Euploid Frozen Embryo Transfer Research Articles

Routine endometrial receptivity array in first embryo transfer cycles does not improve live birth rate

To compare the live birth rate between patients who undergo personalized embryo transfer (pET) after endometrial receptivity array (ERA) versus frozen embryo transfer (FET) with standard timing in first single euploid FET cycles. To report the rate of displacement of the window of implantation (WOI) in an infertile population without a history of implantation failure. Prospective cohort study of patients who underwent their first single euploid programmed FET. Private fertility clinic. Patients who underwent first autologous single euploid programmed FET between January 2018 and April2019. Endometrial biopsy with ERA followed by pET as indicated. Live birth rate and rate of receptive and nonreceptive ERA. A total of 228 single euploid FET cycles were included in our analysis. Of those, 147 (64.5%) were ERA/pET cycles, and 81 (35.5%) were standard timing FET cycles. Endometrial receptivity array was receptive in 60/147 (40.8%) and nonreceptive in 87/147 (59.2%) patients. Nonreceptive ERAs were prereceptive in 93.1% of cases. The live birth rate did not differ between patients who underwent FET with standard timing and patients who underwent ERA/pET, 45/81 (56.6%) and 83/147 (56.5%), respectively. Our data do not support the routine use of ERA in an unselected patient population undergoing first autologous single euploid programmed embryo transfer.

Endometrial compaction does not predict live birth rate in single euploid frozen embryo transfer cycles.

To evaluate whether endometrial compaction using sequential transvaginal ultrasound is associated with improved live birth rates in medicated single euploid frozen embryo transfer (FET) cycles. Prospective observational cohort study at a private fertility clinic. Patients who underwent FETs between January and December 2018 were assessed for inclusion. The change in endometrial thickness between the end of the estrogen phase and the day before embryo transfer, measured by sequential transvaginal ultrasound, was used to categorize cycles with compaction (≥ 5%), no change, or expansion (≥ 5%). FET cycle outcomes were then compared between groups. The primary outcome was live birth. Secondary outcomes include clinical pregnancy rate and rate of spontaneous abortion. Of the 259 single euploid medicated FETs performed during the study period, only 43/259 (16.6%) of the cycles demonstrated ≥ 5% compaction, whereas 152/259 (58.7%) expanded and 64/259 (24.7%) were unchanged. Live birth rates did not differ between cycles with compaction (58.1%), no change (54.7%), or expansion (58.6%), p = 0.96. Clinical pregnancy and spontaneous abortion rates were also similar between groups. The vast majority of cycles did not demonstrate endometrial compaction. Endometrial compaction is not associated with live birth rate or spontaneous abortion rate in medicated single euploid FETs in this cohort.

Effect of Embryo Developmental Stage, Morphological Grading, and Ploidy Status on Live Birth Rate in Frozen Cycles of Single Blastocyst Transfer.

To determine whether embryo developmental stage or morphological grading can predict live birth rate (LBR) from a single blastocyst in nonbiopsied and biopsied frozen embryo transfer (FET) cycles. This retrospective study included 1336 nonbiopsied and 360 euploid FET cycles. Blastocysts were divided according to developmental stage (day 5 [D5] and day 6 [D6]) and morphology (good quality and low quality). Nonbiopsied cycles in which D5 blastocysts were transferred were associated with a significantly higher LBR than those in the D6 group (48.5 vs. 24.3%; p< 0.001), as well as in good-quality embryo transfer cycles than that in low-quality embryo cycles (52.6 vs. 25.3%; p< 0.001). Embryos reaching good-quality blastocysts on D5 yielded significantly higher LBR than those similar quality blastocysts on D6. The same trend was seen in low-quality embryos. Concerning only D5 or D6 blastocyst transfer, the LBRs of good-quality embryos were still superior to those of low-quality embryos. In the case of euploid embryo transfers, the LBR (48.9 vs. 44.9%, p= 0.444) of D5 blastocysts did not significantly differ from that of D6 blastocysts. Good-quality embryos showed a higher LBR than low-quality embryos (51.6 vs. 40.0%, p= 0.030); the adjustedodds ratio remained insignificant after controlling for confounders (aOR 1.56; 95% CI 0.99-2.45; p= 0.056). The LBRs in the same developmental stage or morphology subgroups were not statistically significant. Embryo developmental stage and morphological grade are useful predictors of LBR in nonbiopsied FET cycles. However, no association was found in euploid transfer cycles.

Endometriosis does not impact live-birth rates in frozen embryo transfers of euploid blastocysts

To determine whether subfertility in patients with endometriosis is due to impaired endometrial receptivity by comparing pregnancy and live-birth outcomes in women with endometriosis versus two control groups without suspected endometrial factors: noninfertile patients who underwent assisted reproduction to test embryos for a single-gene disorder and couples with isolated male factor infertility. Retrospective cohort. Multicenter private practice. All patients aged 24 to 44 years undergoing euploid frozen blastocysts transfer from January 2016 through March2018. None. Live birth, clinical pregnancies, pregnancy losses, and aneuploid rates in preimplantation genetic testing for aneuploidy cycles. The analysis included 459 euploid frozen embryo transfer cycles among 328 unique patients. There were no differences in clinical pregnancy, pregnancy loss, or live-birth rates in patients with endometriosis compared with both control groups. The aneuploidy rates were lowest in the preimplantation genetic testing for monogenic disorders cohort, and the endometriosis patients had aneuploidy rates similar to those of the male factor infertility patients. It is unclear whether endometriosis primarily affects invitro fertilization outcomes via oocyte quality or the endometrium. By controlling for embryo quality using euploid frozen embryo transfer cycles, we found no difference in pregnancy outcomes in patients with endometriosis compared with patients undergoing treatment for male factor infertility and noninfertile patients.

WEIGHING IN ON LIVE BIRTH RATE AFTER A SINGLE EUPLOID TRANSFER

Prior studies have evaluated the effect of body mass index (BMI) on outcomes following euploid frozen embryo transfer (FET) with varying results, and have been limited by small sample sizes[i][ii][iii]. The purpose of this study was therefore to investigate whether BMI impacts pregnancy outcomes following euploid FET using a larger population that contains a greater proportion of patients with obesity.

ASSOCIATION OF MITOSCORE AND TIME TO BLASTULATION: EVALUATION AS PREDICTORS OF REPRODUCTIVE OUTCOMES AFTER SINGLE FROZEN EMBRYO TRANSFER

Evaluate the correlation of mitoscore and time to blastulation (TTB) among euploid embryos and its predictive value on reproductive outcomes Single-center retrospective cohort study We performed a retrospective chart review of patients who underwent IVF with ICSI and pre-implantation genetic testing for aneuploidy (PGT-A) with mitoscore (Igenomix) from 10/2017 to 12/2019. Embryos were cultured in a time-lapse incubator and timing to blastulation (TTB) was recorded. Medical records were reviewed for patient demographics and FET cycle characteristics. The primary outcome was to assess correlation of mitoscore and TTB. Secondary outcomes included implantation and ongoing pregnancy, defined as cardiac activity on ultrasound at 10wks gestation or later. Spearman correlation analysis was performed to assess association of mitoscore and TTB, and a p <0.05 was considered statistically significant. Statistical analyses were done between patient groups using t-test or Mann-Whitney U test. Logistic regression was applied to assess predictors of implantation and pregnancy. We identified 137 patients with 465 embryos and 145 frozen embryo transfers (FET). We found an overall implantation rate of 68.3% (n=99) and ongoing pregnancy rate of 53.7% (n=78). A significant correlation between Mitoscore and TTB ranking were found among all embryos (ρ=0.54, p<.0001, 95%CI 0.47-0.60). This positive correlation persisted amongst patients with implantation (ρ=0.52, p<0.001, 95% CI 0.36-0.65) and no implantation (ρ=0.44, p<0.002, 95% CI 0.17-0.65) following single FET. We noted no differences in mitoscore or TTB among patients with or without implantation (Mitoscore p=0.61, 95%CI -2.31 to 1.43: TTB p=0.41, 95%CI -3.77-1.55) or ongoing pregnancy (Mitoscore p=0.28, 95%CI -2.66-7.60: TTB p=0.92, 95%CI -2.29-2.52). Logistic regression of demographics, FET cycle characteristics, mitoscore and TTB revealed no predictors of implantation. Factors including age, BMI, parity, endometrial thickness, and FET protocol were not different between implanted vs. non-implanted groups. Mitoscore and TTB are correlated amongst euploid embryos. However, neither was found to be an independent predictor of implantation. Continued efforts to refine embryo selection outside of ploidy status may help address implantation failure following single euploid FET.

Late follicular phase progesterone elevation during ovarian stimulation is not associated with decreased implantation of chromosomally screened embryos in thaw cycles

What is the impact of a late follicular phase progesterone elevation (LFPE) during controlled ovarian hyperstimulation (COH) on embryonic competence and reproductive potential in thaw cycles of preimplantation genetic testing for aneuploidy (PGT-A) screened embryos? Our study findings suggest that LFPE, utilizing a progesterone cutoff value of 2.0 ng/ml, is neither associated with impaired embryonic development, increased rate of embryonic aneuploidy, nor compromised implantation and pregnancy outcomes following a euploid frozen embryo transfer (FET) cycle. Premature progesterone elevation during COH has been associated with lower pregnancy rates due to altered endometrial receptivity in fresh IVF cycles. Also, increased levels of progesterone (P) have been suggested to be a marker for ovarian dysfunction, with some evidence to show an association between LFPE and suboptimal embryonic development. However, the effect of LFPE on embryonic competence is still controversial. Retrospective cohort analysis in a single, academic ART center from September 2016 to March 2020. In total, 5244 COH cycles for IVF/PGT-A were analyzed, of those 5141 were included in the analysis. A total of 23991 blastocysts underwent trophectoderm biopsy and PGT analysis. Additionally, the clinical IVF outcomes of 5806 single euploid FET cycles were evaluated. Cohorts were separated in two groups: Group 1: oocytes retrieved from cycles with normal P levels during ovulation trigger (P ≤ 2.0 ng/ml); Group 2: oocytes retrieved after cycles in which LFPE was noted (P > 2.0 ng/ml). Extended culture and PGT-A was performed. Secondly, IVF outcomes after a single euploid FET were evaluated for each cohort. Four thousand nine hundred and twenty-five cycles in Group 1 were compared with 216 cycles on Group 2. Oocyte maturity rates, fertilization rates and blastulation rates were comparable among groups. A 65.3% (n = 22654) rate of utilizable blastocysts was found in patients with normal P levels and were comparable to the 62.4% (n = 1337) observed in those with LFPE (P = 0.19). The euploidy rates were 52.8% (n = 11964) and 53.4% (n = 714), respectively, albeit this difference was not statistically significant (P = 0.81). Our multivariate analysis was fitted with a generalized estimating equation (GEE) and no association was found with LFPE and an increased odds of embryo aneuploidy (adjusted odds ratio 1.04 95% CI 0.86-1.27, P = 0.62). A sub-analysis of subsequent 5806 euploid FET cycles (normal P: n = 5617 cycles and elevated P: n = 189 cycles) showed no differences among groups in patient's BMI, Anti-Müllerian hormone (AMH), endometrial thickness at FET and number of prior IVF cycles. However, a significant difference was found in patient's age and oocyte age. The number of good quality embryos transferred, implantation rate, clinical pregnancy rate, ongoing pregnancy rate, multiple pregnancy rate and clinical pregnancy loss rates were comparable among groups. Of the registered live births (normal P group: n = 2198; elevated P group: n = 52), there were no significant differences in gestational age weeks (39.0 ± 1.89 versus 39.24 ± 1.53, P = 0.25) and birth weight (3317 ± 571.9 versus 3 266 ± 455.8 g, P = 0.26) at delivery, respectively. The retrospective nature of the study and probable variability in the study center's laboratory protocol(s), selected progesterone cutoff value and progesterone assay techniques compared to other ART centers may limit the external validity of our findings. Based on robust sequencing data from a large cohort of embryos, we conclude that premature P elevation during IVF stimulation does not predict embryonic competence. Our study results show that LFPE is neither associated with impaired embryonic development nor increased rates of aneuploidy. Embryos obtained from cycles with LFPE can be selected for transfer, and patients can be reassured that the odds of achieving a healthy pregnancy are similar to the embryos exposed during COH cycles to physiologically normal P levels. No funding was received for the realization of this study. Dr A.B.C. is advisor and/or board member of Sema 4 (Stakeholder in data), Progyny and Celmatix. The other authors have no conflicts of interest to declare. NA.

Prognostic value of blastocyst grade after frozen euploid embryo transfer in patients with recurrent pregnancy loss

ObjectiveTo determine whether trophectoderm (TE) grade or inner cell mass (ICM) grade have predictive value after euploid frozen embryo transfer (euFET) among recurrent pregnancy loss (RPL) patients.DesignRetrospective cohort study.SettingSingle fertility center.Patient(s)Women with ≥2 prior pregnancy losses with ≥1 euploid embryo for transfer undergoing preimplantation genetic testing for aneuploidy.Intervention(s)Intracytoplasmic sperm injection, TE biopsy, blastocyst grading and vitrification, and single euFET, with first transfer outcome recorded.Main Outcome Measure(s)Live birth and clinical miscarriage rates.Result(s)The study included 660 euFET cycles. In a binomial logistic regression analysis accounting for age, body mass index, antimüllerian hormone level, and day of blastocyst biopsy, or ICM grade C was not significantly associated with odds of live birth, miscarriage, or biochemical pregnancy loss. TE grade C was significantly associated with odds of live birth and was not associated with odds of miscarriage or biochemical pregnancy loss. Blastocyst grade CC had significantly lower live birth rate compared with all other blastocyst grades.Conclusion(s)Embryo grade CC and TE grade C are associated with decreased odds of live birth after euFET in RPL patients. Embryo grade is not associated with odds of clinical miscarriage in this cohort of RPL patients, suggesting that additional embryonic or uterine factors may influence the risk of pregnancy loss.

Why Do Euploid Embryos Fail to Implant? The Role of CD138 and Chronic Endometritis

The objective of this prospective cohort study was to investigate the relationship between chronic endometritis (CE) and its treatment on pregnancy outcomes in patients undergoing frozen embryo transfers (FETs) from in vitro fertilization (IVF) with preimplantation genetic testing (PGT) who had previously failed ≥ 1 euploid FET. The diagnosis of CE was made using CD138 as a marker. This study occurred at a single, high volume academic based fertility center. 305 patients were included with a history of ≥ 1 failed euploid transfers. 59 patients underwent endometrial biopsies (EMB) prior to subsequent FET (Tested), 246 patients did not undergo EMB prior to subsequent transfer (Untested). Patients in the Tested group had an EMB prior to subsequent FET, whereas the patients in the Untested group did not have an EMB prior to next FET. Patients tested and found positive for CE were treated with antibiotics and underwent test-of-cure (TOC) EMBs prior to next FET to assess for adequate treatment. Patients without CE on EMB proceeded to next FET without antibiotic treatment. Main outcome measures included positive Beta-hCG (βhCG) on cycle day 28, implantation rate (IR), and subsequent ongoing pregnancy/live birth rates (OPR/LBR). Our results showed that 51% of patients (30/59) were diagnosed with CE and treated with antibiotics (Tested, CE treated); negative TOC biopsies were obtained prior to next FET. 49% of patients (29/59) tested negative for CE (Tested, No CE) and were not treated prior to next FET. Tested patients without CE (CE treated and No CE) had significantly higher incidences of positive βhCG, IR and OPR/LBR than patients who were not tested. Those who were biopsied and treated for CE had significantly higher OPR/LBR compared to patients who were biopsied and negative for CE (80% vs. 55%). We conclude that CE is common, with a prevalence of 51% in patients who have failed euploid FETs. Testing for CE may provide a benefit to patients, assuring higher incidences for positive βhCG, implantation, and subsequent ongoing/live births. CE is a treatable condition warranting investigation in patients with poor pregnancy outcomes.

Erratum. Worth the wait? Day 7 blastocysts have lower euploidy rates but similar sustained implantation rates as Day 5 and Day 6 blastocysts.

STUDY QUESTION Does the reproductive potential of embryos change when blastocyst development takes longer than the traditionally accepted 5 days when accounting for aneuploidy and endometrial-embryo asynchrony? SUMMARY ANSWER Aneuploidy increases with increasing duration of blastulation, but if blastocyst morphologic quality and endometrial-embryo asynchrony are controlled for, euploid Day 7 embryos have similar sustained implantation as compared to Days 5 and 6 euploid blastocysts. WHAT IS KNOWN ALREADY The relative contributions of diminished embryo quality versus endometrial and embryo asynchrony to poor outcomes associated with embryos cultured past Day 6 are not clear. Asynchrony can be eliminated by embryo vitrification with transfer in a subsequent month after retrieval. STUDY DESIGN, SIZE, DURATION Retrospective cohort study of patients from a single center attempting conception through ICSI and utilizing preimplantation genetic testing for aneuploidy screening (PGT-A) from January 2017 to September 2018. Cycles were excluded if they utilized surgical sperm or preimplantation genetic testing for monogenetic/single gene defects. ICSI cycle outcomes from 2586 patients were evaluated for ploidy status of embryos. PARTICIPANTS/MATERIALS, SETTING, METHODS Only patients undergoing single, euploid frozen embryo transfer were included when analyzing cycle outcomes by day of blastocyst expansion of the transferred embryo (n = 2130). Ploidy rates by the day upon which an embryo was considered to be usable (denoted, 'usable blastulation day') were determined so as to assess the contribution of aneuploidy to slow embryo development. Outcomes of euploid frozen single embryo transfers (SET) of Day 7 embryos were evaluated to assess the reproductive potential associated with embryos that were slowly developing for reasons other than aneuploidy. Analyses were adjusted by maternal age and blastocyst morphology. MAIN RESULTS AND THE ROLE OF CHANCE Overall, 67.7% (n = 3508) of usable Day 5 blastocysts were euploid, 52.1% (n = 5560) of usable Day 6 blastocysts were euploid and 43.1% (n = 229) of usable Day 7 embryos were euploid (Day 5 versus Day 6: odds ratio (OR) 0.7 (95% CI, 0.64-0.76), P < 0.001; Day 5 versus Day 7: OR 0.56 (95% CI, 0.46-0.69), P < 0.001; Day 6 versus Day 7: OR 0.81 (95% CI, 0.67-0.99), P = 0.036). Stratified by Society for Assisted Reproductive Technology maternal age groups, a reduction in the prevalence of euploidy by increasing time to embryo blastulation was still seen. The sustained implantation rate (SIR) was similar after euploid SET of Days 5 and 6 embryos (overall, 68.9% (95% CI, 66.0-71.6) and 66.8% (95% CI, 63.8-69.7), respectively; P = 0.81). SIR after euploid Day 7 SET appeared slightly lower than that of Days 5 and 6 embryos (52.6% (95% CI, 35.8-69.0); (Day 5 versus Day 7: OR, 0.67 (95% CI, 0.32-1.41), P = 0.29; Day 6 versus Day 7: OR 0.58 (95% CI, 0.28-1.2), P = 0.14)) but did not achieve statistical significance. LIMITATIONS, REASONS FOR CAUTION The primary limitation is the low number of Day 7 blastocyst transfers that limits statistical power. Additionally, the retrospective nature of this study may prevent full elucidation of potential biases with respect to culture, morphologic assessment and selection of Day 7 embryos for transfer. WIDER IMPLICATIONS OF THE FINDINGS Routine culture through Day 7 may successfully increase the pool of transferrable embryos for patients who would otherwise have no usable embryos if culture terminated on Day 6. This is particularly true for older patients (i.e. greater than 35 years of age), whose embryos take longer to blastulate and, therefore, are more susceptible to cycle cancelation. Additionally, as evidenced by an adequate overall SIR of 52.6% after euploid SET of Day 7 blastocysts, embryos developing to a usable blastocyst on Day 7 are likely within the 'window of blastulation.' STUDY FUNDING/COMPETING INTEREST(S) None.

Robotic Assisted Laparoscopic Resection of Anterior Adenomyoma

Video Objective This video demonstrates a unique technique of anterior adenomyoma resection and repair of the defect laparoscopically. Setting Our patient is a 40 yo G 3P0020 with secondary infertility and had multiple failed euploid frozen embryo transfers. She was diagnosed to have an anterior adenomyoma and decision was taken to excise the adenomyoma to optimize the fertility outcome. Interventions We performed a robotic assisted laparoscopic anterior adenomyomectomy where we excised the adenomyoma leaving approximately 1 cm of myometrium to the endometrium and serosa and then close d the defect by the overlap flap technique. Conclusion We describe an unique technique for optimal adenomyoma resection and then the effective way to close the uterine defect. This technique is easily adaptable and reproducible. This repair technique achieves good myometrial thickness after closure that reduces the chance of uterine rupture and the addition of extra suture layer decreases the chance of hematoma formation.

Minimally invasive uterine aspiration 24 hours ahead of embryo transfer characterizes the compromised RIF uterine microenvironment and is predictive of reproductive outcome

Repeat implantation failure (RIF) is particularly challenging to treat in ART, resulting in limited success even when adequate preparation of the endometrium is established and a transfer is performed with a high grade euploid blastocyst. The objective of this study was to utilize a multidisciplinary approach to decipher the complexity of RIF through investigations of the maternal molecular components ahead of an embryo transfer. Research study. Patients were recruited with IRB consent 24 hours prior to a programmed frozen embryo transfer (FET) with a euploid blastocyst. Uterine secretions were collected by gentle aspiration (∼2-5ul) under ultrasound guidance and grouped according to reproductive outcomes: Failed euploid FET (RIF patients, ≥3 prior IVF failures) and Positive live birth FET (maternally age-matched patients; mean 36.6 ±3.8 years). Total and small RNA (n = 22) was isolated for sequencing on the NovaSEQ 6000 (Illumina). Reads were aligned to hg38 using GSNAP and analyzed with edgeR (FDR cutoff of 5%; P<0.01). Metabolite analysis (n = 20) was performed by UHPLS-MS (Thermo) using MassMatrix and Maven (Princeton Univ). Proteomic analysis (n = 6) involved FASP digestion and LC-MS/MS, with protein identifications generated by Mascot (v 2.6) and Scaffold (v 4.8.9) (α of 0.05; fold change >1.5 or <0.5). A unique uterine microenvironment was observed for RIF patients and negative implantation outcomes 24 hours prior to an embryo transfer (P<0.05). An interplay of several biological processes were evident in RIF failed aspirates with a focused interest on 13 significantly reduced transcripts, 7 significantly increased maternal miRNAs, 12 significantly decreased amino acids and 16 proteins of significantly altered abundance (P<0.05). Specific examples included decreased expression of PLA2G4D (P<0.0001) which regulates the eicosanoid pathway, thereby impacting downstream synthesis of prostaglandins like PGE2. Decreased expression of TET1 (P<0.0001), an epigenetic regulator required for DNA methylation. Increased expression of miR-17, a known negative regulator of VEGFA, required for successful implantation (P<0.01). Decreased quantities of arginine, essential for blastocyst activation and trophectoderm motility (P<0.05). Lastly, an increased abundance of SERPING1, a protein associated with inflammation, which regulates complement activation (P<0.05). Analysis of uterine secretions 24 hours prior to FET, allowed for an in-depth molecular characterization of the compromised RIF uterine microenvironment and was predictive of reproductive outcome. The negative influence on key miRNAs and gene transcription levels, in addition to altered amino acid and protein concentrations, were all identified as critical contributors to poor RIF outcomes. Ongoing investigations into the relationships of these molecular networks will lead to the possibility of more effective clinical interventions for this difficult patient population.

Endometriosis does not impact live birth rates in frozen embryo transfer (FET) of euploid blastocysts

One explanation proposed for subfertility among women with endometriosis is impaired endometrial receptivity. We sought to test this hypothesis by comparing pregnancy and live birth (LB) outcomes in women with endometriosis versus two control groups without suspected endometrial factor: (1) non-infertile patients who underwent ART in order to test embryos for a single gene disorder and (2) couples with isolated male factor infertility. Retrospective Cohort. FETs of PGT-A normal blastocysts performed from January 2016 through March 2018 were included in the analysis. Patients with endometriosis were compared to those with male factor infertility and non-infertile patients using PGT-M for a single gene disorder. Endometriosis was confirmed surgically in 90% of the endometriosis cohort. Patients with multiple infertility diagnoses and those using gestational carriers or donor oocyte were excluded from the analysis. All blastocysts vitrified and warmed for transfer were grade BB or better. Comparisons were made with multigroup chi-square and P<0.05 was considered statistically significant. 472 euploid FET cycles were available for analysis. 59 transfers occurred in patients with endometriosis, 362 transfers in patients with male factor infertility, and 51 transfers in non-infertile patients. There was no difference in patient age in each treatment group and age was not associated with live birth in euploid embryo transfers. An equal number of embryos were transferred in each group. Patients with endometriosis had similar rates of clinical pregnancy (CP) and spontaneous abortion (SAB) when compared to male factor and non-infertile patients. There was no difference in LB in patients with endometriosis (63%) compared to patients with male factor (51%) and non-infertile patients (53%). While the study was only powered to detect a 20% decrease in LB, the 63% LB rate in endometriosis patients did not suggest a negative effect.Tabled 1Endometriosis (n = 59)Male Factor (n = 362)PGT-M (n = 51)P valueNo. Embryos Transferred1.051.091.060.97Positive hCG80%74%80%0.44CP73%65%63%0.43SAB10%14%10%0.63LB63%53%51%0.34 Open table in a new tab Whether endometriosis primarily affects IVF outcomes via oocyte quality or the endometrium is debated. By controlling for embryo quality using euploid FET cycles, we found no difference in pregnancy outcomes in patients with endometriosis compared to those with male factor and non-infertile patients.

Worth the wait? Day 7 blastocysts have lower euploidy rates but similar sustained implantation rates as Day 5 and Day 6 blastocysts

Does the reproductive potential of embryos change when blastocyst development takes longer than the traditionally accepted 5 days when accounting for aneuploidy and endometrial-embryo asynchrony? Aneuploidy increases with increasing duration of blastulation, but if blastocyst morphologic quality and endometrial-embryo asynchrony are controlled for, euploid Day 7 embryos have similar sustained implantation as compared to Days 5 and 6 euploid blastocysts. The relative contributions of diminished embryo quality versus endometrial and embryo asynchrony to poor outcomes associated with embryos cultured past Day 6 are not clear. Asynchrony can be eliminated by embryo vitrification with transfer in a subsequent month after retrieval. Retrospective cohort study of patients from a single center attempting conception through ICSI and utilizing preimplantation genetic testing for aneuploidy screening (PGT-A) from January 2017 to September 2018. Cycles were excluded if they utilized surgical sperm or preimplantation genetic testing for monogenetic/single gene defects. ICSI cycle outcomes from 2586 patients were evaluated for ploidy status of embryos. Only patients undergoing single, euploid frozen embryo transfer were included when analyzing cycle outcomes by day of blastocyst expansion of the transferred embryo (n = 2130). Ploidy rates by the day upon which an embryo was considered to be usable (denoted, 'usable blastulation day') were determined so as to assess the contribution of aneuploidy to slow embryo development. Outcomes of euploid frozen single embryo transfers (SET) of Day 7 embryos were evaluated to assess the reproductive potential associated with embryos that were slowly developing for reasons other than aneuploidy. Analyses were adjusted by maternal age and blastocyst morphology. Overall, 67.7% (n = 3508) of usable Day 5 blastocysts were euploid, 52.1% (n =5560) of usable Day 6 blastocysts were euploid and 43.1% (n =229) of usable Day 7 embryos were euploid (Day 5 versus Day 6: odds ratio (OR) 0.7 (95% CI, 0.64-0.76), P < 0.001; Day 5 versus Day 7: OR 0.56 (95% CI, 0.46-0.69), P < 0.001; Day 6 versus Day 7: OR 0.81 (95% CI, 0.67-0.99), P = 0.036). Stratified by Society for Assisted Reproductive Technology maternal age groups, a reduction in the prevalence of euploidy by increasing time to embryo blastulation was still seen. The sustained implantation rate (SIR) was similar after euploid SET of Days 5 and 6 embryos (overall, 68.9% (95% CI, 66.0-71.6) and 66.8% (95% CI, 63.8-69.7), respectively; P = 0.81). SIR after euploid Day 7 SET appeared slightly lower than that of Days 5 and 6 embryos (52.6% (95% CI, 35.8-69.0); (Day 5 versus Day 7: OR, 0.67 (95% CI, 0.32-1.41), P = 0.29; Day 6 versus Day 7: OR 0.58 (95% CI, 0.28-1.2), P = 0.14)) but did not achieve statistical significance. The primary limitation is the low number of Day 7 blastocyst transfers that limits statistical power. Additionally, the retrospective nature of this study may prevent full elucidation of potential biases with respect to culture, morphologic assessment and selection of Day 7 embryos for transfer. Routine culture through Day 7 may successfully increase the pool of transferrable embryos for patients who would otherwise have no usable embryos if culture terminated on Day 6. This is particularly true for older patients (i.e. greater than 35years of age), whose embryos take longer to blastulate and, therefore, are more susceptible to cycle cancelation. Additionally, as evidenced by an adequate overall SIR of 52.6% after euploid SET of Day 7 blastocysts, embryos developing to a usable blastocyst on Day 7 are likely within the 'window of blastulation.' None.

What is the reproductive potential of day 7 euploid embryos?

What is the rate of euploidy and the reproductive potential of embryos biopsied after 6days of development? Embryos biopsied after 6days of development have higher rates of aneuploidy; however, day 7 euploid embryos selected at transfer can achieve acceptable pregnancy rates and live birth (LB) outcomes. Recent publications have shown promising treatment results after euploid day 7 embryo transfers (ETs), albeit these studies were limited by small sample sizes. Whereas the current clinical standard has been to discard embryos that do not reach expansion by day 6 of development, the lack of robust data surrounding the clinical utility of day 7 embryos warrants further evaluation. Retrospective cohort analysis in a single, academic in vitro fertilization (IVF) center from January 2012 to March 2018. A total of 25 775 embryos underwent trophectoderm (TE) biopsy and preimplantation genetic testing for aneuploidy (PGT-A). Additionally, the clinical IVF outcomes of 3824 single, euploid frozen embryo transfer (FET) cycles were evaluated. Cohorts were segregated by day of TE biopsy following oocyte retrieval (day 5, day 6 or day 7). PGT-A was performed to identify embryonic ploidy rates. Secondly, IVF and LB outcomes after single, euploid FET were evaluated for each cohort. A total of day 5 (n= 12 535), day 6 (n= 11 939) and day 7 (n= 1298) embryos were included in the study analysis. The rate of embryo euploidy was significantly lower in day 7 blastocysts compared to day 5 or day 6 cohorts (day 7 = 40.5%; day 5 = 54.7%; day 6 = 52.9%; (P< 0.0001)). After adjusting for age, anti-Müllerian hormone, BMI, embryo quality and number of embryos biopsied, there was a significant association between aneuploidy and embryos biopsied on day 7 when compared to day 5 biopsied embryos (OR = 1.34, CI 95% 1.09-1.45, P= 0.001) and day 6 biopsied embryos (OR = 1.26, CI95% 1.07-1.16, P< 0.001).A sub-analysis of subsequent 3824 single, euploid FET cycles (day 5: n= 2321cycles; day 6: n= 1381cycles; and day 7: n= 116cycles) showed significant differences among cohorts in implantation, clinical pregnancy, LB and clinical loss rates. There was a significant decrease in the odds of implantation, clinical pregnancy and LB, but no association with clinical loss or multiple pregnancy rates in patients who utilized day 7-biopsied embryos during treatment. The retrospective nature of the study and potential variability in the study center's laboratory protocol(s) compared to other reproductive treatment centers may limit the external validity of our findings. Additionally, patients who transferred euploid embryos, biopsied on day 7 of development due to an absence of day 5 or day 6 counterparts, may have introduced selection bias in this study. Embryonic developmental stage, morphological grade and ploidy status are paramount factors affecting ET selection and implantation potential. This study reveals that embryos ineligible for TE biopsy on day 5 or day 6 of development may benefit from extended culture to day 7. Our study demonstrates patient benefit when extended culture to day 7 of development is routinely performed for embryos failing to meet biopsy criteria by day 5 or 6. No funding was received for the realization of this manuscript. Dr Alan Copperman is Advisor or Board Member of Sema 4 (Stake holder in Data), Progyny and Celmatix. This retrospective analysis was approved by an Institutional Review Board (WIRB PRO NUM: 20161791; Study Number: 1167398).

The correlation between morphology and implantation of euploid human blastocysts.

Does the composite morphology score or a particular developmental component (expansion stage, inner cell mass [ICM] or trophectoderm [TE]) of euploid blastocysts undergoing single frozen embryo transfer (FET) impact ongoing pregnancy/live birth (OP/LB) rates? Retrospective cohort study including a total of 2236 embryos from 1629 patients who underwent single euploid FET between 2012 and 2017. Embryos with an ICM grade of A compared with C had a higher OP/LB rate (55.6% versus 32.3%, P<0.001). Blastocysts with a TE grade of A or B compared with C had a higher likelihood of OP/LB (A versus C: odds ratio [OR] 1.6, 99% confidence interval [CI] 1.1-2.3, B versus C: OR 1.5, 99% CI 1.1-2.1), and blastocysts with a developmental stage of 4 or 5 compared with 6 had higher odds of OP/LB (4 versus 6: OR 1.6, 99% CI 1.2-2.2, 5 versus 6: OR 1.6, 99% CI 1.2-2.3). Among euploid embryos, ICM morphology is the best predictor of sustained implantation; however, a composite score may provide additional guidance. While there is a known benefit in genomic screening prior to embryo selection, morphology provides individualized, prognostic information about implantation potential.

Sperm selection for ICSI using hylauronan binding in males with high DNA fragmentation does not appear to select against sperm chromosome aneuploidies

Hyalyronic acid (HA) surrounding the human oocyte acts as a natural selector for morphologically normal sperm with hyaluronic acid receptors and minimal DNA fragmentation. An association between high sperm DNA fragmentation and pregnancy loss has been reported, however the clinical value of selecting sperm for intracytoplasmic sperm injection (ICSI) in conjunction with hyaluronic acid binding assays remains to be clarified. The objective of this study was to evaluate the IVF outcomes of sperm with low HA-binding ability (≤65%) following physiological ICSI (PICSI). Retrospective study. Infertility patients with high sperm DNA fragmentation (≥14%; TUNEL assay) that underwent in vitro fertilization (IVF) and PICSI with low HA-binding ability (≤65%; n=23) were evaluated for IVF outcomes including fertilization, blastocyst development and chromosome constitution. Euploid frozen embryo transfer (FET) outcomes which included implantation rate with fetal heart tone, miscarriage rates and live birth rates, were compared to maternally age-matched infertility patients with normal sperm DNA fragmentation that underwent IVF with ICSI. Statistical analysis was performed using Students t-test and Chi square test where appropriate, significance at P<0.05. Mean maternal and paternal ages for these PICSI patients with low HA-binding ability were 37.9±3.7 and 40.9±6.2 years, respectively. High sperm DNA fragmentation (mean 21.5±6.3%) was the only male factor variable significantly associated with these couples. Fertilization and usable blastocyst development with PICSI selected sperm was observed at acceptable rates of 78% and 46%, respectively. Following trophectoderm biopsy, 38% of blastocysts were identified as euploid, significantly less than maternally age-matched ICSI patients at 52% (P<0.05). To date, there have been 12 euploid FETs resulting in comparable good clinical outcomes to maternally age-matched ICSI patients: 66.7% implantation with fetal heart tone, 83.3% live birth and no clinical pregnancy losses. There were 7 cycles that resulted in all aneuploid blastocysts with no FET, thereby calculating a 45.5% live birth rate from oocyte retrieval for PICSI patients with high sperm DNA fragmentation and low HA-binding ability. No significant differences were observed for the chromosomes involved in the errors between the aneuploid blastocysts from the PICSI patients with low HA-binding ability and the maternally age-matched ICSI patients. In conclusion, this study revealed that PICSI patients with high sperm DNA fragmentation and low HA-binding ability have significantly higher blastocyst aneuploidy rates than maternally age-matched ICSI patients. Nevertheless, following a euploid FET these patients exhibited positive clinical outcomes and no pregnancy losses to date.

Lactobacillus non-dominant (LBND) microbiome (MB) is associated with decreased vitamin D receptor (VDR) expression in the endometrium of women who fail euploid frozen embryo transfers (FET)

Lactobacillus non-dominant (LBND) microbiome (MB) is associated with decreased vitamin D receptor (VDR) expression in the endometrium of women who fail euploid frozen embryo transfers (FET)

Behind the bleed: analysis of the formation of subchorionic hematomas (SCH) in single euploid embryo transfer cycles by protocol

Subchorionic hematomas (SCH) are a known risk factor for poor obstetric outcomes such as spontaneous abortion and preterm delivery. We sought to determine if there is a difference in the prevalence of SCH formation in pregnancies after frozen embryo transfer (FET) between natural and programmed preparation. Retrospective cohort study of single euploid FET cycles resulting in clinical pregnancy performed between 1/2016 and 12/2017 at our center. All single euploid FET cycles utilizing Next Generation Sequencing were reviewed. Exclusion criteria included FET cycles with ploidy determined by aCGH, or cycles in which untested, mosaic, or multiple embryos were transferred. All transfer cycles that resulted in clinical pregnancy (defined as presence of gestational sac) were included. These cycles were analyzed by protocol; natural versus programmed. Patients undergoing programmed cycles took oral estradiol daily followed by either 50-75mg intramuscular progesterone (P4) in oil or vaginal P4 suppository. Patients undergoing natural cycles (or supplemented with letrozole for 5 days) were monitored until a dominant follicle reached >18mm and ovulation was confirmed followed by the initiation of vaginal P4 suppository. SCH were documented at the time of luteal ultrasound as a measurable clot behind the gestational sac. Primary outcome was the rate of SCH noted on luteal ultrasound. Statistical analyses included students T-test, chi-squared and Fischer’s Exact test where appropriate (mean +/- SD, p < 0.05). A total of 719 cycles were included; 86 natural and 633 programmed (Table 1). SCH formation was diagnosed in 12.9% (n = 93) of clinical pregnancies. The formation of SCH was significantly lower in natural cycles compared to programmed cycles (RR 0.4, 95% CI 0.17 - 0.98, p < 0.04). Relevant cycle parameters were similar between groups (Table 1); cycle day 28 estrogen was higher in programmed cycles reflecting exogenous estrogen exposure. When programmed cycles utilizing vaginal P4 only were excluded (n=36), the formation of SCH is still statistically lower in natural compared to programmed cycles (5.8% v 14.2%, RR 0.4 (0.17-0.97, p <0.03). SCH occurred less frequently in single euploid embryo transfers using a “natural” endometrial preparation. Further analyses of long term outcomes could help provide insight into estimates of obstetrical risk.Tabled 1SCH Formation in Clinical Pregnancies by FET Protocol: Patient and Cycle CharacteristicsNatural Cycles (n=86)Programmed Cycles (n=633)p - valueDeveloped SCH5.8% (5/86)14.0% (88/633)p < 0.04 RR 0.4 (0.17-0.98)Average CD SCH diagnosed44.8±3.547.7±7.3p < 0.40Age37.45±4.336.81±4.4p < 0.20CD 28 hCG202.3±147.4189.3±176.5p < 0.52CD 28 E2284.9±234.5477.4±395.2p < 0.0001CD 28 P426.4±11.326.7±17.9p < 0.89Transfer Difficulty Marked “Easy” by Provider91.9% (79/86)95.6% (605/633)p < 0.13 RR 1.84 (0.83-4.1)Endometrial Thickness (mm)8.8±1.510.4±2.4p < 0.54 Open table in a new tab

The role of the endometrial receptivity array (ERA) in patients who have failed euploid embryo transfers.

Endometrial receptivity issues represent a potential source of implantation failure. The aim of this study was to document our experience with the endometrial receptivity array (ERA) among patients with a history of euploid blastocyst implantation failure. We investigated whether the contribution of the endometrial factor could be identified with the ERA test and if actionable results can lead to improved outcomes. A retrospective review was performed for 88 patients who underwent ERA testing between 2014 and 2017. Reproductive outcomes were compared for patients undergoing frozen embryo transfer (FET) using a standard progesterone protocol versus those with non-receptive results by ERA and subsequent FET according to a personalized embryo transfer (pET) protocol. Of patients with at least one previously failed euploid FET, 22.5% had a displaced WOI diagnosed by ERA and qualified for pET. After pET, we found that implantation and ongoing pregnancy rates were higher (73.7 vs. 54.2% and 63.2 vs. 41.7%, respectively) compared to patients without pET, although differences were not statistically significant. Our experience demonstrates that a significant proportion of patients with a history of implantation failure of a euploid embryo have a displaced WOI as detected by the ERA. For these patients, pET using a modified progesterone protocol may improve the outcomes of subsequent euploid FET. Larger randomized studies are required to validate these results.