise Medicine Curriculum Committee (PCEMCC) was formed to establish core and advanced exercise physiology training recommendations for pediatric cardiology trainees. The PCEMCC includes a diverse group of pediatric cardiologists, exercise physiologists, and fellowship program directors. The expert consensus training recommendations are by no means a mandate and are summarized herein, including suggestions for achieving the minimum knowledge and training needed for general pediatric cardiology practice.

Outcomes of clinical in vitro maturation programs for treating infertility in hyper responders: a systematic review

Oocyte in vitro maturation (IVM) has been proposed as an alternative to conventional ovarian stimulation (COS) in subfertile women with polycystic ovary syndrome. To evaluate the effectiveness and safety of IVM compared with COS in women with predicted hyperresponse to gonadotropins, we searched the published literature for relevant studies comparing any IVM protocol with any COS protocol followed by in vitro fertilization or intracytoplasmic sperm injection. A systematic review was undertaken on 3 eligible prospective studies. Live birth rate was not significantly lower after IVM vs. COS (odds ratio [95% confidence interval] of 0.56 [0.32-1.01] overall, 0.83 [0.63-1.10] for human chorionic gonadotropin (hCG)-triggered IVM [hCG-IVM] and 0.45 [0.18-1.13] for non-hCG-triggered IVM [non-hCG-IVM]), irrespective of the stage of transferred embryos. Data from nonrandomized studies generally showed either significantly low or statistically comparable rates of live birth with IVM vs. COS. Most studies have not identified any significant difference between IVM and COS with respect to the rates of obstetric or perinatal complications, apart from a potentially higher rate of hypertensive disorders during pregnancy. The development of offspring from IVM and COS with in vitro fertilization or intracytoplasmic sperm injection appears to be similar. Additional research is needed to identify which patient populations will benefit most from IVM, to define the appropriate clinical protocol, and to develop the optimal culture system.

Association between sequence variants in Follicle Stimulating Hormone Receptor gene and reproductive outcomes following in vitro fertilization in predicted normoreponders. A multicenter multinational prospective cohort study

RESEARCH QUESTION

Is there an association between FSHR sequence variants and reproductive outcomes following IVF in predicted normoresponders?

DESIGN

Multicentre prospective cohort study conducted from November 2016 to June 2019 in Vietnam, Belgium and Spain including patients aged <38 years, and undergoing IVF with a predicted normal response with fixed-dose 150 IU rFSH in an antagonist protocol. Genotyping was performed for three FSHR (c.919A>G, c.2039A>G, c.-29G>A) and one FSHB sequence variants (c.-211G>T). Clinical pregnancy rate (CPR), live birth rate (LBR) and miscarriage rate in the first embryo transfer and cumulative live birth rate (CLBR) were compared between the different genotypes.

RESULTS

A total of 351 patients underwent at least one embryo transfer. Genetic model analysis that adjusted for patient age, body mass index, ethnicity, type of embryo transfer, embryo stage and number of top-quality embryos transferred revealed a higher CPR for homozygous patients for the variant allele G of c.919A>G when compared to patients with genotype AA (60.3% versus 46.3%, adjusted odds ratio [ORadj] 1.96, 95% confidence interval [CI] 1.09-3.53). Also, c.919A>G genotypes AG and GG presented a higher CPR and LBR when compared with genotype AA (59.1% versus 46.3%, ORadj 1.80, 95% CI 1.08-3.00, and 51.3% versus 39.0%, ORadj 1.69, 95% CI 1.01-2.80, respectively). Cox regression models revealed a statistically significantly lower CLBR for c.2039A>G genotype GG in the codominant model (hazard ratio [HR] 0.66, 95% CI 0.43-0.99).

CONCLUSION

These results demonstrate a previously unreported association between variant c.919A>G genotype GG and higher CPR and LBR in infertile patients and reinforce a potential role for genetic background in predicting the reproductive prognosis following IVF.

Effect of post‐warming culture time on the live birth rate after frozen embryo transfer

Purpose

Methods

Results

Conclusions

OUP accepted manuscript

We present a rare case of a jejunal ulcer perforation in the alimentary limb ~15 cm distal to the gastro-jejunal anastomosis on the background of a previous Roux-en-Y gastric bypass (RYGB) 4 months prior to presentation. Marginal ulcer is the most common cause of jejunal perforation following RYGB. However, this is usually confined to the first few centimetres, and the incidence is highest within the first month following surgery. Other risk factors include smoking and non-steroidal anti-inflammatory drug use, Helicobacter pylori infection, trauma, foreign body ingestion, Crohn’s disease, typhoid, tuberculosis and malignancy. This case does not possess any of these risk factors and thus represents a unique presentation. Not all jejunal ulcers will present with classical risks factors but still will need to be excluded, given their life-threatening nature. Also, the whole alimentary limb can be susceptible to ulceration; therefore, a thorough investigation of this limb is important to exclude perforation.

Positive effects of amphiregulin on human oocyte maturation and its molecular drivers in patients with polycystic ovary syndrome

STUDY QUESTION

Does use of medium containing amphiregulin improve meiotic maturation efficiency in oocytes of women with polycystic ovary syndrome (PCOS) undergoing in vitro maturation (IVM) preceded by a capacitation culture step capacitation IVM (CAPA-IVM)?

SUMMARY ANSWER

Use of medium containing amphiregulin significantly increased the maturation rate from oocytes retrieved from follicles with diameters <6 or ≥6 mm pre-cultured in capacitation medium.

WHAT IS KNOWN ALREADY

Amphiregulin concentration in follicular fluid is correlated with human oocyte developmental competence. Amphiregulin added to the meiotic trigger has been shown to improve outcomes of IVM in a range of mammalian species.

STUDY DESIGN, SIZE, DURATION

This prospective, randomized cohort study included 30 patients and was conducted at an academic infertility centre in Vietnam from April to December 2019. Patients with PCOS were included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In the first stage, sibling oocytes from each patient (671 in total) were allocated in equal numbers to maturation in medium with (CAPA-AREG) or without (CAPA-Control) amphiregulin 100 ng/ml. After a maturation check and fertilization using intracytoplasmic sperm injection (ICSI), all good quality Day 3 embryos were vitrified. Cumulus cells (CCs) from both groups were collected at the moment of ICSI denudation and underwent a molecular analysis to quantify key transcripts of oocyte maturation and to relate these to early embryo development. On return for frozen embryo transfer (second stage), patients were randomized to have either CAPA-AREG or CAPA-Control embryo(s) implanted. Where no embryo(s) from the randomized group were available, embryo(s) from the other group were transferred. The primary endpoint of the study was meiotic maturation efficiency (proportion of metaphase II [MII] oocytes; maturation rate).

MAIN RESULTS AND THE ROLE OF CHANCE

In the per-patient analysis, the number of MII oocytes was significantly higher in the CAPA-AREG group versus the CAPA-Control group (median [interquartile range] 7.0 [5.3, 8.0] versus 6.0 [4.0, 7.0]; P = 0.01). When each oocyte was evaluated, the maturation rate was also significantly higher in the CAPA-AREG group versus the CAPA-Control group (67.6% versus 55.2%; relative risk [RR] 1.22 [95% confidence interval (CI) 1.08-1.38]; P = 0.001). No other IVM or embryology outcomes differed significantly between the two groups. Rates of clinical pregnancy (66.7% versus 42.9%; RR 1.56 [95% CI 0.77-3.14]), ongoing pregnancy (53.3% versus 28.6%; RR 1.87 [95% CI 0.72-4.85]) and live birth (46.7% versus 28.6%; RR 1.63 [95% CI 0.61-4.39]) were numerically higher in the patients who had CAPA-AREG versus CAPA-Control embryos implanted, but each fertility and obstetric outcome did not differ significantly between the groups. In the CAPA-AREG group, there were significant shifts in CC expression of genes involved in steroidogenesis (STAR, 3BHSD), the ovulatory cascade (DUSP16, EGFR, HAS2, PTGR2, PTGS2, RPS6KA2), redox and glucose metabolism (CAT, GPX1, SOD2, SLC2A1, LDHA) and transcription (NRF2). The expression of three genes (TRPM7, VCAN and JUN) in CCs showed a significant correlation with embryo quality.

LIMITATIONS, REASONS FOR CAUTION

This study included only Vietnamese women with PCOS, limiting the generalizability. Although 100 ng/ml amphiregulin addition to the maturation culture step significantly improved the MII rate, the sample size in this study was small, meaning that these findings should be considered as exploratory. Therefore, a larger patient cohort is needed to confirm whether the positive effects of amphiregulin translate into improved fertility outcomes in patients undergoing IVM.

WIDER IMPLICATIONS OF THE FINDINGS

Data from this study confirm the beneficial effects of amphiregulin during IVM with respect to the trigger of oocyte maturation. The gene expression findings in cumulus indicate that multiple pathways might contribute to these beneficial effects and confirm the key role of the epidermal growth factor system in the stepwise acquisition of human oocyte competence.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the Vietnam National Foundation for Science and Technology Development (NAFOSTED; grant number FWO.106-YS.2017.02) and by the Fund for Research Flanders (FWO; grant number G.OD97.18N). L.N.V. has received speaker and conference fees from Merck, grants, speaker and conference fees from Merck Sharpe and Dohme, and speaker, conference and scientific board fees from Ferring. T.M.H. has received speaker fees from Merck, Merck Sharp and Dohme and Ferring. J.S. reports speaker fees from Ferring Pharmaceuticals and Biomérieux Diagnostics and grants from FWO Flanders, is co-inventor on granted patents on CAPA-IVM methodologies in USA (US10392601B2), Europe (EP3234112B1) and Japan (JP 6806683 registered 08-12-2020) and is a co-shareholder of Lavima Fertility Inc., a spin-off company of the Vrije Universiteit Brussel (VUB, Brussels, Belgium). NA, TDP, AHL, MNHN, SR, FS, EA and UDTH report no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work.

TRIAL REGISTRATION NUMBER

NCT03915054.

Impact of Polycystic Ovary Syndrome Phenotypes on in Vitro Fertilization Outcomes in Vietnamese Women: A Secondary Analysis of a Randomized Controlled Trial

Background: Polycystic ovary syndrome (PCOS) is diagnosed when [Formula: see text]2 of the following symptoms are present: ovulation disorder (OD), hyperandrogenism (HA), and polycystic ovary morphology (PCO). Clinical features of PCOS are heterogeneous and there are four clinical phenotypes: A (OD + HA + PCO); B (HA + OD); C (HA + PCO); and D (OD + PCO). Women with a PCOS phenotype that includes severe HA are at increased risk for pregnancy complications. There are currently no data on impact of PCOS phenotypes on in vitro fertilization (IVF) outcomes in Vietnamese women. This study investigated the association between PCOS phenotypes and IVF outcomes.

Methods: This is a secondary analysis of a randomized controlled trial conducted in patients with PCOS undergoing IVF at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam between January 2018 and April 2019. The primary outcome was live birth rate.

Results: A total of 192 patients were included, of whom 33 patients had phenotype A (17.2%) and 159 had phenotype D (82.8%); no patients had phenotype B or C. Body mass index was significantly higher in patients with phenotype A than D (25.36 ± 4.78 versus 22.08 ± 3.21, [Formula: see text] = 0.001). There were no differences in laboratory and pregnancy outcomes between patients with phenotypes A and D. The live birth rate was lower in patients with phenotype A versus D, but the between-group difference did not reach statistical significance (33.3% vs. 42.8%, [Formula: see text] = 0.419).

Conclusions: The common PCOS phenotypes in Vietnamese women with infertility were A and D. No impact of PCOS phenotypes on IVF treatment outcomes was detected in this secondary analysis; larger studies are needed

Cumulative delivery rate per aspiration IVF/ICSI cycle in POSEIDON patients: a real-world evidence study of 9073 patients

STUDY QUESTION

What is the cumulative delivery rate (CDR) per aspiration IVF/ICSI cycle in low-prognosis patients as defined by the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria?

SUMMARY ANSWER

The CDR of POSEIDON patients was on average ∼50% lower than in normal responders and varied across POSEIDON groups; differences were primarily determined by female age, number of embryos obtained, number of embryo transfer (ET) cycles per patient, number of oocytes retrieved, duration of infertility, and BMI.

WHAT IS KNOWN ALREADY

The POSEIDON criteria aim to underline differences related to a poor or suboptimal treatment outcome in terms of oocyte quality and quantity among patients undergoing IVF/ICSI, and thus, create more homogenous groups for the clinical management of infertility and research. POSEIDON patients are presumed to be at a higher risk of failing to achieve a live birth after IVF/ICSI treatment than normal responders with an adequate ovarian reserve. The CDR per initiated/aspiration cycle after the transfer of all fresh and frozen–thawed/warmed embryos has been suggested to be the critical endpoint that sets these groups apart. However, no multicenter study has yet substantiated the validity of the POSEIDON classification in identifying relevant subpopulations of patients with low-prognosis in IVF/ICSI treatment using real-world data.

STUDY DESIGN, SIZE, DURATION

Multicenter population-based retrospective cohort study involving 9073 patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were women with infertility between 22 and 42 years old in their first IVF/ICSI cycle of standard ovarian stimulation whose fresh and/or frozen embryos were transferred until delivery of a live born or until all embryos were used. Patients were retrospectively classified according to the POSEIDON criteria into four groups based on female age, antral follicle count (AFC), and the number of oocytes retrieved or into a control group of normal responders (non-POSEIDON). POSEIDON patients encompassed younger (<35 years) and older (35 years or above) women with an AFC ≥5 and an unexpected poor (<4 retrieved oocytes) or suboptimal (4–9 retrieved oocytes) response to stimulation, and respective younger and older counterparts with an impaired ovarian reserve (i.e. expected poor responders; AFC <5). Non-POSEIDON patients were those with AFC ≥5 and >9 oocytes retrieved. CDR was computed per one aspirated cycle. Logistic regression analysis was carried out to examine the association between patient classification and CDR.

MAIN RESULTS AND ROLE OF CHANCE

The CDR was lower in the POSEIDON patients than in the non-POSEIDON patients (33.7% vs 50.6%; P < 0.001) and differed across POSEIDON groups (younger unexpected poor responder [Group 1a; n = 212]: 27.8%, younger unexpected suboptimal responder [Group 1b; n = 1785]: 47.8%, older unexpected poor responder [Group 2a; n = 293]: 14.0%, older unexpected suboptimal responder [Group 2b; n = 1275]: 30.5%, younger expected poor responder [Group 3; n = 245]: 29.4%, and older expected poor responder [Group 4; n = 623]: 12.5%. Among unexpected suboptimal/poor responders (POSEIDON Groups 1 and 2), the CDR was twice as high in suboptimal responders (4–9 oocytes retrieved) as in poor responders (<4 oocytes) (P = 0.0004). Logistic regression analysis revealed that the POSEIDON grouping, number of embryos obtained, number of ET cycles per patient, number of oocytes collected, female age, duration of infertility and BMI were relevant predictors for CDR (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Our study relied on the antral follicle count as the biomarker used for patient classification. Ovarian stimulation protocols varied across study centers, potentially affecting patient classification.

WIDER IMPLICATIONS OF THE FINDINGS

POSEIDON patients exhibit lower CDR per aspirated IVF/ICSI cycle than normal responders; the differences are mainly determined by female age and number of oocytes retrieved, thereby reflecting the importance of oocyte quality and quantity. Our data substantiate the validity of the POSEIDON criteria in identifying relevant subpopulations of patients with low-prognosis in IVF/ICSI treatment. Efforts in terms of early diagnosis, prevention, and identification of specific interventions that might benefit POSEIDON patients are warranted.

STUDY FUNDING/COMPETING INTEREST(S)

Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. J.F.C. declares receipt of statistical services fees from ANDROFERT Clinic. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. P.H. declares receipt of unrestricted research grants from Merck, Ferring, Gedeon Richter and IBSA and lecture fees from Merck, Gedeon Richter and Med.E.A. C.A. declares receipt of unrestricted research grants from Merck and lecture fees from Merck. The remaining authors have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Micronized progesterone plus dydrogesterone versus micronized progesterone alone for luteal phase support in frozen-thawed cycles (MIDRONE): a prospective cohort study

STUDY QUESTION

Does the addition of oral dydrogesterone to vaginal progesterone as luteal phase support improve pregnancy outcomes during frozen embryo transfer (FET) cycles compared with vaginal progesterone alone?

SUMMARY ANSWER

Luteal phase support with oral dydrogesterone added to vaginal progesterone had a higher live birth rate and lower miscarriage rate compared with vaginal progesterone alone.

WHAT IS KNOWN ALREADY

Progesterone is an important hormone that triggers secretory transformation of the endometrium to allow implantation of the embryo. During IVF, exogenous progesterone is administered for luteal phase support. However, there is wide inter-individual variation in absorption of progesterone via the vaginal wall. Oral dydrogesterone is effective and well tolerated when used to provide luteal phase support after fresh embryo transfer. However, there are currently no data on the effectiveness of luteal phase support with the combination of dydrogesterone with vaginal micronized progesterone compared with vaginal micronized progesterone after FET.

STUDY DESIGN, SIZE, DURATION

Prospective cohort study conducted at an academic infertility center in Vietnam from 26 June 2019 to 30 March 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied 1364 women undergoing IVF with FET. Luteal support was started when endometrial thickness reached ≥8 mm. The luteal support regimen was either vaginal micronized progesterone 400 mg twice daily plus oral dydrogesterone 10 mg twice daily (second part of the study) or vaginal micronized progesterone 400 mg twice daily (first 4 months of the study). In women with a positive pregnancy test, the appropriate luteal phase support regimen was continued until 7 weeks' gestation. The primary endpoint was live birth after the first FET of the started cycle, with miscarriage <12 weeks as one of the secondary endpoints.

MAIN RESULTS AND THE ROLE OF CHANCE

The vaginal progesterone + dydrogesterone group and vaginal progesterone groups included 732 and 632 participants, respectively. Live birth rates were 46.3% versus 41.3%, respectively (rate ratio [RR] 1.12, 95% CI 0.99-1.27, P = 0.06; multivariate analysis RR 1.30 (95% CI 1.01-1.68), P = 0.042), with a statistically significant lower rate of miscarriage at <12 weeks in the progesterone + dydrogesterone versus progesterone group (3.4% versus 6.6%; RR 0.51, 95% CI 0.32-0.83; P = 0.009). Birth weight of both singletons (2971.0 ± 628.4 versus 3118.8 ± 559.2 g; P = 0.004) and twins (2175.5 ± 494.8 versus 2494.2 ± 584.7; P = 0.002) was significantly lower in the progesterone plus dydrogesterone versus progesterone group.

LIMITATIONS, REASONS FOR CAUTION

The main limitations of the study were the open-label design and the non-randomized nature of the sequential administration of study treatments. However, our systematic comparison of the two strategies was able to be performed much more rapidly than a conventional randomized controlled trial. In addition, the single ethnicity population limits external generalizability.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings study suggest a role for oral dydrogesterone in addition to vaginal progesterone as luteal phase support in FET cycles to reduce the miscarriage rate and improve the live birth rate. Carefully planned prospective cohort studies with limited bias could be used as an alternative to randomized controlled clinical trials to inform clinical practice.

STUDY FUNDING/COMPETING INTERESTS

This study received no external funding. LNV has received speaker and conference fees from Merck, grant, speaker and conference fees from Merck Sharpe and Dohme, and speaker, conference and scientific board fees from Ferring; TMH has received speaker fees from Merck, Merck Sharp and Dohme, and Ferring; R.J.N. has received scientific board fees from Ferring and receives grant funding from the National Health and Medical Research Council (NHMRC) of Australia; BWM has acted as a paid consultant to Merck, ObsEva and Guerbet, and is the recipient of grant money from an NHMRC Investigator Grant.

TRIAL REGISTRATION NUMBER

NCT0399876.

Ostracods as pollution indicators in Lap An Lagoon, central Vietnam

Southeast Asia is particularly susceptible to the negative impacts of increasing coastal pollution as coastal populations and cities grow at unprecedented rates. Although water chemistry can be monitored, there are greater advantages in using bioindicators as reflectors of the combined effect of multiple pollution types on coastal ecosystem health and for early detection of the negative impacts of pollutants on biotic systems. This study explores the utility and application of ostracods as pollution bioindicators and examines the response of ostracod assemblages to variable pollution in Lap An Lagoon, central Vietnam. From 14 sites within the lagoon, 79 species of 46 genera were identified and sediment grain size, total organic carbon, organic matter and heavy metal concentration were measured. Cluster analysis, detrended correspondence analysis and canonical correspondence analysis identified four distinct ostracod biofacies that were highly correlated to the physical environmental variables (salinity, depth, sediment type, heavy metal concentrations, total organic carbon and organic matter) and are shown to be the main factors controlling ostracod biofacies. Low ostracod diversities were found in silty sediments with heavy metal concentrations likely toxic. Sinocytheridea impressa was indicative of a marginally polluted environment within the lagoon. This study provides evidence for the potential for Southeast Asian ostracods to be used in water quality assessments and the data collected can be used as a baseline for future pollution monitoring.

Antral follicle count and anti-Müllerian hormone to classify low-prognosis women under the POSEIDON criteria: a classification agreement study of over 9000 patients

STUDY QUESTION

What is the agreement between antral follicle count (AFC) and anti-Müllerian hormone (AMH) levels when used to patient classification according to the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria?

SUMMARY ANSWER

Our study indicates a strong agreement between the AFC and the AMH levels in classifying POSEIDON patients; thus, either can be used for this purpose, although one in four women will have discordant values when both biomarkers are used.

WHAT IS KNOWN ALREADY

According to the POSEIDON criteria, both AFC and AMH may be used to classify low-prognosis patients. Proposed AFC and AMH thresholds of 5 and 1.2 ng/ml, respectively, have their basis in published literature; however, no study has yet determined the reproducibility of patient classification in comparing one biomarker with the other, nor have their thresholds ever been validated within this patient population.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study involving 9484 consecutive patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were infertile women between 22 and 46 years old in their first in vitro fertilization/intracytoplasmic sperm injection cycle of standard ovarian stimulation with exogenous gonadotropins whose baseline ovarian reserves had been assessed by both AFC and AMH. Details of pre- and post-treatment findings were input into a coded research file. Two indicators of interest were created to classify patients according to the POSEIDON criteria based upon AFC and AMH values. Patients who did not fit any of the four POSEIDON groups were classified as non-POSEIDON. AFC was determined in the early follicular phase using two-dimensional (2D) transvaginal ultrasonography, whereas AMH values were based on the modified Beckman Coulter generation II enzyme-linked immunosorbent assay. Agreement rates were computed between AFC and AMH to classify patients using Cohen's kappa statistics. Logistic regression analyzes were carried out to examine the association between ovarian markers and low (<4) and suboptimal (4-9) oocyte yield.

MAIN RESULTS AND THE ROLE OF CHANCE

The degree of agreement in classifying patients according to POSEIDON groups was strong overall (kappa = 0.802; 95% CI: 0.792-0.811). A total of 73.8% of individuals were classified under the same group using both biomarkers. The disagreement rates were ∼26% and did not diverge when AFC or AMH was used as the primary biomarker criterion. Significant regression equations were found between ovarian markers and oocyte yield (P < 0.0001). For low oocyte yield, the optimal AFC and AMH cutoff values were 5 and 1.27 ng/ml with sensitivities of 0.61 and 0.66, specificities of 0.81 and 0.72, and AUC receiver operating characteristics of 0.791 and 0.751, respectively. For suboptimal oocyte yield respective AFC and AMH cutoffs were 12 and 2.97 ng/ml with sensitivities of 0.74 and 0.69, specificities of 0.76 and 0.66 and AUCs of 0.81 and 0.80.

LIMITATIONS, REASONS FOR CAUTION

Our study relied on 2D transvaginal sonography to quantify the AFC and manual Gen II assay for AMH determination and classification of patients. AMH data must be interpreted in an assay-specific manner. Treatment protocols varied across centers potentially affecting patient classification.

WIDER IMPLICATIONS OF THE FINDINGS

Three of four patients will be classified the same using either AFC or AMH values. Both biomarkers provide acceptable and equivalent accuracy in predicting oocyte yield further supporting their use and proposed thresholds in daily clinical practice for patient classification according to the POSEIDON criteria. However, the sensitivity of POSEIDON thresholds in predicting low oocyte yield is low. Clinicians should adopt the biomarker that may best reflect their clinical setting.

STUDY FUNDING/COMPETING INTEREST(S)

Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. The remaining authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

not applicable.

Reference Intervals of Thyroid Function Tests in First Trimester Vietnamese Pregnant Women

BACKGROUND

Although TSH suppression by elevated β-hCG is essentially seen during first trimester, differences in TSH reference ranges between various countries have been reported. Physiologic changes during pregnancy may also influence FT4 assays. This study aims to establish method-specific reference intervals (RIs) of TSH, FT4, and FT3 in Vietnamese, first trimester pregnant women.

METHODS

This cross-sectional study was conducted at My Duc Hospital, Ho Chi Minh, Vietnam. Women with singleton pregnancies in the first trimester and conceived naturally were included. Those with a history of thyroid disease, positive thyroid-specific autoantibodies, diffuse goiter or one thyroid nodule > 10 mm in size or ≥ 2 nodules detected by ultrasound, and taking medications affecting thyroid function were excluded. Serum TSH, FT4, and FT3 were measured by chemiluminescent detection technology on the Access 2 Immunoassay System (Beckman Coulter, Inc., USA). Intra- and interassay coefficients of variations (CV) were 3.6% and 4.4% for TSH, 5.4% and 6.1% for FT4, 6.6%, and 6.0% for FT3, respectively. The 2.5th and 97.5th percentiles were used to determine RIs.

RESULTS

Between August 1, 2017, to December 1, 2018, there were 876 pregnant women who fulfilled inclusion and exclusion criteria. They had a mean age of 30.1 years, an average BMI of 21.3 kg/m2, and 77.3% of them were primigravida. The RIs for TSH, FT4 and FT3 were 0.17 - 2.35 mIU/L, 0.67 - 1.11 ng/dL and 2.82 - 3.90 pg/mL, respectively.

CONCLUSIONS

Established RIs for TSH, FT4, and FT3 in Vietnamese women would help to reduce the misdiagnosis of gestational thyroid disorders.

In-vitro maturation of oocytes versus conventional IVF in women with infertility and a high antral follicle count: a randomized non-inferiority controlled trial

STUDY QUESTION

Is one cycle of IVM non-inferior to one cycle of conventional in IVF with respect to live birth rates in women with high antral follicle counts (AFCs)?

SUMMARY ANSWER

We could not demonstrate non-inferiority of IVM compared with IVF.

WHAT IS KNOWN ALREADY

IVF with ovarian hyperstimulation has limitations in some subgroups of women at high risk of ovarian stimulation, such as those with polycystic ovary syndrome. IVM is an alternative ART for these women. IVM may be a feasible alternative to IVF in women with a high AFC, but there is a lack of data from randomized clinical trials comparing IVM with IVF in women at high risk of ovarian hyperstimulation syndrome.

STUDY DESIGN, SIZE, DURATION

This single-center, randomized, controlled non-inferiority trial was conducted at an academic infertility center in Vietnam from January 2018 to April 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 546 women with an indication for ART and a high AFC (≥24 follicles in both ovaries) were randomized to the IVM (n = 273) group or the IVF (n = 273) group; each underwent one cycle of IVM with a prematuration step versus one cycle of IVF using a standard gonadotropin-releasing hormone antagonist protocol with gonadotropin-releasing hormone agonist triggering. The primary endpoint was live birth rate after the first embryo transfer. The non-inferiority margin for IVM versus IVF was -10%.

MAIN RESULTS AND THE ROLE OF CHANCE

Live birth after the first embryo transfer occurred in 96 women (35.2%) in the IVM group and 118 women (43.2%) in the IVF group (absolute risk difference -8.1%; 95% confidence interval (CI) -16.6%, 0.5%). Cumulative ongoing pregnancy rates at 12 months after randomization were 44.0% in the IVM group and 62.6% in the IVF group (absolute risk difference -18.7%; 95% CI -27.3%, -10.1%). Ovarian hyperstimulation syndrome did not occur in the IVM group, versus two cases in the IVF group. There were no statistically significant differences between the IVM and IVF groups with respect to the occurrence of pregnancy complications, obstetric and perinatal complications, preterm delivery, birth weight and neonatal complications.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of the study was its open-label design. In addition, the findings are only applicable to IVM conducted using the prematuration step protocol used in this study. Finally, the single ethnicity population limits the external generalizability of the findings.

WIDER IMPLICATIONS OF THE FINDINGS

Our randomized clinical trial compares live birth rates after IVM and IVF. Although IVM is a viable and safe alternative to IVF that may be suitable for some women seeking a mild ART approach, the current study findings approach inferiority for IVM compared with IVF when cumulative outcomes are considered. Future research should incorporate multiple cycles of IVM in the study design to estimate cumulative fertility outcomes and better inform clinical decision-making.

STUDY FUNDING/COMPETING INTEREST(S)

This work was partly supported by Ferring grant number 000323 and funded by the Vietnam National Foundation for Science and Technology Development (NAFOSTED) and by the Fund for Research Flanders (FWO). LNV has received speaker and conference fees from Merck, grant, speaker and conference fees from Merck Sharpe and Dohme, and speaker, conference and scientific board fees from Ferring; TMH has received speaker fees from Merck, Merck Sharp and Dohme, and Ferring; RJN has received conference and scientific board fees from Ferring, is a minor shareholder in an IVF company, and receives grant funding from the National Health and Medical Research Council (NHMRC) of Australia; BWM has acted as a paid consultant to Merck, ObsEva and Guerbet, and is the recipient of grant money from an NHMRC Investigator Grant; RBG reports grants and fellowships from the NHMRC of Australia; JS reports lecture fees from Ferring Pharmaceuticals, Biomérieux, Besins Female Healthcare and Merck, grants from Fund for Research Flanders (FWO), and is co-inventor on granted patents on CAPA-IVM methodology in the US (US10392601B2) and Europe (EP3234112B1); TDP, VQD, VNAH, NHG, AHL, THP and RW have no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work.

TRIAL REGISTRATION NUMBER

NCT03405701 (www.clinicaltrials.gov).

TRIAL REGISTRATION DATE

16 January 2018.

DATE OF FIRST PATENT’S ENROLMENT

25 January 2018.

The early luteal hormonal profile in IVF patients triggered with hCG

STUDY QUESTION

What is the early luteal phase hormonal profile in patients undergoing ovarian stimulation for IVF/ICSI followed by hCG trigger and a freeze-all strategy without luteal phase support?

SUMMARY ANSWER

The peak concentration of progesterone occurred 4 days after oocyte pick-up (OPU + 4), with an average 35% fall from OPU + 4 to OPU + 6, and progesterone levels before and 12 h after hCG administration predicted levels during the early luteal phase.

WHAT IS KNOWN ALREADY

The luteal phase during IVF differs from that during normal cycles, particularly with respect to the serum progesterone level profile. This can cause asynchrony between the embryo and the endometrium, potentially resulting in implantation failure and poor reproductive outcomes.

STUDY DESIGN, SIZE, DURATION

This prospective study included 161 women with normal ovarian reserve receiving GnRH antagonist co-treatment during ovarian stimulation with FSH who were followed up to 6 days after OPU in a single IVF cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged 18-42 years undergoing IVF with ovarian stimulation using FSH were included. Ovulation was triggered with recombinant hCG 250 μg. Hormone levels were determined from blood samples taken on the day of trigger, before hCG, at 12, 24 and 36 h after hCG and at 1, 2, 3, 4, 5 and 6 days after OPU. The primary endpoint was early luteal phase serum concentrations of progesterone, LH, estradiol and hCG.

MAIN RESULTS AND THE ROLE OF CHANCE

One outlier with a pre-hCG serum progesterone level of 11.42 ng/mL was excluded, so all analyses included 160 subjects. Progesterone levels began to increase 1 day after OPU, peaked 4 days after OPU (114 ng/mL), then declined from OPU + 5 onwards. Peak progesterone levels were at OPU + 4, OPU + 5 or OPU + 6 in 38.8, 29.4 and 13.8% of patients, respectively. Approximately two-thirds of patients had a fall in serum progesterone from OPU + 4 to OPU + 6. Pre-hCG progesterone levels correlated significantly with those at 24 h after hCG (r2 = 0.28; P < 0.001), which in turn correlated significantly with progesterone at OPU + 4 (r2 = 0.32; P < 0.001). LH peaked (4.4 IU/L) 12 h after hCG trigger, persisting for 24 h but was barely elevated compared with physiological levels. Serum estradiol peaked twice: at 24 h post-trigger and at OPU + 4. Highest hCG levels (130 mIU/mL) occurred at 24 h post-injection. The best correlations between the number of follicles ≥11 mm and serum progesterone level were seen at 24 and 36 h after hCG and OPU + 1.

LIMITATIONS, REASONS FOR CAUTION

The influence of different profiles of serum progesterone on reproductive outcomes could not be determined because a freeze-all strategy was used in all patients. In addition, data were not available to relate serum hormone level findings with endometrial histology or endometrial receptivity analysis to clearly identify the relationship between serum hormones and the window of implantation.

WIDER IMPLICATIONS OF THE FINDINGS

Detailed information about early luteal phase hormone levels could be used to optimize and individualize luteal phase support to improve reproductive outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by My Duc Hospital, Ho Chi Minh City, Vietnam. All authors state that they have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

NCT02798146; NCT03174691.

Intracytoplasmic sperm injection versus conventional in-vitro fertilisation in couples with infertility in whom the male partner has normal total sperm count and motility: an open-label, randomised controlled trial

BACKGROUND

The use of intracytoplasmic sperm injection has increased substantially worldwide, primarily in couples with non-male factor infertility. However, there is a paucity of evidence from randomised trials supporting this approach compared with conventional in-vitro fertilisation (IVF). We aimed to investigate whether intracytoplasmic sperm injection would result in a higher livebirth rate compared with conventional IVF.

METHODS

This open-label, multicentre, randomised trial was done at two IVF centres in Ho Chi Minh City, Vietnam (IVFMD, My Duc Hospital and IVFAS, An Sinh Hospital). Eligible couples were aged at least 18 years and the male partner's sperm count and motility (progressive motility) were normal based on WHO 2010 criteria. Couples had to have undergone two or fewer previous conventional IVF or intracytoplasmic sperm injection attempts, have used an antagonist protocol for ovarian stimulation, and agree to have two or fewer embryos transferred. Couples were randomly assigned (1:1) to undergo either intracytoplasmic sperm injection or conventional IVF, using block randomisation with variable block size of 2, 4, or 8 and a telephone-based central randomisation method. The computer-generated randomisation list was prepared by an independent statistician who had no other involvement in the study. Embryologists and couples were not masked to study groups because of the type of interventions and differences in hospital fees, but clinicians performing embryo transfer were unaware of study group allocation. The primary outcome was livebirth after the first embryo transfer from the initiated cycle. Analyses were done on an intention-to-treat basis. The trial is registered with ClinicalTrials.gov, NCT03428919.

FINDINGS

Between March 16, 2018, and Aug 12, 2019, we randomly assigned 1064 couples to intracytoplasmic sperm injection (n=532) or conventional IVF (n=532). Livebirth after the first embryo transfer from the initiated cycle occurred in 184 (35%) of 532 couples randomly assigned to intracytoplasmic sperm injection and in 166 (31%) of 532 couples randomly assigned to conventional IVF (absolute difference 3·4%, 95% CI -2·4 to 9·2; risk ratio [RR] 1·11, 95% CI 0·93 to 1·32; p=0·27). 29 (5%) couples in the intracytoplasmic sperm injection group and 34 (6%) couples in the conventional IVF group had fertilisation failure (absolute difference -0·9%, -4·0 to 2·1, RR 0·85, 95% CI 0·53 to 1·38; p=0·60).

INTERPRETATION

In couples with infertility in whom the male partner has a normal total sperm count and motility, intracytoplasmic sperm injection did not improve the livebirth rate compared with conventional IVF. Our results challenge the value of the routine use of intracytoplasmic sperm injection in assisted reproduction techniques for this population.

FUNDING

My Duc Hospital and Merck Sharp and Dohme.

Low Prognosis by the POSEIDON Criteria in Women Undergoing Assisted Reproductive Technology: A Multicenter and Multinational Prevalence Study of Over 13,000 Patients

OBJECTIVE

To estimate the prevalence of low-prognosis patients according to the POSEIDON criteria using real-world data.

DESIGN

Multicenter population-based cohort study.

SETTINGS

Fertility clinics in Brazil, Turkey, and Vietnam.

PATIENTS

Infertile women undergoing assisted reproductive technology using standard ovarian stimulation with exogenous gonadotropins.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Per-period prevalence rates of POSEIDON patients (overall, stratified by POSEIDON groups and by study center) and the effect of covariates on the probability that a patient be classified as "POSEIDON".

RESULTS

A total of 13,146 patients were included. POSEIDON patients represented 43.0% (95% confidence interval [CI] 42.0-43.7) of the studied population, and the prevalence rates varied across study centers (range: 38.6-55.7%). The overall prevalence rates by POSEIDON groups were 44.2% (group 1; 95% CI 42.6-45.9), 36.1% (group 2; 95% CI 34.6-37.7), 5.2% (group 3; 95% CI 4.5-6.0), and 14.4% (group 4; 95% CI: 13.3-15.6). In general, POSEIDON patients were older, had a higher body mass index (BMI), lower ovarian reserve markers, and a higher frequency of female factor as the primary treatment indication than non-POSEIDON patients. The former required larger doses of gonadotropin for ovarian stimulation, despite achieving a 2.5 times lower number of retrieved oocytes than non-POSEIDON patients. Logistic regression analyses revealed that female age, BMI, ovarian reserve, and a female infertility factor were relevant predictors of the POSEIDON condition.

CONCLUSIONS

The estimated prevalence of POSEIDON patients in the general population undergoing ART is significant. These patients differ in clinical characteristics compared with non-POSEIDON patients. The POSEIDON condition is associated with female age, ovarian reserve, BMI, and female infertility. Efforts in terms of diagnosis, counseling, and treatment are needed to reduce the prevalence of low-prognosis patients.

In-vitro maturation versus IVF: a cost-effectiveness analysis

RESEARCH QUESTION

How do costs and effects of in-vitro maturation (IVM) compare to IVF in women with a high antral follicle count (AFC)?

DESIGN

This cost-effectiveness analysis (CEA) was based on data of a previous retrospective cohort study at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam. Between July 2015 and December 2017, 608 women underwent IVM and 311 women IVF. The effectiveness measure for the CEA was cumulative live birth rate (LBR) after one completed cycle including subsequent cryo-cycles within 12 months of inclusion. Data were collected on resource use related to treatment, medication and pregnancy from the case report forms. The mean costs and effects, average cost differences and incremental cost-effectiveness ratios (ICER) were calculated using non-parametric bootstrap resampling to assess the effect of uncertainty in the estimates.

RESULTS

Cumulative LBR after one completed cycle were 239/608 (39.3%) in the IVM group versus 155/311 (49.8%) in the IVF group (adjusted odds ratio 0.52, 95% confidence interval [CI] 0.30-0.89). Ovarian hyperstimulation syndrome (OHSS) did not occur in the IVM group versus 11/311 (3.5%) in the IVF group. The mean costs per couple were €4300 (95% CI €1371-18,798) for IVM and €6493 (95% CI €2204-20,136) for IVF. The ICER per additional live birth with IVF was €20,144 (95% CI €9116-50,418). Results were robust over a wide range of assumptions.

CONCLUSIONS

IVM is less expensive than IVF in women with a high AFC undergoing treatment with assisted reproductive technology, while leading to a slightly lower effectiveness in terms of cumulative LBR.

Association between Vitamin D Levels and Fertility Outcomes in Patients Undergoing IVF/ICSI

Background: Several studies have demonstrated that vitamin D (vitD) might play an important role in the reproductive system due to expression of vitD receptor and vitD-metabolizing enzymes in many reproductive tissues. VitD deficiency has been associated with increased risk of obstetric complications. However, the effect of vitD levels on in vitro fertilization (IVF)/ICSI outcomes is not fully understood. Evidence shows that women with adequate vitD levels might have higher pregnancy rates. This study evaluated the association between serum vitD levels and IVF/ICSI outcomes.

Methods: This multicenter, retrospective cohort study was conducted at IVFMD, My Duc Hospital and IVFMDPN, My Duc Phu Nhuan Hospital, Ho Chi Minh City, Vietnam between November 2017 and July 2019. Vietnamese patients aged 18–40 years with serum vitD (25(OH)D) samples collected before starting controlled ovarian stimulation and undergoing embryo transfer were eligible. Patients were divided into four groups based on 25(OH)D levels: <10 ng/mL, 10 to <20 ng/mL, 20 to <30 ng/mL, and [Formula: see text]30 ng/mL. The primary outcome was ongoing pregnancy rate.

Results: Of 3779 patients recruited, 25(OH)D levels were <10 ng/mL in 564 (14.9%), 10 to <20 ng/mL in 436 (11.5%), 20 to <30 in 1,142 (30.2%), and [Formula: see text]30 ng/mL in 1,637 (43.3%). Ongoing pregnancy rates were similar across the four subgroups (36%, 40%, 36%, and 36%, respectively; p = 0.409). The number of oocytes retrieved, embryos, clinical pregnancy, implantation, and miscarriage rates did not differ significantly between subgroups.

Conclusions: In this analysis, serum vitD levels did not appear to be correlated with pregnancy outcomes in patients undergoing IVF/ICSI.

Angioleiomyoma presenting as a lateral neck lump: a diagnostic dilemma

Angioleiomyomas are defined as benign dermal or subcutaneous tumours consisting of smooth muscle cells arranged around vascular channels. Head and neck angioleiomyomas are rarely encountered as they usually occur in the extremities. We report a case of a 71-year-old male, who presented with a 3-month history of a painless lateral neck lump. Ultrasound and computed tomography scans localised the suspicious hypervascular tumour to the right supraclavicular fossa between the two heads of sternocleidomastoid muscle. He subsequently underwent an excisional biopsy, where histological analysis determined that the lateral neck mass was a venous subtype angioleiomyoma. To the best of our knowledge, this is only the third reported case of an angioleiomyoma in the supraclavicular fossa. Although supraclavicular masses are typically synonymous with malignancy, this case report highlights that angioleiomyoma should be considered as a differential diagnosis when investigating patients with a lateral neck lump.

Live births after oocyte in vitro maturation with a prematuration step in women with polycystic ovary syndrome

Purpose

Standard oocyte in vitro maturation (IVM) usually results in lower pregnancy rates than in vitro fertilization (IVF). IVM preceded by a prematuration step improves the acquisition of oocyte developmental competence and can enhance embryo quality (EQ). This study evaluated the effectiveness of a biphasic culture system incorporating prematuration and IVM steps (CAPA-IVM) versus standard IVM in women with polycystic ovarian morphology (PCOM).

Methods

Eighty women (age < 38 years, ≥ 25 follicles of 2–9 mm in both ovaries, no major uterine abnormalities) were randomized to undergo CAPA-IVM (n = 40) or standard IVM (n = 40). CAPA-IVM uses two steps: a 24-h prematuration step with C-type natriuretic peptide-supplemented medium, then 30 h of culture in IVM media supplemented with follicle-stimulating hormone and amphiregulin. Standard IVM was performed using routine protocols.

Results

A significantly higher proportion of oocytes reached metaphase II at 30 h after CAPA-IVM versus standard IVM (63.6 vs 49.0; p < 0.001) and the number of good quality embryos per cumulus-oocyte complex tended to be higher (18.9 vs 12.7; p = 0.11). Clinical pregnancy rate per embryo transfer was 63.2% in the CAPA-IVM versus 38.5% in the standard IVM group (p = 0.04). Live birth rate per embryo transfer was not statistically different between the CAPA-IVM and standard IVM groups (50.0 vs 33.3% [p = 0.17]). No malformations were reported and birth weight was similar in the two treatment groups.

Conclusions

Use of the CAPA-IVM system significantly improved maturation and clinical pregnancy rates versus standard IVM in patients with PCOM. Furthermore, live births after CAPA-IVM are reported for the first time.

Determinants of the hCG Concentration in the Early Luteal Phase After Final Maturation of Follicles With Bolus Trigger of Recombinant hCG

Introduction: It has recently been shown that late follicular phase progesterone levels correlate well with those in the early luteal phase, and that progesterone levels before and 12 h after human chorionic gonadotropin (hCG) administration predict levels during the early luteal phase. This study investigated determinants of serum hCG levels after a bolus dose of hCG for triggering ovulation in women undergoing in vitro fertilization (IVF). Materials and Methods: This retrospective analysis was performed on data from a prospective study of women aged 18-42 years with normal ovarian reserve receiving gonadotropin-releasing hormone (GnRH) antagonist co-treatment during ovarian stimulation with follicle-stimulating hormone (FSH) who were followed until 6 days after oocyte pick-up (OPU) in a single IVF cycle. The main outcome measures were early luteal phase serum hCG levels, and predictors of those levels. Results: There was wide inter-individual variability in early phase hCG concentrations over the period from 12 h after hCG injection up to 6 days after OPU. Patients with serum hCG values in the bottom 10% had a significantly higher body mass index (BMI; p = 0.038) and a significantly longer duration of stimulation (p = 0.014) than those with higher serum hCG values. Serum progesterone levels up to the first 36 h after hCG injection were significantly higher in the low vs. higher serum hCG group, but were similar at all other time points. There was a significant correlation between serum hCG level after hCG administration and BMI (lower BMI = higher serum hCG). In a cluster analysis, patients with the lowest serum hCG and progesterone levels at 12 h after hCG injection had significantly higher BMI, and significantly lower anti-Müllerian hormone level, duration of stimulation, and number of follicles of ≥11 and ≥14 mm compared with the other three clusters. Conclusion: Predictors of low serum hCG after a trigger bolus were difficult to determine, but BMI seems to be important. More detailed information on the luteal phase hormonal profile and data on predictors of hormone levels during this critical period can facilitate the development of strategies to allow individualization of the luteal phase support regimen, potentially improving IVF outcomes.

Live Birth Rate After Transfer of Fresh or Frozen Poor Quality Day-3 Embryos Only

Background: Embryo quality is an important predictor of successful outcome in in vitro fertilization (IVF). However, current knowledge on the live birth rate after transfer of poor quality embryos is limited. This study investigated the live birth rate after transfer of only poor quality day-3 embryos in women undergoing IVF.

Methods: This retrospective study included 153 couples who underwent IVF at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam between June 2014 and January 2017 and had only poor quality day-3 embryos available for fresh (n [Formula: see text] 102) or frozen (n [Formula: see text] 51) transfer. The control group included patients who had transfer of one good embryo (n [Formula: see text] 64). Embryos were rated using the Istanbul criteria.

Results: In the poor quality embryo group, the mean number of oocytes retrieved and number of embryos were 7.5 ± 4.4 and 1.8 ± 0.9, respectively. Mean number of embryos transferred was 1.6 ± 0.5 in the fresh transfer group and 2.0 ± 0.2 in the freeze-only group. Live births did occur after transfer of poor quality embryos, but the implantation, clinical pregnancy and live birth rates were significantly lower than after fresh or frozen transfer of a single good quality embryo (9.5 vs. 26.6%, p < 0.001; 13.7 vs. 26.6%, p < 0.001; and 7.2 vs. 18.8%, p [Formula: see text] 0.02, respectively).

Conclusions: Live birth was achieved after transfer of only poor quality embryos in women undergoing IVF. This suggests that transfer of poor quality embryos could be an option when higher grade embryos are not available, after the chances of live birth have been discussed with the patient.

The effect of intra-ovarian androgen priming on ovarian reserve parameters in Bologna poor responders

RESEARCH QUESTION

What are the effects of long-term androgen priming in Bologna criteria poor ovarian reserve (POR) patients undergoing IVF?

DESIGN

This open-label pilot study was conducted at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam. It included consecutive patients aged 18-41 years who fulfilled Bologna criteria for POR undergoing intra-ovarian androgen priming and ultra-long down-regulation with a gonadotrophin-releasing hormone agonist (GnRHa), followed by stimulation with gonadotrophins and GnRH antagonist co-treatment for IVF (n = 30). Priming consisted of low-dose recombinant human chorionic gonadotrophin (rHCG) 260 IU every second day plus letrozole 2.5 mg/day, both for 8 weeks; priming stopped on the first day of ovarian stimulation. The primary endpoint was serum anti-Müllerian hormone (AMH) concentration 8 weeks after priming. Secondary endpoints included antral follicle count (AFC) (2-10 mm), serum human chorionic gonadotrophin (HCG), testosterone and progesterone levels.

RESULTS

Circulating testosterone, progesterone, oestradiol and HCG levels remained unchanged during androgen priming; the mean AMH level decreased steadily from 0.49 ng/ml (baseline) to 0.33 ng/ml (8 weeks). AFC was 4-5 throughout the study. A mean of 1.1 ± 0.9 good transferable embryos were obtained; embryo transfer was performed in 15 patients; no ongoing pregnancies were obtained.

CONCLUSIONS

Long-term intra-ovarian androgen priming in the current set-up had no significant effect on hormone levels, AFC and recruitable follicles after ovarian stimulation in Bologna POR patients undergoing IVF. Further studies are needed to explore other androgen priming protocols and the clinical value of priming regimens in IVF.

Abstract 4618: A novel Pik3ca-driven mouse model and syngeneic cancer cell line for the preclinical testing of targeted and immune therapies for anal squamous cell carcinoma (ASCC)

Although many patients with localised anal squamous cell carcinoma (ASCC) initially achieve a complete response with standard chemoradiotherapy, those with persistent, relapsed or metastatic disease (35% of all patients) have limited treatment options and poor outcomes. Recent genomic profiling studies have identified PIK3CA as the most frequently mutated gene in anal cancers. Amplification of the PIK3CA gene and mutations in other PI3K pathway genes, have also been detected providing a strong rationale for targeting the PI3K pathway in these tumours. Similarly, the finding that many ASCC tumours express immune checkpoint receptors including PD-L1, has focussed attention on the potential use of checkpoint blockade in anal cancer. However, the use of targeted and/or immune therapies in the management of ASCC has been hampered by a lack of representative preclinical models for in vitro and in vivo testing of potential new therapeutic approaches. We have used mice with a Cre recombinase (Cre)-conditional knock-in of the Pik3caH1047R mutation and deletion of PTEN, crossed with mice expressing a tamoxifen-inducible Cre under the control of the ubiquitin C promoter, to generate a novel model of ASCC. By applying 4-hydroxy-tamoxifen topically to the anal canal we simultaneously induce expression of Pik3caH1047R and deletion of PTEN specifically in the anal epithelium. This results in anal tumors within 3 weeks with 100% penetrance. As all mice are on a C57Bl/6 background we are able to transplant the tumors subcutaneously into wild type C57Bl/6 mice as a syngeneic graft. To improve the utility of the model, we used tumors from these mice to establish a syngeneic mouse ASCC cell line. This line was then transduced with a human papilloma virus 16 E6/7 lentivirus to recapitulate the human virally-driven form of the disease. The cell line expresses both the Pik3ca mutation and E6/7 oncogenes and is positive for the squamous markers p63 and CK5/6. It had a similar response to 5-fluorouracil, Mitomycin C and radiotherapy, as a panel of human ASCC cell lines (also derived in our laboratory) and was sensitive to a PI3K inhibitor (BYL719). It was tumorigenic in both immunocompetent C57Bl/6 and immunodeficient NSG mice, additionally developing lung metastases in the NSG mice. The syngeneic C57Bl/6 tumors induce a peri-tumoral infiltrate, consisting of a heavy myeloid population, with high PDL1 expression, and a T-cell population expressing PD1; similar to human patients with treatment resistant disease. A major barrier to identifying new treatment options and improving overall survival in anal cancer has been the lack of preclinical models. We have now generated and characterised a novel, relevant Pik3ca-driven mouse model and syngeneic cancer cell line that will facilitate the in vitro and in vivo preclinical testing of targeted and immune therapies for ASCC.

Citation Format: Glen R. Guerra, Sara Roth, Joseph C. Kong, Rosemary M. Millen, David S. Liu, Shienny Sampurno, Vignesh Narasimhan, Toan D. Pham, Karen G. Montgomery, Alexander G. Heriot, Robert G. Ramsay, Wayne A. Phillips. A novel Pik3ca-driven mouse model and syngeneic cancer cell line for the preclinical testing of targeted and immune therapies for anal squamous cell carcinoma (ASCC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4618.

Abstract 1472: Novel vaccine targeting colonic adenoma: A pre-clinical model

Background

Colorectal cancer (CRC) is the second leading cause of cancer related mortality. Over 80% of CRC develop from adenomatous polyps. Hence, early treatment and prevention of adenomas would lead to a significant decrease of disease burden for CRC. MYB is a transcription factor that is over-expressed in both adenomatous polyp precursors and colorectal cancer and hence an ideal immunotherapeutic target. We have developed a cancer vaccine, TetMYB, that targets MYB and aim to evaluate its efficacy in the prophylactic and therapeutic management of adenomatous polyps.

Material and Methods

Six to eight-week-old Apcmin/+ (Familial Adenomatous Polyposis model) and Apc580S (sporadic model) C57BL/6 mice were used. The Apcmin/+ mice are carried a germline mutation of one Apc allele whereas the Apc580S model has an inducible silencing of one Apc allele, when exposed to Tamoxifen, via the Cre-Lox recombination enzyme system.

In the prophylactic treatment group, Apcmin/+ and Apc580S C57BL/6 mice were vaccinated and then surveyed for clinical signs of distress according to animal ethical endpoints. Number of adenoma and survival were measured.

In the therapeutic cohort, Apc580S C57BL/6 mice were given Tamoxifen-laced food to activate Cre-Lox recombinase mediated silencing of one Apc allele and thus inducing adenoma development. Following adenoma detection using mouse colonoscopy, mice were vaccinated with TetMYB and treated with anti-PD-1 antibody and were analyzed for adenoma growth rate.

Results

In both the prophylactic and therapeutic setting, mice vaccinated with TetMYB had a significantly improved outcome.

In the prophylactic treatment group, the vaccinated Apcmin/+ mice had a median survival benefit of 70 days (p = 0.008) and the vaccinated Apc580S mice having a mean survival benefit of 134 days (p = 0.01) over the unvaccinated mice.

In the prophylactic cohort, immunofluorescence confirmed a stronger cytotoxic CD8+ T-cell infiltrate in the vaccinated group, implying an anti-tumor immune response. In the therapeutic cohort, vaccinated Apc580S mice showed significantly reduced adenoma growth rate compared to the unvaccinated mice (p = 0.0005).

Conclusion

TetMYB vaccine has shown benefit in a prophylactic and therapeutic setting in the management of colonic adenoma in a murine model. This will form the basis for a future clinical trial to prevent and treat colonic adenomatous polyps, and perhaps colorectal cancer prevention.

Citation Format: Toan D. Pham, Sandra Carpinteri, Shienny Sampurno, Lloyd Pereira, Sara Roth, Vignesh Narasimhan, Kasmira Wilson, Phillip Darcy, Jayesh Desai, Alexander G. Heriot, Robert G. Ramsay. Novel vaccine targeting colonic adenoma: A pre-clinical model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1472.

Gonadotropin-Releasing Hormone Agonist Versus Human Chorionic Gonadotropin for Ovulation Induction in Polycystic Ovary Syndrome Patients Undergoing Intrauterine Insemination: A Randomised Controlled Trial

Background: Gonadotropins have been recommended to improve ovulation, pregnancy and live birth rates in polycystic ovary syndrome (PCOS) patients with anovulatory infertility and clomiphene citrate (CC) resistance. However, this could increase the risk of ovarian hyperstimulation syndrome (OHSS). Gonadotropin-releasing hormone agonist (GnRHa) triggering could significantly reduce the risk of OHSS in patients undergoing in vitro fertilisation. However, data on the use of GnRHa in intrauterine insemination (IUI) is limited. This study compared the effectiveness of GnRHa and human chorionic gonadotropin (hCG) for ovulation induction in PCOS patients undergoing IUI.

Methods: This non-inferiority, single-centre, randomised controlled trial was conducted at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam between April 2016 and May 2018. PCOS patients aged 18–37 years with CC resistance and [Formula: see text] 3 developing ([Formula: see text] 16 mm) follicles on trigger day after stimulation with gonadotropins were eligible. Those with uterine abnormalities or tubal damage or inseminated with frozen semen were excluded. Triptorelin 0.1 mg or hCG 5000 IU was used when there was [Formula: see text] 1 follicle of [Formula: see text] 17 mm. IUI was performed at 36 hours after triggering. Primary outcome was ongoing pregnancy. Secondary outcomes were clinical pregnancy, multiple pregnancy, miscarriage and OHSS.

Results: A total of 380 patients were randomised (190 per group). Treatment groups had similar characteristics at baseline. Ongoing pregnancy rate was 23.7% in the GnRHa group versus 25.3% in the hCG group (Relative risk 0.94; 95% confidence interval, 0.66–1.34; p [Formula: see text] 0.81). Secondary outcome parameters were also not significantly different between the two groups. There were two cases of mild OHSS in the hCG group and none in the GnRHa group.

Conclusion: 0.1 mg triptorelin was non-inferior to 5000 IU hCG IU in PCOS patients undergoing ovulation induction by hMG followed by IUI with respect to pregnancy outcomes.

Use of Corifollitropin Alfa for Ovarian Stimulation: A Retrospective Analysis of 804 Women Undergoing IVF/ICSI

Background: Corifollitropin alfa in GnRH antagonist protocol could provide a friendly treatment for IVF patients. There is limited evidence regarding the outcomes of corifollitropin alfa in ovarian hyperstimulation in Asian population.

Methods: This was a retrospective study conducted on IVF women from July 2012 to July 2018. The recruited patients were expected normal responders, expected poor responders and oocyte donors. The patients underwent GnRH antagonist protocol with corifollitropin alfa.

Results: There were 804 IVF patients included in the study. The patients were analyzed into: normal ovarian reserve-autologous cycles ([Formula: see text] 36 years and [Formula: see text] 60 kg, n = 33; [Formula: see text] 36 years and [Formula: see text] 60 kg, n [Formula: see text] 9; [Formula: see text] 36 years and [Formula: see text] 50 kg, n [Formula: see text] 204; [Formula: see text] 36 years and [Formula: see text] 50 kg, n [Formula: see text] 52), normal ovarian reserve-donor cycles ([Formula: see text] 60 kg, n [Formula: see text] 234; [Formula: see text] 60 kg, n [Formula: see text] 104) and diminished ovarian reserve cycles (n [Formula: see text] 168). In each group of patients, the pregnancy outcomes of fresh embryo transfer were comparable to those of frozen embryo transfer.

Conclusions: Corifollitropin alfa could offer an effective and simple treatment option for all groups of patients without PCOS.

A cost-effectiveness analysis of freeze-only or fresh embryo transfer in IVF of non-PCOS women

STUDY QUESTION

Is a freeze-only strategy more cost-effective from a patient perspective than fresh embryo transfer (ET) after one completed In Vitro Fertilization/ Intracytoplasmic Sperm Injection (IVF/ICSI) cycle in women without polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

There is a low probability of the freeze-only strategy being cost-effective over the fresh ET strategy for non-PCOS women undergoing IVF/ICSI.

WHAT IS KNOWN ALREADY

Conventionally, IVF embryos are transferred in the same cycle in which oocytes are collected, while any remaining embryos are frozen and stored. We recently evaluated the effectiveness of a freeze-only strategy compared with a fresh ET strategy in a randomized controlled trial (RCT). There was no difference in live birth rate between the two strategies.

STUDY DESIGN, SIZE, DURATION

A cost-effectiveness analysis (CEA) was performed alongside the RCT to compare a freeze-only strategy with a fresh ET strategy in non-PCOS women undergoing IVF/ICSI. The effectiveness measure for the CEA was the live birth rate. Data on the IVF procedure, pregnancy outcomes and complications were collected from chart review; additional information was obtained using patient questionnaires, by telephone.

PARTICIPANTS/MATERIALS, SETTING, METHODS

For all patients, we measured the direct medical costs relating to treatment (cryopreservation, pregnancy follow-up, delivery), direct non-medical costs (travel, accommodation) and indirect costs (income lost). The direct cost data were calculated from resources obtained from patient records and prices were applied based on a micro-costing approach. Indirect costs were calculated based on responses to the questionnaire. Patients were followed until all embryos obtained from a single controlled ovarian hyperstimulation cycle were used or a live birth was achieved. The incremental cost-effectiveness ratio (ICER) was based on the incremental cost per couple and the incremental live birth rate of the freeze-only strategy compared with the fresh ET strategy. Probabilistic sensitivity analysis (PSA) and a cost-effectiveness acceptability curve (CEAC) were also performed.

MAIN RESULTS AND THE ROLE OF CHANCE

Between June 2015 and April 2016, 782 couples were randomized to a freeze-only (n = 391) or a fresh ET strategy (n = 391). Baseline characteristics including mean age, Body Mass Index (BMI), anti-Mullerian hormone, total dose of Follicle Stimulating Hormone (FSH), number of oocytes obtained, good quality Day 3 embryos, fertility outcomes and treatment complications were comparable between the two groups. The live birth rate (48.6% vs. 47.3%, respectively; risk ratio, 1.03; 95% Confidence Interval [CI], 0.89, 1.19; P = 0.78) and the average cost per couple (3906 vs. 3512 EUR, respectively; absolute difference 393.6, 95% CI, -76.2, 863.5; P = 0.1) were similar in the freeze-only group versus fresh ET. Corresponding costs per live birth were 8037 EUR versus 7425 EUR in the freeze-only versus fresh ET group, respectively. The incremental cost for the freeze-only strategy compared with fresh ET was 30 997 EUR per 1% additional live birth rate. The direct non-medical costs and indirect costs of infertility treatment strategies represented ~45-52% of the total cost. PSA shows that the 95% CI of ICERs was -263 901 to 286 681 EUR. Out of 1000 simulations, 44% resulted in negative ICERs, including 13.0% of simulations in which the freeze-only strategy was dominant (more effective and less costly than fresh ET), and 31% of simulations in which the fresh embryo strategy was dominant. In the other 560 simulations with positive ICERs, the 95% CI of ICERs ranged from 2155 to 471 578 EUR. The CEAC shows that at a willingness to pay threshold of 300 000 EUR, the probability of the freeze-only strategy being cost-effective over the fresh ET strategy would be 58%.

LIMITATIONS, REASONS FOR CAUTION

Data were collected from a single private IVF center study in Vietnam where there is no public or insurance funding of IVF. Unit costs obtained might not be representative of other settings. Data obtained from secondary sources (medical records, financial and activity reports) could lack authenticity, and recall bias may have influenced questionnaire responses on which direct costs were based.

WIDER IMPLICATIONS OF THE FINDINGS

In non-PCOS women undergoing IVF/ICSI, the results suggested that the freeze-only strategy was not cost-effective compared with fresh ET from a patient perspective. These findings indicate that other factors could be more important in deciding whether to use a freeze-only versus fresh ET strategy in this patient group.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by My Duc Hospital; no external funding was received. Ben Willem J. Mol is supported by an NHMRC Practioner Fellowship (GNT 1082548) and reports consultancy for Merck, ObsEva and Guerbet. Robert J. Norman has shares in an IVF company and has received support from Merck and Ferring. All other authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Proceed or palliate: Surgicel® mimicking tumor recurrence and causing a small bowel obstruction

Surgicel® is a commonly used hemostatic agent. We report a case of small bowel obstruction secondary to the prior placement of Surgicel® within the peritoneal cavity, and the radiological diagnosis conundrum and potential prognostic implications this finding has in a patient with a known history of malignancy.

Live birth rates with a freeze-only strategy versus fresh embryo transfer: secondary analysis of a randomized clinical trial

RESEARCH QUESTION

What are the roles of serum progesterone and endometrial thickness as biomarkers in the decision between a freeze-only and fresh embryo transfer in IVF for women without polycystic ovary syndrome (PCOS)?

DESIGN

This was a secondary analysis of a randomized controlled trial including 782 couples who were followed up until the end of the first completed cycle. Couples scheduled for their first or second IVF cycle with a FSH/gonadotrophin-releasing hormone antagonist protocol were randomized to a freeze-only (n = 391) or fresh embryo transfer (n = 391) strategy. The endpoint for this analysis was live birth rate (LBR) after the first embryo transfer.

RESULTS

There was no significant difference in LBR after the first cycle between a freeze-only and fresh transfer strategy. When serum progesterone levels at trigger were in the third quartile (Q3, 1.14-1.53 ng/ml), LBR was significantly higher in the freeze-only versus fresh transfer group (P = 0.01); when serum progesterone was ≥1.14 ng/ml, LBR was significantly better in the freeze-only group (37.4% versus 23.8% in the fresh transfer group; P = 0.004). LBRs in the freeze-only and fresh embryo transfer groups were similar across all quartiles of endometrial thickness, although a small advantage for freeze-only in women with a very thin endometrium could not be excluded.

CONCLUSIONS

Serum progesterone level on the day of trigger may have potential as a biomarker on which to base a prospective decision about whether to use a freeze-only or fresh embryo transfer strategy in women undergoing IVF.

Effectiveness and safety of in vitro maturation of oocytes versus in vitro fertilisation in women with high antral follicle count: study protocol for a randomised controlled trial

INTRODUCTION

In vitro maturation (IVM) is a potential alternative to conventional in vitro fertilisation (IVF) to avoid ovarian hyperstimulation syndrome (OHSS). This is particularly relevant in women with a high antral follicle count (AFC) and/or polycystic ovary syndrome (PCOS), who are at increased risk for OHSS. However, no randomised controlled trials of IVM versus IVF in women with high AFC have reported both pregnancy and OHSS rates. The aim of this study is to compare the effectiveness and safety of one IVM cycle and one IVF with segmentation cycle within women with PCOS or high AFC-related subfertility.

METHODS AND ANALYSIS

This randomised controlled trial will be conducted at a specialist IVF centre in Vietnam. Eligible subfertile women with PCOS and/or high AFC will be randomised to undergo either IVM or IVF. The primary outcome is live birth after the first embryo transfer of the started treatment cycle. Cycles in which no embryo is available for transfer will be considered as failures. The study has a non-inferiority design, with a maximal acceptable between-group difference of 5%. Rates of OHSS will also be reported.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the participating centre, and informed patient consent was obtained before study enrolment. Results of the study will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03405701; Pre-results.

IVF Transfer of Fresh or Frozen Embryos in Women without Polycystic Ovaries

BACKGROUND

Among women who are undergoing in vitro fertilization (IVF), the transfer of frozen embryos has been shown to result in a higher rate of live birth than the transfer of fresh embryos in those with infertility associated with the polycystic ovary syndrome. It is not known whether frozen-embryo transfer results in similar benefit in women with infertility that is not associated with the polycystic ovary syndrome.

METHODS

We randomly assigned 782 infertile women without the polycystic ovary syndrome who were undergoing a first or second IVF cycle to receive either a frozen embryo or a fresh embryo on day 3. In the frozen-embryo group, all grade 1 and 2 embryos had been cryopreserved, and a maximum of two embryos were thawed on the day of transfer in the following cycle. In the fresh-embryo group, a maximum of two fresh embryos were transferred in the stimulated cycle. The primary outcome was ongoing pregnancy after the first embryo transfer.

RESULTS

After the first completed cycle, ongoing pregnancy occurred in 142 of 391 women (36.3%) in the frozen-embryo group and in 135 of 391 (34.5%) in the fresh-embryo group (risk ratio in the frozen-embryo group, 1.05; 95% confidence interval [CI], 0.87 to 1.27; P=0.65). Rates of live birth after the first transfer were 33.8% and 31.5%, respectively (risk ratio, 1.07; 95% CI, 0.88 to 1.31).

CONCLUSIONS

Among infertile women without the polycystic ovary syndrome who were undergoing IVF, the transfer of frozen embryos did not result in significantly higher rates of ongoing pregnancy or live birth than the transfer of fresh embryos. (Funded by My Duc Hospital; ClinicalTrials.gov number, NCT02471573 .).

Emergence of New Delhi metallo-beta-lactamase 1 and other carbapenemase-producing Acinetobacter calcoaceticus-baumannii complex among patients in hospitals in Ha Noi, Viet Nam

Acinetobacter baumannii is an important cause of multidrug-resistant hospital acquired infections in the world. Here, we investigate the presence of NDM-1 and other carbapenemases among carbapenem-resistant A. baumannii isolated between August 2010 and December 2014 from three large hospitals in Hanoi, Vietnam. We identified 23/582 isolates (4 %) (11 from hospital A, five from hospital B, and seven from hospital C) that were NDM-1 positive, and among them 18 carried additional carbapenemase genes, including seven isolates carrying NDM-1, IMP-1, and OXA-58 with high MICs for carbapenems. Genotyping indicated that NDM-1 carrying A. baumannii have expanded clonally in these hospitals. Five new STs (ST1135, ST1136, ST1137, ST1138, and ST1139) were identified. One isolate carried NDM-1 on a plasmid belonging to the N-repA replicon type; no NDM-1-positive plasmids were identified in the other isolates. We have shown the extent of the carbapenem resistance and the local clonal spread of A. baumannii carrying NDM-1 in these hospitals; coexistence of NDM-1 and IMP-1 is reported for the first time from Vietnam here, and this will further seriously limit future therapeutic options.

Detection of tubule boundaries based on circular shortest path and polar-transformation of arbitrary shapes

In studies of germ cell transplantation, counting cells and measuring tubule diameters from different populations using labelled antibodies are important measurement processes. However, it is slow and sanity grinding to do these tasks manually. This paper proposes a way to accelerate these processes using a new image analysis framework based on several novel algorithms: centre points detection of tubules, tubule shape classification, skeleton-based polar-transformation, boundary weighting of polar-transformed image, and circular shortest path smoothing. The framework has been tested on a dataset consisting of 27 images which contain a total of 989 tubules. Experiments show that the detection results of our algorithm are very close to the results obtained manually and the novel approach can achieve a better performance than two existing methods.

A curvelet-based morphological segmentation of abdominal CT images

This paper presents a segmentation methodology of abdominal axial CT images. The aim of the study is to determine the location of mesenteric area from the axial images so the organs enclosed within can be localized precisely for diagnostic purposes. The challenge confronted here is that there is no a certain deterministic shape of abdominal organs. The methodology implemented here utilizes a curvelets stage followed by morphological image processing to achieve a contour emphasized segmentation from the gestalts of surrounding organs. This paper gives a detailed analysis of approach taken with the problems faced and a brief comparison wrt to other wavelet approaches.

Segmentation of clustered nuclei based on concave curve expansion

Segmentation of nuclei from images of tissue sections is important for many biological and biomedical studies. Many existing image segmentation algorithms may lead to oversegmentation or undersegmentation for clustered nuclei images. In this paper, we proposed a new image segmentation algorithm based on concave curve expansion to correctly and accurately extract markers from the original images. Marker-controlled watershed is then used to segment the clustered nuclei. The algorithm was tested on both synthetic and real images and better results are achieved compared with some other state-of-the-art methods.

Enteric dopaminergic neurons: definition, developmental lineage, and effects of extrinsic denervation

The existence of enteric dopaminergic neurons has been suspected; however, the innervation of the gut by sympathetic nerves, in which dopamine (DA) is the norepinephrine precursor, complicates analyses of enteric DA. We now report that transcripts encoding tyrosine hydroxylase (TH) and the DA transporter (DAT) are present in the murine bowel (small intestine > stomach or colon; proximal colon > distal colon). Because sympathetic neurons are extrinsic, transcripts encoding TH and DAT in the bowel are probably derived from intrinsic neurons. TH protein was demonstrated immunocytochemically in neuronal perikarya (submucosal >> myenteric plexus; small intestine > stomach or colon). TH, DA, and DAT immunoreactivities were coincident in subsets of neurons (submucosal > myenteric) in guinea pig and mouse intestines in situ and in cultured guinea pig enteric ganglia. Surgical ablation of sympathetic nerves by extrinsic denervation of loops of the bowel did not affect DAT immunoreactivity but actually increased numbers of TH-immunoreactive neurons, expression of mRNA encoding TH and DAT, and enteric DOPAC (the specific dopamine metabolite). The fetal gut contains transiently catecholaminergic (TC) cells. TC cells are the proliferating crest-derived precursors of mature neurons that are not catecholaminergic and, thus, disappear after embryonic day (E) 14 (mouse) or E15 (rat). TC cells appear early in ontogeny, and their development/survival is dependent on mash-1 gene expression. In contrast, the intrinsic TH-expressing neurons of the murine bowel appear late (perinatally) and are mash-1 independent. We conclude that the enteric nervous system contains intrinsic dopaminergic neurons that arise from a mash-1-independent lineage of noncatecholaminergic precursors.

Neurotrophin-3 is required for the survival-differentiation of subsets of developing enteric neurons

Neurotrophin-3 (NT-3) promotes enteric neuronal development in vitro; nevertheless, an enteric nervous system (ENS) is present in mice lacking NT-3 or TrkC. We thus analyzed the physiological significance of NT-3 in ENS development. Subsets of neurons developing in vitro in response to NT-3 became NT-3 dependent; NT-3 withdrawal led to apoptosis, selectively in TrkC-expressing neurons. Antibodies to NT-3, which blocked the developmental response of enteric crest-derived cells to exogenous NT-3, did not inhibit neuronal development in cultures of isolated crest-derived cells but did so in mixed cultures of crest- and non-neural crest-derived cells; therefore, the endogenous NT-3 that supports enteric neuronal development is probably obtained from noncrest-derived mesenchymal cells. In mature animals, retrograde transport of (125)I-NT-3, injected into the mucosa, labeled neurons in ganglia of the submucosal but not myenteric plexus; injections of (125)I-NT-3 into myenteric ganglia, the tertiary plexus, and muscle, labeled neurons in underlying submucosal and distant myenteric ganglia. The labeling pattern suggests that NT-3-dependent submucosal neurons may be intrinsic primary afferent and/or secretomotor, whereas NT-3-dependent myenteric neurons innervate other myenteric ganglia and/or the longitudinal muscle. Myenteric neurons were increased in number and size in transgenic mice that overexpress NT-3 directed to myenteric ganglia by the promoter for dopamine beta-hydroxylase. The numbers of neurons were regionally reduced in both plexuses in mice lacking NT-3 or TrkC. A neuropoietic cytokine (CNTF) interacted with NT-3 in vitro, and if applied sequentially, compensated for NT-3 withdrawal. These observations indicate that NT-3 is required for the normal development of the ENS.