To collapse or not to collapse blastocysts before vitrification? A matched case-control study on single vitrified-warmed blastocyst transfers.

RESEARCH QUESTION: Does laser-induced artificial blastocoel collapse result in better blastocyst cryopreservation survival and a higher live birth rate (LBR) in comparison with intact counterparts? DESIGN: Half of the supernumerary blastocysts from IVF cycles were randomly selected before vitrification for laser-induced artificial collapsing or vitrification in intact form. A matched case-control study of first transfers of single blastocysts artificially collapsed (case) or intact (control) before vitrification was conducted. Controls were matched to cases on a 1:1 ratio by female age, parity, fresh and vitrified cycle protocol, blastocyst age and quality, resulting in 309 case-control pairs. RESULTS: The two groups were comparable in terms of their characteristics. Survival rates in the case and control groups (97.8% and 95.7%; P = 0.133) were comparable, but the optimal survival rate was higher in the case group (78.2% and 69.3%; P = 0.03). Clinical pregnancy rates (38.2% and 35.3%; P = 0.518), miscarriage rates (15.2% and 22%; P = 0.190), LBR per transfer (32.4% and 27.5%; P = 0.221) and LBR per warmed blastocyst (31.6% and 26.3%; P = 0.137) were not statistically different between the case and control groups. No significant difference in preterm births (11.1% versus 15.7%), birthweights (3333 ± 723 g versus 3304 ± 609 g) or sex ratio (49.3% versus 50.7% boys) was observed between the two groups. No major malformations were detected in the study population. CONCLUSIONS: Compared with vitrification of intact blastocysts, collapsed blastocysts resulted in a significantly higher optimal survival rate, and although they resulted in a 5% higher LBR, this was not significant for the chosen sample size. Neonatal outcomes were comparable in the two groups.

Outcome of vitrified-warmed blastocyst transfer performed on days 5-7 after urine LH detection.

RESEARCH QUESTION: What is the clinical importance of vitrified-warmed blastocyst transfer timing if performed on days 5, 6 and 7 after detecting the LH surge using urine tests? DESIGN: Between 2013 and 2019, 2080 vitrified-warmed blastocyst transfers in a true natural cycle were performed and later analysed at the Department of Reproductive Medicine, University Medical Centre Maribor, Slovenia. Urine LH tests were performed twice daily to monitor the onset of the LH surge. Vitrified-warmed blastocyst transfer (frozen embryo transfer [FET]) was performed on day 5 (group 1), 6 (group 2) or 7 (group 3) after the LH surge in 18%, 77% and 4% of cycles, respectively. The patient and cycle characteristics among the groups were compared using the Cochran-Mantel-Haenszel test and respective generalized linear mixed models. Propensity score matching was used to adjust for potential differences among the groups. RESULTS: There were no statistically significant differences between groups 1, 2 and 3 in the cycle and patient characteristics, clinical pregnancy rate (38% versus 39% versus 31%), implantation rate (34% versus 36% versus 31%), miscarriage rate (7% versus 9% versus 7%) and delivery rate (31% versus 31% versus 24%). The day of FET after the LH surge detected using a urine test was not significantly associated with live births. CONCLUSIONS: The results of the current study suggested that the vitrified-warmed blastocyst transfer could be scheduled on day 5, 6 or 7 after a positive LH urine test without having a significant impact on the clinical outcome.

Can methods of artificial intelligence aid in optimizing patient selection in patients undergoing intrauterine inseminations?

PURPOSE: AI and its machine learning algorithms have proven useful in several fields of medicine, including medically assisted reproduction. The purpose of the study was to construct several predictive models based on clinical data and select the best models to predict IUI procedure outcomes. METHODS: Clinical data (patient baseline characteristics, sperm quality, hormonal status, and cycle data) from 1029 IUI procedures performed in 413 couples stimulated by clomiphene citrate, letrozole, or gonadotropins were used to build several models to predict clinical pregnancy. The models included ANN, random forest, PLS, SVM, and linear models using the caret package in R. The models were evaluated using ROC analysis by means of random CV on test data. RESULTS: Out of the best performing models, the random forest model achieved an AUC of 0.66, a sensitivity of 0.432, and a specificity of 0.756. This performance was followed by the PLS model, which achieved a sensitivity of 0.459 and specificity of 0.734. The other models achieved significantly lower AUCs. When adjusting the predictive cutoff value, confusion matrices show that clinical pregnancy is twice as likely in the case of positive prediction. CONCLUSION: Among the compared methods, the random forest and PLS models demonstrated superior performance in predicting the clinical outcome of IUI. With additional research and clinical validation, AI methods may be successfully used in improving patient selection and consequently lead to better clinical results.

Diagnosis and management of rudimentary horn pregnancy rupture, misinterpreted as bicornuate uterus in the 14th week of pregnancy.

We present a 26-year-old primigravida with rudimentary horn pregnancy rupture at 14 weeks of pregnancy. Uterine anomaly was first diagnosed at the time of nuchal translucency scan and was presumed to be a bicornuate uterus with normal intrauterine pregnancy in the right horn. One day later, she was admitted to our department with abdominal pain, shortly leading to massive hemoperitoneum and hypovolemic shock. Uterine rupture was confirmed ultrasonically, followed by immediate laparotomy. Ruptured rudimentary horn with already expulsed pregnancy was encountered during surgery. Despite significant advances in ultrasonography, diagnosis of prerupture stage remains controversial. However, high mortality of the condition should ensure low threshold for surgical exploration.

Public database for validation of follicle detection algorithms on 3D ultrasound images of ovaries.

BACKGROUND AND OBJECTIVE: Automated follicle detection in ovarian ultrasound volumes remains a challenging task. An objective comparison of different follicle-detection approaches is only possible when all are tested on the same data. This paper describes the development and structure of the first publicly accessible USOVA3D database of annotated ultrasound volumes with ovarian follicles. METHODS: The ovary and all follicles were annotated in each volume by two medical experts. The USOVA3D database is supplemented by a general verification protocol for unbiased assessment of detection algorithms that can be compared and ranked by scoring according to this protocol. This paper also introduces two baseline automated follicle-detection algorithms, the first based on Directional 3D Wavelet Transform (3D DWT) and the second based on Convolutional Neural Networks (CNN). RESULTS: The USOVA3D testing data set was used to verify the variability and reliability of follicle annotations. The intra-rater overall score yielded around 83 (out of a maximum of 100), while both baseline algorithms pointed out just a slightly lower performance, with the 3D DWT-based algorithm being better, with an overall score around 78. CONCLUSIONS: On the other hand, the development of the CNN-based algorithm demonstrated that the USOVA3D database contains sufficient data for successful training without overfitting. The inter-rater reliability analysis and the obtained statistical metrics of effectiveness for both baseline algorithms confirmed that the USOVA3D database is a reliable source for developing new automated detection methods.

Predictive Factors for Live Birth in Autologous in Vitro Fertilization Cycles in Women Aged 40 Years and Older.

BACKGROUND: The aim of the study was to determine predictive factors for live birth after in vitro fertilization with autologous oocytes in women ≥40 years of age. METHODS: Authors conducted a retrospective analysis of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles performed at the Department of Reproductive Medicine and Gynecologic Endocrinology, University Medical Centre Maribor, Slovenia between January 2006 and December 2015 in women aged 40 or more. The characteristics of patients and cycles were compared regarding live birth as the final outcome. RESULTS: A total of 1920 IVF/ICSI cycles with egg retrieval in women ≥40 years of age were performed leading to 1591 embryo transfers. The live birth rate per embryo transfer was 17.3% at 40, 11.6% at 41, 8.2% at 42, 7.9% at 43, 1.9% at 44 and 0.0% at ≥45 years of age. The multivariate logistic regression model showed that besides women's age (OR 0.66, 95% CI: 0.55-0.78), the number of previous cycles (OR 0.88, 95% CI: 0.82-0.95), number of good quality embryos on day 2 (OR 1.19, 95% CI: 1.05-1.36), number of embryos transferred (OR 1.57, 95% CI: 1.19-2.07) and day 5 embryo transfer (OR 2.21, 95% CI: 1.37-3.55) were also independent prognostic factors for live birth. CONCLUSIONS: The chance of in vitro fertilization success in women ≥40 years of age should not be estimated only on the woman's age, but also on other predictive factors: number of previous cycles, number of good quality embryos on day 2, number of transferred embryos and blastocyst embry transfer.

Maternal serum levels of angiogenic markers and markers of placentation in pregnancies conceived with fresh and vitrified-warmed blastocyst transfer.

PURPOSE: The aim of the study was to compare the levels of angiogenic markers and markers of placentation between pregnancies conceived with fresh (ET) and vitrified-warmed blastocyst transfer (FET). METHODS: Women with singleton pregnancies resulting from fresh ET or FET during the period between 2013 and 2017 were included in this prospective observational study. Fresh ET was performed in a stimulated and FET in natural cycle. At 6-7 weeks of gestation, after ultrasound confirmation of a single gestational sac with a viable embryo, serum levels of free ß-hCG, pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PIGF) and fms-like tyrosine kinase (sFlt-1) were measured. Data on the patients' characteristics, pregnancy complications and outcomes were collected from a questionnaire and National Perinatal Information System of Slovenia. RESULTS: Among 211 pregnancies, 126 were achieved with fresh ET and 85 with FET. There were no significant differences in perinatal outcome, pregnancy complication and PIGF level between the fresh ET and FET group. Women achieving pregnancy with FET had significant higher levels of free ß-hCG (40.20 ± 30.62 IU/L vs. 28.74 ± 23.52, p = 0.002), PAPP-A (0.09 ± 0.06 vs. 0.06 ± 0.05 IU/L, p = 0.004) and sFlt-1 (596.19 ± 283.06 vs. 436.53 ± 248.23 pg/L, p < 0.0001) compared to women having conceived with fresh ET. There were no significant differences in the levels of evaluated biomarkers between patients with different pregnancy outcomes and complications. CONCLUSION: Levels of angiogenic markers and markers of placentation differ between pregnancies achieved with fresh ET and FET which may reflect altered implantation and early placentation with some forms of assisted reproductive technologies.

Medical management of first trimester missed miscarriage: the efficacy and complication rate.

Our aim of the study was to evaluate the efficacy and complication rate of our inpatient medical management protocol for missed miscarriages. Three-hundred and ninety women hospitalised at our tertiary centre because of a missed miscarriage/anembryonic pregnancy in 2012-2013 were included in this retrospective study. The women underwent either a low (until 9 + 0 weeks of gestation) or high gestational age (from 9 + 1 until 15 + 6 weeks of gestation) management protocol. The success rate, curettage in the first 48 hours after the procedure, the complication rate and the factors that might influence these outcomes were evaluated. The overall success rate was 83.3%. The curettage in the first 48 hours after the procedure was performed in 7.4% of the patients and was more often in the high gestational age protocol. Complications that required another outpatient visit or hospitalisation occurred in 9% of the patients. Higher beta-hCG values 14 days after the procedure and the absence of evacuation of products of conception during hospitalisation were associated with a higher complication rate. IMPACT STATEMENT What is already known on this subject? As much as 10-20% of clinically recognised pregnancies end in a spontaneous abortion. A missed miscarriage and a blighted ovum represent a form of spontaneous abortion, which has long been treated with surgical evacuation. However, nowadays, medical management represents a well-established alternative with very high success rates and is considered as an equivalent and safe method that is also very well accepted by patients. What do the results of this study add? According to our results, a medical management of a first trimester missed miscarriage and a blighted ovum is very effective with an overall success rate of 83.3% and a very low percentage of curettage in the first 48 hours after the procedure (7.4%). Our study was also able to identify higher beta-hCG values 14 days after procedure and absence of evacuation of products of conception during hospitalisation as risk factors for complication occurrence. What are the implications of these findings for clinical practice and/or further research? Our study helps to identify patients who are at greater risk for developing complications after the medical management of a first trimester missed miscarriage.

Causes of Massive Vulvar Edema in Patients with Severe Ovarian Hyperstimulation Syndrome: A Case Report and Literature Review.

BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is a potentially serious complication of ovulation stimulation. Modest vulvar edema is frequently seen in a severe form of OHSS; however, cases of massive bilateral vulvar edema are rare and pathogenesis is uncertain. CASE REPORT We report a 31-year-old patient with massive vulvar edema and severe OHSS after IVF treatment with GnRH antagonist and gonadotropins. Five days after embryo transfer, she was hospitalized because of severe clinical manifestation of OHSS and on the fifth day after admission she developed a massive bilateral vulvar edema. After conventional medical therapy of OHSS, vulvar edema spontaneously resolved. CONCLUSIONS Hypoproteinemia with low oncotic pressure and certain personal tissue characteristics may play the main role in the pathogenesis of massive vulvar edema in OHSS.

Endometrial injury, the quality of embryos, and blastocyst transfer are the most important prognostic factors for in vitro fertilization success after previous repeated unsuccessful attempts.

PURPOSE: The purpose of this study was to find out the most important prognostic factors for achieving a pregnancy after in vitro fertilization (IVF) in women with history of repeated unsuccessful IVF attempts. METHODS: We analyzed factors affecting pregnancy rate in a retrospective study including 429 IVF/ICSI cycles performed in women younger than 40 years with at least three previous consecutive failed IVF/ICSI attempts. RESULTS: Clinical pregnancy was observed in 140/429 (32.6%) cycles. Clinical pregnancy rate (CPR) was significantly higher in cycles with LEI compared to cycles without LEI before embryo transfer (44.4 vs 26.54%, p = 0.007). The CPR was also higher in cycles with day 5 blastocyst- compared with day 3 cleavage-stage embryo transfers (45.51 vs 26.54%, p < 0.001). In multivariate logistic regression model, only transfer of at least one good quality embryo (OR = 4.32, 95% CI 2.41-7.73), local endometrial injury (OR = 1.73, 95% CI 1.02-2.92), and transfer on day 5 (OR = 3.02, 95% CI 1.53-5.94) remained important independent prognostic factors for clinical pregnancy. CONCLUSIONS: These results suggest that hysteroscopy with local injury to the endometrium prior to ovarian stimulation for IVF/ICSI can improve implantation and pregnancy rates in women experiencing recurrent IVF failure. However, large studies are needed to confirm these findings.

Human chorionic gonadotropin levels are equally predictive for pregnancy outcome after fresh and vitrified-warmed blastocyst transfer.

PURPOSE: The aim of the present study was to evaluate if the live birth predictive values of ß-hCG levels differ in fresh and vitrified-warmed blastocyst transfer cycles. METHODS: In the retrospectively designed study, 775 cycles with positive ß-hCG values 13 days after fresh blastocyst transfer (fresh ET; n = 568) or vitrified-warmed blastocyst transfer (FET; n = 207) were selected for analysis. Average ß-hCG levels stratified according to pregnancy outcome (biochemical pregnancy, spontaneous abortion, ectopic pregnancy, and singleton or twin birth) were compared between fresh ET and FET cycles. To determine the optimal sensitivity and specificity of ß-hCG levels for live birth prediction, a ROC curve was constructed. Fisher's exact test was used to compare the positive predictive values (PPV). RESULTS: Average ß-hCG levels stratified according to pregnancy outcome were not statistically different between fresh ET and FET cycles. In fresh ET and in FET group, the ß-hCG levels were significantly higher in pregnancies resulting in live birth compared to non-viable pregnancies (1,035 vs. 462 IU/L, p < 0.001 and 968 vs. 411 IU/L, p < 0.001). Optimal cut-off level for live birth prediction was 495 IU/L (sensitivity 83.0 %, specificity 71.8 %) after ET and 527 IU/L (sensitivity 80.0 % and specificity 76.6 %) after FET. The PPV for live birth rate in the groups after ET and FET were 90.6 % and 84.9 % respectively, without statistically significant difference (p > 0.05). CONCLUSION: Beta-hCG levels after fresh and vitrified-warmed blastocyst transfer are equally predictive for pregnancy outcome. Clinicians can be encouraged to interpret ß-hCG results in the same manner.

Evaluation of coagulation abnormalities among women with vaginal bleeding in the first trimester of pregnancy.

OBJECTIVE: To compare blood coagulation parameters between pregnant women with vaginal bleeding in the first trimester of pregnancy and pregnant women with normal pregnancy in the first trimester. METHODS: A prospective controlled study of 98 women in the first trimester of vital pregnancy was conducted at the University Medical Centre Maribor, Slovenia. The study group comprised women with vaginal bleeding (n=50) while the control group women with normal pregnancy, admitted for artificial abortion (n=48). Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen concentration, number of platelets, hemogram, coagulation factor VIII (FVIII) and von Willebrand factor (VWF) activity were compared between the 2 groups. RESULTS: No significant between-group differences were detected in mean PT, fibrinogen concentration, FVIII, and VWF activity. Mean aPTT was significantly higher in the control group than the study group (32.47 versus 30.46 seconds; P<0.05). The mean number of platelets was significantly lower in the study group than the control group (181.69 versus 203.52×10(9)/L; P<0.05). All measured coagulation parameters, except VWF activity, were within normal ranges. CONCLUSION: Coagulation abnormalities are rarely the cause of vaginal bleeding in the first trimester of pregnancy among women with no previous symptoms of bleeding disorders.

Clinical use of pentoxifylline for activation of immotile testicular sperm before ICSI in patients with azoospermia.

The testicular sperm from biopsy and frozen/thawed tissue are frequently immotile. The purpose of our retrospective study was to assess the effect of short exposure of testicular samples with only immotile sperm to pentoxifylline (PF)-sperm motility stimulator. In 77 of 294 (26.2%) testicular sperm ablation/testicular sperm extraction-intracytoplasmic sperm injection (TESA/TESE-ICSI) cycles in patients with azoospermia, only immotile sperm were found in biopsies even after 2 hours of incubation of tissue in the medium. These 77 cycles were divided into 2 groups. In group 1 (cycles between 1999 and 2001; n = 30), ICSI was performed with untreated immotile sperm. In group 2 (cycles between 2002 and 2004; n = 47), immotile testicular sperm were treated for 20 minutes with pentoxifylline (PF) (1.76 mM) before ICSI. Both groups had the same proportion of ICSI cycles with fresh, frozen/thawed, and aspirated testicular sperm. The overall pregnancy rate of TESA/TESE-ICSI did not vary during the study period. In 45 of 47 (95.7%) testicular samples with total immotility, the sperm started to move 20 minutes after PF treatment. The mean time required for ICSI was shortened in the PF group (30 minutes [minimum 10, maximum 90] vs 120 minutes [minimum 60, maximum 240]) due to easier identification of motile sperm. In comparison with the nontreated group, the PF group had a higher fertilization rate (66% vs 50.9%; P < .005) and mean number of embryos per cycle (4.7 +/- 3.3 vs 2.7 +/- 2.1; P < .01). The clinical pregnancy rate per cycle in PF and non-PF groups was 38.3% and 26.7%, respectively. By using PF in cases of only immotile testicular sperm we can cause movement of testicular sperm, allow easier identification of vital sperm, shorten the procedure, improve fertilization rates, and increase the number of embryos.

Developmental capacity of different morphological types of day 5 human morulae and blastocysts.

After prolonged culture of human embryos, the expanded blastocysts with oval inner cell mass (ICM) and cohesive trophectoderm (TE) are preferably selected for transfer. In cycles with poor embryonic development, the selection has to be done from among suboptimal blastocysts for which no grading system exists. In this study, 1396 transferred blastocysts and morulae were classified into eight morphologic categories. The B1 category constituted the optimal blastocysts. The other categories were characterized by different deviations from optimal blastocysts: cytoplasmic fragments and necrosis in TE (B2), unexpanded blastocoele (B3), non-compact or small ICM (B4), fragments in TE and ICM (B5), up to 20% excluded blastomeres (B6), necrotic TE and ICM (B7), and more than 20% excluded cells from blastocysts (B8). The live birth rate was calculated from blastocysts with known outcome after transfer (88.9% transferred blastocysts). The birth rate declined from B1 to B8 by the same order and was: 45.2, 32.8, 26.9, 23, 17.7, 16.7, 7.7 and 1.2% respectively. Normal ICM was recognized as the most important parameter for implantation. There was a strong relation between such ordered morphology categories and implantation capacity (P < 0.0001). Such a grading system is helpful in selecting the best of all available day-5 embryos for transfer.

Comparable effectiveness using flexible single-dose GnRH antagonist (cetrorelix) and single-dose long GnRH agonist (goserelin) protocol for IVF cycles--a prospective, randomized study.

This prospective randomized study compared the effectiveness of a flexible single-dose gonadotrophin-releasing hormone (GnRH) antagonist (cetrorelix) and a single-dose long GnRH agonist (goserelin) protocol for ovarian stimulation in IVF/intracytoplasmic sperm injection (ICSI) cycles. All patients from the waiting list were successively included in the study, pre-programmed with an oral contraceptive, and randomized into goserelin and cetrorelix groups. Depending on the date on which their menstrual period started, patients took oral contraceptives for one or two cycles. Ultimately, 236 patients in the first group received a single dose of depot preparation of goserelin and 224 patients received a single 3 mg dose of cetrorelix in the late follicular phase, when the mean follicle diameter exceeded 12 mm. The mean number of ampoules of FSH and the duration of stimulation was statistically significantly lower in the cetrorelix group than in the goserelin group (25.9 versus 34.5, and 9.6 versus 12.2 days, P < 0.01). The mean number of oocytes retrieved was similar (6.7 +/- 4.5 versus 7.2 +/- 4.6, NS). Similar results were observed in fertilization rates, blastulation rates and blastocyst transfer rates in both groups. Clinical pregnancy and delivery rates per cycle were higher in the goserelin group (34.3 and 30.1%) than in the cetrorelix group (31.9 and 28.3%), but the differences were not statistically significant. The flexible single-dose GnRH antagonist protocol is an advantageous alternative to the long GnRH agonist protocol, with similar efficacy, shorter duration, a significant reduction in the number of FSH ampoules used and without the menopause-like effects of the GnRH antagonist.

Results of intracytoplasmic sperm injection of single oocyte in 362 unstimulated cycles.

PURPOSE: The purpose was to test the adequacy of unstimulated cycles for intracytoplasmic sperm injection (ICSI) and to evaluate implantation and pregnancy rates in three different age groups. METHODS: ICSI was performed in 362 unstimulated cycles in women up to 45 years old. All cycles were monitored by serum estradiol, urinary LH, and ultrasound. RESULTS: The delivery rate per started cycle was higher in patients younger than 36 (9.4%) than in cycles with patient's age between 36 and 39 years (4.8%) or older than 40 (4.6%) but the difference was not statistically significant. In all groups, the fertilization rate was similar (70.4, 77.6, and 84.8%, respectively). The pregnancy rate per cycle and the pregnancy rate per puncture was similar in the group of patients in age between 36 and 39 years (8.3 and 9.7%) and those older than 40 (7.7 and 9.3%). CONCLUSIONS: Unstimulated cycles monitored by serum estradiol, urinary LH, and ultrasound can produce an acceptable pregnancy rate after ICSI procedure only in patients younger than 36.

Clinical outcome of day 2 versus day 5 transfer in cycles with one or two developed embryos.

OBJECTIVE: To determine whether extended culture of embryos to blastocysts has any benefit in cycles with only one or two created embryos. DESIGN: Retrospective analysis of cycles comparing outcomes of day 2 and day 5 transfers. Our day 2 group was from the year 1999 and our day 5 group, from the year 2000. SETTING: Assisted reproductive technology program of a teaching hospital. PATIENT(S): All patients, irrespective of age, who had developed one or two embryos. INTERVENTION(S): Stimulated IVF, intracytoplasmic sperm injection, or testicular sperm extraction and intracytoplasmic sperm injection cycles with 2-day culture in universal IVF medium (n = 133) or 5-day culture in BlastAssist media (MediCult, Jyllinge, Denmark; n = 132). MAIN OUTCOME MEASURE(S): Pregnancy, implantation, and take-home baby rates. RESULT(S): In the groups of 2-day and 5-day culture, embryo transfer was performed in 98% and in 57% of cycles, respectively. However, the total implantation rate per created embryo (18% vs. 18%), the pregnancy rate per cycle (23% vs. 21%), and the take-home baby rate (69.4% vs. 71.4%) did not differ between the day 2 and day 5 groups. CONCLUSION(S): Extended culture of embryos does not improve or decrease their capacity for implantation but only allows for better selection and is therefore not necessary in cycles with fewer than three embryos.