Noninferiority, randomized, controlled trial comparing embryo development using media developed for sequential or undisturbed culture in a time-lapse setup.

OBJECTIVE: To study whether a culture medium that allows undisturbed culture supports human embryo development to the blastocyst stage equivalently to a well-established sequential media. DESIGN: Randomized, double-blinded sibling trial. SETTING: Independent in vitro fertilization (IVF) clinics. PATIENT(S): One hundred twenty-eight patients, with 1,356 zygotes randomized into two study arms. INTERVENTION(S): Embryos randomly allocated into two study arms to compare embryo development on a time-lapse system using a single-step medium or sequential media. MAIN OUTCOME MEASURE(S): Percentage of good-quality blastocysts on day 5. RESULT(S): Percentage of day 5 good-quality blastocysts was 21.1% (standard deviation [SD] ± 21.6%) and 22.2% (SD ± 22.1%) in the single-step time-lapse medium (G-TL) and the sequential media (G-1/G-2) groups, respectively. The mean difference (-1.2; 95% CI, -6.0; 3.6) between the two media systems for the primary end point was less than the noninferiority margin of -8%. There was a statistically significantly lower number of good-quality embryos on day 3 in the G-TL group [50.7% (SD ± 30.6%) vs. 60.8% (SD ± 30.7%)]. Four out of the 11 measured morphokinetic parameters were statistically significantly different for the two media used. The mean levels of ammonium concentration in the media at the end of the culture period was statistically significantly lower in the G-TL group as compared with the G-2 group. CONCLUSION(S): We have shown that a single-step culture medium supports blastocyst development equivalently to established sequential media. The ammonium concentrations were lower in the single-step media, and the measured morphokinetic parameters were modified somewhat. CLINICAL TRIAL REGISTRATION NUMBER: NCT01939626.

Media composition: macromolecules and embryo growth.

Most embryo culture media are still supplemented with proteins rather than with nonprotein macromolecules or recombinant protein products. HSA is probably the most common supplement followed by globulin-enriched preparations. Serum supplementation and Co-Culture of embryos belong to the past. Defined nonprotein or recombinant protein supplements are becoming a viable alternative during gamete and embryo manipulation procedures. Biological protein supplements are still preferred for any extended period of embryo culture. Understanding the goals and purpose of supplemented macromolecules in embryo culture media during each step of the laboratory IVF process should assist us in choosing the safest and most consistent macromolecule for each step, but also selecting a product that has the capability of delivering the best clinical outcome. Each batch of biological protein supplement is unique, even if supplied by the same manufacturer. Each lot of protein supplement typically contains many lot-specific, potentially harmful, and unintended hormone and protein contaminants. Macromolecular embryo culture medium supplements should be identified as one of the highest risk factors in an IVF laboratory that may contribute towards clinical compromise. All efforts should be made to use a proven batch of supplement for as long as the expiration date will allow. The beneficial effect of more complex protein supplements is evident after the activation of the embryonic genome and probably due to the presence of growth factors. Lower live-birth rates due to suboptimum protein supplementation may be a direct result of the preferential loss of female embryos. When deciding on a culture system, thought should be given specifically to the interaction between the culture medium and the macromolecular supplement. Ready-to-use pre-supplemented culture media may be advisable over a more complex product if a comprehensive macromolecular quality management program is not feasible. However, the question remains as to whether the increasing simplification of embryo culture media supplements is ready for large-scale clinical use.

A randomized controlled study of human serum albumin and serum substitute supplement as protein supplements for IVF culture and the effect on live birth rates.

BACKGROUND: It has been speculated that the addition of proteins more complex than human serum albumin (HSA) to culture media may improve IVF outcomes. Whether the expense, labor and risk of adding additional human-derived protein to IVF media are warranted is a question unanswered. METHODS: In a randomized controlled trial with couples undergoing routine IVF or ICSI, 528 patients were assigned to one of two treatment groups. Embryos were cultured in either media supplemented with HSA as a solitary protein supplement or in media supplemented with HSA+serum substitute supplement (SSS) from the 2PN stage until the time of embryo transfer. Clinical end-points monitored included implantation (total 1151 embryos) and live birth rates (total 528 patients). RESULTS: The transfer of embryos cultured in HSA+SSS resulted in higher embryo implantation (289/571, 50.6% versus 254/580, 43.8%; difference 6.8% with 95% CI 1.0-12.7, P = 0.042) and live birth rates (167/266, 62.8% versus 142/262, 54.2%; difference 8.6% with 95% CI 0.1-17.3, P = 0.043) when compared with those of women whose embryos were cultured with HSA as the sole protein supplement. CONCLUSIONS: SSS added to commercial HSA-supplemented embryo culture media resulted in an overall increase in implantation and live birth rates. It remains uncertain whether the use of human-derived blood products in culture media and the requirement for ultra-rigorous quality control measures make these findings applicable to the average IVF laboratory. Protein enrichment of media may significantly improve the blastocyst implantation rate, creating opportunities to transfer single blastocysts without compromising the live birth rate. The study was registered at clinicaltrials.gov. NCT00708383.

A controlled randomized trial evaluating the effect of lowered incubator oxygen tension on live births in a predominantly blastocyst transfer program.

BACKGROUND: The potentially damaging effect of free O(2) radicals to cultured embryos may be reduced by adding scavengers to the culture media or by reducing the incubator O(2) levels. However, lowering the O(2) in the culture environment can be expensive, troublesome and may not be justifiable. The objective of this study was to evaluate the effect of lowered incubator O(2) tension on live birth rates in a predominately Day 5 embryo transfer program. METHODS: Two hundred and thirty first-cycle women undergoing routine IVF or ICSI with ejaculated sperm were randomized in a prospective clinical trial and stratified for patient age and physician. Embryos of patients were randomly assigned for culture in either a 21% O(2) (atmospheric) or 5% O(2) (reduced) environment. Clinical endpoints monitored were rates of implantation, clinical pregnancy, live birth and blastocyst cryopreservation. RESULTS: Embryos cultured in a 5% O(2) environment consistently resulted in higher rates of live birth implantation (106/247, 42.9% versus 82/267, 30.7%; difference of 12.2% with 95% confidence interval (CI) of 3.9-20.3, P = 0.005) and live births (66/115, 57.4% versus 49/115, 42.6%; difference of 14.8% with 95% CI of 1.9-27.0, P = 0.043) when compared with rates among women whose embryos were cultured in an atmospheric O(2) environment. CONCLUSIONS: The overall increase in live births demonstrated by this study indicates that the effort and expense to culture embryos in a low-O(2) environment is justified. The study was registered at clinicaltrials.gov. NCT00708487.