Total Number Of Oocytes Research Articles

O-183 Forecast of Total and Mature Oocyte Number for Three Different Trigger Days using Machine Learning Prediction Models

Abstract Study question Can an Artificial Intelligence (AI) algorithm accurately predict the number of total\mature (MII) oocytes retrieved during an antagonist protocol cycle for different trigger days. Summary answer AI algorithm can accurately predict the number of total and MII oocytes for three different trigger days in an antagonist protocol. What is known already Two recent studies used machine learning prediction models for determining the number of MII oocytes retrieved during ovarian stimulation. These studies predicted MII with mean absolute error (MAE) 2.87-3.11 and R2 0.62-0.64. However, currently no studies show results for predicting total and MII oocytes two days in advance. Study design, size, duration The data used for developing this algorithm consists of 9,622 antagonist protocol cycles performed in a large center serving over 50 physicians, between August 2017 and November 2022. This dataset contains a subset of 5,517 cycles with information about the maturity of each retrieved oocyte representing ICSI cycles and egg freezing (MII dataset). Participants/materials, setting, methods Two sets of prediction models were developed using XGBoost, to estimate the number of total and MII oocytes, each with three individual predictors for different possible trigger days: today, tomorrow, in two days. Parameters used include estradiol and LH levels, follicles’ size, stimulation days, gonadotropin dosage, and patients’ characteristics. Accuracy of the model was evaluated by comparing the predictions to the actual values on 20% of the data that was reserved as a test set. Main results and the role of chance The accuracy of the models for the total number of oocytes evaluated using the entire test set, while the models for the number of MII oocytes evaluated using the MII dataset test. The performance of the prediction models for the number of oocytes: (1) trigger today, R2=0.72, MAE=2.59 (2) trigger tomorrow, R2=0.66, MAE=2.95 (3) trigger in two days, R2=0.64, MAE=3.12. Of the prediction models for the number of MII oocytes: (1) trigger today, R2=0.68, MAE=2.24 (2) trigger tomorrow, R2=0.62, MAE=2.53 (3) trigger in two days, R2=0.59, MAE=2.54. Further evaluation was done on a refined subset, excluding cycles with a very large difference between the number of follicles in the last ultrasound and the number of oocytes retrieved (∼10%). The performance of the prediction models for the number of oocytes: (1) trigger today, R2=0.81, MAE=2.14 (2) trigger tomorrow, R2=0.73, MAE=2.42 (3) trigger in two days, R2=0.69, MAE=2.77. Of the prediction models for the number of MII oocytes: (1) trigger today, R2=0.74, MAE=2.03 (2) trigger tomorrow, R2=0.66, MAE=2.25 (3) trigger in two days, R2=0.62, MAE=2.38. Limitations, reasons for caution To ensure accurate predictions, it is important to only provide predictions on days when a trigger can be performed. Thus, an outlier detection mechanism is required to identify predictable days. This requirement is a limitation when using the prediction models for the number of total or MII oocytes in real-time. Wider implications of the findings Estimating the number of oocytes retrieved for different trigger days may assist in selecting the optimal trigger day and potentially improving outcomes. Additionally, if the estimated number of oocytes retrieved for different trigger days are similar, it may provide more flexibility in choosing the trigger day. Trial registration number HMC-0011-22

P-227 ICSI outcomes after using in-situ microfluidics of fluidic walls versus DGC: a prospective non-inferiority comparative pilot study in sibling oocytes

Abstract Study question Does the novel strategy in-situ microfluidics (isM) yield comparable ICSI outcomes to the control sperm selection methodology density gradient centrifugation (DGC)? Summary answer ICSI outcomes show that handmade in-situ microfluidics of fluidic walls are as effective as DGC to achieve fertilization and usable day 5 blastocyst formation rate. What is known already Microfluidics technologies are proving their capability to select suitable sperm for ICSI. Increasingly, publications show novel and ingenious microfluidics strategies aimed to integrate sperm biomimicry during in vitro sperm selection while simplifying the IVF-workflow. We recently designed a microfluidics system which allows selecting sperm for ICSI in the same ICSI-dish, only using microfluidics and disregarding centrifugation, washing and plasticware. A previous proof-of-concept study showed that this methodology was efficient to select suitable sperm for ICSI as it could separate at least 20 progressive spermatozoa in less than 15 minutes in a clean microdroplet free of any remaining seminal plasma. Study design, size, duration The present pilot study included a total of 280 fresh MII-oocytes allocated in a 1:1 ratio to the study (isM-ICSI) and control (DGC-ICSI) groups. The statistical power was established at 80% at a CI 95%. For comparison we relied in the KPIs: ICSI normal fertilization rate (INFR) and Day 5 usable blastocyst rate (D5UBR). The non-inferiority margin (Δ) was established using 2-sigma warning limit and our historical control mean values (ΔINFR = 7% and ΔD5UBR = 10%). Participants/materials, setting, methods An informed consent was signed by all participants. The comparative study included 29 consecutive ICSI cases performed in fresh oocytes from women under 40 years old and with an oocyte yield ≥6 MII. All semen samples had ≥1 × 106/ml progressive spermatozoa and were split into three aliquots: 1-seminogram (100 µl), 2-isM (10 µl), 3-DGC (surplus). Embryos were cultured in bench-top Time-lapse incubators, using GTL-media under 6,4% CO2 and 5% O2 conditions up to blastocyst stage. Main results and the role of chance Sperm characteristics showed the following total mean values for total concentration (42,83 ± 31,1 × 106/ml), total motility (51,28 ± 14,16 %) and progressive sperm concentration (17 ± 12 × 106/ml). The mean number of MII per patient was 9,66. From the total number of oocytes (n = 280), 139 were allocated to isM (study group) and 141 to DGC (control group) groups. INFR was 72,0 % vs 76,6 %, respectively. Non-significant differences were observed (p = 0,54). We observed that the mean total number of usable blastocysts (day 5/6) per patient was 1,83 (53/29) in isM vs 1,66 (48/29) in DGC. Moreover, D5UBR was 53,0% vs 44,4 % (p = 0,26) with a difference between the study and the control of within the non-inferiority margin. We observed a lower rate of arrested embryos (up to day 6) in the study group (19,0% vs 30,0%), although results were not statistically significant (p = 0,08). Limitations, reasons for caution This pilot study includes a limited number of oocytes. The present isM protocol depends on a free-hand preparation. Although the use of templates and the training reduces inter and intra-operator variability, a ready-to-use surface would benefit the operability. Further investigation is required to evaluate clinical pregnancy and live birth outcomes. Wider implications of the findings Sperm DNA fragmentation is cited among the causes of embryo arrest. As the use of isM resulted in a lower proportion of arrested embryos, exploring its capacity to select non-fragmented sperm warrants further interest. The isM protocol streamlines sperm selection for ICSI, reduces costs and risks along the procedure. Trial registration number na

O-130 Initiation of ovarian stimulation in the late follicular phase, a randomized controlled trial

Abstract Study question Does late follicular phase stimulation yield similar outcomes compared with conventional early follicular phase stimulation in a GnRH antagonist protocol in oocyte donors? Summary answer Late follicular phase stimulation is not inferior in terms of number of oocytes compared to early follicular phase stimulation in a GnRH antagonist protocol. What is known already In patients undergoing fertility preservation for medical reasons, late follicular phase stimulation has been effectively used, resulting in similar numbers of total and mature oocytes obtained, oocyte maturation rate, mature oocyte yield, and fertilization rates compared to conventional early follicular phase ovarian stimulation. Because of LH suppression by endogenous progesterone in the luteal phase, there is less need for the use of a GnRH antagonist. Study design, size, duration This is an open label, phase 3, non-inferiority, randomized controlled trial using a two-arm design with 1:1 allocation ratio. The study included 71 oocyte donors between 18 and 36 years, with a regular menstrual cycle length and BMI 19-35 kg/m2, who underwent ovarian stimulation between November 2018 and May 2022. Patients were allocated to either early follicular start (Group A, n = 36), or to late follicular start (Group B, n = 35). Participants/materials, setting, methods In Group A, patients followed a fixed GnRH antagonist protocol with r-FSH 225IU daily. In Group B, r-FSH 225IU daily was initiated when a dominant follicle and late follicular hormonal values were observed, a GnRH antagonist was added if serum LH-levels were >10IU/L. The primary outcome was number of cumulus-oocyte-complexes (COCs). Secondary endpoints included number of mature oocytes, consumption of gonadotropins, duration of ovarian stimulation, days of GnRH antagonist used, and cost of the stimulation. Main results and the role of chance Using an intention-to-treat analysis, the total number of oocytes did not differ between Group A and Group B (17.7±10.0 vs 17.2±9.1, p = 0.82, difference 0.49 ,95% CI (-4.04 to 5.03)). In the per protocol analysis, after excluding 4 patients, there was no difference between Group A and Group B (18.2±9.7 vs 18.8±7.8, p = 0.62, difference -0.6, 95% CI (-4.9 to 3.7)).The number of mature oocytes did not differ between Group A and Group B (14.1±8.1 vs 12.7±8.5, p = 0.48). In none of the treatment arms OHSS was observed. The duration of stimulation was shorter in Group A than in Group B (10.0±1.6 vs 10.9±1.5 days, p = 0.01). The total amount of r-FSH used was lower in group A than in Group B (2240.7±313.9 IU vs 2453.9±330.1 IU p = 0.008). A GnRH antagonist was used for approximately 6 days in Group A, while in group B, only in one patient a GnRH antagonist was prescribed for 4 days (6.0±1.4 days vs 0.13±0.7 days p < 0.001). There was a significant difference in total medication cost per cycle between both protocols (1147.9±182.8 € in Group A, vs 979.9±129.0 € in group B, p < 0.001), i.e. a cost reduction of 15% for Group B as compared with Group A. Limitations, reasons for caution A limitation of the study is the lack of embryology data. Because of adaptations in the oocyte donation program in our center over the years, this study contains a mix of fresh and frozen donation cycles, leading to a very heterogenous group, making correct interpretation of the embryology data difficult. Wider implications of the findings Late follicular phase stimulation is as efficient as early follicular phase stimulation in terms of number of oocytes. It is patient-friendly, with reduced cost and reduced number of injections. Trial registration number NCT03767218

O-293 An Artificial Intelligence Based Approach for Selecting the Optimal Day for Triggering in Antagonist Cycles

Abstract Study question Can a machine learning (ML) algorithm suggest an optimal trigger day for maximizing the number of mature (MII) oocytes retrieved during an antagonist protocol cycle? Summary answer Using ML algorithm for trigger day selection may increase the mean number of MII oocytes and usable embryos by 3.6 and 1.1 per cycle respectively. What is known already ML has been increasingly used in the field of reproductive medicine, mainly in lab related technologies such as embryo selection. Only a few studies, aimed at improving clinical decision making, were published. A recent study used ML to optimize trigger day selection based on a retrospective analysis, showing an increase of 2.3 MII oocytes and 1.0 usable embryo. Study design, size, duration A retrospective cohort study including data of 9,622 antagonist protocol cycles performed between August 2017 to November 2022. The evaluation of the ML algorithm was conducted using a test dataset including the following quality groups: 1. “Freeze all- oocytes” cycles – a unique population of patients mostly for social fertility preservation. 2. “ICSI only” cycles – for maturation rate evaluation 3. “Fertilize all” cycles including IVF and ICSI, for evaluation of the number of embryos. Participants/materials, setting, methods The ML algorithm suggested optimal trigger days for maximizing the number of MII oocytes retrieved by considering the MII prediction, prediction errors and outlier detection results. The model suggested one, two, or three days as trigger options, depending on the difference in potential outcomes. It recommended the days that have a 10% higher prediction of MII oocytes with a confidence level of over 50% compared to less optimal options if they exist. Main results and the role of chance To evaluate the performance of the management algorithm, it was applied to cycles in the test sets. For each cycle, the algorithm provided a suggestion for trigger days, and this was compared to the actual trigger day chosen by the physician. When the day chosen by the physician was one of the algorithm’s suggestions, the result was labeled as “correct”, otherwise it was labeled as “incorrect”. Comparing the “correct” and “incorrect” groups, using the trigger management algorithm resulted in a higher number of total and MII oocytes retrieved, 2PN and usable embryos. Specifically, when using the algorithm in the “Freeze All” test set, an average increase of 4.8 oocytes and 3.4 MII oocytes retrieved in the “correct” group (consisting 36.2% of the quality group subset) compared to the “incorrect group” (63.8%). In the “ICSI-only” test set, the algorithm resulted in an average increase of 4.5 oocytes, 3.8 MII oocytes, 2.4 2PN and 1.1 usable embryos in the “correct” group (26.8%) compared to the “incorrect group” (73.2%). Lastly, in the “Fertilize all” test set, the algorithm resulted in an average increase of 3.6 oocytes, 2.1 2PN, and 0.9 usable embryos in the “correct” group (25.1%) compared to the “incorrect group” (74.9%). Limitations, reasons for caution The trigger management algorithms' decision-making is based solely on the predicted number of MII oocytes to be retrieved. Moreover, it was developed and applied exclusively for antagonist cycles. Wider implications of the findings The trigger management algorithm may improve oocyte yield and IVF outcomes in antagonist cycles. Moreover, provision of two or three trigger options allows for more flexibility when choosing the trigger day and enables taking into account other factors without negatively affecting the outcome. Trial registration number NA

P-772 Three-dimensional folliculometry (SonoAVC) provides a better estimation of total and mature oocyte yields compared to conventional two-dimensional assessment in oocyte donors: a prospective, cohort study

Abstract Study question Does three-dimensional folliculometry (using SonoAVC) provide a better estimate of the number of retrieved and mature oocytes in egg donors compared to conventional two-dimensional assessment? Summary answer Three-dimensional folliculometry was superior to the two-dimensional ultrasound assessment and provided an excellent prediction (+/-20%) of total oocyte yield in almost two-thirds of participants. What is known already When used for monitoring ovarian stimulation, 3-D folliculometry has been shown to reduce inter-, and intra-observer variability and was significantly faster than conventional, two-dimensional ultrasound assessment (Vandekerchove F, 2014, Rei 2019). Although so far, no study has demonstrated improved clinical outcomes in IVF patients, the impact of 3D-folliculometry was not yet thoroughly evaluated in oocyte donation programmes, where expected total and mature oocyte yield is a crucial variable. Study design, size, duration Ninety-one consecutive oocyte donors were prospectively evaluated using three-dimensional folliculometry with SonoAVC software (E8, General Electric). A single operator (DB) performed all 3D ultrasound measurements immediately before starting oocyte retrieval and the oocyte retrieval procedure too. Two-dimensional measurement of follicles (average of two perpendicular diameters) was performed two days before egg retrieval by a single operator (NR) (Mindray DC7). Oocyte donors’ age (26.2±3.7 years), BMI (23.8±3.9), and baseline AMH (4.6±2.3 ng/mL) were also registered. Participants/materials, setting, methods Voluntary, anonymous oocyte donors were stimulated with a GnRH antagonist protocol and triggered with a GnRH agonist. Good, moderate, and poor prediction by ultrasound were defined as an oocyte/follicle count ratio of 80-120% (+/-0-20%), 60-79% or 121-140% (+/- 21-40%), and less than 60% or more than 140% (+/- more than 40%), respectively. For total oocyte yield, a threshold of all follicles 13 mm or above was used, both for the two- and three-dimensional assessment. Main results and the role of chance The number of total and mature oocytes retrieved was 22.2±9.4 and 19.0±8.3, respectively with an excellent average maturity rate of 86% (range: 44-100%). No donors were excluded from the study due to suboptimal visualization of ovaries with SonoAVC. For total oocyte yield; good, moderate, and poor prediction was achieved in 37, 44, 19% of donors with two-dimensional and in 63, 29, 8% of participants with three-dimensional folliculometry, respectively (p = 0.002). Significant underestimation of total oocyte yield (defined as more than 6 „missing” total oocytes) was less frequent with 3D assessment (12 versus 25% p = 0.022). For total oocyte yield, linear regression analysis showed a significantly higher r-square value with three-dimensional assessment (0.676 vs 0.278). For mature oocytes, the prediction was less precise than for total oocyte yield. Good, moderate, and poor prediction was achieved in 40, 30, 30% of donors with two-dimensional and in 55, 30, 15% of participants with three-dimensional folliculometry, respectively (p = 0.031). For mature oocytes, linear regression analysis showed a significantly higher r-square value with three-dimensional assessment (0.664 vs 0.282). The best SonoAVC threshold to predict total and mature oocyte yields was the sum of all follicles equal or above 13 mm and total follicle count between 24-13 mm, respectively. Limitations, reasons for caution Due to practical reasons, three- and two-dimensional measurements were not performed on the same day or with the same ultrasound equipment. In future studies, 3D-folliculometry could be used at the egg collection scheduling (2-3 days before the procedure) so that predictive information on oocyte yield would be available earlier. Wider implications of the findings Apart from reducing inter-observer variability and diminishing discomfort (faster examination time), 3D-folliculometry might have a significant role in the management of OD programmes by improving the prediction of total/mature oocyte yields. 3D-measurements performed before the procedure could also play a role in the quality control of the egg collection procedure. Trial registration number Not applicable

P-268 Artificial intelligence (AI) image analysis outperforms patient age as a surrogate marker for oocyte quality, demonstrating an increased accuracy in predicting blastocyst development

Abstract Study question Can an AI image analysis tool (VIOLET) provide better predictions of oocyte potential than the current standard, patient age, as it relates to blastocyst development? Summary answer While increasing patient age slightly correlates with decreases in blastocyst development, VIOLET provides personalized assessments of individual oocytes correlated to blastocyst development with improved accuracy. What is known already Increasing patient age correlates to decreases in oocyte competency, leading to greater challenges in successful fertility treatment. Clinically, patient age is used to estimate probabilities of success based on national databases. Such as the case in oocyte cryopreservation cycles, considering only age and number of mature oocytes vitrified. However, oocyte quality may vary widely between patients of the same age, and even within each cohort of oocytes. VIOLET is an AI tool that assesses images of mature denuded oocytes to provide an analysis shown to significantly correlate with subsequent blastocyst development and quality, consistently outperforming embryologists in this task. Study design, size, duration This large-scale retrospective study assessed 9,120 mature denuded oocytes retrieved during 2014-2022, representing 1,384 patients between ages 19-49, attending 7 fertility clinics across 5 countries. The VIOLET prediction model is based on image analysis of mature denuded oocytes, without incorporating clinical variables, such as age. Patient age was used to build a separate predictive model of blastocyst development (10,947 training and 3,750 validation samples) to assess the predictive value of age in comparison to VIOLET. Participants/materials, setting, methods Blastocyst development was determined by embryos achieving a Gardner grade by Day5/6 post-ICSI. Blastocyst rates per oocyte cohort were calculated by number of blastocysts divided by total number of mature oocytes retrieved. Various machine learning techniques were trialed to build the predictive model strictly using age; with Random Forest model providing the best-balanced performance. VIOLET and the age model assessed the images and age of 9,120 mature denuded oocytes, respectively, providing predictions of blastocyst development. Main results and the role of chance Blastocyst development was significantly different between patients <35 years old compared to those ≥35 years old [47% vs 42%; p < 0.05 by Two Proportion Z-test]; however, not when the older age group was stratified further. On a patient level, the cohort of oocytes was evaluated by the blastocyst development ratio. Among four age groups (<35, 35-37, 37-40, >40), the blastocyst development ratios per cohort were very similar, with overlapping distributions of 84-94% using Kernel Density estimates. Thus, patient age group does not provide enough information to explain blastocyst development success for an individual oocyte or within an oocyte cohort. In comparison, VIOLET probability is significantly correlated to blastocyst development (p < 0.05; Welch’s Two sample t-test). And blastocyst development rates display a stepwise positive correlation that is significantly different between VIOLET probability quartiles [24% vs 39% vs 47% vs 53%; p < 0.05 by Two Proportion Z-test], providing meaningful information on individual oocytes. Additionally, the predictive model built with age as the only feature had poor ability to predict blastocyst success of an individual oocyte with a limited area-under-the-curve (AUC) of 0.5—unable to separate positive and negative classes. This was outperformed by VIOLET, which displayed an AUC of 0.62 on the same unseen dataset. Limitations, reasons for caution Increasing maternal age causes increased chromosomal abnormalities in oocytes, which translates to lower efficacy with treatment outcomes; therefore, further research to assess VIOLET correlation with PGT-A and implantation outcomes is needed and underway. Wider implications of the findings Patient age correlates with blastocyst development on a general level; however, it does not provide meaningful insights to distinguish rates of blastocyst success on an individual oocyte or oocyte cohort level. VIOLET augments oocyte understanding over the current standard of care, which can be utilized to support personalized clinical decision-making. Trial registration number Not applicable.

P-598 Analysis of the oocyte yield and Ovarian Sensitivity Index with the use of two gonadotropins (FSHr/FSHu) and two pituitary suppression protocols (PPOS/GnRH-ant)

Abstract Study question Is there a difference, in terms of ovarian yield and sensitivity, comparing a progestin-primed protocols (PPOS) to a GnRH antagonist (GnRH-ant) and using different follitropin? Summary answer PPOS is an effective choice, with both follitropis. Nevertheless, could improve ovarian sensitivity to FSHu increasing the number of oocyte yield without compromising oocyte quality. What is known already The use of new ovarian stimulation protocols, starting during the luteal phase or randomly shows that endogenous progesterone alone is sufficient to block the LH surge and does not compromises oocyte competence and pregnancy outcomes. For these reasons, exogenous progesterone was utilized as an innovative model of pituitary suppression. Most studies have shown the effectiveness of the use of PPOS compared to the GnRH (antagonist or agonist) in IVF cycles. For oocyte donation only three studies were carried out analyzing the effect of PPOS with a recombinant FSH (FSHr) Study design, size, duration It is a retrospective, cohort, paired study. We analyzed egg donation cycles carried out in Next Fertility Valencia from January 2020 to May 2021. In total 93 donors were selected as eligible, each one undergoing both the PPOS and GnRH antagonist cycles for a total of 186 cycles, 54 received FSHr and 39 HP-FSHu. To attempt to eliminate possible bias due to interpersonal differences, every patient was her own control. Participants/materials, setting, methods All donors underwent two controlled ovarian stimulation cycles within 6 months, one using flexible GnRH antagonist (Ganirelix) and the other using medroxyprogesterone acetate (MPA), with FSHr or FSHu monotherapy and a GnRH-agonist triggering. The oocyte yield was analyzed focusing on: the number of oocytes retrieved, mature (MII) oocytes and useful oocytes (mature oocytes without morphological alterations). We also evaluated the Ovarian sensitivity index (OSI) calculating the oocyte number for each 1000 IU of gonadotropin used Main results and the role of chance Total gonadotropin consumption and duration of ovarian stimulation were similar in both models of pituitary suppression regardless the type of FSH. One less control is required with MPA than the GnRH-ant in both FSH groups. There were no premature ovulations in MPA or GnRH antagonist cycles regardless of the gonadotropin used. In the FSHr group no difference was observed in the oocyte yield and OSI between MPA and GnRHa. On the other hand, in the FSHu group a statistically significant improvement in the number of total oocytes retrieved (20,2 ± 8,5 vs 23,8 ± 10,9), total MII (18,0 ± 7,2 vs 21,2 ± 10,4) and OSI (6,4 ± 3,5 vs 7,7 ± 4,6) was observed in favor of the use of MPA. Also, the number of useful MII was higher with MPA (15,7 ± 6,5 vs 18,6 ± 10,4). No significant differences were detected in fertilization and blastocyst rate regardless the type of pituitary suppression and FSH used Limitations, reasons for caution The main limitation lies in the retrospective nature of the study. However, since each patient is her own control (Paired study), it gives an added value Wider implications of the findings The efficacy and efficiency of the MPA does not seem to be affected by the type of gonadotropin used, this further reassures about the possibility of using it with patients in case of fertility preservation cycles, PGT-A/M, "DuoStim" cycles Trial registration number Not applicable

P-617 Combined oral contraceptive pill (COCP) pre-treatment and progestin-primed ovarian stimulation (PPOS) protocol: a detrimental combination for the oocyte yield in egg donation programs

Abstract Study question Could the use of combined oral contraceptive pill (COCP) pre-treatment before controlled ovarian hyperstimulation (COH) have a negative effect on oocyte yield in normo-responders patients? Summary answer When COH with progestin-primed ovarian stimulation (PPOS) protocol in normo-responders patients is performed, the COCP pre-treatment could have a detrimental effect on oocyte yield. What is known already COCP pre-treatment is widely used to schedule the start of COH and to organize the working week, but its usefulness and efficiency are still not clear. Most of studies on IVF outcomes have shown no effect of COCP on oocyte yield. For oocyte donation only few studies were carried out showing controversial effects on oocyte yield, but all considered short antagonist or long agonist protocols and no one PPOS protocol. COCP leads to long lasting pituitary suppression and lower LH level in follicular phase that could reduce the ability to effectively respond to GnRH-agonist trigger leading to poor oocyte yield. Study design, size, duration The egg donation cycles carried out from January to September 2022 in Next Fertility Valencia were retrospectively analyzed. Two analyses were conducted. Analysis A, comparative retrospective cohort study of 397 COH cycles: 290 with COCP and 107 without COCP. Analysis B, comparative retrospective paired study of 90 COH cycles: 45 with COCP and 45 without COCP, in which, to attempt to eliminate possible bias due to interpersonal differences, every patient was her own control. Participants/materials, setting, methods All donors underwent to COH with FSH monotherapy, PPOS protocol for pituitary suppression and a GnRH-agonist triggering. The oocyte yield was analyzed focusing on: the number of oocytes retrieved, mature (MII) oocytes and useful oocytes (good mature oocytes used for ICSI), the appropriate response to the GnRH-agonist trigger, the stimulation days, the total gonadotropins dose used and the cancellation rate (for low response or low LH level in follicular phase the first day of COH). Main results and the role of chance In both analyses, the data showed no differences in terms of stimulation days, total FSH dose, number of follicles ≥ 15 mm on the trigger day regardless of use of COCP. After conducting the analysis based on the administration or not of COCP, in the Analysis A a higher number of total oocytes retrieved, mature oocytes and useful oocytes were found in the group that did not used COCP. A significant difference in a nominal variable (Pearson's chi-square test) was observed, consisting of a higher proportion of cancellations due to low LH level (< 2,5 mUI/ml) in the group that used COCP (COCP no: 0.7% vs. COCP yes: 3.7% ). While, in the Analysis B (analysis of variance of one factor, Anova test), the variables total oocytes retrieved, total MII oocytes and total useful oocytes showed significant differences consisting of a higher number of oocytes in the group that did not received COCP. These results have statistical significance both before removing the cases in which the values were 0 due to a cancellation (p < 0.01), and after removing the cancelled cases (p < 0.05). Limitations, reasons for caution The main limitation lies in the retrospective nature of the study. However, since each patient is her own control (Paired study), it gives an added value. Wider implications of the findings COCP before COH in PPOS cycles could have detrimental effects on oocyte yield, reducing the efficacy and efficiency of egg donation programs. This could be extended to social freezing programs in normo-responders patients, in which the probability of future pregnancy is closely linked to the number of good oocytes vitrified. Trial registration number Not Applicable

Controlled ovarian hyperstimulation in breast cancer patients: Does oestrogen receptor status make a difference?

The presence of different breast cancer receptor status may impact ovarian stimulation outcomes. To study the association between oestrogen receptor (ER) status in breast cancer patients and fertility preservation outcomes in a major tertiary referral centre. Women who underwent fertility preservation following the diagnosis of breast cancer from 2008 to 2018 were included in the study. Patient age, ovarian stimulation parameters and laboratory outcomes were recorded and compared between the ER positive and negative groups. The primary outcome was total number of oocytes frozen. Secondary outcomes included total number of oocytes collected, mature oocytes, and embryos frozen. The women included in the study (n = 214) were analysed in the following groups based on their fertility preservation method: oocyte freezing (n = 131), embryo freezing (n = 70), and both embryo and oocyte freezing (n = 13). There was an increase in the mean (but not mature) number of oocytes frozen (12.4 and 9.2, P-value = 0.03) favouring the ER positive group, even though the women in this group were older (35.0 and 33.4, P-value of 0.03). There is no difference in the starting follicle-stimulating hormone dose, duration of stimulation, mature oocytes collected, and embryos frozen in both groups. Patients with ER positive breast cancer may have more positive ovarian stimulation outcomes.

Live birth rate per transfer is not impacted by the proportion of smooth endoplasmatic reticulum aggregates oocytes.

Despite the data published to date, prognostic factors and the clinical impact of ICSI cycles with smooth endoplasmatic reticulum aggregates (SERa) positive oocytes remain unclear. Are the clinical outcomes of an ICSI cycle impacted by the proportion of oocytes with SERa? Retrospective study (2016-2019), including data from 2468 ovum pick-ups, performed in a tertiary university hospital. Cases are categorised based on the rate of SERa positive oocytes compared to the total number of MII oocytes: 0% (n=2097), <30% (n=262) and ≥30% (n=109). Patient characteristics, cycle characteristics and clinical outcomes are compared between the groups. Compared to SERa negative cycles, women with ≥30% SERa positive oocytes are older (36.2y vs. 34.5y, p<0.001), have lower anti-mullerian hormone levels (AMH) (1.6ng/ml vs. 2.3ng/ml, p<0.001), have received more gonadotropins (3227U vs. 2858IU, p=0.003), have a lower number of good quality day 5 blastocysts (1.2 vs. 2.3, p<0.001) and face more blastocyst transfer cancellation (47.7 vs. 23.7%, p<0.001). Women with <30% SERa positive oocytes are younger (33.8y, p=0.04), have higher AMH levels (2.6ng/ml, p<0.001), have more oocytes retrieved (15.1, p<0.001), have a higher number of good quality day 5 blastocysts (3.2, p<0.001) and have less transfer cancellations (14.9%, p<0.001) compared to SERa negative cycles A multivariate analysis shows no significant difference in cycle outcomes between the categories. Treatment cycles with ≥30% SERa positive oocytes are less likely to result in an embryo transfer when only non-SER oocytes are used. However, live birth rate per transfer is not affected by the proportion of SERa positive oocytes.

The effect of different FSH administration before ovum pick up on superstimulation response and oocyte yield.

This study aims to evaluate the effect of synchronization and different superstimulation protocols on oocyte yield before ovum-pick up (OPU) to provide a homogeneous follicle population. Animals in all study groups except the control group applied a synchronization protocol including modified ovsynch+progesterone and dominant follicle ablation (DFA, on the 6th day following synchronization). In group 1, oocytes were retrieved by ultrasonography only on the 4th day after DFA. In group 2, 250 μg pFSH (100 μg IM, 150 μg SC) was administered as a single dose on the 2nd day following DFA, and oocytes were retrieved on the 2nd day following this injection. In group 3, 250 μg pFSH was administered IM in four equal doses 12 h apart on the 1st and 2nd days following DFA, and oocytes were retrieved 2 days after the last FSH injection. In group 4, 250 μg pFSH (IM) dissolved in Montanide ISA 206 adjuvant was administered as a single dose on the 2nd day following DFA, and oocytes were retrieved 2 days after this treatment. In the control group (group 5), oocytes were retrieved from animals without any hormonal treatment on a random day of the oestrus cycle. In order to assess the follicle population in the ovary on the day of OPU, the number of follicles according to their diameter was determined by ultrasonography in all groups. The ratio of medium-sized follicles (3-8 mm) was higher in the synchronized groups (Groups 1, 2, 3 and 4) than in the control group (Group 5) (p < .05). It was determined that the total number of oocytes obtained after OPU and the number of oocytes of suitable quality (Grade A and B) in in vitro embryo production were higher in the superstimulated groups (Groups 2, 3 and 4) compared to the control group. It was found that the number of Grade-A quality oocytes was higher in the superstimulated groups (Groups 2, 3 and 4) than the other groups. As a result, it was found that the synchronization and superstimulation treatments prior to the OPU increased the ratio of medium-sized follicles and the total number of oocytes obtained. In addition to the synchronization protocol, it was determined that superstimulation treatments increased the oocyte quality obtained with OPU. Furthermore, it was observed that a single dose of FSH dissolved in Montanide ISA 206 adjuvant produced a superstimulation response similar to that produced by repeated doses of FSH.

Single-Step Genomic Prediction of Superovulatory Response Traits in Japanese Black Donor Cows.

We assessed the performance of single-step genomic prediction of breeding values for superovulatory response traits in Japanese Black donor cows. A total of 25,332 records of the total number of embryos and oocytes (TNE) and the number of good embryos (NGE) per flush for 1874 Japanese Black donor cows were collected during 2008 and 2022. Genotype information on 36,426 autosomal single-nucleotide polymorphisms (SNPs) for 575 out of the 1,874 cows was used. Breeding values were predicted exploiting a two-trait repeatability animal model. Two genetic relationship matrices were used, one based on pedigree information (A matrix) and the other considering both pedigree and SNP marker genotype information (H matrix). Estimated heritabilities of TNE and NGE were 0.18 and 0.11, respectively, when using the H matrix, which were both slightly lower than when using the A matrix (0.26 for TNE and 0.16 for NGE). Estimated genetic correlations between the traits were 0.61 and 0.66 when using H and A matrices, respectively. When the variance components were the same in breeding value prediction, the mean reliability was greater when using the H matrix than when using the A matrix. This advantage seems more prominent for cows with low reliability when using the A matrix. The results imply that introducing single-step genomic prediction could boost the rate of genetic improvement of superovulatory response traits, but efforts should be made to maintain genetic diversity when performing selection.

İn Vitro Fertilizasyon/İntrasitoplazmik Sperm Enjeksiyonu Uygulanan Çiftlerde Paternal Yaşın Düşük Oranlarına Etkisi

Aim: The aim of this study was to determine the effect of paternal age on miscarriage rates in couples undergoing in vitro fertilization/intracytoplasmic sperm injection treatment cycles. Material and Methods: Patients were classified into two groups. The study group consisted of the patients whose pregnancy resulted in a miscarriage (n=73) and a control group in which the patients had a live singleton birth (n=256). Demographic characteristics, treatment indications, duration of infertility, menstruation day 3 follicle stimulating hormone, estradiol, luteinizing hormone, total antral follicle count, anti-Mullerian hormone levels and controlled ovarian stimulation parameters, day of trigger, estradiol and progesterone levels on the day of trigger, the total number of oocytes retrieved, the number of mature oocytes, the number and quality of the embryo, endometrial thickness on the day of trigger, oocyte pick up and embryo transfer, the distance of embryo-fundus and the day of embryo transfer were recorded. Results: Totally 329 women were included in the present study. The number of patients with the diagnosis of unexplained infertility was statistically significantly higher in the study group than in the control group (p=0.020). Maternal age was found statistically significantly higher in the study group than in the control group (p=0.025). When maternal age increased by 1 unit, the risk of miscarriage increased by 8.7% and those with unexplained infertility had a 75.6% higher risk of miscarriage than those without unexplained infertility. Conclusion: Paternal age was not associated with miscarriage whereas maternal age and unexplained infertility had a positive correlation with miscarriage rate.

BDNF promotes mouse follicular development and reverses ovarian aging by promoting cell proliferation

BackgroundBrain-derived neurotrophic factor (BDNF) plays an important role in ovarian function including follicle development and oocyte maturation, and embryonic development. However, whether BDNF treatment can reimpose ovarian aging and impaired fertility remains elusive. In this study, we investigated the reproductive outcomes of BDNF treatment and potential mechanisms in aged mice.Method“Aged” mice (35–37 weeks old, n = 68) were treated with recombinant human BDNF protein (rhBDNF, 1 µg/200 µL) through daily intraperitoneal (IP) injection for 10 days with/without ovulation induction. Reproductive age mice (8–10 weeks old, n = 28) were treated with ANA 12 (a selective BDNF receptor, TrkB antagonist) through daily IP injection for 5 days with/without ovulation induction. Ovarian function was assessed by ovarian weight, number of follicles, and sex hormone productions. Following induction of ovulation, the number of total oocytes or abnormal oocytes, and blastocyst formation were assessed. Reproductive functions of the mice were evaluated, including pregnancy rate, mating duration for conception, implantation sites, litter size, and weight of offspring. Finally, the molecular mechanism of the effects of BDNF on ovarian cell functions in mice were examined by Western blot and immunofluorescence.ResultsrhBDNF treatment increased the ovarian weight, number of follicles, number and quality of oocytes including increased blastocysts formation, blood estrogen levels, and pregnancy rate in 35-37-week-old mice. Conversely, BDNF receptor antagonist, ANA 12, treatment decreased the ovarian volume and number of antral follicles and increased the proportion of abnormal oocytes in 8-10-week-old mice. We further demonstrated that BDNF treatment promoted ovarian cell proliferation as well as activation of TrkB and cyclinD1-creb signalling.ConclusionWe demonstrated that ten consecutive days of daily IP injection of rhBDNF rescued ovarian function in aged mice. Our results further indicate that TrkB and cyclin D1-creb signaling may underlie the BDNF function in ovaries. Targeting BDNF-TrkB signaling is a potential novel therapeutic strategy to reverse ovarian aging.

Runs of homozygosity and signatures of selection for number of oocytes and embryos in the Gir Indicine cattle.

Runs of homozygosity (ROH) and signatures of selection are the results of selection processes in livestock species that have been shown to affect several traits in cattle. The aim of the current work was to verify the profile of ROH and inbreeding depression in the number of total (TO) and viable oocytes (VO) and the number of embryos (EMBR) in Gir Indicine cattle. In addition, we aim to identify signatures of selection, genes, and enriched regions between Gir subpopulations sorted by breeding value for these traits. The genotype file contained 2093 animals and 420,718 SNP markers. Breeding values used to sort Gir animals were previously obtained. ROH and signature of selection analyses were performed using PLINK software, followed by ROH-based (FROH) and pedigree-based inbreeding (Fped) and a search for genes and their functions. An average of 50 ± 8.59 ROHs were found per animal. ROHs were separated into classes according to size, ranging from 1 to 2Mb (ROH1-2Mb: 58.17%), representing ancient inbreeding, ROH2-4Mb (22.74%), ROH4-8Mb (11.34%), ROH8-16Mb (5.51%), and ROH>16Mb (2.24%). Combining our results, we conclude that the increase in general FROH and Fped significantly decreases TO and VO; however, in different chromosomes traits can increase or decrease with FROH. In the analysis for signatures of selection, we identified 15 genes from 47 significant genomic regions, indicating differences in populations with high and low breeding value for the three traits.

Corifolitropin-Alfa plus Five Days Letrozole Versus Daily Recombinant-FSH in Expected Normo-Responder Patients: A Retrospective Comparative Study

Background: In recent times, different novel GnRH-antagonist protocols with various combinations of gonadotropins and other molecules (e.g., aromatase inhibitors, selective estrogen receptor modulators) have been proposed for expected normal ovarian responders undergoing assisted reproductive treatments. The purpose of this study was to evaluate the effectiveness of a novel ovarian stimulation protocol based on the combination of corifollitropin-alfa plus five days of letrozole in E-NOR women undergoing IVF as compared with a daily recombinant-FSH regimen. Methods: We conducted a retrospective-controlled study on 182 couples undergoing their first IVF attempt. In Group A (experimental), letrozole (2.5 mg daily) was administered from day 2 (up to day 6 of the cycle), followed by corifollitropin-alfa on day 3 and daily recombinant FSH from day 10. In Group B, recombinant FSH from day 2 were administered (150 IU-225 IU daily). Statistical analysis was completed using SPSS Statistics. The primary outcome was the total number of MII oocytes retrieved. Results: Group A showed similar results compared to Group B in terms of MII oocytes, live birth, implantation, and clinical pregnancy rates (p = ns). Nevertheless, the experimental group was associated with a trend towards a higher number of developing follicles, total oocytes, and embryos (p < 0.05) with lower estradiol and progesterone values at ovulation induction compared to Group B, resulting in an increased chance of performing a fresh embryo transfer (p < 0.05). Conclusions: The combination of CFα plus five days of letrozole was associated with a trend towards a higher number of developing follicles, total oocytes, and obtained embryos. Moreover, the experimental protocol resulted in lower estradiol and progesterone values at ovulation induction compared to daily rFSH, with an increased chance of performing a fresh embryo transfer (with no OHSS occurrence). Given the observational design of our study, further well-conducted RCTs are needed.

The Eff ect of Testosterone Gel for Patients with Poor Ovarian Response Prior to IVF Cycles: Is It really Eff ective?

Background: Classically, poor women respond with old maternal age and little ovarian standby. Though, some females unpredictably have little reply to measured ovarian stimulation. Aim of the Study: To evaluate the eff ectiveness of transdermal testosterone gel (TTG) before controlled ovarian stimulation (COS) in poor responders undergoing intracytoplasmic sperm injection (ICSI). Methods: An interventional prospective randomized control trial that included 60 females who were defi nite as unfortunate responders undergoing an intracytoplasmic sperm injection (ICSI) procedure. The population was divided into two groups. Approximately 30 patients received 10 mg TTG that was applied daily for 21 days in the cycle preceding COS for ICSI Transdermal testosterone gel (TTG) pretreatment group, while the other 30 patients are the control group. All patients were assessed for their AFC again and to begin in-vitro futilization (IVF) treatment with the beginning of the menstrual cycle. Serum testosterone was measured again in the study group. The primary outcome is the number of retrieved oocytes while the secondary outcome is the number and quality of embryos transferred, chemical gestation rate. Results: No important diff erences in sociodemographic features between both groups compared. Also there was an increase in total number of oocytes in the study group but again, this diff erence was statically non-signifi cant. Although the total dose of gonadotrophin (GT) and the duration of stimulation days were less in study group but this was statically non-signifi cant. No diff erences experiential regarding number and grading of embryos, chemical pregnancy rate nor clinical pregnancy rate. Conclusion: Pretreatment of transdermal testosterone at a dose of 10 mg/day for 21 days not upsurge the number of oocyte retrieved nor the number of embryos or pregnancy rate to a signifi cant level in poor responders undergoing ICSI

The role of elagolix in the suppression of ovulation in donor oocyte cycles

To study the clinical use of elagolix in ovarian stimulation and its effect on premature ovulation in a cohort of women undergoing oocyte donation. A prospective cohort study with the use of historical controls. A private reproductive endocrinology and infertility clinic. Seventy-five oocyte donors and 75 historical donors, aged 21-30 years, who had each passed Food and Drug Administration and American Society for Reproductive Medicine-approved oocyte donor screening. Administration of elagolix 200 mg orally every night at bedtime with development of a follicular size of ≥14 mm for ovulation suppression compared with ganirelix 250 μg every night at bedtime. Premature ovulation rate, total oocytes, mature oocytes, maximum estradiol, luteinizing hormone, and progesterone levels. Oocytes were available in all retrievals because there were no instances of premature ovulation in either the elagolix or ganirelix groups. There were no statistically significant differences between the groups in baseline demographics. Both groups had the same amounts of gonadotropins consumed and days of stimulation. The average number of total oocytes was similar between the control group and elagolix group (30.55 vs. 30.31). Furthermore, the average number of mature oocytes was similar between the control and study groups (25.42 vs. 24.73). An analysis of the 580 fresh oocytes in the elagolix group and the 737 fresh oocytes in the ganirelix group showed similar outcomes with fertilization rates of 79.7% and 84.6%, respectively. Blastocyst development rates were also similar: 62.9% in the elagolix group and 57.3% in the ganirelix group. Compared with a historical control group using ganirelix, patients receiving elagolix demonstrated a similar number of oocytes and mature oocytes with on average 4.2 fewer injections per cycle and average per-cycle patient savings of $289.10. Western IRB Pr. No.: 20191163, April 11, 2019. First enrollment June 20,2019.

Oocyte vitrification for oncological and social reasons.

The aim of this review is to present information related to oocyte cryopreservation, and particularly oocyte vitrification, performed to preserve fertility in oncologic and social indications. The success rates of oocyte cryopreservation have increased with the widespread use of the vitrification technique and are currently similar to those of in vitro fertilization performed with fresh oocytes. Vitrification is the most successful technique for oocyte cryopreservation. The most important factors that influence the success rate are the patient's age at the time of vitrification and the number of mature oocytes frozen. Thus, live birth rates differ for each age depending on the number of oocytes thawed and the freezing method. The American Society of Reproductive Medicine and the American Society of Clinical Oncology recommend presenting the option of oocyte cryopreservation for fertility preservation in cancer patients. Besides cancer patients, use of oocyte vitrification is increasing in women who wish to postpone pregnancy age and to have reproductive freedom with the development of the cryopreservation technique and the achievement of pregnancy rates similar to the use of fresh oocytes. Patients are provided consultancy service in terms of indication, the success rates by age, and the total number of oocytes frozen. It should be emphasized that this procedure is not a type of insurance policy for fertility, especially in elective oocyte cryopreservation.

Oocyte and Embryo Quality of Infertile Patients with Classic Phenotype Polycystic Ovarian Syndrome after Controlled Ovarian Hyperstimulation

The polycystic ovary syndrome (PCOS) is a combination of conditions, closely associated with female infertility and metabolic syndrome. It is recognized mainly with a polycystic ovary morphology (PCOM) of increased ovarian volume and pearl chain-like follicles on ultrasound, producing a large cohort of growing follicles during controlled ovarian hyperstimulation (COH) that are frequently heterogeneous in size and with poor quantity or quality of mature oocytes. However, recent data has proposed controversial opinions. The objective of the present study was to evaluate the relationship between the classical phenotype PCOS and the oocyte and embryo quality after COH for intracytoplasmic sperm injection (ICSI). An observational case control study was conducted for a four years period at the IVF department of a private gynecological hospital. Infertile females under 39, who performed COH for ICSI were included. A total of 496 ICSI cycles were divided into two groups – a PCOS group with 109 ICSI cycles and a control group with tube infertility that encompasses 387 ICSI cycles. The main outcome measures were the quantity and quality of the retrieved oocytes and embryos as well as the ICSI outcomes (fertilization rate, implantation rate and clinical pregnancy rate). The statistical analyses were performed, using SPSS version 12.0 and MEDCALC® statistical software and statistical significance was considered at p &lt; 0.05. Significantly higher mean number of total oocytes (14±6.02 SD vs. 9±3.25 SD; p &lt; 0.0001) and meta-phase II oocytes (10±1.94 SD as opposed to 6±2.89 SD; p = 0.0001), as well as immature and atretic ones were retrieved in the PCOS group compared to the controls (p &lt; 0.0001). However, the fertilization rate did not differ among the two groups (66.8% and 62.4%, respectively). Despite obtaining significantly more embryos in the PCOS patients (9±5.17 SD vs. 6±2.96 SD; p &lt; 0.0001), there were no differences between the two groups regarding the figures of the top quality embryos (25.6% and 29%, respectively), implantation rate (19.7% and 19.95%, respectively) and clinical pregnancy rate (28.4% and 33.6%, respectively, NS). Patients with classic phenotype PCOS are not associated with poor oocyte and embryo quality or with unfavourable ICSI outcome after controlled ovarian hyperstimulation.