Endometrial thickness as a predictor of the reproductive outcomes in fresh and frozen embryo transfer cycles: A retrospective cohort study of 1512 IVF cycles with morphologically good-quality blastocyst

The entire range of trigger-day endometrial thickness in fresh IVF cycles is independently correlated with live birth rate

RESEARCH QUESTION

What is the association of the entire range of trigger-day endometrial thickness (EMT) with live birth rate (LBR) after IVF and fresh embryo transfer? Although EMT is amenable to convenient non-invasive routine measurement, studies of the association between pre-trigger EMT and assisted reproductive technology outcome have yielded equivocal results.

DESIGN

A cohort of IVF fresh day-3 embryo transfers in patients aged 42 years and younger in a single centre between 2009 and 2017. The LBR was calculated for all trigger-day EMT values, stratified into five groups overall and within subgroups of patient age and ovarian response. Univariate analysis and multivariate logistic regression models were used to compare the LBRs at different EMT measurements adjusting for various independent variables.

RESULTS

A total of 5133 cycles were included. The LBRs were as follows: 11.22% (35/312) in cycles with EMT 6 mm or less, 17.98% (380/2114) in cycles with EMT 7-9 mm, 23.44% (476/2031) in cycles with EMT 10-12 mm, 25.62% (144/562) in cycles with EMT 13-15 mm and 34.21% (39/114) in cycles with EMT 16 mm or more (P < 0.001). Similar findings were observed by patient age and ovarian response. The observation was confirmed by multivariate logistic regression analysis in which the EMT was found to be a significant independent predictor of LBR even after controlling for various confounders (OR 0.935, 95% CI 0.908 to 0.962; P < 0.001).

CONCLUSIONS

Pre-trigger EMT is in significant independent correlation with LBR, even after adjusting for age and ovarian response. Maximal endometrial proliferation is beneficial, and fresh embryo transfer can be carried out at high EMT values without endangering the outcome of the cycle.

Predictive factors for successful pregnancy in an egg-sharing donation program

Objective

To investigate the predictive factors for successful pregnancy in oocyte recipient ICSI cycles in an egg-sharing donation program.

Methods

Analysed data were obtained via chart review of 1505 vitrified oocytes donated from 268 patients to 225 oocyte recipients, undergoing 307 ICSI cycles. Patients were participating in an egg-sharing donation program between January 2015 and May 2017. Adjusted generalised linear models were used to investigate the impact of oocyte donor and recipient characteristics on recipients’ pregnancy achievement.

Results

Implantation rate in the oocyte donor was highly correlated with pregnancy achievement in the oocyte recipient’s cycles (ExpB: 1.181, CI: 1.138-1.226, p<0.001). The ROC curve analysis demonstrated that the implantation rate in the oocyte donor has a strong predictive value for pregnancy success in the oocyte recipient (area under the curve: 0.98, CI: 0.95-0.99, p<0.001). Pregnancy in oocyte donors and recipients were highly associated (ExpB: 54.6, CI: 28.1-105.8, p<0.001), regardless of the oocyte recipient’s age. In oocyte recipients, the high-quality embryos rates on days 2 (ExpB: 3.397, CI: 1.635-7.054, p=0.001) and 3 (ExpB: 6.629, CI: 1.185-37.092, p=0.031), and blastocyst development rates (ExpB: 2.331, CI: 1.086-5.001, p=0.030) were positively associated with pregnancy outcome.

Conclusion

The strong association in pregnancy success between donors and recipients, and the lack of correlation between donor characteristics and cycles’ outcomes, demonstrate the power of oocyte quality on the success of ICSI treatment.

Does the ultrasound appearance of the endometrium during treatment with assisted reproductive technologies influence pregnancy outcomes?

We evaluated endometrial pattern, defined as the relative echogenicity of the endometrium on a longitudinal uterine ultrasonic section, as a surrogate for endometrial receptivity in an attempt to evaluate the association between endometrial pattern and pregnancy outcome in women who underwent ART treatment. The primary outcome was live birth and secondary outcomes were clinical intrauterine pregnancy and miscarriage. Potential associations were evaluated using cluster-weighted generalized estimating equations to account for within-couple correlation among repeated ART cycles while adjusting for potentially confounding variables. There were 1034 ART cycles with embryo transfer (778 fresh, 256 frozen) among 695 women (median age: 31.0 (6.0) years). The average number of embryos transferred per cycle was 2.1. The clinical intrauterine pregnancy rate per transfer was 56.0% for fresh and 54.3% for frozen cycles. The overall live birth rate per embryo transfer was 48.4%. Live birth rates were unchanged when the endometrium was semi-trilinear (RR:0.91 CI:0.74,1.12) or unilinear (RR:1.15 CI:0.89,1.49) in comparison to trilinear endometrium after controlling for potentially confounding variables. Results were similar when analysed separately for fresh and frozen cycles and when evaluating associations with clinical intrauterine pregnancy and miscarriage rates. It appears that endometrial pattern does not significantly affect live birth in ART and our data do not support cancelling an ART cycle if the endometrium is less than trilinear.

Major Factors Affecting the Live Birth Rate After Frozen Embryo Transfer Among Young Women

In recent years, the freeze-all strategy has been widely adopted and applied. However, with the exception of age, the factors that affect the outcomes of frozen embryo transfer are still unclear. Therefore, the identification and mitigation of factors that influence the live birth rate after frozen embryo transfer is a good way to increase the "take-home-baby" rate of frozen embryo transfer. The objective of this study was to identify factors affecting the live birth rate after cleavage-stage frozen embryo transfer in young ovulatory women. This was a secondary analysis from a previously published multicenter randomized controlled trial (ChiCTR-IOR-14005406) that was originally designed to compare the live birth rate and perinatal complications after fresh embryo transfer to those after frozen embryo transfer among ovulatory women. This study was carried out using a portion of the data from the original randomized controlled trial, which included 917 young women who underwent cleavage-stage frozen embryo transfer. The 16 clinical candidate variables potentially affecting the live birth rate after frozen embryo transfer were analyzed. Univariable analysis and multivariable analysis were performed to assess the relationship between predictive factors and outcomes, with the aim of identifying independent predictors of live birth after frozen embryo transfer. In this study, the live birth rate was 53.0% (486/917). Three independent predictors were ultimately identified as the main factors affecting the live birth rate of ovulatory young women. Infertility duration [odds ratio (OR): 0.933, 95% confidence interval (CI): 0.876-0.995, p = 0.033], endometrial thickness before frozen embryo transfer (OR: 3.375, 95% CI: 1.556-7.321 p = 0.002), and the number of embryos transferred (OR: 2.653, 95% CI:1.226-5,743, p = 0.013) were the major factors contributing to the live birth rate after cleavage-stage frozen embryo transfer among young women. The cut-off point for infertility duration was 4.5 years, and the cut-off point for endometrial thickness was 0.89 cm. Infertility duration, endometrial thickness and number of embryos transferred might affect the live birth rate after frozen embryo transfer among young women. This result could help inform clinical decisions and counseling to increase the live birth rate after frozen embryo transfer among young women.

The effect of icariin for infertile women with thin endometrium: A protocol for systematic review

BACKGROUND

Thin endometrium, defined as <7 mm of the endometrial thickness around ovulation period, had been identified as a negative factor on pregnancy rate of infertile women. It was considered to be the toughest part in treatment of infertility, because there was a lack of significant effect, although many drugs had been already used. Icariin was one of the major bioactive pharmaceutical constituent extracted from the Chinese herb "Ying Yang Huo," in the genus of Epimedium, and some randomized controlled trials reported its application for thin endometrium. There is no systematic review focusing on the effective of icariin in treating infertile women with thin endometrium, so our review aims to explore it.

METHODS

The bibliographic database and electronic library will be systematically searched online, such as MEDLINE, EMBASE, Web of Science, Clinicaltrails.org., China National Knowledge Infrastructure Database (CNKI), Wan fang Database, China Biology Medicine Database (CBM), VIP Science Technology Periodical Database, and Cochrane Library. And the reference listed for potential literatures of included studies will be scanned additionally. Related randomized controlled trials (RCTs) will be collected and selected before January 4, 2020. Trials will be screened by independent reviewers, and the literature will be search in English or Chinese, with the search terms as "Icariin," "Epimedium," "infertile women," "female infertility," "endometrium," "pregnancy rate." The software for Systematic review and Meta-analysis is RevMan 5.3. The protocol and the systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement.

RESULT AND CONCLUSION

The efficacy of icariin to treat thin endometrium will be evaluated, and the conclusion will be published to help clinicians determine treatment strategy for infertile women with thin endometirum by providing medical evidence.

REGISTRATION INFORMATION

PROSPERO CRD42019148977.

Thin endometrium problem in IVF programs

METHODS

Observational, comparative, prospective, multicenter study (n = 425). Group 1 (n = 228) received estradiol hemihydrate (Divigel, Orion Corporation, Finland), group 2 (n = 197) received oral estradiol valerate (Proginova, Delpharm Lille, France).

RESULTS

An increase in endometrial thickness was comparable (10.1 (2.0) mm versus 10.0 (2.3) mm; p = .571). There was significantly shorter mean duration of estrogen therapy (13.9 (3.9) days versus 14.7 (4.7) days; p = .038) and lower total dose in group 1 (43.6 (27.3) mg versus (71.9 (37.2) mg; p = .0001). Pregnancy rates were comparable (143/228 (62.7%) versus 105/197 (53.3%); p = .077) so as "take home baby" rates (80/228 (35.1%) versus 68/197 (34.5%); p = .077).

CONCLUSION

Estrogens improve the state of the endometrium and increase pregnancy rates in cases of thin endometrium in in vitro fertilization programs. The use of transdermal estrogens (Divigel, Orion Corporation, Finland) ensures an adequate increase in endometrial thickness and significantly lower estrogen doses.

Effect of Endometrial Thickness Change in Response to Progesterone Administration on Pregnancy Outcomes in Frozen-Thawed Embryo Transfer: Analysis of 4465 Cycles

OBJECTIVE

To evaluate whether endometrial thickness (EMT) change in response to progesterone has an effect on pregnancy outcomes in frozen-thawed embryo transfer (FET) cycles.

DESIGN

Retrospective observational study.

SETTING

Tertiary-care academic medical center.

PARTICIPANTS

4465 infertile women undergoing their first FET between January 2010 and December 2015 in our center.

METHODS

This observational study included 4465 patients undergoing their first FET cycles between January 2010 and December 2015. EMT was measured by transvaginal ultrasound one day before progesterone administration and on the day of FET to observe EMT change.

MAIN OUTCOME MEASURES

Clinical pregnancy rate (CPR) and the live birthrate (LBR) was discussed.

RESULTS

Regardless of the endometrial preparation protocols such as artificial cycle, estrogen-progesterone replacement therapy (EP) or natural cycle (NC), EMT may increase, decrease or remain stable on the day of FET compared with that of one day before progesterone administration. CPR in EMT increase, decrease and stable groups were 48.4%, 51.3% and 50.7% in EP cycle versus 49.2%, 52.0% and 48.9% in NC cycle, showing no significant difference between the three groups in both cycles (P= 0.48, P= 0.49). LBR was 40.9%, 45.9% and 42.6% in EP cycle versus 44.2%, 44.8% and 42.1% in NC cycle, also showing no significant difference between the three groups in both cycles (P= 0.16, P= 0.66). In addition, CPR and LBR were not significantly associated with EMT increase.

CONCLUDES

EMT may increase, decrease or remain stable on the day of FET as compared with that of one day before progesterone administration. Whatever change in EMT that occurs after progesterone administration has no significant effect on CPR and LBR in FET cycles.

Analysis of the Number of Euploid Embryos in Preimplantation Genetic Testing Cycles With Early-Follicular Phase Long-Acting Gonadotropin-Releasing Hormone Agonist Long Protocol

Studies have shown that early-follicular phase long-acting gonadotropin-releasing hormone (GnRH) agonist long protocol (EFLL), a popular controlled ovarian hyperstimulation protocol widely used in China, leads to higher rates of implantation and clinical pregnancy, as well as lower rates of spontaneous abortion and ectopic pregnancy in patients undergoing in vitro fertilization treatment. However, the impact of EFLL on euploid embryos and its underlying mechanisms remain unclear. To address these gaps of knowledge, we conducted a retrospective comparative study of 310 preimplantation genetic testing (PGT) cycles with a total of 1,541 embryos using the EFLL protocol or midluteal short-acting GnRH agonist long protocol (MLSL). Patients were matched by PGT subtype [aneuploidies (PGT-A) vs. PGT for chromosomal structural rearrangements (PGT-SR)], age (±2 years), and body mass index (±1 kg/m²). For PGT-A, there was no significant difference in the number of euploid embryos (1.80 ± 1.47 for EFLL vs. 1.84 ± 2.03 for MLSL, p > 0.05) or the rate of euploidy (44.6 vs. 36.9%, p > 0.05). For PGT-SR, the number of euploid embryos in the EFLL group was significantly higher than that in the MLSL group (1.76 ± 1.54 vs. 1.21 ± 1.24, p < 0.05). A higher euploidy rate was also observed with the EFLL protocol compared with that obtained in MLSL (31.9 vs. 25.7%), although the difference was not statistically significant (p > 0.05). Compared with the MLSL protocol, more euploid embryos were achieved when using the EFLL protocol in PGT-SR, demonstrating the value in PGT-SR. To the best of our knowledge, this study is the first one to compare embryonic outcomes between EFLL and MLSL, providing key insights into the clinical application of EFLL in PGT cycles. In the light of the limited sample size of our study, we recommend that these questions be explored using a larger prospective study.

The Potential Role of Growth Hormone on the Endometrium in Assisted Reproductive Technology

Growth hormone (GH) has been considered as an adjuvant treatment in human assisted reproductive technology (ART) for several years. Its action was largely attributed to an improvement of ovarian function and less emphasis was paid to its role in the uterus. However, there is increasing evidence that GH and its receptors are expressed and have actions in the endometrium and may play an important role in modifying endometrial receptivity. Thus, in this review, we firstly describe the existence of GH receptors in endometrium and then summarize the effects of GH on the endometrium in clinical situations and the underlying mechanisms of GH in the regulation of endometrial receptivity. Finally, we briefly review the potential risks of GH in ART and consider rationalized use of GH treatment in ART.

Efficacy and safety of platelet-rich plasma for the treatment of thin endometrium: A protocol for systematic review and meta-analysis

BACKGROUND

Endometrial thickness has been identified as a prognostic factor for pregnancy rate for patients with female infertility. Thin endometrium is defined as <7 mm on the day of ovulation, or on the day of human chorionic gonadotrophin (HCG) injection in fresh in vitro fertilization (IVF) cycles, or the day to start progesterone in frozen-thaw embryo transfer cycles, as stated in the guideline of thin endometrium from the Canadin Fertility and Andrology Society and Chinese expert consensus from the Society of Reproductive Medicine, Chinese Medical Association. Many medicines are used for improving the endometrial thickness and embryo implantation rate of the patients with thin endometirum, but thin endometrium remains a major troublesome clinical problem with limited efficacy.Platelet-rich plasma (PRP), as a growing and robust therapeutic option in musculoskeletal medicine, is a preparation of autologous plasma with a high concentration of platelets, and the therapeutic mechanism is based on the capacity to supply supra physiologic amounts of essential growth factors to provide a regenerative stimulus for promoting repair in tissues with low healing potential. Some randomized controlled trials have reported the application of PRP for patients with thin endometrium with satisfactory effect. However, there is no systematic review on efficacy and safety of PRP as a treatment of thin endometrium.

METHODS

The data and information will be retrieved from the databases of MEDLINE, Embase, Web of Science, Clinicaltrials.org., Cochrane Library, China Biology Medicine Database, Wan Fang Database, China National Knowledge Infrastructure Database, VIP Science Technology Periodical Database, and OpenGrey for gray literature. The randomized controlled clinical trials are going to be selected before December 20, 2019, in English or Chinese language, with the search terms including "thin endometrium,""platelet-rich plasma," "endometrial thickness," "hemorheology of endometrium," "pregnancy rate," and "adverse reactions." RevMan 5.3 will be used for systematic review and meta-analysis. This protocol will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement, and the systematic review will be reported with the PRISMA statement.

RESULTS AND CONCLUSION

The efficacy and safety of PRP for the treatment of thin endometrium will be evaluated, and the conclusion will be published to provide medical evidence for a better clinical decision of patients with thin endometirum.

Cross-linked hyaluronan gel to improve pregnancy rate of women patients with moderate to severe intrauterine adhesion treated with IVF: a randomized controlled trial

PURPOSE

To evaluate whether the cross-linked hyaluronan (cHA) gel can improve the clinical pregnancy rate of patients with moderate to severe intrauterine adhesion (IUA) who underwent operative hysteroscopy followed by embryo transfer.

METHODS

Women with moderate to severe IUA desiring to undergo embryo transfer were recruited in this randomized controlled trial. The patients were randomized on the day of receiving hysteroscopy. The control group received standard hysteroscopy, while cHA gel was applied to the treatment group at the end of hysteroscopy and 5-7 days after operation. All patients were expected to undergo in vitro fertilization (IVF)/intracytoplasmic sperm injection and frozen-thawed embryo transfer (FET).

RESULTS

A total of 306 patients were enrolled in this study, of which 202 were assigned to the treatment group and 104 to the control group. Both the clinical pregnancy rate (26.3% [49/186] vs. 15.3% [13/85], P = 0.045), the implantation rate (17.7% [57/322] vs. 9.8% [15/153], P = 0.025), and the endometrial thickness on the day of embryo transfer (7.97 ± 1.37 vs. 7.50 ± 0.60 mm, P < 0.001) were significantly higher in the treatment group compared to the control group. In addition, histological assessment of the paired endometrial tissues collected before and after operation revealed a relatively higher number of tubular glands after operation (15.1 ± 13.2 vs. 28.8 ± 30.4, P = 0.166).

CONCLUSIONS

To conclude, the application of cHA gel in patients with moderate to severe IUA during hysteroscopy can improve the quality of endometrium and uterine receptivity and consequently enhance the clinical pregnancy rate after IVF/CSI and FET.

Embryo transfer strategy and therapeutic options in infertile patients with thin endometrium: a systematic review

Human endometrium has a key role in implantation process. The measurement of endometrial thickness is the most commonly used in clinical practice. Managing patients with thin endometrium still represents a major challenge for clinicians. The objective of this systematic review was to investigate all available interventions to improve endometrial thickness (EMT) in women with history of thin endometrium undergoing fresh or frozen-thawed embryo transfers (ET). We performed a comprehensive search of relevant studies from January 1978 to February 2018. The different strategies were categorized as hormonal, vascular, and growth factor approaches and specifically analyzed according to the type of ET. Thirty-one studies were included. Overall, quality of the evidence ranged from very low to moderate, with only few randomized controlled trials that support the use of either GnRH analogues in fresh ET or sildenafil in frozen ET for enhancing endometrial growth. Besides, intensified estradiol administration is a common approach that might improve EMT in frozen ET. The present review evidences the paucity of reliable data regarding the efficiency of different interventions aiming at increasing EMT before fresh or frozen-thawed ET. Robust and high-quality randomized controlled trials are still needed before guidelines can be established.

Whole Transcriptome Sequencing Reveals How Acupuncture and Moxibustion Increase Pregnancy Rate in Patients Undergoing In Vitro Fertilization-Embryo Transplantation

Background

In vitro fertilization and embryo transfer (IVF-ET) technology has been widely used in the therapy of refractory infertility. Previous studies showed that acupuncture can effectively increase the clinical pregnancy rate of IVF-ET. However, the molecular mechanism is unknown.

Materials and Methods

In this study, we performed whole transcriptome sequencing for endometrial samples from infertile women who underwent acupuncture and moxibustion therapy or not. Differentially expressed noncoding RNAs (ncRNAs) and mRNAs were identified and their functions were predicted. Besides, a competitive endogenous RNA network was constructed to further interpret the molecular mechanism of acupuncture and moxibustion therapy on infecund patients. In addition, real-time PCR was applied to validate the RNA-seq results.

Results

We identified 317 differentially expressed mRNAs and 82 ncRNAs in acupuncture and moxibustion therapy group compared with control group. Functional enrichment analysis suggested that these genes were significantly enriched in GO-BP terms associated with cellular transport, such as ATP hydrolysis coupled proton transport, vacuolar acidification, transferrin transport, and proton transport and metabolic process, including small molecule metabolic process and metabolic process. Pathway enrichment analysis enriched 11 terms, including oxidative phosphorylation, synaptic vesicle cycle, mineral absorption, and metabolic pathways. Four of five selected differentially expressed genes were validated by real-time PCR.

Conclusion

Our results suggested that acupuncture and moxibustion therapy might increase the pregnancy rate of patients undergoing IVF-ET by the regulation of ncRNAs.

Predictive factors for biochemical pregnancy in intracytoplasmic sperm injection cycles

The aim of this study was to investigate which factors contribute to the incidence of biochemical pregnancy (BP) in intracytoplasmic sperm injection (ICSI) cycles. This cohort study included cycles performed from June 2010 to September 2016 in a private, university-affiliated IVF centre. Cycles were split into four groups, depending on the pregnancy outcomes: Clinical Pregnancy (CP, n = 903), Biochemical Pregnancy (BP, n = 55), Miscarriage (MI, n = 142) and Negative Pregnancy (NP, n = 2034). The effects of ovarian stimulation, laboratory data and seminal parameters on pregnancy outcomes were evaluated using adjusted general linear models. Discriminant analyses were conducted to construct a model for pregnancy prediction and to establish cut-offs for BP. The total sperm count (p = 0.035), total and progressive sperm motility (p = 0.001 and p = 0.023, respectively), total motile sperm count (TMSC, p = 0.029) and the endometrial thickness (p < 0.001) were lower among BP group cycles. Lower rates of high-quality cleavage-stage embryos were observed in the BP group compared to CP and MI groups (p < 0.001). In discriminant analyses, cut-offs for BP prediction were established for the following factors: endometrial thickness < 11 mm, sperm motility < 55.5% and total dose of follicle-stimulating hormone (FSH)> 2400 IU. The incidence of biochemical pregnancy was four times higher when the aforementioned factors did not meet the defined cut-offs. The combination of suboptimal endometrial development and poor seminal and embryo quality contribute to an increased incidence of biochemical pregnancy in ICSI cycles.

Ideal embryo transfer position and endometrial thickness in IVF embryo transfer treatment

OBJECTIVE

To establish an ideal transfer strategy by investigating the relationships among embryo transfer (ET) depth, endometrial thickness, and subsequent in vitro fertilization treatment clinical pregnancy outcomes.

METHODS

In the present retrospective analysis, data from in vitro fertilization-ET treatment cycles conducted at a fertility center in Shanghai, China, between October 2014 and March 2015 were analyzed. Women were divided into groups 1-4 according to transfer depth (<10; 10-15, 15-20, and >20 mm, respectively), as measured by air bubbles. Additionally, 391 women were divided into groups A-C according to endometrial thickness (<7, 1-12, and >12 mm, respectively). Clinical pregnancy outcomes were assessed by group.

RESULTS

Data from 501 cycles were included. Clinical pregnancy and live delivery rates were significantly higher in group 2 (P=0.009 and P=0.002, respectively) and group 3 (P=0.008 and P=0.001, respectively) than in group 4. Among the 394 patients with endometrial thickness data available, clinical pregnancy and live delivery rates were higher in group B (P=0.028 and P=0.015, respectively) and group (P=0.013 and P=0.013, respectively) than in group A.

CONCLUSION

Correct transfer depth and endometrial thickness can increase the rates of clinical pregnancy, implantation, and live delivery. Placing the embryos at 10-20 mm from the fundus and at an endometrial thickness of more than 7 mm is recommended for optimal clinical pregnancy outcomes.