In Vitro Fertilization Population Research Articles

Beyond the Umbrella: A Systematic Review of the Interventions for the Prevention of and Reduction in the Incidence and Severity of Ovarian Hyperstimulation Syndrome in Patients Who Undergo In Vitro Fertilization Treatments.

Ovarian hyperstimulation syndrome (OHSS) is the main severe complication of ovarian stimulation for in vitro fertilization (IVF) cycles. The aim of the current study was to identify the interventions for the prevention of and reduction in the incidence and severity of OHSS in patients who undergo IVF not included in systematic reviews with meta-analyses of randomized controlled trials (RCTs) and assess and grade their efficacy and evidence base. The best available evidence for each specific intervention was identified, analyzed in terms of safety/efficacy ratio and risk of bias, and graded using the Oxford Centre for Evidence-Based Medicine (CEBM) hierarchy of evidence. A total of 15 interventions to prevent OHSS were included in the final analysis. In the IVF population not at a high risk for OHSS, follitropin delta for ovarian stimulation may reduce the incidence of early OHSS and/or preventive interventions for early OHSS. In high-risk patients, inositol pretreatment, ovulation triggering with low doses of urinary hCG, and the luteal phase administration of a GnRH antagonist may reduce OHSS risk. In conclusion, even if not supported by systematic reviews with homogeneity of the RCTs, several treatments/strategies to reduce the incidence and severity of OHSS have been shown to be promising.

P-439 Intimate hygiene practices and the correlation with abnormal vaginal microbiota in in vitro fertilization (IVF) patients – a cohort study in 1421 patients

Abstract Study question What are the intimate hygiene practices of women in IVF treatment and do they correlate with the vaginal microbiota? Summary answer Hygiene practices, in specific douching and use of intimate soap significantly increased the risk of abnormal vaginal microbiota (AVM). What is known already The normal vaginal microbiota acts as a defense system against infection. AVM is a molecularly defined vaginal dysbiosis, resembling bacterial vaginosis (BV) and is dominated by anaerobic bacteria such as Gardnerella vaginalis. Importantly, AVM is associated with an increased risk of genital tract infections, poor IVF outcomes, early miscarriage and preterm labor. The cause of AVM is multifactorial and hygiene practices may interrupt the normal microbiota. Previous small studies suggested vaginal douching to be associated with an increased risk of AVM. Few studies have investigated the possible correlation between intimate hygiene practices, menstrual practices and the vaginal microbiota. Study design, size, duration Observational cohort study, including a total of 1421 IVF patients from four Danish fertility centers. The inclusion period was from 2017 to January 2022. Participants/materials, setting, methods Patients aged 18-42 years and undergoing their first, second or third IVF stimulation cycle were eligible for inclusion. The intimate hygiene practices in terms of type of soap, menstrual protection, douching and probiotics, were reported in a structured questionnaire including a total of 40 questions. Vaginal swabs were obtained prior to ovarian stimulation and subsequently subjected to quantitative PCR testing, targeting DNA of dysbiotic bacteria. Main results and the role of chance AVM was present in a total of 34 % (479/1421) of women, and 20% (272/1384) reported vaginal douching, which significantly correlated with AVM (p < 0.01, OR = 1.62 [1.23-2.12]). Intimate soap was used by 39 % (535/1384) of patients, which also significantly increased the risk of AVM ( P = 0.04, OR = 1.35 [1.08-1.69]). Water only was used by 36% (492/1384), and regular soap was used by 27% (374/1384). No correlation between use of water only and regular soap and AVM was detected. For menstrual protection 40% (433/1078) used pads, followed by tampons alone 25% (265/1078) or a combination 21% (230/1078), and 14 % (148/1078) used a menstrual cup. A trend for an increased risk of AVM when using tampons, OR 1.21 [0.91-1.62] was seen whereas use of a menstrual cup seemed to lower the risk of AVM, OR 0.71 [0.48-1.04] Active smoking, higher BMI, drinking >7 units per week and previous chlamydia infection significantly correlated with AVM (p = 0.01, p = 0.01, p = 0.04 and p = 0.01). Finally, 84% (1190/1421) reported gynecological symptoms such as vaginal discharge, dyspareunia and fungal infection, but only fishy odor significantly correlated with AVM (p < 0.01). Limitations, reasons for caution To the best of our knowledge, this is the largest study investigating the intimate hygiene practice and its correlation with AVM in an IVF population. As these results describe the practices of a Scandinavian IVF population, results may differ from other settings and ethnicities. Wider implications of the findings Exploration of the cause-and-effect relations between intimate hygiene practices and AVM is needed, requiring intervention-based prospective studies. This would lead to evidence-based advice on intimate hygiene practices and AVM prevention, possibly increasing live birth rates. The unexpected high prevalence of douching in a Danish IVF population needs further exploration. Trial registration number NCT03420859

P-508 The adverse effect of a previous late miscarriage on the subsequent pregnancy outcomes: a retrospective cohort study across more than ten years

Abstract Study question To explore whether a previous late miscarriage (LM) has a prognostic impact on the subsequent pregnancy outcomes in in-vitro fertilization (IVF) women. Summary answer Women who had a LM for unexplained factor or cervical factor following first embryo transfer had a significantly poor pregnancy prognosis after the subsequent transfer. What is known already It has been reported that a history of early miscarriages is significantly associated with poor pregnancy outcomes. However, whether and how previous LM might influence future pregnancy outcomes still remain unclear. Study design, size, duration A retrospective cohort study was performed among 1072 infertile women who had a LM following the first embryo transfer from January 2008 to December 2020 at Center for Reproductive Medicine, Shandong University. Participants/materials, setting, methods 1072 infertile women who had a late miscarriage following first embryo transfer were grouped by the causes, 458 women with unexplained factor (unLM), 146 women with fetal factor (feLM), 412 women with cervical factor (ceLM), 56 women with trauma factor (trLM). Subgroup analysis and binary logistic regression were performed to evaluate the associations between late miscarriages with different causes and subsequent pregnancy outcomes. Main results and the role of chance Compared with general IVF population, the early miscarriage rate was significantly higher in the unLM group [8.28% vs 13.47%, adjusted OR (95%CI): 1.596(1.119-2.276), P=0.01]. Further, women with a unLM or ceLM had a dramatically elevated risk of recurrent late miscarriage [for unLM:4.24% vs 9.43%, adjusted OR (95%CI): 1.907(1.237-2.939), P=0.003; for ceLM: 4.24% vs 15.53%, adjusted OR (95%CI): 2.682(1.820-3.952), P=0.000] and a consequently reduced frequency of live birth [for unLM: 49.96% vs 43.01%, adjusted OR (95%CI): 0.746(0.612-0.908), P=0.004; for ceLM: 49.96% vs 38.59%, adjusted OR (95%CI): 0.611(0.494-0.756), P=0.000]. Limitations, reasons for caution This study was limited by the retrospective design from a single center and the sample size in feLM and trLM group is small. Further studies are needed to verify our results and ascertain the mechanisms underlying the reported associations. Wider implications of the findings Only one previous late miscarriage resulted from unexplained factor or cervical factor was significantly associated with a higher risk of miscarriage and a lower live birth rate after subsequent embryo transfer. Women with only one late miscarriage should be informed the great risk and given intense surveillance during subsequent pregnancy. Trial registration number not applicable

Eclampsia, in vitro fertilization and the risk of preterm birth: a retrospective cohort study based on 2,880,759 samples.

Eclampsia and in vitro fertilization (IVF) are independent risk factors for preterm birth. Understanding the combined effects of multiple risk factors for preterm birth is critical to making accurate and personalized risk predictions. This study aimed to explore the interaction between eclampsia and IVF on the risk of preterm birth. A total of 2,880,759 eligible participants from Birth Data Files in the National Vital Statistics System (NVSS) database 2019 were enrolled in this retrospective cohort study. Some characteristics were collected, such as maternal age, prepregnancy body mass index (BMI), history of preterm birth, paternal age, race, newborn sex. Preterm birth was defined as <37 weeks gestation. Univariate and multivariate logistic regression models were utilized to assess the associations between eclampsia, IVF and preterm birth. The odds ratio (OR) and 95% confidence interval (CI) were calculated in this study. Relative excess risk due to interaction (RERI), attributable proportion (AP) and synergy index (S) were adopted to evaluate the interaction between eclampsia and IVF on the risk of preterm birth. The age of mothers and fathers, the number of multiple births, the proportion of mothers with a history of preterm birth, pregnancy infections, eclampsia and IVF among the preterm birth group were all higher than those among the non-preterm birth group. The incidence of preterm birth in eclampsia and IVF population was approximately 37.31% and 22.96%, separately. After adjusting some covariates, subjects with both eclampsia and IVF had a higher risk of preterm birth (OR =9.197, 95% CI: 6.795-12.448, P<0.001). Furthermore, the results (RERI =3.426, 95% CI: 0.639-6.213, AP=0.374, 95% CI: 0.182-0.565, S =1.723, 95% CI: 1.222-2.428) suggested that the interaction between eclampsia and IVF on preterm birth was statistically significant, indicating a synergistic interaction. Eclampsia and IVF might interact in a synergistic manner to increase the risk of preterm birth. Awareness of the risk profile associated with preterm birth is crucial for pregnant woman with IVF to implement dietary and lifestyle modifications.

Impact of a previous late miscarriage on subsequent pregnancy outcomes: A retrospective cohort study over 10 years.

To explore the prognostic impact of a previous late miscarriage (LM) on the subsequent pregnancy outcomes of women with infertility. This retrospective cohort study included couples who had experienced LM following their first embryo transfer during an in vitro fertilization (IVF) cycle from January 2008 to December 2020. Subgroup analysis and binary logistic regression were performed to evaluate the associations between LM due to different causes and subsequent pregnancy outcomes. A total of 1072 women who had experienced LM were included in this study, comprising 458, 146, 412, and 56 women with LM due to unexplained factors (unLM), fetal factors (feLM), cervical factors (ceLM; i.e. cervical incompetence), and trauma factors (trLM), respectively. Compared with the general IVF (gIVF) population, the early miscarriage rate was significantly higher in the unLM group (8.28% vs. 13.47%, adjusted odds ratio [OR] 1.60, 95% confidence interval [95% CI] 1.12-2.28; P = 0.01). Furthermore, women in the unLM and ceLM groups had a dramatically increased risk of recurrent LM (unLM: 4.24% vs. 9.43%, aOR 1.91, 95% CI 1.24-2.94; P = 0.003; ceLM: 4.24% vs.15.53%, aOR 2.68, 95% CI 1.82-3.95; P < 0.001) and consequently a reduced frequency of live birth (unLM: 49.96% vs. 43.01%, aOR 0.75, 95% CI 0.61-0.91; P = 0.004; ceLM: 49.96% vs. 38.59%, aOR 0.61, 95% CI 0.49-0.77; P < 0.001) compared with the gIVF population. A previous LM due to an unexplained factor or cervical incompetence was significantly associated with a higher risk of miscarriage and a lower live birth rate after subsequent embryo transfer.

Comparison of cattle derived from in vitro fertilization, multiple ovulation embryo transfer, and artificial insemination for milk production and fertility traits

The use of assisted-reproduction technologies such as in vitro fertilization (IVF) is increasing, particularly in dairy cattle. The question of consequences in later life has not yet been directly addressed by studies on large animal populations. Studies on rodents and early data from humans and cattle suggest that in vitro manipulation of gametes and embryos could result in long-term alteration of metabolism, growth, and fertility. Our goal was to better describe these presumed consequences in the population of dairy cows produced by IVF in Québec (Canada) and to compare them to animals conceived by artificial insemination (AI) or multiple ovulation embryo transfer (MOET). To do so, we leveraged a large phenotypic database (2.5 million animals and 4.5 million lactations) from milk records in Québec aggregated by Lactanet (Sainte-Anne-de-Bellevue, QC, Canada) and spanning 2012 to 2019. We identified 304,163, 12,993, and 732 cows conceived by AI, MOET, and IVF, respectively, for a total of 317,888 Holstein animals from which we retrieved information for 576,448, 24,192, and 1,299 lactations (total = 601,939), respectively. Genetic energy-corrected milk yield (GECM) and Lifetime Performance Index (LPI) of the parents of cows were used to normalize for genetic potential across animals. When compared with the general Holstein population, MOET and IVF cows outperformed AI cows. However, when comparing those same MOET and IVF cows with only herdmates and accounting for their higher GECM in the models, we found no statistical difference between the conception methods for milk production across the first 3 lactations. We also found that the rate of Lifetime Performance Index improvement of the IVF population during the 2012 to 2019 period was less than the rate observed in the AI population. Fertility analysis revealed that MOET and IVF cows also scored 1 point lower than their parents on the daughter fertility index and had a longer interval from first service to conception, with an average of 35.52 d compared with 32.45 for MOET and 31.87 for AI animals. These results highlight the challenges of elite genetic improvement while attesting to the progress the industry has made in minimizing epigenetic disturbance during embryo production. Nonetheless, additional work is required to ensure that IVF animals can maintain their performance and fertility potential.

P-771 Subfertility versus in vitro fertilization procedures: unravelling the origins of fetal cardiac remodeling in assisted reproductive technologies

Abstract Study question Do spontaneously conceived (SC) fetuses from subfertile couples present signs of cardiac remodeling as those observed after in vitro fertilization (IVF) treatments? Summary answer SC fetuses from subfertile couples do not associate cardiac remodeling, and their cardiac structure and function are similar to those of SC from fertile couples. What is known already Fetuses and children from IVF associate cardiac remodeling and suboptimal function, including dilated atria, more globular and thicker ventricles, reduced longitudinal motion and impaired relaxationin uteroand after birth. Fetal cardiac changes have been demonstrated both after fresh and frozen embryo transfer. The SC fetuses used as ‘controls’ in our previous publications were conceived by fertile couples thus making it difficult to separate the contribution of infertilityper sefrom the IVF procedures on cardiac programming. There are no previous cardiovascular studies investigating the independent effects of infertility in SC fetuses from subfertile couples (time-to-pregnancy (TTP) over 12 months). Study design, size, duration Prospective cohort study of 289 singleton pregnancies recruited from 2017 to 2021, including 96 SC pregnancies from fertile couples (TTP less than 12 months), 97 SC from subfertile couples (TTP over 12 months) and 96 from IVF after fresh ET. Fetal echocardiography was performed in all pregnancies. Epidemiological data and perinatal outcomes were collected in all pregnancies. Participants/materials, setting, methods IVF pregnancies from our centre were identified as eligible at pregnancy diagnosis. Eligible SC pregnancies from fertile and subfertile couples who attended our Maternal-Fetal Unit were invited to participate at third trimester, being matched to the IVF pregnancies by maternal age. Fetal echocardiography was performed at 29-34 weeks of pregnancy to assess cardiac structure and function. Echocardiographic comparisons were adjusted by nulliparity, birthweight centile, gestational age and estimated fetal weight at scan. Main results and the role of chance Parental age, ethnicity, body mass index and smoking exposure, median gestational age and estimated fetal weight were similar in all study groups. There were no significant differences in infertility duration or aetiology between the subfertile and the IVF populations (TTP: subfertile median 30 months [IQR 20-54] versus IVF: 47 [25-61]; p-value=0.052). While both fertile and subfertile SC groups presented similar fetal cardiac results, IVF fetuses showed larger atria (right atria-to-heart ratio: IVF mean 18.9% [SD 3.4] versus subfertile 17.8% [3.5] versus fertile 17.6% [3.3]; adjusted P-value&amp;lt;0.001), more globular ventricles (right ventricular sphericity index: IVF 1.56 [0.25] versus subfertile 1.72 [0.26] versus fertile 1.72 [0.26]; &amp;lt;0.001), and thicker myocardial walls (relative wall thickness: IVF 0.86 [0.22] versus subfertile 0.64 [0.13] versus fertile 0.64 [0.18]; &amp;lt;0.001). Whereas SC fetuses from fertile and subfertile couples had preserved cardiac function, IVF fetuses showed signs of suboptimal systolic and diastolic function with reduced tricuspid ring displacement (IVF 7.26 mm [1.07] versus subfertile 8.04 mm [1.18] versus fertile 7.89 mm [1.51]; &amp;lt;0.001) and increased left myocardial performance index (IVF 0.49 [0.08] versus subfertile 0.45 [0.09] versus fertile 0.45 [0.10]; &amp;lt;0.001). A sub-analysis including only unexplained infertility cases in subfertile SC and IVF groups showed similar results. Limitations, reasons for caution The fetal cardiac changes reported here are subclinical, with most cardiovascular parameters lying within normal ranges. Although echocardiographic changes are recognized as potential cardiovascular risk factors, their association with long-term cardiovascular disease remains to be proven. Wider implications of the findings Subfertility per se does not seem to be associated to fetal cardiac remodeling, which have been previously described in IVF fetuses. Future studies are warranted to further investigate the factors related to fetal cardiac changes associated to ART. Trial registration number Not a trial

P-781 Elective single cleavage-stage embryo transfer in IVF patients with suboptimal ovarian response is not detrimental to cumulative pregnancy and reduces multiple pregnancy rates

Abstract Study question To compare elective single embryo transfer (eSET) with double embryo transfer (DET) in patients with suboptimal response to ovarian stimulation in terms of pregnancy rates. Summary answer Elective single embryo transfer in patients with suboptimal response to ovarian stimulation is not detrimental to cumulative pregnancy and delivery rates. What is known already Even though higher-order pregnancies in in vitro fertilization (IVF) programs have dropped significantly in recent years, the incidence of twin pregnancies is currently not negligible. The greatest efforts to promote eSET have been made in the IVF population with a good prognosis but results obtained in this population can hardly be extrapolated to patients with lower chances of success, such as those with low oocyte yield. Although still under discussion, it has been suggested that in patients with poor or suboptimal response to ovarian stimulation, eSET could achieve acceptable cumulative live birth rates with negligible risk of twin pregnancy. Study design, size, duration A matched case-control pre and post intervention study including IVF patients with poor or sub-optimal response to ovarian stimulation (≤9 oocytes) receiving a double embryo transfer (2016-2018) or elective single embryo transfer (2018-2020). Matching was performed 1:1 for female age (±18 months), AMH ≥1.2 or &amp;lt; 1.2 ng/ml and number of previous cycles. A sample size of 215 patients per group was foreseen to obtain ±5% variability of the main outcome (clinical pregnancy rate per cycle). Participants/materials, setting, methods A strict policy regarding single embryo transfer was introduced in our clinic from September 2018 to reduce twin pregnancy rates independently from ovarian response or embryo quality. Couples undergoing standard IVF or ICSI with ≤9 oocytes and at least 2 viable embryos were divided in two groups and matched for main variables known for influencing results: pre-intervention with DET (controls) and post-intervention with eSET (cases). In both groups, cryopreserved supernumerary embryos were always transferred individually. Main results and the role of chance A total of 463 patients with at least 2 viable embryos undergoing fresh embryo transfer after the recovery of 2 to 9 oocytes were retrospectively evaluated and, according to matching criteria, 212 cases (eSET) and 212 matched controls (DET) were included for data analysis. The cumulative clinical pregnancy rate per cycle was the same in the two groups (26%, 95%CI: 20-32%) with a crude OR = 1.00 (95%CI: 0.65-1.54), p = 1.00 and a mean female age of 37.4 and 38.0 years, respectively. The mean number of mature oocytes was 4 ±2 in both groups. Live birth rate was similar in cases and controls (22% and 21%, respectively) while twin pregnancies were significantly reduced in women receiving single embryo transfer (18% versus 0%, p = 0.008). Women receiving eSET were more likely to undergo a subsequent frozen embryo transfer (26% versus 14%, p = 0.002). Considering the main confounding factors, a binomial logistic model indicated that the cumulative clinical pregnancy rate was not significantly affected when a single embryo transfer was performed in women recovering up to nine oocytes. Similar results were obtained comparing cases and controls within subgroups: 2-4 or 5-9 oocytes; &amp;lt;35 or 35–39 or &amp;gt; 39 years female age). Limitations, reasons for caution This study does not have the statistical power to highlight small differences between the two groups. It was conducted on a specific population of women with 9 or less oocytes therefore results cannot be generalized to other populations, particularly those with a better or poorer prognosis. Wider implications of the findings eSET results are mainly based on good prognosis couples. Despite a trend for better success after fresh DET, cumulative results are not affected by eSET at the cleavage stage with significantly reduced incidence of twins and moderate delay in time to pregnancy also in poor/suboptimal responders. Trial registration number not applicable

B-cell lymphoma 6 expression is not associated with live birth in a normal responder in vitro fertilization population

To determine whether increased endometrial B-cell lymphoma 6 (BCL6) expression is associated with live birth in a normal responder invitro fertilization (IVF) population. Case-control study. University-affiliated infertility center. Two groups of women undergoing IVF with preimplantation genetic testing for aneuploidy followed by warmed, single, euploid embryo transfer. Group 1 consisted of women who failed to achieve live birth, and group 2 consisted of women who achieved live birth. None. Endometrial BCL6 expression measured by immunohistochemistry in endometrial tissue samples. Overexpression was defined by mean HSCORE with a cutoff of positivity of >1.4, as previously described in the literature. Twenty-seven patients who achieved live birth and 23 patients who failed to achieve live birth were included. B-cell lymphoma 6 expression/HSCORE and live birth rate were not associated (Odds ratio [OR], 0.78 [0.24-2.55]). Using a cutoff of >1.4 for positivity, 8 of 23 samples were positive for BCL6 in the no live birth group, whereas 7 of 27 were positive in the live birth group. There was no significant association between BCL6 positivity and live birth (OR, 0.66 [0.19-2.21]). The proportion of patients with BCL6 positivity did not significantly differ between those who achieved live birth and those who did not. In the population of patients at our center, who compromise of women who respond normally to IVF stimulation,BCL6 overexpression was not associated with IVF success. Physicians implementing BCL6 testing as a diagnostic tool for clinical decision making should counsel patients that results may have limited utility in predicting IVF outcomes in this population.

P–766 Neurodevelopment in fetuses conceived by assisted reproductive technologies following fresh and frozen embryo transfer

Abstract Study question Do in vitro fertilization (IVF) offspring present different neurodevelopment assessed by fetal neurosonography and infant neurobehavioral tests as compared to those spontaneously conceived (SC)? Summary answer IVF offspring, especially those obtained after fresh embryo-transfer (ET), showed subtle structural differences in fetal neurosonography and poorer neurobehavioral scores at twelve months of age. What is known already The number of pregnancies following assisted reproductive technologies (ART) is currently increasing worldwide. Concerns about the neurodevelopment of subjects conceived by IVF have been rising and mostly studied in children and adolescents with inconsistent results. Many of the identified risk associations were only observed in subgroups or disappeared after adjustment for covariates, mainly multiple pregnancy and gestational age at birth. It is unknown whether fetal brain development and cortical folding differ prenatally in IVF fetuses as compared to SC. Study design, size, duration This is the first study examining fetal neurodevelopment by neurosonography in IVF fetuses. A prospective cohort study of 210 singleton pregnancies recruited from 2017 to 2020, including 70 SC gestations, 70 conceived by IVF following frozen ET (FET) and 70 IVF after fresh ET. Fetal neurosonography was performed in all pregnancies. Additionally, Ages &amp; Stages Questionnaires (ASQ) were obtained at 12 months of corrected age. Participants/materials, setting, methods IVF pregnancies were recruited from a single Assisted Reproduction Center, ensuring homogeneity in IVF stimulation protocols, endometrial preparation, laboratory procedures and embryo culture conditions. SC pregnancies were randomly selected from low-risk fertile couples and paired to IVF by maternal age. Fetal neurosonography including transvaginal approach was performed at 32±2 weeks of gestation, measured off-line by a single investigator and normalized by biparietal or occipitofrontal diameter. ASQ were obtained postnatally, at 12 months of corrected age. Main results and the role of chance Study groups were similar and comparable regarding maternal age, body mass index, study level and employment rate together with exposure to smoke, alcohol, aspirin and corticoids during pregnancy, gestational age (32±2 weeks) and estimated fetal weight (1700±400g) at neurosonography. As compared to SC pregnancies, both IVF populations showed differences in cortical development with reduced parieto-occipital (fresh ET 12.5mm [SD 2.5] vs FET 13.4 [2.6] vs SC 13.4 [2.6]), cingulate (fresh ET 5.8 [IQR 4.2–7.4] vs FET 5.8 [4.1–7.5] vs SC 6.5 [4.8–7.8]) and calcarine (fresh ET 13.5 [IQR 10.1–16.1] vs FET 14.5 [12.1–15.8] vs SC 16.4 [14.3–17.9]) sulci depth together with lower Sylvian fissure grading. Cortical development changes were more pronounced in the fresh ET group as compared to FET. Corpus callosum length and insula depth were lower in FET and fresh ET groups, respectively. Neurosonographic changes remained statistically significant after adjustment by ethnicity, gender, gestational age and weight centile at scan. IVF infants showed worse ASQ scores, especially in fresh ET for communication, personal-social, fine-motor and problem-solving skills. Gross-motor scores were significantly lower in FET as compared to SC and fresh ET. Differences were statistically significant after adjustment by maternal ethnicity, study level, employment status, breastfeeding, gender and corrected age. Limitations, reasons for caution The reported neurodevelopmental differences are subtle, with most neurosonographic findings lying within normal ranges. Infertility factors contribution to the outcome cannot be unraveled from the ART procedure itself. The milder features found in FET individuals cannot condition the techniqués choice and must be considered together with their global perinatal results. Wider implications of the findings: Neurosonography is an appropriate tool to identify subtle brain differences between fetuses exposed and not exposed to ART. Prenatal features were consistent with postnatal neurobehavioral findings. These results support the relevance of a neurodevelopmental follow-up in IVF patients. Further studies are warranted to assess the long-term performance in these subjects. Trial registration number Not applicable

P-766 Neurodevelopment in fetuses conceived by assisted reproductive technologies following fresh and frozen embryo transfer

Abstract Study question Do in vitro fertilization (IVF) offspring present different neurodevelopment assessed by fetal neurosonography and infant neurobehavioral tests as compared to those spontaneously conceived (SC)? Summary answer IVF offspring, especially those obtained after fresh embryo-transfer (ET), showed subtle structural differences in fetal neurosonography and poorer neurobehavioral scores at twelve months of age. What is known already The number of pregnancies following assisted reproductive technologies (ART) is currently increasing worldwide. Concerns about the neurodevelopment of subjects conceived by IVF have been rising and mostly studied in children and adolescents with inconsistent results. Many of the identified risk associations were only observed in subgroups or disappeared after adjustment for covariates, mainly multiple pregnancy and gestational age at birth. It is unknown whether fetal brain development and cortical folding differ prenatally in IVF fetuses as compared to SC. Study design, size, duration This is the first study examining fetal neurodevelopment by neurosonography in IVF fetuses. A prospective cohort study of 210 singleton pregnancies recruited from 2017 to 2020, including 70 SC gestations, 70 conceived by IVF following frozen ET (FET) and 70 IVF after fresh ET. Fetal neurosonography was performed in all pregnancies. Additionally, Ages &amp; Stages Questionnaires (ASQ) were obtained at 12 months of corrected age. Participants/materials, setting, methods IVF pregnancies were recruited from a single Assisted Reproduction Center, ensuring homogeneity in IVF stimulation protocols, endometrial preparation, laboratory procedures and embryo culture conditions. SC pregnancies were randomly selected from low-risk fertile couples and paired to IVF by maternal age. Fetal neurosonography including transvaginal approach was performed at 32±2 weeks of gestation, measured off-line by a single investigator and normalized by biparietal or occipitofrontal diameter. ASQ were obtained postnatally, at 12 months of corrected age. Main results and the role of chance Study groups were similar and comparable regarding maternal age, body mass index, study level and employment rate together with exposure to smoke, alcohol, aspirin and corticoids during pregnancy, gestational age (32±2 weeks) and estimated fetal weight (1700±400g) at neurosonography. As compared to SC pregnancies, both IVF populations showed differences in cortical development with reduced parieto-occipital (fresh ET 12.5mm [SD 2.5] vs FET 13.4 [2.6] vs SC 13.4 [2.6]), cingulate (fresh ET 5.8 [IQR 4.2-7.4] vs FET 5.8 [4.1-7.5] vs SC 6.5 [4.8-7.8]) and calcarine (fresh ET 13.5 [IQR 10.1-16.1] vs FET 14.5 [12.1-15.8] vs SC 16.4 [14.3-17.9]) sulci depth together with lower Sylvian fissure grading. Cortical development changes were more pronounced in the fresh ET group as compared to FET. Corpus callosum length and insula depth were lower in FET and fresh ET groups, respectively. Neurosonographic changes remained statistically significant after adjustment by ethnicity, gender, gestational age and weight centile at scan. IVF infants showed worse ASQ scores, especially in fresh ET for communication, personal-social, fine-motor and problem-solving skills. Gross-motor scores were significantly lower in FET as compared to SC and fresh ET. Differences were statistically significant after adjustment by maternal ethnicity, study level, employment status, breastfeeding, gender and corrected age. Limitations, reasons for caution The reported neurodevelopmental differences are subtle, with most neurosonographic findings lying within normal ranges. Infertility factors contribution to the outcome cannot be unraveled from the ART procedure itself. The milder features found in FET individuals cannot condition the techniqués choice and must be considered together with their global perinatal results. Wider implications of the findings Neurosonography is an appropriate tool to identify subtle brain differences between fetuses exposed and not exposed to ART. Prenatal features were consistent with postnatal neurobehavioral findings. These results support the relevance of a neurodevelopmental follow-up in IVF patients. Further studies are warranted to assess the long-term performance in these subjects. Trial registration number not applicable

P–793 Validation of French in vitro fertilization (IVF) guideline during Covid–19 pandemic by the research of Sars-Cov–2 RNA in the follicular fluid (FF) after egg retrieval

Abstract Study question Is it possible to find viral Sars-Cov–2 RNA in FF of women undergoing treatment during Covid–19 pandemic that may compromise gamete and embryo safety? Summary answer No viral RNA was detected in tested FF of women undergoing IVF in compliance with recommendations. This was reassuring and supported good medical practice. What is known already Risks due to SARS-CoV–2 during IVF remain difficult to assess despite the screening recommended by French health authorities based on a symptom questionnaire of the couple (systematic testing by RT-PCR for the virus before egg retrieval (ER) is not mandatory). In this context, this is a real challenge for IVF laboratory to guarantee procedure, patients, gametes and embryos safety. Most studies have reported the absence of virus in sperm. No data are available for FF and only one study looked for the presence of the virus in oocytes of Covid-affected patients (Barragan M et al, 2020). Study design, size, duration Between June 17 and September 24, 2020, FF of consenting women were prospectively collected and symptom questionnaire recorded. During this period, women undergoing IVF in our center did not benefit from systematic PCR testing for the virus within 72 hours prior to ER through our health authorities’ recommendations. All collected FF were retrospectively tested to research viral RNA by RT-PCR and patients were recalled to answer an epidemiological follow-up questionnaire. Participants/materials, setting, methods For all couples, symptom questionnaires were prospectively recorded and verified at each step of IVF procedure. For all consenting women, a sample of 1 ml of FF was collected the day of ER and stored at –80 °C. After thawing, a Sars-Cov2 multiplex RT-PCR using CFX96 (Biorad*) was performed, after RNA extraction using Nimbus (Seegene*). A comprehensive epidemiological evaluation was made afterwards by phone interview and data were recorded and analyzed. Main results and the role of chance A total of 183 women was included out of the 214 treated during this period (85.5%). Retrospective epidemiological evaluation showed that 8 patients contracted Covid more than 2 months before the ER, 6 more than 2 months after and only one patient 1 month after ER (diagnosis based on pathognomonic signs as agueusia and anosmia or/and positive PCR ). We observed a prevalence of symptomatic Covid forms in our IVF population of 8.2% during a 6-month period surrounding their IVF cycle. Moreover, until the introduction of systematic testing by RT-PCR for the virus before ER since the end of September 2020, 3 patients have been cancelled out of the 403 planned for positive PCR despite a negative questionnaire, which represents a prevalence of asymptomatic forms on the day of the ER at 0.7%. All the 183 FF tested did not reveal any viral RNA detection, which was reassuring concerning our medical practice and patient compliance and transparency. The absence of detected viral RNA may be due to several reasons: 1) women were not infected the day of ER 2) women had an asymptomatic form of the disease with low viral load 3) FF is not a virus reservoir. Limitations, reasons for caution Not all patients were included (85.5%). Post-diagnosis stays uncertain because PCR tests at the beginning of the epidemic were not mandatory and hardly available. Wider implications of the findings: The absence of viral RNA in FF of women only screened through a symptom questionnaire is reassuring concerning the safety of IVF during Covid pandemic. Trial registration number Not applicable

The Association between Ovarian Hyperstimulation Syndrome and Pregnancy Complications following Fertility Treatments.

This study was aimed to assess the association between ovarian hyperstimulation syndrome (OHSS) and pregnancy complications among women who conceived following fertility treatment. A retrospective population-based cohort study, including all singleton deliveries of patients conceived following ovulation induction (OI) or in vitro fertilization (IVF) between 1988 and 2016, was conducted. All births occurred in a single tertiary medical center. A comparison was performed between deliveries of women who had experienced OHSS at early gestation and subsequently had a pregnancy and women without OHSS. Women lacking prenatal care, multiple gestations, and stillbirths were excluded from the analyses. A multivariable logistic regression model was used to control for confounders. During the study period, 351,373 deliveries met the inclusion criteria, of which 6,748 were deliveries of infants who were conceived by either IVF or OI. Of this study population, 105 cases (1.6%) composed the exposed group, that is, women who had experienced OHSS with a subsequent live birth. In the multivariate analyses, after controlling for confounders, OHSS was not found as an independent risk factor for preeclampsia, gestational diabetes mellitus (GDM), intrauterine growth restriction (IUGR), preterm delivery (both <37 and <34 weeks), low birth weight (LBW), very LBW (VLBW), small for gestational age (SGA), and caesarean delivery. In a subanalysis conducted solely on the IVF population, similar results were found, aside from the association between OHSS and preterm delivery before 34 weeks of gestation which was statistically significant (adjusted odds ratio [AOR] = 2.3 95% confidence interval [CI]: 1.0-5.3, p = 0.049). In our population, OHSS was not found as a risk factor for adverse pregnancy and perinatal outcome. In IVF patients, OHSS is a risk factor for preterm delivery before 34 weeks of gestation. · OHSS is not a risk factor for pregnancy complications.. · Complications investigated were preeclampsia, GDM, prematurity, and others.. · In IVF patients, OHSS is a risk factor for preterm delivery..

Dropout rate and cumulative birth outcomes in couples undergoing in vitro fertilization within a funded and actively managed system of care in New Zealand

To determine the dropout rate between the first and second invitro fertilization (IVF) cycles in a controlled population derived from a funded and actively managed system of care in New Zealand, including the reason for dropout and associated cumulative live birth rate. Retrospective cohort. Multicenter IVF practice. Couples qualifying for publicly funded IVF treatment under New Zealand's Clinical Priority Assessment Criteria. Couples (n = 974) started treatment between July 2011 and June 2013, used their own gametes, and were eligible for up to 2 IVF packages of funded care (including the transfer of surplus embryos). None. IVF dropout rate, reason for dropout, and cumulative live birth rate. A low IVF dropout rate between the first and second IVF cycle was reported within this controlled IVF population, with 10% of couples discontinuing treatment for reasons related to stress. The cumulative live birth rate in this "low dropout" population was 59% at the end of treatment, ranging from 72% (≤30 years) to 42% (38-39 years) according to female age. Most patients who discontinued for stress had a good prognosis, and a third of patients still had embryos in cryostorage. Only 30% of those who discontinued used the funded counseling services. A low dropout rate (10%) can be achieved within an actively managed IVF population. This was lower than previously reported, suggesting that prognosis, cost, and treatment management are the significant causes of dropout within the general IVF population. Couples with many embryos also require psychological support because of treatment fatigue or repeated transfers.

Preimplantation Genetic Testing for Aneuploidy: A Review of the Evidence.

Preimplantation genetic testing for aneuploidy was developed as an invasive embryo-selection technique and is extensively used in in vitro fertilization (IVF) cycles. Around 95,000 preimplantation genetic testing cycles were carried out in the United States between 2014 and 2016, the majority of which were performed for aneuploidy. The objective of preimplantation genetic testing for aneuploidy is to select for transfer a euploid embryo, after embryo biopsy and cytogenetic analysis. The current technique consists of applying comprehensive chromosome screening on trophectoderm cells after blastocyst-stage embryo biopsy. This article reviews all the published randomized controlled trials on preimplantation genetic testing for aneuploidy with comprehensive chromosome screening and comments on the subject of embryo mosaicism detected by this technique. Most of these trials have been criticized because they only included good prognosis patients having normal ovarian reserve producing a high number of embryos available for biopsy. Preimplantation genetic testing for aneuploidy does not improve ongoing pregnancy rates per cycle started when routinely applied on the general IVF population but seems to be a good tool of embryo selection for a selected category of patients with normal ovarian reserve, yet should be only practiced by experienced IVF clinics. If no euploid embryo is available after preimplantation genetic testing for aneuploidy, a low-level mosaic embryo can be considered and prioritized for transfer after appropriate genetic counseling.

Pregnancy outcomes of Chinese women undergoing IVF with embryonic cryopreservation as compared to natural conception

BackgroundTo examine differences in the maternal characteristics and pregnancy outcomes of Chinese women with various causes of infertility who underwent in vitro fertilization (IVF) with embryonic cryopreservation treatment.MethodsCases were pregnancies after IVF-ET with embryonic cryopreservation; controls were spontaneously conceived pregnancies. Subgroup analysis was carried out according to etiology of infertility. The IVF treatment group was divided into 5 subgroups according to infertility etiology as follows: ovulation disorder, tubal disease, male infertility, endometriosis, and mixed infertility. Data on demographic characteristics, medical history, laboratory tests, and delivery were reviewed. Logistic regression analysis was performed for pregnancy and perinatal complications and neonatal outcomes. The multivariable model was adjusted for potential confounders.ResultsAmong singleton pregnancies, compared with spontaneous pregnancies, IVF pregnancies were associated with significant increases in the rates of the following: gestational diabetes mellitus (GDM) (aOR 1.76[95% CI 1.33–2.33]), preeclampsia (2.60[1.61–4.20]), preterm preeclampsia (4.52[2.03–10.06]), postpartum hemorrhage (1.57[1.04–2.36]), intrahepatic cholestasis of pregnancy (3.84[1.06–13.94]), preterm premature rupture of membranes (2.11[1.17–3.81]), preterm birth (1.95[CI 1.26–3.01]), low birthweight (1.90[1.13–3.20]), macrosomia (1.53[1.03–2.27]), and neonatal intensive care unit (NICU) admission (1.69[1.22–2.34]) in the ovulation disorder group; GDM (1.50[1.21–1.86]), placenta previa (2.70[1.59–4.59]), placenta accreta (1.78[1.10–2.89]), postpartum hemorrhage (1.61[1.19–2.18]), macrosomia (1.60[1.21–2.13]) and 5-min Apgar score ≤ 7 (4.09[1.04–16.08]) in the tubal disease group; placenta previa (9.33[4.22–20.62]), small for gestational age (2.29[1.04–5.08]), macrosomia (2.00[1.02–3.95]) and NICU admission (2.35[1.35–4.09]) in the endometriosis group; placenta previa (4.14[2.23–7.68]) and placenta accreta (2.05[1.08–3.87]) in the male infertility group; and GDM (1.85[1.15–2.98]), placenta previa (4.73[1.83–12.21]), placental abruption (3.39[1.20–9.56]), chorioamnionitis (2.93[1.04–8.26]), preterm birth (2.69[1.41–5.15]), and 1-min Apgar score ≤ 7 (4.68[1.62–13.51]) in the mixed infertility group. Among multiple pregnancies, most of the differences that were significant in singleton pregnancies were less extensive or had disappeared.ConclusionsInfertility etiology within the IVF population was found to affect maternal and neonatal outcomes among all births. During the perinatal period, infertility etiology appears to be an additional risk factor for abnormal pregnancy outcomes besides the use of IVF techniques compared with spontaneous pregnancies. Higher risk was found for ovulation disorders, and lower risk was found for male infertility.

Variability of essential and non-essential trace elements in the follicular fluid of women undergoing in vitro fertilization (IVF)

Both essential and non-essential elements have been associated with female reproductive function in epidemiologic investigations, including among IVF populations. To date, most investigators have used blood or urine to assess biomarkers of exposure, with few employing ovarian follicular fluid (FF). FF may offer a more direct “snapshot” of the oocyte microenvironment than blood or urine, however previous studies report follicle-to-follicle variability in FF constituents that may contribute to exposure misclassification. Our objectives were to investigate sources of trace element variability, to estimate FF biomarker reliability among women undergoing IVF (n = 34), and to determine the minimum number of follicles required to estimate subject-specific mean concentrations. We measured As, Hg, Cd, Pb, Cu, Mn, Se, and Zn in FF samples using inductively coupled plasma tandem mass spectrometry. Inter-subject (between-women) variability contributed most of the variability in FF element concentrations, with ovarian, follicular, and analytical as smaller sources of variability. The proportion of variability attributable to sources between-follicles differed by age, body mass index (BMI), race, and cigarette smoking for Cu, Se, and Zn, by BMI and cigarette smoking for As, by primary infertility diagnosis for Hg, Cu, Se, and Zn, and by ovarian stimulation protocol for Mn and Se. Four to five individual follicles were sufficient to estimate subject-specific mean Cu, Se, and Zn concentrations, while >14 were necessary for As, Hg, Cd, Pb, and Mn. Overall, our results suggest that FF is a suitable source of biomarkers of As and Hg exposure in ovarian follicles. Although limited in size, our study offers the most comprehensive exploration of biological variation in FF trace elements to date and may provide guidance for future studies of ovarian trace element exposures.

Activin A increases human trophoblast invasion by upregulating integrin β1 through ALK4.

Activin A promotes human trophoblast invasion during the first trimester of pregnancy and is associated with preeclampsia and pregnancy-induced hypertension (PE/PIH) in naturally conceived pregnancies. However, whether integrin β1 mediates activin A-increased trophoblast invasion remains unknown and the evidence is limited regarding the predictive value of activin A for PE/PIH in women receiving in vitro fertilization (IVF) treatment. Here, we studied the role and underlying molecular mechanisms of integrin β1 in activin A-promoted invasion in immortalized (HTR8/SVneo) and primary human extravillous trophoblast (EVT) cells. A nest case-control study was designed to investigate the predictive/diagnostic value of activin A in IVF pregnancies. Results showed that integrin β1 expression increased after activin A treatment and knockdown of integrin β1 significantly decreased both basal and activin A-increased HTR8/SVneo cell invasion. SB431542 (TGF-β type I receptors inhibitor) abolished activin A-induced SMAD2/SMAD3 phosphorylation and integrin β1 overexpression. Activin A-upregulated integrin β1 expression was attenuated after the depletion of ALK4 or SMAD4 in both HTR8/SVneo and primary EVT cells. Furthermore, we found similar first-trimester activin A levels in IVF patients with or without subsequent PE/PIH. These results reveal that integrin β1 mediates activin A-promoted trophoblast invasion through ALK4-activated SMAD2/3-SMAD4 pathway, and the predictive/diagnostic value of first-trimester maternal serum activin A for hypertensive disorders of pregnancy might be different in IVF population.

Variability of essential and toxic trace elements in the follicular fluid of women undergoing in vitro fertilization (IVF)

Both essential and non-essential elements have been associated with female reproductive function in epidemiologic investigations, including those among IVF populations. To date, most investigators have used blood or urine to assess biomarkers of exposure, with few employing ovarian follicular fluid (FF). FF may offer a more direct 'snapshot' of the oocyte microenvironment, however previous studies report follicle-to-follicle variability in FF constituents which may contribute to exposure misclassification. Our objectives were to: investigate sources of trace element variability in FF among women undergoing IVF (n=34, ≤4 FF collections each; estimate biomarker reliability; and determine the minimum number of follicles to estimate mean concentrations at a 10% confidence level (m10%). We measured As, Cd, Hg, Pb, Cu, Mn, Se, and Zn in FF samples using ICP-MS/MS and employed linear mixed models using restricted maximum likelihood to generate variability components. Sources of variability between women contributed the greatest proportion of total variance for FF As (97.2%), Hg (97.8%), Cd (52.1%), Cu (60.4%), Se (48.1%), and Zn (56.8%), compared to sources between ovaries, between follicles, and analytical variation. The proportion of variability attributable to sources between follicles differed significantly (p&lt;0.05) by age, BMI, race, and cigarette smoking for Cu, Se, and Zn, by BMI and cigarette smoking for As, by primary infertility diagnosis for Hg, Cu, Se, and Zn, and by ovarian stimulation protocol for Mn and Se. To estimate m10% for Cu, Se, and Zn 4 to 5 individual follicles were sufficient, while &gt;14 were necessary for As, Cd, Hg, Pb, and Mn. Our results suggest that while FF As and Hg are suitable biomarkers, these elements and Cd, Pb, and Mn have comparatively higher between-follicle variability than the other analytes. Our findings may help elucidate the impact of trace element exposures on IVF outcomes and inform the design of future studies.

SINGLE MOTHERS BY CHOICE: DEFINING AND UNDERSTANDING SINGLE WOMEN UNDERGOING IN VITRO FERTILIZATION

Single women undergoing in vitro fertilization (IVF) with the goal of achieving a pregnancy during the cycle are a unique and little-studied patient population. The objectives of our study were to define and compare this population to the general IVF population and to assess trends within this group over time.