Embryology Laboratory Research Articles

A Significant Correlation of Glutamine and Interlukin-6 with Pregnancy Rate in Women Undergoing ICSI

Background: The composition of follicular fluid (FF) is significantly influenced by metabolic factors, and the analyses of metabolites in FF could reveal the correlation between metabolites and oocyte quality, embryo development, and pregnancy outcome. FF provides nutrients and growth factors that promote oocyte growth, development, and maturation. Objective: To investigate the relationship between serum and FF glutamine and FF IL-6 levels and their influence on the pregnancy rate in women who are undergoing an ICSI treatment cycle. Materials and Methods: A prospective cross-sectional study was performed on 90 women aged 20- 44 years who underwent ICSI treatment from July 2023 to February 2024. Serum and follicular fluid collected on the day of oocyte pick-up were used as biological material. The embryological laboratory examined the retrieved follicular fluid and collected oocytes using stereomicroscopy. ELISA analysed serum, FF glutamine and FF IL-6. The ICSI method was utilized for fertilization. The pregnancy test is done by measuring serum BHCG. Statistical data processing was conducted using the software package SPSS 23. Results: There was a highly significant correlation between FF glutamine and FF IL-6 (p < 0.001) and a positive correlation between FF glutamine and FF IL-6 with pregnancy rate ( p < 0.001) (p < 0.001 ). Conclusion The correlation of FF glutamine and FF IL-6 affects the pregnancy rate in women undergoing ICSI. FF glutamine and FF IL-6 can be considered predictors for pregnancy while serum glutamine has no significance.

Double Anterior Interventricular Arteries: Prevalence and Morphological Types-A Dissection Study.

This study aimed to evaluate the prevalence of double anterior interventricular artery using the dissection method. A retrospective study was conducted between 2010 and 2024 at the Anatomy and Embryology Laboratory of the Victor Babes University of Medicine and Pharmacy in Timisoara. Eighty cases were analyzed for morphological variants of the coronary arteries, especially the anterior interventricular artery. Two cases of double anterior interventricular arteries were identified. In the first case, the two anterior interventricular arteries originated from the anterior interventricular branch of the left coronary artery. In the second case, an additional anterior interventricular artery with an aortic origin was found running along the lower third of the two interventricular grooves. This shape has not been described before in the specialized literature. Knowing the potential variations of the double left anterior descending artery is critical for interpreting cardiac imaging and choosing and planning percutaneous and surgical reperfusion strategies.

OTO-IVM is a method of fertility preservation for patients with ovarian tumors

Introduction. An increasing number of patients of reproductive age get cancer and are highly interested in preserving fertility. Survival rates for cancer patients are improving. Methods of reproductive technologies are being improved to preserve the ability to bear children. Rehabilitation aimed to ensure a satisfactory quality of life takes on a new meaning, and with the development of new technologies, the level of possible assistance also changes. Today, rehabilitation measures for cancer patients of reproductive age should undoubtedly include all possible ways to preserve and restore fertility. Aim: preservation of fertility in patients with ovarian tumors. Material and Methods. After ovariectomy, the ovaries were transported to the embryology laboratory, where oocyte-cumulus complexes were extracted and subsequently matured using the OTO-IVM (ovarian tissue oocyte in vitro maturation) method. The resulting mature oocytes (Metaphase II) were cryopreserved by vitrification or, if a partner was available, fertilized by ICSI (intracytoplasmic sperm injection), the embryos were cultured to the blastocyst stage and also cryopreserved by vitrification. Cryopreserved oocytes and embryos can be used by patients after cancer treatment in assisted reproductive technology programs. Results. A total of 218 OCCs were recovered, 29.8 % were degraded oocytes (n=65). The proportion of OCC suitable for ripening was 153 (70.2 %). After 36 or 48 hours, 65 oocytes matured in 13 patients, which amounted to 42.5 % of oocytes without signs of degradation. In 11 patients the OCC was removed from the tumor-affected ovary. 149 oocytes were obtained, of which 50 (33.6 %) were oocytes with signs of degradation. The remaining 99 (66.4 %) of OCCs had satisfactory quality; after maturation, the Metaphase II stage reached in 49 (49.5 %) of oocytes. As a result, biological material was cryopreserved in 13 of 15 patients: 5 embryos and 60 oocytes.

Hospital Pharmaceutical Inventory Control in In-Vitro Fertilization Services Using Minimum-Maximum Stock Level

Type C "X" Specialized Hospital in Semarang experienced in vitro fertilization (IVF) and embryology laboratory consumable medical supplies (CMS) stockouts in early 2023, delaying medical care. Minimum-maximum stock level (MMSL) is an alternative pharmaceutical inventory procurement method. Compared to the conventional method, this study examined how well the MMSL method controls IVF medications and embryology laboratory CMS at Hospital “X” Department of Pharmacy. This study is a quantitative, secondary data-based, quasi-experimental, non-equivalent study without a control group. The study sampled all IVF medications and embryology laboratory CMS data from October to December 2023 at Hospital “X” with consistent supply. MMSL was implemented prospectively in January – March 2024. Twelve (12) IVF medications and fifty-six (56) embryology laboratory CMS were studied. Efficiency analysis included inventory value, inventory turnover ratio (ITOR), and stockout value; effectiveness analysis included stockout incidences. Statistics were tested using Wilcoxon signed-rank and McNemar tests. MMSL implementation led to increased inventory value of IVF medications (from IDR21,514,537.00 to IDR49,635,116.00, p=0.040, p<0.05), decreased inventory value of embryology laboratory CMS (from IDR117,421,582.00 to IDR105,318,804.00, p=0.005, p<0.05), and increased ITOR of embryology laboratory CMS (from 0.82 to 0.84 times, p=0.040, p<0.05). MMSL significantly improved IVF medications and embryology laboratory CMS inventory management efficiency.

P-133 Impaired blastocyst viability induced by vitrification during re-expansion after trophectoderm biopsy can be prevented by artificial shrinkage before vitrification

Abstract Study question Does the duration between trophectoderm biopsy and vitrification or blastocyst re-expansion affect blastocyst adhesion and outgrowth competence? Summary answer Outgrowth was impacted when blastocysts were vitrified during re-expansion, especially at 2 h post-biopsy; however, this can be mitigated using artificial shrinkage pre-vitrification. What is known already Biopsied blastocysts are usually vitrified until the results of preimplantation genetic testing for aneuploidy are available. The viability of biopsied blastocysts after vitrification is affected by various factors; in fact, a rodent study reported that the duration from biopsy to vitrification and re-expansion at vitrification affected subsequent developmental competence. The vitrification of biopsied blastocysts immediately post-biopsy is recommended in the clinical setting. However, in some cases, embryologists cannot perform vitrification immediately after a biopsy because of other procedures. In this case, blastocysts start re-expanding, which requires embryologists to wait for the completion of the blastocyst re-expansion. Study design, size, duration Human blastocysts donated for research by consenting couples were randomly allocated into biopsied (n = 175) and non-biopsied (control; n = 50) groups. The re-expansion degree (%) at vitrification was calculated using the following formula: [1- (distance of perivitelline cavity at vitrification)/(distance of perivitelline cavity post-biopsy)] × 100. The blastocysts were categorized according to expansion degree: I, ≤0%; II, 1–49%; III, 50–99%; and IV, ≥100%. Participants/materials, setting, methods Biopsied and control blastocysts were vitrified 0–3 h post-biopsy. Some blastocysts were artificially shrunken in hypertonic solution before the vitrification. The blastocysts were warmed and plated on fibronectin-coated dishes and cultured for 96 h to assess the competence for blastocyst adhesion and outgrowth. The correlations of outgrowth outcomes with vitrification timing, re-expansion degree, and artificial shrinkage were retrospectively analysed. Main results and the role of chance No significant intergroup difference was observed in blastocyst adhesion rate. The multivariate linear regression analysis showed that the blastocyst outgrowth area was significantly smaller when the blastocysts were vitrified at 2 h post-biopsy (P = 0.0103). Re-expansion degree was positively correlated with duration after biopsy (Spearman’s rank correlation coefficient, 0.6921; P < 0.0001). The proportion of expansion in group III was significantly higher at 2 h post-biopsy (P < 0.0001). On multivariate linear regression analysis, the blastocyst outgrowth area was significantly smaller in group III (P = 0.0134). The outgrowth area of blastocysts vitrified at 2 h post-biopsy was significantly increased by artificial shrinkage before vitrification (P = 0.0025) and comparable with those of blastocysts vitrified at 0, 1, and 3 h post-biopsy. Multivariate linear regression analysis also demonstrated the effectiveness of artificial shrinkage for blastocysts vitrified at 2 h post-biopsy and for blastocysts for which re-expansion was initiated at vitrification. Limitations, reasons for caution Since this study used discarded vitrified blastocysts, double vitrification was performed. This was an experimental study; therefore, clinical studies are required to validate our findings. Wider implications of the findings The blastocysts are recommended to be vitrified before the initiation of re-expansion, which complicates the laboratory workflow. Our data demonstrate that blastocysts that expand post-biopsy can be vitrified after artificial shrinkage without decreasing their implantation competence. Our findings may contribute to improving the day-to-day practice in embryology laboratories. Trial registration number Not Applicable

P-757 An artificial intelligence model to predict upcoming patient oocyte collections to help optimize efficiency and safety in the embryology laboratory

Abstract Study question Can artificial intelligence (AI) be used to forecast the number of oocyte collections that will occur at a clinic multiple days in advance? Summary answer An AI model can accurately predict how many oocyte collections will occur across a clinic up to seven days in advance. What is known already There exists significant variability in the duration of ovarian stimulation for patients going through IVF, which can often lead to peaks and valleys of workload for the embryology laboratory. On a given day, a laboratory being under or over resourced can lead to poor utilization of resources or overtime hours. This is especially problematic as the demand for IVF steadily increases, particularly for large clinics doing thousands of oocyte collections (OC) per year. A tool to help predict clinic OC workload many days in advance could assist with laboratory staffing and operational efficiency through load leveling. Study design, size, duration Historical, de-identified electronic medical record data from 6140 patients undergoing ovarian stimulation at a large IVF clinic in the U.S. between January 2021 to January 2023 was collected. Patients who started treatment between January 2021 to December 2021 were used for training the AI model (N = 3126). The remaining patients were used for evaluating the model (N = 3014). Participants/materials, setting, methods A gradient boosting classifier (Catboost) was trained to predict a patient’s remaining cycle duration using E2, follicle sizes, and day of medication. This model outputs a probability that a patient’s OC will land on any specific future day. To predict the number of OC across a clinic on a future day, the model predicts the probability that each patient will have their retrieval on that day, and calculates the convolution to estimate total retrievals. Main results and the role of chance The clinic had an average of 7.9 OC per day. The OC projection accuracy was assessed by iterating through each date in the test dataset and predicting the number of OC each day over the next 7 days, for all patients undergoing stimulation who had not yet been triggered. In this analysis, the model predicted the total number of OC on each day with a mean absolute error of 1.56 retrievals and an R2 of 0.72. The model was able to identify days where workload exceeded 11 OC (80th percentile) with 86% accuracy and 58% precision. The model was able to identify days where workload was below 5 OC (20th percentile) with 95% accuracy and 91% precision. Limitations, reasons for caution This model was trained at a single clinic and evaluated retrospectively. Future work should assess model performance at clinics with varying patient throughput, and evaluate prospectively how this tool could assist with load leveling of OC volume. Wider implications of the findings An AI model can predict when patients will be triggered based on their medication and response to treatment. This tool can be used to forecast the total number of OC at a clinic up to 7 days in advance, which could help improve efficiency for embryology and clinical staff. Trial registration number not applicable

O-319 A randomised trial of time-lapse imaging of embryos in in-vitro-fertilisation treatment

Abstract Study question Do time-lapse imaging (TLI) systems used in IVF/ICSI treatment improve live birth either due to undisturbed culture conditions or improved embryo selection or both? Summary answer In women undergoing IVF/ICSI treatment the use of TLI systems does not significantly increase the odds of live birth compared to standard care without TLI. What is known already TLI systems used in IVF treatment have the potential to improve fertility outcomes either due to undisturbed culture conditions or improved embryo selection or both. However, there remains uncertainty about its benefits. Existing reviews and primary studies predominantly report no differences between the use of TLI and conventional methods. However none of the previous trials were adequaltely powered to detect meaningful differences in live birth and the quality of most trials was deemed to be low to very low. Study design, size, duration TILT (Time-lapse Imaging Trial) is a multi-centre, three-arm, parallel-group, double-blind, randomised controlled trial. Participants were randomly assigned in a 1:1:1 ratio to the TLI system for both undisturbed culture and embryo selection (TLI arm), TLI system for undisturbed culture conditions alone (undisturbed culture arm), and standard care without TLI (control arm). From June 2018 to September 2022, we randomised 1575 participants based on a pre-specified sample size to detect an 8.75% difference in live births. Participants/materials, setting, methods We randomised 1575 couples undergoing IVF/ICSI with broad inclusion criteria across seven IVF centres. The primary outcome was live birth. Secondary outcomes included clinical pregnancy, pregnancy loss, and multiple pregnancy. Primary analysis was performed based on the intention-to-treat principle for all participants with primary outcome data available and the effect estimate reported as an adjusted odds ratio (aOR). Pre-specified sensitivity analyses and subgroup analyses for age and method of embryo transfer were performed. Main results and the role of chance We recruited 2191 and randomised 1575 participants. Live birth data were available for 1558/1575 (98.92%) participants. The livebirth rates were 33.7% (175/520) in the TLI arm, 36.6% (189/516) in the undisturbed culture arm and 33.0% (172/522) in the control arm. The aOR was 1.04 (97.5% confidence interval (CI) 0.73 to 1.47) for TLI arm vs control and 1.20 (97.5% CI 0.85 to 1.70) for undisturbed culture vs control. The clinical pregnancy rates were 42.2% (219/519) in the TLI arm, 43.4% (225/518) in the undisturbed culture arm, and 40.9% (212/519) in the control arm. There were no significant differences for TLI vs control arm (aOR 1.06, 95% CI 0.82-1.38) and undisturbed culture vs control arm (aOR 1.11, 95% CI 0.86-1.46). The rates of pregnancy loss between clinical pregnancy and 24 weeks’ gestation were not statistically different when TLI (8.7%, 45/515) and undisturbed culture arms (6.4%, 33/513) were compared with control arm (8.1%, 42/517) with aOR 1.09 (95% CI 0.66-1.77) and 0.76 (95% CI 0.45-1.29) respectively. None of the other secondary outcomes demonstrated significant differences between the arms The findings were similar irrespective of the woman’s age and use of fresh or frozen embryo replacement, and for all sensitivity analyses, for primary and secondary outcomes. Limitations, reasons for caution Although the trial recruitment was delayed by the SARS-CoV-2 pandemic, this did not impact the results as patient populations, clinical care pathways and time-lapse technology remained similar. The remit of this trial did not allow assessment of the influence of TLI systems on embryology laboratory workflow or perform a health-economic analysis. Wider implications of the findings Our trial provides high-quality definitive evidence of no benefit of the use of TLI systems for embryo incubation and selection to improve success rates in women having IVF and ICSI treatment. Trial registration number ISRCTN17792989

P-690 Medroxyprogesterone acetate versus cetrotide in oocyte donation: Non-randomized clinical trial

Abstract Study question Is oral medroxiprogesterone acetate non-inferior compared to cetrotide with respect to the number of mature oocytes retrieved at ovum pick-up in oocyte donation (OD) cycles? Summary answer MPA is comparable to cetrotide in terms of number of mature oocytes (MII) retrieved at ovum pick-up (OPU) in oocyte donation cycles. What is known already Progesterone primed ovarian stimulation (PPOS) uses progestin as an alternative to a GnRH analog for suppressing a premature LH surge during the follicular phase. Published reports indicate that both the number of MII retrieved and pregnancy rates from these oocytes are comparable to protocols using GnRH analogues. Among new stimulation approaches to OD, the use of MPA taken orally has been used successfully, avoiding the need for injecting a GnRH analogue, allowing for more comfortable and cost-effective ovarian stimulation. Another advantage is that vitrification is avoided because the woman undergoing stimulation is not the recipient of the transfer. Study design, size, duration A prospective, non-randomized clinical trial including 23 oocyte donors was performed between February 2020 and February 2021 to evaluate the non-inferiority of MPA (10 mg/day) versus cetrotide (0.25 mg/day) from day 6, in ovarian stimulation cycles triggered with triptorelin acetate. Trigger criterion was ≥6 follicles with a diameter >18 mm Participants/materials, setting, methods All oocyte donors who came for the first time were included. Two OS were performed, the first with a fixed antagonist protocol (hMG and cetrotide), the second PPOS (hMG and MPA). Transvaginal ultrasound was performed, and serum estradiol levels were recorded during monitoring. The main outcome was the number of MII retrieved at OPU. Secondary outcomes were embryological laboratory outcomes and reproductive outcomes in recipients. Main results and the role of chance Basic characteristics, such as age and BMI were comparable, less than 12 months between one donation and another. Duration of stimulation was similar in both OS (10 days), as well as the total gonadotropin dose up to trigger (2544 IU in MPA and 2630 IU in cetrotide). The number of MII retrieved was no different: 11.9 (SD 2.9) with MPA and 10.9 (SD 3.8) in cetrotide (p = 0.5). Recipients and embryo transfer (ET) characteristics were also similar between groups. The mean number of MII assigned to each recipient was 9.2 (SD 2.8) in MPA and 8.2 (SD 3.09) in cetrotide (P = 0.58). MII were fertilized with partner sperm in 93% cycles overall and fertilization rate was 70% in MPA versus 69% in cetrotide (P = 0.61). The number of D5 blastocysts was 4 (SD 2.9) in MPA and 3.56 (SD 2.6) in cetrotide. Overall, there was 99% of double ET and 1% of single ET, with 93.2% of ETs were performed in D5. No significant difference was found in the clinical pregnancy rate 55.3% versus 54.5% (P = 0.785); ongoing pregnancy rate 55.3% versus 50.9% (P = 0.419) and live birth rate 51.1%versus 45.5%, (P = 0.255). Limitations, reasons for caution The patients and physician were not blinded to the study. Further, a large proportion of patients were still pregnant at the end of the clinical trial, therefore live birth rates were not observed in the follow-up period. Wider implications of the findings Ovarian stimulation using MPA for LH surge prevention produces a comparable number of MII oocytes, fertilization rates and live birth rate compared to cetrotide in oocyte donation cycles with the advantage of being a more comfortable and cost-effective ovarian stimulation. Trial registration number Not applicable

O-185 Far away so close: remote ICSI using an AI-powered robot

Abstract Study question Can intracytoplasmic sperm injection (ICSI) be performed remotely using a personal computer and an intelligent robotic micromanipulation system? Summary answer An AI-enhanced robotic micromanipulation system was developed that allows successful remote execution of ICSI by experts or non-experts. What is known already ICSI has become the method of choice for fertilization of eggs during IVF, but it remains technically demanding, requiring manual control of highly specialized equipment by expert embryologists. Limited automation of the procedure has been achieved but most steps are still performed manually. Remote performance of ICSI has never been attempted. Study design, size, duration To achieve automated ICSI, we explored individual commands for each step, issued from an offsite computer. Steps included AI-assisted sperm selection, laser immobilization, random oocyte positioning, opening a path in the zona pellucida prior to needle entry, and Piezo-mediated oolemma breakage. The modified protocols were optimized using mouse oocytes and mouse sperm and then tested using the automated system to inject hamster oocytes with human sperm. Finally, the system was evaluated in consenting patients. Participants/materials, setting, methods The system consists of an inverted microscope, a motorized stage, motorized micromanipulators, laser, piezo-electric actuator, and microinjectors, all controlled by proprietary digital and AI-driven software. Development of this system was a collaborative effort across four countries in three laboratories, including an engineering and embryo research facility, an experimental embryology laboratory, and an IVF clinic. The pilot clinical procedures were performed after full IRB review and trial registration. Main results and the role of chance To assess the safety of using a laser on sperm tails for immobilization, manual ICSI was performed on mouse oocytes with mouse sperm immobilized using different laser settings. Once the method was optimized, fertilization (n = 176, 98.8%) and blastocyst formation (80.7%) in the experimental group were similar to those in the controls without laser (n = 173, 99.4% and 80.6%, respectively) (p > 0.05). Subsequently, 90 blastocysts from the experimental group were transferred to pseudopregnant mice resulting in 40.4% live pups. This was comparable to the results with control embryos (n = 90, 47.8%) (p = 0.098). The remotely controlled robotic system was then tested in hamster oocytes, demonstrating survival (n = 102, 94.1%) similar to the manually injected control group (n = 102, 97.1%) (p = 0.3). In the clinical pilot trial in four patients, 22 oocytes were assigned to remote ICSI, achieving survival (95%), fertilization (81%), and blastocyst formation (65%) comparable to manually performed ICSI controls on sibling oocytes. These results are within the benchmark values established in the Vienna consensus. Throughout all experiments, the system allowed users to successfully perform ICSI remotely issuing commands by pressing single buttons on a computer screen from various locations, ranging in distance from a few meters to over 9,000 kilometers away from the laboratory. Limitations, reasons for caution This experimental ICSI system requires operators in the laboratory to insert and position the microtools and handle the eggs and sperm before and after ICSI. The system also requires a broadband internet connection with at least 50MBPs speed in upload and download. Latency or delayed reaction is a rare possibility. Wider implications of the findings The functionality of a remotely controlled automated ICSI system was validated. The system demonstrates efficiency gains, even with remote operation. The procedures can be programmed to achieve full microscopic ICSI using a single command. This system represents a significant advancement in automation of IVF. Trial registration number Clinicaltrials.gov: NCT06074835 IRB approval: RA-2023-01 IRB ID: CONBIOÉTICA-09-CEI-001-20170131

Are urologists underrepresented on fertility clinic websites? A web-based analysis.

Infertile couples frequently utilize the Internet to find various reproductive clinics and research their alternatives. Patients are increasingly using self-referral because of online information on health-care providers. The objective is to compare the image of infertility specialists to other team members on the websites of reproductive clinics. Information was gathered during November and December 2022 from two publicly accessible online registries which include the Human Fertilization and Embryology Authority located in the United Kingdom and the Society for Assisted Reproductive Technology located in the United States. We looked over every website that was accessible, paying close attention to how each team member was portrayed online. We examined a total of 447 clinic websites. Only 8% of the profiles of male infertility doctors were included. Contrarily, most websites (96%), which specialize in reproductive endocrinology and infertility, feature the profiles of female infertility experts. Male infertility professionals also had significantly lower representation than other clinic employees, such as nurses (55.7%, P < 0.0001), directors of embryology laboratories (46.5%, P < 0.0001), office personnel (39.6%, P < 0.0001), and embryology specialists (29.7%, P < 0.0001). Although male factor infertility explains the existence of over half of all cases of infertility, urologists who specialize in male infertility are glaringly understated on websites for fertility clinics. By improving this issue, fertility clinics can draw in more patients by making all members of the care team more visible.

Immature oocyte proportion in a cohort led to poor embryo development but did not reduce clinical pregnancy rate

PurposeThis study aimed to evaluate the effects of immature oocyte proportion in a cohort on both IVF laboratory and clinical outcomes.Materials and methodsThis retrospective cohort study took place at Morula IVF Jakarta Clinic from January 2016 to July 2020. A total of 1.826 couples undergoing IVF-ICSI/IMSI were included and classified into four groups according to the proportion of immature oocytes retrieved during OPU as follows: (1) immature ≤ 15% (n = 1.064), (2) immature 16–25% (n = 369), (3) immature 26–50% (n = 331), and (4) immature > 50% (n = 62). Primary outcomes were clinical pregnancy and miscarriage. Embryology laboratory results were assessed as the secondary outcomes. Statistical analyses were carried out utilizing Kruskal–Wallis or chi-square tests. p-value < 0.05 was considered statistically significant.ResultsIncreased proportion of immature oocytes in a cohort was significantly associated with body mass index, tubal factors, and estradiol level on trigger day (p < 0.05). Neither clinical pregnancy nor miscarriage was associated with the immature oocyte proportion (adjusted p-value = 0.872 and p = 0.345, respectively). However, a higher proportion of immature oocytes significantly reduced the total number of fertilized oocytes, number of top-quality cleavages, and blastocysts (p < 0.001). Furthermore, embryo transfer cancelation rates due to poor embryo quality were elevated significantly.ConclusionDespite overall poor embryo development in the laboratory, our study seems to suggest that the proportion of immature oocytes in a cohort has no impact on clinical pregnancy and miscarriage rate in IVF program.

Recruiting and cultivating future leaders in laboratory science.

Technological in-vitro fertilization (IVF) advancements originate in the embryology laboratory, and are accompanied by increased regulatory oversight and risk management. Stakes have never been higher or the need greater for the recruitment and cultivation of leaders in laboratory science to navigate the direction of IVF. Current thought leaders in state-of-the-art laboratories must prioritize this mission to optimize and preserve the future of IVF. Leaders in laboratory science must be able to speak to patients, the lay public, business leaders, scientific colleagues and clinical embryologists. While technically gifted, laboratory leaders may benefit from leadership training. Recruitment of scientists into IVF is currently challenging due to a lack of branding and no clear pipeline for new scientists to enter the field. Once recruited however, cultivation of new leaders requires coaching and skill acquisition over time, in order to create multifaceted laboratory leadership. Laboratory leaders are typically recruited based on education and experience to lead teams of embryologists. These leaders will adopt new technologies in the laboratory. Therefore, laboratory leaders play a powerful role in IVF requiring leadership skills ultimately driving patient outcomes. These laboratory directors must possess innate leadership abilities or learn how to lead their teams.

Does recurrent implantation failure exist? Prevalence and outcomes of five consecutive euploid blastocyst transfers in 123987 patients.

What are the clinical pregnancy and live birth rates in women who underwent up to two more euploid blastocyst transfers after three failures in the absence of another known factor that affects implantation? The fourth and fifth euploid blastocyst transfers resulted in similar live birth rates of 40% and 53.3%, respectively, culminating in a cumulative live birth rate of 98.1% (95% CI = 96.5-99.6%) after five euploid blastocyst transfers. The first three euploid blastocysts have similar implantation and live birth rates and provide a cumulative live birth rate of 92.6%. An international multi-center retrospective study was conducted at 25 individual clinics. The study period spanned between January 2012 and December 2022. A total of 123987 patients with a total of 64572 euploid blastocyst transfers were screened for inclusion. Patients with a history of any embryo transfer at another clinic, history of any unscreened embryo transfer at participating clinics, parental karyotype abnormalities, the use of donor oocytes or a gestational carrier, untreated intracavitary uterine pathology (e.g. polyp, leiomyoma), congenital uterine anomalies, adenomyosis, communicating hydrosalpinx, endometrial thickness <6 mm prior to initiating of progesterone, use of testicular sperm due to non-obstructive azoospermia in the male partner, transfer of an embryo with a reported intermediate chromosome copy number (i.e. mosaic), preimplantation genetic testing cycles for monogenic disorders, or structural chromosome rearrangements were excluded. Ovarian stimulation protocols and embryology laboratory procedures including trophectoderm biopsy followed the usual practice of each center. The ploidy status of blastocysts was determined with comprehensive chromosome screening. Endometrial preparation protocols followed the usual practice of participating centers and included programmed cycles, natural or modified natural cycles. A total of 105 (0.085% of the total population) patients met the criteria and underwent at least one additional euploid blastocyst transfer after failing to achieve a positive pregnancy test with three consecutive euploid blastocyst transfers. Outcomes of the fourth and fifth euploid blastocyst transfers were similar across participating centers. Overall, the live birth rate was similar with the fourth and fifth euploid blastocysts (40% vs 53.3%, relative risk = 1.33, 95% CI = 0.93-1.9, P value = 0.14). Sensitivity analyses excluding blastocysts biopsied on Day 7 postfertilization, women with a BMI >30 kg/m2, cycles using non-ejaculate or donor sperm, double-embryo transfer cycles, and cycles in which the day of embryo transfer was modified due to endometrial receptivity assay test result yielded similar results. Where data were available, the fourth euploid blastocyst had similar live birth rate with the first one (relative risk = 0.84, 95% CI = 0.58-1.21, P = 0.29). The cumulative live birth rate after five euploid blastocyst transfers was 98.1% (95% CI = 96.5-99.6%). Retrospective design has its own inherent limitations. Patients continuing with a further euploid embryo transfer and patients dropping out from treatment after three failed euploid transfers can be systematically different, perhaps with regard to ovarian reserve or economic status. Implantation failure seems to be mainly due to embryonic factors. Given the stable and high live birth rates up to five euploid blastocysts, unexplained recurrent implantation failure should have a prevalence of <2%. Proceeding with another embryo transfer can be the best next step once a known etiology for implantation failure is ruled out. None. N/A.

Comparison of Embryological Results of Microinjection in Two Groups of Men with and without Requesting Sperm DNA Fragmentation Index Measurement.

The sperm DNA fragmentation index (DFI) is considered a valuable measure to assess male fertility, but the predictive value of DFI for the outcomes in assisted reproductive technology (ART) is still controversial. Therefore, this study is aimed at investigating the effect of requesting a DFI test or performing ART without DFI on the results observed in the embryology laboratory (number of embryos, fertilization rate, and embryo quality) after intracytoplasmic sperm injection (ICSI). This retrospective study was conducted on infertile men who underwent ICSI and were referred to the Avicenna Infertility and Recurrent Abortion Treatment Center in Tehran from 2019 to 2022. The samples were categorized into two groups: a case group with DFI measurement and a control group without DFI measurement. We conducted a comparative analysis of the embryology results between the two groups, focusing on parameters such as fertilization rate, number of embryos, and embryo quality. t-tests and Mann-Whitney U tests were used to conduct single variable analysis. Potential confounding effects were adjusted to use the multivariate linear and logistic regression. Data analysis showed no significant statistical difference between the case group and the control group in terms of the number of embryos (95% confidence interval for the regression coefficient (β) = -0.257-0.123), and embryo quality (95% confidence interval for β = -0.199-0.114). There was no significant statistical difference between the two groups due to the fertilization rate (95% confidence interval for β = -3.42-3.42), except for the variables of woman's age and sperm count after ICSI, as determined by adjusted linear regression. Although DFI measurement is used to assess male infertility, its importance as a predictor for the embryology outcomes after ICSI requires further evaluation and the determination of a cut-off point for predicting results. This study was based on retrospectively collected DFI data, and prospective studies confirming the superiority of ICSI outcomes are necessary.

The Clinical Embryologist: Past, Present and Future Challenges

Embryologist is an essential part of infertility care defined as a highly skilled and well-trained person who can work in teamwork to execute continuous tasks with near-zero error and pay attention to detail with excellent clinical judgment. At the very beginning, embryologist’s routine daily tasks were quite simple including processing the sperm and eggs for natural insemination. Following that, advanced infertility treatment emerged quickly including intracytoplasmic sperm injection (ICSI), vitrification-warming, embryo shipping, intracytoplasmic morphologically sperm injection (IMSI), as well as trophectoderm biopsy as a source of chromosomal copy number testing or monogenic disorders analysis. Collectively, the implementation of such improved treatments renders complexity in the IVF laboratory that could be simplified in the future. Apparently, the implementation of advanced technology in the field of IVF nowadays has two main purposes. The first is to improve the IVF success rate including finding precise markers for embryo selection such as genomics, proteomics, and metabolomics fingerprint and images-based artificial intelligence algorithm for embryo selection. The second is to standardize or simplify routine daily tasks in the embryology laboratory by implementing automated software such as for laboratory quality control maintenance, a microfluidic system that allows standardization of handling gametes, micro-robotic for immobilizing sperm for ICSI, fully automated semen analysis, electronic tagging of laboratory devices to improve traceability. All such automated systems will serve as advanced clinical decision tools to boost IVF success rate and infertility care quality. An elevated automated system in the future in an embryology laboratory would impact the clinical embryologist in terms of reduced quantity and conversely, increased qualities of highly scientific embryologists with proper education. Embryologist roles may change from conventional routine daily tasks to well-trained and experienced embryologists who are able to scientifically evaluate the effectiveness of certain approaches or potential clinical use of such implementation in their clinical laboratory setting.

The 50th Anniversary of the Laboratory of Embryology

The 50th Anniversary of the Laboratory of Embryology

Effective protection: the embryonic development and clinical outcomes of emergency vitrification of 1246 oocytes and Day 0-Day 5 embryos in a natural disaster.

Can emergency vitrification protect embryos and oocytes during natural disasters or other events that prevent normal practice to achieve satisfactory embryonic development and clinical outcomes at a later time? Emergency vitrification of oocytes and Day 0-Day 5 (D0-D5) embryos during disasters is a safe and effective protective measure. When some destructive events such as floods, earthquakes, tsunamis, and other accidents occur, emergency vitrification in embryo laboratories to protect human embryos, oocytes, and sperm is one of the important measures of an IVF emergency plan. However, there are few detailed reports on emergency vitrification in a state of disaster, especially about oocytes and D0 zygotes. Therefore, the effectiveness and safety of emergency vitrification of oocytes and D0-D5 embryos in disaster states are still unclear. A retrospective study was made in the Reproductive Medicine Center of the First Affiliated Hospital of Zhengzhou University from January 2018 to November 2022. The record rainstorms in Zhengzhou, China, caused severe flooding, traffic disruptions, and power outages. From 17:30, 20 July 2021 to 17:30, 21 July 2021, 1246 oocytes and D0-D5 embryos of 155 patients were vitrified whilst the laboratory had only an emergency power supply. As of 21 December 2021, 1149 emergency vitrified oocytes and D0-D5 embryos of 124 patients underwent frozen-thawed embryo transfer (FET). They were divided into the following four groups according to the days of embryo culture in vitro: oocyte group, Day 0-Day 1 (D0-D1) group, Day 2-Day 3 (D2-D3) group, and Day 4-Day 5 (D4-D5) group. Control groups for each were selected from fresh cycle patients who underwent IVF/ICSI from January 2018 to October 2021. Control and emergency vitrification patients were matched on criteria that included age, fertilization method, days of embryonic development, and number and grade of transferred embryos. A total of 493 control patients were randomly selected from the eligible patients and matched with the emergency vitrification groups in a ratio of 4:1. The results of assisted reproduction and follow-up of pregnancy were analyzed. The embryonic development, clinical outcomes, and birth outcomes in each group were statistically analyzed. A significant difference was observed in fertilization rate (81% versus 72%, P = 0.022) between the oocyte group and the control group. Significant differences were also observed in the monozygotic twin pregnancy rate (10% versus 0%, P = 0.038) and ectopic pregnancy rate (5% versus 0%, P = 0.039) between the D0-D1 group and the control group. No significant differences (P > 0.05) were observed between vitrified oocytes/D0-D1 embryos/D2-D3 embryos and the control group on the number of high-quality embryos (3.17 ± 3.00 versus 3.84 ± 3.01, P = 0.346; 5.04 ± 3.66 versus 4.56 ± 2.87, P = 0.346; 4.85 ± 5.36 versus 5.04 ± 4.64, P = 0.839), the number of usable blastocysts (1.22 ± 1.78 versus 1.21 ± 2.03, P = 0.981; 2.16 ± 2.26 versus 1.55 ± 2.08, P = 0.090; 2.82 ± 3.23 versus 2.58 ± 3.32, P = 0.706), clinical pregnancy rate (56% versus 57%, P = 0.915; 55% versus 55%, P = 1.000; 40% versus 50%, P = 0.488), miscarriage rate (30% versus 15%, P = 0.496; 5% versus 11%, P = 0.678; 17% versus 20%, P = 1.000), and live birth rate (39% versus 49%, P = 0.460; 53% versus 50%, P = 0.772; 33% versus 40%, P = 0.635). No significant differences (P > 0.05) were observed between the D4-D5 group and the control group on clinical pregnancy rate (40% versus 55%, P = 0.645), miscarriage rate (0% versus 18%, P = 1.000), and live birth rate (40% versus 45%, P = 1.000). The retrospective study design is a limitation. The timing and extent of natural disasters are unpredictable, so the sample size of vitrified oocytes, zygotes, and embryos is beyond experimental control. This study is the first study analyzing embryonic development, clinical outcomes, and birth outcomes of large samples of oocytes, D0 zygotes, and D1-D5 embryos after emergency vitrification under the disaster conditions. The results show that emergency vitrification is a safe and effective protective measure applicable to oocytes and D0-D5 embryos. The embryology laboratories need to be equipped with an emergency uninterrupted power supply capable of delivering for 6-8 h at full load. This work was supported by the National Natural Science Foundation of China (grant 81871206). The authors declare that they have no conflicts of interest. All authors have completed the ICMJE Disclosure form. N/A.

Low E-visibility of embryologists on fertility clinic websites: a web-based cross-sectional study.

This study assessed the visibility of embryologists on fertility clinic websites among Society for Assisted Reproductive Technology (SART) and the Human Fertilisation and Embryology Authority (HFEA) member clinics. During a 1-month interval (March 2022), all Society for Assisted Reproductive Technology (SART) and the Human Fertilisation and Embryology Authority (HFEA) member fertility clinic websites were evaluated. The professional representation of the primary care team was examined including specialties, the presence of headshots, and biographies. A total of 446 fertility clinic websites were scanned in the search. The embryology team has the least common professional identification by their names (53.58%) compared to gynecology clinicians (96.21%, p < 0.001) and nurses (55.58%, p < 0.001). This trend also applies to other types of professional identifiers, such as headshots and biographies. Professional headshots of embryologists (50.34%) were less prominent than those of gynecology clinicians (93.51%, p < 0.001). A similar trend was observed in the biographies of the embryology team (47.20%) compared to gynecology clinicians (95.08%, p < 0.001). The present study revealed that embryologists have low professional visibility on fertility clinic websites. Fertility clinics may prioritize enhancing the online visibility of their embryology laboratory team. This approach could potentially enhance the recognition of their team, foster transparency, and provide accessible information about the skills and expertise of healthcare professionals involved in the treatment process.

Distribution of human papillomaviruses (HPV) by geographical area and affected organ in Greece

Introduction: Even today we do not have a comprehensive picture of the impact of the virus in Greece and its location at various anatomical sites. Aim: The aim of the study was to investigate and record the impact of HPV infection in the Greek population with emphasis on the affected organ/system. Methodology: The data of the tissue bank of the histology and embryology laboratory of the Medical School of Athens was utilized. It includes cases with the following characteristics: a) they are fully characterized in terms of HPV infection (complete subtyping of the virus), b) they belong to benign and malignant neoplasms of various organs with complete histopathological assessment, c) have been collected in at least the last decade d) have accompanying clinical and demographic data and e) their origin covers the entire Prefecture of Attica and a wide age range. Results: In 60% of the samples no type of HPV was detected, while in 12%, low-risk types were detected and in 28% high-risk types. Women had a higher rate of infection with different types of HPV and were at higher risk, with HPV types 16 &amp; 18 being more common than men, who were more likely to have HPV 6 &amp; HPV 11 types. Infection with a high-risk type occurred in 23.4% of women versus 0.3% of men. The most common type in cervical secretions was HPV 16 (14% and 10.3% respectively), followed by HPV 18 with rates of 7.4% and 10.3% respectively. Regarding skin, HPV types 16 &amp; 18 were found with the same frequency (11.1%). In the perineum-rectum, the types of HPV6 &amp; 11 predominated (20.7%), followed by HPV 16 &amp; 18. Conclusion: The present study contributes to the further investigation of the prevalence of HPV in Greece, with emphasis on more types of HPV and more anatomical sites, providing information on the male population. It will help update public health planning, detect and prevent HPV-related cancers in both sexes in Greece

Remote IVF: a clinical and laboratory guide to performing remote oocyte retrievals.

The aim of this guide is to describe different scenarios when remote IVF would be needed, considerations around how to plan for the procedure, proper equipment in the procedure room, and proper transportation of oocytes from the procedure room. There are two different scenarios for remote IVF: (1) IVF clinics designed knowing the embryology laboratory is nonadjacent and (2) IVF clinics that routinely provide care to patients in their clinic and want to provide care to those who are ineligible for a retrieval under anesthesia in an outpatient facility. This guide will focus on both scenarios. Much of the advice can be used for IVF clinics that routinely perform oocyte retrievals nonadjacent to their embryology laboratories. Special considerations are needed when patients with complex comorbidities require high-level of care and hospital-level monitoring while under anesthesia and/or post-oocyte retrieval, and are thus unable to be treated in the standard facility. For these reasons we have created a comprehensive guide to nonadjacent, or off-site, oocyte retrievals for reproductive endocrinology and infertility (REI) physicians, nurses, and embryologists to use when planning care for IVF patients. Going forward, we will refer to both these scenarios as remote IVF.