Comparison of ectopic pregnancy risk among transfers of embryos vitrified on day 3, day 5, and day 6

Evaluation of a scoring system to predict treatment success with single-dose methotrexate in ectopic pregnancy

PURPOSE

This study sought to assess the efficacy of a newly developed scoring system in predicting treatment outcomes for ectopic pregnancy among patients undergoing single-dose methotrexate therapy. The primary research question centered on the reliability and predictive accuracy of objective parameters in determining methotrexate therapy success.

METHODS

Conducted as a retrospective single-center cohort study, data from 172 ectopic pregnancy patients treated with methotrexate between January 2021 and January 2023 were analyzed. Parameters including adnexal mass size, peritoneal fluid presence, yolk sac identification, endometrial thickness, ectopic pregnancy location, and initial B-hCG levels were meticulously evaluated for their association with treatment outcomes.

RESULTS

Following the exclusion of 21 emergency surgery cases, the final analysis comprised 151 patients. Notable associations were observed between specific parameters (fetal cardiac activity, adnexal mass size  > 3.5 cm, peritoneal fluid presence, yolk sac identification, endometrial thickness  > 10 mm, and initial B-hCG levels) and treatment outcomes (p < 0.001). Additionally, the novel scoring system demonstrated promising predictive performance. At a cutoff of 2.50, it achieved a sensitivity of 91.7% and a specificity of 59.7%. Increasing the cutoff to 3.50 resulted in a sensitivity of 94.0%, with a specificity of 46.3%.

CONCLUSION

Objective parameters, particularly those integrated into the developed scoring system, exhibited substantial associations with methotrexate therapy outcomes in ectopic pregnancy. These findings underscore the potential of an objective scoring model to significantly influence clinical decision-making in therapy, offering avenues for enhanced prognostication and patient care in treatment outcomes.

The effect of an extended culture period on birth weight among singletons born after single or double vitrified embryo transfer

Aim

To evaluate the effect of an extended culture period on birth weight among singletons born after vitrified-warmed embryo transfer.

Methods

A retrospective cohort study was performed among 12400 women who gave birth to 1015, 1027, 687, and 9671 singletons after single blastocyst transfer, single cleavage-stage embryo transfer, double blastocyst transfer, and double cleavage-stage embryo transfer, respectively.

Results

The unadjusted birth weight of singletons born after vitrified blastocyst transfer were heavier than those born after cleavage-stage transfer (β=30.28, SE=13.17, P=0.022), as were the adjusted birth weights (β=0.09, SE=0.03, P=0.007). In addition, there was a 37% increased odd of having an infant with high birth weight after vitrified blastocyst transfer compared with vitrified cleavage stage transfer (OR=1.37, 95% CI:1.07-1.77).

Conclusion

The unadjusted and adjusted birth weight and odds of having an infant with high birth weight significantly increased after blastocyst transfer compared with cleavage-stage embryo transfer in vitrified-warmed cycles.

Does Day 3 embryo status matter to reproductive outcomes of single blastocyst transfer cycles? A cohort study

OBJECTIVE

To investigate whether Day 3 (D3) embryo status matter to reproductive outcomes of blastocyst transfer cycles.

DESIGN

Retrospective cohort study.

SETTING

Assisted Reproduction Department of Shanghai Ninth People's Hospital, Shanghai, China.

POPULATION

A total of 6906 vitrified-thawed single blastocyst transfer cycles in 6502 women were included.

METHODS

Generalised estimated equation regression models were used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the associations between embryo status and pregnancy outcomes.

MAIN OUTCOME MEASURES

Biochemical pregnancy, miscarriage, live birth.

RESULTS

High-quality blastocysts derived from poor-grade D3 embryos had comparable pregnancy outcomes to those derived from high-grade D3 embryos (40.0% versus 43.2%, aOR 1.00, 95% CI 0.85-1.17 for live birth rate; 8.3% versus 9.5%, aOR 0.82, 95% CI 0.63-1.07 for miscarriage rate). Cycles with low D3 cell number (five cells or fewer) had significantly higher miscarriage rate (9.2% versus 7.6%, aOR 1.33, 95% CI 1.02-1.75) compared with cycles with eight cells on D3.

CONCLUSIONS

Poor-quality cleavage embryos should be cultivated to the blastocyst stage because high-quality blastocysts derived from poor-grade D3 embryos had acceptable pregnancy outcomes. When the blastocyst grade is identical, choosing embryos with higher D3 cell number (eight or more cells) for transfer could reduce the risk of early miscarriage.

Body mass index impacts ectopic pregnancy during in vitro fertilization: an analysis of 42,362 clinical pregnancy cycles

PURPOSE

This large, single-center, retrospective cohort study was aimed to explore the effect of female body mass index (BMI) on ectopic pregnancy (EP) following fresh and frozen-thawed embryo transfers (ET).

METHODS

A total of 27,600 pregnancies after fresh ET and 14,762 pregnancies after frozen-thawed ET were included between January 2010 to June 2022. Women were divided into three groups based on BMI according to the Working Group on Obesity in China (WGOC), International Life Sciences Institute (ILSI): underweight (BMI < 18.5 kg/m2), normal weight (BMI, 18.5-23.9 kg/m2), and overweight or obesity (≥ 24 kg/m2). Compare EP rates among BMI categories in fresh and frozen-thawed ET cycles respectively. Multivariate logistic regression analyses were used to investigate the association between female BMI and EP.

RESULTS

The overall EP rates in fresh, and frozen thawed transfer cycles were 2.43% (672/27,600) and 2.82% (417/14,762), respectively. In fresh ET cycles, underweight women yielded a significantly higher EP rate than those with normal and excess weight (3.29% vs. 2.29% vs. 2.54%, P = 0.029). But EP rates did not differ among the three BMI groups (2.72% vs. 2.76% vs. 2.96%, P = 0.782) in frozen-thawed ET cycles. In fresh ET cycles, after adjusting for potential confounding factors, no significant association was found between female BMI and EP occurrence (adjusted OR: 0.98, 95% CI 0.70-1.37, P = 0.894, for BMI 18.5-23.9 kg/m2; adjusted OR: 0.89, 95% CI 0.75-1.06, P = 0.205, for BMI ≥ 24 kg/m2. Reference = BMI < 18.5 kg/m2).

CONCLUSION(S)

Female BMI did not affect the occurrence of ectopic pregnancy in either fresh or frozen-thawed embryo transfer cycles.

Factors affecting male-to-female ratio at birth in frozen-thawed embryo transfer cycles: a large retrospective cohort study

Background

ICSI (intracytoplasmic sperm injection) leads to a reduced male-to-female ratio at birth, whereas blastocyst transfer results in an increased male-to-female ratio. However, limited knowledge exists regarding the impact of these factors on the live birth rate for each gender. This study aimed to investigate the influence of patient characteristics and treatment parameters on the live birth rate for each gender, as well as the ultimate male-to-female ratio at birth in frozen-thawed embryo transfer (FET) cycles.

Method

This retrospective cohort study involved a total of 28,376 FET cycles and 9,217 subsequent deliveries, spanning from January 2003 to December 2015. The study consisted of two parts. First, logistic regression models were constructed to determine the factors influencing the male-to-female ratio among babies born after FET. Second, we aimed to investigate the mechanisms underlying this sex ratio imbalance by analyzing data from all transfer cycles. Generalized estimated equations were employed to assess the impact of risk factors on rates of male and female live births separately.

Results

ICSI resulted in a lower proportion of male offspring compared to in vitro fertilization (IVF) (50.1% vs. 53.7%, aOR: 0.87, 95% CI: 0.80-0.96). Conversely, blastocyst transfer yielded a higher proportion of male offspring than cleavage-stage embryo transfer (58.7% vs. 51.6%, aOR: 1.32, 95% CI: 1.17-1.48). Analysis of all cycles indicated that ICSI resulted in a reduced likelihood of male live birth in comparison to IVF (19.8% vs. 21.6%, aOR: 0.90, 95% CI: 0.83-0.97). However, the transfer of blastocysts rather than cleavage-stage embryos not only increased the chance of male live birth (26.9% vs. 20.2%, aOR: 1.70, 95% CI:1.56-1.85) but also facilitated female live birth (20.3% vs. 19.3%, aOR: 1.26, 95% CI: 1.15-1.39).

Conclusion

ICSI was associated with a reduction in the male-to-female sex ratio and a lower rate of male live births, while blastocyst transfer was associated with an increased male-to-female sex ratio at birth and a higher rate of male live births.

COVID-19 infection after oocyte retrieval did not have detrimental effects on embryo implantation for frozen embryo transfer

Patients preparing for their renewal fertility treatments with embryos frozen before coronavirus disease 2019 (COVID-19) infection do not need to be concerned about the potential impact of COVID-19 infection on oocyte quality and embryonic development. However, many women are still hesitant to undergo frozen embryo transfer (FET) due to fear of the detrimental effect of COVID-19 infection on endometrial receptivity and embryo implantation. The objective was to explore whether COVID-19 infection after oocyte retrieval is related to an increased risk of adverse pregnancy outcomes in a cohort of Chinese women undergoing FET. A retrospective cohort study was conducted among 300 infertile women undergoing FET with embryos frozen before COVID-19 infection. Women were categorized into noninfection, infection before FET, or infection after FET groups. Multivariable logistic regression was performed to assess the association of COVID-19 infection with clinical pregnancy outcomes, including biochemical pregnancy, clinical pregnancy, and early miscarriage. The implantation rates for patients in the group with infection before FET (29.14%) and the group with infection after FET (30.38%) were not significantly lower than those in the noninfection group (31.03%). The rate of biochemical pregnancy (54.55% vs. 52.27%, p = 0.750; 43.14% vs. 52.27%, p = 0.209) was not significantly different among the three groups. Although the clinical pregnancy rate showed a declining trend from 45.45% in the noninfection group to 38.27% in the group with infection after FET, this result was not statistically significant. The early miscarriage rate was similar in the group with infection before FET and the group with infection after FET compared with that in the noninfection group (3.64% vs. 5.68%, p = 0.496; 6.86% vs. 5.68%, p = 0.739). After adjusting for potential confounders, the biochemical pregnancy rate, clinical pregnancy rate, and early miscarriage rate were not significantly different for patients with infection before or after FET compared with patients without infection. This research indicated that COVID-19 infection after oocyte retrieval with embryos frozen before infection did not cause any detrimental effect on endometrial receptivity for embryo implantation.

Pregnancy Outcomes of Freeze-All versus Fresh Embryo Transfer in Women with Adenomyosis: A Retrospective Study

Adenomyosis has been associated with adverse fertility and pregnancy outcomes, and its impact on the outcomes of in vitro fertilization (IVF) has received much attention. It is controversial whether the freeze-all strategy is better than fresh embryo transfer (ET) in women with adenomyosis. Women with adenomyosis were enrolled in this retrospective study from January 2018 to December 2021 and were divided into two groups: freeze-all (n = 98) and fresh ET (n = 91). Data analysis showed that freeze-all ET was associated with a lower rate of premature rupture of membranes (PROM) compared with fresh ET (1.0% vs. 6.6%, p = 0.042; adjusted OR 0.17 (0.01-2.50), p = 0.194). Freeze-all ET also had a lower risk of low birth weight compared with fresh ET (1.1% vs. 7.0%, p = 0.049; adjusted OR 0.54 (0.04-7.47), p = 0.642). There was a nonsignificant trend toward a lower miscarriage rate in freeze-all ET (8.9% vs. 11.6%; p = 0.549). The live birth rate was comparable in the two groups (19.1% vs. 27.1%; p = 0.212). The freeze-all ET strategy does not improve pregnancy outcomes for all patients with adenomyosis and may be more appropriate for certain patients. Further large-scale prospective studies are needed to confirm this result.

Impact of recurrent pregnancy loss history on reproductive outcomes in women undergoing fertility treatment

BACKGROUND

Recurrent pregnancy loss negatively affects the reproductive outcomes of natural conception. Preimplantation genetic testing for aneuploidies has been the focus of interventions in women with recurrent pregnancy loss. However, the risk of no embryos being available, high costs, and uncertainties surrounding its effectiveness limit its use. Factors beyond euploidy, such as an appropriate intrauterine environment, are also important for improving the reproductive outcomes in women with recurrent pregnancy loss. It remains unknown whether a history of recurrent pregnancy loss can affect reproductive outcomes after fertility treatment.

OBJECTIVE

This study aimed to investigate the impact of history of recurrent pregnancy loss on the reproductive outcomes of women undergoing fertility treatment.

STUDY DESIGN

This was a retrospective cohort study of women who underwent their first frozen embryo transfer cycle or intrauterine insemination cycle between January 2014 and July 2020 in Shanghai, China. We excluded couples with known karyotypic abnormalities (eg, balanced translocation) or uterine malformation. We performed multivariate binary logistic regressions for biochemical pregnancy, miscarriage, and live birth rates to investigate the associations between recurrent pregnancy loss history and reproductive outcomes.

RESULTS

A total of 29,825 women who underwent frozen embryo transfer cycles and 5476 women who underwent intrauterine insemination cycles were included in this study. In those who underwent frozen embryo transfer, history of recurrent pregnancy loss was not significantly associated with biochemical pregnancy (adjusted odds ratio, 1.19; 95% confidence interval, 0.87-1.63), miscarriage (adjusted odds ratio, 0.99; 95% confidence interval, 0.78-1.26), or live birth rates (adjusted odds ratio, 0.91; 95% confidence interval, 0.79-1.06). Similarly, in frozen embryo transfer cycles that led to clinical pregnancy, recurrent pregnancy loss history was not significantly associated with live birth (adjusted odds ratio, 0.99; 95% confidence interval, 0.76-1.28) or miscarriage rates (adjusted odds ratio, 1.04; 95% confidence interval, 0.81-1.35). In women with intrauterine insemination, history of recurrent pregnancy loss showed no significant associations with fertility outcomes in all cycles ([adjusted odds ratio, 1.36; 95% confidence interval, 0.88-2.10] for live birth rate and [adjusted odds ratio, 1.74; 95% confidence interval, 0.75-4.01], for miscarriage rate) and in cycles that led to clinical pregnancy ([adjusted odds ratio, 0.70; 95% confidence interval, 0.31-1.63] for live birth rate and [adjusted odds ratio, 1.45; 95% confidence interval, 0.58-3.63] for miscarriage rate).

CONCLUSION

In women without obvious chromosome abnormality and uterine malformation who undergo fertility treatment, recurrent pregnancy loss history was not significantly associated with miscarriage and live birth rates, suggesting that it has little or no prognostic value in predicting the reproductive outcomes of frozen embryo transfer or intrauterine insemination cycles.

Effects of Different Endometrial Preparation Regimens during IVF on Incidence of Ischemic Placental Disease for FET Cycles

We conducted this retrospective cohort study aiming to compare the different pregnancy outcomes of endometrial preparation regimens on ischemic placental disease in a frozen embryo transfer cycle. The study included a total of 9351 women who had undergone therapy at our single tertiary hospital from January 2015 to July 2020. The women were divided into three groups depending on their endometrial regimens: natural cycle, stimulation cycle, hormone replacement therapy cycle. The data were analyzed after propensity score matching, then we used multiple linear regression to study the relationship between ischemic placental disease and endometrial regimens, adjusted by confounding factors including age, body mass index, and score of propensity score matching. We performed univariate logistic regression, as well as multivariate logistic regression for ischemic placental disease, small for gestational age infant, placental abruption. and pre-eclampsia, respectively, listing the odds ratio and p-values in the table. As a result, risk of ischemic placental disease and small for gestational age infant were detected as higher in stimulation cycles compared to natural cycles before or after adjustment. Hormone replacement therapy cycles conferred a higher risk of pre-eclampsia and preterm delivery compared to natural cycles. No difference was found between stimulation cycles and hormone replacement therapy cycles, regardless of whether they are adjusted or not. In summary, more pharmacological intervention in endometrial preparation was associated with a higher risk of ischemic placental disease related symptoms than natural cycles for endometrial preparation in women undergoing frozen embryo transfer. Our findings supported that minimizing pharmacological interventions during endometrial preparation when conditions permit has positive implications for improving pregnancy outcomes.

Spontaneous Bilateral Ectopic Pregnancy Treated With Combination of Methotrexate, Unilateral Salpingectomy, and Unilateral Expulsion of Pregnancy

Spontaneous bilateral ectopic pregnancies are rare. In the majority of case reports, treatments prescribed were methotrexate, bilateral salpingectomy, or salpingectomy/salpingostomy. A 31-year-old gravida 3 para 0 at our institution underwent diagnostic laparoscopy due to ruptured ectopic pregnancy, and based on visual inspection, had a bilateral ectopic pregnancy. She underwent right salpingectomy for a ruptured ectopic pregnancy and had spontaneous expulsion of the left ectopic pregnancy with mobilization of the fallopian tube. She received methotrexate as per the two-dose protocol and was followed with a negative beta-human chorionic gonadotropin (b-hCG). Pathology confirmed bilateral tubal ectopic pregnancies. Spontaneous bilateral tubal ectopic pregnancy requires a high level of clinical suspicion. If a tubal pregnancy has expulsion of tissue intraoperatively, a two-dose protocol for methotrexate administration may be used for treatment, especially in the case of a bilateral ectopic pregnancy with fertility desires.

Differences in Ectopic Pregnancy Rates between Fresh and Frozen Embryo Transfer after In Vitro Fertilization: A Large Retrospective Study

Ectopic pregnancy (EP) is increasingly found in women treated with in vitro fertilization and embryo transfer (IVF−ET). With the development of the freeze-all policy in reproductive medicine, it is controversial whether frozen embryo transfer (FET) could reduce the rate of EP. In this single-center, large-sample retrospective study, we analyzed 16,048 human chorionic gonadotrophin (hCG)-positive patients who underwent fresh embryo transfer (ET) or FET cycles between January 2013 and March 2022. Throughout the study, the total EP rate was 2.09% (336/16,048), 2.16% (82/3803) in the ET group, and 2.07% (254/12,245) in the FET group. After adjustment for age, infertility causes, and other confounding factors, logistic regression results showed no statistical difference in EP rates between FET and ET groups (odds ratio (OR) 0.93 (0.71−1.22), p > 0.05). However, among the 3808 patients who underwent fresh ET cycles, the OR for EP was significantly lower in the long agonist protocol group than in the gonadotropin-releasing hormone antagonist (GnRH-ant) protocol group (OR 0.45 (0.22−0.93), p < 0.05). Through a large retrospective study, we demonstrated a slightly lower EP rate in FET cycles than in fresh ET cycles, but there was no significant difference. The long agonist protocol in ET cycles had a significantly lower risk of EP than the GnRH-ant protocol.

Cumulative live birth rates for low-prognosis women over 5 years or 9 frozen-thawed embryo transfer cycles

Background

For heterogeneous populations of low-prognosis women, it remains unclear as to how long individuals should continue undergoing ART when attempting to have a baby, as there have been insufficient studies to date tracking the cumulative live birth rates (CLBRs) for these women over the entire course of their ART treatment, particularly over extended time periods.

Methods

This was a retrospective analysis of 17,698 women at a tertiary care academic medical center who had begun undergoing IVI/ICSI cycles using a progestin-primed ovarian stimulation (PPOS) approach between January 2013 and January 2019. Low-prognosis patients were stratified into four groups based upon POSEIDON criteria, with patients exhibiting normal or high ovarian reserves and response to stimulation (defined as AFC ≥5, > 9 oocytes retrieved) being included as controls (group 5). The CLBR within 5 years or 9 FET cycles from the ovum pick-up (OPU) day of the first cycle was the primary endpoint for this study, including all repetitive oocyte retrieval cycles and subsequent FET cycles. Optimistic and conservative approaches were used for the analysis of CLBRs and the depiction of cumulative incidence curves.

Results

Under both optimistic and conservative model analyses, normal and good responders exhibited the highest CLBR within 5 years or 9 FET cycles, followed by younger unexpected poor responders, younger expected poor responders, older unexpected poor responders, and older expected poor responders. Upward trends in CLBRs were evident across the five groups with the prolongation of time or an increase in FET cycle counts. Within the first 2 years or 3 FET cycles, the CLBRs rose rapidly, followed by more moderate increases over the following 2–3.5 years or 4–6 cycles, with expected poor responders exhibiting the most obvious improvements. All Patients reached a CLBR plateau after 3.5 years or 6 FET cycles.

Conclusions

All low-prognosis women should undergo ART treatment for a minimum of 2 years or 3 FET cycles, and exhibit better outcomes when extending ART treatment to 3.5 years or 6 FET cycles (particularly for POSEIDON groups 3 and 4), but should consider ceasing further treatment thereafter due to a lack of apparent benefit.

Impact of uterine malformations on pregnancy and neonatal outcomes of IVF/ICSI–frozen embryo transfer

STUDY QUESTION

What is the impact of uterine malformations on reproductive and neonatal outcomes of IVF/ICSI–frozen embryo transfer?

SUMMARY ANSWER

Unification defective uteri are associated with poorer neonatal outcomes including higher preterm delivery rate and lower birthweight, and septate uteri are associated with worse fertility outcomes including higher miscarriage and lower live birth rates (LBRs).

WHAT IS KNOWN ALREADY

Several studies have investigated the negative effects of uterine malformations on pregnancy outcomes. However, an all-round and definitive conclusion has not been reached yet owing to the relatively low incidence of the disease and the heterogeneity of study populations, especially among women undergoing ART.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study including 411 women with congenital uterine anomalies and 14 936 women with a normal uterus who underwent first frozen-thawed embryo transfer cycles of IVF/ICSI from July 2008 to August 2019. We compared reproductive outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Reproductive outcomes of women with uterine malformations were studied through three propensity score-matched comparisons (patients with bicorporeal uterus, septate uterus and hemi-uterus [bicorporeal, septate and hemi-uterus groups, respectively] along with corresponding control groups without uterine malformations). We also compared pregnancy and neonatal outcomes, and performed subgroup analysis addressing didelphus, bicornuate uteri and septate uteri before and after surgery independently.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to the matched control group, women with a bicorporeal uterus had a significantly lower LBR (24.4% versus 34.8%, odds ratio (OR) 0.61 [95% CI: 0.37, 1.00], P = 0.048). The incidence of miscarriage and preterm delivery was higher but not statistically significant (29.0% versus 18.1%, OR 1.85 [95% CI: 0.82, 4.19], P = 0.135; 22.6% versus 9.9%, OR 2.64 [95% CI: 1.07, 6.52], P = 0.063, respectively). In addition, the bicorporeal group had a significantly lower gestational age, higher caesarean rate and lower birthweight than bicorporeal control. Women with a septate uterus had comparable clinical pregnancy rates to controls (43.3% versus 49.9%, OR 0.77 [95% CI: 0.57, 1.04], P = 0.091), increased miscarriage rates (23.5% versus 13.0%, OR 2.05 [95% CI: 1.18, 3.58], P = 0.010) and lower LBRs (29.4% versus 42.2%, OR 0.57 [95% CI: 0.41, 0.79], P = 0.001). In both singleton and twins pregnancies, pregnancy and neonatal outcomes were comparable between women with a septate uterus and control. Women with a hemi-uterus had a tendency for lower clinical pregnancy rate (36.8% versus 42.3%, OR 0.80 [95% CI: 0.52, 1.21], P = 0.287) and LBR (29.8% versus 33.1%, OR 0.86 [95% CI: 0.55, 1.34], P = 0.502), compared to women without malformations. The incidences of miscarriage and preterm delivery, respectively, were 16.7% versus 16.6% (OR 1.01 [95% CI: 0.41, 2.47], P = 0.989), and 9.5% versus 11.4% (OR 0.82 [95% CI: 0.27, 2.51], P = 1) in women with a hemi-uterus as compared to control.

LIMITATIONS, REASONS FOR CAUTION

This was a single-centre, retrospective study in which neonatal data were extracted from parental questionnaires. The information on uteri septum type and surgery methods was poorly presented, with limited detail. In patients with uterine malformations, the number of babies with birth defects and twin pregnancies was relatively small, limiting the power of the study.

WIDER IMPLICATIONS OF THE FINDINGS

Compared to patients with a normal uterus, women with uterine malformation have poorer reproductive outcomes. Pregnant women with a uterine anomaly need to be managed as high-risk pregnancies and followed with appropriate obstetric review.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Ministry of Technology (2018YFC1003000), the Elite Team Project of Ninth People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JY201801), Shanghai Sailing Program (21YF1423200) and the Fundamental Research Program Funding of Ninth People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JYZZ117). B.W.M. is supported by an NHMRC Investigatorgrant (GNT1176437). B.W.M. reports consultancy (with stock options) for ObsEva. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Impact of Maternal Age on Singleton Birthweight in Frozen Embryo Transfer Cycles

BACKGROUND

Previous studies have investigated the effect of maternal age on assisted reproductive technology success rates. However, little is known about the relationship between maternal age and neonatal birthweight in frozen embryo transfer (FET) cycles. Whether maternal age influences singleton birthweight in FET cycles remains to be elucidated.

METHODS

This study was conducted at a tertiary care center, involving singleton live births born to women undergoing frozen-thawed embryo transfer during the period from January 2010 to December 2017. A total of 12,565 women who fulfilled the inclusion criteria were enrolled and grouped into four groups according to the maternal age: <30, 30-34, 35-39, and ≥40 years old. A multivariable linear regression analysis was conducted to reveal the relationship between maternal age and neonatal birthweight with controlling for a number of potential confounders.

RESULTS

The highest proportions of low birthweight (LBW, 4.1%), high birthweight (1.2%), preterm birth (PTB, 5.9%), and very PTB (0.9%) were found in the group over 40 years old, but no significant difference was observed among the four groups. Additionally, the 35-39-year-old group had the highest rate of very LBW (0.6%), whereas the 30-34-year-old group had the lowest rate of small for gestational age (SGA, 2.7%). However, multivariate analyses revealed that neonatal outcomes including PTB, LBW, and SGA were similar between the different maternal age groups.

CONCLUSION

Grouping with different maternal age was not associated with mean birthweight and Z-scores of singletons resulting from FET.

An Endometrial Thickness < 8 mm Was Associated With a Significantly Increased Risk of EP After Freeze-Thaw Transfer: An Analysis of 5,960 Pregnancy Cycles

INTRODUCTION

Endometrium characteristics that are most likely to induce ectopic pregnancy were investigated on the basis of the data of 5,960 pregnant freeze-thaw cycles.

METHODS

A total of 5,960 pregnancy cycles after freeze-thaw embryos transfer were included, with the number of intrauterine and ectopic pregnancies being 5,777 and 183, respectively. Ectopic pregnancy was the primary outcome. Endometrial thickness was the main measured variable. The risk factors of ectopic pregnancy were eventually determined based on univariate analysis and subsequent multiple-stepwise logistic regression analysis.

RESULTS

1. After adjusting for confounders, endometrial thickness could independently predict ectopic pregnancy. The adjusted odd ratios for women with endometrial thickness in the ranges of < 8 mm, 8-9.9 mm, and 10-11.9 mm were 3.270 [95% confidence interval (CI), 1.113-9.605, P = 0.031], 2.758 (95% CI, 0.987-7.707, P = 0.053), and 1.456 (95% CI, 0.502-4.225, P = 0.489), respectively, when compared with those having an endometrial thickness of 12-13.9 mm. 2. Endometrial type and preparation protocol were however not identified as risk factors for ectopic pregnancy.

DISCUSSION

1. After freeze-thaw embryo transfer, risks of ectopic pregnancy were significantly higher when the endometrial thickness was < 8 mm. 2. A thin endometrial thickness could be linked with abnormal endometrial peristaltic waves or abnormal endometrial receptivity. 3. Adequate attention should therefore be paid to patients with a thin endometrial thickness to prevent EP or to achieve early diagnosis during the peri-transplantation period.

The incidence of ectopic/heterotopic pregnancies after blastocyst-stage frozen-thawed embryo transfers compared with that after cleavage-stage: a Society for Assisted Reproductive Technologies Clinical Outcomes Reporting System study

Objective

To investigate whether there is a difference in the ectopic/heterotopic pregnancy rate of blastocyst-stage frozen-thawed embryo transfers (FETs) compared with that of cleavage-stage FETs.

Design

A retrospective cohort study.

Setting

Not applicable.

Patient(s)

Women undergoing autologous FETs at either the blastocyst stage (n = 118,572) or the cleavage stage (n = 117,619), as reported to the Society for Assisted Reproductive Technology from 2004 to 2013.

Intervention(s)

None.

Main Outcome Measure(s)

Pregnancy outcomes, specifically ectopic pregnancy rates and heterotopic pregnancy rates.

Result(s)

Among those who became pregnant, there was a significantly lower incidence of ectopic/heterotopic pregnancies in blastocyst-stage FETs versus that in cleavage-stage FETs (0.8% vs. 1.1%). The differences in ectopic/heterotopic pregnancy rates remained statistically significant after controlling for confounders such as tubal factor infertility and number of embryos transferred.

Conclusion(s)

Blastocyst-stage FET was associated with a lower ectopic/heterotopic pregnancy rate compared with cleavage-stage FET.

Association between paternal age and singleton birthweight in frozen embryo transfer cycles

BACKGROUND

Many studies have considered maternal age as a determinant factor for success in assisted reproductive technologies (ART), but the potential role of paternal age on neonatal outcomes has been overlooked. This study aimed to explore the association between paternal age and birthweight in frozen embryo transfer (FET) cycles.

METHODS

This retrospective study involved singleton live births born to women undergoing frozen embryo transfer from January 2013 to December 2017 at a tertiary care center in Shanghai, China. The paternal age was classified into four categories: ≤ 30, 31-35, 36-40, and ≥ 41 years. The group consisting of respondents with paternal age of 31-35 was set as the reference group. Singleton birthweight was the primary outcome measure. Z-scores were calculated according to gestational age and newborn gender on birthweight based on the national birthweight reference. Multivariable linear regression analysis was performed to reveal the relationship between paternal age and newborns' birthweight after considering several potential confounders.

RESULTS

Exactly 9765 women who fulfilled the inclusion criteria were enrolled. No significant difference was found on mean birthweight (P = 0.082) and gestation-adjusted Z-scores (P = 0.569) among paternal age categories. The reference group and the group with aged 36-40 years had the highest mean birthweight and Z-scores, respectively (3350.2 ± 467.8 g, 0.36 ± 1.00). A decline in mean birthweight with paternal age was observed, and the group over 40 years had the lowest value of 3309.4 ± 474.3 g, but the difference was not statistically significant. In multivariate analyses, the adjusted odds of very low birthweight (LBW), LBW, and high birthweight in the reference group did not significantly differ with the three other groups. After correcting several potential confounders, no significant correlation was observed between paternal age and neonatal birthweight (P = 0.289).

CONCLUSION

Paternal age was not associated with mean birthweight and gestational age- and gender-adjusted birthweight (Z-scores) of singletons among women who became pregnant in FET cycles.

Advanced trophectoderm quality increases the risk of a large for gestational age baby in single frozen-thawed blastocyst transfer cycles

STUDY QUESTION

Does trophectoderm (TE) quality affect birthweight after single frozen-thawed blastocyst transfer?

SUMMARY ANSWER

Transfer of single blastocyst with advanced TE quality was associated with higher birthweight and increased risk of a large for gestational age (LGA) baby.

WHAT IS KNOWN ALREADY

Transfer of blastocysts with advanced TE quality results in higher ongoing pregnancy rates and a lower miscarriage risk. However, data on the relationship between TE quality and birthweight are still lacking.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study at a tertiary-care academic medical center included 1548 singleton babies born from single frozen-thawed blastocyst transfer from January 2011 to June 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Babies were grouped into four groups according to embryo expansion (Stages 3, 4, 5 and 6), three groups according to inner cell mass (ICM) quality (A, B and C), and three groups according to TE quality (A, B and C). Main outcomes included absolute birthweight, Z-scores adjusted for gestational age and gender, and adverse neonatal outcomes. Multivariable linear and logistic regression analyses were performed to investigate the association of neonatal outcomes with expansion stage, ICM quality and TE quality.

MAIN RESULTS AND THE ROLE OF CHANCE

As TE quality decreased, birthweight (3468.10 ± 471.52, 3357.69 ± 522.06, and 3288.79 ± 501.90 for A, B and C, respectively, P = 0.002), Z-scores (0.59 ± 1.07, 0.42 ± 1.04, and 0.27 ± 1.06 for A, B and C, respectively, P = 0.002) and incidence of LGA (28.9%, 19.7% and 17.4% for A, B and C, respectively, P = 0.027) decreased correspondingly. After adjusting for confounders, compared with the Grade A group, blastocysts with TE Grade B (standardized coefficients (β): -127.97 g, 95% CI: -234.46 to -21.47, P = 0.019) and blastocysts with TE grade C (β: -200.27 g, 95% CI: -320.69 to -79.86, P = 0.001) resulted in offspring with lower birthweight. Blastocysts with TE grade C brought babies with lower Z-scores than TE Grade A (β: -0.35, 95% CI: -0.59 to -0.10, P = 0.005). Also, embryos with TE Grade B (adjusted odds ratio (aOR):0.91, 95% CI: 0.84 to 0.99, P = 0.033) and embryos with TE Grade C (aOR : 0.89, 95% CI: 0.81 to 0.98, P = 0.016) had lower chance of leading to a LGA baby than those with TE Grade A. No association between neonatal outcomes with embryo expansion stage and ICM was observed (all P > 0.05).

LIMITATIONS, REASONS FOR CAUTION

The retrospective design, lack of controlling for several unknown confounders, and inter-observer variation limited this study.

WIDER IMPLICATIONS OF THE FINDINGS

The study extends our knowledge of the down-stream effect of TE quality on newborn birthweight and the risk of LGA.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by National Key R&D Program of China (2018YFC1003000), National Natural Science Foundation of China (81771533 to Y.P.K. and 31200825 to L.S.) and Innovative Research Team of High-level Local Universities in Shanghai (SSMU-ZLCX20180401), Shanghai Sailing Program(21YF1423200) and the Fundamental research program funding of Ninth People's Hospital affiliated to Shanghai Jiao Tong university School of Medicine (JYZZ117). The authors declare no conflict of interest in this present study.

TRIAL REGISTRATION NUMBER

N/A.

Effect of male age on pregnancy and neonatal outcomes in the first frozen-thawed embryo transfer cycles of IVF/ICSI treatment

BACKGROUND

The effect of male age on pregnancy outcomes after assisted reproductive technology (ART) treatment shown in the previous literature is controversial. In addition, the influence of male age on neonatal outcomes following ART treatment has less been investigated.

OBJECTIVES

The aim of this study was to evaluate the effect of male age on reproductive and neonatal outcomes in couples following ART treatment.

MATERIALS AND METHODS

A retrospective cohort study was performed in two centers for assisted reproduction from June 2010 to February 2019. A total of 5512 frozen-thawed embryo transfer (FET) cycles were included according to the criteria. The primary outcome measures were pregnancy and neonatal outcomes. Patients were categorized into five groups according to male age (younger than 30, 31-35, 36-40, 41-45, and older than 45), and the group younger than 30 years old was treated as the reference group.

RESULTS

The logistic regression analysis showed that clinical pregnancy and live birth were all no statistic difference among the male age-groups compared with the reference group (p values, 0.743, 0.979, 0.948, 0.28; p values, 0.823, 0.342, 0.817, 0.381, respectively). Furthermore, no significant differences were found in the preterm birth rate, child sex, neonatal malformation, birth weight, and gestational age (p > 0.05). The advanced male age was not associated with a higher risk of adverse neonatal outcomes.

DISCUSSION AND CONCLUSION

This study showed that there were no effects of male age on pregnancy or neonatal outcomes in infertile couples following their first FET cycles when females were younger than 36 years old.

Benzodiazepine use before conception and risk of ectopic pregnancy

STUDY QUESTION

Are women who fill a benzodiazepine prescription before conception at increased risk of ectopic pregnancy?

SUMMARY ANSWER

Risk of ectopic pregnancy is 50% higher among women who fill a benzodiazepine prescription before conception.

WHAT IS KNOWN ALREADY

Benzodiazepine use in pregnancy increases the risk of miscarriage, adverse birth outcomes and adverse child development outcomes.

STUDY DESIGN, SIZE, DURATION

Using data from US commercial insurance claims, we performed a cohort study of 1 691 366 pregnancies between 1 November 2008 and 30 September 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We identified ectopic pregnancies using diagnosis and procedure codes and used unadjusted and inverse probability of treatment (IPT)-weighted log-binomial models to calculate relative risks (RR) of ectopic pregnancy for pregnant women who did and did not fill any prescriptions for benzodiazepines in the 90 days before conception. Two sub-groups of women with specific indications for benzodiazepine use were also examined-women who had a least one diagnosis for anxiety disorder and women who had at least one diagnosis of insomnia in the year before conception.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 1 691 366 pregnancies, 1.06% filled at least two benzodiazepine prescriptions totaling at least 10 days supply in the 90 days before conception. Among women with a benzodiazepine prescription, there was an excess of 80 ectopic pregnancies per 10 000 pregnancies, and their IPT-weighted risk of ectopic pregnancies was 1.47 (95% CI 1.32 to 1.63) times greater relative to women without benzodiazepine prescriptions before conception. The IPT-weighted RR between ectopic pregnancy and benzodiazepine use was 1.34 (95% CI 1.18 to 1.53) among women with anxiety disorder diagnoses and 1.28 (95% CI 0.99 to 1.68) among women with an insomnia diagnosis.

LIMITATIONS, REASONS FOR CAUTION

We relied on outpatient prescription data to identify benzodiazepine use before conception, which could result in over- or under-estimation of actual benzodiazepine consumption. We relied on medical claim codes to identify pregnancies and conception date, which may result in misclassification of pregnancy outcomes and gestational length.

WIDER IMPLICATIONS OF THE FINDINGS

This study found that women who have a benzodiazepine prescription before conception are at an increased risk of ectopic pregnancy. This information can help women, and their healthcare providers make more fully informed decisions about benzodiazepine use in their reproductive years.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this project was provided by a Banting Postdoctoral Fellowship and a Stanford Maternal and Child Health Research Institute Postdoctoral Award. Data access for this project was provided by the Stanford Center for Population Health Sciences Data Core. The PHS Data Core is supported by a National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award (UL1 TR001085) and internal Stanford funding. The authors have no competing interest.

TRIAL REGISTRATION NUMBER

N/A.

The effect of storage time after vitrification on pregnancy and neonatal outcomes among 24 698 patients following the first embryo transfer cycles

STUDY QUESTION

To evaluate the impact of storage time after vitrification on embryo viability, pregnancy outcomes and neonatal outcomes.

SUMMARY ANSWER

The prolonged storage time of vitrified embryos negatively affected pregnancy outcomes, including biochemical pregnancy rate, clinical pregnancy and live birth rate; but did not influence neonatal outcomes.

WHAT IS KNOWN ALREADY

Although vitrification has been the fundamental tool of ART treatments in recent years, few studies have explored the influence of storage period after vitrification on embryonic and clinical outcomes.

STUDY DESIGN, SIZE, DURATION

A retrospective study was performed among 24 698 patients with the first vitrified embryo transfer following a freeze-all strategy during the period from January 2011 to December 2017.

PARTICIPANTS/MATERIAL, SETTING, METHODS

A total of 24 698 patients met the inclusion criteria and were grouped according to the storage time (11 330 patients in Group 1 with storage time <3 months, 9614 patients in Group 2 with storage time between 3 and 6 months, 3188 patients in Group 3 with storage time between 6 and 12 months and 566 in Group 4 with storage time between 12 and 24 months). The pregnancy outcomes and neonatal outcomes were compared between different storage time groups. Multivariate logistic regression and linear regression were performed to evaluate the independent effect of storage time on clinical outcomes, adjusting for important confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjustment for potential confounding factors, the chance of biochemical pregnancy (Group 1 as reference; Group 2: adjusted odds ratio (aOR) = 0.92, 95% CI 0.87-0.97; Group 3: aOR = 0.83, 95% CI 0.76-0.90; Group 4: aOR = 0.68, 95% CI 0.56-0.81), clinical pregnancy (Group 2: aOR = 0.91, 95% CI 0.86-0.96; Group 3: aOR = 0.80, 95% CI 0.73-0.87; Group 4: aOR = 0.65, 95% CI 0.54-0.79) and live birth (Group 2: aOR = 0.89, 95% CI 0.85-0.95; Group 3: aOR = 0.83, 95% CI 0.76-0.91; Group 4: aOR = 0.59, 95% CI 0.48-0.72) significantly decreased with the increasing storage time, whereas the relationship between miscarriage, ectopic pregnancy and storage time did not reach statistical significance. In addition, there was no evidence of differences in adverse neonatal outcomes (preterm birth, low birthweight, high birthweight, macrosomia or birth defects) between groups.

LIMITATION, REASONS FOR CAUTION

Our study was limited by the retrospective design from a single center, the conclusion from our study needs to be verified in further studies.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides new findings about the relationship between prolonged storage time of vitrified embryos and clinical outcomes and offers evidence for the safety of using long-stored embryos after vitrification.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (grant nos. 81903324, 81771533, 81571397, 81701523), National Key Research and Development Program of China (grant no. SQ2018YFC100163). None of the authors have any conflicts of interest to declare.

Effect of Day 3 and Day 5/6 Embryo Quality on the Reproductive Outcomes in the Single Vitrified Embryo Transfer Cycles

Objective

To explore the live birth rate and neonatal outcome after single vitrified blastocyst transfer versus single vitrified cleavage-stage embryo transfer at different grades of embryo quality.

Methods

A retrospective cohort study including 6077 single vitrified-thawed embryo transfer cycles was performed in the time-period from January 2013 to December 2018.

Results

After controlling for potential confounding variables, there are 161% increased odds of a live birth after transfer of single good quality embryo at day 5, 152% increased odds of a live birth after transfer of single poor quality embryo at day 5, 60% increased odds of a live birth after transfer of single good quality embryo at day 6 compared with transfer of single good quality embryo at day 3. Results from the generalized estimated equation regression showed significant relationship of unadjusted birth weight with development stage of embryo and embryo quality (good quality embryo on day 5 vs. Good quality embryo on day 3:β=108.55, SE=34.89, P=0.002; good quality embryo on day 6 vs. Good quality embryo on day 3:β=68.80, SE=33.75, P=0.041). However, no significant differences were seen in birth weight between transfer single poor quality embryo on day 5, 6 and transfer single good quality embryo on day 3.

Conclusion

A significant increase in live birth rate and birth weight after transfer of single good quality embryo on day 5 and day 6 compared with transfer of single good quality embryo on day 3 in the vitrified embryo transfer cycles.

Neonatal outcomes in women with polycystic ovary syndrome after frozen-thawed embryo transfer

OBJECTIVE

To compare the risk of adverse neonatal outcomes after frozen embryo transfer (FET) among women with polycystic ovary syndrome (PCOS) with those among women without PCOS.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care academic medical center.

PATIENT(S)

In this study, we included 1,167 singletons born to mothers with PCOS and 9,995 singletons born to mothers without PCOS after FET during the period from January 1, 2007, to December 31, 2019.

INTERVENTION(S)

None.

MAIN OUTCOMES MEASURE(S)

Adverse neonatal outcomes including preterm birth, low birth weight, high birth weight, small for gestational age (SGA), and large for gestational age.

RESULT(S)

The odds of preterm birth were significantly higher among infants from mothers with PCOS compared with those from mothers without PCOS. The odds of low birth weight and SGA were lower in mothers with PCOS compared with mothers without PCOS in the overall analysis, but the differences in low birth weight and SGA between mothers with and without PCOS did not exist in the subgroup analysis with a normal BMI population.

CONCLUSION(S)

The diagnosis of PCOS was independently associated with increased odds of preterm birth among women with singleton pregnancies by FET. In addition, decreased odds of low birth weight and SGA were observed among patients with PCOS, but the increased odds were not observed in the subset analysis of patients with PCOS with normal BMI.

Antidepressant Use around Conception, Prepregnancy Depression, and Risk of Ectopic Pregnancy

OBJECTIVE

To compare the risk of ectopic pregnancy among women with and women without antidepressant prescriptions around conception and examine whether this risk differs by prepregnancy depression status.

METHODS

We conducted a cohort study of all pregnancies between November 1, 2008, and September 30, 2015, identified in the nationwide (American) IBM® MarketScan® Databases. At least one day's supply of antidepressants in the 3 weeks after a woman's last menstrual period defined active antidepressant use around conception. At least one depression diagnosis in the year before the last menstrual period defined prepregnancy depression. Relative risk (RR) of ectopic pregnancy was estimated using unadjusted and inverse probability of treatment (IPT)-weighted log-binomial models.

RESULTS

Of the 1,703,245 pregnancies, 106,788 (6.3%) women had a prepregnancy depression diagnosis. Among women with a depression diagnosis, 40,287 (37.7%) had an active antidepressant prescription around conception; the IPT-weighted risk of ectopic pregnancy was similar among women who did and did not fill an antidepressant prescription around conception (IPT-weighted RR = 1.01; 95% CI, 0.93 to 1.10). Overall, the risk of ectopic pregnancy was higher among women who had a prepregnancy depression diagnosis than women who did not have a prepregnancy depression diagnosis (IPT-weighted RR = 1.09; 95% CI, 1.04 to 1.15).

CONCLUSIONS

This study's findings suggest that women who have a prepregnancy depression diagnosis are at a slightly increased risk of ectopic pregnancy, and among women who have a prepregnancy depression diagnosis, the use of antidepressants around conception does not increase the risk of ectopic pregnancy.

The Valuable Reference of Live Birth Rate in the Single Vitrified-Warmed BB/BC/CB Blastocyst Transfer: The Cleavage-Stage Embryo Quality and Embryo Development Speed

Background

It is unclear whether we should focus attention on cleavage-stage embryo quality and embryo development speed when transferring single particular grade vitrified-warmed blastocysts, especially poor-quality blastocysts (grade “C”).

Method

This retrospective study considered 3386 single vitrified-warmed blastocyst transfer cycles from January 2010 to December 2017. They were divided into group 1 (AA/AB/BA, n = 374), group 2 (BB, n = 1789), group 3 (BC, n = 901), and group 4 (CB, n = 322). The effects of cleavage-stage embryo quality and embryo development speed were measured in terms of clinical pregnancy and live birth rates in each group.

Results

Pregnancy outcomes showed a worsening trend from groups 1 to 4; the proportion of embryos with better cleavage-stage quality and faster development speed decreased. In group 1, only the blastocyst expansion degree 3 was a negative factor in the clinical pregnancy rate (odds ratio (OR) [95% confidence interval (CI)]: 0.233 [0.091–0.595]) and live birth rate (0.280 [0.093–0.884]). In the other groups (BB, BC, and CB), blastocysts frozen on day 5 had significantly better clinical pregnancy outcomes than those frozen on day 6: 1.373 [1.095–1.722] for group 2, 1.523 [1.055–2.197] for group 3, and 3.627 [1.715–7.671] for group 4. The live birth rate was 1.342 [1.060–1.700] for group 2, 1.544 [1.058–2.253] in group 3, and 3.202 [1.509–6.795] in group 4, all Ps < 0.05). The degree of blastocoel expansion three for clinical pregnancy rate in group 2 (0.350 [0.135–0.906], P < 0.05) and day 3 blastomere number (>7) for live birth rate in group 4 (2.455 [1.190–5.063], P < 0.05) were two important factors.

Conclusion

We should consider choosing BB/BC/CB grade blastocysts frozen on day 5, CB grade blastocysts with day 3 blastomere numbers (>7), and AA/AB/BA grade blastocysts with degrees of expansion (≥4) to obtain better pregnancy outcomes.

The Association Between Embryo Quality, Number of Transferred Embryos and Live Birth Rate After Vitrified Cleavage-Stage Embryos and Blastocyst Transfer

Objective

The single-embryo transfer (SET) is the recommended approach to improve the live birth rate and reduce the complications related with multiple pregnancies. However, the physicians generally chose to transfer two embryos when the embryo quality decreased. The effect on the in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) outcomes following the transfer of a poor-quality embryo (PQE) along with a good-quality embryo (GQE) has been explored. However, previous studies were limited by the fresh embryo transfer cycles or the small sample size.

Methods

A retrospective cohort study was performed among 26,676 women (the mean age was 31.72 years) undergoing first frozen embryo transfer (FET) from January 2011 to December 2017. Patients were grouped into five subgroups, including SET with one GQE (SET-GQE, 2235 patients for cleavage-stage embryo transfer and 756 patients for blastocyst transfer), SET with one PQE (SET-PQE, 148 patients for cleavage-stage embryo transfer and 362 patients for blastocyst transfer), double-embryo transfer with two GQE (DET-2GQE, 20,461 patients for cleavage-stage embryo transfer and 519 patients for blastocyst transfer), double-embryo transfer (DET) with one GQE plus one PQE (DET-GQE+PQE, 1541 patients for cleavage-stage embryo transfer and 266 patients for blastocyst transfer), and DET with two PQE (DET-2PQE, 228 patients for cleavage-stage embryo transfer and 160 patients for blastocyst transfer). Multivariable logistic regression models were performed after controlling for other potential confounders to estimate the effect of number and quality of transferred embryos on pregnancy outcomes.

Result

Although the live birth rate was significantly higher after DET-GQE+PQE compared with SET-GQE for cleavage-stage embryo transfer [574 of 1541 (37.25%) vs. 571 of 2235 (25.55%)], no significant difference was found between DET-GQE+PQE and SET-GQE for blastocyst transfer [143 of 266 (53.76%) vs. 325 of 756 (42.99%)]. However, DET-GQE+PQE also had the highest multiple live births in both cleavage-stage embryo transfer [134 of 1541 (8.70%)] and blastocyst transfer [46 of 266 (17.29%)]. The live birth rate after SET-PQE significantly decreased in comparison with SET-GQE [cleavage-stage embryo transfer: 18 of 148 (12.16%) vs. 571 of 2235 (25.55%); blastocyst transfer: 107 of 362 (29.56%) vs. 325 of 756 (42.99%)] and significantly increased after DET-2GQE compared with SET-GQE [cleavage-stage embryo transfer: 9357 of 20,461 (45.73%) vs. 571 of 2235 (25.55%); blastocyst transfer: 313 of 519 (60.31%) vs. 325 of 756 (42.99%)]. The live birth rate was also not different between DET-2PQE and SET-GQE for cleavage-stage embryo transfer and blastocyst transfer [cleavage-stage embryo transfer: 75 of 228 (32.89%) vs. 571 of 2235 (25.55%); blastocyst transfer: 74 of 160 (46.25%) vs. 325 of 756 (42.99)].

Conclusion

In order to minimize the risk of multiple births, the data from this study did not support transferring DET with a GQE plus a PQE compared with SET with a GQE, especially for blastocyst transfer. However, the proportion of patients older than 35 years was small (12.07% for patients aged 36-39 years and 7.31% for patients 40 years or older), which limited the generalization of these results to other population.

Low body mass index is associated with ectopic pregnancy following assisted reproductive techniques: a retrospective study

OBJECTIVE

To investigate the association between body mass index (BMI) and ectopic pregnancy (EP) following embryo transfer (ET).

DESIGN

Retrospective cohort study.

SETTING

University-affiliated hospital.

POPULATION

A total of 16 378 pregnancies derived from either fresh ET or frozen-thawed ET between January 2008 and December 2017.

METHODS

We used the generalised estimating equation (GEE) to analyse the association between BMI categories and EP, as one woman may contribute to more than one pregnancy. Generalised additive models were also used to demonstrate the non-linear association. Models were adjusted for age, parity, gravidity, previous history of ectopic pregnancy, duration of infertility, polycystic ovary syndrome, endometriosis, diagnosis of tubal problems, ovarian reserve markers, ovarian stimulation parameters, insemination protocol, endometrial thickness and embryo transfer policies.

MAIN OUTCOME MEASURES

Ectopic pregnancy.

RESULTS

According to the WHO criteria, the number of cycles with low (<18.5 kg/m² ), normal (18.5-24.9 kg/m² ) and high (≥25 kg/m² ) BMI were 2155, 13 447 and 776, respectively. In comparison with the normal BMI group, the rate of EP was significantly increased in the low BMI group (2.92% versus 2.02%, relative risk 1.45, 95% CI 1.11-1.90), but not in the high BMI group (2.84%, relative risk 1.41, 95% CI 0.92-2.20). Adjusted for confounding factors, the odds ratio for EP comparing low BMI versus normal BMI was 1.61 (95% CI 1.19-2.16) and that comparing high BMI versus normal BMI was 1.12 (95% CI 0.72-1.76).

CONCLUSIONS

Low BMI is associated with an increased risk of EP.

TWEETABLE ABSTRACT

The ectopic pregnancy rate after embryo transfer for lean women is higher than that for women of normal weight.

The live birth and neonatal outcomes in the subsequent pregnancy among patients with adverse pregnancy outcomes in first frozen embryo transfer cycles

PURPOSE

To explore whether the adverse pregnancy outcomes in first frozen embryo transfer (FET) cycles affect live birth and neonatal outcomes in the subsequent pregnancy?

METHODS

This was a retrospective study. Women with a history of adverse pregnancy outcomes in first FET cycles started their subsequent embryo transfer cycles. The adverse pregnancy outcomes included biochemical pregnancy, ectopic pregnancy, and first-trimester pregnancy loss. The main outcomes of present study were live birth rate and neonatal outcomes.

RESULTS

Results showed patients with first-trimester pregnancy loss in first FET cycles had a 95 percent greater chance of live birth in subsequent FET cycles (OR 1.95, 95% CI 1.33-2.88). However, the biochemical pregnancy/ectopic pregnancy in initial FET cycles did not affect the chance of live birth in second cycles (biochemical pregnancy: OR 1.21, 95% CI 0.82-1.77; ectopic pregnancy: OR 1.06, 95% CI 0.55-2.05). The neonatal outcomes of singletons were not affected by the number of embryo transfer cycles.

CONCLUSIONS

Patients with first-trimester pregnancy loss in first FET cycle had a greater chance of live birth in second FET cycles, but the biochemical pregnancy/ectopic pregnancy in first FET cycles did not significantly affect the live birth in second FET cycles. The three types of adverse pregnancy outcomes in first FET cycles did not affect neonatal outcomes in the second cycles.

Suboptimal endometrial-embryonal synchronization is a risk factor for ectopic pregnancy in assisted reproduction techniques

RESEARCH QUESTION

What are the main risk factors associated with ectopic pregnancy and what is the true incidence of ectopic pregnancies in an IVF programme?

DESIGN

Retrospective single-centre study of 12,429 blastocyst transfers (8182 fresh and 4247 frozen embryo transfers) conducted between January 2010 and December 2017. IVF outcome was analysed, and ectopic pregnancy risk evaluated according to patient's characteristics and assisted reproductive technology treatment factors.

RESULTS

Of 5061 patients reporting a positive pregnancy test, 43 were diagnosed with ectopic pregnancy (0.85%). Neither female age (36.7 versus 35.8 years), body mass index, quality of transfer nor stimulation protocol affected the ectopic pregnancy rate, but history of previous ectopic pregnancy (OR 3.26; P = 0.0080), tubal surgery, or both (OR 6.20; P < 0.0001) did. The incidence of ectopic pregnancy was increased in women with uterine malformations (OR 3.85; P = 0.0052), uterine pathologies (OR 5.35; P = 0.0001), uterine surgeries (OR 2.29; P = 0.0154) or sub-optimal endometrial build-up (OR 4.46 to 5.31; P < 0.0001). Transfer of slow-developing blastocysts (expressed by expansion) significantly increased the risk of ectopic pregnancy (OR 2.59; P = 0.0102).

CONCLUSIONS

Unfavourable uterine environment, including uterine pathologies, uterine or tubal surgery and suboptimal endometrial build-up were related to ectopic pregnancy. Low expansion grade of blastocysts was identified as an additional putative risk factor for ectopic pregnancy, indicating the importance of proper embryonal-maternal synchronization. The overall ectopic pregnancy rate after blastocyst transfer was low, comparable with reported ectopic pregnancy rates in spontaneous conceptions. Proper evaluation of tubal and uterine pathologies, optimizing endometrial preparation and the transfer of expanded blastocysts in a frozen embryo transfer cycle, might be beneficial.

Blastocyst-stage embryos provide better frozen-thawed embryo transfer outcomes for young patients with previous fresh embryo transfer failure

Older patients or patients with a reduced ovarian response have a low number of embryos, which limits the opportunity for embryo selection. However, for young patients undergoing frozen-thawed embryo transfer (ET), it remains unclear whether embryo stage affects pregnancy outcomes. In the present study, a total of 2952 patients undergoing their first frozen-thawed ET were divided into two groups: patients who had experienced one failed fresh ET (Group A) and patients who had not received fresh ET because of the high risk of ovarian hyperstimulation syndrome (OHSS) (Group B). Our results show that Group B patients had a significantly higher clinical pregnancy rate (CPR) and live birth rate (LBR) than Group A patients. However, Group A patients who underwent blastocyst-stage frozen-thawed ET had a significantly higher CPR and LBR and a lower ectopic pregnancy rate (ePR) than did those who underwent cleavage-stage frozen-thawed ET. In Group B, CPR, ePR, LBR and spontaneous abortion rate (sAR) were similar with blastocyst-stage and cleavage-stage frozen-thawed ET. These results suggest that blastocyst-stage frozen-thawed ET is more appropriate for young patients who had previously undergone one failed fresh ET cycle.

Impact of Day 7 Blastocyst Transfer on Obstetric and Perinatal Outcome of Singletons Born After Vitrified-Warmed Embryo Transfer

Background

Extended embryo culture has been reported to affect perinatal outcome regarding higher risks of large for gestational age (LGA) and preterm birth (PTB) yet decreased risk of small for gestational age (SGA). However, existing data about the obstetric outcome and the safety for offspring resulting from the transfer of day 7 blastocysts is rare.

Objectives

To compare obstetric and perinatal outcome using embryos vitrified on day 7 with those vitrified on day 3, day 5, and day 6.

Methods

Data were collected from 4489 infertile women who gave birth to live-born singletons after vitrified-warmed embryo transfer cycles from January 1, 2006 to December 31, 2017. Singletons were compared depending on the age of embryos. Main perinatal outcome parameters included PTB (gestational age < 37 weeks), very PTB (VPTB, gestational age < 32 weeks), LGA (birthweights > 90th percentiles), and SGA (birthweights < 10th percentiles). Obstetric outcomes included gestational diabetes (GDM), pregnancy-induced hypertension (PIH), preterm premature rupture of membranes (PPROM), pre-eclampsia, placenta previa, placental abruption, and postpartum hemorrhage. Propensity score matching (PSM) was used to adjust the confounding factors across groups and then analyze the association between in vitro culture period and the outcome measures.

Results

After PSM, the transfer of day 7 blastocysts was associated with higher birth weight Z-scores and increased incidence of very large for gestational age (VLGA) compared with the transfer of day 3 cleavage-stage embryos while the incidence of PTB, low birth weight (LBW), SGA did not reach statistical significance. Moreover, comparable perinatal outcome was found in the comparison of day 7 vs. day 5 and day 7 vs. day 6. Day 7 blastocysts did not result in adverse obstetric outcome compared with day 3, day 5, and day 6 embryos, respectively.

Conclusion

In vitrified-warmed transfer cycles, day 7 blastocysts were associated with adverse perinatal outcome regarding higher risk of VLGA compared with day 3 cleavage-stage embryo, while blastocysts with diverse growth rates embrace similar developmental viability regardless of blastocysts vitrified on day 5, day 6, or day 7.

The impact of embryo quality on singleton birthweight in vitrified-thawed single blastocyst transfer cycles

STUDY QUESTION

Does the quality of a single transferred blastocyst affect singleton birthweight in frozen-embryo transfer (FET) cycles?

SUMMARY ANSWER

The transfer of a poor-quality blastocyst was associated with lower mean birthweight and gestation-adjusted birthweight (Z-scores) when compared with the transfer of an excellent-quality blastocyst during FET cycles.

WHAT IS KNOWN ALREADY

Embryo quality is a strong predictor of IVF success rates. However, very few studies have examined the effect of embryo quality on singleton birthweight.

STUDY DESIGN, SIZE, DURATION

This retrospective study involved singleton live births born to women undergoing frozen-thawed single blastocyst transfers during the period from January 2010 to December 2017 at a tertiary care centre.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1207 women who fulfilled the inclusion criteria were included and were grouped into four groups depending on the blastocyst quality: excellent, good, average and poor. The primary outcome measure was singleton birthweight. The Z-score was employed to calculate the birthweight adjusted for gestational age and newborn gender. Multiple linear regression analysis was performed to investigate the relationship between embryo quality and neonatal birthweight after adjustment for some potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

In the primary multivariable model, singletons from the poor-quality blastocyst group weighed 183.5 g less than those from the excellent-quality blastocyst group (95% CI: −295.1 to −71.9 g, P = 0.001) in terms of mean birthweight after accounting for patient characteristics, IVF treatment parameters, the year of treatment and newborn gender. Likewise, poor-quality blastocyst transfer was associated with lower gestation-adjusted Z-scores than the transfer of excellent-quality blastocysts (β = −0.35, 95% CI: −0.59 to −0.12, P = 0.003).

LIMITATIONS AND REASONS FOR CAUTION

The current study was limited by its retrospective design and the fact that our analysis was restricted to women with singleton births from single blastocyst transfers. Future prospective studies are required to confirm our findings.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings provide new insight into the relationship between embryo quality and neonatal outcomes by showing that poor-quality blastocyst transfer was associated with a decrease in singleton birthweight.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the National Key Research and Development Program of China (grant no. 2018YFC1003000), the National Natural Science Foundation of China (grant nos. 81771533, 81571397 and 31770989), and the China Postdoctoral Science Foundation (Grant no. 2018M630456). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Effect of maternal body mass index on neonatal outcomes in women with endometriosis undergoing IVF

RESEARCH QUESTION

Does preconception body mass index (BMI) affect neonatal outcomes in women with endometriosis who conceive with IVF?

DESIGN

This retrospective study included 7086 women who delivered a singleton live birth through IVF between December 2006 and December 2017. Of these, 1111 women were diagnosed with endometriosis by laparoscopy or laparotomy, while 5975 women received IVF treatment due to tubal factor or male factor infertility. Women were categorized according to predefined BMI groups (<18.5 kg/m², BMI 18.5-24.9 kg/m², ≥25 kg/m²). All comparisons performed were between women undergoing cryopreserved embryo transfer.

RESULTS

After stratification by BMI, underweight women with endometriosis showed higher preterm birth (PTB) rates compared with controls (14.61% versus 3.28%, P < 0.001), whereas normal weight and overweight/obese endometriotic women had similar PTB rates to controls. There was a significant interactive effect of endometriosis and maternal BMI on preterm delivery (P for interaction <0.05). After adjustment for potential confounding factors, the PTB rate remained consistently higher in the low BMI subgroup of women with endometriosis (adjusted odds ratio 4.66, 95% confidence interval 2.54-8.57), whereas this difference was not observed for the other BMI categories. Additionally, we noted no differences in the rate of early PTB, low birthweight, macrosomia, small for gestational age and large for gestational age between women with endometriosis and controls with respect to any preconception category of BMI.

CONCLUSIONS

Endometriotic patients who were underweight before conception (BMI <18.5 kg/m²) had a higher rate of PTB than women without endometriosis, but the difference was not observed in the other BMI categories.

Risk Factors of Recurrent Ectopic Pregnancy in Patients Treated With in vitro Fertilization Cycles: A Matched Case-Control Study

Objective: To study the risk factors for recurrent ectopic pregnancy (REP) in patients undergoing in vitro fertilization (IVF). Methods: This was a 1:4 matched case-control study that enrolled 227 REP patients and 908 matched intrauterine pregnancy (IUP) patients from the assisted reproductive technology (ART) center of the First Affiliated Hospital of Zhengzhou University from January 2012 to November 2019. Univariate analysis was carried out between the two groups for the occurrence of REP. Multivariate logistic regression analysis was used to explore the risk factors of REP after IVF. Results: The results of univariate analysis showed that there were significant differences in previous treatment of EP, stage of embryo and the number of embryos transferred between the two groups (all P < 0.05). The other factors did not have a significant effect on the probability of developing REP. Multivariate logistic regression analysis showed that after adjusting for confounders, previous treatment of EP, type of embryos transferred and stage of embryo were related to the occurrence of REP (all P < 0.05). Conclusion: Conservative treatment, frozen-thawed embryo transfer and cleavage embryo transfer were independent risk factors for REP after ART treatment.