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Apter S, Ebner T, Freour T, Guns Y, Kovacic B, Le Clef N, Marques M, Meseguer M, Montjean D, Sfontouris I, Sturmey R, Coticchio G. Good practice recommendations for the use of time-lapse technology †. Hum Reprod Open 2020; 2020:hoaa008. [PMID: 32206731 PMCID: PMC7081060 DOI: 10.1093/hropen/hoaa008] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/05/2019] [Accepted: 01/29/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
| | | | - Thomas Ebner
- Department of Gynecology, Obstetrics, and Gynecological Endocrinology, Kepler Universitätsklinikum, Linz, Austria
| | - Thomas Freour
- Médecine de la Reproduction, CHU de Nantes, Nantes, France
| | - Yves Guns
- Center for Reproductive Medicine, UZ Brussel, Brussels, Belgium
| | - Borut Kovacic
- Department of Reproductive Medicine and Gynecologic Endocrinology, Univerzitetni klinicni center Maribor, Maribor, Slovenia
| | - Nathalie Le Clef
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | | | - Marcos Meseguer
- IVF Laboratory, Instituto Valenciano de Infertilidad, Valencia, Spain
| | - Debbie Montjean
- Médecine et Biologie de la Reproduction, Hopital Saint Joseph, Marseille, France
| | | | - Roger Sturmey
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK
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Morphokinetics and in vitro developmental potential of monopronucleated ICSI zygotes until the blastocyst stage. ZYGOTE 2020; 28:217-222. [DOI: 10.1017/s0967199420000027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SummaryThe aim of this study was to provide a more comprehensive understanding of 1PN intracytoplasmic sperm injection (ICSI) zygotes. To achieve this objective, we assessed whether all 1PN-derived embryos showed a similar morphokinetic pattern, and if the morphokinetic behaviour of 1PN-derived embryos was comparable with that of 2PN-derived embryos. In total, 149 1PN ICSI zygotes (study group) and 195 2PN ICSI zygotes (control group) were included in the study. Embryo development potential was evaluated in terms of blastocyst rate. Morphokinetic parameters, including the pronucleus diameter and kinetics of in vitro development, were also analyzed. Embryos derived from 1PN ICSI zygotes showed impaired development compared with 2PN-derived embryos, with blastocyst rates of 28.9% and 67.2%, respectively. The diameter of the pronucleus of 1PN zygotes was larger than that of 2PN zygotes. When compared with 2PN-derived embryos, those derived from 1PN zygotes had a visible pronucleus for a shorter time, in addition to a longer syngamy time and slower kinetic behaviour from two to nine cells. When 1PN-derived blastocysts and 2PN-derived blastocysts were compared, the developmental kinetics were similar in both groups, except for a delayed and longer duration of the compaction phase in 1PN-derived embryos. In conclusion, monopronucleated ICSI zygotes present differences in developmental capacity and morphokinetic behaviour compared with 2PN ICSI zygotes, showing particular morphokinetic parameters related to pronucleus formation. Only the 1PN ICSI-derived embryos that reached the blastocyst stage have similar morphokinetic development to blastocysts from 2PN zygotes.
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Ranisch R. Germline genome editing versus preimplantation genetic diagnosis: Is there a case in favour of germline interventions? BIOETHICS 2020; 34:60-69. [PMID: 31448423 PMCID: PMC6973094 DOI: 10.1111/bioe.12635] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 06/12/2019] [Accepted: 06/25/2019] [Indexed: 06/05/2023]
Abstract
CRISPR is widely considered to be a disruptive technology. However, when it comes to the most controversial topic, germline genome editing (GGE), there is no consensus on whether this technology has any substantial advantages over existing procedures such as embryo selection after in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD). Answering this question, however, is crucial for evaluating whether the pursuit of further research and development on GGE is justified. This paper explores the question from both a clinical and a moral viewpoint, namely whether GGE has any advantages over existing technologies of selective reproduction and whether GGE could complement or even replace them. In a first step, I review an argument of extended applicability. The paper confirms that there are some scenarios in which only germline intervention allows couples to have (biologically related) healthy offspring, because selection will not avoid disease. In a second step, I examine possible moral arguments in favour of genetic modification, namely that GGE could save some embryos and that GGE would provide certain benefits for a future person that PGD does not. Both arguments for GGE have limitations. With regard to the extended applicability of GGE, however, a weak case in favour of GGE should still be made.
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Affiliation(s)
- Robert Ranisch
- Institute of Ethics and History of Medicine, University of TübingenGermany
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A. Lea R, K. Niakan K. Human germline genome editing. Nat Cell Biol 2019; 21:1479-1489. [DOI: 10.1038/s41556-019-0424-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 10/25/2019] [Indexed: 12/14/2022]
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Amargant F, García D, Barragán M, Vassena R, Vernos I. Functional Analysis of Human Pathological Semen Samples in an Oocyte Cytoplasmic Ex Vivo System. Sci Rep 2018; 8:15348. [PMID: 30337543 PMCID: PMC6194145 DOI: 10.1038/s41598-018-33468-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 09/28/2018] [Indexed: 11/08/2022] Open
Abstract
Human fertilization and embryo development involve a wide range of critical processes that determine the successful development of a new organism. Although Assisted Reproduction Technologies (ART) may help solve infertility problems associated to severe male factor, the live birth rate is still low. A high proportion of ART failures occurs before implantation. Understanding the causes for these failures has been difficult due to technical and ethical limitations. Diagnostic procedures on human spermatozoa in particular have been limited to morphology and swimming behaviours while other functional requirements during early development have not been addressed due to the lack of suitable assays. Here, we have established a quantitative system based on the use of Xenopus egg extracts and human spermatozoa. This system provides novel possibilities for the functional characterization of human spermatozoa. Using clinical data we show that indeed this approach offers a set of complementary data for the functional evaluation of spermatozoa from patients.
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Grants
- 2014 DI 065 Departament d'Innovació, Universitats i Empresa, Generalitat de Catalunya (Department of Innovation, Education and Enterprise, Government of Catalonia)
- 2014 DI 065 Departament d'Innovació, Universitats i Empresa, Generalitat de Catalunya (Department of Innovation, Education and Enterprise, Government of Catalonia)
- 4363 Ministerio de Ciencia y Tecnología (Ministry of Science and Technology)
- Departament d'Innovació, Universitats i Empresa, Generalitat de Catalunya (Department of Innovation, Education and Enterprise, Government of Catalonia)
- Ministerio de Ciencia y Tecnología (Ministry of Science and Technology)
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Affiliation(s)
- Farners Amargant
- Cell and Developmental Biology Programme, Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Dr. Aiguader 88, Barcelona, 08003, Spain
- Clínica EUGIN, Travessera de les Corts 322, Barcelona, 08029, Spain
| | - Désirée García
- Fundació EUGIN, Travessera de les Corts 314, Barcelona, 08029, Spain
| | | | - Rita Vassena
- Clínica EUGIN, Travessera de les Corts 322, Barcelona, 08029, Spain.
| | - Isabelle Vernos
- Cell and Developmental Biology Programme, Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Dr. Aiguader 88, Barcelona, 08003, Spain.
- Institució Catalana de Recerca I Estudis Avançats (ICREA), Pg. Lluis Companys 23, Barcelona, 08010, Spain.
- Universitat Pompeu Fabra (UPF), Barcelona, Spain.
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Mitochondrial activity and cytoskeleton organization in three pronuclei oocytes after intracytoplasmic sperm injection. ZYGOTE 2018; 26:319-325. [DOI: 10.1017/s0967199418000278] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SummaryDigyny, the presence of a third pronucleus due to the failure of second polar body extrusion, is problematic after intracytoplasmic sperm injection (ICSI) practices. Mitochondria have critical roles such as production of adenosine triphosphate (ATP) and regulation of Ca2+ homeostasis during oocyte maturation, fertilization and the following development, while the regulation of meiotic spindle formation, chromosome segregation, pronuclear apposition and cytokinesis is closely associated with the cytoskeleton. In this study, mitochondrial membrane potential, distribution of F-actin and γ-tubulin, and the ultrastructure of three pronuclear (3PN) oocytes were investigated. 3PN oocytes after ICSI procedure were taken from patients who were enrolled in assisted reproduction programmes. For mitochondrial membrane potential analysis, fresh oocytes stained with the mitochondrial membrane potential probe JC-1, were evaluated under fluorescence microscopy. The mitochondrial membrane potential of three pronuclear oocytes showed similar results to normal zygotes. γ-Tubulin was stained strongly at the subplasmalemmal domain and microfilaments were localized at the cortical, but not the perinuclear, area. Cytoplasmic halos were moderately or not detected by electron microscopy; lipofuscin granules, degenerated mitochondria, and multilamellated bodies were seen in the ooplasm. Immunohistochemistry and electron microscopic findings suggested that mitochondrial membrane potential has no direct effect on second polar body extrusion. This abnormality can be associated with an altered cytoskeleton due to poor oocyte quality.
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Ebner T, Höggerl A, Oppelt P, Radler E, Enzelsberger SH, Mayer RB, Petek E, Shebl O. Time-lapse imaging provides further evidence that planar arrangement of blastomeres is highly abnormal. Arch Gynecol Obstet 2017; 296:1199-1205. [DOI: 10.1007/s00404-017-4531-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 07/18/2017] [Indexed: 12/11/2022]
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Morphokinetic Characteristics and Developmental Potential of In Vitro Cultured Embryos from Natural Cycles in Patients with Poor Ovarian Response. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4286528. [PMID: 28097133 PMCID: PMC5206428 DOI: 10.1155/2016/4286528] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/23/2016] [Indexed: 11/17/2022]
Abstract
Background. Patients with poor ovarian response to ovarian hyperstimulation represent an interesting group for studying the impact of embryo cleavage irregularities on clinical outcome since all embryos, regardless of their quality, are usually transferred to the uterus. The aim of our study was to follow the morphokinetics of fertilized oocytes from natural cycles in poor responders. Methods. Zygotes from 53 cycles were cultured in vitro for 3 days. The morphokinetics of their development and transfer outcomes were retrospectively analyzed for the normally and irregularly cleaved embryos. Results. Of all embryos, 30.2% had single and 20.8% multiple cleavage irregularities with the following prevalence: developmental arrest 30.2%, direct cleavage to more than two cells 24.5%, chaotic cleavage 13.2%, and reverse cleavage 11.3%. These embryos had longer pronuclear phases, first cytokinesis, second embryo cell cycles, and less synchronized divisions. The transfer of normally developing embryos resulted in an implantation rate of 30.8% and a delivery rate of 23.1%, but irregularly cleaved embryos did not implant. Conclusions. The use of time-lapse microscopy in poor responder patients identified embryos with cleavage abnormalities that are related with no or extremely low implantation potential. Gained information about embryo quality is important for counselling patients about their expectations.
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Time-lapse embryo imaging and morphokinetic profiling: Towards a general characterisation of embryogenesis. Anim Reprod Sci 2016; 174:2-10. [DOI: 10.1016/j.anireprosci.2016.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/22/2016] [Accepted: 09/28/2016] [Indexed: 12/19/2022]
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Azzarello A, Hoest T, Hay-Schmidt A, Mikkelsen AL. Live birth rate and number of blastomeres on day 2 transfer. J Assist Reprod Genet 2016; 33:1337-1342. [PMID: 27491644 DOI: 10.1007/s10815-016-0737-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 05/13/2016] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To investigate whether the presence of large fragment (LF) and abnormal cell divisions (ACDs) has influenced the correlation between live birth rate and number of blastomeres detected on day 2 by conventional scoring. METHODS This study included 578 embryos cultured in time lapse and selected for transfer by conventional scoring on day 2. By time-lapse recordings, embryos were reassessed to identify ACDs and/or LFs mistaken as blastomeres. The latter identifications were used to recalculate fragmentation rate and the number of blastomeres. Life birth rate according to number of blastomeres was compared in (a) embryos selected by conventional scoring and (b) embryos reassessed by time lapse. RESULTS After conventional scoring, embryos with four cells had a significantly higher pregnancy rate than embryos with less than four cells and embryos with more than four cells. By time-lapse assessment, ACDs and/or recalculated fragmentation >25 % was recognized in 106/578 (18.3 %) of transferred embryos. None of them resulted in a live birth. After exclusion of these embryos, the number of blastomeres on the day of transfer did not have any impact on life birth rate. CONCLUSION Conventional scoring on day 2 did not detect ACDs and LFs mistaken as blastomeres. LFs can lead to a recalculated fragmentation rate to >25 %. No significant correlation between live birth rate and number of blastomeres in day 2 embryos was observed when embryos with ACDs and fragmentation >25 % were excluded. Recognition of ACDs and fragmentation >25 % is more predictive of live birth than number of blastomeres.
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Affiliation(s)
| | - Thomas Hoest
- Holbaek Fertility Clinic, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Anders Hay-Schmidt
- Department of Neuroscience and Pharmacology, Copenhagen University, Blegdamsvej 3, 2200, København N, Denmark
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Abstract
Hydatidiform moles (HMs) are abnormal human pregnancies with vesicular chorionic villi, imposing two clinical challenges; miscarriage and a risk of gestational trophoblastic neoplasia (GTN). The parental type of most HMs are either diandric diploid (PP) or diandric triploid (PPM). We consecutively collected 154 triploid or near-triploid samples from conceptuses with vesicular chorionic villi. We used analysis of DNA markers and/or methylation sensitive-MLPA and collected data from registries and patients records. We performed whole genome SNP analysis of one case of twinning (PP+PM).In all 154 triploids or near-triploids we found two different paternal contributions to the genome (P1P2M). The ratios between the sex chromosomal constitutions XXX, XXY, and XYY were 5.7: 6.9: 1.0. No cases of GTN were observed. Our results corroborate that all triploid human conceptuses with vesicular chorionic villi have the parental type P1P2M. The sex chromosomal ratios suggest approximately equal frequencies of meiosis I and meiosis II errors with selection against the XYY conceptuses or a combination of dispermy, non-disjunction in meiosis I and meiosis II and selection against XYY conceptuses. Although single cases of GTN after a triploid HM have been reported, the results of this study combined with data from previous prospective studies estimate the risk of GTN after a triploid mole to 0% (95% CI: 0–1,4%).
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Grau N, Escrich L, Galiana Y, Meseguer M, García-Herrero S, Remohí J, Escribá MJ. Morphokinetics as a predictor of self-correction to diploidy in tripronucleated intracytoplasmic sperm injection–derived human embryos. Fertil Steril 2015; 104:728-35. [DOI: 10.1016/j.fertnstert.2015.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/19/2015] [Accepted: 05/19/2015] [Indexed: 11/29/2022]
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Joergensen MW, Labouriau R, Hindkjaer J, Stougaard M, Kolevraa S, Bolund L, Agerholm IE, Sunde L. The parental origin correlates with the karyotype of human embryos developing from tripronuclear zygotes. Clin Exp Reprod Med 2015; 42:14-21. [PMID: 25874169 PMCID: PMC4390676 DOI: 10.5653/cerm.2015.42.1.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 12/29/2014] [Accepted: 01/19/2015] [Indexed: 11/12/2022] Open
Abstract
Objective It has previously been suggested that embryos developing from intracytoplasmic sperm-injected (ICSI) zygotes with three pronuclei (3PN) are endowed with a mechanism for self-correction of triploidy to diploidy. 3PN are also observed in zygotes after conventional in vitro fertilization (IVF). The parental origin, however, differs between the two fertilization methods. Whereas the vast majority of 3PN IVF zygotes are of dispermic origin and thus more likely to have two centrioles, the 3PN ICSI zygotes are digynic in origin and therefore, more likely to have one centriole. In the present study, we examine whether the parental origin of 3PN embryos correlates with the karyotype. Methods The karyotype of each nucleus was estimated using four sequential fluorescence in situ hybridizations-each with two probes-resulting in quantitative information of 8 different chromosomes. The karyotypes were then compared and correlated to the parental origin. Results 3PN ICSI embryos displayed a significantly larger and more coordinated reduction from the assumed initial 3 sets of chromosomes than 3PN IVF embryos. Conclusion The differences in the parental origin-and hence the number of centrioles-between the 3PN IVF and the 3PN ICSI zygotes are likely to be the cause of the differences in karyotypes.
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Affiliation(s)
- Mette Warming Joergensen
- Department of Clinical Genetics, Vejle Hospital, Vejle, Denmark. ; Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Johnny Hindkjaer
- The Fertility Clinic and Centre for Preimplantation Genetic diagnosis, Aarhus University Hospital, Skejby, Denmark
| | - Magnus Stougaard
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen Kolevraa
- Department of Clinical Genetics, Vejle Hospital, Vejle, Denmark
| | - Lars Bolund
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Lone Sunde
- Department of Biomedicine, Aarhus University, Aarhus, Denmark. ; Department of Clinical Genetics, Aarhus University Hospital, Skejby, Denmark
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Siristatidis C, Komitopoulou MA, Makris A, Sialakouma A, Botzaki M, Mastorakos G, Salamalekis G, Bettocchi S, Palmer GA. Morphokinetic parameters of early embryo development via time lapse monitoring and their effect on embryo selection and ICSI outcomes: a prospective cohort study. J Assist Reprod Genet 2015; 32:563-70. [PMID: 25617087 DOI: 10.1007/s10815-015-0436-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/13/2015] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To compare the outcomes of embryos selected via time lapse monitoring (TLM) versus those selected with conventional methods of selection in subfertile women undergoing ICSI. METHODS The study population (239 women) was classified into two groups, based on the monitoring method used: Group 1 (TLM) and Group 2 (conventional monitoring). Groups were compared according to the clinical and ICSI cycle characteristics and reproductive outcomes, while transfers were performed at day 2 or 3. Subgroup analyses were performed, in women of both groups according to age and clinical parameters, and in embryos of Group 1 based on their cellular events. RESULTS There was a statistically significant difference between the two study groups with regard to the outcome parameters, favoring Group 1 and especially in women >40 years of age. No differences were found in subgroup analyses in participants of both groups, regarding the stimulation protocol used, number of the oocytes retrieved and type of subfertility, while in Group 1 the percentages of "in range" cellular events were higher in certain divisions in ages 35-40, non-smokers, and the GnRH-agonist group, and in embryos that resulted in pregnancy. CONCLUSION Morphokinetic parameters of early embryo development via TLM are related to the characteristics of subfertile patients and associated with ICSI outcomes.
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Affiliation(s)
- Charalampos Siristatidis
- Assisted Reproduction Unit, 3rd Department of Obstetrics and Gynecology, University of Athens, Rimini 1, Chaidari, Athens, Greece, 12642,
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Gardner DK, Meseguer M, Rubio C, Treff NR. Diagnosis of human preimplantation embryo viability. Hum Reprod Update 2015; 21:727-47. [PMID: 25567750 DOI: 10.1093/humupd/dmu064] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 12/08/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Transfer of more than a single embryo in an IVF cycle comes with the finite possibility of a multiple gestation. Even a twin pregnancy confers significant risk to both mother and babies. The move to single-embryo transfer for all patients will be greatly facilitated by the ability to quantify embryo viability. Developments in time-lapse incubation systems have provided new insights into the developmental kinetics of the human preimplantation embryo. Advances in molecular methods of chromosomal analysis have created platforms for highly effective screening of biopsied embryos, while noninvasive analysis of embryo physiology reveals more about the embryo than can be determined by morphology alone. METHODS Recent developments in time-lapse microscopy, molecular karyotyping and in proteomics and metabolomics have been assessed and presented here in a descriptive review. RESULTS AND CONCLUSIONS New algorithms are being created for embryo selection based on their developmental kinetics in culture, and the impact of factors such as patient etiology and treatment are being clarified. Potential links between morphokinetic data and embryo karyotype are being elucidated. The introduction of new molecular methods of determining embryo chromosomal complement is proving to be accurate and reproducible, with the future trending toward CGH arrays or next generation sequencing as a rapid and reliable means of analysis, that should be suitable for each IVF clinic to adopt. A relationship between embryo metabolism and viability is established and is now being considered together with morphokinetic data to create more robust algorithms for embryo selection. Microfluidic devices have the capacity and potential to be used in human IVF clinics for the routine diagnosis of embryo biomarkers.
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Affiliation(s)
- David K Gardner
- School of BioSciences, University of Melbourne, Parkville, VIC 3010, Australia
| | - Marcos Meseguer
- Laboratorio Fiv, IVI Valencia, Plaza Policía Local, 3, Valencia 46015, Spain
| | - Carmen Rubio
- IGENOMIX and Fundación Instituto Valenciano de Infertilidad (FIVI)/INCLIVA, Valencia, Spain
| | - Nathan R Treff
- Reproductive Medicine Associates of New Jersey, Basking Ridge, NJ 07960, USA
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