Natural Cycle IVF Research Articles

P–663 The ratio of serum progesterone (P4) to the number of follicles (P4/Follicle) is a more objective parameter for euploidy rate as compared to systemic progesterone

Abstract Study question Does the ratio of serum progesterone (P4) to the number of follicles (P4/Follicle) on the day of final oocyte maturation affect the ploidy status of the embryos? Summary answer A high P4/Follicle ratio negatively affects the euploid rate of the embryos. What is known already During ovarian stimulation, exogenous gonadotropins are administered to achieve multifollicular growth. Intense gonadotropin stimulation towards the end of the follicular phase seems to cause a premature progesterone rise in stimulated IVF cycles. The impact of serum progesterone elevation during the follicular phase has been studied intensively. Though most studies have focused on the effect of progesterone elevation on the endometrial receptivity, little is known about its possible impact on embryo development and ploidy status. The only study that investigated the effect of progesterone on the embryo ploidy status, was unable to show any significant impact. Study design, size, duration This retrospective study was performed at ART Fertility Clinics Abu Dhabi, UAE and Muscat, Oman. All stimulation cycles (n = 975) were performed between January 2015 to December 2019 with patients aged between 18–45, Body mass index (BMI) of 18–35, stimulated either with rFSH or hMG. All embryos underwent ICSI and Preimplantation Genetic Testing for Aneuploidies (PGT-A),Patients with surgical sperm extraction, warmed oocytes or natural cycle IVF were excluded. Participants/materials, setting, methods Serum P4 was measured on the last ultrasound prior triggering for final oocyte maturation. The P4/Follicle ratio was calculated as the ratio of P4 on trigger day to the number of follicles > 10 mm on the last ultrasound. Serum P4 and P4/Follicle ratio were then analyzed using linear and univariate regression model to find potential correlation with the number of oocytes retrieved, number of mature oocytes, embryo quality (day 3 and 5), and euploid rate. Main results and the role of chance A total of 975 cycles were analyzed, with a mean age of 33.88±0.05 years, a mean BMI of 26.7±0.035 kg/m2. The mean number of oocytes collected was 12.53±0.058. Mean serum P4 on trigger day was 0.83±0.005 ng/ml and higher serum P4 values were observed as the number of oocytes retrieved and the number of mature oocytes increased (β = 0.026, p < 0.0001 and β = 0.028, p < 0.001, respectively). On the other hand, the mean P4/Follicle ratio was 0.056±0.00041 ng/ml and, unlike serum P4, the P4/Follicle ratio showed a negative correlation with the number of oocytes retrieved as well as with the number of mature oocytes (β=–0.001, p < 0.001 and β=–0.001, p < 0.001, respectively). While day 3 embryos were not affected by serum P4 or P4/Follicle ratio, the blastocyst quality was negatively affected by both increasing serum P4 levels and the P4/Follicle ratio (β=–0.012 p < 0.05, β=–0.002, p < 0.001, respectively). Euploid rates were positively correlated in cycles with increased serum P4 β = 0.18, p < 0.001), while negatively correlated in cycles with a high P4/Follicle ratio (β=–0.015, p < 0.001). After adjusting for potential confounders, only P4/Follicle remained as a significant negative factor for euploid rate (β=–0.004, p < 0.001, 95% CI: –0.007- –0.001, p < 0.001), which was not observed for serum P4 (p = 0.46). Limitations, reasons for caution This is an observational study based on retrospective data; an improved extrapolation of the results might be obtained by performing a prospective study. Wider implications of the findings: The findings of this study should encourage clinicians to optimize the ovarian stimulation protocols not only based on serum P4, but also considering the P4/Follicle ratio. Trial registration number Not applicable

P–707 Does the dose or type of gonadotropin affect the reproductive outcomes of poor responders undergoing modified natural cycle IVF (MNC-IVF)?

Abstract Study question Does the dose or type of gonadotropin affect the reproductive outcomes of poor responders undergoing MNC-IVF? Summary answer Neither the type nor the dose of gonadotropins affects the reproductive outcomes of poor responders undergoing MNC-IVF. What is known already Poor ovarian response (POR) to ovarian stimulation remains a major therapeutic challenge in routine IVF practice, because of the association with low live birth rates and high cancellation rates. Although high doses of gonadotropins are traditionally used to stimulate the ovaries in women with predicted POR, MNC-IVF has been proposed as a mild-approach alternative in this population. Typically, the MNC protocol includes GnRH-antagonists to avoid premature ovulation and gonadotropin add-back stimulation at the late follicular phase. However, evidence is sparse, and there is no consensus regarding a specific dose or type of gonadotropins in this mild stimulation protocol. Study design, size, duration This is a retrospective cohort study including patients attending a tertiary referral University Hospital from 1st January 2017 until 1st March 2020. Participants/materials, setting, methods All women who underwent MNC-IVF in our center were included. Gonadotropins [recombinant FSH (rFSH), urinary FSH (uFSH) or highly purified human menopausal gonadotrophin (hp-hMG)] were started when a follicle with a mean diameter of 12–14 mm was observed on ultrasound scan, followed by GnRH antagonists (0.25mg/day) from the next day onwards. Mature oocytes were inseminated using ICSI. Main results and the role of chance In total, 484 patients undergoing 1398 cycles were included. Mean (SD) age and serum AMH were 38.2 (3.7) years and 0.46 (0.78) ng/ml, respectively. The daily dose of gonadotropins was either <75 IU/d [11/1398 (0.8%)] or 75 to < 100 IU/d [1303/1398 (93.2%)] or ≥ 100 IU/d [84/1398 (6%)]. Patients were stimulated with: rFSH [251/1398 (18%)], uFSH [45/1398 (3.2%)] or hp-hMG [1102/1398 (78.8%)]. Biochemical and clinical pregnancy rates were 142/1398 (10.1%) and 119/1398 (8.5%). Live birth was achieved in 80/1398 (5.7%) of cycles. Live birth rates (LBR) were similar between the different type and doses of gonadotropins (p-value 0.3 and 0.51, respectively). The GEE multivariate regression analysis adjusting for relevant confounders (age, BMI, number of MII oocytes) showed that the type of treatment strategy (rFSH/uFSH/hp-hMG) and the dose of gonadotropins were not significantly associated with LBR (coefficient 0.01 and –0.02, p value 0.09 and 0.3, respectively). Limitations, reasons for caution The main limitation is the retrospective design of our study, with an inherent risk of bias. Wider implications of the findings: This is the first and largest study evaluating MNC-IVF protocol modalities. Our data demonstrate that any type of gonadotropin can be used and there is no benefit from daily doses beyond 75IU. Trial registration number N/A

P–232 A trophectoderm morphology can predict a live birth rate and gender imbalance

Abstract Study question Which morphology parameter is the most predictable in the live birth rate and can affect the sex ratio? Summary answer The trophectoderm grade (TE) can predict the live birth rate and skewed to male gender after single vitrified-warmed blastocyst transfers (SVBT). What is known already The Gardner and Schoolcraft grading system of blastocyst evaluation with morphology is the major predictor of the clinical outcome in ART. Inner cell mass (ICM) and trophectoderm (TE) morphology are strongly correlated between clinical pregnancy, live birth, and miscarriage. A greater degree of expansion of the transferred blastocysts showed a higher implantation rate. Therefore, it is essential to clarify which parameter is more predictable in clinical outcome during elective SVBT. However, SVBT has some potential limitations, including adverse effects such as a male-biased imbalance in the sex ratio. Study design, size, duration The retrospective analysis used 1138 cycles of SVBT in the Ojinmed IVF center, Mongolia, between May 2015 to January 2019. The morphology grade and blastocyst inner diameter compared with clinical pregnancy rate (CPR), live birth rate (LBR), and miscarriage. The sex ratio was estimated for all patients, excluding those who underwent PGT-A, donor oocytes, and monozygotic twins. Blastocyst quality was evaluated with Gardner and Schoolcraft grading system and measured inner diameter of the blastocyst. Participants/materials, setting, methods All patients underwent a clomiphene-based minimal ovarian stimulation protocol or drug-free natural cycle IVF treatment. On day 5 to 6, blastocysts that reached an inner diameter >160μm were immediately vitrified. Blastocyst morphology evaluated by ICM and TE grade. The CPR (with a confirmed gestational sac at 6–7 weeks of pregnancy) and the LBR (live birth at 22 weeks of pregnancy over) were estimated per embryo transfer procedure, followed by miscarriage rate. Main results and the role of chance The CPR was 44.69%, 38.97%, and 25.91% for A, B, C grades of ICM, respectively. And the LBR was 39.82%, 34.62%, and 19.1% for A, B, C grades of ICM, respectively. TE was strongly related to CPR (aOR=2.47, 95% CI 1.71–3.58, p < 0.01) and LBR (aOR=1.77, 95% CI 1.06–2.96, p = 0.028) in univariate and multivariable logistic regression analysis (A grade vs C grade). Also, CPR and LBR were increased with blastocyst inner diameter, proportionally. The A and B grade ICM blastocysts showed 2.8 - 2.9 times less miscarriage rate than the C grade of ICM in the univariate logistic regression analysis. The result of multivariable logistic regression analysis showed B grade of ICM had 2.3 times less than C grade of ICM (aOR 2.36, CI 95% 1.20–4.61, p = 0.012) and TE, patient age and blastocyst inner diameter were not significantly associated with miscarriage rate. The gender ratio was 56.8% (204/359) for male. The result of multivariable logistic regression analysis showed that A grade TE had a 2.3 times higher probability of male than C grade (aOR 2.31, CI 95% 1.22–4.37, p = 0.01). Neither fertilization method, ICM, expiation grade, nor fertility case was significantly associated with the sex ratio. Limitations, reasons for caution The result of the current retrospective study is limited to data from a single IVF center. Wider implications of the findings: Our study suggests that TE grade is the most predictable and ICM grade was associated with miscarriage. The high grade such as A-grade TE blastocyst transfer has more live birth rate, whereas it can affects at sex ratio in favor of male embryos after SVBT. Trial registration number Not applicable

Retrospective outcome in women aged 45 years and older undergoing natural cycle IVF treatment

Research questionIs natural cycle IVF treatment beneficial to middle-aged women with poor ovarian response? DesignRetrospective investigation of outcomes in women aged 45 years and older, who underwent natural cycle IVF treatment between 2009 and 2018 in a single assisted reproduction clinic with the aim of reporting several successful outcomes. ResultsIn total, 2408 IVF retrievals in women aged 45 years and older were included in this study. Mean serum FSH level on day 3 was 21.4 ± 12.5 (range: 0.3–93.7) IU/ml. One fresh cleavage-stage embryo was transferred in 37.4% (900/2408) of the initiated cycles. The overall clinical pregnancy rate and live birth rate per fresh embryo transfer were 2.8% (25/900) and 0.8% (7/900), respectively. Natural cycle IVF treatment led to seven successful deliveries during the period. All seven women who successfully delivered were poor ovarian responders who met the diagnostic Bologna criteria and, among them, three had elevated serum FSH levels on day 3 (range: 39.0–47.1 mIU/ml). All seven had full-term delivery, and no congenital abnormalities were observed in their infants. No significant difference was found in serum FSH level on day 3 between those with and without positive beta-HCG test results. ConclusionsThese findings suggest that natural cycle IVF treatment could be an option for older poor responders in countries that do not permit egg donation. Careful counselling is required, however, because of the low probability of live births after IVF in middle-aged women.

The endocrine milieu in naturally matured follicles is different in women with high serum anti-Müllerian hormone concentrations

Research questionIs the endocrine milieu different in women with low serum anti-Müllerian hormone (AMH) concentration compared with women with high concentration? DesignCohort study of 84 women (four groups) classified according to AMH concentration and age undergoing natural cycle IVF treatment. Concentrations of LH, oestradiol, testosterone, androstenedione and AMH were determined in follicular fluid (FF), associations analysed and clinical outcome parameters evaluated. ResultsA positive correlation between serum and FF AMH concentrations was confirmed. Follicular fluid androstenedione concentration was positively correlated with serum AMH concentration (P < 0.0001, r2 = 0.197). The correlation between FF LH and FF testosterone concentration in all women was not significant (P = 0.050, r2 = 0.046); however, the correlation between FF androstenedione in women with high serum AMH concentration was significant (P = 0.032, r2 = 0.220). Follicular fluid testosterone and androstenedione were positively correlated with FF oestradiol overall and in some individual groups. The high serum AMH concentration group showed the highest FF AMH and androstenedione concentrations and lowest oestradiol–testosterone and oestradiol–androstenedione ratios. High FF AMH concentration was associated with a higher clinical pregnancy rate and high FF oestradiol concentration with a slightly better embryo quality. ConclusionsDifferences in the endocrine milieu in women with high serum AMH concentration seem to be caused by increased follicular LH concentration. In women with high serum AMH concentration, FF androstenedione is increased and ratios of oestradiol–testosterone and oestradiol–androstenedione are decreased, suggesting a disturbed endocrine milieu caused by reduced metabolization of FF androgens into oestrogens. In natural cycles, FF AMH concentrations are positively associated with higher clinical pregnancy rates and oestradiol concentrations with a higher embryo score.

Gonadotropin Stimulation Has Only a Limited Effect on the Concentration of Follicular Fluid Signalling Proteins: An Antibody Array Analysis.

Objective The follicular fluid (FF) plays an essential role in the physiology of the follicle and the oocyte. Gonadotropin stimulation affects the FF steroid hormone and anti-Mullerian hormone (AMH) concentrations, which has been suggested to be the reason for lower oocyte competence in conventional gonadotropin stimulated in vitro fertilisation (cIVF) compared to natural cycle IVF (NC-IVF). To analyse the effect of gonadotropin stimulation on a broad spectrum of signalling proteins, we ran proteomic antibody arrays on FF of women undergoing both treatments NC-IVF and cIVF. Method Twenty women underwent one NC-IVF and one cIVF treatment cycle. Follicular fluids of the first aspirated follicle were compared between the two groups using a protein microarray which included antibodies against 224 proteins related to cell signalling and reference proteins. Each of the 40 albumin-stripped, matched-pair samples was labelled in the reverse-dye (Cy3/Cy5) procedure before undergoing array hybridisation. Signal analysis was performed using normalisation algorithms in dedicated software. Five proteins yielding a value of P < 0.05 in the array experiment (Cystatin A, Caspase-3, GAD65/67, ERK-1, and ERK-2) were then submitted to quantitative determination by ELISA in the same follicular fluids. Results Array analysis yielded only a small number of differentially expressed signalling markers by unadjusted P values. Adjustment as a consequence of multiple determinations resulted in the absence of any significant differential marker expression on the array. Five unadjusted differentially expressed proteins were quantified immunometrically with antibodies from different sources. Follicular fluid concentrations of Cystatin A and MAP kinase ERK-1 concentrations were significantly higher in the cIVF than in the NC-IVF follicles, while GAD-2 (GAD65/67) did not differ. The assays for Caspase-3 and MAP kinase ERK-2 did not have the required sensitivities. Conclusion In contrast to FF steroid hormones and AMH, FF concentrations of signalling proteins are not or only marginally altered by gonadotropin stimulation.

Assessing the practice of LuPOR for poor responders: a prospective study evaluating follicular fluid cfDNA levels during natural IVF cycles.

The aim of this study is to provide data on the practice of Luteal Phase Oocyte Retrieval (LuPOR). The authors assess cell-free DNA levels in follicular fluid (ff cfDNA) from poor responders undergoing natural cycles, and comparing it to respective data originating from follicular phase oocyte retrievals. Forty-seven women were eligible for this prospective study. Participants were classified as poor responders based on Bologna criteria while being detected with a second follicular wave. Follicular fluid was collected and prepared for cfDNA extraction. Levels of cfDNA were quantified via Q-PCR employing the ALU115 and ALU247 primers. These primers are associated with apoptotic and necrotic events. Levels of ff cfDNA resulting from follicular phase oocyte retrieval (FoPOR) and LuPOR-performed in a single menstrual cycle were associated with the number and maturation status of yielded oocytes and the number and fertilization status of resulting zygotes. Survival rate following thawing of cryopreserved zygotes, along with the resulting number of cleavage stage and blastocyst stage embryos are provided. Mean levels of ALU115 were significantly lower during FoPOR when compared to LuPOR (0.79 ± 0.72 vs 1.46 ± 1.59ng/μl, p = 0.02). Regarding the FoPOR group, a significant positive correlation of serum estradiol and ALU115 concentration (p = 0.04) was revealed. A significant negative correlation between serum estradiol and cfDNA integrity was observed both during FoPOR (p = 0.03) and LuPOR (p = 0.03). A significant lower number of retrieved (1.09 ± 0.28 vs 1.29 ± 0.58, p = 0.02) and MII oocytes (0.77 ± 0.55 vs 1.08 ± 0.61, p = 0.02) was observed when comparing the FoPOR to LuPOR groups respectively. The integrity of cfDNA was observed to be higher in FoPOR originating embryos that arrested either prior to cleavage (0.28 ± 0.13 vs 0.17± 0.10, p = 0.006) or prior to blastocyst formation (0.28 ± 0.12 vs 0.13± 0.06, p = 0.04). In the case of LuPOR originating embryos, cfDNA integrity was observed to be higher in embryos that arrested only prior to the blastocyst stage (0.27 ± 0.20 vs 0.11± 0.07, p = 0.008). Similarly, cfDNA integrity was observed to be lower in top quality blastocysts originating from FoPOR (0.07± 0.04 vs 0.17 ± 0.05, p = 0.03) and in top quality cleavage stage embryos (0.09± 0.06 vs 0.31 ± 0.22, p = 0.01) and blastocysts (0.06 ± 0.02 vs 0.14 ± 0.06, p = 0.02) originating from LuPOR. Our results indicate that ff originating from LuPOR presents with higher levels of cfDNA. The higher cfDNA levels are attributed to mainly apoptotic events, as the ALU247 levels and DNA integrity did not differ statistically significantly between FoPOR and LuPOR. The absolute mean level of ALU247 corresponding to necrotic events was higher in LuPOR. Regarding embryological data, cfDNA integrity was correlated with both number and quality of cleavage stage embryos in both FoPOR and LuPOR, along with blastocyst stage embryos in LuPOR. Necrotic events were associated with poorer blastocyst formation rate and blastocyst quality in LuPOR. As the comparison between FoPOR and LuPOR results to similar IVF laboratory data, the practice of LuPOR may stand as a promising approach for poor responders, while it merits further investigation.

Impact of embryo quality and endometrial thickness on implantation in natural cycle IVF.

PurposeThe aim of this study is to assess the effect of the endometrial thickness and embryo quality on the implantation potential in natural cycle IVF (NC-IVF).MethodsA retrospective single-center study was performed on 552 single embryo transfers after NC-IVF. The ‘quality' of the embryos was evaluated trough the number and regularity of blastomeres, degree of fragmentation, and nuclear content of cells. Endometrial thickness was measured in millimeters with transvaginal ultrasound on the day of hCG application.ResultsOur findings showed a statistically significant difference in successful implantation until a plateau of 10 mm is reached (p = 0.001). Only one pregnancy was achieved where endometrial thickness was less than 7 mm, and this resulted in an early miscarriage. The predictors of favorable implantation were fragmentation (≤ 10%, p < 0.05) and the number of blastomeres (preferably 8-cell, p < 0.01) on day 3. Embryo quality (R = 0.052) and endometrial thickness (R = 0.18) were closely related to pregnancy rate. The overall implantation rate per embryo transfer was 18.8%.ConclusionsEmbryo quality and endometrial thickness have a significant impact on implantation in NC-IVF. Highest implantation potential has an 8-cell embryo with ≤ 10% fragmentation in the third day following oocyte retrieval. Endometrial thickness of at least 7 mm seems to be the optimal edge of successful pregnancy.

Anti-oxidative function of follicular fluid HDL and outcomes of modified natural cycle-IVF

High density lipoproteins (HDL) are the main cholesterol carriers in follicular fluid (FF), the natural environment of oocyte development. Additionally, HDL have critical biological functions such as anti-oxidative capacity, which have not been studied in reproduction. Therefore, this study aimed to investigate whether the anti-oxidative function of FF-HDL is associated with fertility outcomes. From 253 women undergoing modified natural cycle (MNC)- IVF at a single academic centre FF and plasma were collected (n = 375 cycles). Anti-oxidative function of FF was mainly attributable to HDL (n = 8; 83%). FF-HDL had a higher anti-oxidative function than plasma HDL (n = 19, P < 0.001) coinciding with increased vitamin E and sphingosine 1 phosphate content (P = 0.028 each). Proteomic analysis indicated no significant differences in major anti-oxidative proteins such as paraoxonase 1, apolipoprotein (apo) A-I or apoA-IV between FF-HDL and matched plasma-HDL (n = 5), while apoC-III, apoE and apoC-II were relatively lower in FF-HDL. Finally, FF-HDL anti-oxidative function was related to a decrease in the odds of the oocyte undergoing normal fertilization, an association that persisted after adjustment for confounders (odds ratio 0.97 (0.93–1), P = 0.041). In conclusion, FF-HDL has considerable anti-oxidative properties that might be relevant for embryo quality.

What are the chances of success for couples performing an IVF cycle with only poor quality day-3 embryos cultured to the blastocyst stage?

In recent years, more and more IVF centers have chosen to culture all embryos until the blastocyst stage, in order to increase implantation rates. Therefore, it is important to inform couples of the strategy and to estimate their chances of getting a good quality blastocyst; especially if the entire embryo cohort is of poor quality. The objective of this study was to evaluate the rate of usable blastocysts and the live birth rate, in couples undergoing an IVF/ICSI who obtained only poor quality day-3 (D3) embryos. This retrospective cohort study, carried out between 2012 and 2016, analyzed 59 cycles of IVF/ICSI that resulted in at least one D3 embryo without any high quality embryos. A comparison to a control group comprising 122 cycles with D3 embryos of both good and poor quality was performed. Cycles in which all D3 embryos were of poor quality were included. All embryos were cultured until day 5 or 6 and were either transferred, cryopreserved or discarded. Exclusion criteria were egg donors, patients performing fertility preservation or modified natural cycle IVF. The embryo quality was scored according to the classification of the Istanbul consensus (Alpha / EHSRE 2011). Thus, D3 embryos were considered of poor quality if the blastomeres had a fragmentation rate > 25% (= grade 3 embryos) or if the number of cells was less than 6 (= slow-development embryos). The « usable blastocysts » rate was defined as the ratio of the number of transferred or cryopreserved blastocysts (if Gardner score ≥ 2BB) to the total number of D3 embryos. Blastulation and live birth rates were expressed as a percentage and compared between the groups by the Chi2 test. In a total of 136 poor quality D3 embryos (from 59 patients), the blastulation rate was 23.5% (compared to a mean blastulation rate of 62% in our laboratory), the rate of usable blastocysts was 11.0% and the live birth rate was 26.7% per embryo transfer. The rate of usable blastocysts was significantly lower if they originated from grade 3 embryos compared to slow-development embryos (6.8% vs 24.2%, p = 0.0054). The live birth rates were comparable by origin of blastocysts. Patients were statistically older and had lower anti-Mullerian hormone (AMH) levels than the control group, composed of 270 poor quality D3 embryos. Blastulation rates were statistically lower than in the control group (23.5% vs. 37.4%, p = 0.005). However, the rates of usable blastocysts and rates of live birth did not differ between the two groups. In the control group, the rate of usable blastocysts was also higher for slow-developing embryos compared to grade 3 embryos (16.1% vs 7.7%, p = 0.048). Despite the absence of good quality D3 embryos, a cohort composed entirely of "rejected" embryos can result in a transferable blastocyst and live birth. It appears that the high fragmentation rate of blastomeres is associated with a poorer prognosis than the decreased number of cells on D3. This study could improve the counseling of couples facing this situation.

Evaluation of uterine receptivity after gonadotropin releasing hormone agonist administration as an oocyte maturation trigger: a rodent model

In natural cycle or minimal stimulation cycle IVF, buserelin acetate (buserelin), a gonadotropin-releasing hormone agonist, is often used as a maturation trigger; however, its effect on pregnancy outcomes remains unclear. Therefore, in the present study, we compared uterine receptivity in buserelin-administered mice with that in human chorionic gonadotropin (hCG)-administered mice during the peri-implantation period. Implantation, decidualisation, and term-pregnancy were impaired following hCG, but not buserelin administration. hCG stimulated the synthesis and secretion of progesterone and oestradiol, whereas ovarian steroidogenesis in the buserelin-treated group was comparable with that in the control group. Furthermore, similar to the observation in controls, the buserelin-treated group exhibited activation of progesterone receptor signalling and inhibition of oestrogen receptor signalling in the endometrial epithelium on the day of implantation. However, epithelial progesterone signalling was not detected, and a high expression of genes downstream to oestrogen was observed on day 4 following hCG administration. These results suggest that buserelin administration does not impact uterine receptivity as it did not affect ovarian steroidogenesis and endometrial steroid signalling. Therefore, buserelin is preferred as an oocyte maturation trigger to optimise uterine receptivity during treatments involving timed intercourse, intrauterine insemination, or fresh embryo transfer following in vitro fertilisation.

Сell-free D N A in follicular fluid of women with different parameters of ovarian function

The aim of the study was to evaluate cell-free DNA (cfDNA) in the follicular fluid (FF) of women undergoing IVF treatment and to analyze the relationship between cfDNA levels and the parameters of folliculogenesis and oogenesis as well as the quality of embryos. Materials and methods. The study included 53 women aged 20 to 45 years. In 49 patients, oocytes were obtained by stimulating ovulation with gonadotropins, and 4 patients underwent natural cycle IVF without hormonal stimulation. Measurement of cfDNA was carried out by fluorimetry using QuantiFluor™ Handheld Fluorometers (BioSilica, Russian Federation). Results. The FF of women with ovulation stimulation revealed a higher level of cfDNA as opposed to FF of women in the natural cycle. There were no differences in the cfDNA levels in women with infertility and oocyte donors. Women with infertility lasting for more than 5 years had a higher level of cfDNA. Women with the elevated anti-Mullerian hormone (AMH) levels were characterized by the high FF cfDNA concentration and a large number of follicles. Likewise, correlation analysis showed that FF cfDNA was significantly and positively correlated with the AMH level. The obtained data revealed the participation of cfDNA in different stages of oogenesis. Conclusions. The level of FF cfDNA in women may serve as an additional biomarker of the effectiveness of ovulation induction.

Asthma in 9-year-old children of subfertile couples is not associated with in vitro fertilization procedures

Asthma is a chronic reversible obstructive airway disease, which is common among children and leads to respiratory impairment. Studies showed that asthma is more common among children born after in vitro fertilization (IVF) than among spontaneously conceived children. However, it is unknown which component of the IVF procedure contributes to this putative link. Therefore, the aim of this prospective follow-up study was to differentiate the possible effect of ovarian hyperstimulation from that of the in vitro culture procedure on asthma and rhinitis in 9-year-old children conceived with IVF. The study comprised three groups of singletons: (I) conceived with ovarian hyperstimulation-IVF (COH-IVF, n = 95); (II) conceived with modified natural cycle-IVF (MNC-IVF, n = 48); and (III) naturally conceived to subfertile couples (Sub-NC, n = 68). Parents filled out the validated Dutch version of the asthma questionnaire of the International Study of Asthma and Allergies. Asthma prevalence in the groups did not differ: COH-IVF n = 8 (8%); MNC-IVF n = 0 (0%); and Sub-NC n = 4 (6%). Adjustment for confounders did not alter the results.Conclusion: Neither ovarian hyperstimulation nor the in vitro culture procedure was associated with asthma and rhinitis at 9 years. IVF children had a similar prevalence of asthma compared with children conceived naturally by subfertile couples.Trial registration: ISRCTN76355836What is Known:• An increased risk for asthma has been observed in children born after in vitro fertilization at preschool and school age.• The association between IVF and asthma may be partly explained by parental subfertility.What is New:• IVF children do not have a higher prevalence of asthma than children of subfertile couples conceived naturally.• Ovarian hyperstimulation used in IVF is not associated with asthma in 9-year-old children of subfertile couples.

Modified natural cycle IVF versus conventional stimulation in advanced-age Bologna poor responders.

Do ongoing pregnancy rates (OPR) differ between modified natural cycle IVF (MNC-IVF) and conventional high-dose ovarian stimulation (HDOS) in advanced-age Bologna poor responders? This was a retrospective cohort study including patients with poor ovarian response (POR) attending a tertiary referral university hospital from 1 January 2011 to 1 March 2017. All women who fulfilled the Bologna criteria for POR and aged ≥40 years who underwent their first intracytoplasmic sperm injection (ICSI) cycle in the study centre were included. In total, 476 advanced-age Bologna poor responder patients were included in the study: 189 in the MNC-IVF group and 287 in the HDOS group. OPR per patient were significantly lower in the MNC-IVF group (5/189, 2.6%) compared with the HDOS group (29/287, 10.1%) (P=0.002). However, after adjustment for relevant confounders (number of oocytes and presence of at least one top-quality embryo), the multivariate logistic regression analysis showed that the type of treatment strategy (HDOS versus MNC-IVF) was not significantly associated with OPR (odds ratio 2.56, 95% confidence interval 0.9-7.6). In advanced-age Bologna poor responders, MNC-IVF, which is a more patient-friendly approach, could be a reasonable alternative in this difficult-to-treat group of women.

Only women's age and the duration of infertility are the prognostic factors for the success rate of natural cycle IVF.

It is controversial who should be recommended to undergo natural cycle IVF (NC-IVF). Therefore, objective prognostic criteria which are already known at the time of counselling were defined. A retrospective observational study was performed with 201 couples (age 34.7 ± 4.1) undergoing 311 NC-IVF treatments with 201 transfers, corresponding to a transfer rate of 65.3%. The first cycle resulting in a transfer of one embryo was further analysed. Clinical pregnancy and live birth rates were analysed. Pregnancy rate and live birth rates per first cycle were 21.9% and 13.2%, respectively. Groupwise comparison revealed the following clinical pregnancy/live birth rates per transfer cycle: duration of infertility 1-2years 34.3/25.7%, 3-4years 21.8/14.9% and > 4years 9.1/4.5%. Women's age < 34years 26.3/22.4%, 34-37years 25.7/18.9% and 38-42years 15.7/3.9%. Linear regression analysis showed that pregnancy and live birth rate correlated negatively with the duration of infertility and that live birth rate but not pregnancy rate correlated negatively with increasing female age. In contrast, AMH and infertility factors did not correlate with the success rate. Statistically significant correlations remained if a multivariate logistic regression analysis was performed, supporting further that the duration of infertility (OR 0.61, 95% CI 0.42-0.86) (P = 0.006) and female age (OR 0.87, 95% CI 0.78-0.95) (P = 0.008) are the predictors for live birth rates in NC-IVF transfer cycles. Based on the success rates, NC-IVF can especially be recommended for women with short duration of infertility and young age, whereas older women and those with long duration of infertility are not the best candidates for this technique.

Comparison of follicular fluid concentrations of anti-mullerian hormone, bone morphogenetic protein 15 and transforming growth factor ß1 between modified natural and stimulated in-vitro fertilization cycles.

Analysis of biochemical characteristics of follicular fluid (FF) can serve as a non-invasive method for the prediction of oocyte and embryo quality. The aim of the present study was to compare concentrations of anti-mullerian hormone, bone morphogenetic protein 15 and transforming growth factor ß1 in FF of follicles giving rise to high quality embryos between natural and stimulated IVF cycles. Concentration of BMP-15 was significantly higher and concentration of TGF-ß1 was significantly lower in stimulated IVF cycles. Concentrations of markers of oocyte and embryo quality were significantly different between natural and stimulated IVF cycles. This could be the cause for lower pregnancy rates in natural IVF cycles.

Thin Endometrium Is Also Associated With Lower Clinical Pregnancy Rate in Unstimulated Menstrual Cycles: A Study Based on Natural Cycle IVF.

Introduction: Does the endometrial thickness (EMT) at the time of follicle aspiration correlate with the pregnancy rate in unstimulated menstrual cycles?Materials and Methods: This is a retrospective, observational single center study.105 women with regular menstrual cycles undergoing their first NC-IVF cycle with an embryo transfer were analyzed. Clinical pregnancy and live birth rates were calculated and data were adjusted for women's age, cycle day of follicle aspiration and body mass index (BMI).Results: Age of participants was 35.0 y [32.0; 37.0]. Follicle aspiration was performed on day 14.0 [12.0; 15.0] of the cycle. Total clinical pregnancy rate was 24.8% and live birth rate 15.2% per transfer. Pregnancy rate in women with endometrial thickness ≤7 mm (n = 27) was 7.4 and 30.8% in women >7 mm (n = 78) (OR 5.56, 1.22–25.36) (P = 0.03). Live birth rates were not significantly different. Quadratic regression analysis revealed lower pregnancy rates in women with thin (around <8 mm) as well as with thick (around >11 mm) endometria. P-value after crude quadratic analysis was 0.028 and after adjustment for age, day of aspiration and BMI was 0.039. Significance was not reached for live birth rates.Conclusion: Thin endometrium should also be considered as an independent negative prognostic factor for achieving pregnancy in women without ovarian stimulation.

Endogenous progesterone levels could predict reproductive outcome in frozen embryo replacement cycles supplemented with synthetic progestogens: A retrospective cohort study.

PurposeA retrospective, cohort study was conducted between 2009 and 2017 in a private infertility center to determine the predictive value of endogenous estrogen (E2) and progesterone (P4) levels in hormone‐replacement frozen embryo replacement (FER) treatment cycles.MethodsA total of 120 consecutive, infertile patients who became pregnant after FER cycles were analyzed (age: 37.4 ± 4.4 years). Electively vitrified blastocysts were created during natural cycle IVF or mild ovarian stimulation treatments and subsequently transferred through delayed vitrified‐thawed blastocyst transfer cycles supplemented with estrogens and a combination of synthetic progestogens. Serum E2 and progesterone P4 levels were intensively monitored every five days (from the day after embryo transfer until 9w1d of pregnancy) and compared among patients with a subsequent live birth (n = 76) or first‐trimester pregnancy loss (n = 44).ResultsEndogenous placental activity started as early as 5‐6th pregnancy week differing significantly according to pregnancy outcome. For P4, the exponential rise from 6w2d onwards allowed distinguishing between failing and successful conceptions. For P4, lower quartiles of the live birth group did not intersect with upper quartiles of the miscarriage group.ConclusionsInnovative FER protocols incorporating synthetic progestogens allow the correct measurement of endogenous placental activity and could help to monitor early first‐trimester ART pregnancies.

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.

Comparison of pregnancy outcomes following fresh and electively frozen single blastocyst transfer in natural cycle and clomiphene-stimulated IVF cycles.

STUDY QUESTIONAre there any differences in live birth rates (LBR) following fresh blastocyst transfer in natural or clomiphene-stimulated cycles, or after elective blastocyst freezing in clomiphene-stimulated cycles followed by thawing and transfer at different time-points?SUMMARY ANSWERClomiphene citrate (CC) administration adversely affected the LBR after single fresh blastocyst transfer (SBT) in CC cycles compared with that in natural cycles, while this adverse effect of CC is not present when a single vitrified-warmed blastocyst transfer (SVBT) is performed in subsequent natural ovulatory cycles, regardless of the duration between CC administration and the day of SVBT.WHAT IS KNOWN ALREADYCC affects uterine receptivity associated with a thinning of the uterine endometrium through an antioestrogenic effect. However, the duration that this adverse effect of CC on uterine endometrium persists after initial use is still unknown.STUDY DESIGN, SIZE, DURATIONA retrospective cohort study of 157 natural cycle IVFs followed by SBT and 1496 minimal ovarian stimulation with CC IVF cycles followed by SBT (n = 24) or SVBT (n = 1472) from January 2010 to December 2014 was conducted. SVBT cycles were classified into two groups according to the period between the last day of CC administration and the day of SVBT (A: ≤60 d and B: ≥61 d). All groups were then compared based on pregnancy outcomes (natural-SBT group: n = 157, CC-SBT group: n = 24, SVBT-A: n = 1143, SVBT-B: n = 329).PARTICIPANTS/MATERIALS, SETTING, METHODSWomen were aged 30–39 years at oocyte retrieval. In SVBT cycles, blastocysts were vitrified and warmed using a Cryotop safety kit. SVBT was performed in subsequent natural ovulatory cycles. The main outcomes were LBR and neonatal outcome, and both were compared among the groups.MAIN RESULTS AND THE ROLE OF CHANCEThe LBR in the CC-SBT group (29.2%, 7/24) was significantly lower compared with the natural-SBT (56.1%, 88/157) (P = 0.01) and SVBT-A (50.0%, 572/1143) (P = 0.04), but not SVBT-B (47.4%, 156/329), groups. Furthermore, multivariate logistic regression analysis revealed that the LBR was comparable among the natural-SBT and SVBT groups, but was significantly lower in the CC-SBT group (adjusted odds ratio: 0.324, 95% CI: 0.119–0.800, P = 0.01). No significant differences among all groups were observed for gestational age (P = 0.19), birthweight (P = 0.41) and incidence of malformation (P = 0.53).LIMITATIONS, REASONS FOR CAUTIONIn this study we analysed a biased sample, based on clinical judgement regarding endometrial thickness, and the study was limited by its retrospective nature. The low statistical power caused by the group size disparity was also a limitation, especially in the CC-SBT group. Although the outcome showing inferiority of CC-SBT compared to natural-SBT is consistent with general findings in the literature, further large-scale clinical studies, ideally RCTs, are necessary to validate our results and clarify the prolonged effect of CC in SVBT cycles on pregnancy and neonatal outcomes.WIDER IMPLICATIONS OF THE FINDINGSOur observation suggests that CC administered in minimal ovarian stimulation cycles affects adversely the pregnancy outcomes when SBT is performed. Therefore, for a CC-based minimal stimulation IVF cycle, we suggest that frozen embryo transfer should be performed in a subsequent natural ovulatory cycle to avoid the possibility of implantation failure associated with CC administration.STUDY FUNDING/COMPETING INTERESTSThe authors have no conflicts of interest to declare. No external funding was either sought or obtained.