Frozen Embryo Replacement Cycles Research Articles

P-639 Are GnRH-agonists (GnRH-a) safer and more effective ovulation triggers than human chorionic gonadotrophin (hCG)? A retrospective analysis of frozen embryo replacement cycle (FERC) outcomes

Abstract Study question Are GnRH-agonists (GnRH-a) safer and more effective ovulation triggers than human chorionic gonadotrophin (hCG)? A retrospective analysis of frozen embryo replacement cycle (FERC) outcomes Summary answer GnRH-a trigger reduces the incidence and severity of ovarian hyperstimulation syndrome (OHSS) leading to significantly improved clinical outcomes when compared to hCG trigger for FERCs. What is known already Ovulation induction plays a crucial role in the success and safety of ART cycles. hCG is extensively used as an alternative to LH to trigger ovulation. However, high levels of sustained hCG exposure increases the risk of OHSS, a potentially life-threatening complication of ART. To eliminate the risk and incidence of OHSS, GnRH-a can be used to trigger ovulation. Although there are concerns regarding clinical outcomes with fresh transfers following GnRH-a trigger, it elicits a more physiological response compared to hCG. This may lead to improved embryo quality, utilisation, and better clinical outcomes following a freeze-all strategy, reducing patients’ time-to-pregnancy. Study design, size, duration This was a retrospective data analysis of FERC outcomes following fresh IVF or ICSI cycles, involving ovulation induction using either hCG or GnRH-a as a final trigger. The evaluation included results from cycles spanning an eight-year period, from January 2012 to December 2019 at Hammersmith Hospital London. A total of 160 cycles were included in the study, with 76 in the hCG trigger group and 84 in the GnRH-a trigger group. Participants/materials, setting, methods Strict inclusion criteria were employed to render the study groups as comparable as possible and to minimise the effect of independent variables, such as oocyte and sperm factors, on oocyte or embryo developmental competence. Inclusion criteria: women ≤37 years old at the start of treatment, GnRH antagonist stimulation, blastocyst vitrification-warming and transfers only. Statistical significance was calculated using independent t-test and Fisher’s Chi-square exact test. Main results and the role of chance The mean age (±SD) of patients at the time of oocyte retrieval was comparable across groups. The average number of oocytes collected were significantly higher in the GnRH-a group compared to hCG (28.31 vs. 18.07, respectively, P < 0.001). Embryological data (maturation, fertilisation, blastocyst formation, blastocyst utilisation and good quality blastocyst formation rates) were comparable across both groups. OHSS rate was significantly lower in the GnRH-a group (17% vs. 50%. P < 0.0001). The following clinical data were significantly higher (P < 0.05) in the GnRH-a group compared to hCG: implantation rate (56% vs. 36%), clinical pregnancy rate (56% vs. 36%) and live birth rate (42% vs. 27%). Limitations, reasons for caution The biggest limitation of this study is its retrospective nature and the application of various inclusion-exclusion criteria that have resulted in relatively small sample sizes. Additionally, numerous other confounders, e.g. patient body mass index, cause/duration of infertility and stimulation duration, have not been considered in this study. Wider implications of the findings The findings of this study are promising and demonstrate a great potential for benefit in the use of GnRH-a trigger with a freeze-all strategy to minimise the risk of OHSS, diminishing the associated patient morbidity and mortality, reducing healthcare costs, improving clinical outcomes, and reducing the overall time-to-pregnancy for patients. Trial registration number not applicable

P-152 The impact of one-step fast warming protocol on vitrified-warmed blastocysts on reproductive outcome

Abstract Study question Does the implementation of one-step fast warming protocol affect the post warming quality of embryos and/or the reproductive outcome in frozen embryo replacement cycles? Summary answer The implementation of a one-step fast warming protocol provides similar survival, pregnancy, and clinical pregnancy rates with standard warming protocols. What is known already Cryopreservation process presents a significant challenge for embryos, as the formation of ice crystals can be lethal to their cells. Therefore, effective cryopreservation protocols are essential to mitigate this risk. Vitrification method protects the cells during cryopreservation by transforming water from a liquid state to a glass-like phase, thereby preventing the ice crystals formation. Moreover, the warming procedure can itself contribute to ice crystal formation, particularly through recrystallization. Studies have shown that embryo survival is related to warming rate and a one-step fasting warming protocol can be equally or more effective than the conventional protocol. Study design, size, duration This prospective randomized study was performed at Embryolab Fertility Clinic, in Thessaloniki, Greece between July and December 2023 and included 118 frozen embryo transfers. Both study and control group included only expanded blastocysts of good quality (AA or AB according to Gardner’s criteria). Control group was matched to the study group according to treatment, time period, woman age, quality of embryos and number of transferred embryos. The embryos were vitrified using open system. Participants/materials, setting, methods Fast warming group included embryos that were warmed using the one-step warming protocol: the embryos were exposed to 1M sucrose solution for 1’ at 37 °C and then immediately placed into culture media where laser-assisted hatching was performed. Control group included embryos that were warmed using conventional protocol: 1’ in 1M, 2’ in 0.5M, 2’ in 0.25M and 3’ in washing solution at room temperature and then placed into culture media for laser-assisted hatching. Main results and the role of chance The analyzed cases were 118 in total, 59 in the fast-warming group and 59 in the control group. Survival rate was 100% in both groups. Pregnancy rate (positive b-HCG) was not significantly different between the two groups: 72.41% in the fast-warming group and 67.79% in the control group (p = 0.687). Clinical pregnancy rate was also not significant between the two groups: 78.26% in the fast-warming group and 81.81% in the control group (p = 0.753). Limitations, reasons for caution The study included a limited number of cases, and information on the live birth rate was still pending. To establish the efficacy of fast warming conclusively, it is recommended that additional prospective randomized studies be conducted to validate its potential benefits. Wider implications of the findings One-step fast warming protocol resulted in similar survival rates post warm compared to the conventional warming protocol, while pregnancy and clinical pregnancy rates were not significantly different. Furthermore, it is worth noting that by minimizing the duration of the warming protocol, the workflow efficiency in the IVF laboratory is enhanced. Trial registration number N/A

O-039 Con - the faster the better

Abstract Late o’clock: Are slow growing embryos clinically usable? Con - the faster the better Reproductive medicine and, within it, embryology, have experienced milestones in the understanding of pre-implantation embryonic development over the last quarter of a century. The development of blastocyst culture media for embryo culture even after embryonic genome activation and the possibility of continuous monitoring of embryonic morphokinetics throughout the pre-implantation period have been major contributors. The development of molecular genetic techniques has also played an important role. The introduction of new cryopreservation techniques has also improved the success rate of the clinical use of surplus embryos, including slow-growing embryos not otherwise selected for fresh cycle transfer. Two questions are most frequently encountered in clinical embryology today: which embryo in a cohort has the best chance of resulting in a live-born child, and how slow and morphologically suboptimal can an embryo be to still be considered clinically useful? In particular, the latter question does not have an easy answer, as embryos demonstrate varying pace of development. A further problem arises if there are no optimal embryos available in the cohort and this answer has to be given on day 2, 3 or 5, as this is when the embryo transfer is scheduled to take place. Some studies suggest that longer timing of any stage of embryonic development from pronuclear fading onwards means that the embryo is late in development due to certain abnormalities and is likely to be energetically depleted by the activation of its repair mechanisms. Such embryos not only have a lower implantation potential compared to fast embryos, but also diverge in time from the optimal receptivity of the endometrium. Additional testing and/or storage of slow-growing embryos brings the question of their clinical usability to the time of frozen embryo replacement cycles and quiets the couple's expectation of a “successful” completion of the stimulated cycle. Whether embryos are to be selected for fresh ET or FER, the “the faster - the better” principle is likely to be applied. In daily clinical practice, decisions on the use of slow-growing and/or morphologically sub-optimal embryos and the timing of embryo transfer are made on an individual basis, taking into account various medical as well as non-medical (e.g. economic, logistical) factors. These may also include portraying a positive image of the centre's performance. However, patients expect infertility specialists to make realistic assessments not only of the viability of slow growing embryos, but also of the outcome of the transfer of them. The assessment must be based not only on medical and ethical but also on rational grounds.

P-181 The impact of high proportion of immature oocyte in a cohort on the reproductive outcome following icsi

Abstract Study question Whether high proportion of immature oocyte in a cohort impacts outcome of sibling mature oocyte in ICSI cycles. Summary answer Study demonstrate that if immature oocyte retrieved was more than 50% in a cycle then it reduces reproductive outcome with the remaining mature sibling oocytes. What is known already The selection of competent oocyte is crucial to assisted reproductive technique procedure outcome. In ICSI procedure where only metaphase II oocytes (MII) are injected correlates with number of MII oocytes available, embryo development and pregnancy outcome. Percentage of immature oocyte {Metaphase I (MI) and Germinal Vessicle (GV) } retrieved in a cycle is always a concern for stimulation protocol, patient response which affects IVF laboratory outcome. Study design, size, duration A prospective study was conducted from 1st January 2020 to 1st December 2022 in the Department of Reproductive medicine at a tertiary infertility centre in India. Participants/materials, setting, methods Patients were divided into 3 groups on the basis of percentage of immature oocyte retrieved in a single cycle. Group A (n = 100), where percentage of immature oocyte (MI and GV) was between 0 to 20%, while Group B (n = 60) where percentage of immature oocyte was between 21 to 50% and Group C (n = 20) where percentage of immature oocyte was between 51 to 100%. Main results and the role of chance This study included all normal responder patients and cycles using in-vitro fertilisation (IVF) and poor responders were excluded. All blastocyst formed were vitrified and transferred in frozen embryo replacement cycle. All the 3 groups were compared on the basis of fertilisation rate, blastocyst formation rate, clinical pregnancy rate and miscarriage rate. Group A and group B had no significant difference in fertilisation rate (82% vs. 78%, p > 0.5), blastocyst formation rate (60% vs. 58%, p > 0.5), clinical pregnancy rate (58% vs. 55%, p > 0.5) and miscarriage rate (12% vs. 11%, p > 0.5). While significant reduction was observed in group C ( > 50% MI & GV oocyte) in fertilisation rate (40%, p < 0.1), blastocyst formation rate (28%, p < 0.1), clinical pregnancy rate (15%, p < 0.1). Limitations, reasons for caution Larger randomised control studies are needed to strengthen these results. Wider implications of the findings Percentage of immature oocyte can help in predicting the success of assisted reproductive technique. This will help in counselling patient about outcome. Trial registration number NA

P-358 Impact of localization of diffuse adenomyosis on reproductive outcomes and pregnancy complications: A prospective cohort study of 585 patients after frozen embryo replacement cycle

Abstract Study question Does localization of diffuse adenomyosis impact reproductive outcomes after the frozen embryo transfer (FET)? Summary answer Diffuse adenomyotic lesions involving the junctional zone (JZ) have a greater negative impact on reproductive outcomes than diffuse adenomyosis of the outer myometrium (OM). What is known already Adenomyosis is associated with higher miscarriage rate, significantly lower live-birth (LB) rate, and increased risk for pregnancy-related complications. However, the impact of adenomyosis on IVF outcomes remains unclear. Adenomyosis is often treated as a homogenous disease and studies on the effects of different types of adenomyosis on reproductive outcomes have yielded inconsistent results, due to a lack of standardized diagnostic criteria and a lack of agreement on the phenotypic classification of the disease based on their severity or location. There is a lack of studies considering the effects of the severity or location of adenomyosis on reproductive outcomes after FET. Study design, size, duration This prospective cohort study was conducted at a tertiary-care hospital between January 2019 and December 2022. A total of 585 infertile women undergoing the first FET cycle were recruited. The study population included 368 women with diffuse adenomyosis where 201 women had diffuse adenomyosis of JZ and, 167 women had diffuse adenomyosis of OM. 217 women with male infertility were taken as controls. Participants/materials, setting, methods Adenomyosis was diagnosed with 2D-TVS using MUSA criteria where patients with two or more features and diffuse adenomyosis were included. Patients with diffuse adenomyosis were further divided based on the localization of adenomyotic lesions in OM or JZ. All the patients underwent FET-cycle. Pregnancy outcomes and complications were compared between different groups-those with diffuse adenomyosis of JZ, those with diffuse adenomyosis of OM, and controls. Adenomyosis patients as one group were also compared with controls. Main results and the role of chance The pregnancy rate was significantly lower in women with diffuse adenomyosis of JZ (26.37%) compared to diffuse adenomyosis of OM (47.9%) (OR:0.39, 95% CI 0.25-0.60; P < 0.0001). Similarly, the clinical pregnancy rate was also lower in diffuse adenomyosis with JZ involvement (23.38%) compared to women with diffuse adenomyosis of OM (42.51%) (OR:0.41, 95% CI 0.26-0.65; P = 0.0001). However, the biochemical pregnancy and miscarriage rates were comparable between the two adenomyosis groups. The LB rate was significantly lower in patients with JZ-involvement (16.42%) compared to women with OM-involvement (25.75%) (OR:0.57, 95% CI 0.34-0.94; P = 0.029). When all the adenomyosis patients were compared with the controls as one group, pregnancy rates were similar, but the miscarriage rate was significantly higher, and the LB rate was significantly lower in adenomyosis (P < 0.05). When the individual groups with adenomyosis were compared with controls, clinical pregnancy, and LB were comparable with the controls (P > 0.05) in women with OM involvement. However, when JZ was involved, the differences were significant (P < 0.05), highlighting the adverse impact of JZ involvement on IVF outcome. Pregnancy complications were comparable between the adenomyosis groups; however, there was a significantly higher incidence of gestational hypertension, IUGR, and pre-term labor for adenomyosis patients compared to the control (P < 0.05). Limitations, reasons for caution In the absence of a universally accepted diagnostic modality and classification system for adenomyosis, this study used ultrasound due to its lower cost and easy availability. The sample size of this study is limited to 368 patients from a single centre, larger multicentric studies are needed to make definitive conclusions. Wider implications of the findings Localizing adenomyotic lesions before starting IVF, may help in planning treatment strategies and provide adequate counseling on reproductive outcomes specific to each type. Pregnant women with adenomyosis should be managed carefully as high-risk pregnancies, considering the possible serious obstetric complications. Trial registration number CTRI/2019/01/016919

Alloimmune Disorders in Recurrent Implantation Failures after IVF/ET Procedures

Recurrent Implantation Failures (RIF) can be defined as the absence of implantation after 2 to 6 consecutive cycles of IVF, ICSI or frozen embryo replacement cycles where the cumulative numer of transferred high-quality embryos was no less than four for cleavage-stage embryos and no less than two for blastocytes. RIF can be considered with appropriate developemental stage with determination of implantation by an increasing quantitative Human Chorionic Gonadotropin (hCG) level and usually include also biochemical pregnancies [1]. Successful pregnancy implantation is related to adequate utero-placental circulation, absence of uterine anomalities and adequate endometrial receptivity. Immunological causes and thrombophilias play important roles in implantation failure through mechanisms similar to recurrent miscarriages [2]. Pregnancy is believed to appear a period of immunomodulation with greater pro-inflammatory activity at the beginning of pregnancy and change during the second and third trimester [3].

Spontaneous and iatrogenic ovarian hyperstimulation syndrome in the absence of FSHR mutations: a case report of two unexpected cases

BackgroundOvarian hyperstimulation syndrome (OHSS) is a complication of controlled ovarian hyperstimulation (COH). It is a potentially life-threatening condition that usually occurs either after human chorionic gonadotropins (hCG) administration in susceptible patients or as a result of an implanting pregnancy, regardless of whether it was achieved by natural conception or infertility treatments. Despite many years of clinical experience regarding the adoption of preventive measures and the identification of patients at high risk, the pathophysiology of OHSS is poorly understood and no reliable predictive risk factors have been identified.Cases presentationWe report about two unexpected cases of OHSS following infertility treatments, occurring after freeze-all strategy with embryo cryopreservation approaches. The first case developed spontaneous OHSS (sOHSS), despite efforts to prevent its manifestation by a segmentation approach, including frozen embryo replacement cycle. The second case developed a late form of iatrogenic OHSS (iOHSS), even though the absence of any risk factors. No mutations in the follicle-stimulating hormone (FSH) receptor (FSHR)-encoding gene were detected, suggesting that the high levels of hCG due to the twin implanting pregnancies could be the only triggering factor of OHSS outbreak.ConclusionFreeze-all strategy with embryo cryopreservation cannot entirely prevent the development of OHSS, which may occur in its spontaneous form independently from the FSHR genotype. Although OHSS remains a rare event, all infertile patients requiring ovulation induction or controlled ovarian stimulation (COS) may be at potential risk of OHSS, either in the presence or in the absence of risk factors. We suggest closely monitoring cases of pregnancy following infertility treatments in order to provide early diagnosis and adopt the conservative management.

P-128 Role of PGT-A and ERA to optimise reproductive outcomes of couples with recurrent implantation failure

Abstract Study question In couples with Recurrent Implantation Failure (RIF), can Pre-implantation Genetic Testing for Aneuploidy (PGT-A) or Endometrial Receptive Array (ERA) help to optimise the reproductive outcomes? Summary answer In RIF patients PGT-A or ERA individually do not seem to optimize outcomes. PGT-A in-combination with ERA seems to be a beneficial intervention. What is known already Role of PGT-A and ERA to optimize reproductive outcomes has been ambigious. In this current study we wanted to evaluate their efficacy in RIF patients. Study design, size, duration This is a retrospective data of couples undergone treatment for RIF at our private fertility centre from January 2014 to July 2019. The study population was divided to four groups based on the treatments offered: Group A: ERA (n = 47) Group B: PGT-A (n = 54) Group C: ERA+PGT-A (n = 49) Group D: No PGT-A/ No ERA (n = 189) Participants/materials, setting, methods Couples with minimum two failed transfers were recruited. ICSI was the method of insemination. Blastocysts were subjected to genetic testing through Next-Generation Sequencing(NGS). All embryo transfers performed in a Frozen Embryo Replacement Cycle(FET). ERA was done as per our institutes Standard Operating Procedures(SOP) and for ERA patients ET was done as per the receptivity status. Elective Single Euploid Blastocyst transfer (eSET) was done in grpB&C un-screened double Blastocyst Transfer (DET) was done in grpA&D. Main results and the role of chance Clinical Pregnancy Rate (CPR), Miscarriage Rate (MR) Implantation Rate (IR), Multiple Pregnanacy rates (MPR) and Live Birth Rate (LBR) was evaluated in all groups. Outcomes of groups A, B, C & D were as follows: CPR – 68.09% Vs 62% Vs 68.42% Vs 70% IR – 48.89% Vs 47.50% Vs 65.22% Vs 45% MR – 12.77% Vs 9.25% Vs 5.26% Vs 17.89% MPR – 16% Vs 0% Vs 0% Vs 17% LBR – 51.06% Vs 46.8% Vs 63.16% Vs 45% CPR was comaparble between all groups ERA & PGT-A group seems to have the best IR, LBR with least miscarriage rates. For RIF patients role of PGT or ERA when offered individually, doesn’t seem to optimize outcomes. PGT-A in-combination with ERA seems to be beneficial to optimize outcomes. Limitations, reasons for caution This data is retrospective and there is a need for a well designed RCT to further validate the conclusion of this study. Caution needs to be exercised while offering PGT and ERA as they incurr additional financial burden to the patients. Wider implications of the findings Embryo Transfer cycles with a personalised window of implantation and transfer of a single Euploid embryo can help RIF patinets to have the best reproductive outcomes and can also help shorten the time to pregnancy. Trial registration number Not applicable

P-070 Comparison of Microfluidic Sperm Sorting (MFSS) versus Physiological Intracytoplasmic Sperm Injection (PICSI) versus Density Gradient versus Swim Up in high DNA fragmentation index sperm samples

Abstract Study question To evaluate the effectiveness of using Microfluidic Sperm Sorting (MFSS) over other technique in patient with high DNA fragmentation index (DFI) sperm samples? Summary answer Microfluidic is not only correlated with better DNA integrity but also with the better reproductive outcome. What is known already DNA damage is unrecognisable in living sperm prior to insemination and an increased sperm DNA fragmentation index has been associated with lower fertilization rates, impaired embryo development and reduced pregnancy rates. Standard semen processing techniques are associated with centrifugation, which may induce reactive oxygen species and DNA damage. In strategies to minimize sperm DNA fragmentation, Physiological ICSI can relatively reduce sperm DNA fragmentation by 67.9% (Parmegiani et al., 2010) while new technique Microfluidic sperm sorter technique also demonstrate sperm selection with significantly reduced DNA damage Study design, size, duration A prospective randomised study was conducted from 1st January 2019 to 1st December 2021. Four hundred patients were randomised by computer generated list and divided into 4 groups. Group A (n = 100) , in which sperm were processed by microfluidic sperm sorter (MFSS) while in group B (n = 100), sperm were selected by Physiological Intracytoplasmic Sperm Injection (PICSI), Group C (n = 100), sperm were processed by density gradient and Group D (n = 100), sperm were processed by swim-up technique. Participants/materials, setting, methods The study period included all normozoospermic patients with high DNA fragmentation index (>25%) while oligospermic, asthenozoospermic samples, patients with poor ovarian reserve and advanced age were excluded from the study. All A grade embryos were vitrified and transferred in frozen embryo replacement cycle. All the 3 groups were compared on the basis of fertilisation rate, day 3 grade A embryo development rate, clinical pregnancy rate and miscarriage rate. Main results and the role of chance Cycle characteristics (female age, length of stimulation, gonadotrophin dose, number of oocytes and number of transferred embryos) were similar among all 4 groups. Among 4 groups, There was a statistically significant increase observed in Group A (Microfluidic Sperm Sorting), day 3 grade A embryo development rate (60% vs. 42% vs. 38% vs. 40%, p-0.016) and clinical pregnancy rate (62% vs. 46% vs. 41% vs 43%, p-0.049), while no statistical significant difference observed in fertilisation rate (82% vs. 78% vs. 76% vs. 78%, p-0.80) comparing group B, group C and group D. But significantly higher miscarriage rate (12% vs. 11% vs. 25%, 12%) observed in density gradient (Group C) technique. Limitations, reasons for caution Larger randomised control studies are needed to strengthen these results. Wider implications of the findings We have demonstrated that sperm sorted by microfluidic helps in selection of sperm with better DNA integrity over Physiological ICSI, Density Gradient and Swim-up techniues. Using it in routine practice can help in reducing the negative effect of reactive oxygen species and thus improve pregnancy rate and live birth rate. Trial registration number MCDH/2019/35

O-023 A randomized control trial on the effect of intrauterine HCG flushing on reproductive outcomes

Abstract Study question Can Intra Uterine Flushing with Human Chorionic Gonadotropin (hCG) optimize embryo implantation and reproductive outcomes in Assisted Reproductive Technique(ART) cycles? Summary answer Uterine flushing with hCG does not seem to enhance embryo implantation and optimize reproductive outcomes What is known already Human Chorionic Gonadotropin (hCG) hormone has shown to play an important role in embryo implantation. Role of hCG flushing to uterine cavity has been proposed as one of the interventions to optimize embryo implantation, but its efficiency has been debatable. Study design, size, duration This study is a Randomised Control trial (RCT) with prior approval from Institution Ethical Review Board(IEC Ref. No. ECR/1312/inst/tg/2019). Study duration between November 2020-November 2021 at a private clinic. Women undergoing In-Vitro fertilization (IVF) cycles were randomised to no hCG flush group (n = 80) and hCG flush group (n = 100). Women >37yrs age and BMI >30 or having some uterine pathology or willing for Pre-Implantation Genetic Testing (PGT) or donor gamete cycles were excluded from this study Participants/materials, setting, methods Women recruited in this study underwent ovarian stimulation as per the institutes standard operating protocols (SOP). All embryos subjected to blastocyst culture and freeze all strategy followed. In a frozen embryo replacement cycle two good grade blastocysts were transferred. In hCG flush group, 48-72hrs before anticipated embryos transfer (ET) 500IU of commercially available hCG hormone was instilled into the uterine cavity. No hCG Flush group did not have any intervention Main results and the role of chance Clinical Pregnancy rates (CPR), Implantation Rates (IR), Multiple Pregnancy rates (MPR) were compared between the groups. Means of Reproductive outcomes between hCG Vs no hCG group were as follows CPR – 71% Vs 76% (p = 0.45) IR – 59% Vs 55%(p=0.59)MPR – 18% Vs 25%(p=0.25) Data from this RCT shows that hCG flush does not seem to enhance embryo implantation. Role of hCG flush to optimize reproductive outcomes is questionable. Limitations, reasons for caution This study has not evaluated the miscarriage rates and live birth rates Wider implications of the findings Ways to enhance embryo implantation and optimising reproductive outcomes still needs further research. hCG flushing might not be a beneficial intervention to optimise embryo implantation. However, a subgroup analysis to identify efficiency of hCG in a particular group of patients like thin endometrium could be further explored. Trial registration number NA

O-131 Progesterone Primed Ovarian Stimulation (PPOS) Vs Clomiphene Primed Ovarian Stimulation (CPOS) in high responder (HR) patients undergoing controlled ovarian stimulation - A Randomized Control Trial

Study questionIn high responder individuals, stimulation with PPOS or CPOS would offer better outcomes?Summary answerData from this trial concludes that stimulation with CPOS or PPOS seem to offer comparable outcomes in high responders individuals.What is known alreadyProgesterone and Clomiphene Citrate have been used to suppress premature LH surge in patients undergoing controlled ovarian stimulation (COS) for In Vitro Fertilization. Their use will negate the need of using additional injections and thereby would improve the patient acceptability and reduce pain and drop out rates. This Randomized Control Trial (RCT) intends to look at the efficiency of these protocols.Study design, size, durationThis is a Prospective RCT conducted between September 2020-December 2021 with prior approval from Institutional Ethical committee (ECR/1312/INST/TG/2019). HR patients as defined by Antral Follicular Count (AFC), Anti-Mullerian hormone (AMH) or previous response were randomized into PPOS (n = 50) & CPOS (n = 50) arm at start of stimulation based on a computer generated randomization sheet.Exclusion criteriaAge > 35 yrs, history of Total Fertilization Failure, Inadequate post-trigger hormonal values, incomplete retrieval of oocytes.Participants/materials, setting, methodsAfter randomization, all patients were started on Inj rFSH & Inj HP-HMG (dosage depending upon BMI). PPOS arm- Tab.Medroxy Progesterone Acetate10 mg/day started from day 2 of the cycle along with gonadotropins and continued until trigger. CPOS arm- Clomiphene citrate 150 mg/day (divided doses) starting from the 8thday of stimulation or when lead follicle reached 12 mm diameter and continued until trigger.All the subjects underwent Frozen Embryo replacement cycle with two good grade blastocysts.Main results and the role of chanceBaseline variables of patients were comparable between both arms. There were 6-dropouts in PPOS arm and 8 dropouts in CPOS arm due to Covid -19 infection. Hence a total of 44 patients in PPOS arm and 42 patients in CPOS arm were available for analysis.Premature LH surge rates, cycle cancellation rate, blastocyst rate (BR), Implantation Rate (IR) per initiated FET cycle were the primary outcomes.Dose and duration of gonadotropins, number of oocytes, maturation rate, fertilization rate (FR), and OHSS rate were the secondary outcomesOutcomes between PPOS Vs CPOS were as follows: LH Surge – 2.3% vs 2.5% (p = 1)Cycle cancellation rate – 9.1% Vs 10% (p = 1)BR – 57% vs 56% (p = 0.547)IR – 44% Vs 49% (p = 0.687)Secondary outcomes - Dose and duration of gonadotropins, number of oocytes retrieved, fertilization rate, maturation rate & OHSS rate were comparable in both groups.All the outcomes compared between the two arms seemed to be similar with no statistical significance. Progesterone or Clomiphene priming seems to offer optimal outcomes with no superiority of one protocol over the other.Limitations, reasons for cautionThe RCT was performed on a small sample size and should be confirmed on a larger cohort. Moreover, this is the first study comparing both the drugs in high responders and confirms the efficacy of both drugs as LH suppressants without compromising outcomes.Wider implications of the findingsThis study provides assuring data on using the two oral agents, progesterone and clomiphene citrate with equal efficacy and without affecting the outcomes. These agents can help in reducing the dosage of gonadotropins and this in turn can help in minimizing the complications like OHSS during controlled ovarian stimulation.Trial registration numberNot applicable

P-619 A prospective RCT comparing luteal phase treatment with estradiol and follicular antagonist for ovarian follicular synchronization in ICSI cycle in women with low ovarian reserve

Study questionIn women with low reserve for ovarian follicular synchronization, luteal phase treatment with estradiol (LE) or follicular antagonist(FA) would offer better outcomes?Summary answerData concludes that priming protocols with FA seem to offer statistically significant blastulation rate with similar outcome for metaphase 11 and fertilization rate.What is known alreadyThe heterogenecity of follicular growth, particularly in women with low reserve, may cause decreased retrieval of mature oocytes and reduced blastocysts. Luteal estradiol and follicular anatagonist have been used as priming protocols for synchronizing follicles by suppressing endogenous FSH. This RCT intends to compare these two protocols, in terms of clinical outcome.Study design, size, durationThis is a Prospective RCT conducted between September 2020-December 2021 with prior approval from Institutional Ethical committee (ECR/1312/INST/TG/2019). Total number of subjects were 100. Women with poor response, defined based on POSEIDON criteria were randomized into LE (n = 50) and FA (n = 50) and recruited into the study protocol based on a computer generated randomization sheet.Exclusion criteria: Age>40Participants/materials, setting, methodsAfter randomization, all patients were started on Inj rFSH & Inj HP-HMG1. Estradiol valerate pre treatment armEstradiol dosage of 4mg/day, started 7 to 10 days before day 1 of the stimulation cycle.2. Follicular Antagonist armUltrasound performed on cycle day 1/2 to identify the absence of ovarian cyst or follicle >10mm. Pretreatment with Inj Cetrotide 0.25mg sc once day for 5-7 days,thereafter stimulation was started.All the subjects underwent Frozen Embryo replacement cycle .Main results and the role of chanceBaseline variables of patients were comparable between both arms. There was 1-dropout in FA arm due to covid -19 infection and no dropouts in LE arm. Hence a total of 49 patients in FA arm and 50 patients in LE arm were available for analysis.Total days of stimulation, total dose of FSH used ,number of oocytes retrieved, M11 rate, fertilization rate, blastulation rate, FSG/oocyte used were the primary outcomes.Implantation rate, ongoing pregnancy rate ,live birth rate were the secondary outcomesOutcomes between FA Vs LE were as followsDays of stimulation – 10.65 vs 10.10 (p = 0 .289)FSH dosage- 2654 vs 2360 (p = 0.730) Fertilization rate – 91% vs 80% (p = 0.48) Blastulation rate – 67% vs 40% (p = 0.006) All outcomes compared between the two arms seemed to be similar except follicular antagonist group that showed to have a higher blastulation rate compared to luteal estradiol group which was statistically significant.Limitations, reasons for cautionThe RCT was performed on a small sample size and should be confirmed on a larger cohort.Wider implications of the findingsThis study provides assuring data on using the two agents, with statistically significant blastulation rate in FA group. Furthur research on larger sample size is required .Trial registration number12

P-374 Serum progesterone levels on the of embryo transfer in replacement cycles (HRT-ET): soft capsules vs suppositories may make a difference

Abstract Study question Are there differences in serum progesterone levels when vaginal progesterone is administered in soft capsules vs suppositories in HRT-ET? Summary answer Mean serum levels of progesterone in embryo replacement cycles are higher when progesterone suppositories are used instead of soft capsules. What is known already Serum levels of progesterone on the day of the embryo transfer has captured recent attention, as it may vary among patients and different vaginal progesterone formulations. Previous studies have suggested that natural micronized vaginal progesterone induces a comparable decidual transformation and clinical pregnancy rates to vaginal progesterone gel. However, no data exists comparing suppositories versus soft capsules. Study design, size, duration Prospective, observational, single center study to compare serum progesterone levels on the day of the embryo transfer in women undergoing HRT-ET and being treated with vaginal progesterone in capsules or suppositories. Also, a patient satisfaction questionnaire was given to women participating in the study to investigate patient experience. Sample size calculation estimated 50 patients per group needed for a = 0.05 and power 90%, considering standard deviation of 5.1. Participants/materials, setting, methods From April to October 2021, 100 patients undergoing HRT-ET were recruited. Only one type of progesterone was administered. 50 patients received soft capsules (Progeffik©, Utrogestan©) and the other half suppositories (Cyclogest©). After estradiol priming for 10-12 days and once confirmed that endometrial thickness was >7mm, 400 mg vaginal progesterone was started b.i.d. Blood was drawn on the day of embryo transfer by venipuncture and progesterone levels in blood were evaluated. Main results and the role of chance Mean serum levels of progesterone were significantly higher when suppositories were compared with soft capsules (16.2 ± 7 vs 12.5 ± 5.2 ng/ml, p = 0.0034). According to our previous studies we considered an adequate cut-off of progesterone of 8.8 ng/ml, and patients with a suboptimal serum level of progesterone were supplemented with subcutaneous progesterone. Of those patients receiving suppositories, only 6 out 50 (12%) required subcutaneous supplementation, whereas it was needed in 12 out of 50 (24%) women receiving soft capsules. No differences were observed in pregnancy rate (70% vs 50%) or ongoing pregnancy rate (48% vs 36%). Regarding patient satisfaction, no differences were observed in the frequency of itching, burning, leakage of medication or drowsiness between groups. Limitations, reasons for caution We should consider the limited sample size and the study design, not randomized, before generalizing the results observed. Wider implications of the findings In luteal support of frozen embryo replacement cycles, vaginal progesterone suppositories yields superior progesterone serum levels than soft capsules. Trial registration number Not applicable

Assisted Reproductive Technologies in the Republic of Kazakhstan: A 6-Year Trend Analysis from Efficacy to Availability.

Background:The first child after in vitro fertilization (IVF) in the country was born in 1996. However, registering and recording data on assisted reproductive technologies (ARTs) in Kazakhstan is not mandatory. The purpose of the current study was to assess the treatment outcomes, availability, regulations, and ART cycles trends between 2011 and 2016.Methods:Cycle-based data were collected from voluntarily participating ART centers and then descriptive analysis was performed. The study included 10470 ART cycles using different ART methods during 2011–2016. The availability rate of ART in the country was calculated by dividing the number of treatment cycles per million of the population.Results:The availability of ART per million inhabitants increased by 53.6%, from 236.9/million in 2011, to 364.0/million in 2016. In IVF cycles, clinical pregnancy rates (PRs) per aspiration remained stable, on average 37.1%. After ICSI, the average PR was 42.5%. In frozen embryo replacement cycles, there was an increase in the PR per transfer from 37.0% in 2011, to 42.5% in 2016, on average 39.2%.Conclusion:Assisted reproductive technologies are developing rapidly in Kazakhstan; therefore, ART monitoring should be improved and become mandatory. Although the data is not yet representative, the most compelling evidence points to low access to ART. Since the use of ART in Central Asian countries is infrequent in comparison to European countries, there is a need to combine IVF data across different nations. This will allow for a deeper assessment of the scientific evidence and reduction of infertility burden through joint efforts.

COMPARISON OF MICROFLUIDIC SPERM SORTING (MFSS) VERSUS PHYSIOLOGICAL INTRACYTOPLASMIC SPERM INJECTION (PICSI) VERSUS DENSITY GRADIENT IN HIGH DNA FRAGMENTATION INDEX SPERM SAMPLES

To evaluate the best method for sperm separation in high DNA fragmentation index (DFI) sperm samples. A prospective randomised study was conducted from 1st January 2019 to 1st January 2021. Three hundred patients were randomised by computer generated list and divided into 3 groups. Group A (n=100) , in which sperm were processed by microfluidic sperm sorter (MFSS) while in group B (n=100), sperm were selected by Physiological Intracytoplasmic Sperm Injection (PICSI) technique and Group C (n=100), where sperm were processed by density gradient technique. Morphologically normal motile sperm were injected by Intracytoplasmic sperm injection (ICSI) technique in mature oocytes after all three techniques. The study period included all normozoospermic patients with high DNA fragmentation index (>25% ) while oligospermic, asthenozoospermic samples, patients with poor ovarian reserve and advanced age were excluded from the study. All A grade embryos were vitrified and transferred in frozen embryo replacement cycle. All the 3 groups were compared on the basis of fertilisation rate, day 3 grade A embryo development rate , clinical pregnancy rate and miscarriage rate. Cycle characteristics (female age, length of stimulation, gonadotrophin dose, number of oocytes and number of transferred embryos) were similar among all 3 groups. Between the 3 groups, there was a statistically significant increase observed in Group A (Microfluidic Sperm Sorting) in the day 3 grade A embryo development rate (60% vs. 42% vs. 38%, p-0.016) and clinical pregnancy rate (62% vs. 46% vs. 41%, p-0.049), while no statistical significant difference observed in fertilisation rate (82% vs. 78% vs. 76%, p-0.80) comparing with group B and group C. But significantly higher miscarriage rate ( 12% vs. 11% vs. 25%, p-0.019) observed in density gradient (Group C) technique. We have demonstrated that sperm sorted by microfluidic is not only correlated with better DNA integrity but also with the reproductive outcome. Using it in routine practice can help in reducing the extraneous affect of sperm processing techniques and achieving higher pregnancy rate and sustaining it comparing with PICSI and Density Gradient techniques.

P–084 Microfluidic Sperm Sorting (MFSS) technique versus Physiological Intracytoplasmic Sperm Injection (PICSI) technique in high DNA fragmentation index sperm samples

Abstract Study question To evaluate the effectiveness of using Microfluidic Sperm Sorting (MFSS) technique and Physiological Intracytoplasmic Sperm Injection (PICSI) technique in patient with high DNA fragmentation index (DFI) sperm samples. Summary answer Sperm selected by microfluidic sorting are associated with significant increase in day 3 grade A embryo development rate, clinical pregnancy rate over PICSI. What is known already DNA damage is unrecognisable in living sperm prior to insemination and an increased sperm DNA fragmentation index has been associated with lower fertilization rates, impaired embryo development and reduced pregnancy rates. Standard semen processing techniques are associated with centrifugation, which may induce reactive oxygen species and DNA damage. In strategies to minimize sperm DNA fragmentation, Physiological ICSI can relatively reduce sperm DNA fragmentation by 67.9% (Parmegiani et al., 2010) while new technique Microfluidic sperm sorter technique also demonstrate sperm selection with significantly reduced DNA damage. Study design, size, duration A prospective randomised study was conducted from 1st August 2019 to 31st December 2020. Two hundred patients were randomised by computer generated list and divided into 2 groups. Group A (n = 100) , in which sperm were processed by microfluidic sperm sorter (MFSS) while in group B (n = 100), sperm were selected by Physiological Intracytoplasmic Sperm Injection (PICSI) technique and morphologically normal motile sperm were injected by Intracytoplasmic sperm injection (ICSI) technique in all mature oocytes. Participants/materials, setting, methods The study period included all normozoospermic patients with high DNA fragmentation index (>25% ) while oligospermic, asthenozoospermic samples, patients with poor ovarian reserve and advanced age were excluded from the study. All A grade embryos were vitrified and transferred in frozen embryo replacement cycle. Both groups were compared on the basis of fertilisation rate, day 3 grade A embryo development rate , clinical pregnancy rate and miscarriage rate. Main results and the role of chance Cycle characteristics (female age, length of stimulation, gonadotrophin dose, number of oocytes and number of transferred embryos) were similar in both groups. Between the 2 groups, There was a significant increase observed in day 3 grade A embryo development rate (60% vs. 42%, p–0.016) and clinical pregnancy rate (62% vs. 46%, p–0.049), while no statistical significant difference observed in fertilisation rate (82% vs. 78%, p–0.80) and miscarriage rate ( 12% vs. 11%, p- 1). Limitations, reasons for caution: Larger randomised control studies are needed to strengthen these results. Wider implications of the findings: We have demonstrated that sperm sorted by microfluidic helps in selection of sperm with better DNA integrity over Physiological ICSI. Using it in routine practice can help in reducing the negative effect of reactive oxygen species and thus improve pregnancy rate and live birth rate. Trial registration number MCDH/2019/31

P–635 Standard versus mild ovarian stimulation in women with polycystic ovaries (PCO): Impact on outcomes in subsequent frozen embryo treatment cycles (FET)

Abstract Study question Does mild ovarian stimulation in women with PCO result in higher live birth rates during subsequent FET cycles? Summary answer Mild ovarian stimulation with FSH doses <150IU did not result in higher clinical pregnancy or livebirth rates in subsequent FET. What is known already Ovarian stimulation during IVF in women with PCO is associated with an exaggerated response, ovarian hyperstimulation syndrome, poor egg to follicle ratio, low fertilisation rates and poor blastocyst conversion. Mild ovarian stimulation, often referred to as protocols with FSH doses under 150IU, is often employed to overcome these challenges. One of the perceived benefits of this approach is improved oocyte and embryo quality reflected in lower aneuploidy rates. Study design, size, duration This was a retrospective observational study looking at 99 FET between January 2011 and Jan 2021 that followed a fresh cycle in women with a pre-treatment antral follicle count of 12 + 12 or greater. Patients were identified through the antral follicle count at the pre-treatment investigation ultrasound scan. Ultrasound findings, treatment cycle details and clinical outcomes were entered prospectively into a dedicated clinic database. Data was retrieved and analysed using SPSS V25. Participants/materials, setting, methods The study was conducted in a large IVF centre. Data on women with an AFC of 12 + 12 or above, undergoing an autologous FET cycle following a fresh cycle were collected. Women were split into those receiving <150IU of FSH (Group1, n = 51) and those receiving FSH ³150 IU (Group 2, n = 48). Binary logistic regression analysis was performed to control for confounders. Live birth was the primary outcome, with biochemical and clinical pregnancy being secondary outcomes. Main results and the role of chance Women in Group 1 were younger (30.8±3.6 v 33.8±3.65, p < 0.005) but had a similar antral follicle count (38.2±11.7 v 34.2±9.1, p = 0.07). The total number of eggs collected (24.1±13.8 v 25.9±8.8, p = 0.45) and fertilisation rate (0.59±0.2 v 0.58±0.18, p = 0.77) during their fresh cycle were comparable. Women in Group 2 had a larger number of embryos suitable for cryopreservation (7.36±4.2 v 4.8±3.5, p = 0.001) In the subsequent frozen embryo replacement cycle, there was no difference in the number or quality of embryos transferred with most women having a single embryo transfer (63% v 48%, p = 0.14) and at least one top quality embryo transferred (68.6% v 81%, p = 0.15). There was a higher biochemical pregnancy rate in Group 1 (84% v 66%, p = 0.035) but with no difference in clinical pregnancy rate (53% v 44%, p = 0.37) or live birth rate (49% v 42%, p = 0.76). Live birth rates remained comparable even after controlling for age, and number and quality of embryos transferred (OR: 1.21 (95% CI 0.50–2.94). Limitations, reasons for caution This was a retrospective analysis raising the risk of allocation bias. This study was also at risk of information bias as it relied on accurate documentation of the AFC at the pre-treatment scan. Wider implications of the findings: Patients can be reassured that both stimulation protocols result in similar live birth rates in subsequent frozen embryo replacement cycles. Prospective trials using PGT-A are required to assess whether aneuploidy could account for the discrepancy in biochemical pregnancy rates in the two groups considering the subsequent comparable clinical pregnancy rates. Trial registration number Not applicable

DOES PRE-IMPLANTATION GENETIC TESTING FOR ANEUPLOIDY OPTIMISE THE REPRODUCTIVE OUTCOMES INWOMEN WITH IDIOPATHIC RECURRENT PREGNANCY LOSS?

To evaluate the role of Pre-Implantation Genetic Testing for Aneuploidy (PGT-A) for improving live birth and reducing miscarriage in patients with Idiopathic Recurrent Pregnancy Loss (RPL). This is a retrospective study where patients with previous two or more pregnancy loss (idiopathic) who underwent IVF cycles in the period of January 2014 to June 2019 were considered. A total of 112 patients were analysed for the study. Out of which 82 patients underwent PGT-A (n=82) and 30 patients did not underwent PGT-A (n=30), but had history of RPL considered as the control group. All the women underwent controlled ovarian stimulation and oocyte retrieval as per our clinic’s standard operating protocol (SOP). ICSI was the choice of insemination considering history of multiple pregnancy loss, fertilized oocytes were cultured till blastocysts. Day 5, day 6 biopsy was done in study group and freeze all policy was adopted. Trophectoderm biopsy and Next-Generation Sequencing (NGS) were used for PGT-A. Study group underwent elective Euploid Single Embryo Transfer (eSET) in a Frozen Embryo Replacement cycle (FET). Control group underwent transfer of two blastocysts (DET) in FET cycle. Live Birth Rate (LBR), Multiple Pregnancy Rates (MPR) and Miscarriage Rate (MR) were considered as primary outcomes. Aneuploidy rates were evaluated in the study group. Mean reproductive outcomes in Study Vs Control group were as follows: MR - 9.68% vs 23.33% (p value 0.0610) MPR – 0% Vs 10% (p value 0.0039) LBR- 32.32% vs 30.00% (p value 0.8160) Aneuploidy in Study group - 55.74% No difference in LBR was observed when PGT-A was introduced in RPL patients. However a marked reduction in MR was observed with PGT-A in RPL patients. In Idiopathic RPL women, though the incidence of miscarriage comes down with transfer of an Euploid embryo, take home baby rates doesn’t seem to improve. Role of PGT-A for RPL women needs further research through well designed randomized control trials. PGT-A as an intervention for Idiopathic RPL women doesn’t seem to improve Live Birth.

RAISED SPERM DNA FRAGMENTATION – WILL INTERVENTION WITH SURGICAL RETRIEVAL OF TESTICULAR SPERMS OPTIMIZE REPRODUCTIVE AND PERI-NATAL OUTCOMES ?A DECADE’S OBSERVATIONAL STUDY FROM AN INDIAN CLINIC

For Individuals with Raised Sperm DNA Fragmentation (SDF), will intervention with Surgical Retrieval of Sperms (SRS) from testes optimize Reproductive and Peri-Natal outcomes in Assisted Reproductive Techniques (ART) cycles. This is a retrospective study at our private IVF clinic from 2010 to 2019. SAMPLE SIZE: Couples with history of at least one failed IVF cycle were offered testing for SDF by SCSA method. SDF >30% was considered high and such couples were offered SRS from testes and testicular sperms were used for ICSI (n= 342). Couples were counselled about the risks, benefits and experimental nature of this intervention. Written consent was obtained from the couple and taken through an ART cycle with SRS from tests. Women underwent controlled ovarian stimulation and oocyte retrieval as per our clinic’s standard operating protocol (SOP). Fertilized oocytes were cultured till blastocyst stage and freeze all policy was adopted. Two blastocysts were transferred in a frozen embryo replacement cycle. INCLUSION CRITERIA: Individuals who had successful SRS with self-gamete cycles were included in this study. Exclusion CRITERIA: Donor gamete cycles and individuals who had failed SRS were excluded from this study. Primary Outcomes: Implantation rate (IR), Live birth rates (LBR) and Perinatal outcomes (Gestation Diabetes (GDM), Pregnancy Induced Hypertension (PIH), Intra Uterine Growth Restriction (IUGR), mean Pre-Term Birth rate (PTB), Birth weight (BW Normal - >2.5kgs), Low Birth weight (LBW – 1.5-2.5kgs), Very LBW (VLBW - <1.5kgs) Secondary Outcomes: Fertilization rate (FR); blastocyst rate (BR), Clinical pregnancy rate (CPR); Miscarriage rate (MR) and Multiple Pregnancy rate (MPR) Mean of the outcomes were as follows: FR - 93.35%, BR - 35%, IR - 40.34%, CPR - 56.90 %, MR was 12.03 %, MPR – 17.2% , LBR - 35.23, GDM – 6.06%, PIH – 6.82%, No IUGR reported in the study group. 17.4% had PTB. Mean BW was 2.5 kg. Out of this Normal BW was 55.6 %, LBW was 36.7 % and VLBW was 13.3 %. Use of SRS in couples with raised SDF seems to offer optimal reproductive and perinatal outcomes. Couples seeking ART with raised SDF, SRS can be offered as an active intervention. Testicular sperm for Raised SDF seem to offer beneficial reproductive and perinatal outcomes in ART cycles. TESA can be offered as an active intervention.

18. EUPLOID BLASTOCYSTS IMPLANT IRRESPECTIVE OF THEIR MORPHOLOGY AFTER PREIMPLANTATION GENETIC TESTING-ANEUPLOIDY USING NEXT GENERATION SEQUENCING

Introduction In the context of IVF, it has become imperative to emphasize on embryo evaluation in order to maximise assisted conception outcome while minimising the risk of multiple pregnancy. Despite the exponential rise in knowledge and understanding of the dynamic process of embryo development in the laboratory, the classical evaluation methods based on morphology are still considered as the gold standard methods to classify and select embryos. Morphology assessment helps embryologists to detect dysmorphic or arrested embryos but chromosomal abnormalities can still be only identified by preimplantation genetic testing for aneuploidies (PGT-A). It remains controversial the strength of morphology as a tool to ensure replacement of euploid blastocysts. The present research aims to corroborate whether blastocyst morphology, using a modified Gardner and Cornell's group scoring system, correlates with ploidy status of embryos analysed with next generation sequencing (NGS). We also wanted to ascertain whether biopsy of poor quality embryo yield a euploid embryo to transfer and thus result in a favourable outcome. This is the first data set describing the correlation between blastocyst morphology and embryo ploidy status using NGS and clinical outcomes. Materials and Methods 296 patients underwent PGT-A. Of 1,549 blastocysts, 1,410 blastocysts had a conclusive result after PGT-A and were included for analysis. An elective single embryo transfer (eSET) policy was followed in a frozen embryo replacement cycle. A total of 179 euploid blastocysts were thawed and transferred. Clinical outcomes were categorised in four different embryo quality groups: excellent, good, average and poor. Results Euploidy rates were 19/36 (52.7%, 95% CI 37-68), 199/470 (42.3%, 95% 38-47), 156/676 (23.0%, 95% CI 20-26) and 39/228 (17.1%, 95% CI 13-23) in the excellent, good, average and poor quality blastocyst groups, respectively. Fitted logistic regression analysis taking into account the following co-variables; female age, embryo chromosomal status, and day of blastocyst development/biopsy showed that good (OR 0.6; 95% CI 0.4-0.8;p=0.001), average (OR 0.5; 95% CI 0.4-0.7; p=0.001) and poor (OR 0.2;95% CI 0.1-0.5; p=0.005) morphology with excellent morphology being the reference group was predictive of the comprehensive chromosome testing result. A logistic regression analysis was also performed on clinical outcomes taking into account for the effect of blastocyst morphology and day of blastocyst development/biopsy. None of the parameters were shown to be significant suggesting morphology irrespective of the embryo quality category and day of blastocyst development/biopsy do not reduce the competence of euploid embryos (p>0.05). Conclusions After euploid eSET, implantation rate was 80-86%; live birth rate per embryo transfer was 60-73% and clinical miscarriage rate was found to be less than 10% and were not significanlty affected by the embryo morphology category. These results are concordant with those reported when using array compartive genomic hybridization and highlights the competence of poor quality euploid embryos.