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Alteri A, Arroyo G, Baccino G, Craciunas L, De Geyter C, Ebner T, Koleva M, Kordic K, Mcheik S, Mertes H, Pavicic Baldani D, Rodriguez-Wallberg KA, Rugescu I, Santos-Ribeiro S, Tilleman K, Woodward B, Vermeulen N, Veleva Z. ESHRE guideline: number of embryos to transfer during IVF/ICSI†. Hum Reprod 2024; 39:647-657. [PMID: 38364208 PMCID: PMC10988112 DOI: 10.1093/humrep/deae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Indexed: 02/18/2024] Open
Abstract
STUDY QUESTION Which clinical and embryological factors should be considered to apply double embryo transfer (DET) instead of elective single embryo transfer (eSET)? SUMMARY ANSWER No clinical or embryological factor per se justifies a recommendation of DET instead of eSET in IVF/ICSI. WHAT IS KNOWN ALREADY DET is correlated with a higher rate of multiple pregnancy, leading to a subsequent increase in complications for both mother and babies. These complications include preterm birth, low birthweight, and other perinatal adverse outcomes. To mitigate the risks associated with multiple pregnancy, eSET is recommended by international and national professional organizations as the preferred approach in ART. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for development and update of ESHRE guidelines. Literature searches were performed in PUBMED/MEDLINE and Cochrane databases, and relevant papers published up to May 2023, written in English, were included. Live birth rate, cumulative live birth rate, and multiple pregnancy rate were considered as critical outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the collected evidence, recommendations were discussed until a consensus was reached within the Guideline Development Group (GDG). A stakeholder review was organized after the guideline draft was finalized. The final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE The guideline provides 35 recommendations on the medical and non-medical risks associated with multiple pregnancies and on the clinical and embryological factors to be considered when deciding on the number of embryos to transfer. These recommendations include 25 evidence-based recommendations, of which 24 were formulated as strong recommendations and one as conditional, and 10 good practice points. Of the evidence-based recommendations, seven (28%) were supported by moderate-quality evidence. The remaining recommendations were supported by low (three recommendations; 12%), or very low-quality evidence (15 recommendations; 60%). Owing to the lack of evidence-based research, the guideline also clearly mentions recommendations for future studies. LIMITATIONS, REASONS FOR CAUTION The guideline assessed different factors one by one based on existing evidence. However, in real life, clinicians' decisions are based on several prognostic factors related to each patient's case. Furthermore, the evidence from randomized controlled trials is too scarce to formulate high-quality evidence-based recommendations. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides health professionals with clear advice on best practice in the decision-making process during IVF/ICSI, based on the best evidence currently available, and recommendations on relevant information that should be communicated to patients. In addition, a list of research recommendations is provided to stimulate further studies in the field. STUDY FUNDING/COMPETING INTEREST(S) The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, the literature searches, and the dissemination of the guideline. The guideline group members did not receive payment. DPB declared receiving honoraria for lectures from Merck, Ferring, and Gedeon Richter. She is a member of ESHRE EXCO, and the Mediterranean Society for reproductive medicine and the president of the Croatian Society for Gynaecological Endocrinology and Reproductive Medicine. CDG is the past Chair of the ESHRE EIM Consortium and a paid deputy member of the Editorial board of Human Reproduction. IR declared receiving reimbursement from ESHRE and EDCD for attending meetings. She holds an unpaid leadership role in OBBCSSR, ECDC Sohonet, and AER. KAR-W declared receiving grants for clinical researchers and funding provision to the institution from the Swedish Cancer Society (200170F), the Senior Clinical Investigator Award, Radiumhemmets Forskningsfonder (Dnr: 201313), Stockholm County Council FoU (FoUI-953912) and Karolinska Institutet (Dnr 2020-01963), NovoNordisk, Merck and Ferring Pharmaceuticals. She received consulting fees from the Swedish Ministry of Health and Welfare. She received honoraria from Roche, Pfizer, and Organon for chairmanship and lectures. She received support from Organon for attending meetings. She participated in advisory boards for Merck, Nordic countries, and Ferring. She declared receiving time-lapse equipment and grants with payment to institution for pre-clinical research from Merck pharmaceuticals and from Ferring. SS-R received research funding from Roche Diagnostics, Organon/MSD, Theramex, and Gedeo-Richter. He received consulting fees from Organon/MSD, Ferring Pharmaceuticals, and Merck Serono. He declared receiving honoraria for lectures from Ferring Pharmaceuticals, Besins, Organon/MSD, Theramex, and Gedeon Richter. He received support for attending Gedeon Richter meetings and participated in the Data Safety Monitoring Board of the T-TRANSPORT trial. He is the Deputy of ESHRE SQART special interest group. He holds stock options in IVI Lisboa and received equipment and other services from Roche Diagnostics and Ferring Pharmaceuticals. KT declared receiving payment for honoraria for giving lectures from Merck Serono and Organon. She is member of the safety advisory board of EDQM. She holds a leadership role in the ICCBBA board of directors. ZV received reimbursement from ESHRE for attending meetings. She also received research grants from ESHRE and Juhani Aaltonen Foundation. She is the coordinator of EHSRE SQART special interest group. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (full disclaimer available at https://www.eshre.eu/Guidelines-and-Legal).
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Affiliation(s)
| | - Alessandra Alteri
- Department of Obstetrics and Gynaecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gemma Arroyo
- Reproductive Medicine Service, Dexeus Mujer, Dexeus University Hospital, Barcelona, Spain
| | | | - Laurentiu Craciunas
- Department of Fertility Services and Gynaecology, Newcastle Fertility Centre, Newcastle upon Tyne, UK
| | - Christian De Geyter
- Reproductive Medicine and Gynaecological Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland
| | - Thomas Ebner
- Department of Gynaecology, Obstetrics and Gynaecological Endocrinology, Kepler University Hospital, Linz, Austria
| | | | - Klaudija Kordic
- Patient Representative, Executive Committee, Fertility Europe, Brussels, Belgium
| | | | - Heidi Mertes
- Department of Philosophy and Moral Sciences, Gent University, Gent, Belgium
| | - Dinka Pavicic Baldani
- Division of Reproductive Medicine and Gynaecological Endocrinology, Department of Obstetrics and Gynaecology, Clinical Hospital Centre Zagreb, and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Kenny A Rodriguez-Wallberg
- Laboratory of Translational Fertility Preservation, Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Division of Gynaecology and Reproduction, Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ioana Rugescu
- Cells Department, National Transplant Agency, Bucharest, Romania
| | - Samuel Santos-Ribeiro
- Department of Reproductive Medicine, Valencian Institute of Infertility in Lisbon (IVI-RMA Lisboa), Lisbon, Portugal
| | - Kelly Tilleman
- Department of Reproductive Medicine, Gent University Hospital, Gent, Belgium
| | | | | | - Zdravka Veleva
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
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Hynes JS, Weber JM, Truong T, Acharya KS, Eaton JL. Body mass index is negatively associated with a good perinatal outcome after in vitro fertilization among patients with polycystic ovary syndrome: a national study. F S Rep 2023; 4:77-84. [PMID: 36959962 PMCID: PMC10028420 DOI: 10.1016/j.xfre.2022.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To evaluate the association between body mass index (BMI) and good perinatal outcomes after in vitro fertilization (IVF) among women with polycystic ovary syndrome (PCOS). Design Retrospective cohort study using 2012-2015 Society for Assisted Reproductive Technology Clinic Outcomes Reporting System data. Setting Fertility clinics. Patients To identify patients most likely to have PCOS, we included women with a diagnosis of ovulation disorder and serum antimüllerian hormone >4.45 ng/mL. Exclusion criteria included age ≥ 41 years, secondary diagnosis of diminished ovarian reserve, preimplantation genetic testing, and missing BMI or primary outcome data. Interventions None. Main Outcome Measures Good perinatal outcome, defined as a singleton live birth at ≥ 37 weeks with birth weight ≥ 2,500 g and ≤ 4,000 g. Results The analysis included 9,521 fresh, autologous IVF cycles from 8,351 women. Among women with PCOS, the proportion of cycles with a good perinatal outcome was inversely associated with BMI: underweight 25.1%, normal weight 22.7%, overweight 18.9%, class I 18.4%, class II 14.9%, and class III or super obesity 12.2%. After adjusting for confounders, women in the highest BMI category had 51% reduced odds of a good perinatal outcome compared with normal weight women (adjusted odds ratio 0.49, 95% confidence interval 0.36-0.67). Conclusions Among women with PCOS undergoing fresh, autologous IVF, the odds of a good perinatal outcome decline with increasing BMI. Women with PCOS should be counseled that the odds of achieving a good perinatal outcome decrease as their weight increases.
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Affiliation(s)
- Jenna S. Hynes
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Durham, NC
- Reprint requests: Jenna S. Hynes, M.D., Division of Reproductive Endocrinology and Infertility, Columbia University Fertility Center, 5 Columbus Circle, PH Floor, New York, New York 10019.
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Kelly S. Acharya
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Durham, NC
| | - Jennifer L. Eaton
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Durham, NC
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Wu X, Zhou WJ, Xu BF, Chen Q, Xia L, Zhao S, Xu HH, Zhang AJ, Niu ZH. Association between transferred embryos and multiple pregnancy/live birth rate in frozen embryo transfer cycles: A retrospective study. Front Endocrinol (Lausanne) 2023; 13:1073164. [PMID: 36686447 PMCID: PMC9849691 DOI: 10.3389/fendo.2022.1073164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/07/2022] [Indexed: 01/06/2023] Open
Abstract
Background Physicians need an appropriate embryo transfer strategy to address the challenge of reducing multiple birth rates, while maintaining the couples' live birth rate during assisted reproductive technology. Methods We included 10,060 frozen embryo transfer cycles from January 2015 to March 2020 in reproductive medical center of Ruijin hospital, Shanghai, China. Patients were grouped according to the number and grade of cleavage-stage embryo or blastocysts transferred. Live birth rate and multiple live birth rate were compared among groups of women of different ages. Multivariable logistic regression models were used to estimate the risk of multiple live birth using different combinations of transferred embryos. Results The transfer of double good-quality embryos was an independent predictor for multiple birth in women aged <30 years and those aged 36-39 years [<30 years: aOR =1.54 (95% CI: 1.14-2.06, P < 0.01); 36-39 years: aOR =1.84 (95% CI: 1.0-3.4, P < 0.01)]. Further, for women aged <36 years, the transfer of good-quality + poor-quality blastocysts was an independent predictor for multiple birth rate [<30 years: aOR=2.46 (95% CI: 1.45-4.18, P < 0.01); 31-35 years: aOR =4.45 (95% CI: 1.97-10.06, P < 0.01)]. Conclusions Single-good-quality blastocyst transfer is recommended for women of all ages. When good-quality cleavage embryos are available, the choice of single or double embryo transfer with good- or average-quality embryo should depend on the age of women. Double embryo transfer with the highest possible grade of embryos is recommended for women aged ≥40 years.
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Affiliation(s)
| | | | | | | | | | | | | | - Ai-jun Zhang
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-hong Niu
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Ma S, Peng Y, Hu L, Wang X, Xiong Y, Tang Y, Tan J, Gong F. Comparisons of benefits and risks of single embryo transfer versus double embryo transfer: a systematic review and meta-analysis. Reprod Biol Endocrinol 2022; 20:20. [PMID: 35086551 PMCID: PMC8793185 DOI: 10.1186/s12958-022-00899-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/18/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Evidence referring to the trade-offs between the benefits and risks of single embryo transfer (SET) versus double embryo transfer (DET) following assisted reproduction technology are insufficient, especially for those women with a defined embryo quality or advanced age. METHODS A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched based on established search strategy from inception through February 2021. Pre-specified primary outcomes were live birth rate (LBR) and multiple pregnancy rate (MPR). Odds ratio (OR) with 95% confidence interval (CI) were pooled by a random-effects model using R version 4.1.0. RESULTS Eighty-five studies (14 randomized controlled trials and 71 observational studies) were eligible. Compared with DET, SET decreased the probability of a live birth (OR = 0.78, 95% CI: 0.71-0.85, P < 0.001, n = 62), and lowered the rate of multiple pregnancy (0.05, 0.04-0.06, P < 0.001, n = 45). In the sub-analyses of age stratification, both the differences of LBR (0.87, 0.54-1.40, P = 0.565, n = 4) and MPR (0.34, 0.06-2.03, P = 0.236, n = 3) between SET and DET groups became insignificant in patients aged ≥40 years. No significant difference in LBR for single GQE versus two embryos of mixed quality [GQE + PQE (non-good quality embryo)] (0.99, 0.77-1.27, P = 0.915, n = 8), nor any difference of MPR in single PQE versus two PQEs (0.23, 0.04-1.49, P = 0.123, n = 6). Moreover, women who conceived through SET were associated with lower risks of poor outcomes, including cesarean section (0.64, 0.43-0.94), antepartum haemorrhage (0.35, 0.15-0.82), preterm birth (0.25, 0.21-0.30), low birth weight (0.20, 0.16-0.25), Apgar1 < 7 rate (0.12, 0.02-0.93) or neonatal intensive care unit admission (0.30, 0.14-0.66) than those following DET. CONCLUSIONS In women aged < 40 years or if any GQE is available, SET should be incorporated into clinical practice. While in the absence of GQEs, DET may be preferable. However, for elderly women aged ≥40 years, current evidence is not enough to recommend an appropriate number of embryo transfer. The findings need to be further confirmed.
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Affiliation(s)
- Shujuan Ma
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, No. 567, Tongzipo West Road, Yuelu District, Changsha, 410205, China
| | - Yangqin Peng
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, No. 567, Tongzipo West Road, Yuelu District, Changsha, 410205, China
| | - Liang Hu
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, No. 567, Tongzipo West Road, Yuelu District, Changsha, 410205, China
| | - Xiaojuan Wang
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, No. 567, Tongzipo West Road, Yuelu District, Changsha, 410205, China
| | - Yiquan Xiong
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China
| | - Yi Tang
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, No. 567, Tongzipo West Road, Yuelu District, Changsha, 410205, China
| | - Jing Tan
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China.
| | - Fei Gong
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Reproductive and Genetic Hospital of CITIC-Xiangya, No. 567, Tongzipo West Road, Yuelu District, Changsha, 410205, China.
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Peng Y, Ma S, Hu L, Wang X, Xiong Y, Yao M, Tan J, Gong F. Effectiveness and Safety of Two Consecutive Cycles of Single Embryo Transfer Compared With One Cycle of Double Embryo Transfer: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2022; 13:920973. [PMID: 35846284 PMCID: PMC9279578 DOI: 10.3389/fendo.2022.920973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/23/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To date, evidence regarding the effectiveness and safety of two consecutive cycles of single embryo transfer (2SETs) compared with one cycle of double embryo transfer (DET) has been inadequate, particularly considering infertile women with different prognostic factors. This study aimed to comprehensively summarize the evidence by comparing 2SETs with DET. METHODS PubMed, Embase, Cochrane Library databases, ClinicalTrails.gov, and the WHO International Clinical Trials Registry Platform were searched up to March 22, 2022. Peer-reviewed, English-language randomized controlled trials (RCTs) and observational studies (OS) comparing the outcomes of 2SETs with DET in infertile women with their own oocytes and embryos were included. Two authors independently conducted study selection, data extraction, and bias assessment. The Mantel-Haenszel random-effects model was used for pooling RCTs, and a Bayesian design-adjusted model was conducted to synthesize the results from both RCTs and OS. MAIN RESULTS Twelve studies were finally included. Compared with the DET, 2SETs were associated with a similar cumulative live birth rate (LBR; 48.24% vs. 48.91%; OR, 0.97; 95% credible interval (CrI), 0.89-1.13, τ2 = 0.1796; four RCTs and six observational studies; 197,968 women) and a notable lower cumulative multiple birth rate (MBR; 0.87% vs. 17.72%; OR, 0.05; 95% CrI, 0.02-0.10, τ2 = 0.1036; four RCTs and five observational studies; 197,804 women). Subgroup analyses revealed a significant increase in cumulative LBR (OR, 1.33; 95% CrI, 1.29-1.38, τ2 = 0) after two consecutive cycles of single blastocyst transfer compared with one cycle of double blastocyst transfer. Moreover, a lower risk of cesarean section, antepartum hemorrhage, preterm birth, low birth weight, and neonatal intensive care unit admission but a higher gestational age at birth and birth weight were found in the 2SETs group. CONCLUSION Compared to the DET strategy, 2SETs result in a similar LBR while simultaneously reducing the MBR and improving maternal and neonatal adverse outcomes. The 2SETs strategy appears to be especially beneficial for women aged ≤35 years and for blastocyst transfers.
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Affiliation(s)
- Yangqin Peng
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Shujuan Ma
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Liang Hu
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Xiaojuan Wang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Yiquan Xiong
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Minghong Yao
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Tan
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Jing Tan, ; Fei Gong,
| | - Fei Gong
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
- *Correspondence: Jing Tan, ; Fei Gong,
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Li Y, Liu S, Lv Q. Single blastocyst stage versus single cleavage stage embryo transfer following fresh transfer: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 267:11-17. [PMID: 34689021 DOI: 10.1016/j.ejogrb.2021.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/15/2021] [Accepted: 10/03/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To compare the available evidence of the effectiveness of single blastocyst stage transfer against the effectiveness of single cleavage stage embryo transfer. STUDY DESIGN A systematic research based on Pubmed, Embase and the Cochrane Library was performed until May 2, 2020 to identify all relevant studies. The Cochrane Collaboration's Review Manager (RevMan) 5.0.2 software was used for statistical analysis. RESULTS Five randomized controlled trials (RCTs) were included in analysis, involving 1784 patients in total, who were divided into 2 groups, which were the single blastocyst stage transfer (SBT) group of 932, and the single cleavage stage transfer (SCT) group of 852. Our meta-analysis concluded that SBT group had a significantly higher clinical pregnancy rate (RR 1.26; 95%CI: 1.14-1.39), ongoing pregnancy rate (RR 1.19; 95%CI: 1.05-1.35) and delivery rate (RR 1.4; 95%CI: 1.13-1.75) than SCT group during the fresh transfer. While miscarriage rate (RR 0.93; 95% CI: 0.66-1.33), multiple pregnancy rate (RR, 1.12; 95% CI, 0.51-2.45) and ectopic pregnancy rate (RR, 0.5; 95% CI: 0.13-1.90) between two groups showed no significant difference. However, the SCT group contained notably more cryopreserved embryos than the SBT group. (RR -0.68, 95% CI: -0.95 to -0.41). CONCLUSIONS Our results indicate that single blastocyst stage transfer is associated with higher ongoing pregnancy rate and delivery rate comparing to single cleavage stage transfer in the clinical practice. Due to the low quality of the evidence of the primary outcomes, other higher-quality lager RCTs are necessary before a fully informed decision is made.
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Affiliation(s)
- Yutao Li
- Department of Assisted Reproduction Center, Eastern Hospital, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610101, China.
| | - Siqiao Liu
- Department of Urology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Qun Lv
- Department of Assisted Reproduction Center, Eastern Hospital, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610101, China
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Neblett MF, Kim T, Jones TL, Baumgarten SC, Coddington CC, Zhao Y, Shenoy CC. Is there still a role for a cleavage-stage embryo transfer? F S Rep 2021; 2:269-274. [PMID: 34553150 PMCID: PMC8441559 DOI: 10.1016/j.xfre.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 12/05/2022] Open
Abstract
Objective To determine whether pregnancy outcomes are poor or futile when an intended day 5 transfer is converted to a cleavage-stage transfer because of poor embryo development or a lower number of embryos. Design Retrospective cohort study. Setting Academic medical center. Patient(s) Women with a limited number of embryos, defined as ≤6 two pronuclear embryos, after in vitro fertilization. Intervention(s) Patients who had a cleavage-stage transfer were age matched with patients who had a day 5 transfer. Main Outcome Measure(s) Live birth rate. Result(s) A total of 146 women were included in the study with 73 women in each group. Cleavage-stage transfer was associated with significantly lower implantation and clinical pregnancy rates compared with those of day 5 transfer. Although the live birth rate of the cleavage-stage transfer group was lower than that of the day 5 transfer group (25% vs. 40%, respectively), the cleavage-stage transfer still resulted in a live birth rate of 25%. A subanalysis comparing women who did and did not achieve live birth after cleavage-stage transfer demonstrated a live birth rate of 27% when at least one grade A embryo was transferred vs. 17% when a lesser quality embryo (grade B or C) was transferred. Conclusion(s) As expected, the live birth rate after cleavage-stage transfer was lower than that after day 5 transfer. However, the live birth rate of cleavage-stage transfer still fell into acceptable practice, >5%, for patients who were otherwise at very high risk of having no day 5 embryo transfer. Extended culture may not be necessary for all patients.
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Affiliation(s)
- Michael F Neblett
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota.,Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Tana Kim
- Reproductive Medicine and Infertility Associates, Woodbury, Minnesota
| | | | - Sarah C Baumgarten
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Charles C Coddington
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota.,Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Yulian Zhao
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota.,Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Chandra C Shenoy
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota.,Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Orvieto R, Nahum R, Frei J, Zandman O, Frenkel Y, Haas J. GnRH-Agonist Ovulation Trigger in Patients Undergoing Controlled Ovarian Hyperstimulation for IVF with Stop GnRH-Agonist Combined with Multidose GnRH-Antagonist Protocol. Gynecol Obstet Invest 2021; 86:427-431. [PMID: 34537779 DOI: 10.1159/000517177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to characterize those patients undergoing the stop gonadotropin-releasing hormone (GnRH)-agonist combined with multidose GnRH-antagonist protocol, with suboptimal response to GnRH-agonist trigger in in vitro fertilization (IVF) cycles. DESIGN This is a cohort study. SETTING The study was conducted in a university hospital. PATIENTS All consecutive women admitted to our IVF unit from February 2020 through November 2020 who reached the ovum pick-up stage were reviewed. INTERVENTIONS Triggering final oocyte maturation by GnRH-ag alone (GnRH-ag trigger group), or combined with hCG (dual trigger group), in patients undergoing the stop GnRH-agonist combined with multidose GnRH-antagonist protocol was performed. MAIN OUTCOME MEASURE The main outcome measure was LH level 12 h after the trigger. RESULTS Five out of the 32 patients (15.6%) demonstrated suboptimal response as reflected by LH levels <15 IU/L 12 h after GnRH-agonist trigger. Moreover, while no differences were observed in oocyte recovery rate, maturity, or embryo quality between the different study groups (GnRH-ag trigger and dual trigger groups), those achieving a suboptimal response to the GnRH-agonist trigger (post-trigger LH <15 mIU/mL) demonstrated significantly higher number of follicles and peak estradiol levels at the day of trigger, compared to those with optimal response (post-trigger LH >15 mIU/mL). CONCLUSIONS The stop GnRH-agonist combined with GnRH-antagonist protocol enables the substitution of hCG with GnRH-ag for final oocyte maturation. However, caution should be taken in high responders, where the dual trigger with small doses of hCG (1,000-1,500 IU) should be considered, aiming to avoid suboptimal response (post-trigger LH levels <15 IU/L).
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Affiliation(s)
- Raoul Orvieto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ravit Nahum
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Judith Frei
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Orit Zandman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Yulia Frenkel
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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9
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Mignini Renzini M, Dal Canto M, Guglielmo MC, Garcia D, De Ponti E, La Marca A, Vassena R, Buratini J. Sperm donation: an alternative to improve post-ICSI live birth rates in advanced maternal age patients. Hum Reprod 2021; 36:2148-2156. [PMID: 34143887 DOI: 10.1093/humrep/deab148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/25/2021] [Indexed: 01/26/2023] Open
Abstract
STUDY QUESTION Can sperm donation increase live birth rates following ICSI in advanced maternal age (AMA) patients? SUMMARY ANSWER Sperm donation increases the live birth rate in AMA ICSI cycles. WHAT IS KNOWN ALREADY In ICSI practice, sperm donation has been predominantly applied to overcome male infertility. The involvement of paternal age and lower sperm quality in the severe reduction in fertility observed in AMA patients remains to be clarified. STUDY DESIGN, SIZE, DURATION Retrospective multicenter cohort study including data generated between 2015 and 2019 from 755 ICSI cycles achieving a fresh embryo transfer, of which 337 were first homologous cycles (normozoospermic partner sperm and homologous oocytes) and 418 were first sperm donation cycles (donor sperm and homologous oocytes). The association of sperm origin (partner vs donor) with live birth was assessed by multivariate analysis in non-AMA (<37 years, n = 278) and AMA (≥37 years, n = 477) patients, separately, including in the model all variables previously found to be associated with live birth in a univariate analysis (number of MII oocytes recovered, number of embryos transferred, and maternal age). ICSI outcomes were compared between sperm donation and homologous cycles in overall, non-AMA and AMA patients. PARTICIPANTS/MATERIALS, SETTING, METHODS The study was conducted in three fertility clinics and included 755 Caucasian patients aged 24-42 years undergoing their first homologous or sperm donation ICSI cycle achieving a fresh embryo transfer. MAIN RESULTS AND THE ROLE OF CHANCE The multivariate analysis revealed that sperm donation was positively associated with the likelihood of a live birth independently of all other variables tested in AMA (P = 0.02), but not in non-AMA patients. Live birth, delivery, and miscarriage rates differed substantially between sperm donation and homologous AMA cycles; live birth and delivery rates were 70-75% higher (25.4% vs 14.5% and 22.5% vs 13.5%, respectively; P < 0.01), while miscarriage occurrence was less than half (18.0% vs 39.5%; P < 0.01) in sperm donation compared to homologous AMA cycles. LIMITATIONS, REASONS FOR CAUTION This study is limited by its retrospective nature, differences in patients profiles between sperm donation and homologous-control groups and varying proportion of donor cycles between fertility centers, although these variations have been controlled for in the statistical analysis. WIDER IMPLICATIONS OF THE FINDINGS The findings suggest that sperm donation increases live birth rates while reducing miscarriage occurrence in AMA patients, and thus may be a valid strategy to improve ICSI outcomes in this growing and challenging patient group. STUDY FUNDING/COMPETING INTEREST(S) N/A. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- M Mignini Renzini
- Clinica EUGIN, Modena, Italy.,Biogenesi Reproductive Medicine Centre, Istituti Clinici Zucchi, Monza, Italy
| | - M Dal Canto
- Clinica EUGIN, Modena, Italy.,Biogenesi Reproductive Medicine Centre, Istituti Clinici Zucchi, Monza, Italy
| | - M C Guglielmo
- Clinica EUGIN, Modena, Italy.,Biogenesi Reproductive Medicine Centre, Istituti Clinici Zucchi, Monza, Italy
| | | | - E De Ponti
- ASST Monza, Department of Medical Physics, Monza, Italy
| | - A La Marca
- Clinica EUGIN, Modena, Italy.,Department of Medical and Surgical Sciences of the Mother, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | | | - J Buratini
- Clinica EUGIN, Modena, Italy.,Biogenesi Reproductive Medicine Centre, Istituti Clinici Zucchi, Monza, Italy.,Department of Structural and Functional Biology, Institute of Biosciences, Sao Paulo State University, Botucatu, Brazil
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10
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When using donor oocytes, does embryo stage matter? An analysis of blastocyst versus cleavage stage embryo transfers using a cryopreserved donor oocyte bank. J Assist Reprod Genet 2021; 38:1777-1786. [PMID: 33821428 DOI: 10.1007/s10815-021-02183-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Oocyte donor in vitro fertilization (IVF) represents an ideal model to study the effects of embryo stage on reproductive success, as embryos come from young women with high-quality oocytes. Our study aimed to determine if embryo transfer stage affected outcomes in oocyte donor IVF, including the common scenario where only a limited number of quality embryos are available after culture. METHODS This retrospective cohort analyzed anonymous vitrified donor oocyte cycles at a single clinic between 2008 and 2015. Overall, 983 recipients underwent 1178 warming cycles resulting in fresh transfer of one-to-two embryos. Our primary outcome was live birth; secondary outcomes included multiple birth, birthweight, and gestational age. Log binomial regression with cluster-weighted generalized estimating equations were used to calculate adjusted risk ratios (aRR) accounting for recipient age, race, and transfer year. RESULTS Among 132 cleavage and 1046 blastocyst transfer cycles, cleavage transfers were associated with lower probability of live birth (aRR 0.72, 95% CI 0.59-0.88). Subgroup analysis focused on cycles with a limited number of quality embryos 3 days post-fertilization (≤2), as clinically these women were most likely to be considered for cleavage transfers. Among these cycles (120 cleavage, 371 blastocyst), cleavage transfers were still associated with lower live birth rates compared to blastocyst (aRR 0.66, 95% CI 0.51-0.87) CONCLUSIONS: Even in a donor oocyte model with high-quality oocytes, there was a benefit to extended culture and blastocyst transfer, including when only one-to-two quality embryos were available after early culture. This is possibly owed to improved uterine synchronicity or decreased contractility.
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Pi R, Liu Y, Zhao X, Liu P, Qi X. Tubal infertility and pelvic adhesion increase risk of heterotopic pregnancy after in vitro fertilization: A retrospective study. Medicine (Baltimore) 2020; 99:e23250. [PMID: 33181716 PMCID: PMC7668441 DOI: 10.1097/md.0000000000023250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To analyze risk factors associated with heterotopic pregnancy and the uterine pregnant outcome of those patients after surgery.We retrospectively analyzed 22 patients diagnosed as HP after in vitro fertilization (IVF) between January 2015 and December 2018.HP was diagnosed at gestation age of 55.4 ± 11.8 days. HP were presented as irregular vaginal bleeding, abdominal pain, and sometimes no symptoms. 81.8% of ectopic lesion in HP occurred at fallopian tubes, especially ampullary; cornual pregnancy takes up 13.6%. Compared with clinical intrauterine pregnancy (IUP), IVF with tubal infertility factors had higher risks of HP (OR 4.185, 95% CI 1.080- 16.217); IVF with pelvic adhesion also had higher risks of HP (OR 5.552 95% CI 1.677-18.382); IVF with more than 2 embryos transferred increased risks of HP (OR 23.253, 95% CI 1.804-299.767). The abortion rates of surgery-treated HP and IUP after IVF were 27.8% versus 10.3% (P = .042).These results demonstrate IVF with tubal infertility, pelvic adhesion or multiembryos transfer are risk factors of HP. Furthermore, surgery could induce abortion.
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12
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Adamson GD, Norman RJ. Why are multiple pregnancy rates and single embryo transfer rates so different globally, and what do we do about it? Fertil Steril 2020; 114:680-689. [PMID: 33010940 DOI: 10.1016/j.fertnstert.2020.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
| | - Robert J Norman
- Robinson Research Institute, University of Adelaide, Adelaide, Australia
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13
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Faster fertilization and cleavage kinetics reflect competence to achieve a live birth after intracytoplasmic sperm injection, but this association fades with maternal age. Fertil Steril 2020; 115:665-672. [PMID: 32888678 DOI: 10.1016/j.fertnstert.2020.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the relationship of early developmental kinetics with competence to provide a live birth and the impact of maternal age in this context. DESIGN Retrospective cohort study including 4,915 embryos, of which 1,390 were transferred and provided a clinical outcome paired with morphokinetic data; 168 of them resulted in a live birth (LB), and 1,222 did not (NLB). Early morphokinetic parameters were compared between LB and NLB embryos from patients stratified into two age groups (<37 and ≥37 years), and between embryos at the same competence group from patients aged <37 and ≥37 years. The association of morphokinetic parameters with live birth was tested by univariate and multivariate analyses. SETTING Fertility clinic. PATIENT(S) The study population included 1,066 patients undergoing autologous intracytoplasmic sperm injection cycles with fresh single (SET), double (DET) or triple (TET) embryo transfers on day 2 or 3. Of them, 669 patients produced NLB embryos and 134 produced LB embryos. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Fertilization and cleavage morphokinetic parameters and live birth. RESULT(S) In the total patient population, all morphokinetic parameters were achieved earlier in LB compared with NLB embryos. The same was observed in patients aged <37 years (P<.015), but not ≥37 years. Except for the t8 (time at which an 8-blastomere embryo was identified), all morphokinetic parameters were reached earlier in LB embryos from patients aged <37 years compared with LB embryos from patients aged ≥37 years. Univariate analysis revealed that earlier occurrence of all morphokinetic parameters was associated with live birth, although only earlier t2 (time at which two separate and distinct cells were identified) was associated with live birth independently from maternal age in the multivariate analysis. CONCLUSION(S) Despite its retrospective nature and performance in a single IVF center, this study presents novel data indicating that embryos competent to provide a live birth display overall faster early developmental kinetics compared with embryos that do not achieve a live birth after transfer, a difference that, however, narrows as maternal age advances. The findings suggest that fertilization and cleavage morphokinetic parameters may constitute valuable references for embryo selection strategies aiming to improve live birth rates, specifically before advanced maternal age while holding limited usefulness in advanced maternal age.
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14
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Prevalence of a Good Perinatal Outcome With Cryopreserved Compared With Fresh Donor Oocytes. Obstet Gynecol 2020; 135:709-716. [PMID: 32028490 DOI: 10.1097/aog.0000000000003695] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the odds of a good perinatal outcome between cryopreserved and fresh donor oocytes. METHODS We used the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System to conduct a retrospective cohort study of women undergoing donor oocyte in vitro fertilization (IVF) from 2012 to 2015. Cycles using cryopreserved embryos, a gestational carrier, or preimplantation genetic testing were excluded. The primary outcome was a good perinatal outcome, defined as a singleton live birth at 37 weeks of gestation or more with birth weight at or within 2,500 g and 4,000 g. Secondary outcomes included live birth, multiple birth, and prematurity. Generalized estimating equation models were used to test the effect of oocyte type on the primary outcome while accounting for covariates and the correlation induced by repeated cycles within a patient. RESULTS Of the 36,925 cycles included in the analysis, 8,381 (22.7%) used cryopreserved and 28,544 (77.3%) used fresh oocytes. The odds of a good perinatal outcome were marginally but significantly lower with cryopreserved than with fresh oocytes before and after covariate adjustment (22.0% vs 24.1%, unadjusted odds ratio [OR] 0.90, 95% CI 0.85-0.96, adjusted OR 0.88, 95% CI 0.81-0.95). Compared with fresh oocytes, cryopreserved oocytes were associated with lower rates of live birth (39.6% vs 47.7%, OR 0.75, 95% CI 0.72-0.79), multiple birth (22.3% vs 31.2%, OR 0.63, 95% CI 0.58-0.69), and prematurity (27.6% vs 30.6%, OR 0.86, 95% CI 0.79-0.94). CONCLUSION This retrospective national study demonstrated that the use of cryopreserved compared with fresh donor oocytes in IVF cycles is associated with marginally lower odds of a good perinatal outcome.
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15
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Abstract
The male contribution to infertility has traditionally been overlooked, or at best oversimplified. In recent years efforts have been made to optimize diagnostic and therapeutic techniques to maximize fertility outcomes. A renewed focus on the male partner has resulted in an increased understanding of both genetic and epigenetic changes within the male germline. Furthermore, single-nucleotide polymorphisms, copy-number variants, DNA damage, sperm cryopreservation, obesity, and paternal age have recently been recognized as important factors that play a role in male fertility. Developing a deeper knowledge of these issues could potentially lead to improved success with assisted reproductive technology.
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16
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Bacal V, Fell DB, Shapiro H, Lanes A, Sprague AE, Johnson M, Walker M, Gaudet LM. The Canadian Assisted Reproductive Technologies Register (CARTR) Plus database: a validation study. Hum Reprod Open 2020; 2020:hoaa005. [PMID: 32161819 PMCID: PMC7059854 DOI: 10.1093/hropen/hoaa005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Are data accurately documented in the Canadian Assisted Reproductive Technologies Register (CARTR) Plus database? SUMMARY ANSWER Measures of validity were strong for the majority of variables evaluated while those with moderate agreement were FSH levels, oocyte origin and elective single embryo transfer. WHAT IS KNOWN ALREADY Health databases and registries are excellent sources of data. However, as these databases are typically not established for the primary purpose of performing research, they should be evaluated prior to utilization for research both to inform the study design and to determine the extent to which key study variables, such as patient characteristics or therapies provided, are accurately documented in the database. CARTR Plus is Canada's national register for collecting extensive information on IVF and corresponding pregnancy outcomes, and it has yet to be validated. STUDY DESIGN SIZE DURATION This study evaluating the data translation CARTR Plus database examined IVF cycles performed in 2015 using data directly from patient charts. Six clinics across Canada were recruited to participate, using a purposive sampling strategy. Fixed random sampling was employed to select 146 patient cycles at each clinic, representing unique patients. Only a single treatment cycle record from a unique patient at each clinic was considered during chart selection. PARTICIPANTS/MATERIALS SETTING METHODS Twenty-five data elements (patient characteristics, treatments and outcomes) were reabstracted from patient charts, which were declared the reference standard. Data were reabstracted by two independent auditors with relevant clinical knowledge after confirming inter-rater reliability. These data elements from the chart were then compared to those in CARTR Plus. To determine the validity of these variables, we calculated kappa coefficients, sensitivity, specificity, positive predictive value and negative predictive value with 95% CI for categorical variables and calculated median differences and intraclass correlation coefficients (ICC) for continuous variables. MAIN RESULTS AND THE ROLE OF CHANCE Six clinics agreed to participate in this study representing five Canadian provinces. The mean age of patients was 35.5 years, which was similar between the two data sources, resulting in a near perfect level of agreement (ICC = 0.99; 95% CI: 0.99, 0.99). The agreement for FSH was moderate, ICC = 0.68 (95% CI: 0.64, 0.72). There was nearly perfect agreement for cycle type, kappa = 0.99 (95% CI: 0.98, 1.00). Over 90% of the cycles in the reabstracted charts used autologous oocytes; however, data on oocyte source were missing for 13% of cycles in CARTR Plus, resulting in a moderate degree of agreement, kappa = 0.45 (95% CI, 0.37, 0.52). Embryo transfer and number of embryos transferred had nearly perfect agreement, with kappa coefficients greater than 0.90, whereas that for elective single or double embryo transfer was much lower (kappa = 0.55; 95% CI: 0.49, 0.61). Agreement was nearly perfect for pregnancy type, and number of fetal sacs and fetal hearts on ultrasound, all with kappa coefficients greater than 0.90. LARGE-SCALE DATA N/A. LIMITATIONS REASONS FOR CAUTION CARTR Plus contains over 200 variables, of which only 25 were assessed in this study. This foundational validation work should be extended to other CARTR Plus database variables in future studies. WIDER IMPLICATIONS OF THE FINDINGS This study provides the first assessment of the quality of the data translation process of the CARTR Plus database, and we found very high quality for the majority of the variables that were analyzed. We identified key data points that are either too often lacking or inconsistent with chart data, indicating that changes in the data entry process may be required. STUDY FUNDING/COMPETING INTERESTS This study was funded by Canadian Institutes of Health Research (CIHR) (Grant Number FDN-148438) and by the Canadian Fertility and Andrology Society Research Seed Grant (Grant Number: N/A). The authors report no conflict of interest. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- V Bacal
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health (SEPH), University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - D B Fell
- School of Epidemiology and Public Health (SEPH), University of Ottawa, Ottawa, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - H Shapiro
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
- Mount Sinai Fertility, Toronto, Canada
| | - A Lanes
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Better Outcomes Registry and Network (BORN), Ontario, Ottawa, Canada
| | - A E Sprague
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Better Outcomes Registry and Network (BORN), Ontario, Ottawa, Canada
| | - M Johnson
- Children’s Hospital of Eastern Ontario, Better Outcomes Registry and Network (BORN), Ontario, Ottawa, Canada
| | - M Walker
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health (SEPH), University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
- Children’s Hospital of Eastern Ontario, Better Outcomes Registry and Network (BORN), Ontario, Ottawa, Canada
| | - L M Gaudet
- School of Epidemiology and Public Health (SEPH), University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Obstetrics and Gynecology, Queen’s University, Kingston, Canada
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Xiong F, Sun Q, Li G, Yao Z, Chen P, Wan C, Zhong H, Zeng Y. Association between the number of top-quality blastocysts and live births after single blastocyst transfer in the first fresh or vitrified-warmed IVF/ICSI cycle. Reprod Biomed Online 2020; 40:530-537. [PMID: 32139157 DOI: 10.1016/j.rbmo.2020.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/19/2019] [Accepted: 01/08/2020] [Indexed: 01/13/2023]
Abstract
RESEARCH QUESTION Is there an association between the total number of top-quality blastocysts (TQB) developed in the first IVF/intracytoplasmic sperm injection cycle (ICSI) and live births after a single blastocyst transfer (SBT)? DESIGN Pregnancy outcomes from 1336 infertile women who had undergone their first IVF/ICSI treatment and accepted a first-time embryo transfer with a single fresh or vitrified-warmed blastocyst between January 2016 and August 2018 were assessed retrospectively. The restricted cubic splines method was used to evaluate the association between the number of TQB, and ongoing pregnancies and live births. RESULTS A significant non-linear functional form was found between the number of TQB and the ongoing pregnancies and live births (P < 0.05). The odds of an ongoing pregnancy or live birth were similar, at about 11% or higher for each additional TQB up to five TQB (odds ratio [OR] 1.11; 95% confidence interval [CI] 1.01-1.21). After this, pregnancy outcomes nearly plateaued, indicating that the number of TQB was not related to pregnancy when it was greater than five. CONCLUSIONS The quantity of TQB available for transfer or cryopreservation can provide important predictors for pregnancy and live birth after the first embryo transfer cycle with a single blastocyst. This valuable information may assist with the future application of SBT.
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Affiliation(s)
- Feng Xiong
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China
| | - Qing Sun
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China
| | - Guangui Li
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China
| | - Zhihong Yao
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China
| | - Peilin Chen
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China
| | - Caiyun Wan
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China
| | - Huixian Zhong
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China
| | - Yong Zeng
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Fertility Center, Shenzhen Zhongshan Urology Hospital, Shenzhen Guangdong 518045, People's Republic of China.
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18
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Clinical pregnancy and live birth increase significantly with every additional blastocyst up to five and decline after that: an analysis of 16,666 first fresh single-blastocyst transfers from the Society for Assisted Reproductive Technology registry. Fertil Steril 2019; 112:866-873.e1. [DOI: 10.1016/j.fertnstert.2019.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 11/21/2022]
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19
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Song J, Xiang S, Yang Y, Sun Z. Assessment of follicular fluid metabolomics of polycystic ovary syndrome in kidney yang deficiency syndrome. Eur J Integr Med 2019. [DOI: 10.1016/j.eujim.2019.100944] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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20
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McCabe ERB. Preventable Preterm Birth: A Patient Safety Problem. Pediatrics 2019; 143:peds.2018-0940. [PMID: 30940677 DOI: 10.1542/peds.2018-0940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Edward R B McCabe
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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21
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Blastocyst culture and transfer in clinically assisted reproduction: a committee opinion. Fertil Steril 2019; 110:1246-1252. [PMID: 30503113 DOI: 10.1016/j.fertnstert.2018.09.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 11/28/2022]
Abstract
The purposes of this Practice Committee Opinion, which replaces the 2013 ASRM Practice Committee Opinion of the same name (Fertil Steril 2013; 99:667-72), are to review the literature regarding the clinical application of blastocyst transfer and identify the potential risks and laboratory issues related to the use of this technology. This document does not apply to patients undergoing blastocyst culture and transfer for preimplantation genetic testing.
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Affiliation(s)
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- American Society for Reproductive Medicine, Birmingham, Alabama
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- American Society for Reproductive Medicine, Birmingham, Alabama
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22
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Elective Single Embryo Transfer in the Setting of Funded In Vitro Fertilization: Two Years’ Experience in an Ontario Hospital-Based Fertility Clinic. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:421-427. [DOI: 10.1016/j.jogc.2018.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/13/2018] [Indexed: 10/27/2022]
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23
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Freeman MR, Hinds MS, Howard KG, Howard JM, Hill GA. Guidance for elective single-embryo transfer should be applied to frozen embryo transfer cycles. J Assist Reprod Genet 2019; 36:939-946. [PMID: 30859416 DOI: 10.1007/s10815-019-01433-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/28/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To provide clinicians with data showing the benefits of transferring a single blastocyst in frozen embryo transfer (FET) cycles so that they may counsel their patients accordingly. METHODS This is a closed cohort study of 678 FET cycles occurring between January 2011 and December 2017 in a private IVF laboratory and associated physicians' practice. Patients included in the analysis were less than 38 years of age at oocyte collection, had at least two vitrified blastocysts, and were undergoing their first autologous FET cycle. The patients were categorized into four groups after they had chosen either elective single-embryo transfer (eSET) or double-embryo transfer (eDET). Outcomes for eSET and eDET were compared within groups of patients having freeze-all IVF cycles (PGT-A patient vs. non-PGT-A patient) and fresh IVF transfer groups (negative outcome vs. pregnant/delivered in fresh cycle). Main outcome measures of the study were live birth, multiple pregnancy, and implantation rates. RESULTS There were no statistically significant differences observed in live birth rates for eSET (54-62%) vs. eDET (54-66%) (P = 0.696-1.000) in the four patient groups evaluated. Multiple pregnancy rates were significantly decreased in all eSET groups (0-3%), compared with eDET groups (24-65%) (P = 0.0001-0.037). CONCLUSIONS This data shows that transfer of a single vitrified-warmed blastocyst maintains live birth rates, while decreasing multiple pregnancies, and may become more acceptable to physicians and patients.
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Affiliation(s)
- Melanie R Freeman
- Ovation Fertility, 345 23rd Ave. N, Suite 401, Nashville, TN, 37203, USA.
| | - M Shaun Hinds
- Ovation Fertility, 345 23rd Ave. N, Suite 401, Nashville, TN, 37203, USA
| | - Kay G Howard
- Ovation Fertility, 345 23rd Ave. N, Suite 401, Nashville, TN, 37203, USA
| | - Julie M Howard
- Ovation Fertility, 345 23rd Ave. N, Suite 401, Nashville, TN, 37203, USA
| | - George A Hill
- Nashville Fertility Center, 345 23rd Ave. N., Suite 401, Nashville, TN, 37203, USA
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24
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Jain T, Grainger DA, Ball GD, Gibbons WE, Rebar RW, Robins JC, Leach RE. 30 years of data: impact of the United States in vitro fertilization data registry on advancing fertility care. Fertil Steril 2019; 111:477-488. [DOI: 10.1016/j.fertnstert.2018.11.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 12/18/2022]
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25
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Tiitinen A. Single embryo transfer: Why and how to identify the embryo with the best developmental potential. Best Pract Res Clin Endocrinol Metab 2019; 33:77-88. [PMID: 31005505 DOI: 10.1016/j.beem.2019.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Multiple pregnancies with higher risk of preterm birth and the associated higher morbidity have been a major obstacle from the early days of in vitro fertilization. A good strategy to avoid multiple pregnancies is elective single embryo transfer and cryopreservation of spare embryos. Important factors in adopting this strategy are good counselling of the patients and the selection of embryos with high implantation potential. Technical advances in embryo selection have been described during recent years, time lapse monitoring and genetic assessment of the embryos being the most important achievements. With these studies we have gained new information on early embryos. However, at present, there is insufficient evidence to recommend the routine use of these new techniques. The ultimate goal of infertility treatment is a healthy baby.
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Affiliation(s)
- Aila Tiitinen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, FI-00029 Helsinki, Finland.
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26
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Esteves SC, Alviggi C, Humaidan P, Fischer R, Andersen CY, Conforti A, Bühler K, Sunkara SK, Polyzos NP, Galliano D, Grynberg M, Yarali H, Özbek IY, Roque M, Vuong LN, Banker M, Rienzi L, Vaiarelli A, Cimadomo D, Ubaldi FM. The POSEIDON Criteria and Its Measure of Success Through the Eyes of Clinicians and Embryologists. Front Endocrinol (Lausanne) 2019; 10:814. [PMID: 31824427 PMCID: PMC6880663 DOI: 10.3389/fendo.2019.00814] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 11/06/2019] [Indexed: 12/19/2022] Open
Abstract
This article represents a viewpoint on the POSEIDON criteria by a group of clinicians and embryologists. Its primary objective is to contextualize the Poseidon criteria and their metric of success for the relevant Frontiers Research Topic "POSEIDON's Stratification of Low Prognosis Patients in ART: The WHY, the WHAT, and the HOW". "Low prognosis" relates with reduced oocyte number, which can be associated with low or sometimes a normal ovarian reserve and is aggravated by advanced female age. These aspects will ultimately affect the number of embryos generated and consequently, the cumulative live birth rate. The novel system relies on female age, ovarian reserve markers, ovarian sensitivity to exogenous gonadotropin, and the number of oocytes retrieved, which will both identify the patients with low prognosis and stratify such patients into one of four groups of women with "expected" or "unexpected" impaired ovarian response to exogenous gonadotropin stimulation. Furthermore, the POSEIDON group introduced a new measure of clinical success in ART, namely, the ability to retrieve the number of oocytes needed to obtain at least one euploid blastocyst for transfer in each patient. Using the POSEIDON criteria, the clinician can firstly identify and classify patients who have low prognosis in ART, and secondly, aim at designing an individualized treatment plan to maximize the chances of achieving the POSEIDON measure of success in each of the four low prognosis groups. The novel POSEIDON classification system is anticipated to improve counseling and management of low prognosis patients undergoing ART, with an expected positive effect on reproductive success and a reduction in the time to live birth.
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Affiliation(s)
- Sandro C. Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- *Correspondence: Sandro C. Esteves
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Peter Humaidan
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | - Claus Y. Andersen
- Laboratory of Reproductive Biology, Faculty of Health and Medical Sciences, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Klaus Bühler
- Center for Gynecology, Endocrinology, and Reproductive Medicine, Ulm, Germany
- Department of Gynaecology, Jena-University Hospital-Friedrich, Schiller University, Jena, Germany
| | - Sesh K. Sunkara
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | | | | | - Michael Grynberg
- Service de Médecine de la Reproduction et Préservation de la Fertilité, Hôpital Antoine Béclère, Clamart, France
| | | | | | - Matheus Roque
- ORIGEN, Center for Reproductive Medicine, Rio de Janeiro, Brazil
| | - Lan N. Vuong
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | | | - Laura Rienzi
- GENERA, Center for Reproductive Medicine, Rome, Italy
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Meldrum DR, Adashi EY, Garzo VG, Gleicher N, Parinaud J, Pinborg A, Van Voorhis B. Prevention of in vitro fertilization twins should focus on maximizing single embryo transfer versus twins are an acceptable complication of in vitro fertilization. Fertil Steril 2018; 109:223-229. [PMID: 29447664 DOI: 10.1016/j.fertnstert.2017.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 11/30/2022]
Affiliation(s)
- David R Meldrum
- Reproductive Partners San Diego, San Diego, California; Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California.
| | - Eli Y Adashi
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - V Gabriel Garzo
- Reproductive Partners San Diego, San Diego, California; Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California
| | | | - Jean Parinaud
- Department of Reproductive Medicine, Paule de Viguier Hospital, Toulouse Teaching Hospital Group, Toulouse, France
| | - Anja Pinborg
- Fertility Clinic, Department of Obstetrics and Gynecology, Hvidovre University Hospital, Hvidovre, Copenhagen, Denmark
| | - Brad Van Voorhis
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Remião MH, Segatto NV, Pohlmann A, Guterres SS, Seixas FK, Collares T. The Potential of Nanotechnology in Medically Assisted Reproduction. Front Pharmacol 2018; 8:994. [PMID: 29375388 PMCID: PMC5768623 DOI: 10.3389/fphar.2017.00994] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/26/2017] [Indexed: 12/16/2022] Open
Abstract
Reproductive medicine is a field of science which searches for new alternatives not only to help couples achieve pregnancy and preserve fertility, but also to diagnose and treat diseases which can impair the normal operation of the reproductive tract. Assisted reproductive technology (ART) is a set of methodologies applied to cases related to infertility. Despite being highly practiced worldwide, ART presents some challenges, which still require special attention. Nanotechnology, as a tool for reproductive medicine, has been considered to help overcome some of those impairments. Over recent years, nanotechnology approaches applied to reproductive medicine have provided strategies to improve diagnosis and increase specificity and sensitivity. For in vitro embryo production, studies in non-human models have been used to deliver molecules to gametes and embryos. The exploration of nanotechnology for ART would bring great advances. In this way, experiments in non-human models to test the development and safety of new protocols using nanomaterials are very important for informing potential future employment in humans. This paper presents recent developments in nanotechnology regarding impairments still faced by ART: ovary stimulation, multiple pregnancy, and genetic disorders. New perspectives for further use of nanotechnology in reproductive medicine studies are also discussed.
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Affiliation(s)
- Mariana H Remião
- Biotechnology Graduate Program, Molecular and Cellular Oncology Research Group, Laboratory of Cancer Biotechnology, Technology Development Center, Federal University of Pelotas, Pelotas, Brazil
| | - Natalia V Segatto
- Biotechnology Graduate Program, Molecular and Cellular Oncology Research Group, Laboratory of Cancer Biotechnology, Technology Development Center, Federal University of Pelotas, Pelotas, Brazil
| | - Adriana Pohlmann
- Post-graduation Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Silvia S Guterres
- Post-graduation Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fabiana K Seixas
- Biotechnology Graduate Program, Molecular and Cellular Oncology Research Group, Laboratory of Cancer Biotechnology, Technology Development Center, Federal University of Pelotas, Pelotas, Brazil
| | - Tiago Collares
- Biotechnology Graduate Program, Molecular and Cellular Oncology Research Group, Laboratory of Cancer Biotechnology, Technology Development Center, Federal University of Pelotas, Pelotas, Brazil
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29
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Single-embryo transfer point—it is the way forward. Fertil Steril 2017; 108:757. [DOI: 10.1016/j.fertnstert.2017.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/23/2017] [Indexed: 10/18/2022]
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