International committee for monitoring assisted reproductive technologies: world report on assisted reproductive technologies, 2007

The impact of IVF patients' characteristics on their satisfaction and quality-of-life with overseas treatment: A mixed methods approach

Recent advances in infertility therapy, such as hormone medication and in vitro fertilization (IVF), have led to an increase in the demand for IVF. North Cyprus is a new medical tourist destination, and this study aimed to discover influential demographic predictors of IVF patients' satisfaction and quality-of-life (QoL) after receiving reproductive IVF services. Two questionnaires on IVF patient satisfaction and QoL were administered to 101 patients who received services in selected IVF clinics. Parametric and nonparametric tests were used for statistical analysis. The results showed that the mean satisfaction level with IVF service introduction and doctor professionalism increased with age, and a maximum satisfaction level was found in older patients. Doctor professionalism was another significant factor for greater satisfaction in older patients than in young patients who underwent IVF treatment. Satisfaction with IVF services was reduced by increasing education levels. IVF services must be managed and provided based on the needs of patients from different demographic backgrounds and efforts must be made to improve satisfaction with fertility services.

Developmental outcomes of children born through ICSI versus conventional IVF (cIVF) in couples with non-male factor infertility

STUDY QUESTION

In non-male factor infertile couples, are there any differences in the developmental outcomes between children born through ICSI and conventional IVF (cIVF)?

SUMMARY ANSWER

In this preliminary study, ICSI and cIVF seem to have a comparable effect on developmental outcomes after 12 months in children born to non-male factor infertile couples.

WHAT IS KNOWN ALREADY

ICSI, an invasive technique, has raised concerns about potential developmental abnormalities in children. Limited data are available regarding the developmental outcomes of ICSI-conceived infants born to non-male factor infertile couples.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study involved a follow-up of all children aged 12 months or older who were born from pregnancies resulting from either ICSI or cIVF as part of a previous randomized controlled trial (RCT) (NCT03428919).

PARTICIPANTS/MATERIALS, SETTING, METHODS

In the original RCT, 1064 women were randomly assigned to the ICSI or cIVF groups (532 women for each group). Follow-up was conducted with 155 couples (195 children) in the ICSI group and 141 couples (185 children) in the cIVF group. The Vietnamese version of the Ages & Stages Third Edition Questionnaires (ASQ-3) and the Development Red Flags questionnaires were completed by the participants. A total of 141 (90.1%) women (177 children) in the ICSI group and 113 (80.1%) women (145 children) in the cIVF group returned fully completed questionnaires. The primary outcomes were the developmental outcomes based on responses to the ASQ-3 and the Red Flags questionnaire.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean age of children at follow-up was 19.5 ± 5.0 months in the ICSI group and 19.3 ± 5.5 months in the cIVF group. The mean height and weight of children in both groups were similar. The overall proportion of children with any abnormal ASQ-3 score did not differ significantly between the ICSI and cIVF groups (16.9% vs 13.1%, P = 0.34). The proportion of children with Red Flag signs was also comparable between the two groups (6.2% vs 9.2%, P = 0.36, ICSI vs cIVF, respectively).

LIMITATIONS, REASONS FOR CAUTION

Despite a reasonably high follow-up response rate, there is a potential risk of sampling bias, and overall, the number of children with developmental abnormalities was very small. The study relied solely on questionnaires as screening tools, rather than incorporating additional behavioral observations or physical developmental tests; this may have affected the statistical power and the significance of between-group comparisons.

WIDER IMPLICATIONS OF THE FINDINGS

The current findings contribute to the existing evidence and support the comparative safety of ICSI and cIVF regarding early childhood development. However, more extensive and prolonged follow-up data for these children are needed to draw definitive conclusions.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received for this study, and no authors reported conflicting interests.

TRIAL REGISTRATION NUMBER

NCT04866524 (clinicaltrials.gov).

Effectiveness of psychological interventions on pregnancy rates in infertile women undergoing assisted reproductive technologies: a meta-analysis of randomised controlled trials

The purpose of this study was to assess the effects of psychological interventions on the pregnancy rates of infertile women undergoing assisted reproductive technology (ART). Using the electronic databases PubMed, EM Base, Cochrane Library, WOS, CNKI, WanFang Data, CSTJ, and CBM, a systematic literature search was conducted in the second week of August 2019. Randomized controlled trials (RCTs) on the effect of psychological interventions on the pregnancy rate of infertile women undergoing assisted reproductive technology were collected. There is no time limit for this search setting. The language is limited to Chinese or English. Two investigators independently screened the literature, extracted data, and assessed the risk of bias of the included studies, and then used Revman5.3 and STATA16.0 software for meta-analysis. A total of 25 randomized controlled trials were included in this meta-analysis, including 2098 patients in the experimental group and 2075 patients in the control group. There was a significant difference in the pregnancy rate between the two groups [RR=1.31, 95%CI(1.22,1.40)]. Subgroup analysis showed that this is also true of infertile women of different nationalities, different intervention timing and format. However, different psychological interventions may indeed have different effects. Current evidence suggests that psychological interventions may improve pregnancy rates in infertile women undergoing assisted reproductive technology. Limited by the quantity and quality of included studies, the above conclusions need to be verified by more high-quality studies. Our PROSPERO registration number is: CRD42019140666.

Laser-assisted hatching improves pregnancy outcomes in frozen-thawed embryo transfer cycles of cleavage-stage embryos: a large retrospective cohort study with propensity score matching

INTRODUCTION

Laser-assisted hatching (LAH) is a commonly used adjunct technique; however, its effectiveness has not been fully established.

OBJECTIVE

We evaluated the effects of LAH on pregnancy outcomes in frozen-thawed embryo transfer (FET) cycles of cleavage-stage embryos.

MATERIALS AND METHODS

This retrospective study involved 5779 FET cycles performed at the Reproductive and Genetic Center in the Affiliated Hospital of Shandong University of Traditional Chinese Medicine between January 2016 and December 2020. After propensity score matching, 3535 FET cycles were included, out of which 1238 were subjected to LAH while the remaining 2297 cycles were non-LAH (NLAH). The primary outcomes were clinical pregnancy rate (CPR) and live birth rate (LBR) while secondary outcomes included implantation rate (IR), biochemical pregnancy rate (BPR), ectopic pregnancy rate (EPR), pregnancy loss rate (PLR), multiple pregnancy rate (MPL), and monozygotic twinning rate (MTR). Logistic regression analysis was conducted to adjust for possible confounders. Subgroup analysis was also performed based on the endometrial preparation regimen.

RESULTS

The LAH group exhibited a higher LBR, compared to the NLAH group (34.9% vs. 31.4%, OR = 1.185, 95% CI = 1.023, 1.374, P = 0.024). Additionally, the LAH group showed a decreasing trend in PLR and EPR; however, differences were insignificant (P = 0.078, P = 0.063 respectively). Differences in IR (24.6% vs. 24.3%), BPR (41.8% vs. 40.4%), CPR (40.7% vs. 38.3%), MPR (14.1% vs. 17.3%), and MTR (1.4% vs. 1.1%) were insignificant. Subgroup analysis revealed that LAH may be more conducive for pregnancy outcomes in hormone replacement cycles.

CONCLUSIONS

In summary, LAH has an increased chance of achieving live births. However, further prospective studies should be performed to confirm our findings.

Association Between MitoScore, BMI, and Body Fat Percentage as a Predictive Marker for the Outcome of In-Vitro Fertilization (IVF)

Background

Infertility is defined as the inability to establish a pregnancy within 12 months of regular and unprotected sexual intercourse. In response to these problems, assisted reproductive techniques (ARTs) have made profound impacts on the therapeutic management of infertility. However, in-vitro fertilization (IVF) success rates are confounded by several internal and external factors. A relatively new approach to embryo assessment is known as MitoScore (Igenomix, Miami, USA). As a result, we sough to evaluate whether MitoScore can help in predicting in IVF outcomes, and to assess the relationship between MitoScore, BMI, and body fat percentage in determining the success of ARTs.

Methods

Using retrospective cohort, a study population consisting of 166 women aged 26-43 who were undergoing ART with pre-implantation genetic testing for aneuploidy (PGT-A) was assessed to determine if MitoScore, BMI, and body fat percentage impacted IVF outcomes.

Results

MitoScore, BMI, and body fat percentage were significantly lower in pregnant women as compared to non-pregnant women. Furthermore, MitoScore was correlated with subclasses of IVF outcomes (delivery, biochemical pregnancy, and spontaneous abortion) and was found to be positively correlated with BMI in patients with biochemical pregnancies.

Conclusion

Our findings suggest that MitoScore, BMI, and body fat percentage could act as critical parameters in determining the success of ART. However, the association between MitoScore, BMI, and body fat percentage does not appear to be a significant confounding factor to determine pregnancy outcome at this stage. Still, many factors need to be considered to establish the correlation reliably.

Paternal adherence to healthy dietary patterns in relation to sperm parameters and outcomes of assisted reproductive technologies

OBJECTIVE

To investigate whether men's adherence to dietary patterns promoted for the prevention of cardiovascular disease is associated with semen parameters and couples' assisted reproductive technology (ART) outcomes.

DESIGN

Prospective cohort study.

SETTING

Fertility center at an academic medical center.

PATIENT(S)

A total of 245 men and their female partners who underwent 438 ART cycles between 2007 and 2020.

INTERVENTION(S)

Male pretreatment dietary intake was assessed with a 131-item food frequency questionnaire from which we calculated eight a priori defined scores: Trichopoulou Mediterranean, Alternate Mediterranean, Panagiotakos Mediterranean, Healthy Eating Index, Alternative Healthy Eating Index, American Heart Association, Dietary Approaches to Stop Hypertension, and Plant-based.

MAIN OUTCOME MEASURE(S)

The primary outcome was live births per treatment cycle. The secondary outcomes were fertilization, implantation, and clinical pregnancy and seminogram parameters.

RESULT(S)

There was an inverse association between greater adherence by men to the Panagiotakos Mediterranean diet and the American Heart Association dietary pattern and lower fertilization rate. However, there were no significant associations between men's adherence to any of the analyzed dietary patterns and the probabilities of implantation, clinical pregnancy, or live birth in multivariable-adjusted models. No significant differences in any of the semen parameters were found between participants of the lowest quartile and those of the highest quartile of the eight dietary patterns.

CONCLUSION(S)

These findings suggest that men's adherence to several a priori defined dietary scores with documented cardiovascular benefits is not related to major outcomes of infertility treatment with ART or semen quality.

Recombinant human luteinizing hormone co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Several studies suggest that luteinizing hormone (LH) could improve IVF outcome in women of advanced reproductive age by optimizing androgen production. In this review, we assessed the role of recombinant-human LH (r-hLH) and recombinant human follicle stimulating hormone (r-hFSH) co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age candidates for assisted reproduction.

MATERIAL AND METHODS

Using a preregistered protocol we systematically searched Medline/PubMed, Scopus and the ISI Web of Science databases to identify randomized controlled trials in which r-hFSH monotherapy protocols were compared with r-hFSH/r-hLH co-treatment in women ≥35 years undergoing fresh IVF cycles. We calculated the pooled odds ratio (OR) for dichotomous data and the weight mean difference (WMD) for continuous data with an associated 95% confidence interval (CI). The meta-analyses were conducted using the random-effect model. P values < 0.05 were considered statistically significant. Subgroup analyses of all primary and secondary outcomes were performed only in women aged 35-40 years.

RESULTS

Twelve studies were identified. In women aged between 35 and 40 years, r-hFSH/r-hLH co-treatment was associated with higher clinical pregnancy rates (OR 1.45, CI 95% 1.05-2.00, I² = 0%, P = 0.03) and implantation rates (OR 1.49, CI 95% 1.10-2.01, I² = 13%, P = 0.01) versus r-hFSH monotherapy. Fewer oocytes were retrieved in r-hFSH/r-hLH-treated patients than in r-hFSH-treated patients both in women aged ≥35 years (WMD -0.82 CI 95% -1.40 to - 0.24, I² = 88%, P = 0.005) and in those aged between 35 and 40 years (WMD -1.03, CI - 1.89 to - 0.17, I² = 0%, P = 0.02). The number of metaphase II oocytes, miscarriage rates and live birth rates did not differ between the two groups of women overall or in subgroup analysis.

CONCLUSION

Although more oocytes were retrieved in patients who underwent r-hFSH monotherapy, this meta-analysis suggests that r-hFSH/r-hLH co-treatment improves clinical pregnancy and implantation rates in women between 35 and 40 years of age undergoing ovarian stimulation for assisted reproduction technology. However, more RCTs using narrower age ranges in advanced age women are warranted to corroborate these findings.

ChromInst: A single cell sequencing technique to accomplish pre-implantation comprehensive chromosomal screening overnight

Next Generation Sequencing (NGS) is a powerful tool getting into the field of clinical examination. Its preliminary application in pre-implantation comprehensive chromosomal screening (PCCS) of assisted reproduction (test-tube baby) has shown encouraging outcomes that improves the success rate of in vitro fertilization. However, the conventional NGS library construction is time consuming. In addition with the whole genome amplification (WGA) procedure in prior, makes the single cell NGS assay hardly be accomplished within an adequately short turnover time in supporting fresh embryo implantation. In this work, we established a concise single cell sequencing protocol, ChromInst, in which the single cell WGA and NGS library construction were integrated into a two-step PCR procedure of ~ 2.5hours reaction time. We then validated the feasibility of ChromInst for overnight PCCS assay by examining 14 voluntary donated embryo biopsy samples in a single sequencing run of Miseq with merely 13M reads production. The good compatibility of ChromInst with the restriction of Illumina sequencing technique along with the good library yield uniformity resulted superior data usage efficiency and reads distribution evenness that ensures precisely distinguish of 6 normal embryos from 8 abnormal one with variable chromosomal aneuploidy. The superior succinctness and effectiveness of this protocol permits its utilization in other time limited single cell NGS applications.

Prospective longitudinal cohort study of uterine arteries Doppler in singleton pregnancies obtained by IVF/ICSI with oocyte donation or natural conception

STUDY QUESTION

Do uterine arteries Doppler studies show different pulsatility index (UtA-PI) measurements in IVF/ICSI pregnancies with oocyte donation (OD) as compared to natural conceptions?

SUMMARY ANSWER

In IVF/ICSI pregnancies with OD, UtA-PI is reduced by an average of about 40% as compared to pregnancies with natural conception.

WHAT IS KNOWN ALREADY

OD pregnancies present worse pregnancy outcomes as compared to natural conception, particularly for increased incidence of pre-eclampsia (PE). Recent evidence shows that IVF/ICSI pregnancies with frozen blastocyst transfer also present higher prevalence of PE and 15% lower UtA-PI as compared to pregnancies after fresh blastocyst transfers.

STUDY DESIGN, SIZE, DURATION

Prospective, longitudinal matched cohort study performed in the Fetal Medicine and Obstetric Departments of San Raffaele Hospital in Milan, between 2013 and 2018. The analysis is based on 584 Doppler observations collected from 296 women with different method of conception (OD n = 122; natural conception n = 174).

PARTICIPANTS/MATERIALS, SETTING, METHODS

IVF/ICSI viable singleton pregnancies with OD and natural conception control pregnancies matched for BMI and smoking, performing repeated UtA-PI measurements at 11-34 weeks. Miscarriages, abnormalities, twins, significant maternal diseases and other types of ARTs were excluded. Log mean left-right UtA-PI was used for analysis with linear mixed model (LMM) and correction for significant confounders. Pregnancy outcome was also analyzed.

MAIN RESULTS AND THE ROLE OF CHANCE

Participants after OD were older and more frequently nulliparous (mean age: OD 43.4, 95% CI from 42.3 to 44.6; natural conception 35.1, 95% CI from 34.5 to 35.7; P-value < 0.001; nulliparous: OD 96.6%; natural conception 56.2%; P-value < 0.001). Mean pulsatility index was lower in OD (UtA-PI: natural conception 1.22; 95% CI from 1.11 to 1.28; OD 1.04; 95% CI from 0.96 to 1.12; P-value < 0.001). A significant effect of parity, gestational age (GA) modeled with a cubic polynomial and BMI was described in the LMM. The mean Log UtA-PI was on average 37% lower in OD as compared to natural conception pregnancies at LMM (P-value < 0.001). We also found a significant interaction between longitudinal UtA-PI Doppler and GA. Therefore, at 11 weeks' gestation the Log UtA-PI was 42% lower and, at 34 weeks, the differences reduced to 32%. GA at delivery and birth weight were statistically lower in OD group; however, birthweight centile was not statistically different. Preeclampsia was 11-fold more common in the OD group (0.6% and 6.6%, P-value = 0.003). No other significant difference in pregnancy outcome was shown in the study groups (gestational diabetes mellitus, small or large for GA).

LIMITATIONS, REASONS FOR CAUTION

It was not possible to properly match for maternal age and to blind the assessment given the major differences between cohorts; however, we did not find significant within-groups effects related to maternal age. Future research is needed to reassess outcomes and correct them for maternal characteristics (e.g. cardiovascular function).

WIDER IMPLICATIONS OF THE FINDINGS

This finding reproduces our previous discovery of lower UtA-PI in frozen as compared to fresh blastocyst transfer. The vast majority of OD is obtained by the use of cryopreservation. We speculate that increased uterine perfusion may be the physiological response to compensate dysfunctions both in the mother and in the placenta.

STUDY FUNDING/COMPETING INTEREST(S)

This is a non-funded study. The authors do not declare competing interest.

TRIAL REGISTRATION NUMBER

N/A.

Normalized Mitochondrial DNA Copy Number Can Optimize Pregnancy Outcome Prediction in IVF

The aim of this study is to explore the relationship between mitochondrial DNA (mtDNA) copy number and embryo implantation potential in in vitro fertilization (IVF). A retrospective study of 319 blastocysts from patients undergoing preimplantation genetic testing (PGT) at Reproductive Medicine Center in Tongji Hospital from January 2016 to February 2018 was conducted. We used multiple annealing- and looping-based amplification cycles (MALBAC) technology to amplify the genetic materials from the trophectoderm cells of blastocysts, and next-generation sequencing (NGS) technology to test mitochondrial DNA copy number. Box-Cox transformation was introduced to eliminate the skewness distribution of mtDNA copy number, and the transformed data were defined as adjusted mtDNA. Subsequently, associations between adjusted mtDNA and the clinical characteristics of patients were assessed by univariate analysis and multiple linear regression. In addition, Gaussian Naive Bayes classifier was also used to predict pregnancy outcomes. We observed that only antral follicle count (AFC) was significantly associated with adjusted mtDNA without the influence of multicollinearity. What's more, the distribution of the adjusted mtDNA of blastocysts resulting in live birth was more concentrated than that of others. The area under the curve (AUC) of the prediction model that combined adjusted mtDNA with other clinical characteristics of patients was up to 0.81, higher than that excluded adjusted mtDNA. Among patient clinical characteristics, AFC was significantly associated with adjusted mtDNA. Mitochondrial DNA copy number may help to optimize the pregnancy outcome prediction in IVF.

Anxiety Level During the Second Localized COVID-19 Pandemic Among Quarantined Infertile Women: A Cross-Sectional Survey in China

Infertility usually causes mental health problems for patients and unfavorable emotions such as anxiety and depression can have an adverse effect on women's normal pregnancy. We aimed to compare the anxiety level between infertile female patients in quarantined and non-quarantined areas during the second wave of COVID-19 epidemic. A total of 759 infertile women were included in this cross-sectional study conducted through an online survey. Anxiety was measured by the State-Trait Anxiety Inventory (STAI) tool. Participants were divided into the quarantined group (QG) and non-quarantined group (Non-QG). Independent sample T-test and chi-square test were performed to examine the difference between the two groups. There was no significant difference in the average STAI score of the two groups of infertile women, but responses to the emotional state showed that women in the QG had a higher tendency to be anxious. Participants in QG spent more time paying attention to the dynamics of the epidemic every day, and their sleep (p < 0.01) and mood conditions were worse (p < 0.01) than in the Non-QG. The family relationship of QG is more tense than non-QG. Through the research on the infertility treatment information of the overall research population, it is found the average STAI-State (STAI-S) (p = 0.031) score and STAI-Trait (STAI-T) (p = 0.005) score of women who were infertile for more than 3 years were significantly higher than those of women with <2 years. The STAI-T score of infertile women who underwent in vitro fertilization (IVF) was higher than that of non-IVF women (p = 0.007), but no significant difference was observed with the STAI-S score. To conclude, although the second wave of quarantine during COVID-19 epidemic did not significantly increase anxiety in infertile women, it did lead to an increase in other negative emotions and worse family relationships. Patients with long-term infertility treatment and those who have had IVF are more anxious subgroups.

The Analysis of Anxiety and Depression in Different Stages of in vitro Fertilization-Embryo Transfer in Couples in China

BACKGROUND

This study aimed to examine the differences in anxiety and depression between infertile Chinese couples in diverse stages of in vitro fertilization-embryo transfer (IVF-ET) and their relationship with the IVF-ET outcomes.

METHODS

From February 2016 to December 2018, a total of 247 couples that were undergoing IVF-ET were randomly selected for this study. On the day they started their treatment (T1), the day human chorionic gonadotropin was administered (T2), and 4 days after the embryo transfer (T3), self-designed questionnaires, the Self-Rating Anxiety Scale, and the Self-Rating Depression Scale were completed to investigate anxiety and depression in different stages.

RESULTS

Age had an effect on the anxiety and depression in women. Male infertility type and the cause of infertility had an effect on the anxiety and depression in men. The incidence of anxiety in women in the T1, T2, and T3 stages was 29.96%, 44.94%, and 17.81%, respectively. The anxiety scores of women were 46.14 ± 8.37, 50.83 ± 8.50, and 44.09 ± 8.17, respectively, which were significantly higher than those of men (p < 0.05). The anxiety score in stage T2 was the highest in women, and the depression score of women in stage T1 was the highest. The incidence of anxiety in men in the T1, T2, and T3 stages was 20.65%, 8.50%, and 6.07%, respectively. The incidence of anxiety was not significantly different in diverse stages (p > 0.05), and the same result was obtained for the incidence of depression. The anxiety and depression scores of the infertile couples in different stages were not related to the outcome of IVF-ET.

CONCLUSION

The incidence of anxiety and depression in infertile couples in diverse stages of IVF-ET is different, especially in women, and the anxiety and depression of infertile couples in the process of IVF-ET may not be related to the outcome of assisted pregnancy.

Follicular fluid anti-Müllerian hormone (AMH) concentrations and outcomes of in vitro fertilization cycles with fresh embryo transfer among women at a fertility center

PURPOSE

To enhance the understanding of the clinical significance of anti-Müllerian hormone (AMH) in follicular fluid, we aimed to determine the variability of AMH concentrations in follicular fluid within and across IVF cycles and whether high follicular fluid AMH concentrations are associated with improved clinical IVF outcomes.

METHODS

This was a retrospective cohort study of companion follicular fluid and serum samples from 162 women enrolled in the Environment and Reproductive Health (EARTH) Study between 2010 and 2016. AMH concentrations were quantified using a sandwich enzyme-linked immunosorbent assay. Spearman correlation and intra-class correlation (ICC) were calculated to assess variability of follicular fluid AMH, and generalized linear mixed models were used to evaluate the associations of FF AMH with IVF outcomes.

RESULTS

The median (interquartile range, IQR) age of the 162 women was 34.0 years (32.0, 37.0). Follicular fluid AMH concentrations were highly correlated between follicles within each IVF cycle (Spearman r = 0.78 to 0.86) and across cycles for each woman (ICC 0.87 (95% CI 0.81 to 0.92)). Compared with women in the highest tertile of FF AMH (mean AMH = 2.3 ng/ml), women in the lowest tertile (mean AMH = 0.2 ng/ml) had lower serum AMH (T1 = 0.1 ng/ml vs. T3 = 0.6 ng/ml, p < 0.0001). In adjusted models, higher tertiles of follicular fluid AMH concentrations were associated with lower mean endometrial thickness and higher probability of clinical pregnancy.

CONCLUSIONS

Follicular fluid AMH concentrations show little variability between pre-ovulatory follicles, and higher pre-ovulatory follicular fluid AMH may predict a higher probability of clinical pregnancy.

Why are multiple pregnancy rates and single embryo transfer rates so different globally, and what do we do about it?

In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed.

Incidences and risk factors of moderate-to-severe ovarian hyperstimulation syndrome and severe hemoperitoneum in 1,435,108 oocyte retrievals

RESEARCH QUESTION

What are the risk factors affecting the incidences of moderate-to-severe ovarian hyperstimulation syndrome (OHSS) and severe hemoperitoneum in assisted reproductive technology (ART) treatment cycles?

DESIGN

A retrospective cohort study was conducted on 1,435,108 oocyte retrieval cycles among Japanese ART registry data between 2007 and 2015. The study included 11,378 cycles with moderate-to-severe OHSS, 1182 cycles with severe hemoperitoneum, including 27 cycles with both conditions, and 1,422,575 cycles without moderate-to-severe OHSS and severe hemoperitoneum.

RESULTS

The incidences of moderate-to-severe OHSS and severe hemoperitoneum were 0.79% and 0.08%, respectively, and decreased by 0.57-fold and 0.29-fold from 2007 to 2015, respectively. In cycles with OHSS and cycles with hemoperitoneum women were younger (odds ratios [OR] 0.91 and 0.95, respectively) and had more retrieved oocytes (OR 1.09 and 1.01, respectively) compared with cycles without both complications. The use of a gonadotrophin-releasing hormone (GnRH) agonist protocol for ovarian stimulation was the highest risk factor in cycles with OHSS and hemoperitoneum (OR 1.83 and 1.24, respectively), followed by GnRH antagonist protocol (reference), gonadotrophin with or without oral medicine (OR 0.45 and 0.56, respectively) and natural or oral medicine (OR 0.02 and 0.19, respectively). In fresh embryo transfer, clinical pregnancy was associated with an increased risk of OHSS and hemoperitoneum (OR 1.19 and 2.34, respectively).

CONCLUSIONS

The highest risk factors affecting OHSS and hemoperitoneum were the use of a GnRH agonist protocol and clinical pregnancy following fresh embryo transfer. The incidences of OHSS and hemoperitoneum have decreased yearly with a reduction of GnRH agonist use and fresh embryo transfer.

Thyroid hormones in ovarian follicular fluid: Association with oocyte retrieval in women undergoing assisted fertilization procedures

Objective:

Our aim was to analyze the role of thyroid hormones in follicular fluid (FF) in relation to the number of oocytes retrieved in women recruited for an assisted fertilization procedure.

Methods:

Retrospective cohort study of 51 women 37.5±3.3 years, range 29-42, evaluated after a controlled ovarian stimulation protocol in a University Hospital. FF was sampled by transvaginal ultrasound-guided aspiration after ovarian hyperstimulation and we measured T3 (T3f), T4 (T4f), TSH (TSHf) and free T4 (T4ff). The oocyte maturation rate was calculated as: Number of metaphase II oocytes/Number of oocytes retrieved x 100. Statistical analysis was performed using the SPSS-19 software.

Results:

Hormone levels in FF were: TSHf 1.3µIU/ml (0.4 - 2.7), T3f: 1.52±0.46 nmol/L, T4f 88.8±30.9nmol/L and T4ff: 15.44±2.57pmol/L. The number of oocytes recovered was dependent onT4f following the equation: Log (oocyte) = 0.379+0.042*T4f (r:0.352, p=0.012). After a logistic regression model analysis, T3f showed a tendency to be associated with the OMR: OR (95 % CI)= 0.977 (0.954 to 1.001), p=0.057.

Conclusions:

The correlation found between thyroid hormones and the number of oocytes retrieved suggests an interaction between thyroid and gonadal axes in relation to follicular development.

Development of assisted reproductive technology services in Thailand between 2008 and 2014 before the new law: Results generated from the National ART Registry, Royal Thai College of Obstetricians and Gynecologists

Background

While the assisted reproductive technology (ART) relieves the burden of infertility in many couples, it presents significant public health challenges due to the substantial risk for multiple birth delivery and preterm birth, which are associated with poor maternal and fetal health outcomes. For this reason, it is important to monitor the development and effectiveness of ART services in Thailand.

Objective

To analyze the trends of ART services in Thailand between 2008 and 2014.

Methods

ART clinics in Thailand are required to submit data to the Royal Thai College of Obstetricians and Gynecologists via the National Reporting System. The data from 2008 to 2014 were collected and analyzed.

Results

The number of ART centers was increased from 35 to 47. The total fresh ART cycles were also increased from 3,723 to 6,516. The percentage values of intracytoplasmic sperm injection (ICSI), in vitro fertilization, gamete intrafallopian transfer, and zygote intrafallopian transfer cycles were changed from 77.87 to 95.59, 21.43 to 4.31, 0.21 to 0.09, and 0.45 to 0.05, respectively. The clinical pregnancy rates were 28.79–33.19, 22.84–51.34, 14.29–42.86, and 0.00–26.67, respectively. The clinical pregnancy rates in fresh vs. frozen-thawed cycles were 31.01–36.33 vs. 31.54–37.34 (P < 0.05). The clinical pregnancy rates in female age <35 vs. 35–39 vs. ≥40 years were 36.97–40.70 vs. 32.74–33.42 vs. 21.08–31.34, respectively (P < 0.001), and the percentage values of multifetal pregnancy rate were 18.75 vs. 13.30 and 13.69, respectively (P < 0.001). There were increasing preimplantation genetic screening (PGS) cycles, with the percentage of the clinical pregnancy rate (25.90–42.63, P < 0.05). The clinical pregnancy rates in medium-sized ART centers (100–300 cycles per year) vs. in small and large centers were 30.79–41.14 vs. 28.01–34.04 and 8.70–40.35, respectively (P < 0.001). Trends of increasing percentage of ART birth rate to total birth rate ratio were 0.24–0.34 (P < 0.05).

Conclusions

There were higher clinical pregnancy rates in frozen-thawed cycles. Higher multifetal pregnancy rate and clinical pregnancy rate were also found in younger females. There were increasing uses of ICSI and PGS. A trend toward increasing ART birth to total birth ratio was observed.

Building Oncofertility Core Competency in Developing Countries: Experience From Egypt, Tunisia, Brazil, Peru, and Panama

PURPOSE

Little is known about oncofertility practice in developing countries that usually suffer from a shortage of health services, especially those related to cancer care.

MATERIALS AND METHODS

To learn more about oncofertility practice in developing countries, we generated a survey to explore the barriers and opportunities associated with oncofertility practice in five developing countries from Africa and Latin America within our Oncofertility Consortium Global Partners Network. Responses from Egypt, Tunisia, Brazil, Peru, and Panama were collected, reviewed, and discussed.

RESULTS

Common barriers were identified by each country, including financial barriers (lack of insurance coverage and high out-of-pocket costs for patients), lack of awareness among providers and patients, cultural and religious constraints, and lack of funding to help to support oncofertility programs.

CONCLUSION

Despite barriers to care, many opportunities exist to grow the field of oncofertility in these five developing countries. It is important to continue to engage stakeholders in developing countries and use powerful networks in the United States and other developed countries to aid in the acceptance of oncofertility on a global level.

Blastocyst hatching site is regularly distributed and does not influence foetal development in mice

Hatching out from the zona pellucida (ZP) is a crucial step for blastocyst implantation and development. However, it is still unknown whether the location of the hatching site relative to the inner cell mass (ICM) affects embryo implantation and foetal development. Here, we classified hatching blastocysts into three categories, 0° ≤ θ ≤ 30°, 30° < θ ≤ 60°, and 60° < θ ≤ 90°, in which θ is determined based on the relative position of the hatching site to the arc midpoint of the ICM. Non-surgical embryo transfer (NSET) devices were employed to evaluate blastocyst implantation and embryo development. Of 1,827 hatching blastocysts, 43.84%, 30.60%, and 21.67% were categorized as 30° < θ ≤ 60°, 0° ≤ θ ≤ 30°, and 60° < θ ≤ 90°, respectively. Embryos with different hatching sites showed no distinct differences in blastocyst implantation; surrogate female pregnancy; embryo development to term; litter size, or offspring survival, gender, or body weight. Our results indicate that mouse blastocyst hatching site is not randomly distributed. Embryo implantation and development are not correlated with the blastocyst hatching site in mice. Thus, assessment of the blastocyst hatching site should not be recommended to evaluate mouse blastocyst implantation and developmental potential.

Family Welfare Effort, Total Fertility, and In Vitro Fertilization: Explaining the Israeli Anomaly

The theory of family welfare effort is a leading macro-sociological explanation of variation in human fertility. It holds that states which provide universally available, inexpensive, high-quality day care, generous parental leave, and flexible work schedules lower the opportunity cost of motherhood. They thus enable women, especially those in lower socioeconomic strata, to have the number of babies they want. A considerable body of research supports this theory. However, it is based almost exclusively on analyses of Western European and North American countries. This paper examines the Israeli case because Israel's total fertility rate is anomalously high given its family welfare effort. Based on a review of the relevant literature and a reanalysis of data from various published sources, it explains the country's unusually high total fertility rate as the product of (1) religious and nationalistic sentiment that is heightened by the Jewish population's perception of a demographic threat in the form of a burgeoning Palestinian population and (2) the state's resulting support for pro-natal policies, including the world's most extensive in vitro fertilization (IVF) system. The paper also suggests that Israel's IVF policy may not be in harmony with the interests of many women insofar as even women with an extremely low likelihood of becoming pregnant are encouraged to undergo the often lengthy, emotionally and physically painful, and risky process of IVF.

Dietary patterns and outcomes of assisted reproduction

BACKGROUND

There is growing acceptance that nutrition may be related to fertility and specifically to assisted reproductive technologies success in women; however, there is still no specific dietary guidance.

OBJECTIVE

The objective of the study was to evaluate the relationship between pretreatment adherence to various dietary patterns and outcomes of assisted reproductive technologies.

STUDY DESIGN

We followed up 357 women enrolled in the prospective Environment and Reproductive Health (EARTH) study, who underwent 608 assisted reproductive technologies cycles (2007-2017). Using a validated food frequency questionnaire completed prior to treatment, we assessed adherence to the Mediterranean diet, the alternate Healthy Eating Index 2010, the Fertility Diet (developed based on risk factors for anovulatory infertility), and a profertility diet we developed based on factors previously related to assisted reproductive technologies outcomes (higher intake of supplemental folic acid, vitamin B12, vitamin D, low- rather than high-pesticide residue produce, whole grains, dairy, soy foods, and seafood rather than other meats).

RESULTS

Higher adherence to the alternate Healthy Eating Index 2010 and Fertility Diet was not related to live birth following assisted reproductive technologies. Women in the second through the fourth quartiles of Mediterranean diet adherence had significantly higher probability of live birth (0.44, 95% confidence interval, 0.39-0.49) compared with women in the first quartile (0.31, 95% confidence interval, 0.25-0.39); however, there was no additional benefit of adherence to the Mediterranean diet above the second quartile. Increased adherence to the profertility diet was linearly associated with assisted reproductive technologies outcomes. The adjusted odds (95% confidence interval) of implantation, clinical pregnancy, and live birth were higher by 47% (21%, 77%), 43% (19%, 72%), and 53% (26%, 85%), respectively, per SD increase. The adjusted difference in the proportion of cycles resulting in live birth for women in the fourth vs first quartile of adherence to the profertility diet was 0.28 (95% confidence interval, 0.16-0.38). While the profertility diet was not related to estradiol levels, oocyte counts, or endometrial thickness, it was inversely associated with clinical pregnancy loss (odds ratio, 0.69, 95% confidence interval, 0.53-0.90 per SD increase).

CONCLUSION

Higher pretreatment adherence to the profertility diet was associated with an increased probability of live birth among women undergoing assisted reproductive technologies. Commonly recommended dietary advice such as adhering to the Mediterranean diet may not provide the most appropriate guidance for women undergoing infertility treatment in the United States.

Increased incidence of obstetric and perinatal complications in pregnancies achieved using donor oocytes and single embryo transfer in young and healthy women. A prospective hospital-based matched cohort study

In this single-center matched-cohort study, women who underwent IVF/ICSI with donor oocytes between 2007 and 2014 (n = 259) were compared to women undergoing autologous cycles during the same time period (n = 515). The matching (1:2) took into consideration the women's age, type of treatment (IVF/ICSI), and year of embryo transfer. All women were healthy and below 40 years of age at the time of IVF/ICSI, and the treatments were performed using a strict policy of single embryo transfer. Multiple logistic regression analysis, adjusted for body mass index (BMI), smoking, and parity, showed a four times increased risk of gestational hypertensive disorders (adjusted odds ratio, AOR 4.25; 95% confidence interval (CI), 2.61-6.92) and pre-eclampsia (AOR 3.99; 95% CI 2.27-7.00) in pregnancies achieved with donor oocytes. There was also a higher rate of cesarean section in women who gave birth after oocyte donation (AOR 1.69; 95% CI 1.22-2.35) and a higher risk of postpartum hemorrhage >1000 mL (AOR 1.59; 95% CI, 1.11-2.27). After further adjustment for preeclampsia in the logistic regression analysis, no additional increased perinatal risks were found. The incidence of preterm delivery, low weight at birth, need of neonatal intensive care, Apgar scores, and incidence of perinatal death were also similar between the groups.

International Committee for Monitoring Assisted Reproductive Technology: world report on assisted reproductive technology, 2011

OBJECTIVE

To report the utilization, effectiveness, and safety of practices in assisted reproductive technology (ART) globally in 2011 and assess global trends over time.

DESIGN

Retrospective, cross-sectional survey on the utilization, effectiveness, and safety of ART procedures performed globally during 2011.

SETTING

Sixty-five countries and 2,560 ART clinics.

PATIENT(S)

Women and men undergoing ART procedures.

INTERVENTION(S)

All ART.

MAIN OUTCOME MEASURE(S)

The ART cycles and outcomes on country-by-country, regional, and global levels. Aggregate country data were processed and analyzed based on methods developed by the International Committee for Monitoring Assisted Reproductive Technology (ICMART).

RESULT(S)

A total of 1,115,272 ART cycles were reported for the treatment year 2011. Imputing data for nonreporting clinics, 1,643,912 cycles resulted in >394,662 babies, excluding People's Republic of China. The best estimate of global utilization including People's Republic of China is approximately 2.0 million cycles and 0.5 million babies. From 2010 to 2011, the number of reported aspiration and frozen ET cycles increased 13.1% and 13.8%, respectively. The proportion of women aged ≥40 years undergoing nondonor ART increased from 23.2% in 2010 to 24.0% in 2011. As a percentage of nondonor aspiration cycles, intracytoplasmic sperm injection (ICSI) decreased slightly from 67.4% in 2010 to 66.5% in 2011. The IVF/ICSI combined delivery rates per fresh aspiration and frozen ET cycles were 19.8% and 21.4%, respectively. In fresh nondonor cycles, single ET increased from 30.0% in 2010 to 31.4% in 2011, whereas the average number of transferred embryos decreased from 1.95 in 2010 to 1.91 in 2011-again with wide country variation. The rates of twin deliveries after fresh nondonor transfers decreased from 20.4% in 2010 to 19.6% in 2011; the triplet rate decreased from 1.1%-0.9%. In frozen ET cycles performed in 2011, single ET was 51.6%, with an average of 1.59 embryos transferred and twin and triplet rates were 11.1% and 0.4%, respectively. The cumulative delivery rate per aspiration increased from 27.1% in 2010 to 28.0% in 2011. Fresh IVF/ICSI carried a perinatal mortality rate per 1,000 births of 21.0 in 2010 and 16.3 in 2011. This compared with a perinatal mortality rate after frozen ET of 14.6 per 1,000 births in 2010 and 8.6 in 2011. The data presented depend on the quality and completeness of data submitted by individual countries. This report covers approximately two-thirds of'world ART activity.

CONCLUSION(S)

Global ART utilization, effectiveness, and safety increased between 2010 and 2011.

Acupuncture in improving endometrial receptivity: a systematic review and meta-analysis

Background

This systematic review aimed at summarizing and evaluating the evidence of randomized controlled trials (RCTs) using acupuncture to improve endometrial receptivity (ER).

Methods

We searched 12 databases electronically through August 2018 without language restrictions. We included RCTs of women of infertility due to low ER, and excluded infertility caused by other reasons or non-RCTs. Two independent reviewers extracted the characteristics of studies and resolved the differences through consensus. Data were pooled and expressed as standard mean difference (SMD) or mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes, with 95% confidence interval (CI).

Results

We found very low to moderate level of evidence that acupuncture may improve pregnancy rate (RR = 1.23 95%CI[1.13, 1.34] P < 0.00001) and embryo transfer rate (RR = 2.04 95%CI[1.13, 3.70] P = 0.02), increase trilinear endometrium (RR = 1.47 95%CI [1.27, 1.70] P < 0.00001), thicken endometrium (SMD = 0.41 95% CI [0.11, 0.72] P = 0.008), reduce resistive index (RI) (MD = -0.08 95% CI [− 0.15, − 0.02] P = 0.01), pulse index (PI) (SMD = -2.39 95% CI [− 3.85, − 0.93] P = 0.001) and peak systolic velocity/ end-diastolic blood velocity (S/D) (SMD = -0.60 95% CI [− 0.89, − 0.30] P < 0.0001), compared with medication, sham acupuncture or physiotherapy. Acupuncture was statistically significant as a treatment approach.

Conclusion

The efficacy and safety of acupuncture on key outcomes in women with low ER is statistically significant, but the level of most evidence was very low or low. More large-scale, long-term RCTs with rigorous methodologies are needed.

Oocyte donation disclosure decisions: a longitudinal follow-up at middle childhood

Few studies have captured oocyte donation (OD) parents' decision processes about intended and actual disclosure over time. Likewise, OD children's perceptions about their family composition during middle childhood are underexplored. To address these gaps, a longitudinally followed cohort of OD recipient families was invited to participate in a qualitative, follow-up study. With an 86% response rate after 12 years, families were composed of oocyte recipient mothers (n = 6) and biological fathers (n = 6) representing 12 donor-oocyte conceived children (10.33 ± 1.23 years; mean ± SD). Of the 12 children, two that were aware and two that were unaware of their conceptual origins completed conversational interviews. Only one family in the initial cohort had disclosed OD to their children by the 12-year follow-up, despite 43% of parents intending to disclose and another 43% undecided about disclosure during pregnancy. Four parental disclosure patterns emerged at 12 years: (i) wanting to disclose; (ii) conflicted about disclosure; (iii) not planning to disclose; and (iv) having disclosed. Children that were unaware of their conceptual origins displayed no knowledge of their method of conception. There is a need for family-centric interventions to assist 'wanting to disclose' parents in their disclosure process and 'conflicted about disclosure' parents in their decision-making process post-OD treatment.

Assisted reproductive technology: prevalence and associated factors in Southern Brazil

OBJECTIVE:

To assess the prevalence of successful assisted reproductive technology and to identify the associated factors.

METHODS:

This population-based birth cohort study was carried out with 4,333 pregnant women expected to deliver in 2015 in the urban area of Pelotas, Southern Brazil. Use of an assisted reproductive technology procedure, type of assisted reproductive technology [in vitro fertilization or intracytoplasmic sperm injection or artificial insemination], number of embryos transferred, success of embryo transfer, number of attempts, and reported reasons for seeking assisted reproductive technology were the main outcomes measured. Use of an assisted reproductive technology procedure was analyzed according to sociodemographic, nutritional, reproductive history, and behavioral characteristics. Unadjusted and adjusted analyses were performed by logistic regression.

RESULTS:

Among the 4,275 newborns enrolled in the Pelotas 2015 Birth Cohort Study, 18 births (0.4%) were conceived by assisted reproductive technology. Most cases of assisted reproductive technology were by in vitro fertilization (70.6%). All cycles were performed in private clinics under direct out-of-pocket payment. Even after controlling for confounders, maternal age > 35 years, nulliparity and high family monthly income were strongly associated with assisted reproductive technology.

CONCLUSIONS:

The use of assisted reproductive technology services was reported by only a few women in the Pelotas 2015 Birth Cohort Study. Our study highlights sociodemographic factors associated to assisted reproductive technology procedures. To better understand the patterns and barriers in overall use of assisted reproductive technology services over time, national-level trend studies in assisted reproductive technology treatments and outcomes, as well as studies exploring the characteristics of women who have sought this kind of treatment are needed in low-middle income countries.

The mitochondrial DNA content of cumulus cells may help predict embryo implantation

PURPOSE

The quantification of mtDNA in cumulus granulosa cells (CGCs) surrounding an oocyte has been positively linked with morphological embryonic quality. In the present study, we evaluated the link between the amount of mtDNA in CGCs surrounding an oocyte and the chances for the corresponding embryo of implanting and leading to an ongoing pregnancy.

METHODS

This is an observational study, performed on 84 oocyte-cumulus-complexes (OCCs) having led to the replacement of an embryo in the maternal uterus, retrieved from 71 patients undergoing IVF with intracytoplasmic sperm. The OCCs were classified in two groups, one including 26 OCCs having led to an implanted embryo and the other including 58 OCCs having led to a non-implanted embryo. The average mtDNA content of CGCs was assessed by using a quantitative real-time PCR technique.

RESULTS

Significantly higher mtDNA copy numbers in CGCs were associated with implanted embryos than with non-implanted embryos (mean 215 [sd 375] and 59 [sd 72], respectively; p < 10⁴). Multivariate analysis, taking into account the women's age, the embryo quality, and the AMH level, suggests an independent relationship between the mtDNA content of CGCs and the potential of embryo implantation.

CONCLUSION

During in vitro fertilization (IVF) procedures, the probability of the implantation of the embryo appears to be closely correlated to the mtDNA copy numbers in the CGCs. Our results highlight the interest of mtDNA quantification in GCGs as a biomarker of the potential of embryo implantation.

Peripartum and postpartum outcomes in uncomplicated term pregnancy following ART: a retrospective cohort study from two Italian obstetric units

STUDY QUESTION

Do singleton uncomplicated term pregnancies conceived by assisted reproductive technology (ART) have adverse peripartum and postpartum outcomes?

SUMMARY ANSWER

Term pregnancies following ART, even if uncomplicated until birth, have a higher risk of retained placenta and postpartum hemorrhage (PPH).

WHAT IS KNOWN ALREADY

There is consistent evidence that pregnancies following ART have higher incidence of complications during pregnancy. However, few studies specifically investigated birth outcomes in ART term pregnancies.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study was conducted on 14 415 deliveries at two university tertiary care obstetric units. Clinical data were extracted by reviewing obstetric records of all deliveries from 1 January 2010 to 31 December 2014, in a standardized electronic database regarding the mother’s health before and during pregnancy, complications during pregnancy and at birth, and neonatal outcome.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Following an accurate evaluation of exclusion criteria (multiparity, maternal pre-pregnancy diseases, prior uterine surgery, fetal malformations, intrauterine deaths, elective cesarean section and pregnancy complications), the group of uncomplicated singleton term pregnancies from autologous ART conception by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) (n = 188) was compared with a maternal age and body mass index (BMI) matched group of spontaneous pregnancies (n = 1168). Cases of intrauterine insemination (IUI) (n = 14) and ovulation induction with timed intercourse (n = 18) were not included. Labor, delivery and postpartum outcomes were evaluated. Odds ratios (OR) were adjusted with multivariable logistic regression to maternal age, BMI, nationality and gestational age at birth.

MAIN RESULTS AND THE ROLE OF CHANCE

The age of women in the final analysis ranged from 25 to 45 years, while BMI ranged from 17 to 34 kg/m². Uncomplicated term pregnancies with ART conception had a higher risk of operative delivery (adjusted OR 1.40, 95% confidence interval (CI) 1.01–1.95), retained placenta (adjusted OR 2.63, 95% CI 1.31–5.26) and PPH (adjusted OR 2.86 95% CI 1.37–5.99). Conversely, ART conception did not increase the risk of induced labor (adjusted OR 1.18, 95% CI 0.85–1.65). However, patients that conceived by ART and underwent labor induction had a higher risk of failed induction compared with the control group (adjusted OR 2.53, 95% CI 1.23–5.21). Infants born after ART had a similar birthweight, Apgar score and arterial blood pH compared with spontaneously-conceived ones.

LIMITATIONS, REASONS FOR CAUTION

The database lacked specific information about causes of infertility, smoking habit, family income and details on ART (fresh versus frozen cycle, IVF versus ICSI), limiting, in part, our analysis of the results. However, only autologous IVF/ICSI pregnancies were included in order to prevent bias related to conception by oocyte/embryo donation. In vivo conception ART cases were excluded because they were too few to allow comparison with IVF/ICSI. Nevertheless, the inclusion of only uncomplicated pregnancies provides a highly homogeneous and still representative population sample. Study sample is representative of a well-resourced obstetric facility in a high-income country, limiting to some extent the generalizability of study results.

WIDER IMPLICATIONS OF THE FINDINGS

Pregnancies conceived by autologous ART that proceed uncomplicated until term may require counseling about the risk of placental retention with PPH.

STUDY FUNDING/COMPETING INTERESTS

The authors have no conflict of interest and funding to declare.

Clinical implications of mitochondrial DNA quantification on pregnancy outcomes: a blinded prospective non-selection study

STUDY QUESTION

Can quantification of mitochondrial DNA (mtDNA) in trophectoderm (TE) biopsy samples provide information concerning the viability of a blastocyst, potentially enhancing embryo selection and improving IVF treatment outcomes?

SUMMARY ANSWER

This study demonstrated that euploid blastocysts of good morphology, but with high mtDNA levels had a greatly reduced implantation potential.

WHAT IS KNOWN ALREADY

Better methods of embryo selection leading to IVF outcome improvement are necessary, as the transfer of chromosomally normal embryos of high morphological grade cannot guarantee the establishment of an ongoing pregnancy. The quantity of mtDNA in embryonic cells has been proposed as a new biomarker of viability-higher levels of mtDNA associated with reduced implantation potential.

STUDY DESIGN, SIZE, DURATION

mtDNA was quantified in 199 blastocysts, previously biopsied and shown to be chromosomally normal using preimplantation genetic testing for aneuploidy (PGT-A). These were generated by 174 couples (average female age 37.06 years). All patients underwent IVF in a single clinic. The study took place in a blinded, non-selection manner-i.e. mtDNA quantity was not known at the time of single embryo transfer. The fate of the embryos transferred was subsequently compared to the mtDNA levels measured.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Embryos were biopsied at the blastocyst stage. The TE samples obtained were subjected to whole genome amplification followed by comprehensive chromosome analysis via next generation sequencing. The same biopsy specimens were also tested using quantitative PCR, allowing highly accurate mtDNA quantification. After blastocyst transfer, the code used for blinding was broken and analysis undertaken to reveal whether the amount of mtDNA had any association with embryo implantation.

MAIN RESULTS AND THE ROLE OF CHANCE

mtDNA analysis of the 199 blastocysts revealed that 9 (5%) contained unusually high levels of mtDNA. All embryo transfers involved a single chromosomally normal blastocyst of good morphology. Of these, 121 (60%) led to ongoing pregnancies, 11(6%) led to biochemical pregnancies, and 10 (5%) spontaneously miscarried. All (100%) of these blastocysts had mtDNA levels considered to be normal/low. The remaining 57 (29%) blastocysts failed to implant. Among these non-viable embryos there were 9 (16%) with unusually high levels of mtDNA. This meant that the ongoing pregnancy rate for morphologically good, euploid blastocysts, with normal/low levels of mtDNA was 64% (121/190). In contrast, the ongoing pregnancy rate for the same type of embryos, but with elevated mtDNA levels, was 0/9 (0%). This difference was highly statistically significant (P < 0.0001).

LIMITATIONS REASONS FOR CAUTION

To determine the true extent of any clinical benefits a randomized clinical trial will be necessary. Research is needed to improve understanding of the biology of mtDNA expansion.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first investigation to evaluate the clinical impact of increased mtDNA in a prospective blinded manner. Results confirm that embryos with elevated mtDNA rarely implant, supporting its use as a viability biomarker. A total of 64% of euploid blastocysts with normal/low mtDNA implanted versus 60% for the cohort as a whole.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by institutional funding (Reprogenetics UK and Reprogenetics). DW is supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre Programme. None of the authors have any competing interests.

The impact of specific fertility treatments on cognitive development in childhood and adolescence: a systematic review

STUDY QUESTION

Does fertility treatment influence cognitive ability in school aged children, and does the impact vary with the type of treatment?

SUMMARY ANSWER

The available high-quality evidence indicates that specific treatments may give rise to different effects on cognitive development, with certain treatments, including ICSI, associated with cognitive impairment.

WHAT IS KNOWN ALREADY

Previous reviews of the literature concerning cognitive outcomes among children conceived with medical assistance have concluded that study findings are generally 'reassuring', but limited attention has been paid to the quality of this research. In addition, no review has separately assessed the range of treatment modalities available, which vary in invasiveness, and thus, potentially, in their effects on developmental outcomes.

STUDY DESIGN, SIZE, DURATION

A systematic review was undertaken. We searched PubMed, PsycINFO and the Educational Resources Information Centre database to identify English-language studies published up until 21 November 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two authors independently reviewed identified articles, extracted data and assessed study quality. Studies were eligible if they assessed cognitive development from age 4 years or more, among children conceived with fertility treatment compared with either children conceived naturally or children born from a different type of fertility treatment. Where available, data were extracted and reported separately according to the various components of treatment (e.g. mode of fertilization, embryo freezing, etc.). Risk of bias was assessed using the Newcastle-Ottawa Scale, with a score ≥7/9 indicative of high quality.

MAIN RESULTS AND THE ROLE OF CHANCE

The search identified 861 articles, of which 35 were included. Of these, seven were rated high quality. Most studies (n = 22) were subject to selection bias, due to the exclusion of children at increased risk of cognitive impairment. Among high-quality studies, there was no difference in cognitive outcomes among children conceived with conventional IVF and those conceived naturally. Findings among high-quality studies of children conceived with ICSI were inconsistent: when compared with children conceived naturally, one study reported lower intelligence quotient (IQ; 5-7 points, on average) among ICSI children whereas the remaining two high-quality studies reported no difference between groups. Furthermore, among the three high-quality studies comparing children conceived with ICSI compared with conventional IVF, one reported a significant increase in the risk of mental retardation, one reported a small difference in IQ (3 points lower, on average) and one no difference at all. There were scant studies examining exposure to embryo freezing, or less invasive treatments such as ovulation induction without IVF/ICSI.

LIMITATION, REASONS FOR CAUTION

Most existing studies had methodological limitations including selection bias and/or failure to address confounding by family background. In addition, a meta-analysis could not be performed due to heterogeneity in the assessment of cognitive outcomes. These factors impeded our ability to synthesize the evidence and draw reliable conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

The conflicting findings among studies of children conceived with ICSI require clarification, in light of the increasing use of this technique for reasons other than male-factor infertility. Further population-based studies are needed that utilize contemporary data to examine specific aspects of treatment and combinations of techniques (e.g. ICSI with frozen embryo cycles). Importantly, studies should include the complete group of children exposed to treatment.

STUDY FUNDING/COMPETING INTEREST(S)

A.R.R. is supported by a Career Development Fellowship from the National Health and Medical Research Council of Australia. L.J.M. is funded by a fellowship from the Heart Foundation of Australia. The authors declare there are no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

The mitochondrial DNA content of cumulus granulosa cells is linked to embryo quality

STUDY QUESTION

Could the mitochondrial DNA (mtDNA) content of cumulus granulosa cells (CGCs) be related to oocyte competence?

SUMMARY ANSWER

The quality of embryos obtained during IVF procedures appears to be linked to mtDNA copy numbers in the CGCs.

WHAT IS KNOWN ALREADY

Oocyte quality is linked to oocyte mtDNA content in the human and other species, and the mtDNA copy number of the oocyte is related to that of the corresponding CGCs. Moreover, the quantification of CGC mtDNA has recently been proposed as a biomarker of embryo viability.

STUDY DESIGN SIZE, DURATION

An observational study was performed on 452 oocyte-cumulus complexes retrieved from 62 patients undergoing ICSI at the ART Center of the University Hospital of Angers, France, from January to May 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The average mtDNA content of CGCs was assessed by using a quantitative real-time PCR technique. The relationship between CGC mtDNA content and oocyte maturity and fertilizability, on one hand, and embryo quality, on the other, was investigated using univariate and multivariate generalized models with fixed and mixed effects.

MAIN RESULTS AND THE ROLE OF CHANCE

No relationship was found between CGC mtDNA content and oocyte maturity or fertilizability. In contrast, there was a significant link between the content of mtDNA in CGCs surrounding an oocyte and the embryo quality, with significantly higher mtDNA copy numbers being associated with good quality embryos compared with fair or poor quality embryos [interquartile range, respectively, 738 (250-1228) and 342 (159-818); P = 0.006]. However, the indication provided by the quantification of CGC mtDNA concerning the eventuality of good embryo quality was seriously subject to patient effect (AUC = 0.806, 95%CI = 0.719-0.869). The quantity of CGC mtDNA was influenced by BMI and smoking.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

The quantification of CGC mtDNA may indicate embryo quality. However, since it is affected by patient specificity, it should be used with caution. It remains to be seen whether this marker could directly predict the implantation capacity of the embryo, which is the main objective in IVF practice.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that the quantification of CGC mtDNA may be a novel biomarker of embryo viability. However, patient specificity makes it impossible to establish a general threshold value, valid for all patients. Nevertheless, further studies are needed to determine whether the quantification of CGC mtDNA may, in combination with the morpho-kinetic method, offer an additional criterion for selecting the best embryo for transfer from a given cohort.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the University Hospital of Angers, the University of Angers, France, and the French national research centres INSERM and the CNRS. There were no competing interests.

A Partnership and Coping Enhancement Program for Couples Undergoing In Vitro Fertilization Treatment: An Intervention Study

This is a feasibility study to examine the effects of a partnership and coping enhancement program (PCEP) on improving the psychological well-being and marital functions of couples undergoing in vitro fertilization treatment. A total of 100 couples were recruited consecutively and assigned to a PCEP intervention group or a routine care control group. The couples in the PCEP group received an additional face-to-face, couple-based, 90-minute session on enhancing partnership and coping on the day of the embryo transfer (ET). The outcome measures were assessed at baseline (T0), 10 days after the ET (T1), and one month after the ET (T2). The level of anxiety of the women was lower in the intervention than in the control group at T1. Significant improvements in partnership and dyadic coping were seen in women at T2. The men of infertile couples reported a significant improvement in the scores for partnership at T2. The PCEP had no significant effects on marital satisfaction and marital adjustment for both the females and males of the infertile couples. The findings indicated that the PCEP is feasible and acceptable. Before a larger simple-size randomized controlled trial with participants drawn from multiple reproductive medical centers is conducted to further confirm its effectiveness.

Building Oncofertility Core Competency in Developing Countries: Experience From Egypt, Tunisia, Brazil, Peru, and Panama

Purpose

Little is known about oncofertility practice in developing countries that usually suffer from a shortage of health services, especially those related to cancer care.

Materials and Methods

To learn more about oncofertility practice in developing countries, we generated a survey to explore the barriers and opportunities associated with oncofertility practice in five developing countries from Africa and Latin America within our Oncofertility Consortium Global Partners Network. Responses from Egypt, Tunisia, Brazil, Peru, and Panama were collected, reviewed, and discussed.

Results

Common barriers were identified by each country, including financial barriers (lack of insurance coverage and high out-of-pocket costs for patients), lack of awareness among providers and patients, cultural and religious constraints, and lack of funding to help to support oncofertility programs.

Conclusion

Despite barriers to care, many opportunities exist to grow the field of oncofertility in these five developing countries. It is important to continue to engage stakeholders in developing countries and use powerful networks in the United States and other developed countries to aid in the acceptance of oncofertility on a global level.

Effects of assisted reproductive technologies in neonates with indications for surgery (2007-2016)

PURPOSE

Recently, the number of births using assisted reproductive technologies (ART) has increased. An associated increase in the incidence of congenital malformations in babies conceived using this technology has also been reported. Therefore, we aimed to investigate the rate of malformations in babies with neonatal surgical diseases, who were conceived using ART.

MATERIALS AND METHODS

Between January 2007 and December 2016, 1737 patients were admitted to our hospital. We analyzed the incidence of congenital cardiac diseases, genetic anomalies, and congenital anomalies of the kidney and urinary tract (CAKUT) in neonates conceived by ART. The χ2 test and logistic regression analysis were used to assess the odds ratios (ORs) for congenital malformations. A P-value < 0.05 indicated statistical significance.

RESULTS

The OR for CAKUT was 16.94 for the first-birth neonates conceived using ART, [P < 0.05, AUC (area under the curve) = 0.86]. However, for non-surgery neonates, the OR for CAKUT was 5.99 (P = 0.15, AUC = 0.87), compared to 32.27 (P < 0.05, AUC = 0.93) for parallel conditions in surgery-neonates.

CONCLUSION

Neonates conceived using ART are prone to develop CAKUT, which will need surgical treatment. Therefore, more management is necessary for associated malformations in these babies, particularly in cases with CAKUT.

Low oocyte yield during IVF treatment and the risk of a trisomic pregnancy

A low number of antral follicles may result in the selection of suboptimal oocytes that are prone to meiotic errors. The aim of this case-control study was to evaluate women receiving IVF treatment with low oocyte yield (defined as three or fewer oocytes retrieved after ovarian stimulation) who are at an increased risk of a trisomic pregnancy. Data were obtained from Danish and Dutch medical registries between 1983 and 2011. Analyses were carried out in 105 cases and 442 controls matched by age and year of IVF treatment. Cases were women with a trisomic pregnancy (trisomies 13, 18 or 21) resulting from fresh IVF treatment and confirmed by karyotyping. Cases were included regardless of pregnancy outcome. Controls were women with a live born child without a trisomy, resulting from fresh IVF treatment. Low oocyte yield was observed in 6.6% (29/440) of the women, of which 8.4% (7/83) were cases and 6.2% (22/357) controls. Low oocyte yield in IVF treatment was not associated with a higher risk of trisomic pregnancy (OR 1.43, 95% CI 0.64 to 3.19). Stratification for female age, adjustment for history of ovarian surgery, and gonadotrophin-releasing hormone protocol used did not change the results.

Epidemiologic Approaches for Studying Assisted Reproductive Technologies: Design, Methods, Analysis and Interpretation

PURPOSE

While considerable progress has been made since the advent of assisted reproductive technology (ART), the field remains a complex and challenging one for clinicians and researchers alike. This review discusses some of the most salient issues pertaining to the study of ART and whenever possible suggestions on how to address them.

RECENT FINDINGS

More than 5 million babies have been born through ART to date, representing up to 4% of all births worldwide. While technologies continue to evolve and demand for treatment grows, it is more important than ever to conduct rigorous and timely research to help guide clinical practice that is safe and effective, and that minimizes potential short- and long-term adverse outcomes to mother and child.

SUMMARY

ART research will require exceedingly more sophisticated research methods, designs, and analyses that are rooted in a reproductive epidemiological framework in order to improve future research and ultimately promote better outcomes for all subfertile couples and their children.

Perinatal outcomes after oocyte donation and in-vitro fertilization

PURPOSE OF REVIEW

To critically appraise the existing literature on perinatal outcomes following oocyte donation (OD) pregnancies and compare it with autologous in-vitro fertilization (IVF) pregnancies.

RECENT FINDINGS

OD pregnancies are at higher risk of developing hypertensive disorders compared with autologous IVF. The risk of preterm birth and low birth weight is higher with singleton and multiple OD compared with autologous IVF pregnancies. There is no increased risk of congenital malformations following OD compared with autologous IVF births.

SUMMARY

OD pregnancies are at higher risk of developing hypertensive disorders and adverse perinatal outcomes compared with autologous IVF.

Cancer Risk in Women Treated with Fertility Drugs According to Parity Status-A Registry-based Cohort Study

Background: Long-term safety of assisted reproductive techniques (ART) is of interest as their use is increasing. Cancer risk is known to be affected by parity. This study examined the risk of cancer after fertility treatment, stratified by women's parity.Methods: Data were obtained from all women (n = 1,353,724) born in Norway between 1960 and 1996. Drug exposure data (2004-2014) were obtained from the Norwegian Prescription Database (drugs used in ART and clomiphene citrate). The Medical Birth Registry of Norway provided parity status. HRs were calculated for all site cancer, breast, cervical, endometrial, ovarian, colorectal, central nervous system, thyroid cancer, and malignant melanoma.Results: In 12,354,392 person-years of follow-up, 20,128 women were diagnosed with cancer. All-site cancer risk was 1.14 [95% confidence interval (95% CI), 1.03-1.26] and 1.10 (95% CI, 0.98-1.23) after clomiphene citrate and ART exposure, respectively. For ovarian cancer, a stronger association was observed for both exposures in nulliparous (HR, 2.49; 95% CI, 1.30-4.78; and HR, 1.62; 95% CI, 0.78-3.35) versus parous women (HR, 1.37; 95% CI, 0.64-2.96; and HR, 0.87; 95% CI, 0.33-2.27). Elevated risk of endometrial cancers was observed for clomiphene citrate exposure in nulliparous women (HR, 4.49; 95% CI, 2.66-7.60 vs. HR, 1.52; 95% CI, 0.67-3.42). Risk was elevated for breast cancer in parous women exposed to clomiphene citrate (HR, 1.26; 95% CI, 1.03-1.54) for thyroid cancer and among nulliparous women after ART treatment (HR, 2.19; 95% CI, 1.08-4.44).Conclusions: Clomiphene citrate appears associated with increased risk of ovarian and endometrial cancer. Elevations in risks of breast and thyroid cancer were less consistent across type of drug exposure and parity.Impact: Continued monitoring of fertility treatments is warranted. Cancer Epidemiol Biomarkers Prev; 26(6); 953-62. ©2017 AACR.

Germ line genome editing in clinics: the approaches, objectives and global society

Genome editing allows for the versatile genetic modification of somatic cells, germ cells and embryos. In particular, CRISPR/Cas9 is worldwide used in biomedical research. Although the first report on Cas9-mediated gene modification in human embryos focused on the prevention of a genetic disease in offspring, it raised profound ethical and social concerns over the safety of subsequent generations and the potential misuse of genome editing for human enhancement. The present article considers germ line genome editing approaches from various clinical and ethical viewpoints and explores its objectives. The risks and benefits of the following three likely objectives are assessed: the prevention of monogenic diseases, personalized assisted reproductive technology (ART) and genetic enhancement. Although genetic enhancement should be avoided, the international regulatory landscape suggests the inevitability of this misuse at ART centers. Under these circumstances, possible regulatory responses and the potential roles of public dialogue are discussed.

Identifying Maternal Constraints on Fetal Growth and Subsequent Perinatal Outcomes Using a Multiple Embryo Implantation Model

INTRODUCTION

Although the majority of singleton births after in vitro fertilization (IVF) are uncomplicated, studies have suggested that IVF pregnancies may be independently associated with low birth weight (LBW), preterm birth (PTB), and perinatal mortality. These outcomes complicate multiple gestations as expected, but have also been reported in singletons. A multiple embryo implantation model allows for assessment of the early in utero environment, and therefore, assessment of any maternal constraints on developing fetuses. We question whether adverse perinatal outcomes associated with assisted reproductive techniques (ART) occur as a result of maternal physiologic adaptations.

PATIENTS AND METHODS

This is a retrospective, single center study of ART cycles, specifically intracytoplasmic sperm injection (ICSI) cycles during a 16-year period. For each positive pregnancy test 9-11 days after embryo transfer, an ultrasonogram was performed at 7 weeks of gestation to record the number of implanted fetal poles with cardiac activity. Controlled ovarian stimulation (COS), hCG trigger, oocyte retrieval and sperm injection were performed as per our standard protocols. First trimester implantation sites that resulted in live births were defined as "true" to distinguish them from those that spontaneously reduced called "virtual." Birth outcomes analyzed included birth weight and gestational age at delivery.

RESULTS

A total of 17,415 cycles were analyzed. The average maternal age was 36.9 (±5.0) years. An overall fertilization rate of 73.4% generated approximately 48,708 good quality cleavage-stage embryos. In most patients (92.8%), an average of 3 embryos were transferred. The clinical pregnancy rate was 39.2% (n = 6,281). The overall occurrence of multiple gestations was 38.2% (n = 2,608) consisting of 2,038 twin, 511 triplet, and 59 quadruplet pregnancies. Of these multiple gestations, 18.6% of twin, 54.2% of triplet and 76.3% of quadruplet gestations spontaneously reduced. Failure of the implanted embryo to progress was not related to maternal age. Singleton newborns resulting from multiple implantation sites had lower birth weights (P<0.01) and shorter gestational ages (P<0.01) than those from a single implanted embryo. The number of embryos transferred did not affect the gestational length of singleton newborns. Although the birth weights of singletons from multiple implantation sites (virtual singletons) were lower than true singletons, the birth weight of virtual singletons were comparable to the birth weights of true twin, triplet, and quadruplet live births. Multiple logistic regression revealed that virtual singletons were an independent risk factor for PTB (odds ratio: 4.55, 95% CI 2.23-9.29) and LBW (odds ratio: 3.61, 95% CI 1.78-7.32), even after controlling for the number of oocytes, stimulation protocol type, sperm source, total gonadotropins administered, age, embryo quality, and day of embryo transfer.

CONCLUSIONS

Our study highlights that embryonic implantation sites during early gestation set the growth profile of each embryo, dictating later growth patterns. Specifically, spontaneous reduction of an embryo after multiple embryo implantations can confer greater perinatal risk in the form of LBW and PTB to the surviving fetus. Our findings suggest that maternal constraints or physiologic adaptations maybe one of the mechanisms mediating adverse perinatal outcomes when multiple embryo implantation occurs.

The Partnership and Coping Enhancement Programme for couples undergoing in vitro fertilization treatment: the development of a complex intervention in China

PURPOSE

Couples as dyads suffer from the diagnosis of infertility and related treatment. These couples commonly experience emotional and physical pain and tension in their marital lives. The purpose of this study is to report on the process of developing a potentially feasible and effective complex intervention for couples undergoing in vitro fertilization treatment in China.

METHODS

The Medical Research Council (MRC) framework for developing and evaluating the complex intervention was adopted to guide the development of the Partnership and Coping Enhancement Programme (PCEP). In developing the PCEP, three steps were taken, namely, (1) identifying evidence by conducting literature reviews, a concept analysis and a qualitative study; (2) identifying/developing a theory-in this case, a preliminary Endurance with Partnership Conceptual Framework (P-EPCF) was proposed; and (3) modelling the process and outcomes of the PCEP.

RESULTS

The PCEP that was developed is targeted mainly at the domains of the partnership mediators of stress in the P-EPCF. It consists of two sections-partnership and coping-and will be delivered to infertile couples on the day of embryo transfer. The main focuses of the programme are to facilitate mutual sharing and support in infertile couples, and to improve their individual and dyadic coping strategies while undergoing IVF treatment, especially in the period when they are waiting for the results of a pregnancy test and after the disclosure of a negative treatment outcome. The programme is couple-based, consisting of experience sharing, psychoeducation, meditation exercise, skill practise and supplemental written materials.

CONCLUSIONS

The Partnership and Coping Enhancement Programme (PCEP) for couples undergoing in vitro fertilization treatment was developed according to the guideline of the MRC framework. It is recommended that a pilot study be conducted to evaluate its feasibility and to model the process and outcomes of the programme.

Serum 25-hydroxyvitamin D concentrations and treatment outcomes of women undergoing assisted reproduction

BACKGROUND

Vitamin D deficiency impairs fertility in animal models, but the role of vitamin D in human fertility or treatment of infertility is less clear.

OBJECTIVE

We examined the association between circulating 25-hydroxyvitamin D [25(OH)D] concentrations and the outcome in women undergoing assisted reproduction technologies (ARTs).

DESIGN

We randomly selected 100 women undergoing infertility treatment with ART enrolled in an ongoing prospective cohort study who underwent 168 treatment cycles. Serum 25(OH)D concentrations were measured in samples collected from women between days 3 and 9 of gonadotropin treatment. Generalized linear mixed models were used to evaluate the association of 25(OH)D concentrations with ART outcomes while adjusting for potential confounders and accounting for repeated treatment cycles per woman.

RESULTS

Median (range) serum 25(OH)D concentrations were 86.5 (33.5-155.5) nmol/L. Ninety-one percent of participants consumed multivitamins. Serum 25(OH)D concentrations were positively related to fertilization rate. The adjusted fertilization rate for women in increasing quartiles of serum 25(OH)D were 0.62 (95% CI: 0.51, 0.72), 0.53 (95% CI: 0.43, 0.63), 0.67 (95% CI: 0.56, 0.76), and 0.73 (95% CI: 0.63, 0.80), respectively (P-trend = 0.03). This association persisted when analyses were restricted to women with serum 25(OH)D between 50 and 125 nmol/L when models were further adjusted for season of blood draw and when analyses were restricted to the first treatment cycle. However, 25(OH)D concentrations were unrelated to probability of pregnancy (P-trend = 0.83) or live birth after ART (P-trend = 0.47).

CONCLUSION

Vitamin D may be associated with higher fertilization rates, but this apparent benefit does not translate into higher probability of pregnancy or live birth. This trial was registered at www.clinicaltrials.gov as NCT00011713.

Prevalences and pregnancy outcome of vanishing twin pregnancies achieved by in vitro fertilization versus natural conception

OBJECTIVE

To evaluate whether vanishing twin (VT) pregnancies achieved by in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) had a more adverse perinatal outcome than those after natural conception.

DESIGN

Longitudinal, retrospective cohort study.

SETTING

Tertiary university hospital.

PATIENT(S)

Three hundred and six (78 after IVF-ICSI and 228 after natural conception) VT pregnancies over a 22-year period, with VT cases matched to primarily singleton controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Obstetric and neonatal outcome data.

RESULT(S)

The incidence of VT was statistically significantly higher after natural conception (18.2% of twins) than after IVF-ICSI (12.6% of twins). The odds of VT in pregnancies complicated with pregestational or gestational diabetes were disproportionally higher in IVF-ICSI cases than in spontaneously conceived VT pregnancies (adjusted odds ratio [AOR]: 0.80 vs. 3.10 and 1.00 vs. 1.07, respectively). Previous induced abortion (AOR 1.34) or second-trimester fetal loss (AOR 3.3) increased the risk of VT pregnancies after spontaneous conception. Gestational diabetes mellitus in both the previous (AOR 5.41) and the present (AOR 2.3) pregnancy as well as chronic maternal diseases (AOR 3.5) and placentation anomalies all represented independent risk factors for VT after IVF-ICSI.

CONCLUSION(S)

Vanishing twin pregnancies had a lower prevalence and a worse perinatal outcome after IVF-ICSI as compared with those of their spontaneously conceived counterparts.

Sperm chromatin maturity and integrity correlated to zygote development in ICSI program

This study aimed to evaluate sperm chromatin maturity and integrity of that injected into good-quality oocytes in an in vitro fertilization-intra cytoplasmic sperm injection (IVF-ICSI) program. A cut-off value of sperm chromatin maturity and integrity was developed as a function of their correlation to the zygote development, i.e., embryo formation and cleavage rate. The study assessed sperm chromatin maturity using aniline blue (AB) staining, whereas toluidine blue (TB) staining was used to assess sperm chromatin integrity. Ejaculates from 59 patients undergoing ICSI and 46 fertile normozoospermic donors for determination of normal values of sperm chromatin status were used in this study. Embryo formation and cleavage rates were observed for the period of 3 days after ICSI. There was a significant difference in the percentage of sperm with mature chromatin between ejaculate from ICSI patients and fertile donor (p=0.020); while there was no significant difference in sperm chromatin integrity of both samples (p=0.120). There was no significant correlation between sperm chromatin maturity and either embryo formation or cleavage rate; as well as sperm chromatin integrity to both parameters of zygote development (p>0.05). Furthermore, we found that the cut-off value of sperm chromatin maturity and integrity of the fertile normozoospermic ejaculates were 87.2% and 80.2%, respectively. Using the cut-offs, we found that low sperm chromatin maturity at the level of <87% correlated significantly with the cleavage rate of the zygote (p=0.022; r=0.371); whereas poor sperm chromatin integrity at the level of <80% correlated with embryo formation (p=0.048; r=0,485). In conclusion, this study showed that poor maturity and integrity of sperm chromatin (AB<87% and TB<80%, respectively), could affect zygote development following ICSI.

ABBREVIATIONS

AB: aniline blue; CMA3: chromomycin A3; ICSI: intra cytoplasmic sperm injection; IVF: in vitro fertilization; PBS: phosphate buffer saline; SPSS: Statistical Package for Social Science; TB: toluidine blue; WHO: World Health Organization.

Outcomes of elective cryopreserved single or double embryo transfers following failure to conceive after fresh single embryo transfer

The main adverse effect of IVF is the high multiple pregnancy rate resulting from the transfer of two or more embryos. The objective was to evaluate pregnancy rates in infertile women with a good prognosis who failed to conceive in a fresh elective single embryo transfer (eSET) and had a second cycle with elective double vitrified-warmed embryo transfer (eDFET) compared with elective single vitrified-warmed embryo transfer (eSFET). A total of 142 intracytoplasmic sperm injection cycles using a conventional protocol were evaluated. Good-prognosis patients underwent eSET in a fresh cycle, and those who failed to conceive underwent a second vitrified-warmed embryo transfer: eDFET (n = 102) or eSFET (n = 40). Embryos were transferred and vitrified on day 5 of development. Patients who received eDFET had fewer implantations (30.9%) than eSFET (52.5%; P = 0.004); pregnancy rates were similar (eDFET: 35.3%, eSFET: 42.5%). Patients with the eSFET had one monozygotic twin (5.9%), and 22.2% of eDFET patients had multiple pregnancies. Patients with a good prognosis who failed to conceive in the first fresh eSET did not have an advantage when receiving eDFET in the second cycle, as pregnancy rates were similar; 22.2% of patients in the eDFET group had multiple pregnancies.