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Hillyear LM, Zak LJ, Beckitt T, Griffin DK, Harvey SC, Harvey KE. Morphokinetic Profiling Suggests That Rapid First Cleavage Division Accurately Predicts the Chances of Blastulation in Pig In Vitro Produced Embryos. Animals (Basel) 2024; 14:783. [PMID: 38473168 DOI: 10.3390/ani14050783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
The study of pig preimplantation embryo development has several potential uses: from agriculture to the production of medically relevant genetically modified organisms and from rare breed conservation to acting as a physiologically relevant model for progressing human and other (e.g., endangered) species' in vitro fertilisation technology. Despite this, barriers to the widespread adoption of pig embryo in vitro production include lipid-laden cells that are hard to visualise, slow adoption of contemporary technologies such as the use of time-lapse incubators or artificial intelligence, poor blastulation and high polyspermy rates. Here, we employ a commercially available time-lapse incubator to provide a comprehensive overview of the morphokinetics of pig preimplantation development for the first time. We tested the hypotheses that (a) there are differences in developmental timings between blastulating and non-blastulating embryos and (b) embryo developmental morphokinetic features can be used to predict the likelihood of blastulation. The abattoir-derived oocytes fertilised by commercial extended semen produced presumptive zygotes were split into two groups: cavitating/blastulating 144 h post gamete co-incubation and those that were not. The blastulating group reached the 2-cell and morula stages significantly earlier, and the time taken to reach the 2-cell stage was identified to be a predictive marker for blastocyst formation. Reverse cleavage was also associated with poor blastulation. These data demonstrate the potential of morphokinetic analysis in automating and upscaling pig in vitro production through effective embryo selection.
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Affiliation(s)
- Lucy M Hillyear
- School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury CT1 1QU, UK
| | - Louisa J Zak
- Topigs Norsvin Research Center, Meerendonkweg 25, 5216 TZ Den Bosch, The Netherlands
| | | | - Darren K Griffin
- School of Biosciences, University of Kent, Canterbury CT2 7NJ, UK
| | - Simon C Harvey
- Faculty of Engineering and Science, University of Greenwich, Medway ME4 4TB, UK
| | - Katie E Harvey
- School of Life, Health and Chemical Sciences, The Open University, Milton Keynes MK7 6AA, UK
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Zou Y, Sui Y, Fu J, Ge N, Sun X, Sun Y. The morphokinetic signature of human blastocysts with mosaicism and the clinical outcomes following transfer of embryos with low-level mosaicism. J Ovarian Res 2024; 17:10. [PMID: 38195558 PMCID: PMC10775590 DOI: 10.1186/s13048-023-01324-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/12/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Genetic mosaicism is commonly observed in human blastocysts. Embryos' morphokinetic feature observed from time-lapse monitoring (TLM) is helpful to predict the embryos' ploidy status in a non-invasive way. However, morphokinetic research on mosaic embryos is extremely limited. Moreover, transfer of mosaic embryos is a new attempt in reproductive medicine, while studies regarding the clinical and neonatal outcomes following transfer of embryos with different levels and types of mosaicism are needed. This study aimed to investigate the morphokinetic characteristics of mosaic blastocysts, uncover clinical outcomes of mosaic embryos, and evaluate the effect of level and type of mosaicism on transfer outcomes. RESULTS A total of 923 blastocysts from 229 preimplantation genetic testing cycles were cultured in TLM incubators in a single fertilization center between July 2016 and July 2021. Multivariate logistic regression models showed mosaic embryos had significantly shorter time to reach morula when compared with euploid (P = 0.002), mosaic with aneuploid (P = 0.005), and aneuploid (P = 0.005) embryos after adjusting the potential confounders. KIDScore is an artificial intelligence scoring program from time lapse incubation system to predict embryo implantation potential. Mosaic with aneuploid embryos had significantly lower KIDScore than euploid (P = 6.47e-4), mosaic (P = 0.005), and aneuploid (P = 0.004) embryos after adjustment. Meanwhile, we compared the clinical outcomes following transfer of low-level (< 50%) mosaic embryos (N = 60) with euploid embryos (N = 1301) matched using propensity scoring collected from September 2020 to January 2023. Mosaic embryos had significantly lower clinical pregnancy rate (41.67% vs. 57.65%, P = 0.015) and live birth rate (38.33% vs. 51.35%, P = 0.048) than the euploid embryos. Subgroup analyses showed the whole, segmental, and complex chromosome mosaic embryos had the similar clinical outcomes. CONCLUSIONS The shortened time to reach morula in mosaic embryos and the low KIDScore in mosaic with aneuploid embryos revealed innovative clues to embryo selection with the non-invasive TLM and provided new insights into biological mechanism of chromosomal abnormality. The analyses of overall and subgroups of mosaic embryo transfer outcomes helped to optimize embryo transfer scheme for in-vitro fertilization procedures. Multi-center prospective studies with large sample sizes are warranted to validate our results in the future.
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Affiliation(s)
- Yaoyu Zou
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics & Gynecology Hospital, Fudan University, Dalin Road, Shanghai, 200011, China
| | - Yilun Sui
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics & Gynecology Hospital, Fudan University, Dalin Road, Shanghai, 200011, China
| | - Jing Fu
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics & Gynecology Hospital, Fudan University, Dalin Road, Shanghai, 200011, China
| | - Naidong Ge
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics & Gynecology Hospital, Fudan University, Dalin Road, Shanghai, 200011, China
| | - Xiaoxi Sun
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics & Gynecology Hospital, Fudan University, Dalin Road, Shanghai, 200011, China.
| | - Yijuan Sun
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics & Gynecology Hospital, Fudan University, Dalin Road, Shanghai, 200011, China.
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Kasaven LS, Marcus D, Theodorou E, Jones BP, Saso S, Naja R, Serhal P, Ben-Nagi J. Systematic review and meta-analysis: does pre-implantation genetic testing for aneuploidy at the blastocyst stage improve live birth rate? J Assist Reprod Genet 2023; 40:2297-2316. [PMID: 37479946 PMCID: PMC10504192 DOI: 10.1007/s10815-023-02866-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/19/2023] [Indexed: 07/23/2023] Open
Abstract
PURPOSE To establish if preimplantation genetic testing for aneuploidy (PGT-A) at the blastocyst stage improves the composite outcome of live birth rate and ongoing pregnancy rate per embryo transfer compared to conventional morphological assessment. METHODS A systematic literature search was conducted using PubMed, EMBASE and Cochrane database from 1st March 2000 until 1st March 2022. Studies comparing reproductive outcomes following in vitro fertilisation using comprehensive chromosome screening (CCS) at the blastocyst stage with traditional morphological methods were evaluated. RESULTS Of the 1307 citations identified, six randomised control trials (RCTs) and ten cohort studies fulfilled the inclusion criteria. The pooled data identified a benefit between PGT-A and control groups in the composite outcome of live birth rate and ongoing pregnancy per embryo transfer in both the RCT (RR 1.09, 95% CI 1.02-1.16) and cohort studies (RR 1.50, 95% CI 1.28-1.76). Euploid embryos identified by CCS were more likely to be successfully implanted amongst the RCT (RR 1.20, 95% CI 1.10-1.31) and cohort (RR 1.69, 95% CI 1.29-2.21) studies. The rate of miscarriage per clinical pregnancy is also significantly lower when CCS is implemented (RCT: RR 0.73, 95% CI 0.56-0.96 and cohort: RR 0.48, 95% CI 0.32-0.72). CONCLUSIONS CCS-based PGT-A at the blastocyst biopsy stage increases the composite outcome of live births and ongoing pregnancies per embryo transfer and reduces the rate of miscarriage compared to morphological assessment alone. In view of the limited number of studies included and the variation in methodology between studies, future reviews and analyses are required to confirm these findings.
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Affiliation(s)
- Lorraine S Kasaven
- Department of Cancer and Surgery, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BX, UK.
- Cutrale Perioperative and Ageing Group, Sir Michael Uren Hub, Imperial College London, London, W12 0BZ, UK.
| | - Diana Marcus
- Department of Cancer and Surgery, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BX, UK
- Department of Gynaecology, Kings College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Efstathios Theodorou
- Centre for Reproductive and Genetic Health, Great Portland Street, London, W1W 5QS, UK
| | - Benjamin P Jones
- Department of Cancer and Surgery, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BX, UK
| | - Srdjan Saso
- Department of Cancer and Surgery, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BX, UK
| | - Roy Naja
- Institute for Women's Health, University College London, 84-86 Chenies Mews, London, WC1E 6HU, UK
| | - Paul Serhal
- Centre for Reproductive and Genetic Health, Great Portland Street, London, W1W 5QS, UK
| | - Jara Ben-Nagi
- Department of Cancer and Surgery, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BX, UK
- Centre for Reproductive and Genetic Health, Great Portland Street, London, W1W 5QS, UK
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Braga DPDAF, Setti AS, Guilherme P, Morishima C, Iaconelli A, Borges E. Time-lapse monitoring: An adjunct tool to select embryos for preimplantation genetic testing. Mol Reprod Dev 2023. [PMID: 37334904 DOI: 10.1002/mrd.23692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
The goal for the present study was to investigate the effect of aneuploidy on embryo morphokinetics events in a time-lapse imaging (TLI) system incubator. This retrospective cohort study was performed in a private university-affiliated in vitro fertilization center, between 2019 March and December 2020. Kinetic data were analyzed in 935 embryos, derived from 316 patients undergoing intracytoplasmic sperm injection cycle with preimplantation genetic testing (PGT) for aneuploidy, individually cultured in a TLI incubator until Day 5 of development. Timing of morphokinetic variables, the incidences of multinucleation, and Known Implantation Data Score (KIDScore)-Day 5 were compared between euploid (n = 352) and aneuploid embryos (n = 583). Aneuploid embryos showed significantly longer timing to complete specific morphokinetic parameters compared to euploidy embryos. Euploidy embryos also showed a significantly higher KIDScore when compared with the aneuploidy ones. Our evidence suggests that TLI monitoring may be an adjunct approach to select embryos for PGT; however, cautious investigation is still needed.
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Affiliation(s)
- Daniela P de Almeida Ferreira Braga
- Fertility Medical Group, São Paulo, Brazil
- Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil
| | - Amanda S Setti
- Fertility Medical Group, São Paulo, Brazil
- Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil
| | | | - Christina Morishima
- Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil
| | - Assumpto Iaconelli
- Fertility Medical Group, São Paulo, Brazil
- Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil
| | - Edson Borges
- Fertility Medical Group, São Paulo, Brazil
- Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil
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Suebthawinkul C, Babayev E, Lee HC, Duncan FE. Morphokinetic parameters of mouse oocyte meiotic maturation and cumulus expansion are not affected by reproductive age or ploidy status. J Assist Reprod Genet 2023; 40:1197-1213. [PMID: 37012451 PMCID: PMC10239409 DOI: 10.1007/s10815-023-02779-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/17/2023] [Indexed: 04/05/2023] Open
Abstract
INTRODUCTION Morphokinetic analysis using a closed time-lapse monitoring system (EmbryoScope + ™) provides quantitative metrics of meiotic progression and cumulus expansion. The goal of this study was to use a physiologic aging mouse model, in which egg aneuploidy levels increase, to determine whether there are age-dependent differences in morphokinetic parameters of oocyte maturation. METHODS Denuded oocytes and intact cumulus-oocyte complexes (COCs) were isolated from reproductively young and old mice and in vitro matured in the EmbryoScope + ™. Morphokinetic parameters of meiotic progression and cumulus expansion were evaluated, compared between reproductively young and old mice, and correlated with egg ploidy status. RESULTS Oocytes from reproductively old mice were smaller than young counterparts in terms of GV area (446.42 ± 4.15 vs. 416.79 ± 5.24 µm2, p < 0.0001) and oocyte area (4195.71 ± 33.10 vs. 4081.62 ± 41.04 µm2, p < 0.05). In addition, the aneuploidy incidence was higher in eggs with advanced reproductive age (24-27% vs. 8-9%, p < 0.05). There were no differences in the morphokinetic parameters of oocyte maturation between oocytes from reproductively young and old mice with respect to time to germinal vesicle breakdown (GVBD) (1.03 ± 0.03 vs. 1.01 ± 0.04 h), polar body extrusion (PBE) (8.56 ± 0.11 vs. 8.52 ± 0.15 h), duration of meiosis I (7.58 ± 0.10 vs. 7.48 ± 0.11 h), and kinetics of cumulus expansion (0.093 ± 0.002 vs. 0.089 ± 0.003 µm/min). All morphokinetic parameters of oocyte maturation were similar between euploid and aneuploid eggs irrespective of age. CONCLUSION There is no association between age or ploidy and the morphokinetics of mouse oocyte in vitro maturation (IVM). Future studies are needed to evaluate whether there is an association between morphokinetic dynamics of mouse IVM and embryo developmental competence.
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Affiliation(s)
- Chanakarn Suebthawinkul
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Elnur Babayev
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hoi Chang Lee
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Francesca E Duncan
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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6
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Jiang VS, Kandula H, Thirumalaraju P, Kanakasabapathy MK, Cherouveim P, Souter I, Dimitriadis I, Bormann CL, Shafiee H. The use of voting ensembles to improve the accuracy of deep neural networks as a non-invasive method to predict embryo ploidy status. J Assist Reprod Genet 2023; 40:301-308. [PMID: 36640251 PMCID: PMC9935776 DOI: 10.1007/s10815-022-02707-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/23/2022] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To determine if creating voting ensembles combining convolutional neural networks (CNN), support vector machine (SVM), and multi-layer neural networks (NN) alongside clinical parameters improves the accuracy of artificial intelligence (AI) as a non-invasive method for predicting aneuploidy. METHODS A cohort of 699 day 5 PGT-A tested blastocysts was used to train, validate, and test a CNN to classify embryos as euploid/aneuploid. All embryos were analyzed using a modified FAST-SeqS next-generation sequencing method. Patient characteristics such as maternal age, AMH level, paternal sperm quality, and total number of normally fertilized (2PN) embryos were processed using SVM and NN. To improve model performance, we created voting ensembles using CNN, SVM, and NN to combine our imaging data with clinical parameter variations. Statistical significance was evaluated with a one-sample t-test with 2 degrees of freedom. RESULTS When assessing blastocyst images alone, the CNN test accuracy was 61.2% (± 1.32% SEM, n = 3 models) in correctly classifying euploid/aneuploid embryos (n = 140 embryos). When the best CNN model was assessed as a voting ensemble, the test accuracy improved to 65.0% (AMH; p = 0.1), 66.4% (maternal age; p = 0.06), 65.7% (maternal age, AMH; p = 0.08), 66.4% (maternal age, AMH, number of 2PNs; p = 0.06), and 71.4% (maternal age, AMH, number of 2PNs, sperm quality; p = 0.02) (n = 140 embryos). CONCLUSIONS By combining CNNs with patient characteristics, voting ensembles can be created to improve the accuracy of classifying embryos as euploid/aneuploid from CNN alone, allowing for AI to serve as a potential non-invasive method to aid in karyotype screening and selection of embryos.
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Affiliation(s)
- Victoria S Jiang
- Division of Reproductive Endocrinology and Infertility, Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 10A, VincentBoston, MA, 02114, USA
| | - Hemanth Kandula
- Division of Engineering in Medicine, Brigham and Women's Hospital, Harvard Medical School, 65 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Prudhvi Thirumalaraju
- Division of Engineering in Medicine, Brigham and Women's Hospital, Harvard Medical School, 65 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Manoj Kumar Kanakasabapathy
- Division of Engineering in Medicine, Brigham and Women's Hospital, Harvard Medical School, 65 Landsdowne Street, Cambridge, MA, 02139, USA
| | - Panagiotis Cherouveim
- Division of Reproductive Endocrinology and Infertility, Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 10A, VincentBoston, MA, 02114, USA
| | - Irene Souter
- Division of Reproductive Endocrinology and Infertility, Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 10A, VincentBoston, MA, 02114, USA
| | - Irene Dimitriadis
- Division of Reproductive Endocrinology and Infertility, Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 10A, VincentBoston, MA, 02114, USA
| | - Charles L Bormann
- Division of Reproductive Endocrinology and Infertility, Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 10A, VincentBoston, MA, 02114, USA.
| | - Hadi Shafiee
- Division of Engineering in Medicine, Brigham and Women's Hospital, Harvard Medical School, 65 Landsdowne Street, Cambridge, MA, 02139, USA.
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Bamford T, Barrie A, Montgomery S, Dhillon-Smith R, Campbell A, Easter C, Coomarasamy A. Morphological and morphokinetic associations with aneuploidy: a systematic review and meta-analysis. Hum Reprod Update 2022; 28:656-686. [PMID: 35613016 DOI: 10.1093/humupd/dmac022] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/10/2022] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND A time lapse system (TLS) is utilized in some fertility clinics with the aim of predicting embryo viability and chance of live birth during IVF. It has been hypothesized that aneuploid embryos display altered morphokinetics as a consequence of their abnormal chromosome complement. Since aneuploidy is one of the fundamental reasons for IVF failure and miscarriage, attention has focused on utilizing morphokinetics to develop models to non-invasively risk stratify embryos for ploidy status. This could avoid or reduce the costs associated with pre-implantation genetic testing for aneuploidy (PGT-A). Furthermore, TLS have provided an understanding of the true prevalence of other dysmorphisms. Hypothetically, the incorporation of morphological features into a model could act synergistically, improving a model's discriminative ability to predict ploidy status. OBJECTIVE AND RATIONALE The aim of this systematic review and meta-analysis was to investigate associations between ploidy status and morphokinetic or morphological features commonly denoted on a TLS. This will determine the feasibility of a prediction model for euploidy and summarize the most useful prognostic markers to be included in model development. SEARCH METHODS Five separate searches were conducted in Medline, Embase, PubMed and Cinahl from inception to 1 July 2021. Search terms and word variants included, among others, PGT-A, ploidy, morphokinetics and time lapse, and the latter were successively substituted for the following morphological parameters: fragmentation, multinucleation, abnormal cleavage and contraction. Studies were limited to human studies. OUTCOMES Overall, 58 studies were included incorporating over 40 000 embryos. All except one study had a moderate risk of bias in at least one domain when assessed by the quality in prognostic studies tool. Ten morphokinetic variables were significantly delayed in aneuploid embryos. When excluding studies using less reliable genetic technologies, the most notable variables were: time to eight cells (t8, 1.13 h, 95% CI: 0.21-2.05; three studies; n = 742; I2 = 0%), t9 (2.27 h, 95% CI: 0.5-4.03; two studies; n = 671; I2 = 33%), time to formation of a full blastocyst (tB, 1.99 h, 95% CI 0.15-3.81; four studies; n = 1640; I2 = 76%) and time to expanded blastocyst (tEB, 2.35 h, 95% CI: 0.06-4.63; four studies; n = 1640; I2 = 83%). There is potentially some prognostic potential in the degree of fragmentation, multinucleation persisting to the four-cell stage and frequency of embryo contractions. Reverse cleavage was associated with euploidy in this meta-analysis; however, this article argues that these are likely spurious results requiring further investigation. There was no association with direct unequal cleavage in an embryo that progressed to a blastocyst, or with multinucleation assessed on Day 2 or at the two-cell stage. However, owing to heterogeneous results and poor-quality evidence, associations between these morphological components needs to be investigated further before conclusions can be reliably drawn. WIDER IMPLICATIONS This first systematic review and meta-analysis of morphological and morphokinetic associations with ploidy status demonstrates the most useful morphokinetic variables, namely t8, t9 and tEB to be included in future model development. There is considerable variability within aneuploid and euploid embryos making definitively classifying them impossible; however, it is feasible that embryos could be prioritized for biopsy. Furthermore, these results support the mechanism by which algorithms for live birth may have predictive ability, suggesting aneuploidy causes delayed cytokinesis. We highlight significant heterogeneity in our results secondary to local conditions and diverse patient populations, therefore calling for future models to be robustly developed and tested in-house. If successful, such a model would constitute a meaningful breakthrough when accessing PGT-A is unsuitable for couples.
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Affiliation(s)
| | | | | | - Rima Dhillon-Smith
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | | | - Christina Easter
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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8
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Jin L, Dong X, Tan W, Huang B. Incidence, dynamics and recurrences of reverse cleavage in aneuploid, mosaic and euploid blastocysts, and its relationship with embryo quality. J Ovarian Res 2022; 15:91. [PMID: 35932054 PMCID: PMC9356443 DOI: 10.1186/s13048-022-01026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background During embryonic development, the normality of cleavage and the ploidy state are closely related to the final clinical outcome. At present, many research teams are focusing on the combined application of timelapse (TL) technology and preimplantation genetic testing (PGT) technology, hoping to find a connection between the two aspects of morphodynamics and genes. In the process of embryonic cleavage, there is a common abnormal cleavage pattern called reverse cleavage (RC). RC refers to blastomere fusion and failed cytokinesis. There are very few reports about it. Whether the occurrence of RC affects blastocyst euploidy is even less clear. Whether the RC phenomenon affects the embryonic developmental potential and whether it is related to the embryo ploidy. This is important for clinicians and embryologists. In this study, we used TL to observe whether there was a phenomenon of RC in each biopsy embryo and then combined it with the ploidy state to give an answer, which provided support for the selection strategy of RC embryos. Methods A total of 405 TL-PGT cycles and 1,467 blastocysts were included in the study. All TL data were collected from the Reproductive Medicine Center, Huazhong University of Science and Technology Hospital. Embryos images throughout embryonic development, from post-insemination to day 5 or 6 until biopsy and cryopreservation, were acquired by the Embryoscope Plus TL microscopy system from January 2019 to December 2020. This study investigated the overall incidence of RC during cleavage; the relationship between RC phenomenon and the number of occurrences and ploidy results; the relationship between RC occurrence and blastocyst developmental quality, as well as the dynamics of RC embryos. Results Among the 1,453 blastocysts biopsied, 400 blastocysts showed RC phenomenon at the cleavage stage, and the incidence rate was 25.9%. In euploid, mosaic and aneuploid embryos, the incidence of RC was 27.2%, 26.6%, and 25.0%, respectively. The incidence of RC was similar among these three groups with no significant difference (P > 0.05). The number of RC occurrences was not associated with embryo ploidy status (P > 0.05). In general, the blastocyst quality of the RC + group was lower than that of the RC- group. In the ICM score, the proportion of A score in the RC + group was significantly lower than that in RC- group (P < 0.05). In the TE score, there was no significant difference between the two groups of A-grade blastocysts, but the proportion of B-grade blastocysts in the RC + group was significantly lower than that in the RC- group (P < 0.01). In terms of developmental kinetic parameters, the cleavage synchrony parameters s2 and s3 were significantly longer in RC + embryos than in RC- embryos (P < 0.05). However, these changes in kinetic parameters were not significantly different between the euploid, mosaic and aneuploid groups. Conclusions The chromosomal euploidy of cleavage-stage embryos with RC phenomenon developed to the blastocyst stage was not significantly different from that of cleavage normal blastocysts. Therefore, RC embryos should not be discarded. It is recommended to select and utilize blastocyst culture, which has similar clinical value to normal cleavage embryos. Supplementary Information The online version contains supplementary material available at 10.1186/s13048-022-01026-9.
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Affiliation(s)
- Lei Jin
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China, 430030
| | - Xiyuan Dong
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China, 430030
| | - Wei Tan
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China, 430030
| | - Bo Huang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China, 430030.
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Zou Y, Pan Y, Ge N, Xu Y, Gu R, Li Z, Fu J, Gao J, Sun X, Sun Y. Can the combination of time-lapse parameters and clinical features predict embryonic ploidy status and implantation outcome of transferred euploid blastocysts: an artificial intelligence perspective. Reprod Biomed Online 2022; 45:643-651. [DOI: 10.1016/j.rbmo.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/06/2022] [Accepted: 06/10/2022] [Indexed: 11/28/2022]
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10
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Marginal differences in preimplantation morphokinetics between conventional IVF and ICSI in patients with preimplantation genetic testing for aneuploidy (PGT-A): A sibling oocyte study. PLoS One 2022; 17:e0267241. [PMID: 35468159 PMCID: PMC9037924 DOI: 10.1371/journal.pone.0267241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/31/2022] [Indexed: 11/19/2022] Open
Abstract
Objective This study aimed to analyze the morphokinetic behaviour between conventional IVF and ICSI, in cycles with preimplantation genetic testing for aneuploidies (PGT-A). Materials A randomized controlled trial (NCT03708991) was conducted in a private fertility center. Thirty couples with non-male factor infertility were recruited between November 2018 and April 2019. A total of 568 sibling cumulus oocyte complexes were randomly inseminated with conventional IVF and ICSI and cultured in an Embryoscope time-lapse system. The morphokinetic behaviour of IVF/ICSI sibling oocytes was analysed as primary endpoint. As secondary endpoints, morphokinetic parameters that predict blastocysts that will be biopsied, the day of biopsy, gender and euploid outcome was assessed. Results When comparing IVF to ICSI, only the time to reach the 2-cell stage (t2) was significantly delayed for IVF embryos: OR: 1.282 [1.020–1.612], p = 0.033. After standardizing for tPNf (ct parameters), only Blast(tStartBlastulation-t2) remained significant: OR: 0.803 [0.648–0.994], p = 0.044. For the analysis of zygotes that will be biopsied on day 5/6 versus zygotes without biopsy, only early morphokinetic parameters were considered. All parameters were different in the multivariate model: ct2: OR: 0.840 [0.709–0.996], p = 0.045; ct6: OR: 0.943 [0.890–0.998], p = 0.043; cc2(t3-t2): OR: 1.148 [1.044–1.263], p = 0.004; cc3(t5-t3): OR: 1.177 [1.107–1.251], p<0.0001. When comparing the development between blastocysts biopsied on day 5 versus day 6, only three morphokinetic parameters were significant: cc2(t3-t2): OR: 1.394 [1.010–1.926], p = 0.044; ctBlastocyst: OR: 0.613 [0.489–0.768], p<0.0001 and ctExpandedBlastocyst: OR: 0.913 [0.868–0.960], p = 0.0004. Multivariate analysis of gender and ploidy did not reveal differences in morphokinetic behaviour. Conclusion Minor morphokinetic differences are observed between IVF and ICSI. Early in the development, distinct cleavage patterns are observed between embryos that will be biopsied or not.
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Nagaya M, Ukita N. Embryo Grading With Unreliable Labels Due to Chromosome Abnormalities by Regularized PU Learning With Ranking. IEEE TRANSACTIONS ON MEDICAL IMAGING 2022; 41:320-331. [PMID: 34748484 DOI: 10.1109/tmi.2021.3126169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
We propose a method for human embryo grading with its images. This grading has been achieved by positive-negative classification (i.e., live birth or non-live birth). However, negative (non-live birth) labels collected in clinical practice are unreliable because the visual features of negative images are equal to those of positive (live birth) images if these non-live birth embryos have chromosome abnormalities. For alleviating an adverse effect of these unreliable labels, our method employs Positive-Unlabeled (PU) learning so that live birth and non-live birth are labeled as positive and unlabeled, respectively, where unlabeled samples contain both positive and negative samples. In our method, this PU learning on a deep CNN is improved by a learning-to-rank scheme. While the original learning-to-rank scheme is designed for positive-negative learning, it is extended to PU learning. Furthermore, overfitting in this PU learning is alleviated by regularization with mutual information. Experimental results with 643 time-lapse image sequences demonstrate the effectiveness of our framework in terms of the recognition accuracy and the interpretability. In quantitative comparison, the full version of our proposed method outperforms positive-negative classification in recall and F-measure by a wide margin (0.22 vs. 0.69 in recall and 0.27 vs. 0.42 in F-measure). In qualitative evaluation, visual attentions estimated by our method are interpretable in comparison with morphological assessments in clinical practice.
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12
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Change in the Strategy of Embryo Selection with Time-Lapse System Implementation-Impact on Clinical Pregnancy Rates. J Clin Med 2021; 10:jcm10184111. [PMID: 34575222 PMCID: PMC8471151 DOI: 10.3390/jcm10184111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/22/2022] Open
Abstract
Time-lapse systems (TLS) and associated algorithms are interesting tools to improve embryo selection. This study aimed to evaluate how TLS and KIDScore™ algorithm changed our practices of embryo selection, as compared to a conventional morphological evaluation, and improved clinical pregnancy rates (CPR). In the study group (year 2020, n = 303 transfers), embryos were cultured in an EmbryoScope+ time-lapse incubator. A first team observed embryos conventionally once a day, while a second team selected the embryos for transfer based on time-lapse recordings. In the control group (year 2019, n = 279 transfers), embryos were selected using the conventional method, and CPR were recorded. In 2020, disagreement between TLS and the conventional method occurred in 32.1% of transfers, more often for early embryos (34.7%) than for blastocysts (20.5%). Irregular morphokinetic events (direct or reverse cleavage, multinucleation, abnormal pronuclei) were detected in 54.9% of the discordant embryos. When it was available, KIDScore™ was decreased for 73.2% of the deselected embryos. Discordant blastocysts mainly corresponded with a decrease in KIDScore™ (90.9%), whereas discordant Day 3 embryos resulted from a decreased KIDScore™ and/or an irregular morphokinetic event. CPR was significantly improved in the TLS group (2020), as compared to the conventional group (2019) (32.3% vs. 21.9%, p = 0.005), even after multivariate analysis. In conclusion, TLS is useful to highlight some embryo development abnormalities and identify embryos with the highest potential for pregnancy.
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Minasi MG, Greco P, Varricchio MT, Barillari P, Greco E. The clinical use of time-lapse in human-assisted reproduction. Ther Adv Reprod Health 2020; 14:2633494120976921. [PMID: 33336190 PMCID: PMC7724395 DOI: 10.1177/2633494120976921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/04/2020] [Indexed: 11/18/2022] Open
Abstract
A major challenge in the assisted reproduction laboratory is to set up
reproducible and efficient criteria to identify the embryo with the
highest developmental potential. Over the years, several methods have
been used worldwide with this purpose. Initially, standard morphology
assessment was the only available strategy. It is now universally
recognized that besides being a very subjective embryo selection
strategy, morphology evaluation alone has a very poor prognostic
value. More recently, the availability of time-lapse incubators
allowed a continuous monitoring of human embryo development. This
technology has spread quickly and many fertility clinics over the
world produced a remarkable amount of data. To date, however, a
general consensus on which variables, or combination of variables,
should play a central role in embryo selection is still lacking. Many
confounding factors, concerning both patient features and clinical and
biological procedures, have been observed to influence embryo
development. In addition, several studies have reported unexpected
positive outcomes, even in the presence of abnormal developmental
criteria. While it does not seem that time-lapse technology is ready
to entirely replace the more invasive preimplantation genetic testing
in identifying the embryo with the highest implantation potential, it
is certainly true that its application is rapidly growing, becoming
progressively more accurate. Studies involving artificial intelligence
and deep-learning models as well as combining morphokinetic with other
non-invasive markers of embryo development, are currently ongoing,
raising hopes for its successful applicability for clinical purpose in
the near future. The present review mainly focuses on data published
starting from the first decade of 2000, when time-lapse technology was
introduced as a routine clinical practice in the infertility
centers.
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Affiliation(s)
| | | | | | - Paolo Barillari
- Center for Reproductive Medicine,
Villa Mafalda, Rome, Italy
| | - Ermanno Greco
- Center for Reproductive Medicine,
Villa Mafalda, Rome, Italy
- Saint Camillus International
University of Health and Medical Sciences (UniCamillus), Rome,
Italy
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14
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Fishel S, Campbell A, Foad F, Davies L, Best L, Davis N, Smith R, Duffy S, Wheat S, Montgomery S, Wachter A, Beccles A. Evolution of embryo selection for IVF from subjective morphology assessment to objective time-lapse algorithms improves chance of live birth. Reprod Biomed Online 2020; 40:61-70. [DOI: 10.1016/j.rbmo.2019.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/31/2019] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
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15
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Neves AR, Devesa M, Martínez F, Garcia-Martinez S, Rodriguez I, Polyzos NP, Coroleu B. What is the clinical impact of the endometrial receptivity array in PGT-A and oocyte donation cycles? J Assist Reprod Genet 2019; 36:1901-1908. [PMID: 31352621 DOI: 10.1007/s10815-019-01535-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To evaluate the influence of the endometrial receptivity array (ERA) test on the implantation rate (IR) and pregnancy rate (PR) in patients with previous failed euploid embryo transfers (Euploid-ET) or oocyte donation embryo transfers (Donor-ET). METHODS Single-center retrospective study of patients with ≥ 1 previous failed Euploi-ET (n = 24) or ≥ 2 failed Donor-ET (n = 32) who underwent an ERA test and a post-ERA Euploid-ET/Donor-ET between 2012 and 2018. Controls were patients with ≥ 1 previously failed Euploid-ET (n = 119) or ≥ 2 failed Donor-ET (n = 158) who underwent Euploid-ET/Donor-ET during the same period without performing an ERA test. Only blastocyst stage embryos were included. IR/PR was compared between the post-ERA ET and the last ET in the control group. RESULTS There was no statistically significant difference regarding IR [55.6% (34.6-76.5%) vs. 65.0% (56.9-73.1%)] nor PR (58.3% vs.70.6%, p = 0.238) in the Euploid-ET ERA vs. Euploid-ET control groups. In the Donor-ET arm, both IR [26.8% (12.3-41.4%) vs. 57.2% (50.1-64.3%)] and PR (34.4% vs. 65.2%, p = 0.001) were significantly lower in the ERA group. Multivariate analysis confirmed that performing an ERA test did not influence the PR in the Euploid-ET arm and was associated with a diminished PR in the Donor-ET arm. In the ERA group, 41.1% patients were non-receptive (NR). No significant difference was found regarding IR/PR in NR vs. receptive patients in both Euploid-ET/Donor-ET arms. CONCLUSIONS In our sample, the performance of an ERA test did not improve pregnancy outcomes. Future prospective studies in larger samples are needed to confirm the role of the ERA test in Euploid-ET/Donor-ET.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics and Gynecology, Coimbra Hospital and University Centre, Rua Augusta 17, 3000-045, Coimbra, Portugal.
| | - Marta Devesa
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain
| | - Francisca Martínez
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain
| | - Sandra Garcia-Martinez
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain
| | - Ignacio Rodriguez
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain.,Faculty of Medicine and Pharmacy, Department of Surgical and Clinical Science, Vrije Universiteit Brussel, 1050, Brussels, Belgium.,Department of Clinical Medicine, Faculty of Health, Aarhus University, 8000, Aarhus, Denmark
| | - Buenaventura Coroleu
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain
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Hammond ER, Cree LM, Morbeck DE. Should extended blastocyst culture include Day 7? Hum Reprod 2019; 33:991-997. [PMID: 29648640 DOI: 10.1093/humrep/dey091] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/27/2018] [Indexed: 11/12/2022] Open
Abstract
Extended culture to the blastocyst stage is widely practised, improving embryo selection and promoting single embryo transfer. Selection of useable blastocysts typically occurs on Days 5 and 6 of embryo culture. Embryos not suitable for transfer, biopsy or cryopreservation after Day 6 are routinely discarded. Some embryos develop at a slower rate, however, forming blastocysts on Day 7 of culture. Day 7 blastocysts can be viable, they can be of top morphological grade, euploid and result in a healthy live birth. Since ending culture on Day 6 is current practice in most clinics, viable Day 7 blastocysts may be prematurely discarded. Although Day 7 blastocysts make up only 5% of useable blastocysts, those which are suitable for cryopreservation or biopsy are clinically significant. Overall, culturing embryos an additional day increases the number of useable embryos per IVF cycle and provides further opportunity for pregnancy for patients, especially those who have only a few or low-quality blastocysts.
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Affiliation(s)
- Elizabeth R Hammond
- Fertility Associates, 7 Ellerslie Racecourse Drive, Remuera, Auckland 1051, New Zealand
| | - Lynsey M Cree
- Fertility Associates, 7 Ellerslie Racecourse Drive, Remuera, Auckland 1051, New Zealand.,Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland 1023, New Zealand
| | - Dean E Morbeck
- Fertility Associates, 7 Ellerslie Racecourse Drive, Remuera, Auckland 1051, New Zealand.,Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland 1023, New Zealand
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17
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Cutting R. Single embryo transfer for all. Best Pract Res Clin Obstet Gynaecol 2018; 53:30-37. [DOI: 10.1016/j.bpobgyn.2018.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 06/28/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
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18
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Nguyen Q, Sommer S, Greene B, Wrenzycki C, Wagner U, Ziller V. Effects of opening the incubator on morphokinetics in mouse embryos. Eur J Obstet Gynecol Reprod Biol 2018; 229:64-69. [DOI: 10.1016/j.ejogrb.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/27/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
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20
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Schenk M, Groselj-Strele A, Eberhard K, Feldmeier E, Kastelic D, Cerk S, Weiss G. Impact of polar body biopsy on embryo morphokinetics-back to the roots in preimplantation genetic testing? J Assist Reprod Genet 2018; 35:1521-1528. [PMID: 29790071 PMCID: PMC6086803 DOI: 10.1007/s10815-018-1207-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/09/2018] [Indexed: 11/29/2022] Open
Abstract
Purpose Polar body biopsy (PBB) is a common technique in preimplantation genetic testing (PGT) to assess the chromosomal status of the oocyte. Numerous studies have been implemented to investigate the impact of biopsies on embryo development; however, information on embryo morphokinetics is still lacking. Hence, we investigated the impact of PBB on morphokinetic parameters in early embryo development. Methods Four hundred four embryos (202 PBB, 202 control) were retrospectively analyzed. Patients were stimulated with a gonadotropin-releasing hormone antagonist ovarian hyperstimulation protocol. After fertilization check, embryos were incubated in a time-lapse incubator. The groups were matched for maternal age at time of oocyte retrieval. Results Mean group times for reaching specific developmental time points showed no significant difference comparing embryos with PBB conducted and without. Likewise, further subdivision of the PBB group in euploid and aneuploid embryos revealed no differences in the early embryo morphokinetic development compared to the control group. Aneuploidy testing revealed a high prevalence of chromosomal aberrations for chromosomes 21, 4, 16, and 19. Conclusions In conclusion, PBB does not impact the morphokinetic parameters of the embryo development. PBB can be safely applied without the risk of impairing the reproductive potential of the embryo and can be highly recommended as safe and practicable PGT approach, especially in countries with prevailing restrictions regarding PGT analysis.
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Affiliation(s)
- Michael Schenk
- Das Kinderwunsch Institut Schenk GmbH, Am Sendergrund 11, 8143, Dobl, Austria.,Institute of Human Genetics, Medical University of Graz, Neue Stiftingtalstrasse 2, 8010, Graz, Austria
| | - Andrea Groselj-Strele
- Core Facility Computational Bioanalytics, Center for Medical Research, Medical University of Graz, Stiftingtalstraße 24, 8010, Graz, Austria
| | - Katharina Eberhard
- Core Facility Computational Bioanalytics, Center for Medical Research, Medical University of Graz, Stiftingtalstraße 24, 8010, Graz, Austria
| | - Elisabeth Feldmeier
- Das Kinderwunsch Institut Schenk GmbH, Am Sendergrund 11, 8143, Dobl, Austria
| | - Darja Kastelic
- Das Kinderwunsch Institut Schenk GmbH, Am Sendergrund 11, 8143, Dobl, Austria
| | - Stefanie Cerk
- Das Kinderwunsch Institut Schenk GmbH, Am Sendergrund 11, 8143, Dobl, Austria
| | - Gregor Weiss
- Das Kinderwunsch Institut Schenk GmbH, Am Sendergrund 11, 8143, Dobl, Austria.
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