Should the flexibility enabled by performing a day-4 embryo transfer remain as a valid option in the IVF laboratory? A systematic review and network meta-analysis

Comparison of pregnancy outcomes between 4th day morula and 5th day blastocyst after embryo transfer: a retrospective cohort study

BACKGROUND

This study was designed to evaluate pregnancy outcomes between morulae transferred on day 4 (D4) and blastocysts transferred on day 5 (D5).

METHODS

From September 2017 to September 2020, 1963 fresh transfer cycles underwent early follicular phase extra-long protocol for assisted conception in our fertility center were divided into D4 (324 cases) and D5 (1639 cases) groups, and the general situation and other differences of patients in both groups were compared. To compare the differences in pregnancy outcomes, the D4 and D5 groups were further divided into groups A and B based on single and double embryo transfers. Furthermore, the cohort was divided into two groups: those with live births (1116 cases) and those without (847 cases), enabling a deeper evaluation of the effects of D4 or D5 transplantation on assisted reproductive outcomes.

RESULTS

In single embryo transfer, there was no significant difference between groups D4A and D5A (P > 0.05). In double embryo transfer, group D4B had a lower newborn birthweight and a larger proportion of low birthweight infants (P < 0.05). The preterm delivery rate, twin delivery rate, cesarean delivery rate, and percentage of low birthweight infants were lower in the D5A group than in the D5B group (P < 0.05). Analysis of factors influencing live birth outcomes further confirmed the absence of a significant difference between D4 and D5 transplantation in achieving live birth (P > 0.05).

CONCLUSION

When factors such as working life and hospital holidays are being considered, D4 morula transfer may be a good alternative to D5 blastocyst transfer. Given the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) success rate and risk of twin pregnancy, D4 morula transfer requires an adapted decision between single and double embryo transfer, although a single blastocyst transfer is recommended for the D5 transfer in order to decrease the twin pregnancy rate. In addition, age, endometrial thickness and other factors need to be taken into account to personalize the IVF program and optimize pregnancy outcomes.

When the Embryo Meets the Endometrium: Identifying the Features Required for Successful Embryo Implantation

Evaluation of the optimal number of embryos, their quality, and the precise timing for transfer are critical determinants in reproductive success, although still remaining one of the main challenges in assisted reproduction technologies (ART). Indeed, the success of in vitro fertilization (IVF) treatments relies on a multitude of events and factors involving both the endometrium and the embryo. Despite concerted efforts on both fronts, the overall success rates of IVF techniques continue to range between 25% and 30%. The role of the endometrium in implantation has been recently recognized, leading to the hypothesis that both the "soil" and the "seed" play a central role in a successful pregnancy. In this respect, identification of the molecular signature of endometrial receptivity together with the selection of the best embryo for transfer become crucial in ART. Currently, efforts have been made to develop accurate, predictive, and personalized tests to identify the window of implantation and the best quality embryo. However, the value of these tests is still debated, as conflicting results are reported in the literature. The purpose of this review is to summarize and critically report the available criteria to optimize the success of embryo transfer and to better understand current limitations and potential areas for improvement.

Embryo Transfer Procedural Parameters Do Not Predict IVF Cycle Outcome

BACKGROUND

this study aims to assess the effect of embryo transfer (ET) performance parameters of a technical nature on IVF outcome.

METHODS

A total of 1417 ETs from a single IVF center were included in this prospective observational study. The parameters investigated were as follows: the presence of cervical mucus post catheter withdrawal, the presence of blood, catheter reload, the employment of a tenaculum and stylet, catheter resistance as experienced by the physician and patient discomfort.

RESULTS

When ET performance parameters were associated with clinical outcomes on a singular level, none of the ET parameters presented with any statistical significance. The evaluation of covariates indicated that the number and the quality of transferred embryos, as well as maternal age, exerted a statistically significant effect on clinical outcomes. In a multivariate analysis, only the presence of mucus along with significant catheter resistance presented with statistical significance; however, when adjusting for covariates, this combination showed no statistically significant effect on clinical outcomes.

CONCLUSIONS

the results indicate that the time-consuming process of recording and analyzing ET performance parameters fails to offer any additional value in predicting the cycle's outcome, while factors like embryo quality and number, as well as maternal age, seem to be the sole robust predictive factors of an IVF cycle.

Commercially Available Molecular Approaches to Evaluate Endometrial Receptivity: A Systematic Review and Critical Analysis of the Literature

Despite the advances in the field of reproductive medicine, implantation failure represents a challenging condition affecting 10-30% of patients subjected to in vitro fertilization (IVF). Research has focused on the identification of molecules playing crucial roles in endometrial receptivity, with the aim of designing predictive tools for efficient detection of the implantation window. To that end, novel molecular genomic and transcriptomic approaches have been introduced as promising tools to enable personalized approaches with the aim of optimizing embryo transfer dating. However, the clinical value of these approaches remains unclear. The aim of this study is to provide a systematic review and critical analysis of the existing evidence regarding the employment of commercially available novel approaches to evaluate endometrial receptivity. An Embase and PubMed/Medline search was performed on 1 February 2022. From the 475 articles yielded, only 27 were included and analyzed. The considerable heterogeneity of the included articles indicates the uniqueness of the implantation window, showcasing that the optimal time for embryo transfer varies significantly between women. Moreover, this study provides information regarding the technical aspects of these advanced molecular tools, as well as an analysis of novel possible biomarkers for endometrial receptivity, providing a basis for future research in the field.

Comparison of pregnancy and live birth rates between fresh day 5 morula transfer and fresh day 6 blastocyst transfer following extended culture for slow growing embryos

PURPOSE

The aim of this study is to evaluate and compare the outcomes of fresh day 5 morula transfers and fresh day 6 blastocyst transfers after extended culture, in women with a whole cohort of slow growing embryos.

METHODS

Fresh embryo transfer cycles of patients that underwent intracytoplasmic sperm injection between 2013 and 2020 with a whole cohort of slow developing embryos on 5th day of fertilization were evaluated for this retrospective cohort study. Outcomes of day 5 morula transfers and day 6 blastocyst transfers after extended culture were compared.

RESULTS

Out of 479 patients, day 5 morula transfers were performed to 194 and embryo culturing was extended to day 6 in 285 women. Blastocyst formation was observed in 129 of 285 patients in extended culture group. Implantation rate of day 6 blastocyst transfer group was significantly higher than day 5 morula transfer group (27% vs. 12%, p < 0.001). However, clinical pregnancy (17% vs 15.4%) and live birth rates (14.4% vs 13%) were found similar in day 5 morula transfer and extended culture group per initiated cycle.

CONCLUSION

Although implantation capacity of day 6 blastocysts seems higher comparing to day 5 morulas, clinical pregnancy and live birth rates are similar among intention to treat population in fresh day 5 morula transfers and day 6 blastocyst transfers after extended culture for women that cohorts consist of only slow developing embryos.

Stress Management during the Intracytoplasmic Sperm Injection Cycle May Slow Down First Embryo Cleavage and Accelerate Embryo Compaction: A Pilot Randomized Controlled Trial

INTRODUCTION

A firm consensus on the effectiveness of psychological interventions during infertility treatment has not been reached yet in terms of mental health and pregnancy rates. Moreover, the influence of these interventions on embryo cleavage kinetics has not been investigated.

OBJECTIVE

The aim of this work was to study whether stress management in couples undergoing an intracytoplasmic sperm injection (ICSI) cycle influences stress levels, mitochondrial DNA (mtDNA) levels in granulosa cells, and cleavage-stage embryos.

METHODS

Infertile couples were randomized into a treatment as usual (TAU) group (n = 30) and stress management program (SMP) group (n = 29) at the beginning of an ICSI cycle. Couples in the SMP group attended education and relaxation sessions at each visit to the clinic for folliculometry. The perceived stress scale (PSS) was used to assess stress levels at the beginning and end of the cycle. Moreover, mtDNA levels of granulosa cells and embryo morphokinetics were evaluated.

RESULTS

Post-intervention, women in the SMP group had significantly lower PSS scores than their initial PSS (p < 0.001; effect size, ES = 0.5) and than the final PSS of the TAU group (p = 0.02; ES = 0.09). Additionally, mtDNA levels were significantly lower in luteal granulosa cells of the SMP group than the TAU group (p = 0.02). An earlier time of pronuclei appearance (p = 0.03) and time to 2 cells (p = 0.015) and a faster time to full compaction (p = 0.045) were detected in the embryos of the SMP group compared with the TAU group.

CONCLUSION(S)

The implemented program may reduce stress levels, retard first embryo cleavage, and accelerate embryo compaction. Further studies with an active control group are needed to confirm these results.

Multivariate analysis of the factors associated with live births during in vitro fertilisation in Southeast Asia: a cross-sectional study of 104,015 in vitro fertilisation records in Taiwan

PURPOSE

To investigate the factors associated with live births and the interaction between age and the number of embryos transferred after in vitro fertilisation (IVF) treatment.

METHODS

This study analyses data from a population-based-assisted reproductive database of all registered artificial reproduction institutions (n = 80) from 2010 to 2016 in Taiwan. The probability of a live birth in correlation with the treatment parameters was measured with multivariate logistic regression analyses using the generalised additive model (GAM) and Pearson's chi-square exact test.

RESULTS

A total of 104,015 IVF treatments performed between 2010 and 2016 were included in our analysis. From these treatments, 31,467 (30.3%) were successfully delivered, and 40,565 test-tube babies were born. Pearson's chi-square exact test indicated that parents' age, cause of infertility, type of ovarian stimulation, additional assisted reproductive technology techniques, donated egg or sperm, fresh or frozen embryo, presence or absence of ovarian hyperstimulation syndrome, and day of embryo transfer were significantly associated with live births after an IVF cycle (p < 0.05). Multiple logistic regression analysis with the GAM revealed that the odds of a live birth with IVF treatment in patients < 34 years of age were 2.55 times higher than that in patients ≥ 45 years of age (odds ratio = 2.55, 95% confidence interval = 1.69-2.90) for patients who underwent a single-embryo transfer (SET); a similar pattern was observed when two or more embryos were transferred. Egg donation, the assisted hatching technique, oral ovarian stimulation agents, and implantation of frozen embryos during SET were shown to improve the chance of a live birth by 29-90%. Implantation of the embryo after the 5th day of culture yielded the highest odds of a live birth. The interaction plot revealed that maternal age, especially < 40 years, was associated with the probability of a live birth. SET and double-embryo transfer showed similar associations with the probability of a live birth across age groups. Transferring more than two embryos might reduce the probability of a live birth during IVF treatment for women ≥ 40 years of age.

CONCLUSIONS

Implanting a greater number of embryos did not improve the age-related decrease in fertility for patients undergoing IVF. Therefore, we suggested that ≤ 2 blastocysts could be transferred during IVF treatments for women ≥ 40 years. Transferring a blastocyst on day 5 of culture was associated with a significant increase in the odds of a live birth resulting from IVF.

Network meta-analyses in reproductive medicine: challenges and opportunities

Network meta-analysis allows researchers to synthesise both direct and indirect evidence, thus enabling simultaneous comparisons of multiple treatments. A relatively recent addition to evidence synthesis in reproductive medicine, this approach has become increasingly popular. Yet, the underlying assumptions of network meta-analyses, which drive the validity of their findings, have been frequently ignored. In this article, we discuss the strengths and limitations of network meta-analyses. In addition, we present an overview of published network meta-analyses in reproductive medicine, summarize their challenges and provide insights into future research opportunities.