Embryo selection criteria based on morphology VERSUS the expression of a biochemical marker (sHLA-G) and a graduated embryo score: prediction of pregnancy outcome

Evaluation of Maternal Serum sHLA-G Levels for Trisomy 18 Fetuses Screening at Second Trimester

Human leukocyte antigen-G (HLA-G) has been widely acknowledged to play critical roles in fetal-maternal maintenance. However, the significance of using maternal serum sHLA-G to detect prenatal chromosomal abnormality has not been investigated. In China, prenatal screening using maternal α-fetoprotein (AFP), unconjugated estriol (uE3), and free β subunit human chorionic gonadotropin (β-hCG) in the second trimester has been widely applied. In this study, we evaluated the use of sHLA-G as a screening marker, compared with traditional second trimester prenatal screening. Serum samples from 1,019 singleton women in their second trimester were assessed. Among them, 139 infants were confirmed with trisomy 21 (T21) by karyotyping, 83 were confirmed with trisomy 18 (T18), and the remaining 797 infants had no abnormalities. The sHLA-G levels in maternal sera were significantly lower in pregnant women with T18 fetuses (median: 47.8 U/ml, range: 9.8-234.2 U/ml) and significantly higher in those with T21 fetuses (median: 125.7 U/ml, range: 28.7-831.7 U/ml), compared with the normal controls (median: 106.3 U/ml, range: 50.5-1136.4 U/ml) (p < 0.001). The risk values of the screening of T21 or T18 fetuses were assessed using mean and standard deviation log₁₀ analyte multiples of median (MoM) which showed that the predictive values of sHLA-G were the same as free β-hCG, and superior to AFP and uE3 for T18 screening. Logistic regression analysis revealed that sHLA-G MoM was the highest risk factor associated with pregnant women carrying T18 fetuses [Exp(B): 171.26, 95% CI: 36.30-807.97, p < 0.001]. Receiver operating characteristic (ROC) analysis revealed that the area under ROC curve for sHLA-G MoM was 0.915 (95% CI, 0.871-0.959, p < 0.001), for AFP MoM was 0.796 (95% CI, 0.730-0.861, p < 0.001), for free β-hCG MoM was 0.881 (95% CI, 0.829-0.934, p < 0.001), and for uE3 MoM was 0.876 (95% CI, 0.828-0.923, p < 0.001) in the T18 group. sHLA-G MoM demonstrated the best sensitivity and negative predictive value. For the first time, our findings reveal that sHLA-G is a better second trimester screening marker for the detection of T18 fetuses and the combined application of sHLA-G with AFP, free β-hCG, and uE3 could improve clinical screening for T18 fetuses.

Necessity is the mother of invention and the evolutionary force driving the success of in vitro fertilization

During the last few decades, millions of healthy children have been born with the aid of in vitro fertilization (IVF). This success belies the fact that IVF treatment is comprised of a complex series of interventions starting with a customized control ovarian stimulation protocol. This is followed by the induction of oocyte maturation, the retrieval of mature oocytes and in vitro fertilization, which often involves the microinjection of a single sperm into the oocyte. After fertilization, the resulting embryos are cultured for up to 7 days. The best embryos are transferred into the uterus where the embryo implants and hopefully develops into a healthy child. However, frequently the best embryos are biopsied and frozen. The biopsied cells are analyzed to identify those embryos without chromosomal abnormalities. These embryos are eventually thawed and transferred with pregnancy rates as good if not better than embryos that are not biopsied and transferred in a fresh cycle. Thus, IVF treatment requires the coordinated efforts of physicians, nurses, molecular biologists and embryologists to conduct each of these multifaceted phases in a seamless and flawless manner. Even though complex, IVF treatment may seem routine today, but it was not always the case. In this review the evolution of human IVF is presented as a series of innovations that resolved a technical hurdle in one component of IVF while creating challenges that eventually lead to the next major advancement. This step-by-step evolution in the treatment of human infertility is recounted in this review.

Can Comprehensive Chromosome Screening Technology Improve IVF/ICSI Outcomes? A Meta-Analysis

Objective

To examine whether comprehensive chromosome screening (CCS) for preimplantation genetic screening (PGS) has an effect on improving in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes compared to traditional morphological methods.

Methods

A literature search was conducted in PubMed, EMBASE, CNKI and ClinicalTrials.gov up to May 2015. Two reviewers independently evaluated titles and abstracts, extracted data and assessed quality. We included studies that compared the IVF/ICSI outcomes of CCS-based embryo selection with those of the traditional morphological method. Relative risk (RR) values with corresponding 95% confidence intervals (CIs) were calculated in RevMan 5.3, and subgroup analysis and Begg’s test were used to assess heterogeneity and potential publication bias, respectively.

Results

Four RCTs and seven cohort studies were included. A meta-analysis of the outcomes showed that compared to morphological criteria, euploid embryos identified by CCS were more likely to be successfully implanted (RCT RR 1.32, 95% CI 1.18–1.47; cohort study RR 1.74, 95% CI 1.35–2.24). CCS-based PGS was also related to an increased clinical pregnancy rate (RCT RR 1.26, 95% CI 0.83–1.93; cohort study RR 1.48, 95% CI 1.20–1.83), an increased ongoing pregnancy rate (RCT RR 1.31, 95% CI 0.64–2.66; cohort study RR 1.61, 95% CI 1.30–2.00), and an increased live birth rate (RCT RR 1.26, 95% CI 1.05–1.50; cohort study RR 1.35, 95% CI 0.85–2.13) as well as a decreased miscarriage rate (RCT RR 0.53, 95% CI 0.24–1.15; cohort study RR 0.31, 95% CI 0.21–0.46) and a decreased multiple pregnancy rate (RCT RR 0.02, 95% CI 0.00–0.26; cohort study RR 0.19, 95% CI 0.07–0.51). The results of the subgroup analysis also showed a significantly increased implantation rate in the CCS group.

Conclusions

The effectiveness of CCS-based PGS is comparable to that of traditional morphological methods, with better outcomes for women receiving IVF/ICSI technology. The transfer of both trophectoderm-biopsied and blastomere-biopsied CCS-euploid embryos can improve the implantation rate.

Omics as a window to view embryo viability

The advent of advanced omics technologies and the application of these techniques to the analysis of extremely limited material have opened the door to the investigation of embryo physiology in a focused, in-depth approach never before possible. The application of noninvasive metabolomic and proteomic platforms to understanding embryo viability permits the characterization of individual embryos in culture. Initial clinical data have highlighted the promise of these technologies for the development of noninvasive embryo selection criteria. In this way, a complex view of embryo function can be compiled and related to embryo development, quality, and outcome. Application of knowledge gained from omics will transform both our understanding of embryo physiology as well as our ability to select viable embryos for transfer in assisted reproductive technology.

Serum progesterone elevation adversely affects cumulative live birth rate in different ovarian responders during in vitro fertilization and embryo transfer: a large retrospective study

In order to explore the relationship between serum progesterone (P) level on the day of human chorionic gonadotrophin (HCG) administration and cumulative live birth rate in patients with different ovarian response during in vitro fertilization (IVF), we carried out this retrospective cohort study including a total of 4,651 patients undergoing their first IVF cycles from January 2011 to December 2012. All patients with a final live birth outcome (4,332 patients) were divided into three groups according to ovarian response: poor ovarian responder (≤5 oocytes, 785 patients), intermediate ovarian responder (6–19 oocytes, 3065 patients) and high ovarian responder (≥20 oocytes, 482 patients). The thresholds for serum P elevation were 1.60 ng/ml, 2.24 ng/ml, and 2.50 ng/ml for poor, intermediate, and high ovarian responders, respectively. Cumulative live birth rate per oocyte retrieval cycle was calculated in each group. The relationship between serum P level and cumulative live birth rate was evaluated by both univariate and multivariate logistic regression analysis. Cumulative live birth rate per oocyte retrieval cycle was inversely associated with serum P level in patients with different ovarian response. For all responders, patients with elevated P level had significantly higher number of oocytes retrieved, but lower high quality embryo rate, and lower cumulative live birth rate compared with patients with normal serum P level. In addition, serum P level adversely affected cumulative live birth rate by both univariate and multivariate logistic regression analysis, independent of ovarian response. Serum P elevation on the day of HCG administration adversely affects cumulative live birth rate per oocyte retrieval cycle in patients with different ovarian response.

The effect of the biochemical marker soluble human leukocyte antigen G on pregnancy outcome in assisted reproductive technology--a multicenter study

OBJECTIVE

To determine whether the presence of soluble human leukocyte antigen G (sHLA-G) affects implantation and pregnancy outcomes in vitro.

DESIGN

A multicenter retrospective study.

SETTING

Six certified in vitro fertilization (IVF) units.

PATIENT(S)

Embryos obtained from 2,040 patients from six different IVF clinics.

INTERVENTION(S)

Soluble HLA-G determination on day-2 embryos after intracytoplasmic sperm injection, with embryos transferred on day 3 using the sHLA-G data.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate (10- to 12-week ultrasound finding).

RESULT(S)

All embryos were individually cultured, and a chemiluminescence enzyme-linked immunosorbent assay was used to detect the presence of sHLA-G in the culture medium surrounding the embryos. Embryos were selected based on a positive sHLA-G result and a graduated embryo scoring (GES) score >70, or on embryo morphology if the test was negative. In all centers, a positive sHLA-G result was associated with an increase in the odds of an ongoing pregnancy. The incidence of an ongoing pregnancy was 2.52 times greater in embryos transferred on day 3 with a positive sHLA-G test result than the incidence of an ongoing pregnancy in embryos with a negative sHLA-G test result.

CONCLUSION(S)

Data from this multicenter study confirm that sHLA-G expression is a valuable noninvasive embryo marker to assist in improving pregnancy outcomes, with the theoretical potential to reduce multiple pregnancies.

Increase in concentration of soluble HLA-G in high-quality embryos after intracytoplasmic sperm injection

Non-invasive methods are normally preferred to conventional invasive methods when selecting suitable embryos to improve pregnancy rates after assisted reproduction techniques. One of the most recognized non-invasive methods is to examine the supernatants of embryo culture media. Soluble human leukocyte antigen, class I, G (sHLA-G) antigen is a non-classical class I molecule that has been widely considered as a marker of pregnancy failure or implantation success. In the current study of some Iranian patients, we examined the concentration of sHLA-G at different time points after intracytoplasmic sperm injection and compared the rates to the morphology and quality of the selected embryos. We showed that the concentration of sHLA-G increases over time in high-quality embryos. We conclude that there is a positive relationship between morphology, quality, and sHLA-G concentration. We suggest that this relationship can be used to increase the chance of a successful pregnancy.