Intra-age, intercenter, and intercycle differences in chromosome abnormalities in oocytes

Validation of prognosis-based in vitro fertilization grant selection criteria

Objective

To validate a prognosis-based scoring system for in vitro fertilization (IVF) grant allocation.

Design

Retrospective cohort study.

Setting

A 501(c)(3) nonprofit foundation that awards donated IVF cycles and grants to those with demonstrated financial need. In contrast to lottery-based or subjective allocation systems, applications are scored according to medical prognostic criteria in addition to personal characteristics.

Patients

Grant recipients from 2015 to 2019.

Interventions

None.

Main outcome measures

Live birth rate (LBR) and cumulative LBR (CLBR) among grant recipients were compared with 2019 Society for Assisted Reproductive Technology (SART) national averages.

Results

A total of 435 applications were reviewed, with 59 grants awarded for 51 autologous IVF cycles, 6 donor oocyte cycles, and 2 gestational carrier cycles, resulting in 39 live births after initial embryo transfer (LBR 61.9%) and 43 CLBRs (CLBR 72.9%). Among autologous cycles, the mean (±SD=3.9 years) age was 31.8 years, and LBR and CLBR were 62.8% and 68.6% vs. 28.2% and 37.1% among all autologous SART cycles, respectively. A subanalysis of grant recipients aged <35 years (n=39) revealed LBR and CLBR of 66.7% and 74.4% vs. 40.7% and 47.8% among autologous SART cycles aged <35 years, respectively.

Conclusions

A scoring system incorporating medical criteria identified IVF grant applicants with a high likelihood of achieving a LB. Although most IVF grant programs select recipients through a lottery or personal characteristics, a prognosis-based scoring system should be considered to maximize LBR in a limited resource setting.

The chances of obtaining a euploid embryo and subsequent live birth remain consistent with national age-based rates after an in vitro fertilization cycle that produced only aneuploid embryos

OBJECTIVE

To determine the prognosis of patients who were only able to obtain aneuploid embryos in their first in vitro fertilization (IVF) cycle if they attempted a second cycle.

DESIGN

Case series and retrospective cohort study.

SETTING

A single, large fertility center.

PATIENT(S)

All patients who obtained only aneuploid embryos after IVF with preimplantation genetic testing for aneuploidy during the initial cycle and returned for a second cycle.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The percentage of patients who obtained a euploid embryo and live birth rates in the second cycle, stratified by Society for Assisted Reproductive Technology-defined age groups, was compared with that of controls from the same period.

RESULT(S)

A total of 538 patients with only aneuploid embryos in their first cycle were included. Three hundred (56%) patients obtained euploid blastocysts in the second cycle, with younger women having a higher chance of obtaining at least 1 euploid embryo (81% in women aged <35 years vs. 25% in women aged >42 years). The cumulative live birth rates were 71%, 62%, 46%, 27%, and 13% for the age groups <35, 35-37, 38-40, 41-42, and >42 years, respectively. The live birth rates per first embryo transfer were >57% across all the age groups and similar to those of the controls in the same age groups.

CONCLUSION(S)

Patients who obtained only aneuploid embryos during their initial IVF cycle retained favorable prognosis in their second cycle, with outcomes comparable with the national age-based standards. Younger women and those who had more embryos available for biopsy had the highest chance of success. These women should receive age-appropriate counseling and should not be discouraged from a second IVF attempt based on the results of their first cycle.

PGT-A: The biology and hidden failures of randomized control trials

OBJECTIVE

PGT-A for embryo selection has undergone significant advancements in the last two decades and yet many studies still fail to demonstrate any clinical benefits over traditional embryo morphology selection. To understand this conundrum, we performed a multi-center clinical study of PGT-A patients, where morphology selection (Mo-S) and euploid selection (Eu-S) outcomes were directly compared.

METHOD

All suitable blastocysts were biopsied and analysed for chromosome copy number. Outcomes (positive beta hCG, implantation, ongoing pregnancy and live birth rates) for euploid selection were compared to morphology selection using single embryo transfers RESULTS: Compared to Eu-S embryos, Mo-S embryos resulted in significant reduction of outcomes for positive beta hCG (P=0.0005), implantation (P=0.0008), ongoing pregnancy (P=0.0046), livebirth (P=0.0112), babies per transfer (P=0.0112) and babies per embryo transferred (P=0.0112). Morphology selection resulted in patients of all age groups having non-euploid embryos chosen for transfer. Post-hoc evaluation of individual clinic performances showed variable transfer outcomes that could potentially confound the true benefits of PGT-A.

CONCLUSION

Embryo chromosome status is central to improved embryo transfer outcomes and sole reliance on current morphology-based selection practices, without euploid selection, will always compromise outcomes. Often overlooked but a major effector of successful PGT-A outcomes are individual clinic performances. This article is protected by copyright. All rights reserved.

Predicting the Likelihood of Live Birth in Assisted Reproductive Technology According to the Number of Oocytes Retrieved and Female Age Using a Generalized Additive Model: A Retrospective Cohort Analysis of 17,948 Cycles

Capsule

We designed a predictive reference model to evaluate how many stimulation cycles are needed for a patient to achieve an ideal live birth rate using assisted reproductive technology.

Objective

To develop a counseling tool for women who wish to undergo assisted reproductive technology (ART) treatment to predict the likelihood of live birth based on age and number of oocytes retrieved.

Methods

This was a 6-year population-based retrospective cohort analysis using individual patient ART data. Between 2012 and 2017, 17,948 women were analyzed from their single ovarian stimulation cycle until they had a live birth or had used all their embryos. All consecutive women between 20 and 49 years old undergoing their ovarian stimulation cycles for ART in our center were enrolled. The cumulative live birth rate (CLBR) was defined as the delivery of a live neonate born during fresh or subsequent frozen-thawed embryo transfer cycles. Only the first delivery was considered in the analysis. Binary logistic regression was performed to identify and adjust for factors known to affect the CLBR independently. A generalized additive model was used to build a predictive model of CLBR according to the woman's age and the number of oocytes retrieved.

Results

An evidenced-based counseling tool was created to predict the probability of an individual woman having a live birth, based on her age and the number of oocytes retrieved in ART cycles. The model was verified by 10 times 10-fold cross-validation using the preprocessed data, and 100 area under the curve (AUC) values for receiver operating characteristic (ROC) curves were obtained on the test set. The mean AUC value was 0.7394. Our model predicts different CLBRs ranging from nearly 90% to less than 20% for women aged 20-49 years with at least 22 oocytes retrieved. The CLBRs of women aged 20-28 years were very similar, nearly on one trend line with a certain number of oocytes retrieved. Differences in the CLBR began to appear by the age of 29 years; these increased gradually in women aged >35 years.

Conclusion

A predictive model of the CLBR was designed to serve as a guide for physicians and for patients considering ART treatment. The number of oocytes needed to be retrieved to achieve a live birth depends on the woman's age.

Prediction of live birth and cumulative live birth rates in freeze-all-IVF treatment of a general population

PURPOSE

To investigate the cumulative live birth (cLB) rate of one complete freeze-all-IVF cycle in a general infertile population and to investigate patient and treatment variables that predict blastocyst development and live birth (LB).

METHOD

In a retrospective observational study, the data of all IVF cycles performed between 1 February 2015 and 31 January 2016 at a single IVF centre was investigated. In the study, patient-couples were followed up for 18 months following oocyte retrieval. After exclusions, the patient and treatment variables of 1582 patient-couples who underwent treatment were included in the analyses.

RESULTS

The median time interval between the oocyte retrieval attempt and the frozen embryo transfer (FET) in which LB was achieved was 38.0 (35.0-67.0) days. The variables of freeze-all-IVF cycles with single blastocyst FET selected by multiple logistic regression to predict LB significantly were female age, infertility duration, FET number (i.e. 1st, 2nd, or ≥ 3rd FET), and blastocyst quality. In a regression adjusting for female age, the number of blastocysts transferred, and oocyte number group (1-3, 4-9, 10-15, and > 15), none of the oocyte number groups were selected to predict LB of 1st FET, significantly. While the per transfer LB rates decreased linearly from the 1st (56.5%) to the 3rd (36.4%) FET, the cLB rate increased from 47.3% after the 1st FET to 55.0% after a 3rd possible FET.

CONCLUSION

The cLB rate of one complete freeze-all-IVF cycle of a general infertile population, with 18-month follow-up, was 55.0%. In freeze-all-IVF, ovarian reserve variables were not selected by regression models to predict LB, significantly.

Optimizing the culture environment and embryo manipulation to help maintain embryo developmental potential

With increased use of comprehensive chromosome screening (CCS), the question remains as to why some practices do not experience the same high levels of clinical success after implementation of the approach. Indeed, the debate surrounding the efficacy and usefulness of blastocyst biopsy and CCS continues. Importantly, several variables impact the success of an assisted reproductive technology cycle. Transfer of a euploid embryo is but one factor in an intricate system that requires numerous steps to occur successfully. Certainly, the culture environment and the manipulations of the embryo during its time in the laboratory can impact its reproductive potential. Environmental stressors ranging from culture media to culture conditions and even culture platform can impact biochemical, metabolic, and epigenetic patterns that can affect the developing cell independent of chromosome number. Furthermore, accompanying procedures, such as biopsy and vitrification, are complex and, when performed improperly, can negatively impact embryo quality. These are areas that likely still carry room for improvement within the IVF laboratory.

The menopause and aging, a comparative perspective

The neuroendocrinology of menopause is reviewed from a comparative perspective, with emphasis on laboratory rodent models. These changes are compared by the 2011 STRAW criteria (Stages of Reproductive Aging Workshop). Ovarian cell loss begins prenatally in all mammals studied, with exponential depletion of primary follicles and oocytes in association with loss of fecundity by midlife. Rodents and humans also share progressively increasing irregularity in ovulatory cycles and increasing fetal aneuploidy as oocyte depletion become imminent. Hypothalamic impairments of the estrogen-induced surge of pituitary gonadotrophins (luteinizing hormone, LH; follicle stimulating hormone, FSH) are prominent in middle-aged rodents, but sporadic in peri-menopausal women. In aging rodents, hypothalamic impairments of the LH surge have been experimentally associated with prolonged phases of sustained estradiol (E2) and very low progesterone (P4) ('unopposed estradiol'). Although peri-menopausal women also show hyper-estrogenic cycles, there is no indication for irreversible hypothalamic desensitization by E2. Ongoing cognitive assessments in clinical trials of estrogen therapy with and without P4 or other progestins may further inform about possible persisting effects of unopposed estrogens.This article is part of a Special Issue entitled 'Menopause'.

Lifestyle factors and reproductive health: taking control of your fertility

Approximately 10 to 15% of couples are impacted by infertility. Recently, the pivotal role that lifestyle factors play in the development of infertility has generated a considerable amount of interest. Lifestyle factors are the modifiable habits and ways of life that can greatly influence overall health and well-being, including fertility. Many lifestyle factors such as the age at which to start a family, nutrition, weight, exercise, psychological stress, environmental and occupational exposures, and others can have substantial effects on fertility; lifestyle factors such as cigarette smoking, illicit drug use, and alcohol and caffeine consumption can negatively influence fertility while others such as preventative care may be beneficial. The present literature review encompasses multiple lifestyle factors and places infertility in context for the couple by focusing on both males and females; it aims to identify the roles that lifestyle factors play in determining reproductive status. The growing interest and amount of research in this field have made it evident that lifestyle factors have a significant impact on fertility.