Cryopreservation of IVF embryos: which stage?

Embryo freezing is a mandatory tool in IVF technology as controlled ovarian hyperstimulation usually leads to extra embryos which are not transferred. One dilemma is the embryonic stage at which the embryos are to be frozen. Early stage freezing (PNs or cleavage stage) leads to a two step selection: at the time of thawing and a few hours or a day after. Then the recovering embryos are submitted to the classical in vitro developmental arrests in relation with maternal, paternal and cytogenetic factors. The "take home baby rate" per frozen embryo is low, rarely over 5%. Blastocyst have overcome the blocks in vitro: a first selection has already been made. The quality of freezing at this stage depends greatly on the culture conditions. It allows freezing of fewer embryos, but with higher yields: a >10% take home baby rate can be expected. It is clear to us that vitrification, beside the technical problems, has to be handled with care, especially if ethylene glycol (EG) is used. Metabolic products of EG might have negative effects on organogenesis.     

Early maternal serum ß-human chorionic gonadotropin (ß-hCG) levels and sex-related growth difference of IVF embryos

Purpose

Maternal serum ß-human chorionic gonadotropin (ß-hCG) represents the trophoblastic cell mass and is an indirect measurement of embryo development at early implantation stage. Studies in animals and human embryos detected sex-related growth differences (SRGD) in favour of male embryos during the pre-implantation period. The purpose of our study was to correlate SRGD and maternal serum ß-hCG at 16 days after embryo transfer.

Methods

We retrospectively analysed all (fresh and frozen) non-donor, single embryo transfers (SET), elective and not elective, that were performed between December 2008 and December 2013. We included ß-hCG values from day 16 after oocyte collection of pregnancies resulting in live birth. Neonatal gender was retrieved from patient files. Male and female embryos were further grouped to cleavage and blastocyst stage transfers. Regression analysis for confounding variables included maternal age, maternal body mass index (BMI), use of micromanipulation (ICSI), embryo quality (grade), assisted hatching, day of transfer and fresh or frozen embryo transfer.

Results

Seven hundred eighty-six non-donor SETs resulted in live birth. After including only day 16 serum ß-hCG results, 525 SETs were analysed. Neonatal gender was available for 522 cases. Mean maternal serum ß-hCG levels were similar, 347 ± 191 IU/L in the male newborn group and 371 ± 200 IU/L in the female group. The difference between ß-hCG levels remained insignificant after adjusting for confounding variables.

Conclusions

Early maternal ß-hCG levels after embryo transfers did not represent SRGD in our study.     

The effect of progesterone level prior to oocyte retrieval on the numbers of oocytes retrieved and embryo quality in IVF treatment cycles: an analysis of 2,978 cycles

Purpose

The study was designed to evaluate the relationship between serum progesterone (P4) response after hCG administration and the number of oocytes retrieved and the embryo quality in fresh IVF cycles.

Methods

We conducted a retrospective cohort study of women aged 24–43 years who underwent first fresh IVF cycle from 2011 to 2013 at a single practice. We compared the post-hCG serum P4 level with values on the day of hCG trigger. Patients were analyzed in long and short protocols independently. In addition, patients were stratified by post-hCG P4 response. Number of oocytes retrieved and embryo quality were the primary outcomes of interest. Ordinary least square regression models and logistic regression analysis models were created to identify predictive factors associated with embryological outcomes while adjusting for potential confounders.

Results

Among the 2,978 IVF cycles, 2,484 patients were in long protocols, and 494 patients were in short protocols. After adjusting for patient age, rFSH duration, and basal FSH levels, the associations between P4 response after hCG administration and number of oocytes retrieved (P < 0.001) remained statistically significant in both long and short protocols. Additionally, mature oocyte rate, fertilization rate, good quality embryo rate, pregnancy rate and implantation rate were not significantly associated with the P4 increase when adjusting for the same factors. However, pregnancy rate and implantation rate from frozen-thawed cycles increased gradually across the seven groups.

Conclusions

Post-hCG P4 levels were positively associated with the number of oocytes retrieved, but did not affect oocyte or embryo quality. Our study suggests that the change in the post-hCG P4 level is another parameter that can be used by clinicians to assess the number of oocytes retrieved, and may further to estimate the pregnancy rate and live birth rate indirectly.     

Endometriosis and IVF: are agonists really better? Analysis of 1180 cycles with the propensity score matching

Abstract

Objective: To compare the outcomes of patients with confirmed endometriosis undergoing in vitro fertilization (IVF)-embryo transfer (ET) treated with either gonadotropin-releasing hormone agonist (GnRHa) or gonadotropin-releasing hormone antagonist (GnRHant) using the propensity score (PS) matching.

Design: Observational, retrospective analysis from January 2000 to December 2010.

Setting: Private tertiary fertility clinic.

Patient(s): Patients with endometriosis confirmed by ultrasound or surgery (American Fertility Society; AFS grades I–IV) that underwent an IVF-ET, stimulated with standard controlled ovarian hyperstimulation (COH) and GnRHa or GnRHant.

Intervention(s): A PS was assigned to all patients, which calculates the conditional probability of receiving a certain treatment; a higher PS (1) meant a higher probability of receiving treatment with GnRHa, and a lower PS (0) meant a higher probability of receiving GnRHant. The PS was calculated with a logistic regression model adjusted specifically for age, follicle stimulating hormone, antral follicle count and previous IVF cycles. All patients were divided into three groups according to their PS.

Main outcome measure(s): pregnancy rate (PR) per cycle.

Results: 1180 patients were analyzed. Raw PR per cycle was 41.8% and 23.4%, and PR per ET was 44.3 and 27%, respectively. PR per cycle: 41.9 versus 30% in group A; in group B, 39.7% versus 36.4% and in group C, 15.4% versus 18.9%. The overall odds ratio for PR adjusted by PS was 1.10 [0.58–2.19].

Conclusions: After matching patients by PS, PR after COH with either GnRHa or GnRHant may be equally effective.     

Optimal dose of HCG for final oocyte maturation in IVF cycles: absence of evidence?

There is an ongoing debate over the optimal dose of urinary HCG (u-HCG) that can trigger final oocyte maturation, leading to higher IVF success rate without increasing the risk of ovarian hyperstimulation syndrome (OHSS). A systematic review was conducted of all studies that compared the effect of at least two doses of u-HCG for final oocyte maturation on IVF outcomes and on the incidence of OHSS. The primary outcome was the live birth rate, and the secondary end-points were the number of oocytes retrieved, fertilization, implantation and pregnancy rates, and the incidence of OHSS. Only two amongst the six included studies were randomized controlled trials (RCT). Meta-analytic pool was not feasible due to insufficient number of studies assessing the same outcome and significant heterogeneity. The majority of studies concluded that the clinical outcomes were similar between women receiving 5000 or 10,000 IU of u-HCG. The incidence of OHSS was not reduced in the high-risk population even with lower dose of u-HCG. Until large scale RCT addressing the clinical effectiveness and the adverse outcomes related to various doses of u-HCG are conducted, the dose of u-HCG for final oocyte maturation for women referred for IVF needs to be individualized.     

Which ovarian stimulation parameters influence the number and proportion of mature oocytes retrieved in IVF cycles?

Journal of Assisted Reproduction and Genetics -     

Effect of chromosomal polymorphisms of different genders on fertilization rate of fresh IVF–ICSI embryo transfer cycles

To explore whether chromosomal polymorphisms of different genders affect outcomes of fresh IVF and intracytoplasmic sperm injection (ICSI) embryo transfer cycles differently, 37 couples with chromosomal polymorphisms were identified out of 614 infertile couples undergoing IVF–ICSI treatments. Group 1 included 20 couples in which only the male carried chromosomal polymorphisms; group 2 included 17 couples with female carriers only; group 3 included 19 infertile couples with normal karyotypes randomly selected as controls. A significantly lower fertilization rate was found in group 1 compared with groups 2 and 3 (56.68% in Group 1, 78.02% in group 2 and 71.74% in group 3; group 1 versus group 2, P < 0.001; group 1 versus group 3, P = 0.001; respectively). When stratified according to fertilization method, the fertilization rate in IVF cycles of group 1 was significantly lower than group 3 (50.00% in Group 1, 73.89% in Group 3, P < 0.001). Fertilization rates in ICSI cycles between groups 1 and 3 were not significantly different. This study suggests that male chromosomal polymorphisms adversely influence fertilization rates of IVF cycles. The use of ICSI may improve the success of infertility treatment by increasing the fertilization rate for men with chromosomal polymorphisms.     

The efficacy of add-ons: selected IVF “add-on” procedures and future directions

Journal of Assisted Reproduction and Genetics - Since the advent of ART, technology has continuously evolved to improve embryology and pregnancy outcomes. However, not all technologies that are...     

Trends in primeval β-hCG level increment after fresh and frozen-thawed IVF embryo transfer cycles

Mid-trimester beta-human chorionic gonadotropin (BHCG) levels are considerably higher in pregnancies resulting from frozen embryo transfer (FET) compared with fresh (FRET), leading to a higher false positive rate in aneuploidy screening tests. We aimed to investigate the dynamics of BHCG increment and its predictive value for cycle outcome. A retrospective analysis of FRET and FET cycles. BHCG values on days 14 and 16 post embryo transfer were compared and stratified according to the number of sacs demonstrated on US scan at six weeks gestation, and pregnancy outcome (biochemical pregnancy, ectopic pregnancy, spontaneous abortion, and a singleton or twin birth). A prediction model for live birth was built. A total of 430 treatment cycles were analyzed. The average BHCG levels were significantly higher in FET compared with FRET group in nonviable pregnancies on day 14, 450 vs. 183?IU/L, p?<?.05 and day 16, 348 vs. 735?IU/L, p?<?.05, respectively. The increment of BHCG was significantly steeper in the FET compared with FRET group in biochemical pregnancies (F?=?6.485, p?=?.012*). Optimal cutoff level for live birth prediction in the FRET group was 211?IU/L (sensitivity 84%, specificity 76.2%) for day 14 and 440?IU/L (sensitivity 86.0% and specificity 72.5%) for day 16. The increment in BHCG differed significantly between the FRET and FET cycles in nonviable pregnancies. Nevertheless, the difference in BHCG levels observed in the second trimester in pregnancies conceived after FRET and FET cycle may begin as early as the fourth week of pregnancy.     

Pregnancy prediction models and eSET criteria for IVF patients–do we need more information?

Purpose: The purpose of the present study was to evaluate statistical prediction models and simple allocation criteria, based on predictors for pregnancy, as tools to identify a good prognosis group in a possible eSET setting. Methods: A pregnancy prediction model based on logistic regression models was generated by analysis of 1675 DET treatment cycles. The model was evaluated and compared to simple eSET allocation criteria. Results: Embryo quality, patient age, and basal FSH were identified as significant predictors (at 5% significance level) of pregnancy. Although comparable to previously generated models, the predictive ability of the present model was relatively poor and practically similar to simple allocation criteria based on age and embryo quality. Conclusions: Existing prediction models, or simple allocation criteria, are limited in identifying good prognosis patients. Future studies of the applicability of improved pregnancy prediction models will need very comprehensive and detailed patient and embryo information.     

Small antral follicle count (2–5 mm) and ovarian volume for prediction of pregnancy in in vitro fertilization cycles

Aims.?To assess the value of antral follicle count (AFC) and other parameters as predictors of pregnancy in in vitro fertilization (IVF).

Methods.?In a cohort study, unselected consecutive women in IVF treatment were evaluated. Pretreatment parameters included AFC (subpopulations of small (2–5?mm) and large (5–10?mm) AFC), ovarian volume, and ovarian stroma Doppler indices.

Results.?The study included 115 women of whom 38 (33%) were pregnant. Total AFC was significantly higher in the pregnant than in the non-pregnant group (13.7?±?5.8 vs. 11.3?±?5.3, p?=?0.034). On receiver operator characteristic (ROC) curve analysis, the pretreatment variables that were significantly associated with pregnancy were small AFC (2–5?mm), total AFC, and ovarian volume/AFC ratio. Women with a positive score (total AFC >15; small AFC (2–5?mm) >10; ovarian volume in mm³/AFC, <1400), had a significantly higher number of retrieved oocytes and a higher pregnancy rate than women with a negative score (12.1?±?5.1 vs. 8.7?±?5.0, p?=?0.027 and 58.3% vs. 30.1%, p?=?0.049, respectively). On multivariate logistic regression analysis, total AFC was the only significant and independent predictor of pregnancy (p?=?0.034).

Conclusion.?Pretreatment small AFC and ovarian volume may identify women with a higher probability to achieve pregnancy in IVF.     

The effect of chromosomal polymorphisms on the outcomes of fresh IVF/ICSI–ET cycles in a Chinese population

Purpose

Chromosomal polymorphisms (CPs) have been reported to be associated with infertility; however, their effects on the outcomes of in vitro fertilization/intracytoplasmic sperm injection–embryo transfer (IVF/ICSI–ET) are still controversial. In this retrospective study, we aimed to evaluate the effect of CPs on IVF/ICSI–ET outcomes.

Methods

To investigate whether CPs affected the outcomes of fresh IVF/ICSI–ET cycles in a Chinese population, we evaluated infertile couples with male carriers of CPs (n?=?348), infertile couples with female carriers (n?=?99), and unaffected couples (n?=?400) who had received their first treatment cycles in our hospital between January 2013 and March 2015.

Results

CPs in either male or female carriers seemed to have adverse effects on IVF/ICSI–ET outcomes. CPs in male carriers affected outcomes mainly by decreasing the rates of fertilization, embryo cleavage, good quality embryos, clinical pregnancies, ongoing pregnancies, and deliveries as well as increasing the biochemical pregnancy rate (P?<?0.05); CPs in female carriers affected outcomes only by lowering the embryo cleavage rate (P?<?0.05). The mean fertilization rate of couples with male CP carriers undergoing IVF was significantly lower than that in those undergoing ICSI (61.1 versus 66.5 %, respectively; P?=?0.0004).

Conclusions

Our data provide evidence for the involvement of CPs in the poor outcomes of fresh IVF/ICSI–ET cycles in a Chinese population. The use of ICSI might improve outcomes by increasing the fertilization rate for men with CPs.

     

To what extent does anti-mullerian hormone contribute to a better prediction of live birth after IVF?

ObjectiveWe assessed the predictive value added by Anti-Mullerian Hormone (AMH) to currently validated live birth (LB) prediction models.MethodsBased on recent data from our center, we compared the external validity of the Templeton Model (TM) and its recent improvement (TMA) to select our model of reference. The added predictive value of AMH was assessed in testing the likelihood ratio significance and the Net Reclassification Index (NRI). The surrogate utility of AMH was tested by conducting an exploratory stepwise logistic regression.ResultsBased on 715 cycles, the original TM had poor performances (auROC C = 0.61 [0.58, 0.66], improving by fitting TM to our data (C = 0.71[0.66, 0.75]. TMA fitting proved better (C = 0.76; 95 %CI: 0.71, 0.80) and was selected as model of reference. Adding AMH to TMA or TM had no effect on discrimination (C = 0.76; 95 %CI: 0.72, 0.80), the likelihood ratio test was significant (p = 0.023), but the NRI was not (6.7 %; p = 0.055). A stepwise exploratory logistic regression identified the effects of age, previous IVF resulting in LB, time trend and AMH, leading to a prediction model reduced to four predictors (C = 0.75 [0.70, 0.81]).ConclusionThe added predictive value of AMH is limited. A possible surrogate/simplifying effect of AMH was found in eliminating 9/13 predictors from the model of reference. We conclude that whereas AMH does not add significant predictive value to the existing model, it contributes to simplifying the equation to reliable, easy to collect, and available in all databases predictors: age, AMH, time trend and female previous fertility history.     

Characterization of early pregnancy placental progesterone production by use of dydrogesterone in programmed frozen–thawed embryo transfer cycles

Research questionWhen and how does the gradual transition of the endocrine control of early pregnancy from the corpus luteum to the placenta, termed luteoplacental shift, take place?DesignProspective analysis of serum progesterone levels in pregnancies (n = 88) resulting from programmed frozen–thawed embryo transfer cycles in which ovulation was suppressed and no corpus luteum was present. Dydrogesterone, which does not cross-react with progesterone in immunoassay or spectrometric assay, was used for luteal phase and early pregnancy support. Progesterone, oestradiol and hCG were measured at regular intervals from before pregnancy achievement until +65 to 71 days after embryo transfer by Roche Elecsys electrochemiluminescence immunoassay (Elecsys ECLIA) and liquid chromatography-tandem mass spectrometry (LC-MS/MS).ResultsSerum progesterone remained at baseline levels on first blood analysis +9 to 15 days after embryo transfer and increased only marginally independently from the type of pregnancy up to +16 to 22 days after embryo transfer. From +23 to 29 days after embryo transfer, progesterone increased non-linearly above 1.0 ng/ml and increased further throughout the first trimester with elevated levels in multiples. Oestradiol levels increased in parallel with progesterone; hCG plateaued around +37 to 43 days. Progesterone levels were significant predictors for pregnancy viability from +23 to 29 days after embryo transfer onwards with best accuracy +37 to 43 days after embryo transfer (receiver operator characteristic analysis area under the curve 0.98; 95% CI 0.94 to 1; P = 0.0009).ConclusionsThe onset of substantial progesterone production is the 7th gestational week. Progesterone increase is non-linear, depends on chorionicity and zygosity, and may have predictive potential on the outcome of pregnancies originating from frozen embryo transfer cycles.     

Follicular fluid concentrations of vascular endothelial growth factor, inhibin A and inhibin B in IVF cycles: are they markers for ovarian response and pregnancy outcome?

OBJECTIVE(S): The aim of this study was to measure concentrations of vascular endothelial growth factor (VEGF), inhibin A and inhibin B in follicular fluid (FF) of women undergoing to in vitro fertilization (IVF) cycles and to determine their relationship with ovarian response and pregnancy. STUDY DESIGN: Follicular fluid was collected from 58 patients undergoing oocyte retrieval for IVF. Ovulation was induced with GnRH analogues and gonadotropins. Follicular fluids of mature follicles (>17 mm) were aspirated and pooled for each patient. Follicular fluid steroid hormone levels (E2, P) and VEGF, inhibin A, inhibin B concentrations were studied. The serum levels of E2, P and VEGF were also assessed on the day of the oocyte retrieval. These parameters and characteristics of the cycles were compared between the pregnant (group 1) and non pregnant (group 2) patients. RESULTS: The serum and FF VEGF levels were found to be significantly lower in the group in whom the pregnancy was achieved (P < 0.001). The FF inhibin A and FF inhibin B were found to be significantly higher in pregnant group (P < 0.001). However, age, day 3 FSH, dosage of gonadotropin administered, fertilization rate, sperm count, motile and morphologically normal sperm percentage were not significantly different in the two groups. There was an negative correlation between VEGF and number of follicles, number of oocytes, FF inhibin A, FF inhibin B. The number of oocytes retrieved, the fertilization rate were positively correlated with FF inhibin B and FF inhibin A. CONCLUSION: This study demonstrated that decreased FF VEGF, serum VEGF and elevated FF inhibin A and B are associated with better ovarian response and high pregnancy rate.