Non-invasive embryo evaluation and selection using time-lapse monitoring: Results of a randomized controlled study.

OBJECTIVE: Continuous monitoring of embryos via time-lapse (TL) provides more information on embryo kinetics and morphology compared to standard daily evaluation. Embryo selection by TL could support single embryo transfer (SET). With SET multiple gestations are avoided and perinatal outcome is improved. Our primary goal was to determine whether selection of a single blastocyst based on an algorithm comprising kinetic and morphologic scores assessed through continuous TL monitoring results in superior clinical outcome compared to embryo selection based on morphology alone. A secondary goal was to assess whether a time-lapse score based on kinetic and morphologic parameters was predictive of implantation. STUDY DESIGN: Randomized controlled trial performed in two private IVF centers in Hungary. Infertile couples scheduled to undergo 1st or 2nd IVF cycles were enrolled. Female age had to be under 36 years. The intervention was embryo evaluation/selection based on TL algorithm. Patients were randomized to SET with TL monitoring (TL-eSET) vs. SET with standard evaluation (control-eSET). Assuming an increase in pregnancy from 44% to 58%, a sample size of 202 per group was calculated based on the interim analysis at 10% information fraction. The primary outcome of the study was pregnancy rate. Secondary outcomes were miscarriage rates, live birth, perinatal outcome and the ability of a time-lapse score constructed based on kinetic and morphologic parameters to predict implantation. Chi-square tests, likelihood-ratio tests and exact tests were used for the analysis of categorical variables. Continuous variables were compared using independent group t-test and analysis of variance. RESULTS: The study was closed after three years. Eventually 161 patients were randomized and analyzed (N = 80 TL-eSET and N = 81 control-eSET). Pregnancy rate did not significantly differ between the groups though there was a trend favoring TL selection (TL-eSET: 46.3% vs control-eSET: 34.6%, p = 0.150; OR: 1.628 (95% CI: 0.857-3.092)). The time-lapse score based on morphologic and kinetic parameters was significantly higher for blastocysts that implanted vs. those that did not (14.5 ± 1.8 vs. 12.1 ± 2.9, p = 0.0001). There were no adverse effects of the intervention. CONCLUSIONS: Selection of a single blastocyst based on information derived from time-lapse monitoring can aid embryo selection for SET.

[Pregnancy and delivery with transfer of vitrified blastocysts following trophectoderm biopsy]. / Terhesség és szülés trophectoderma-biopsziát követoen vitrifikált blasztociszták beültetésével.

Application of preimplantation genetic diagnosis makes it possible to transfer only embryos unaffected by a certain genetic disorder. The authors have applied the combination of trophectoderm biopsy and vitrification in order to detect a monogenic disorder. Previously diagnosed type 1 neurofibromatosis of the woman was the indication for genetic examination. In vitro fertilisation and embryo culture was performed using sequential culture mediums. Seven blastocysts could be sampled on the fifth day and were vitrified subsequently. Two blastocysts turned out to be genetically normal based on the result of genetic examination using polimerase chain reaction. A healthy boy was delivered following the transfer of warmed blastocysts and an uneventful singleton pregnancy.

The role of hyaluronic acid binding assay in choosing the fertilization method for patients undergoing IVF for unexplained infertility.

PURPOSE: Patients with unexplained infertility may have fertilization problems. Split fertilization (ICSI and conventional IVF on sibling oocytes) is often used to avoid poor fertilization. Our aim was to assess the ability of hyaluronic acid binding (HA-binding) assay to predict spontaneous fertilization during IVF. METHODS: Prospective, blinded, controlled trial. Patients undergoing their first IVF cycle for unexplained infertility were eligible. Split fertilization was used. IVF and ICSI fertilization rates and embryo development based on 3 HA-binding cut-offs (< 60%; 60-80%; >80%) were compared. RESULTS: ICSI fertilization was higher than IVF, but none of the HA-binding cut-off levels predicted those cases where IVF was less effective, therefore ICSI only would have lead to improved outcome. Embryo development and morphology were similar in all cut-off groups. CONCLUSIONS: HA-binding did not predict spontaneous fertilization in patients with unexplained infertility undergoing IVF treatment. When it was used for "screening" it did not help to select the method of fertilization.

Embryo selection or uterine environment: which plays the greater role in blastocyst transfer cycles?

AIM: Blastocyst stage embryo transfer (BET) leads to higher pregnancy rates when compared to cleavage stage transfer. Better embryo selection and a more physiologic stage of transfer are possible explanations. We assessed the significance of embryo selection in achieving an improved outcome. METHODS: Retrospective analysis of all BETs from our 2007 IVF database was performed. The BET cycles were grouped based on the number of top-quality cleavage stage embryos (≤3 or >3). A cut-off of ≤3 embryos was chosen, because with ≤3 embryos those that will likely make it to the blastocyst stage have already been identified, therefore embryo selection becomes less important. Baseline characteristics, stimulation and embryology parameters, as well as treatment outcome, were compared. The T-test and χ(2)-test were used where appropriate. P < 0.05 was considered significant. RESULTS: A total of 251 cycles where at least one blastocyst was transferred on day 5 were identified and included in the analysis (≤3 top-quality cleavage embryos, n = 32; >3 top-quality cleavage embryos, n = 219). The number of follicles >14 mm and the number of eggs/mature eggs were higher in the group with >3 good quality day 3 embryos. Slightly more embryos were transferred in the ≤3 embryo group. Pregnancy rates (14/32 [43.8%] vs 96/219 [43.8%]; P = NS) and ongoing pregnancy rates (10/32 [31.2%] vs 80/219 [36.5%]; P = NS) were comparable. CONCLUSION: Based on the analysis of our data, the number of top-quality cleavage stage embryos did not significantly influence BET outcome. Besides embryo selection, other factors such as improved embryo-endometrium synchrony probably play an important role in the higher implantation and pregnancy rates.

Pregnancy achieved by transfer of a single blastocyst selected by time-lapse monitoring.

Appropriate selection of a single blastocyst for transfer decreases the risk of multiple gestations. By using a compact time-lapse microscope system placed inside a regular incubator, combined with a microwell embryo culture dish, the development of all the embryos from a patient was continuously monitored by obtaining images at 10 min intervals. The embryos were not moved during the time-lapse observation. The system was switched off completely between image acquisitions in order to avoid exposure to electromagnetic radiation. The analysis of time-lapse records was used to choose a single blastocyst for transfer, which resulted in a singleton pregnancy and birth of a healthy boy on term.

Prediction of in-vitro developmental competence of early cleavage-stage mouse embryos with compact time-lapse equipment.

Single blastocyst transfer is regarded as an efficient way to achieve high pregnancy rates and to avoid multiple pregnancies. Risk of cancellation of transfer due to a lack of available embryos may be reduced by early prediction of blastocyst development. Time-lapse investigation of mouse embryos shows that the time of the first and second cleavage (to the 2- and 3-cell stages, respectively) has a strong predictive value for further development in vitro, while cleavage from the 3-cell to the 4-cell stage has no predictive value. In humans, embryo fragmentation during preimplantation development has been associated with lower pregnancy rates and a higher incidence of developmental abnormalities. Analysis of time-lapse records shows that most fragmentation is reversible in the mouse and is resorbed in an average of 9 h. Daily or bi-daily microscopic checks of embryo development, applied routinely in human IVF laboratories, would fail to detect 36 or 72% of these fragmentations, respectively. Fragmentation occurring in a defined time frame has a strong predictive value for in-vitro embryo development. The practical compact system used in the present trial, based on the 'one camera per patient' principle, has eliminated the usual disadvantages of time-lapse investigations and is applicable for the routine follow-up of in-vitro embryo development.

Effect of coasting on cycle outcome during in vitro fertilization/intracytoplasmic sperm injection cycles in hyper-responders.

OBJECTIVE: To investigate the effect of coasting on IVF outcome in GnRH agonist cycles. DESIGN: Retrospective analysis. SETTING: Private IVF center. PATIENT(S): Infertile couples undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment (normal responders [control], hyper-responders [coasting] groups). INTERVENTION(S): Coasting to reduce the risk of ovarian hyperstimulation syndrome (OHSS) among hyper-responders. MAIN OUTCOME MEASURE(S): Stimulation, embryology parameters, and pregnancy rate (PR). RESULT(S): The average length of coasting was 2.2 days. Age and baseline FSH were comparable to control cycles. There were more follicles and oocytes in the coasting group, but the number of fertilized oocytes and embryos transferred were similar. Implantation rate (22.4% vs. 13.9%) was higher in the control group but the PRs were comparable (45.1% vs. 38.5%). Within the coasting group, baseline, stimulation, and embryology parameters were comparable between successful and unsuccessful cycles. Pregnancy rates were comparable after 1, 2, and 3 or more days of coasting (36.3% vs. 38.4% vs. 40%). Pregnancy rates were also comparable (28.5% vs. 35.7% vs. 44.4%) when groups were compared based on change in E2 (<25%, 25%-50%, >50%). CONCLUSION(S): Coasting for 3 days can be used successfully in the management of the hyper-responding patients during IVF.

Comparison of clinical outcome and costs with CC + gonadotropins and gnrha + gonadotropins during Ivf/ICSI cycles.

OBJECTIVE: To compare clinical outcome and costs of CC + gonadotropins with GnRHa + gonadotropins during IVF/ICSI cycles. MATERIALS AND METHODS: Clinical outcome and expenses of 382 CC + gonadotropin and 964 GnRHa + gonadotropin cycles were compared. Medication costs were calculated on the basis of the mean number of ampoules and the proportion of various gonadotropins. Costs per clinical pregnancy were calculated on the basis of expenses and clinical pregnancy rates. RESULTS: Women in the CC + gonadotropin group were younger, and had fewer follicles, oocytes, embryos, and embryos transferred. Clinical pregnancy rates were higher in the GnRHa group (35.9 % vs 26.2%, p < 0.001). More ampoules of gonadotropins were used in the GnRHa group (24.0 +/- 0.3 vs 20.0 +/- 0.5, p < 0.001). Medication costs per cycle were higher in the GnRHa group (US dollars 357 vs 248). Expenses per pregnancy however were lower in the GnRHa group (USdollars 4197 vs 5335 with IVF; USdollars 5590 vs 7244 with ICSI). When different age subgroups with similar baseline characteristics and stimulation parameters were compared, pregnancy rates were significantly higher in the GnRHa groups. Medication cost per cycle was higher in the GnRHa subgroups, and the expense per pregnancy was lower with GnRHa protocol. CONCLUSIONS: Cost per cycle is higher with GnRHa + gonadotropin. However, because of the better performance of the GnRHa + gonadotropin stimulation, the cumulative costs are reduced by the time a clinical pregnancy is achieved.

Effect of nickel (ni(2+)) on primary human ovarian granulosa cells in vitro.

Human ovarian granulosa cells obtained from women undergoing in vitro fertilization were exposed to 15.6, 31.25, 62.5, 125, 250, 500, 1000 muM Ni(2+) for 48 h. To determine the site of action of Ni(2+), the granulosa cells were stimulated to produce progesterone (P) by using maximally stimulating amounts of human chorionic gonadotropin (0.1 IU/ml hCG) or dibutyryl cyclic adenosine monophosphate (1 mM db-cAMP). The luteinizing hormone (LH) analog hCG was chosen because resultant P production requires an intact membrane receptor and db-cAMP was used to test for post LH receptor defects caused by Ni(2+). Progesterone content of the culture medium was determined by radioimmunoassay (RIA), and viability of the cells was measured by MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) reduction test. Concentration-dependent depression in both hGC and db-cAMP stimulated P production was seen at 15.625 muM or higher concentration of Ni(2+), which is not cytotoxic on human ovarian granulosa cells. The viability of cells was unaffected up to 31.25 muM and decreased significantly at 62.5 muM. Our results show a dose-related depression in stimulated P production of granulosa cells at a dose that does not induce significant cytotoxic action. These data indicate that the effect of Ni(2+) on P production is not due to cytotoxicity, and the cellular site(s) of inhibitory action appears to be subsequent to the membrane receptor and production of cAMP.