Non-invasive preimplantation genetic testing for aneuploidy: is the promise real?

Recent advances in preimplantation genetic testing for aneuploidy (PGT-A) have significantly enhanced its application in ART, providing critical insights into embryo viability, and potentially reducing both the time spent in fertility treatments and the risk of pregnancy loss. With the integration of next-generation sequencing, PGT-A now offers greater diagnostic precision, although challenges related to segmental aneuploidies and mosaicism remain. The emergence of non-invasive PGT-A (niPGT-A), which analyzes DNA in spent embryo culture media, promises a simpler aneuploidy screening method. This mini review assesses the methodological criteria for test validation, the current landscape of PGT-A, and the potential of niPGT-A, while evaluating its advantages and potential pitfalls. It underscores the importance of a robust three-phase validation process to ensure the clinical reliability of PGT-A. Despite initial encouraging data, niPGT-A not only confronts issues of DNA amplification failure and diagnostic inaccuracies but also has yet to meet the three-prong criteria required for appropriate test validation, necessitating further research for its clinical adoption. The review underscores that niPGT-A, like traditional PGT-A, must attain the high standards of precision and reliability expected of any genetic testing platform used in clinical settings before it can be adopted into routine ART protocols.

Current Status of Ovarian and Endometrial Biomarkers in Predicting ART Outcomes.

This review evaluates the role of ovarian and endometrial biomarkers in predicting outcomes in assisted reproductive technology (ART). It highlights established ovarian biomarkers such as the anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH), alongside emerging ones like growth differentiation factor 9 (GDF9), bone morphogenetic protein 15 (BMP15), connexin, and granulosa cell gene profiles. Additionally, the paper explores endometrial biomarkers such as ERA, BCL6, and immune markers, as well as the potential for genomic and proteomic technologies in customizing implantation. It concludes that while many of these biomarkers show promise, their clinical integration requires rigorous research and validation to confirm their safety and utility in ART.

The Utility and Impact of the Painful Periods Screening Tool (PPST) to Improve Healthcare Delivery for People with Symptoms of Pelvic Pain.

The objective of this study was to evaluate the utility and impact of the Painful Periods Screening Tool (PPST) to improve healthcare delivery for people with symptoms of pelvic pain. The design of this study was a survey study. After IRB approval, patients aged 18-55 years with self-reported pelvic, abdominal, or lower back pain before, during, or after menstrual periods were invited to participate in the study from September 2020 to June 2021. Participants filled out the PPST questionnaire on the day of their Johns Hopkins clinic visit and the follow-up questionnaire 1-14 days after the clinic visit. Demographics and duration of pain were assessed, and participants who completed the PPST questionnaire were sent a follow-up questionnaire to assess utility and impact of PPST. Of the 1352 patients who met study eligibility, 1000 participants responded to both questionnaires. Most subjects (82.9%; 95% CI: 80.4-85.2%) reported having severe pelvic/abdominal or lower back pain during menses. Nine hundred fifteen participants (91.5%; 95% CI: 89.6-93.2%) reported that if given regularly, the PPST would help women discuss their pain symptoms with their healthcare provider. Six hundred seventy-eight participants (67.8%; 95% CI: 64.8-70.7%) reported that the PPST helped them initiate a conversation about their symptoms. Seven hundred seven participants (70.7%; 95% CI: 67.8-73.5%) were more comfortable discussing symptoms of pelvic pain with their provider after filling out the PPST. These findings support the utility of PPST as an endometriosis screening tool and suggest that this tool facilitated communication between patients and providers about pain symptoms.

A Bedside Test to Detect the Presence of Embryonic or Fetal Tissue in Vaginal Blood.

OBJECTIVE: To evaluate a rapid bedside test that detects alpha-fetoprotein (AFP) and insulin-like growth factor-binding protein 1 (IGFBP-1) to identify the presence of embryonic or fetal tissue in vaginal blood. METHOD: This was a prospective cohort study. Reproductive-aged individuals were recruited into three groups: a negative control group consisting of nonpregnant individuals undergoing dilation and curettage (D&C) or experiencing vaginal bleeding; a positive control group of individuals with confirmed intrauterine pregnancy undergoing D&C; and the study group of pregnant individuals with first-trimester bleeding. Lateral flow immunoassay strips capable of detecting both AFP and IGFBP-1 were used to test vaginal blood for the presence of embryonic or fetal tissue. RESULTS: Ninety individuals were recruited: 31 in the positive control group, 23 in the negative control group, and 36 in the study group, including 12 individuals with ectopic pregnancies, 16 with active miscarriages, four with threatened miscarriages, and four with complete miscarriages. Vaginal blood from 14 of the 16 individuals with active miscarriages was correctly positive for embryonic or fetal tissue. Vaginal blood from all individuals with ectopic pregnancies, threatened miscarriages, and complete miscarriages was negative for embryonic or fetal tissue. Overall, 45 of 47 individuals with confirmed embryonic or fetal tissue in vaginal blood correctly tested positive using the test strips, a test sensitivity of 95.7% (95% CI 85.5-99.5%). Of the 43 individuals with confirmed absence of embryonic or fetal tissue in their vaginal blood, 42 were correctly negative, a test specificity of 97.7% (95% CI 87.7-99.9%). CONCLUSION: A rapid test strip detecting both AFP and IGFBP-1 can accurately identify the presence of embryonic or fetal tissue in vaginal blood. When positive, this could aid in diagnosing miscarriage and ruling out ectopic pregnancy at the bedside.

Comparing pregnancy outcomes between natural cycles and artificial cycles following frozen-thaw embryo transfers.

BACKGROUND: Frozen embryo transfer (FET) is increasing in prevalence. In contrast to the amount of research performed on the actual cryopreservation procedure, there are limited data with respect to optimal endometrial preparation in FET cycles. Increasingly artificial cycle (AC) preparation is being adopted over the natural cycle (NC) to facilitate greater access to FET. However, there remains a paucity of data comparing pregnancy outcomes between these two commonly used cycle types. AIMS: To examine the efficacy of AC vs NC following FET, by comparing pregnancy outcomes including biochemical, clinical and live birth rates, along with miscarriage rates. MATERIALS AND METHOD: This is a large single-centre retrospective analysis, examining a standardised data set from January 2015 to July 2018. It included 3030 cycles (NC = 2033, AC = 997). Main outcomes were biochemical pregnancy (beta-human chorionic gonadotropin > 5 IU), ultrasound-diagnosed clinical pregnancy, and live births. Using the χ2 test, the above pregnancy outcomes were compared between AC and NC. A multivariate logistic regression, controlling for factors such as age, embryo quality, and day of blastocyst freeze was further utilised to assess for confounding variables. RESULTS: No difference was observed between biochemical pregnancy rates (NC = 39.45% vs AC = 37.71%, P = 0.357); statistically significant differences were observed between clinical pregnancy (30.84% vs 26.08%, P = 0.007), and live birth rates (24.40% vs 18.86% P = 0.001). Multivariate analysis confirmed that NC produces superior pregnancy outcomes when controlling for confounding variables. CONCLUSION: This analysis demonstrates the non-inferiority of NC thaw compared to AC, on continuing pregnancy rates. Taken together with patient acceptability and possibly increased obstetric risks with AC, these findings support the use of NC when medically possible.

Do serum progesterone levels on day of embryo transfer influence pregnancy outcomes in artificial frozen-thaw cycles?

PURPOSE: The purpose of this study is to investigate whether progesterone (P4) levels on the day of frozen-thawed embryo transfer (FET) to a hormonally prepared endometrium correlate with pregnancy outcomes. METHODS: This is a large retrospective cohort analysis comprising of N = 2010 FETs. In these cycles, P4 levels on the day of transfer were assessed in relation to pregnancy outcomes. A threshold of 10 ng/mL was used to simulate currently accepted levels for physiological corpus luteal function. Biochemical pregnancy, clinical pregnancy, and live birth rates were compared between those with P4 levels above and below this threshold. Analyses using transfer day P4 thresholds of 5 ng/mL and 20 ng/mL were then completed to see if these could create further prognostic power. RESULTS: When comparing FET outcomes in relation to P4 levels < 10 ng/mL and ≥ 10 ng/mL, we observed no differences in biochemical pregnancy rates (39.53% vs. 40.98%, p = 0.52), clinical pregnancy rates (20.82 vs. 22.78, p = 0.30), and live birth rates (14.25 vs. 16.21 p = 0.23). In patients whose P4 met the threshold of 20 ng/mL, there was similarly no statistically significant improvement in pregnancy outcomes. While there was no difference for biochemical or clinical pregnancy rates, a statistically significant improvement in live birth rates was observed for those with a transfer day P4 level ≥ 5 ng/mL. CONCLUSIONS: We demonstrated that P4 levels at or above 10 ng/mL on the day of FET do not confer a statistically significant improvement in pregnancy outcomes. P4 below 5 ng/mg was associated with lower live birth rates suggesting that there is a threshold below which it is difficult to salvage FET cycles.

Should intrauterine human chorionic gonadotropin infusions ever be used prior to embryo transfer?

PURPOSE: The aim of this study was to explore the factors that influence the outcome of intrauterine human chorionic gonadotropin (hCG) infusion at the time of embryo transfer (ET), in particular, the effect of hCG infusions on fresh and frozen embryo transfers (FETs) and whether prior recurrent implantation failure (RIF) impacts upon outcomes. METHOD: This was a case-control study based on a standardized database from a multi-site in vitro fertilization clinic. The analysis contains 458 cases and 749 matched controls, with an intervention group of those given intrauterine hCG prior to ET and a control group of patients receiving no hCG infusion. Outcomes were defined as clinical pregnancy and live birth rates. Two analyses were performed. The first separated FETs (cases n = 224, controls n = 325) and fresh ETs (cases n = 234, controls n = 424), with outcomes calculated in each group. The second analysis divided patients into those with RIF (cases n = 149, controls n = 200) and those without (cases n = 309, controls n = 549). RESULTS: Results in fresh ETs demonstrated a 5.8% reduction (adjusted odds ratio (AOR) = 0.60, p = 0.041) in clinical pregnancy rates with the use of intrauterine hCG. In those without defined RIF, clinical pregnancy rates were reduced by 8.1% (AOR = 0.61, p = 0.023) and live birth rates by 7.2% (AOR = 0.56, p = 0.32) with intrauterine hCG use. There were no significant differences in outcomes in FETs and in the RIF cohort. CONCLUSION: Intrauterine hCG at the time of ET not only seems to have no benefit, but rather a negative effect in fresh ETs and those without RIF.

Progesterone concentrations and dosage with frozen embryo transfers - What's best?

BACKGROUND: There is a lack of consensus on the optimal dose and form of progesterone supplementation during frozen-thawed embryo transfer with hormone replacement therapy. AIMS: We aim to identify the serum progesterone concentration on day 16 most likely to result in positive pregnancy outcomes. MATERIALS AND METHODS: We undertook a retrospective study of 4582 women who underwent frozen embryo transfer with hormone replacement therapy, or natural frozen embryo transfer, over 14 years at a multi-site private in vitro fertilisation clinic. Embryos were 3-5 days of age at time of transfer. We extracted data on serum progesterone concentrations and outcomes, as well as dose and form of progesterone supplementation, from patient and pharmacy records. RESULTS: Increased live birth rates for frozen embryo transfer with hormone replacement therapy were seen with day 16 serum progesterone concentrations >50 nmol/L (26.4% vs 11.3% for <50 nmol/L; adjusted odds ratio (OR) 3.14 (95% CI 2.21-4.48)). Similarly, a decreased pregnancy loss rate was seen in this group (14.3% vs 32.6% for ≤50 nmol/L; adjusted OR 0.26 (95% CI 0.12-0.58)). There was a positive correlation between live births and the number of progesterone doses per day (r = 0.119, P = 0.026) and day 16 progesterone concentrations (r = 0.128, P = 0.011). CONCLUSION: Improved pregnancy outcomes are seen with day 16 serum progesterone concentrations >50 nmol/L. There is a statistically significant correlation between live births, number of progesterone doses per day and day 16 serum progesterone concentrations in this study.

The Effects of Adjuvant Therapies on Embryo Transfer Success.

BACKGROUND: Many adjuvant therapies are employed during IVF treatment in an attempt to improve outcomes. The objective of our study was to evaluate the impact of thirteen adjuvants (Intralipid, steroids, melatonin, coenzyme Q10, Filgrastim, testosterone, DHEA, growth hormone, antibiotics, hCG infusion, aspirin, enoxaparin/heparin and dopamine agonists) on the success of embryo transfers. METHODS: This is a retrospective cohort study of all embryo transfers between January 2010 and April 2015 from a multi-site IVF clinic. To ensure data independence, random number was applied to each included transfer and used to pick an individual transfer for each patient (n=13,372). Outcomes were clinical pregnancy, live birth and pregnancy loss. Univariate comparison with Chi square testing and logistic regression analysis were used. The level of significance was p<0.05. RESULTS: Steroid use was significantly associated with both reduced clinical pregnancy loss (aOR 0.39, CI 0.19-0.76) and improved live birth rates (aOR 1.40, CI 1.11-1.77). While aspirin was associated with improved live birth rates (aOR 1.48, CI 1.08-2.02), melatonin was linked with reduced rates (aOR 0.66, CI 0.45-0.96). Analyses for all other adjuvant therapies did not reach statistical significance after logistic regression. CONCLUSION: Many of the interventions investigated in this study fail to significantly demonstrate any effects on the success of embryo transfers. Our analysis results show negative effects with the use of melatonin; however, use of aspirin or steroids demonstrated promising, potentially beneficial outcomes. Additional exploration is needed to guide evidence-based practice.