Multiple IVF Cycles Research Articles

P-481 The decisional needs for women dealing with multiple IVF cycles: A qualitative study

Abstract Study question What are the decisional needs of women experiencing multiple unsuccessful IVF treatments? Summary answer The decisional needs of women experiencing multiple IVF cycles included the provision of tailored information, psychosocial support and available social resources, and collaborative decision-making. What is known already Treatment failures can be devastating for couples trying to conceive. Several studies have demonstrated that the information provisions promote decision-making. Nevertheless, there exists a deficiency in research regarding the manner in which patients perceive their clinical decision-making requirements. The determination of patients’ decisional requirements can uncover obstacles and facilitators to infertility treatment. Asia is experiencing the most rapid expansion in ART cycles, yet existing research on treatment decision-making primarily concentrates on Western populations. This study aimed to investigate the decisional needs related to clinical practices in the context of repeated unsuccessful treatment cycles, with a particular emphasis on Chinese women. Study design, size, duration This study utilized the qualitative methodology to investigate the decisional needs of participants who had undergone multiple failed IVF cycles. Between October 2022 to January 2023, a total of 25 participants were recruited. Participants/materials, setting, methods A purposive sampling method was employed to recruit Chinese females who had undergone a minimum of three embryo transfers and failed to achieve clinical pregnancy. Healthcare professionals from Chinese reproductive clinics referred participants. Data was collected via a 60-minute semi-structured interview. Thematic analysis was employed to identify the underlying themes. Main results and the role of chance Three prominent themes were identified: (1) “provision of customized information”, encompassing specific preferences for content, channels, and format. Participants expressed a need for content that specifically addresses the potential medical ramifications of multi-cycle therapy. They showed a preference for mutual support networks and online platforms, specifically self-media platforms like TikTok; (2) “the quest for psychosocial supports and available social resources”, with a particular focus on decision support and financial resources; and (3) “involvement of stakeholders’ preferences in decision-making”. Participants favored collaborative decision-making over shared decision-making and desired their partner’s involvement while still giving the doctor the lead. These themes were important foundations that provided information and empowerment to patients as they dealt with the complicated process of fertility treatment decision-making after experiencing repeated setbacks. Limitations, reasons for caution First, the recruitment method favored clinical patients and may have overlooked the needs of patients who disengaged from the hospital and decided to end treatment. Second, this study exclusively recruited women. Because women face greater decisional challenges than their partners, their needs deserve attention in a clinical setting. Wider implications of the findings To prepare patients for multiple IVF cycles, healthcare professionals should provide customized care, including specific information about the procedures and consequences of multiple cycles, the utilization of mutual support networks and online platforms, psychosocial resources, and stakeholder involvement. This can enable women to handle challenges following repeated treatment failures. Trial registration number not applicable

P-156 A statistical model to pinpoint oocyte donors subject to IVF outcomes significantly poorer than expected: a tool for egg banks’ management and Research

Abstract Study question What is the prevalence of egg donors resulting in oocyte maturation/fertilization/blastulation rates significantly poorer than expected? Summary answer 6.7% of the egg donors (N = 34/504) elicited outcomes significantly poorer than expected mostly due to low oocyte maturation rates (N = 27/34, 79.4%). What is known already 5-10% of donor oocyte cycles produce no blastocyst involving challenging follow-up counseling. Recent research outlined a statistical model identifying women subject to IVF outcomes poorer than expected. These infertile women underwent whole-exome-sequencing (WES) to identify genes involved in oocyte-maturation-defects (OOMD) and/or preimplantation-embryo-lethality (PREMBL). Oocyte donors are the ideal population to apply this model, because they are young, theoretically-fertile, and undergo multiple retrievals of numerous oocytes. This model can find clinical application in improving egg banks’ management, social application in pinpointing young women potentially-infertile because of oocyte defects, and improving knowledge on the molecular pathways involved in human oocyte/embryo competence. Study design, size, duration Retrospective study involving oocyte donors recruited at three private IVF centers in 2020-2021. 504 donors (25.6 ± 4.7 years; range: 18-35) undergoing 1684 retrievals (N = 32056 cumulus-oocyte-complexes, 24288 metaphase-II) and whose metaphase-II were used (N = 6996 to date) in 487 fresh and 445 frozen ICSI cycles, respectively, were included. Recipient couples affected from severe-male-factor infertility were excluded. Blastocyst culture was systematically conducted. We leveraged clinical/embryological key-performance-indicators to pinpoint outliers subject to outcomes significantly poorer than expected. Participants/materials, setting, methods We quantitatively described donors’ performance as oocyte maturation, fertilization and blastulation rates. The outlier identification was based on the probabilistic modeling of the rates as independent binomial processes, whose baseline success probabilities were estimated from the whole dataset and accounted both for donor age and oocyte type (fresh/vitrified-warmed). The model assigns low probability to individuals with unusually large numbers of immature/unfertilized oocytes or arrested embryos. Donors with low probability (p < 0.001) were designated as outliers. Main results and the role of chance Oocyte donors underwent 3.3 ± 1.9 retrievals (1-8) collecting 63.6 ± 44.4 cumulus-oocyte-complexes (5-241), of which 48.2 ± 34.6 (3-162) metaphase-II (maturation-rate: 75 ± 13%,19-100). 13.9 ± 10.5 (3-75) metaphase-II were used during 1.8 ± 1.3 (1-9) cycles per donor, 1.0 ± 1.0 (0-6) cycles with 7.1 ± 7.6 (0-45) fresh metaphase-II oocytes and 0.9 ± 1.0 (0-7) cycles with 6.8 ± 8.1 (0-59) vitrified-warmed metaphase-II oocytes. Overall, 10.1 ± 8.0 (0-58) 2PN-zygotes were obtained per donor (fertilization-rate: 72 ± 16%,0-100), 5.1 ± 5.8 (0-34) in fresh (fertilization-rate: 72 ± 17%,0-100) and 5.0 ± 6.1 (0-41) in frozen cycles (fertilization-rate: 74 ± 16%,20-100). Overall, 5.5 ± 5.0 (0-31) blastocysts were obtained per donor (blastulation-rate: 55 ± 25%,0-100), 3.0 ± 3.8 (0-25) in fresh (blastulation-rate: 59 ± 25%,0-100) and 2.5 ± 3.6 (0-31) in frozen cycles (50 ± 24%,0-100). The model applied to this dataset designated 34 outliers (N = 34/504,6.7%, p < 0.001, FDR<0.1%). Most of them (N = 27) showed oocyte maturation-rates significantly lower than expected (51 ± 10%,19-66). These women were 26.9 ± 5.1 years old (19-35) and underwent 4.3 ± 1.7 retrievals, collecting 91.2 ± 45.0 cumulus-oocyte-complexes (25-210), of which 49.1 ± 31 (8-127) were metaphase-II oocytes. Three outliers showed fertilization-rates significantly poorer than expected (19 ± 17%,0-31). They were 21 ± 4.4 years old (18-26) and their metaphase-II oocytes (12.7 ± 4.9,7-16) were inseminated in 1.3 ± 0.6 donation cycles (1-2) resulting in 3 ± 2.6 (0-5) 2PN-zygotes. Four outliers showed blastulation-rates significantly poorer than expected (13 ± 7%,7-22SAME). They were 26.3 ± 6.2 years old (19-34) and their oocytes resulted in 28.5 ± 20.5 (14-58) 2PN-zygotes across 4.5 ± 3.1 (2-9) donation cycles that developed into 4.5 ± 5.7 (1-13) blastocysts. Limitations, reasons for caution Euploidy, another pivotal measure of oocyte competence, was not assessed. Larger studies are warranted, also accounting for putative additional confounders on all embryological outcomes under investigation. Nonetheless, gathering well-structured data on the cumulative performance of donor oocytes collected across multiple retrievals and through multiple IVF cycles is challenging and remarkable. Wider implications of the findings These outlier oocyte donors could benefit from follow-up investigation aimed at underpinning OOMD/PREMBL-related genetic factors. The development of genetic prediction tools to this end will improve egg donation cycles’ management and equity and might pave the way to preventive screening strategies and precision reproductive interventions in theoretically-fertile young women. Trial registration number not applicable

P-473 The reproductive performance of euploid blastocysts declines after each consecutive embryo transfer: The pendulum is swinging back?

Abstract Study question the impact of euploid blastocysts on reproductive performance by association between the number of previous failed IVF cycles and live birth rate per transfer Summary answer Our findings suggest a negative association between the number of previous failed IVF cycles per euploid transfers. implantation rates decreased following each consecutive FE-ET cycles What is known already In assisted reproductive technologies, implantation failure presents a challenging clinical dilemma since its underlying etiology is unknown. Implantation is a very complex process which involves a variety of factors related to the embryo, endometrium, and immune system (Fox et al. 2016). Therefore, implantation failure is also a complex pathological condition that involve both embryonic defects and/or endometrial dysfunctions (Das et al.2012). This situation poses a therapeutic dilemma. Hence implantation failure etiologies and treatments remain unresolved. which results in ongoing debate over whether embryonic chromosomal aneuploidy is a major contributor or within the endometrium itself. Study design, size, duration This observational cohort study included 387 patients undergoing euploid embryo transfer between January 2015 and until October 2022. Participants/materials, setting, methods Participants: Women with an anatomically normal uterus who underwent autologous vitrified-warmed euploid blastocyst transfer (Frozen Euploid Embryo Transfer: FE-ET) cycles were included in the study. Setting: Fertility center at a university-affiliated public hospital. Intervention(s): Trophectoderm biopsy and comprehensive preimplantation 24-chromosome analysis using Next Generation Sequencing (NGS). Main Outcome Measure(s): Cumulative outcomes from these cycles were analyzed. A logistic regression model was used to assess the differences in outcomes between the first, second, and third FE-ET. Main results and the role of chance The mean age of the patient population under investigation was 33.4 ± 5.3 years. Maternal age at oocyte retrieval was negatively associated with the mean euploidy rate per cohort of biopsied blastocysts from each patient (m-ER). The m-ER did not show any association with the number of previous failed IVF cycles (0/1-2/≥3) among different ranges of maternal age at oocyte retrieval (≤30/31-35/36-39/≥40). The transfer of the first single vitrified-warmed euploid blastocyst was associated with an implantation rate (IR) of 47%, a miscarriage rate of 17.9% and a live birth rate (LBR) of 33.9%. Miscarriage rate and LBR were sensitive to the number of previous failed IVF cycles, showing statistically significant differences between women with no previous and ≥3 failed IVF cycles (11.3% versus 27.8%, P = 0.04) and (40.7% versus 26.3%, P = 0.05) respectively. Sustained implantation rates of the first, second, and third FE-ET were 47%, 40.5%, and 30% per transfer, respectively. The sustained IR was sensitive to the number of consecutive euploid blastocyst transfers (P = 0.03). Limitations, reasons for caution The retrospective nature of the study. The data should also be verified using a multicenter approach, to increase the sample size. Wider implications of the findings After experiencing multiple unsuccessful IVF cycles, transferring euploid blastocysts leads to improved clinical outcomes, but these improvements eventually level off. Additional information beyond embryo euploidy is needed to further enhance clinical outcomes. Trial registration number not applicable

A "Good" Patient

A "Good" Patient Erica C. Kaye All I wanted was to be a mother. The yearning was an animal thing, instinctive and unconstrained, fierce and precarious. Everything else became surrounding noise. Each day, I went through the motions; but in a parallel world, fragile hope cyclically fractured, again and again. I've struggled with infertility and pregnancy loss for as long as I've been a doctor. Most memories from my medical training and career are tethered to the pain of childlessness. On 24-hour shifts, I hid in an empty parent room in the pediatric intensive care unit, injecting hormones into my knotted backside. Three hours after transferring a fragmenting embryo into my inhospitable, cramping uterus, I led a memorial service at the hospital for children who died. I received the call that I was not pregnant while sitting on a crowded city bus on my way to staff a resident clinic, tears streaming down my face. A decade later, the memories are still raw. Like visceral imprints, they silhouette and contour my sense of self. Across my training, so many people told me who I was "supposed to be." A dedicated clinician, dependable colleague, erudite researcher, thoughtful educator, devoted mentor. I tried hard to meet everyone's expectations, but I was compressed by misery. In my guts, I knew that what I was supposed to be was a mom. Anxiously, I sought out fertility treatment. As a physician, I thought I was prepared to navigate the healthcare system as a patient. In retrospect, I was brutally naïve and inexperienced. I was training to become a pediatric palliative care physician, and I saw the practice of medicine as a pathway towards holistic care for a person's physical, emotional, spiritual, and social wellbeing. I was learning to ask patients about their goals, values, hopes, fears. To see the whole patient and wonder about their personhood. To prioritize their dignity and humanity. When I entered the fertility healthcare system, I was disoriented and scared. The clinic was a cold, sterile space. When I felt invisible, I blamed myself for not being savvy enough to navigate the system. I think a part of me believed that, if I was a "good" patient, someone in the system would see me and care. It was strange to be wholly unseen, and yet completely, grossly exposed. Infertility stripped me bare—bodily, mentally, financially, existentially. I was systematically surveyed for defects, my failings interrogated, the broken parts scrutinized. Problems without a straightforward fix were discarded. Healthcare professionals calculated the sum of my deficits with ease, but no one noticed a person drowning in grief. Medical training conditioned me to take up as little space as possible, to apologize for the inconvenience that my issues or worries might cause for others. The fertility clinic made repeated mistakes: incorrect prescriptions, instructions that didn't make sense, communication breakdowns. But I was too overwhelmed to question or examine things closely, and I was incapacitated by isolation. My husband, also in medical training, was living in another state. We had not told anyone about our [End Page E1] infertility struggles, and I shouldered the weight of navigating my medical care alone. It's hard to think back to those days. Grief was a physical hole in my chest, sucking out air. I didn't know how to function, to be whole again. Anguish born from invisible, intangible loss is intense and alienating. I felt guilty about my degree of suffering when I lacked visible scars to justify the wound. Practically, I didn't have the emotional bandwidth to explore or tend to my grief; I was too overwhelmed and drained by the stamina needed to steer through a disinterested, chaotic healthcare system. After residency, I joined my husband in another state. We were devastated to learn that, in crossing state lines, we had lost our fertility coverage. We found a new clinic in the area and began draining our hope and savings. Across two subspecialty fellowships and an early faculty career, we did multiple IVF cycles and mourned the loss of five desperately wanted pregnancies. It was the darkest time in my life. As hard as it was...

P–210 Abnormal cleavage patterns during embryo preimplantation development and their effect on blastulation: an overview from IVF patients with multiple IVF cycles in a time-lapse incubator

Abstract Study question How common abnormal cleavage patterns (ACP) are in IVF and what are their consequences on embryo developmental competence? Summary answer ACP might affect up to 25% of the 2PN-zygotes, independently from patients’/cycles’ characteristics, and mostly cause embryo developmental arrest around the 4-to–8-cell transition. What is known already Since its implementation in IVF, time-lapse-microscopy (TLM) allowed the standardization of embryo culture within undisturbed incubators, but it has not improved embryo selection especially if blastocyst transfer is performed. Nevertheless, TLM holds the potential for boosting our knowledge of embryo preimplantation development. In particular, a continuous observation of embryo morpho-dynamics unveiled peculiar blastomere cleavage patterns previously unidentifiable with a static morphological assessment. These events are possibly associated with massive mitotic errors, affecting both chromosomes and cytoskeletal components, as well as downstream metabolic imbalances. Still, the causes of ACP and their consequences on embryo developmental/reproductive competence require further investigation. Study design, size, duration Observational study including 75 patients (age:38.6±3.7yr, FSH:8.8±3.6IU/l, AMH:1.7±1.3ng/ml; BMI:21.4±2.4) who conducted multiple IVF cycles (N = 160; 8.7±5.0 cumulus-oocyte-complexes and 6.3±3.6 metaphase-II collected; 201±245 days between first and second cycles) in a time-lapse incubator between 2014–2020. All annotations were performed blindly by two operators and confirmed by a third in case of discordance. The outcomes were the blastulation rate after any ACP, their association between each other and with patients’/cycles’ characteristics. Participants/materials, setting, methods We included only ICSI-cycles after ovarian-stimulation with blastocyst culture conducted in the Embryoscope. Overall, 981 metaphase-II were inseminated and 677 2PN-zygotes annotated. The ACP investigated were: (i)cytokinesis-failure, formation of cytoplasmic septa without cell division; (ii)Chaotic-cleavage, disordered and uneven cleavages; (iii)Direct-unequal-cleavage (DUC), cleavage of zygotes or single blastomeres directly into 3; (iv)Rapid-cleavage, t3-t2<5hr; (v)Reverse-cleavage, fusion of 2 blastomeres into 1; (vi)Fragmentation, presence of numerous non-nucleated fragments; (vii)Blastomeres’ exclusion/extrusion, nucleated cells excluded/extruded from the morula. Main results and the role of chance Among the 2PN-zygotes, the prevalence of cytokinesis-failure was 5.9% (N = 40/677), 15.7% for chaotic-cleavage (N = 106/677), 18.6% for DUC (N = 126/677), 4.1% for rapid-cleavage (N = 28/677), 3.5% for reverse-cleavage (N = 24/677) and 24.1% for fragmentation (N = 163/677). Among the morulae, the prevalence of blastomere exclusion/extrusion was 27% (N = 109/410;1.5±1.2 excluded/extruded cells,range:1–7). The risk for reverse-cleavage was higher among 2PN-zygotes facing failed-cytokinesis (N = 8/40,20% versus N = 16/637,2.5%, OR:9.7,95%CI:3.9–24.3,p<0.01). Fragmentation was instead higher among 2PN-zygotes undergoing chaotic cleavage (N = 47/106,44.3% versus N = 116/571,20.3%, OR:3.1,95%CI:2–4.8,p<0.01) or DUC (N = 46/126,36.5% versus N = 117/551,21.2%, OR:2.1,95%CI:1.4–3.2,p<0.01). Lastly, higher prevalence of blastomeres’ exclusion/extrusion were reported among morulae obtained after chaotic-cleavage (N = 17/29,58.6% versus N = 92/381,24.1%, OR:4.4,95%CI:2–9.7,p<0.01), DUC (N = 26/37,70.3% versus N = 83/373,22.3%, OR:8.3,95%CI:3.9–17.4,p<0.01) and in presence of fragmentation (N = 79/195,75.2% versus N = 30/305,9.8%, OR:27.8,95%CI:15.6–49.8,p<0.01); only a higher trend after rapid-/reverse-cleavage. No predictive factor of ACP was identified among patients’ and cycles’ characteristics, except for higher risks of fragmentation (OR:2.6,95%CI:1.1–6.3,p= 0.04) and blastomeres’ exclusion/extrusion (OR:2.7,95%CI:1.1–7.2,p=0.04) among patients with previous experience with these events. The viable-blastocyst rate per 2PN-zygote was 45.1% (N = 305/677). It was lower in case of failed-cytokinesis (N = 12/40,30% versus N = 293/637,46%, OR:0.5,95%CI:0.25–0.99,p=0.05), chaotic cleavage (N = 20/106,18.9% versus N = 285/571,49.9%, OR:0.23,95%CI:0.14–0.39,p<0.01), DUC (N = 27/126,21.4% versus N = 278/551,50.5%, OR:0.27,95%CI:0.17–0.42,p<0.01), rapid-cleavage (N = 6/22,21.4% versus N = 299/649,46.1%, OR:0.32,95%CI:0.13–0.8,p=0.02), and reverse-cleavage (N = 5/19,20.8% versus N = 300/653,45.9%, OR:0.31, 95%CI:0.11–0.84,p=0.02). No difference was instead shown in case of fragmentation and/or blastomeres’ exclusion/extrusion. Limitations, reasons for caution The patients included were poor-prognosis women undergoing ≥2 cycles. We are expanding the sample size to account for all cycles conducted in time-lapse incubators. Larger sample size will provide also statistical-power to investigate the effect of ACP on blastocysts’ chromosomal and implantation competence, and more visualizations of rapid-/reverse-cleavage events. Wider implications of the findings: After ACP,developmental-arrest mostly occurs around the 4-to–8-cell transition (50–70% versus ∼30%), when embryonic-genome-activation takes place. Surviving embryos often fragment and/or exclude/extrude blastomeres at morulation, without further impact on blastulation-rates. Moreover, ACP seem independent from patients’/cycles’ characteristics. These evidence incite future Research on the biological/genetic mechanisms triggering ACP and their consequences. Trial registration number None

Can repeat IVF/ICSI cycles compensate for the natural decline in fertility with age? an estimate of cumulative live birth rates over multiple IVF/ICSI cycles in Chinese advanced-aged population.

In order to find out to what extent ovarian aging could be compensated by the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments, a total of 4102 women above the age of 35 undergoing 6489 complete cycles from 2009 to 2015 with follow-up visits until 2017 were retrospectively analyzed. Cumulative live birth rates (CLBRs) across multiple IVF/ICSI cycles were compared in the study population stratified by age and ovarian reserve (classified by the POSEIDON criteria). Younger patients (aged between 35 and 40) could well benefit from repeat IVF treatments, with the optimal CLBRs ranging from 62%-72% for up to four complete cycles. However, the CLBRs sharply declined to 7.7%-40% in older patients (>40yrs). In light of ovarian reserve, the optimal-estimated-four-cycle CLBR of younger patients (35-40yrs) in POSEIDON group 2 could approached to those with normal ovarian response (non-POSEIDON), with 57.3%-70% versus 74.5%-81% respectively. However, the CLBR of older patients (>40yrs) in POSEIDON group 2 only reached 50% of their counterparts. Extending the number of IVF cycles beyond three or four is effective for advanced-aged women, especially in younger normal responders (non-POSEIDON) and unexpected poor/suboptimal responders (POSEIDON group 2). The real turning point at which female fecundity dropped after multiple IVF cycles is at the age of 40.

Do patient factors influence embryologists' decisions to freeze borderline blastocysts?

To investigate whether patient factors influence the decision to freeze a blastocyst with low implantation potential. This experimental study assessed 170 practicing embryologists from a variety of countries who were recruited via an online survey. Participants were currently practicing embryologists, who grade blastocysts as part of this role. The survey presented decision-making 'vignettes' to participants. These included specific patient information, as well as an image of an expanded blastocyst that was of borderline quality for inner cell mass and trophectoderm, for which the embryologist selected whether or not to freeze. High/low maternal age, the presence/absence of other top quality blastocysts, and the presence/absence of previously unsuccessful IVF cycles were systematically varied within the patient information in a 2 × 2 × 2 design. Participants reported how likely they would be to freeze a particular blastocyst on a scale of 1 (Extremely Unlikely) to 7 (Extremely Likely), and whether or not they would ultimately freeze each blastocyst (Yes or No). Lower maternal age, no other high-quality blastocysts within the cohort, and multiple unsuccessful IVF cycles were associated with greater likelihood of recommending to freeze (P < .001). Furthermore, significant interactions among all three patient factors were noted. This study provides evidence suggesting that when faced with an uncertain blastocyst, factors pertaining to the patient (maternal age, the presence/absence of other top quality blastocysts, and the presence/absence of previously unsuccessful IVF cycles) influence the decision to freeze.

Acupuncture performed around the time of embryo transfer: a systematic review and meta-analysis.

This was a systematic review and meta-analysis to examine the efficacy, effectiveness and safety of acupuncture as an adjunct to embryo transfer compared with controls to improve reproductive outcomes. The primary outcome was clinical pregnancy. Twenty trials and 5130 women were included in the review. The meta-analysis found increased pregnancies (risk ratio [RR] 1.32, 95% confidence interval [CI] 1.07-1.62, 12 trials, 2230 women), live births (RR 1.30, 95% CI 1.00-1.68, 9 trials, 1980 women) and reduced miscarriage (RR 1.43, 95% CI 1.03-1.98, 10 trials, 2042 women) when acupuncture was compared with no adjunctive control. There was significant heterogeneity, but no significant differences between acupuncture and sham controls. Acupuncture may have a significant effect on clinical pregnancy rates, independent of comparator group, when used in women who have had multiple previous IVF cycles, or where there was a low baseline pregnancy rate. The findings suggest acupuncture may be effective when compared with no adjunctive treatment with increased clinical pregnancies, but is not an efficacious treatment when compared with sham controls, although non-specific effects may be active in both acupuncture and sham controls. Future research examining the effects of acupuncture for women with poorer IVF outcomes is warranted.

Methodological approaches to analyzing IVF data with multiple cycles.

Which methodological approaches are most appropriate for analyzing IVF data with multiple cycles in the context of a binary outcome? Both mixed effect models and generalized estimating equation (GEE) modeling approaches can account for multiple IVF cycles and may reduce bias over first-cycle only approaches, but CIs were narrowest with cluster-weighted generalized estimating equation models (CWGEE). There is a lack of consensus among investigators regarding how to best incorporate data from multiple cycles and whether to present odds or risks in the analysis of IVF data. Failure to account for correlated outcomes within individuals and informative cluster size may lead to invalid CIs and biased estimates. The Environment and Reproductive Health (EARTH) Study is an ongoing prospective cohort study of subfertile couples conducted at an academic medical center. This cohort was established in 2004 and follows couples seeking treatment for infertility throughout the course of their treatment and pregnancy. Women aged 18-46 years enrolled in the EARTH Study from 2004 to 2017 who initiated at least one IVF cycle were eligible. Cycle initiation was defined as beginning ovulation induction with the intent to progress through an IVF or ICSI cycle. This analysis included 442 women undergoing 642 cycles who met the study inclusion criteria. We compared the results and interpretations of log-binomial and logistic models restricting to the first cycle, as well as mixed effects models, unweighted GEE models, and CWGEE models including all cycles. This analysis was conducted for two distinct exposures: maternal age at cycle initiation, and maternal preconception urinary concentrations of di(2-ethylhexyl) phthalate (DEHP) metabolites (previously reported to be associated with a decreased probability of live birth). In general, the CIs were widest for mixed effects models and narrowest for CWGEE models. Further, in models evaluating the sum of urinary concentrations of DEHP metabolites (∑DEHP, available for 91% of women), the point estimates were surprisingly different between the first-cycle and multiple-cycle models. We observed significant associations between maternal age and live birth in all models. However, we observed no associations between ∑DEHP and live birth. This analysis was limited to an example dataset in which the true effect of any exposure is unknown. While this allows us to observe model performance in the context of real data, future analyses should be conducted within simulated datasets under various assumptions to further evaluate the appropriateness of each approach. In addition, we did not address differential loss to follow-up in our statistical approaches. The use of CWGEE models should be more widely considered in the analysis of IVF data with multiple cycles per woman. The CWGEE approach is computationally simple, addresses non-ignorable (informative) cluster size, and is robust against mis-specification of the underlying covariance structure. Among the methods compared in this analysis, CWGEE models generally yielded the narrowest CIs, possibly indicating the most precise estimates. We also stress the importance of estimating risks rather than odds in the analysis of IVF data. The project was funded by Grants (R01ES022955, R01ES009718, and P30ES000002) from the National Institutes of Health. None of the authors has any conflicts of interest to declare.

Predicting the cumulative chance of live birth over multiple complete cycles of in vitro fertilization: an external validation study.

Are the published pre-treatment and post-treatment McLernon models, predicting cumulative live birth rates (LBR) over multiple complete IVF cycles, valid in a different context? With minor recalibration of the pre-treatment model, both McLernon models accurately predict cumulative LBR in a different geographical context and a more recent time period. Previous IVF prediction models have estimated the chance of a live birth after a single fresh embryo transfer, thereby excluding the important contribution of embryo cryopreservation and subsequent IVF cycles to cumulative LBR. In contrast, the recently developed McLernon models predict the cumulative chance of a live birth over multiple complete IVF cycles at two certain time points: (i) before initiating treatment using baseline characteristics (pre-treatment model) and (ii) after the first IVF cycle adding treatment related information to update predictions (post-treatment model). Before implementation of these models in clinical practice, their predictive performance needs to be validated in an independent cohort. External validation study in an independent prospective cohort of 1515 Dutch women who participated in the OPTIMIST study (NTR2657) and underwent their first IVF treatment between 2011 and 2014. Participants underwent a total of 2881 complete treatment cycles, with a complete cycle defined as all fresh and frozen thawed embryo transfers resulting from one episode of ovarian stimulation. The follow up duration was 18 months after inclusion, and the primary outcome was ongoing pregnancy leading to live birth. Model performance was externally validated up to three complete treatment cycles, using the linear predictor as described by McLernon et al. to calculate the probability of a live birth. Discrimination was expressed by the c-statistic and calibration was depicted graphically in a calibration plot. In contrast to the original model development cohort, anti-Müllerian hormone (AMH), antral follicle count (AFC) and body weight were available in the OPTIMIST cohort, and evaluated as potential additional predictors for model improvement. Applying the McLernon models to the OPTIMIST cohort, the c-statistic of the pre-treatment model was 0.62 (95% CI: 0.59-0.64) and of the post-treatment model 0.71 (95% CI: 0.69-0.74). The calibration plot of the pre-treatment model indicated a slight overestimation of the cumulative LBR. To improve calibration, the pre-treatment model was recalibrated by subtracting 0.35 from the intercept. The post-treatment model calibration plot revealed accurate cumulative LBR predictions. After addition of AMH, AFC and body weight to the McLernon models, the c-statistic of the updated pre-treatment model improved slightly to 0.66 (95% CI: 0.64-0.68), and of the updated post-treatment model remained at the previous level of 0.71 (95% CI: 0.69-0.73). Using the recalibrated pre-treatment model, a woman aged 30 years with 2 years of primary infertility who starts ICSI treatment for male factor infertility has a chance of 40% of a live birth from the first complete cycle, increasing to 72% over three complete cycles. If this woman weighs 70 kg, has an AMH of 1.5 ng/mL and an AFC of 10 measured at the beginning of her treatment, the updated pre-treatment model revises the estimated chance of a live birth to 30% in the first complete cycle and 59% over three complete cycles. If this woman then has five retrieved oocytes, no embryos cryopreserved and a single fresh cleavage stage embryo transfer in her first ICSI cycle, the post-treatment model estimates the chances of a live birth at 28 and 58%, respectively. Two randomized controlled trials (RCT) evaluating the effectiveness of gonadotropin dose individualization on basis of the AFC were nested within the OPTIMIST study. The strict dosing regimens, the RCT in- and exclusion criteria and the limited follow up time of 18 months might have influenced model performance in this independent cohort. Also, consistent with the original model development study, external validation was performed using the optimistic assumption that the cumulative LBR in couples who discontinue treatment without a live birth would have been equal to that of those who continue treatment. After national recalibration to account for geographical differences in IVF treatment, the McLernon prediction models can be introduced as new counselling tools in clinical practice to inform patients and to complement clinical reasoning. These models are the first to offer an objective and personalized estimate of the cumulative probability of a live birth over multiple complete IVF cycles. No external funds were obtained for this study. M.J.C.E., D.J.M. and S.B. have nothing to disclose. J.A.L, S.C.O, T.C.v.T. and H.LT. received an unrestricted personal grant from Merck BV. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy for ObsEva, Merck and Guerbet. F.J.M.B. receives monetary compensation as a member of the external advisory board for Merck BV (the Netherlands) and Ferring pharmaceutics BV (the Netherlands), for consultancy work for Gedeon Richter (Belgium) and Roche Diagnostics on automated AMH assay development, and for a research cooperation with Ansh Labs (USA). Not applicable.

Cumulative live birth rates in more than 3,000 patients with poor ovarian response: a 15-year survey of final in vitro fertilization outcome

To estimate the cumulative live birth rates (CLBRs) in women with poor ovarian response (POR) diagnosed according to the Bologna criteria. A 15-year population-based observational cohort study. Teaching hospital. Between 2002 and 2016 a total of 3,391 women with POR were followed from their first fresh, nondonor IVF cycle until they had a live birth or discontinued treatment. All IVF and intracytoplasmic sperm injection (ICSI) cycles and cryocycles were included. None. Live birth rates per initiated cycle, the conservative and optimistic CLBR for multiple IVF cycles. The CLBRs after six IVF cycles were 14.9% for the conservative and 35.3% for the optimistic estimate. The CLBR decreased from 22% for women ≤30years to 18.3% for women aged 31-34years, 17.2% for 35-37years, 13.5% for 38-40years, 10.5% for 41-43years, and 4.4% among women >43years in the conservative analysis. There was a significant decreased CLBR starting at age 38years compared with women <35years. After adjusting for age, antral follicle count, basal FSH level, and IVF cycle number, natural cycles were associated with the lowest CLBR among all the protocols, and this difference was significant compared with the other protocols. For women with POR, the CLBR declined with increasing age. Women with advanced age (≥38years) achieved a significantly lower CLBR than young poor responders (<35years). Very low CLBR was associated with women aged >43years old. Natural cycle IVF is of no benefit for these patients.

Association between ambient air pollution and pregnancy rate in women who underwent IVF.

Are the concentrations of five criteria air pollutants associated with probabilities of biochemical pregnancy loss and intrauterine pregnancy in women? Increased concentrations of ambient particulate matter (PM10), nitrogen dioxide (NO2), carbon monoxide (CO) during controlled ovarian stimulation (COS) and after embryo transfer were associated with a decreased probability of intrauterine pregnancy. Exposure to high ambient air pollution was suggested to be associated with low fertility and high early pregnancy loss in women. Using a retrospective cohort study design, we analysed 6621 cycles of 4581 patients who underwent one or more fresh IVF cycles at a fertility centre from January 2006 to December 2014, and lived in Seoul at the time of IVF treatment. To estimate patients' individual exposure to air pollution, we computed averages of hourly concentrations of five air pollutants including PM10, NO2, CO, sulphur dioxide (SO2) and ozone (O3) measured at 40 regulatory monitoring sites in Seoul for each of the four exposure periods: period 1 (start of COS to oocyte retrieval), period 2 (oocyte retrieval to embryo transfer), period 3 (embryo transfer to hCG test), and period 4 (start of COS to hCG test). Hazard ratios (HRs) from the time-varying Cox-proportional hazards model were used to estimate probabilities of biochemical pregnancy loss and intrauterine pregnancy for an interquartile range (IQR) increase in each air pollutant concentration during each period, after adjusting for individual characteristics. We tested the robustness of the result using generalised linear mixed model, accounting for within-woman correlation. Mean age of the women was 35 years. Average BMI was 20.9 kg/m2 and the study population underwent 1.4 IVF cycles on average. Cumulative pregnancy rate in multiple IVF cycles was 51.3% per person. Survival analysis showed that air pollution during periods 1 and 3 was generally associated with IVF outcomes. Increased NO2 (adjusted HR = 0.93, 95% CI: 0.87, 0.99) and CO (0.94, 95% CI: 0.89, 1.00) during period 1 were associated with decreased probability of intrauterine pregnancy. PM10 (0.92, 95% CI: 0.85, 0.99), NO2 (0.93, 95% CI = 0.86, 1.00) and CO (0.93, 95% CI: 0.87, 1.00) levels during period 3 were also inversely associated with intrauterine pregnancy. Both PM10 (1.17, 95% CI: 1.04 1.33) and NO2 (1.18, 95% CI: 1.03, 1.34) during period 3 showed positive associations with biochemical pregnancy loss. The district-specific ambient air pollution treated as an individual exposure may not represent the actual level of each woman's exposure to air pollution. Smoking, working status, parity or gravidity of women, and semen analysis data were not included in the analysis. This study provided evidence of an association between increased ambient concentrations of PM10, NO2 and CO and reduced probabilities for achieving intrauterine pregnancy using multiple IVF cycle data. Specifically, our results indicated that lower intrauterine pregnancy rates in IVF cycles may be linked to ambient air pollution during COS and the post-transfer period. This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2013 R1A6A3A04059017, 2016 R1D1A1B03933410 and 2018 R1A2B6004608) and the National Cancer Center of Korea (NCC-1810220-01). The authors report no conflicts of interest. N/A.

Transcutaneous electrical acupoint stimulation (TEAS) treatment improves pregnancy rate and implantation rate in patients with implantation failure

ObjectiveAlthough major advances have greatly improved the outcomes of assisted reproductive technology in the last two cascades, there remains significant difficulty in achieving pregnancy for many patients even after repeated attempts of IVF. Interestingly, recent studies have shown that transcutaneous electrical acupoint stimulation (TEAS) can improve the reproductive outcomes of select IVF patients. To determine the utility of TEAS in improving IVF outcomes in patients with a history of implantation failure, we conducted a retrospective study of clinical outcomes of women, who had a prior history of unsuccessful pregnancy outcome after IVF-embryo transfer (IVF-ET), following TEAS treatment. Materials and methodsA total of 25 patients, who had failed to conceive after multiple IVF cycles in which good embryos were transferred, received noninvasive low frequency TEAS treatment prior to and during an IVF-ET cycle. The clinical outcomes, including biochemical pregnancy rate, clinical pregnancy rate and implantation rate, were compared to those of prior cycles which received only standard IVF treatment. ResultsAnalysis of reproductive outcomes showed that implantation rate and clinical pregnancy rate increased significantly in IVF cycles that included the TEAS treatment when compared to prior cycles that received only the standard IVF treatment in this cohort of patients. ConclusionsThis surprising finding indicated that TEAS treatment is a promising technique to improve reproductive outcomes in difficult cases of IVF-ET. Because TEAS treatment is noninvasive and has high reproducibility, and can be applied with limited training, further refinement of this procedure would not only substantiate the beneficial effects of TEAS, but also allow the technique to be more effective and reproducible.

Men's meat intake and treatment outcomes among couples undergoing assisted reproduction

To study the relationship between men's meat intake and clinical outcomes in couples undergoing infertility treatment with the use of assisted reproductive technology (ART). Prospective cohort study. Fertility center. A total of 141 men whose female partners underwent 246 ART cycles from 2007 to 2014. None. Total and specific types of meat intake were estimated from dietary questionnaires. Fertilization, implantation, clinical pregnancy, and live-birth rates per initiated cycle. Mixed-effects models account for multiple IVF cycles per woman. There was a positive association between poultry intake and fertilization rate, with a 13% higher fertilization rate among men in the highest quartile of poultry intake compared with those in the lowest quartile (78% vs. 65%). Processed meat intake was inversely related to fertilization rate in conventional IVF cycles but not in IVF cycles using intracytoplasmic sperm injection. The adjusted fertilization rates for men in increasing quartiles of processed meat intake were 82%, 67%, 70%, and 54% in conventional IVF cycles. Men's total meat intake, including intake of specific types of meat, was not associated with implantation, clinical pregnancy, or live-birth rates. Poultry intake was positively associated with fertilization rates, whereas processed meat intake was negatively associated with fertilization rates among couples undergoing conventional IVF. This, however, did not translate into associations with clinical pregnancy or live-birth rates.

Max day 3 FSH predicts reproductive outcome better than same cycle FSH levels: waiting for a “good month” conveys minimal benefit

Follicle stimulation hormone(FSH) remains a measurement for predicting ovarian reserve, along with forming vaginal egg retrieval(VOR) expectations. Patients repeating an IVF cycle have been discouraged from proceeding if Day 3(D3) FSH levels are elevated; encouraged to skip a month and wait for a lower FSH level (“Good Month”) to improve outcome. Also, whether patients with adverse maximum(Max) FSH(≥13mIU/ml)will have better retrieval outcomes in latter cycles if levels decrease is unknown. Our study seeks to determine the utility of cycle-specific and Max FSH values in predicting VOR outcomes of multiple IVF cycles patients.

A pilot case control study of the use of melatonin in patients with multiple failed IVF cycles

Egg quality and therefore embryo quality is a limiting factor in IVF. Mitochondria supply ATP to cells, and higher levels are associated with better quality eggs. Excessive reactive oxygen species (ROS) are implicated in mitochondrial damage. Melatonin regulates reproductive physiology via gonadotropin release, but is also a powerful free radical scavenger and antioxidant. Our study examined the use of melatonin in IVF patients with multiple unsuccessful cycles.

Urinary bisphenol A concentrations and early reproductive health outcomes among women undergoing IVF.

In women undergoing IVF, are urinary bisphenol A (BPA) concentrations associated with ovarian response and early reproductive outcomes, including oocyte maturation and fertilization, Day 3 embryo quality and blastocyst formation? Higher urinary BPA concentrations were found to be associated with decreased ovarian response, number of fertilized oocytes and decreased blastocyst formation. Experimental animal and in vitro studies have reported associations between BPA exposure and adverse reproductive outcomes. We previously reported an association between urinary BPA and decreased ovarian response [peak serum estradiol (E(2)) and oocyte count at the time of retrieval] in women undergoing IVF; however, there are limited human data on reproductive health outcomes, such as fertilization and embryo development. Prospective preconception cohort study. One hundred and seventy-four women aged 18-45 years and undergoing 237 IVF cycles were recruited at the Massachusetts General Hospital Fertility Center, Boston, MA, USA, between November 2004 and August 2010. These women were followed until they either had a live birth or discontinued treatment. Cryothaw and donor egg cycles were not included in the analysis. Urinary BPA concentrations were measured by online solid-phase extraction-high-performance liquid chromatography-isotope dilution-tandem mass spectrometry. Mixed effect models, poisson regression and multivariate logistic regression models were used wherever appropriate to evaluate the association between cycle-specific urinary BPA concentrations and measures of ovarian response, oocyte maturation (metaphase II), fertilization, embryo quality and cleavage rate. We accounted for correlation among multiple IVF cycles in the same woman using generalized estimating equations. The geometric mean (SD) for urinary BPA concentrations was 1.50 (2.22) µg/l. After adjustment for age and other potential confounders (Day 3 serum FSH, smoking, BMI), there was a significant linear dose-response association between increased urinary BPA concentrations and decreased number of oocytes (overall and mature), decreased number of normally fertilized oocytes and decreased E(2) levels (mean decreases of 40, 253 and 471 pg/ml for urinary BPA quartiles 2, 3 and 4, when compared with the lowest quartile, respectively; P-value for trend = 0.001). The mean number of oocytes and normally fertilized oocytes decreased by 24 and 27%, respectively, for the highest versus the lowest quartile of urinary BPA (trend test P < 0.001 and 0.002, respectively). Women with urinary BPA above the lowest quartile had decreased blastocyst formation (trend test P-value = 0.08). Potential limitations include exposure misclassification due to the very short half-life of BPA and its high variability over time; uncertainty about the generalizability of the results to the general population of women conceiving naturally and limited sample. The results from this extended study, using IVF as a model to study early reproductive health outcomes in humans, indicate a negative dose-response association between urinary BPA concentrations and serum peak E(2) and oocyte yield, confirming our previous findings. In addition, we found significantly decreased metaphase II oocyte count and number of normally fertilizing oocytes and a suggestive association between BPA urinary concentrations and decreased blastocyst formation, thus indicating that BPA may alter reproductive function in susceptible women undergoing IVF. This work was supported by grants ES009718 and ES000002 from the National Institute of Environmental Health Sciences and grant OH008578 from the National Institute for Occupational Safety and Health. None of the authors has actual or potential competing financial interests. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Recurrent IVF failure: other factors

IVF failure is a problem for a couple in the singular but can be a tragedy in the plural. Recurrent IVF failure has multiple known causes but many which are not routinely considered as part of the posttreatment analysis. The reason is there are several causes associated with lifestyle and other causes related to pre-existing conditions that have only a tenuous or no apparent connection to fertility. This article examines the impact of obesity, cigarette smoke, uterine anatomy, body mass index, thyroid dysfunction, immune factors, the hereditary and acquired thrombophilias, and embryo transfer technique on recurrent IVF failure.

A prospective study assessing anxiety, depression and maternal-fetal attachment in women using PGD

PGD has been described in previous cross-sectional and retrospective studies as a stressful experience. No prospective studies of the psychological impact of PGD are currently available. Using a prospective study design, validated measures exploring anxiety and depression were used to assess women using PGD prior to treatment, following embryo transfer, following the pregnancy test result and at 24 weeks of pregnancy. Maternal-fetal attachment was also assessed during pregnancy. The prospective design revealed the cyclical pathway through PGD for many women, often comprising repeated cycles of ovarian stimulations and IVF and frozen embryo transfers. As predicted, there were significant fluctuations in women's anxiety scores, with increases observed following embryo transfer and pregnancy testing. Women's anxiety scores returned to baseline levels during pregnancy as assessed at 24 weeks gestation. Depression scores did not significantly fluctuate during PGD. Maternal-fetal attachment scores in this sample did not differ from the normative Australian data. For some women, the PGD pathway is convoluted and requires multiple IVF cycles and embryo transfers to achieve pregnancy. A subset of women experience significant emotional burden during PGD treatment, and it is these women who require closer attention and support. In this sample, emotional adjustment in pregnancy following PGD appears to be sound.

High rate of biological loss in assisted reproduction: it is in the seed, not in the soil.

The vast majority of embryos produced in vitro and transferred fail to develop into an infant, supporting the concept that only a small fraction of embryos is destined to become a live birth. One of the main reasons for such a low embryo-to-infant ratio is the remarkably high number of embryos that after preimplantation genetic diagnosis are found to have a chromosome imbalance. This study reports the overall biological wastage from oocytes inseminated to ongoing pregnancies in patients undergoing preimplantation genetic screening (PGS) because of advanced age, recurrent pregnancy losses or multiple failed IVF cycles. The analysis of biological wastage per oocyte showed that in this cohort of patients, of 333 eggs inseminated, 183 (55.0%) provided embryos for biopsy, and of these, only 33 (18.0% per embryo and 9.9% per oocyte) were normal. A total of 26 embryos were suitable for transfer (14% per embryo and 7.8% per oocyte), but only five (1.5%) implanted and three (1.0%) resulted in live births. In conclusion, there is enormous biological wastage during assisted reproduction, and the data obtained from both embryos and oocytes of patients undergoing PGS support the concept that many embryos and eggs obtained during IVF are intrinsically abnormal and thus fail to implant.