Impact of PCOS on early embryo cleavage kinetics

Optimizing ICSI outcomes in women with PCOS: the influence of BMI, hormonal levels, and male fertility parameters

OBJECTIVES

Women with PCOS often experience significant difficulties in achieving spontaneous pregnancy. Intracytoplasmic sperm injection (ICSI) is a viable treatment option for these patients, offering an acceptable success rate. This study purposes to identify factors that may positively or negatively influence pregnancy rates in PCOS women undergoing ICSI and explore potential modifications to enhance successful pregnancy outcomes.

METHODS

The study included ninety sub-fertile couples with female partners with diagnosed PCOS. Comprehensive evaluations of the partners included medical history, physical examination, hormonal analysis, transvaginal ultrasound (TVUS), and seminal fluid analysis. All couples underwent ICSI. Pregnancy rates were determined by positive pregnancy tests 14 days after fresh embryo transfer, and participants were divided into two groups: pregnant and non-pregnant.

RESULTS

Of the 90 women who underwent ICSI cycles, 24 achieved pregnancies, resulting in a pregnancy rate of 26.66 %. Non-pregnant women had significantly higher body mass indices (BMI). Additionally, women with elevated cycle day 2 serum estradiol (E2) levels and low follicle-stimulating hormone (FSH) levels exhibited significantly lower pregnancy rates. Women whose male partners had abnormal semen parameters also demonstrated significantly lower pregnancy rates.

CONCLUSIONS

Several factors negatively impact pregnancy rates in PCOS women undergoing ICSI, including high BMI, elevated E2, low FSH levels on cycle day 2, a lower number of mature oocytes, and male factor sub-fertility. Many of these factors can be mitigated through the use of ICSI, thereby improving the chances of achieving a successful pregnancy.

Diameter of Human Day Five Blastocysts and Birth Sex

Background This study aimed to evaluate the offspring sex ratio, born through fresh and cryo-thawed single blastocyst (BL) transfers regarding a single morphological, static parameter, namely, BL diameter. Methodology This retrospective, observational study was conducted at an assisted reproductive technology (ART) center, Kinderwunschzentrum Niederrhein Germany. We conducted a statistical analysis of all births resulting from fresh and thawed in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles after a single embryo transfer (SET). The main outcome measure was the offspring sex ratio after SET of a day five BL in relation to the BL diameter measurement. Results There were more female than male babies born in our study. We observed a tendency for BL to have a higher diameter, resulting in female offspring, which was not statistically relevant. We also compared the BL diameter in the fresh embryo transfer (ET) group with that of the cryo-thawed ET group, showing a tendency toward a larger diameter in the fresh ET group. In the ICSI cycles, there was a higher tendency for a larger BL diameter when compared to IVF cycles. In the fresh ET cycles, BL leading to the male sex at birth had a tendency toward a larger diameter than the female BL. In the cryo-thaw ET cycles, BL leading to the female sex had a tendency toward a larger diameter than the male BL. Conclusions Our results showed a tendency in the sex of offspring toward the female sex and no significant difference in the BL diameter of BL leading to birth after ART and consecutive transfer of day five BL.

Comparing Assisted Reproductive Outcomes in Women with Different Polycystic Ovary Syndrome Phenotypes Undergoing Frozen Embryo Transfer

Background

Patients with polycystic ovarian syndrome (PCOS) have unique characteristics depending on its phenotype. Therefore, prediction of controlled ovarian stimulation (COS) response and assisted reproductive technique (ART) outcome in these becomes challenging.

Aims

To assess the outcomes of assisted reproductive technology (ART) in various polycystic ovary syndrome (PCOS) phenotypes and to evaluate the predictive value of anti-Mullerian hormone (AMH) and total testosterone on ART success. Clinical pregnancy rate (CPR) was measured as the primary outcome.

Settings and Design

This was a prospective observational study conducted at a tertiary care centre.

Materials and Methods

A total of 190 infertile women with PCOS (Rotterdam criteria) were enrolled and were subdivided into four phenotypes. Baseline screening and transvaginal scan were done. All patients underwent COS using antagonist protocol with recombinant follicle-stimulating hormone, and an agonist trigger was given for follicular maturation. One or two blastocysts were transferred in a frozen-thawed embryo transfer cycle. Luteal phase support was given with vaginal progesterone.

Statistical Analysis Used

For quantitative variables, we employed the Kruskal-Wallis Test with post hoc Tukey's analysis. For continuous or ordinal variables, the Mann-Whitney U test was utilized. The analysis of categorical data was conducted using the Chi-square (χ2) test with SPSS 21 software.

Results

Phenotype A was the most prevalent (37%). CPR was the highest in phenotype D (57.7%), followed by phenotype C (53.06%), A (43%) and B (36%). The mean serum AMH level was the highest in phenotype A (9.7 ± 4.3 ng/dL) and the lowest in phenotype B (5.9 ± 1.8 ng/dL). The mean total testosterone level was 103 ± 15.68 ng/mL in Type A, 109.46 ± 37.08 ng/mL in Type B and 48.52 ± 17.07 ng/ml in Type D.

Conclusion

Phenotype D showed higher CPR and lower miscarriage rate compared to other phenotypes (not significant) and was associated with good clinical outcome. No correlation could be established with serum AMH, total testosterone levels and CPR.

Polycystic ovarian syndrome and miscarriage in IVF: systematic revision of the literature and meta-analysis

PURPOSE

To evaluate the risk of miscarriage in IVF cycles in women with PCOS.

METHODS

Systematic review and meta-analysis. Systematic search of MEDLINE, EMBASE and Google Scholar. The language search was restricted to English, Spanish and French, from 2000 to 2019, with crosschecking of references from relevant articles. Inclusion criteria were: (1) IVF cycles (2) a group of patients with PCOS was considered separately, (3) the miscarriage rate was reported, (4) there was a control group, (5) definition of PCOS according the Rotterdam criteria. Exclusion criteria were been excluded from the meta-analysis: (1) publication prior to the year 2000, (2) animal studies, (3) reviews, (4) abstracts or conference papers, (5) letters, (6) case reports, (7) studies comparing different IVF techniques, (8) studies comparing groups with and without metformin or other treatments, (9) studies on induced abortions. Risk of bias was assessed by the Newcastle-Ottawa score (NOS). All the included studies had a low risk of bias (NOS scores ranging 7-8). The review protocol was registered in PROSPERO (CRD42020186713). Seventeen studies were included in the meta-analysis. There was a total of 10,472 pregnancies (2650 in PCOS and 7822 in controls) of which 1885 were miscarriages (682 in PCOS and 1203 in controls). We considered the miscarriage rate (MR), preclinical MR, early MR, and late MR.

RESULTS

In IVF pregnancies the risk of miscarriage was significantly increased when considering miscarriages in total (RR = 1.59; CI = 1.45-1.75), preclinical miscarriages (RR = 1.59; CI = 1.35-1.88), and early miscarriages (RR = 1.44; CI = 1.16-1.79). The increased miscarriage rate persisted in Chinese and Western populations when considered separately. The risk of miscarriage was increased in the subgroup of fresh transfers (RR = 1.21; CI = 1.06-1.39) as well as in the subgroup including either fresh or frozen transfers (RR = 1.95; CI = 1.72-2.22).

CONCLUSION

PCOS is linked to an increased MR in IVF pregnancies both of miscarriages in total, and to an increase in preclinical and early miscarriages.

PROSPERO NUMBER

CRD42020186713.

Circulating miRNAs in Women with Polycystic Ovary Syndrome: A Longitudinal Cohort Study

BACKGROUND

Women with polycystic ovary syndrome (PCOS) often change their metabolic profile over time to decrease levels of androgens while often gaining a propensity for the development of the metabolic syndrome. Recent discoveries indicate that microRNAs (miRNAs) play a role in the development of PCOS and constitute potential biomarkers for PCOS. We aimed to identify miRNAs associated with the development of an impaired metabolic profile in women with PCOS, in a follow-up study, compared with women without PCOS.

METHODS AND MATERIALS

Clinical measurements of PCOS status and metabolic disease were obtained twice 6 years apart in a cohort of 46 women with PCOS and nine controls. All participants were evaluated for degree of metabolic disease (hypertension, dyslipidemia, central obesity, and impaired glucose tolerance). MiRNA levels were measured using Taqman^® Array cards of 96 pre-selected miRNAs associated with PCOS and/or metabolic disease.

RESULTS

Women with PCOS decreased their levels of androgens during follow-up. Twenty-six of the miRNAs were significantly changed in circulation in women with PCOS during the follow-up, and twenty-four of them had decreased, while levels did not change in the control group. Four miRNAs were significantly different at baseline between healthy controls and women with PCOS; miR-103-3p, miR-139-5p, miR-28-3p, and miR-376a-3p, which were decreased in PCOS. After follow-up, miR-28-3p, miR-139-5p, and miR-376a-3p increased in PCOS women to the levels observed in healthy controls. Of these, miR-139-5p correlated with total testosterone levels (rho = 0.50, p_adj = 0.013), while miR-376-3p correlated significantly with the waist-hip ratio at follow-up (rho = 0.43, p_adj = 0.01). Predicted targets of miR-103-3p, miR-139-5p, miR-28-3p, and miR-376a-3p were enriched in pathways associated with Insulin/IGF signaling, interleukin signaling, the GNRH receptor pathways, and other signaling pathways. MiRNAs altered during follow-up in PCOS patients were enriched in pathways related to immune regulation, gonadotropin-releasing hormone signaling, tyrosine kinase signaling, and WNT signaling.

CONCLUSIONS

These studies indicate that miRNAs associated with PCOS and androgen metabolism overall decrease during a 6-year follow-up, reflecting the phenotypic change in PCOS individuals towards a less hyperandrogenic profile.

Gonadotropins as pharmacological agents in assisted reproductive technology and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex endocrinopathy associated with subfertility/infertility and pregnancy complications. Most PCOS women opt for assisted reproductive technologies (ART) for successful conception; however, optimization of the relative doses of the gonadotropins [follicle-stimulating hormone (FSH), luteinizing hormone (LH)/human chorionic gonadotropin (hCG)] for appropriate steroidogenesis, without causing ovarian hyperstimulatory syndrome (OHSS), is challenging. Embryonic factors probably do not contribute to pregnancy loss in PCOS women, albeit hormonal imbalance impairs the metabolic microenvironment critical for oocyte maturation and endometrial receptivity. Certain clinical studies have confirmed the role of metabolic corrections in increasing the rate of pregnancy in PCOS women. This review focuses on the impact of untimely high LHCGR and/or LH levels on oocyte/embryo quality, pregnancy outcomes in ART, and exploring LHCGR as a potential drug target in PCOS women.

Inhibition of oocyte maturation by follicular extracellular vesicles of non-hyperandrogenic PCOS patients requiring IVF

CONTEXT

Polycystic ovarian syndrome (PCOS) is one of the most common diseases that contribute to subfertility. Recent evidence showed that oocytes of women with PCOS matured in vitro away from the follicular fluid presented better potentials, whereas the reason remained unclear.

OBJECTIVE

To investigate whether follicular extracellular vesicles (EVs) of PCOS patients interfere with the quality of oocytes.

METHODS

Follicular EVs of women with PCOS (PCOS-EVs) and control women (CTRL-EVs) were isolated and determined using western blotting, nanoparticle tracking analysis, and transmission electron microscopy. The two types of EVs were co-cultured with murine germinal vesicle oocytes, respectively. Fluorescence labeled EVs were used to visualize internalization by oocytes. After co-culture, oocyte maturation rates were calculated. Mitochondria distribution and reactive oxygen species (ROS) level were detected in the different groups. Spindle morphology was evaluated using immunofluorescence. Moreover, the expression of catalase (CAT), glutathione synthetase (GSS), and superoxide dismutase (SOD) was determined in the oocytes.

RESULTS

Both PCOS-EVs and CTRL-EVs are bilayered vesicles, approximately 100-150 nm in size, and enriched in EV-associating protein markers. EVs were internalized by oocytes within one hour. Oocyte maturation rate decreased significantly in the PCOS-EV group compared with the CTRL-EV group; whereas the abnormal mitochondria distribution rate and abnormal spindle rate were significantly increased in the PCOS-EV group. Moreover, PCOS-EVs increased the ROS level and the expression of CAT, GSS, and SOD in the oocytes.

CONCLUSIONS

PCOS-EVs interfered with oocyte mitochondria and spindles and inhibited oocyte maturation. Moreover, oxidative stress induced by PCOS-EVs might be a potential cause.

Pregnancy outcomes in patients with polycystic ovary syndrome who conceived after single thawed blastocyst transfer: a propensity score-matched study

Background

It remains unclear whether polycystic ovary syndrome (PCOS) is an independent risk factor for pregnancy complications in women undergoing assisted reproductive technology (ART) treatment. For the integrative treatment of PCOS patients, it is still important to investigate the pregnancy outcomes of PCOS patients after adjusting for potential biases, such as body mass index, embryo quality and endometrial preparation method.

Methods

This retrospective cohort study ultimately included a total of 336 PCOS patients who conceived after single thawed blastocyst transfer in the PCOS group and 2,325 patients in the control group from January 2018 to December 2020. A propensity score matching (PSM) model was used, and 336 PCOS patients were matched with 336 patients in the control group.

Results

Before PSM, no differences in the miscarriage rate, pregnancy complication rate, preterm birth rate, or live birth rate were found between the PCOS group and the control group. After PSM, the late miscarriage rate of the PCOS group was significantly higher than that of the control group (3.3% vs. 0.6%, P = 0.040), although the early miscarriage rates were similar (14.0% vs. 13.7%). The rates of pregnancy complications, preterm birth and live birth in the PCOS group were comparable to those in the matched control group (P = 0.080, P = 0.105, P = 0.109, respectively). The neonatal weights of male infants and female infants were similar between the two groups (P = 0.219, P = 0.169). Subgroup analysis showed that PCOS patients with homeostasis model assessment of insulin resistance (HOMA-IR) levels ≥ 2.49 had a significantly increased risk of preterm birth compared with those with HOMA-IR levels < 1.26 and 1.26 ≤ HOMA-IR levels < 2.49 (26.0% vs. 6.0% vs. 9.8%, P = 0.005). PCOS patients with total testosterone levels ≥ 0.7 ng/ml had a higher early miscarriage rate but a lower late miscarriage rate than those with total testosterone levels < 0.7 ng/ml (29.4% vs. 12.3%, 0% vs. 3.6%, respectively, P = 0.032).

Conclusions

PCOS is an independent risk factor for late miscarriage in patients conceived after a single thawed blastocyst transfer, even after adjusting for biases. Among PCOS patients, insulin resistance and hyperandrogenism are associated with a higher risk of preterm birth and early miscarriage, respectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05011-4.

The reproductive endocrine feature and conception outcome of women with unknown etiological menstrual cycle (36-45 days) with long follicular phase

OBJECTIVE

To explore the reproductive endocrine feature and conception outcome of women with unknown etiological long menstrual cycle (LMC) (36-45 days) with long follicular phase.

METHODS

In the cohort study, we included 80 women with unknown etiological long menstrual cycle of biphasic basal body temperature (BBT) lasting for 36-45 days and 87 controls with normal cycle of biphasic BBT into LMC group and NMC group, respectively. Serum hormone levels, fasting glucose, and insulin of participants were tested, and ovulation was observed by ultrasound. The conception outcome was followed up within 12 menstrual cycles.

RESULTS

In the LMC group, the rate of abnormality of HOMA-insulin resistance index (40.0% vs. 20.7%, p < .01), luteal phase defect (30.9% vs. 13.8%, p < .05) and abnormality of FSH/LH ratio (15.6% vs. 5.7%, p < .05) were all significantly higher, but the serum estradiol level on the day before ovulation (261.10 pg/mL vs. 320.26 pg/mL, p < .01) was lower. The rate of poor ovulation quality (31.3% vs.15.4%, p < .05) in the LMC group was significantly higher than the NMC group. In the LMC group, the natural conception rate within 12 menstrual cycles was lower (41.9% vs. 66.2%, p < .01), whereas the spontaneous abortion rate in early pregnancy (29.0% vs. 9.8%, p < .05) and the conversion rate (21.6% vs. 5.2%, p < .01) to anovulation within 12 cycles were significantly higher.

CONCLUSIONS

Women with unknown etiological menstrual cycle (36-45 days) with long follicular phase have greater endocrine abnormality and higher risk of spontaneous abortion, infertility, and conversion to anovulation. Moderate early intervention may be advisable for these women, especially those who wish to get pregnant.

Follicular fluid PlGF and IVF/ICSI outcomes among PCOS and normo-ovulatory women using different controlled hyperstimulation protocols: A prospective case-control study

Background

Gonadotropin-releasing hormone (GnRH) analogues are used to prevent premature luteinizing hormone (LH) surge during In-Vitro Fertilization. However, the follicular fluid levels of the Placental growth factor (FF PlGF), the novel angiogenic factor, differ significantly between GnRH-agonist and GnRH-antagonist protocols. Thus, we compared the IVF/ICSI outcomes and their correlations with FF PlGF levels in polycystic ovary syndrome (PCOS) and normo-ovulatory women during different hyperstimulation protocols.

Methods

This case-control study is a re-analysis of two prospective trials that were conducted on women who were referred to Orient Hospital, Damascus, Syria, from December 2019 to August 2021. A total of 75 PCOS-women (PCOS-Agonist, n = 53; PCOS-Antagonist, n = 22) and 83 normo-ovulatory women (Control-Agonist, n = 50; Control-Antagonist, n = 33) were included. Follicular fluid samples were collected on retrieval day.

Results

Although PCOS-women were stimulated using lower gonadotropin doses, the Ovarian-sensitivity-indexes were higher in PCOS-groups (PCOS-Agonist vs Control-Agonist; P-value <0.001), (PCOS-Antagonist vs Control-Antagonist; P-value = 0.042). However, FF PlGF levels, maturation rate, fertilization rate, and oocytes morphology were comparable between PCOS and controls independently of the protocol used. Interestingly, FF PlGF levels were positively correlated with Ovarian-sensitivity-indexes in the PCOS-Antagonist, Control-Agonist, and Control-Anta groups, but not in the PCOS-Agonist group. Nevertheless, FF PlGF levels were comparable between pregnant and non-pregnant women in all studied groups.

Conclusions

Although PCOS exaggerates ovarian response to stimulation irrespective of the protocol used, it does not have a detrimental impact on oocytes morphology or competence. Moreover, FF PlGF levels could be a marker of the ovarian response other than a predictor of pregnancy achievement.

The Impact of Culture Medium on Morphokinetics of Cleavage Stage Embryos: An Observational Study

To study the impact of culture media on preimplantation morphokinetics used for predicting clinical outcomes. All IVF and ICSI cycles performed between 2012 and 2017 with time-lapse information available were included. In November 2014, culture medium was changed from Vitrolife G-1 PLUS to SAGE 1-Step. Each embryo was retrospectively assigned a morphokinetic-based KIDScore for prediction of implantation. Clinical outcomes were retrieved from medical records. Linear mixed models were used to study differences in morphokinetic parameters, a proportional odds model for KIDScore ranking and logistic regression for differences in clinical outcomes. All analyses were adjusted for patient and treatment characteristics. In 253 (63.1%) cycles, embryos (n = 671) were cultured in Vitrolife, and in 148 (36.9%) cycles, embryos (n = 517) were cultured in SAGE. All cleavage divisions occurred earlier for SAGE embryos than for Vitrolife embryos (2-cell: -2.28 (95%CI: -3.66, -0.89), 3-cell: -2.34 (95%CI: -4.00, -0.64), 4-cell: -2.41 (95%CI: -4.11, -0.71), 5-cell: -2.54 (95%CI: -4.90, -0.18), 6-cell: -3.58 (95%CI: -6.08, -1.08), 7-cell: -5.62 (95%CI: -8.80, -2.45) and 8-cell: -5.32 (95%CI: -9.21, -1.42) hours, respectively). Significantly more embryos cultured in SAGE classified for the highest KIDScore compared to embryos cultured in Vitrolife (p < 0.001). No differences were observed in clinical outcomes. Our results demonstrate an impact of culture medium on preimplantation embryo developmental kinetics, which affects classification within the KIDScore algorithm, while pregnancy outcomes were comparable between the groups. This study underscores the need to include the type of culture medium in the development of morphokinetic-based embryo selection tools.

Long-term Hyperandrogenemia and/or Western-style Diet in Rhesus Macaque Females Impairs Preimplantation Embryogenesis

Hyperandrogenemia and obesity are common in women with polycystic ovary syndrome, but it is currently unclear how each alone or in combination contribute to reproductive dysfunction and female infertility. To distinguish the individual and combined effects of hyperandrogenemia and an obesogenic diet on ovarian function, prepubertal female rhesus macaques received a standard control (C) diet, testosterone (T) implants, an obesogenic Western-style diet (WSD), or both (T + WSD). After 5 to 6 years of treatment, the females underwent metabolic assessments and controlled ovarian stimulations. Follicular fluid (FF) was collected for steroid and cytokine analysis and the oocytes fertilized in vitro. Although the T + WSD females exhibited higher insulin resistance compared to the controls, there were no significant differences in metabolic parameters between treatments. Significantly higher concentrations of CXCL-10 were detected in the FF from the T group, but no significant differences in intrafollicular steroid levels were observed. Immunostaining of cleavage-stage embryos revealed multiple nuclear abnormalities in the T, WSD, and T + WSD groups. Single-cell DNA sequencing showed that while C embryos contained primarily euploid blastomeres, most cells in the other treatment groups were aneuploid. Despite yielding a higher number of mature oocytes, T + WSD treatment resulted in significantly reduced blastocyst formation rates compared to the T group. RNA sequencing analysis of individual blastocysts showed differential expression of genes involved in critical implantation processes between the C group and other treatments. Collectively, we show that long-term WSD consumption reduces the capacity of fertilized oocytes to develop into blastocysts and that the addition of T further impacts gene expression and embryogenesis.

Pathology of hyperandrogenemia in the oocyte of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common ovulatory disorder in the world and is associated with multiple adverse outcomes. The phenotype is widely varied, with several pathologies contributing to the spectrum of the disease including insulin resistance, obesity and hyperandrogenemia. Of these, the role of hyperandrogenemia and the mechanism by which it causes dysfunction remains poorly understood. Early studies have shown that androgens may affect the metabolic pathways of a cell, and this may pose hazards at the level of the mitochondria. As mitochondria are strictly maternally inherited, this would provide an exciting explanation not only to the pathophysiology of PCOS as a disease, but also to the inheritance pattern. This review seeks to summarize what is known about PCOS and associated adverse outcomes with focus on the role of hyperandrogenemia and specific emphasis on the oocyte.

Pronounced Trace Element Variation in Follicular Fluids of Subfertile Women Undergoing Assisted Reproduction

Female subfertility is a growing concern, especially in view of an increasing prevalence of polycystic ovary syndrome (PCOS). Assisted reproductive technologies (ART) offer a perspective for pregnancy, but the outcome rate is still suboptimal. The trace elements (TE), copper (Cu), selenium (Se), and zinc (Zn) are essential for fertility and development. We hypothesized that TE concentrations are related to oocyte quality and growth and affect pregnancy outcomes in women undergoing ART. Concentrations of TE were measured by total reflection X-ray fluorescence. Extracellular glutathione peroxidase 3 (GPX3) and selenoprotein P (SELENOP) were determined as additional Se biomarkers. Corresponding serum and follicular fluid (FF) samples were available from women with (n = 20) and without (n = 20) PCOS diagnosis undergoing hormone treatment within the ART procedure, respectively, and FF samples were classified into five groups based on morphological assessment. Serum showed higher TE concentrations than FF, and TE levels correlated positively between both matrices. Individual FF from the same women showed surprisingly high variability in TE concentration, and follicles without oocytes displayed the lowest TE concentrations. Both Se biomarkers GPX3 and SELENOP were present in FF and correlated positively to Se concentrations. Some notable relationships were observed between morphokinetic parameters, TE concentrations, and GPX3 activity. A slightly depressed serum Zn concentration was observed in PCOS. Our results indicate a direct relationship between TE in serum and FF, positive correlations between the three Se biomarkers in FF, and high variability between the FF from the same woman with the lowest TE concentrations in the follicles with the poorest quality. The differences observed in relation to PCOS diagnoses appear relatively minor. Collectively, the data support the notion that TE assessment of follicles may contribute to optimal oocyte selection and subsequently influence ART success.

The effect of curcumin on embryonic in vitro development in experimental polycystic ovary syndrome: An experimental study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common disease in women. Some plant compounds which have antioxidant properties, such as curcumin, may be useful for these patients when delivered orally or in vitro.

OBJECTIVE

The aim of this study was to evaluate the impact of PCOS on oocyte quality and the effect of curcumin on in vitro fertilization of oocytes.

MATERIALS AND METHODS

In this experimental study, Naval Medical Research Institute mice aged six to eight wk were used. Mice were divided into five experimental groups (control, experimental PCOS, curcumin 6, 12 and 24 μM). To induce experimental PCOS, estradiol valerate (100 mg/kg, IP) was injected. The total antioxidant capacity and production of malondialdehyde in ovarian tissue and blood serum were evaluated in all groups. Finally, 6, 12 and 24 μM of curcumin were added to the culture medium of the PCOS group oocytes and development in the different groups was evaluated.

RESULTS

A high percentage of oocytes for fertilization were not in good condition in terms of number and quality in the group of PCOS. The addition of curcumin to the embryo culture medium was associated with a higher percentage of fertilized oocytes, two-cells and blastocysts. This increase was significant at a concentration of 24 μM (p ≤ 0.01).

CONCLUSION

Given that adding curcumin seemed to improve fetal growth and prevent the harmful effects of oxygen free radicals on the culture medium, it is recommended to add a certain concentration of curcumin under normal conditions without oxidative stress.

Higher preconceptional maternal body mass index is associated with faster early preimplantation embryonic development: the Rotterdam periconception cohort

BACKGROUND

Overweight and obesity affect millions of people globally, which has also serious implications for reproduction. For example, treatment outcomes after in vitro fertilisation (IVF) are worse in women with a high body mass index (BMI). However, the impact of maternal BMI on embryo quality is inconclusive. Our main aim is to study associations between preconceptional maternal BMI and morphokinetic parameters of preimplantation embryos and predicted implantation potential. In addition, associations with clinical IVF outcomes are investigated.

METHODS

From a tertiary hospital, 268 women undergoing IVF or IVF with intracytoplasmic sperm injection (ICSI) were included; 143 normal weight, 79 overweight and 46 obese women. The embryos of these women were cultured in the EmbryoScope, a time-lapse incubator. The morphokinetic parameters of preimplantation embryos and predicted implantation potential, assessed by the KIDScore algorithm were longitudinally evaluated as primary and secondary outcomes, respectively. The tertiary outcomes included clinical outcomes, i.e., fertilization, implantation and live birth rate.

RESULTS

After adjustment for patient- and treatment-related factors, we demonstrated in 938 embryos that maternal BMI is negatively associated with the moment of pronuclear appearance (β_tPNa -0.070 h (95%CI -0.139, -0.001), p = 0.048), pronuclear fading (β_tPNf -0.091 h (95%CI -0.180, -0.003), p = 0.043 and the first cell cleavage (β_t2 -0.111 h (95%CI -0.205, -0.016), p = 0.022). Maternal BMI was not significantly associated with the KIDScore and tertiary clinical treatment outcomes. In embryos from couples with female or combined factor subfertility, the impact of maternal BMI was even larger (β_tPNf -0.170 h (95%CI -0.293, -0.047), p = 0.007; β_t2 -0.199 h (95%CI -0.330, -0.067), p = 0.003). Additionally, a detrimental impact of BMI per point increase was observed on the KIDScore (β -0.073 (se 0.028), p = 0.010).

CONCLUSIONS

Higher maternal BMI is associated with faster early preimplantation development. In couples with female or combined factor subfertility, a higher BMI is associated with a lower implantation potential as predicted by the KIDScore. Likely due to power issues, we did not observe an impact on clinical treatment outcomes. However, an effect of faster preimplantation development on post-implantation development is conceivable, especially since the impact of maternal BMI on pregnancy outcomes has been widely demonstrated.

Is fertility reduced in ovulatory women with polycystic ovary syndrome? An opinion paper

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility; however, whether women with PCOS and spontaneous or drug-induced ovulatory cycles have the same reproductive potential as non-PCOS controls is a matter of debate. In the present opinion paper, the author takes the opportunity to summarize the collective evidence supporting the hypothesis of reduced fertility potential in women with PCOS, regardless of ovulatory status, and speculate that reduced reproductive potential may be caused by altered oocytes, embryo and endometrial competence, and infertility-related co-morbidities as well as an increased risk of pregnancy complications.

Early pregnancy loss in patients with polycystic ovary syndrome after IVM versus standard ovarian stimulation for IVF/ICSI

STUDY QUESTION

Is the incidence of early pregnancy loss (EPL) in patients with polycystic ovary syndrome (PCOS) higher after IVM of oocytes than after ovarian stimulation (OS) for IVF/ICSI?

SUMMARY ANSWER

Women with PCOS who are pregnant after fresh embryo transfer have a higher probability of EPL following IVM, but after frozen embryo transfer (FET), no significant difference in the incidence of EPL was observed following IVM compared to OS.

WHAT IS KNOWN ALREADY

There is conflicting evidence in the current literature with regard to the risk of EPL after IVM of oocytes when compared with OS. Because of the limited sample size in previous studies, the use of different IVM systems and the possible bias introduced by patient characteristics and treatment type, firm conclusions cannot be drawn.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study evaluating 800 women, with a diagnosis of infertility and PCOS as defined by Rotterdam criteria, who had a first positive pregnancy test after fresh or FET following IVM or OS between January 2010 and December 2017 in a tertiary care academic medical centre.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pregnancies after non-hCG triggered IVM following a short course of highly purified human menopausal gonadotropin were compared with those after conventional OS. The primary outcome was EPL, defined as a spontaneous pregnancy loss before 10 weeks of gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 329 patients with a positive pregnancy test after IVM and 471 patients with a positive pregnancy test after OS were included. Women who were pregnant after IVM were younger (28.6 ± 3.4 years vs 29.3 ± 3.6 years, P = 0.005) and had higher serum anti-Mullerian hormone levels (11.5 ± 8.1 ng/ml vs 7.2 ± 4.1 ng/ml, P < 0.001) compared to those who were pregnant after OS. The distribution of PCOS phenotypes was significantly different among women in the IVM group compared to those in the OS group and women who were pregnant after OS had previously suffered EPL more often (28% vs 17.6%, P = 0.003). EPL was significantly higher after fresh embryo transfer following IVM compared to OS (57/122 (46.7%) vs 53/305 (17.4%), P < 0.001), while the results were comparable after FET (63/207 (30.4%) vs 60/166 (36.1%), respectively, P = 0.24). In the multivariate logistic regression analysis evaluating fresh embryo transfer cycles, IVM was the only independent factor (adjusted odds ratio (aOR) 4.24, 95% CI 2.44-7.37, P < 0.001)) significantly associated with increased odds of EPL. On the other hand, when the same model was applied to FET cycles, the type of treatment (IVM vs OS) was not significantly associated with EPL (aOR 0.73, 95% CI 0.43-1.25, P = 0.25).

LIMITATIONS, REASONS FOR CAUTION

The current data are limited by the retrospective nature of the study and the potential of bias due to unmeasured confounders.

WIDER IMPLICATIONS OF THE FINDINGS

The increased risk of EPL after fresh embryo transfer following IVM may point towards inadequate endometrial development in IVM cycles. Adopting a freeze-all strategy after IVM seems more appropriate. Future studies are needed to ascertain the underlying cause of this observation.

STUDY FUNDING/COMPETING INTEREST(S)

The Clinical IVM research has been supported by research grants from Cook Medical and Besins Healthcare. All authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Notch signaling pathway in cumulus cells reflecting zygote and embryo quality in polycystic ovary syndrome

PURPOSE

The present study aimed to explore the associations between the expression pattern of molecules in the Notch pathway in the cumulus cells of polycystic ovary syndrome (PCOS) patients and the quality of zygotes and embryos.

METHODS

A total of 200 cumulus complexes surrounding mature oocytes were obtained from 40 patients with and without PCOS undergoing intracytoplasmic sperm injection (ICSI). The expressions of Notch-1, Notch-2, and Notch-3 genes were examined by Reverse Transcription Q-PCR assay. Moreover, immunocytochemistry was performed for the expressions of Jagged-1 and Jagged-2 proteins. The correlations between the Notch receptors and their ligand expressions and the qualities of the zygote and embryo were investigated.

RESULTS

The expression levels of Notch-2, Notch-3, Jagged-1, and Jagged-2 were significantly lower in patients with PCOS than in normal women (p < 0.05), while Notch-1 showed no meaningful difference between the groups. A positive correlation was found between Notch-1 and embryo quality. Furthermore, only Notch-2 and Jagged-2 marginally correlated with zygote quality.

CONCLUSION

The data of the present study indicated that evaluating the molecules in the Notch pathway in PCOS patients' cumulus cells provides a novel approach to predict the zygote and embryo quality. However, further studies on a larger population are needed to validate this finding.

Comparison of single euploid blastocyst transfer cycle outcome derived from embryos with normal or abnormal cleavage patterns

RESEARCH QUESTION

To assess incidence of abnormal cleavage among biopsied blastocysts; to compare euploidy rates of the blastocysts with abnormal and normal cleavage; and to compare single euploid blastocyst transfer (SEBT) outcome derived from embryos with normal or abnormal cleavage.

DESIGN

Retrospective analysis of prospectively collected data in a private IVF clinic. Consecutive 554 patients (749 cycles) undergoing preimplantation genetic testing for aneuploidy (n = 497; 671 cycles) or monogenic diseases (n = 57; 78 cycles) were included. All assessments for abnormal cleavage were carried out retrospectively; presence of abnormal cleavage was not a factor in deciding which euploid embryo to transfer. A total of 1015 blastocysts were biopsied and 295 SEBT procedures were carried out. Main outcome measure was live birth rate (LBR).

RESULTS

Incidence of reverse cleavage, direct cleavage, and reverse plus direct cleavage, were 7.7%, 6.4% and 2.3%, respectively. Of the 1015 biopsied blastocysts, 35.0% were euploid. Blastocysts with abnormal cleavage, in total, had a significantly higher euploidy rate compared with blastocysts with normal cleavage (44.6% [74/166] versus 33.1% [281/849]; P = 0.017). The LBR after SEBT with normal, reverse and direct cleavage, and direct cleavage plus reverse cleavage, was 133/238 (55.9%), 6/26 (23.1%), 8/24 (33.3%) and 0/3 (0.0%) (P < 0.001). Generalized estimating equation analysis showed that the presence of abnormal cleavage pattern was the only independent predictor of LBR (OR 0.316; 95% CI 0.115 to 0.867; P = 0.013).

CONCLUSIONS

Blastocysts with direct or reverse cleavage should be biopsied in preimplantation genetic testing cycles if they are morphologically eligible. Euploid blastocysts with abnormal cleavage, however, have approximately half the LBR of those euploid blastocyst with normal cleavage, hence, blastocysts with abnormal cleavage should have lower priority for transfer.

Fetal growth, fetal development, and placental features in women with polycystic ovary syndrome: analysis based on fetal and placental magnetic resonance imaging

OBJECTIVE

Polycystic ovary syndrome (PCOS), a common endocrine-metabolic dysfunction in reproductive-aged women, may be involved in compromised pregnancy and offspring outcomes. This study aimed to investigate whether maternal PCOS affects fetal growth, fetal development, and placental features.

METHODS

This retrospective case-control study included 60 pregnant women with PCOS (PCOS group) and 120 healthy pregnant women without PCOS (control group). Fetal magnetic resonance imaging (MRI) was performed followed by an ultrasound examination and indications for imaging, including known or suspected fetal pathology, history of fetal abnormality in previous pregnancy or in a family member, and concern for placenta accreta. Fetal MRI images were analyzed for head circumference (HC), abdomen circumference (AC), lung-to-liver signal intensity ratio (LLSIR, a prenatal marker of fetal lung maturity), lengths of liver and kidney diameters in fetuses, and placental relative signal intensity on T2-weighted single-shot fast spin echo (SSFSE) imaging (rSISSFSE), and placental relative apparent diffusion coefficient value (rADC). Data on height and weight of offspring were collected through telephone follow-up.

RESULTS

Compared to the control group, the PCOS group showed the following characteristics: (1) smaller biparietal diameter and femur length in fetuses (P=0.026 and P=0.005, respectively), (2) smaller HC in fetuses (evident after 32 weeks; P=0.044), (3) lower LLSIR and smaller dorsoventral length of liver in fetuses (evident before 32 weeks; P=0.005 and P=0.019, respectively), and (4) smaller placental thickness (evident before 32 weeks; P=0.017). No significant differences in placental rSISSFSE or rADC were observed between the groups (all P>0.05). No significant differences in height and weight of offspring during childhood existed between the groups (all P>0.05).

CONCLUSIONS

There exist alterations of fetal growth, fetal development, and placental features from women with PCOS.

Effect of a Combination of Myo-Inositol, Alpha-Lipoic Acid, and Folic Acid on Oocyte Morphology and Embryo Morphokinetics in non-PCOS Overweight/Obese Patients Undergoing IVF: A Pilot, Prospective, Randomized Study

Herein we aimed at assessing whether Myo-Inositol (MI), Alpha–Lipoic acid (ALA), and Folic acid (FA) could improve oocyte quality and embryo development in non-PCOS overweight/obese women undergoing IVF. Three hundred and twenty-four mature oocytes were obtained from non-PCOS overweight/obese patients, randomized to receive either MI, ALA, and FA (MI + ALA + FA group, n = 155 oocytes) or FA alone (FA-only group, n = 169 oocytes). Oocytes were examined using Polarized Light Microscopy to assess morphological features of zona pellucida (ZP) and meiotic spindle (MS). One hundred and seventy-six embryos (n = 84 in the MI + ALA + FA group, n = 92 in the FA-only group) were assessed by conventional morphology on days 2 and 5, as well as using the Time-Lapse System morphokinetic analysis. A significantly higher ZP retardance, area, and thickness (p < 0.05), and a shorter MS axis (p < 0.05) were observed in the MI + ALA + FA group, suggesting a positive effect on oocyte quality. Conventional morphology evaluation on day 2 showed a higher mean embryo score in the MI + ALA + FA group, whereas embryo morphokinetic was comparable in the two groups. Overall, our data show a possible beneficial effect of the combination of MI, ALA, and FA on oocyte and embryo morphology, encouraging testing of this combination in adequately powered randomized trials to assess their impact of clinical IVF results.

Embryos from polycystic ovary syndrome patients with hyperandrogenemia reach morula stage faster than controls

Objective

To investigate if patients with polycystic ovary syndrome (PCOS) have altered embryo morphokinetics when compared with controls.

Design

Retrospective cohort analysis.

Setting

Single academic fertility clinic in a tertiary hospital setting.

Patients

Age- and body mass index-matched patients who underwent in vitro fertilization diagnosed with PCOS using the Rotterdam criteria. A subanalysis was performed on patients with PCOS with hyperandrogenemia. Sixty-four patients with PCOS were identified with 990 embryos that were matched with 64 control patients with 628 embryos.

Interventions

None.

Main Outcome Measures

Time to blastulation.

Results

Embryos from women with PCOS displayed faster growth rate at t7, t8, and t9; all other morphokinetic points were similar. Patients with PCOS also had a higher number of oocytes retrieved. No differences were seen in the fertilization rate or blastulation rate. Patients with PCOS had a higher miscarriage rate (38.1% in PCOS vs. 18.8% in controls). Patients with hyperandrogenic PCOS showed a faster growth rate at t5, t6, t7, t8, t9, and morula.

Conclusions

Embryos from women with PCOS grew faster until 9-cell stage and women with hyperandrogenic PCOS until morula. Patients with PCOS also showed a higher miscarriage rate. The alterations in early embryo development are consistent with altered fertility and obstetric outcomes in the population with PCOS and may be due to the hyperandrogenic microenvironment in the ovarian follicle.

Can novel early non-invasive biomarkers of embryo quality be identified with time-lapse imaging to predict live birth?

STUDY QUESTION

Can time-lapse imaging systems make it possible to identify novel early non-invasive biomarkers to predict live birth?

SUMMARY ANSWER

From mostly high-grade embryos, out of 35 morphometric, morphologic and morphokinetic variables, only pronuclei (PN) position at time of PN juxtaposition and the absence of multinucleated blastomeres at the 2-cell stage (MNB2cell), were potentially associated with live birth.

WHAT IS KNOWN ALREADY

Previous studies indicate that some kinetic markers may be predictive of blastocyst development and embryonic implantation. Certain teams have suggested including some of them in decisional algorithms for embryo transfers.

STUDY DESIGN, SIZE, DURATION

Using a time-lapse incubator (EmbryoScope, Unisense FertiliTech), we retrospectively explored the associations between the morphometric, morphologic and morphokinetic parameters of oocytes, zygotes and embryos, and their associations with live birth. This study assessed 232 embryos from single embryo transfers after ICSI cycles performed between January 2014 and December 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The morphometric, morphologic and morphokinetic parameters (18, 4 and 13, respectively) of oocytes, zygotes and early embryos were studied retrospectively. The associations between these parameters were examined using a Spearman's correlation, Mann-Whitney or chi-squared test as appropriate. We examined whether these parameters were associated with outcomes in univariate and multivariate logistic regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

Central PN juxtaposition was associated with a 2-fold increase in the odds of live birth (OR = 2.20; 95% CI, [1.26-3.89]; P = 0.006), while the presence of MNB2cell was associated with half the odds of live birth (OR = 0.51; 95% CI, [0.27-0.95]; P = 0.035). These two parameters were independent of embryo kinetics. The 33 remaining parameters had no significant association with the capacity of transferred embryos to develop to term.

LIMITATIONS, REASONS FOR CAUTION

Even though the population size was relatively small, our analyses were based on homogeneous cycles, i.e. young women whose transferred embryos were found to be high-grade according to conventional morphology evaluation. In addition, our conclusions were established from a specific, highly selected population, so other study populations, such as women in an older age bracket, may yield different results. Finally, because we assessed day 2/3 transfers, our findings cannot be generalized to embryos cultured up to the blastocyst stage.

WIDER IMPLICATIONS OF THE FINDINGS

It would be interesting to explore, prospectively, whether PN localisation is a relevant measure to predict embryo development when added into further algorithms and whether this parameter could be suitable for use in other IVF clinics. Further studies are needed, notably to explore the added value of timing evaluation in cohorts of embryos with low or intermediate morphology grade, as well as in other maternal populations (i.e. older women).

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. P. Sagot received funding from the following commercial companies: Merck Serono, Finox Biotech, Ferring, MSD France SAS, Teva Sante ́ SAS, Allergan France, Gedeon Richter France, Effik S.A., Karl Storz Endoscopie France, GE Medical Systems SCS, Laboratoires Genevrier, H.A.C. Pharma and Ipsen.All the authors confirm that none of this funding was used to support the research in this study. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the journal policies on sharing data and materials.

Association between mild stimulated IVF/M cycle and early embryo arrest in sub fertile women with/without PCOS

BACKGROUND

The in vitro maturation (IVM) technique has physical and financial benefits, but a lower efficiency and outcome that is still unclear whether it is related to polycystic ovary syndrome (PCOS) itself or the IVM procedure. In this study, we analyzed the clinical and laboratory outcomes of an optimized IVM protocol in patients with and without PCOS. We also discussed the possible reasons for early embryo arrest in the IVM cycle.

METHODS

This prospective study involved 58 PCOS patients and 56 non-PCOS patients who underwent mild stimulated IVF combined IVM (IVF/M) cycles. The clinical and laboratory outcomes were compared between the two groups. Also, metaphase II (MII) oocytes were obtained after IVM from the two groups, and in vivo MII oocytes randomly collected from IVF patients were examined for mitochondrial function using a laser scanning confocal microscope (LSCM). The aneuploidy rate for arrested cleavage embryos from IVM and IVF oocytes were screened using Next Generation Sequencing (NGS).

RESULTS

Mildly stimulated IVF/M resulted in cumulative clinical pregnancy and implantation rates (40.2, 28.7% in the PCOS group vs. 41.9, 36% in the non-PCOS group), respectively. The blastocyst formation rates were comparable (28% vs. 28.2%) in PCOS and non-PCOS groups, respectively. Using LSCM, there was a significant decrease in the mitochondrial membrane potential of IVM oocytes compared with the control IVF oocytes (P < 0.001), but no significant difference between the PCOS and non-PCOS groups. The NGS showed that the aneuploidy rates were comparable (75, 75, and 66.6%) in IVM-PCOS, IVM-non-PCOS, and control IVF arrested embryos, respectively.

CONCLUSIONS

The mildly stimulated IVF/M protocol produced acceptable clinical outcomes in PCOS and non-PCOS patients. IVM itself rather than the PCOS condition adversely affected the embryo development through its effect on mitochondrial function, which appeared to be a possible cause for the embryo arrest in the IVM cycles rather than chromosomal aneuploidy.

Preconceptional Maternal Vegetable Intake and Paternal Smoking Are Associated with Pre-implantation Embryo Quality

Inadequate nutrition and lifestyle behaviors, particularly during the periconception period, are associated with a negative impact on embryonic and subsequent fetal development. We investigated the associations between parental nutritional and lifestyle factors and pre-implantation embryo development. A total of 113 women and 41 partners, with a corresponding 490 embryos, who underwent intracytoplasmic sperm injection (ICSI) treatment subscribed to the mHealth coaching platform "Smarter Pregnancy." At baseline, nutrition and lifestyle behaviors (intake of fruits, vegetables, folic acid, and smoking and alcohol use) were identified and risk scores were calculated. A lower risk score represents healthier behavior. As outcome measure, a time-lapse morphokinetic selection algorithm (KIDScore) was used to rank pre-implantation embryo quality on a scale from 1 (poor) to 5 (good) after being cultured in the Embryoscope™ time-lapse incubator until embryonic day 3. To study the association between the nutritional and lifestyle risk scores and the KIDScore in men and women, we used a proportional odds model. In women, the dietary risk score (DRS), a combination of the risk score of fruits, vegetables, and folic acid, was negatively associated with the KIDScore (OR 0.86 (95% CI 0.76 to 0.98), p = 0.02). This could mainly be attributed to an inadequate vegetable intake (OR 0.76 (95% CI 0.59 to 0.96), p = 0.02). In men, smoking was negatively associated with the KIDscore (OR 0.53 (95% CI 0.33 to 0.85), p < 0.01). We conclude that inadequate periconceptional maternal vegetable intake and paternal smoking significantly reduce the implantation potential of embryos after ICSI treatment. Identifying modifiable lifestyle risk factors can contribute to directed, personalized, and individual recommendations that can potentially increase the chance of a healthy pregnancy.

Between-laboratory reproducibility of time-lapse embryo selection using qualitative and quantitative parameters: a systematic review and meta-analysis

PURPOSE

To investigate the between-laboratory reproducibility of embryo selection/deselection effectiveness using qualitative and quantitative time-lapse parameters.

METHODS

A systematic search was performed on MEDLINE, EMBASE, and the Cochrane Library (up to February 2020) without restriction on date, language, document type, and publication status. Measuring outcomes included implantation, blastulation, good-quality blastocyst formation, and euploid blastocyst.

RESULTS

We detected 6 retrospective cohort studies externally validating the first clinical time-lapse model (Meseguer) emphasizing quantitative parameters, of which 3 (including one involving 2 independent centers) were included for the pooled analysis. Receiver operating characteristics analysis showed reduced predictive power of the model when either including or not including sister clinic validation. Fifteen cohort studies evaluating qualitative parameters were included for meta-analysis, and the mean Newcastle-Ottawa Scale was 5.3. Overall, meta-analysis showed significantly adverse association between the presence of ≥ 1 cleavage abnormalities and embryo implantation rates (11 studies, n = 7266; RR = 0.39[0.28, 0.55]_{95% CI}; I² = 57%). Further analysis showed adverse impacts of direct cleavage (7 studies, n = 7065; RR = 0.28 [0.15, 0.54] _{95% CI}; I² = 46%), reverse cleavage (2 studies, n = 3622; RR = 0.16 [0.03, 0.75] _{95% CI}; I² = 0%), chaotic cleavage (2 studies, n = 3643; RR = 0.11 [0.02, 0.69] _{95% CI}; I² = 24%), and multinucleation (5 studies, n = 2576; RR = 0.59 [0.50, 0.69] _{95% CI}; I² = 0%), but not the < 6 intercellular contact points at the 4-cell stage (1 study, n = 185; RR = 0.17 [0.02, 1.15] _{95% CI}).

CONCLUSIONS

Qualitative time-lapse parameters are reliably associated with embryo developmental potential among laboratories, whereas the reproducibility of time-lapse embryo selection model that emphasizes quantitative parameters may be compromised when externally applied.

Intraindividual Embryo Morphokinetics Are Not Affected by a Switch of the Ovarian Stimulation Protocol Between GnRH Agonist vs. Antagonist Regimens in Consecutive Cycles

Background: The impact of controlled ovarian stimulation (COS) during medically assisted reproduction (MAR) on human embryogenesis is still unclear. Therefore, we investigated if early embryonic development is affected by the type of gonadotropin-releasing hormone (GnRH) analog used to prevent a premature LH surge. We compared embryo morphology and morphokinetics between GnRH agonist and antagonist cycles, both involving human chorionic gonadotropin (hCG)-trigger. To reduce possible confounding factors, we used intraindividual comparison of embryo morphokinetics in consecutive treatment cycles of the same patients that underwent a switch in the COS protocol. Methods: This retrospective cohort study analyzed morphokinetics of embryos from patients (n = 49) undergoing a switch in COS protocols between GnRH agonists followed by GnRH antagonists, or vice versa, after culture in a time-lapse incubator (EmbryoScope®, Vitrolife) in our clinic between 06/2011 and 11/2016 (n = 49 GnRH agonist cycles with n = 172 embryos; n = 49 GnRH antagonist cycles with n = 163 embryos). Among time-lapse cycles we included all embryos of the two consecutive cycles before and after a switch in the type of COS in the same patient. In-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) was performed and embryos were imaged up to day 5. Data were analyzed using Mann-Whitney U test or Fisher's exact test. The significance level was set to p = 0.05. Patients with preimplantation genetic screening cycles were excluded. Results: The mean age (years ± standard deviation) of patients at the time of treatment was 35.7 ± 4.3 (GnRH agonist) and 35.8 ± 4.0 (GnRH antagonist) (p = 0.94). There was no statistically significant difference in the number of oocytes collected or the fertilization rate. The numbers of top quality embryos (TQE), good-quality embryos (GQE), or poor-quality embryos (PQE) were also not different in GnRH agonist vs. antagonist cycles. We found no statistically significant difference between the analyzed morphokinetic parameters between the study groups. Conclusions: Our finding supports the flexible use of GnRH analogs to optimize patient treatment for COS without affecting embryo morphokinetics.

How do elevated levels of testosterone affect the function of the human fallopian tube and fertility?-New insights

Excess testosterone levels affect up to 20% of the female population worldwide and are a key component in the pathogenesis of polycystic ovary syndrome. However, little is known about how excess testosterone affects the function of the human fallopian tube-the site of gamete transport, fertilization, and early embryogenesis. Therefore, this study aimed to characterize alterations caused by long-term exposure to male testosterone levels. For this purpose, the Fallopian tubes of nine female-to-male transsexuals, who had been undergoing testosterone treatment for 1-3 years, were compared with the tubes of 19 cycling patients. In the ampulla, testosterone treatment resulted in extensive luminal accumulations of secretions and cell debris which caused ciliary clumping and luminal blockage. Additionally, the percentage of ciliated cells in the ampulla was significantly increased. Transsexual patients, who had had sexual intercourse before surgery, showed spermatozoa trapped in mucus. Finally, in the isthmus complete luminal collapse occurred. Our results imply that fertility in women with elevated levels of testosterone is altered by tubal luminal obstruction resulting in impaired gamete transport and survival.

Hyperandrogenism and Metabolic Syndrome Are Associated With Changes in Serum-Derived microRNAs in Women With Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) remains one of the most common endocrine disorder in premenopausal women with an unfavorable metabolic risk profile. Here, we investigate whether biochemical hyperandrogenism, represented by elevated serum free testosterone, resulted in an aberrant circulating microRNA (miRNAs) expression profile and whether miRNAs can identify those PCOS women with metabolic syndrome (MetS). Accordingly, we measured serum levels of miRNAs as well as biochemical markers related to MetS in a case-control study of 42 PCOS patients and 20 Controls. Patients were diagnosed based on the Rotterdam consensus criteria and stratified based on serum free testosterone levels (≥0.034 nmol/l) into either a normoandrogenic (n = 23) or hyperandrogenic (n = 19) PCOS group. Overall, hyperandrogenic PCOS women were more insulin resistant compared to normoandrogenic PCOS women and had a higher prevalence of MetS. A total of 750 different miRNAs were analyzed using TaqMan Low-Density Arrays. Altered levels of seven miRNAs (miR-485-3p, -1290, -21-3p, -139-3p, -361-5p, -572, and -143-3p) were observed in PCOS patients when compared with healthy Controls. Stratification of PCOS women revealed that 20 miRNAs were differentially expressed between the three groups. Elevated serum free testosterone levels, adjusted for age and BMI, were significantly associated with five miRNAs (miR-1290, -20a-5p, -139-3p, -433-3p, and -361-5p). Using binary logistic regression and receiver operating characteristic curves (ROC), a combination panel of three miRNAs (miR-361-5p, -1225-3p, and -34-3p) could correctly identify all of the MetS cases within the PCOS group. This study is the first to report comprehensive miRNA profiling in different subgroups of PCOS women with respect to MetS and suggests that circulating miRNAs might be useful as diagnostic biomarkers of MetS for a different subset of PCOS.

Endometriosis accelerates synchronization of early embryo cell divisions but does not change morphokinetic dynamics in endometriosis patients

OBJECTIVE

The pathology of endometriosis and its impact on embryo development is still a black box in reproductive medicine. In this time-lapse study we investigated the influence of endometriosis on morphokinetic parameters of embryo development, taking variables of dynamic monitoring into account. Furthermore we evaluated reproductive medicine treatment outcome such as fetal heartbeat and live birth rate.

METHODS

1148 embryos (control: n = 596, endometriosis: n = 552) were retrospectively analyzed. Patients were stimulated with GnRH antagonist protocol. After fertilization, embryos were incubated in a time-lapse system (EmbryoScope).

RESULTS

The mixed-model analysis revealed a significant main effect of time (p<0.001), with post-hoc tests showing that any time needed to reach a specific developmental stage was significantly different from all the others (all p<0.001). Embryos of endometriosis patients showed the same absolute morphokinetic time parameters as the control group, however, synchronization of early embryo cell divisions (s2) was faster in endometriosis patients compared to the control group.

CONCLUSION

In general, endometriosis does not induce changes in early embryo morphokinetics. However, observed acceleration in cell cycle synchronization of embryo cleavage patterns might be a missing explanation for contradicting results in literature regarding the impairments in reproductive medicine treatment outcome of endometriosis patients.

[Polycystic ovary syndrome does not affect blastulation nor cumulative live birth rates]

OBJECTIVES

Polycystic ovarian syndrome (PCOS) brings complications in the management of the assisted reproductive technology (ART) because of an oocyte quality probably impaired due to modifications of intra- and extra-ovarian factors. Our study aimed to investigate the extended culture in PCOS patients and its influence on the cumulative live birth rates.

METHODS

Fifty-nine PCOS patients (as defined by the Rotterdam criteria) and 114 normo-ovulatory patients (i.e. with tubal, male or idiopathic infertility, regular cycles and AMH>2ng/mL) aged<37years old who underwent a 1st or 2nd ART attempt with extended culture to day 6 were included from October 2015 to December 2017. The blastulation and cumulative live birth rates were compared between the two groups.

RESULTS

The PCOS and control patients were 32.22 and 32.91years old respectively (P=0.05). The median number of oocytes retrieved was significantly higher in the PCOS group and the median oocyte maturity rate significantly lower compared with controls. The blastulation rates were similar between the PCOS and the control groups, respectively 57.8% vs. 58.6%, P=0.88. Because of the risks of hyperstimulation syndrome, a freeze all strategy was achieved for 38.9% of PCOS patients vs. 14.0% of the control patients (P<0.01). The cumulative live birth rates were not statistically different: 31.7% in the PCOS group vs. 37.2% in the control group, P=0.50.

CONCLUSIONS

PCOS was not observed to affect the extended culture nor the cumulative live birth rates in comparison to normo-ovulatory patients, supporting the blastocyst transfer strategy as a suitable option to PCOS patients.

Does polycystic ovary syndrome affect morphokinetics or abnormalities in early embryonic development?

OBJECTIVES

This study aimed to investigate whether oocyte retrieval from PCOS patients affects the morphokinetics or the incidence of abnormalities in early embryonic development, using time-lapse imaging analysis.

METHODS

This was a prospective study in total of 39 PCOS patients and 67 women with normal ovarian function, underwent a GnRH antagonist protocol of controlled ovarian stimulation and fertilization by ICSI. 402 zygotes from the PCOS group and 449 zygotes from the control group were observed by time-lapse monitoring for 48 h following sperm injection.

RESULTS

Patients with PCOS showed a significantly higher number of retrieved oocytes, and a significantly higher number of metaphase II oocytes per cycle than that of the non-PCOS group (18.85 ± 9.41 vs. 11.48 ± 5.51 and 14.97 ± 7.43 vs. 9.51 ± 4.7, respectively). However, oocyte maturation rate and morphologically assessed embryo quality did not differ between two groups. After 48 h of the embryo culture using time-lapse video recording, most of the embryos in both groups had reached the 4-cell stage (353/449 vs. 314/402 embryos). There were no significant differences between the control and PCOS group regarding the time-points of the successive events in early embryonic development from the appearance of 2 polar bodies to the 6-cell stage. However, the percentage of t2 stages which fell in "optimal range" (>24 h and ≤28 h) was significantly lower in the PCOS group than in the control group (37.8% vs. 48.1%, P = 0.004). The proportion of embryos manifesting abnormal fertility, multinucleation, direct cleavage and reverse cleavage were not significantly different between the two groups.

CONCLUSION

Our data indicated that PCOS does not affect the morphokinetics or incidence of abnormalities in early embryonic development.

Time-lapse videography for embryo selection/de-selection: a bright future or fading star?

The recent clinical introduction of time-lapse videography into in vitro fertilization laboratories has offered a novel opportunity for embryologists to explore improved methods for embryo selection. While the concept of uninterrupted culture of embryos provided by such systems is welcomed, the current evidence does not support its full application in routine clinical practice. The issue of whether or not algorithms for embryo selection can be extrapolated between laboratories, which may represent a major hurdle to its wide application, is currently gaining increasing attention amongst embryologists worldwide. In this commentary issues identified in time-lapse embryo selection/de-selection algorithms, such as quantitative versus qualitative parameters, are discussed alongside the reference start point for the timing system, and types of datasets used for developing and validating time-lapse algorithms. Considering these factors, alternative future research directions which could potentially solve current issues are proposed.

Establishing an Anti-Müllerian Hormone Cutoff for Diagnosis of Polycystic Ovarian Syndrome in Women of Reproductive Age-Bearing Indian Ethnicity Using the Automated Anti-Müllerian Hormone Assay

Context:

Polycystic ovary syndrome diagnosed by Rotterdam criteria, is the most common cause of anovulatory infertility. The criteria of polycystic ovarian morphology (PCOM) are subject to operator variability and technological advances. Serum anti-Müllerian hormone (AMH) level has been proposed as a more reliable alternative to antral follicle count. There is a paucity of data on use of AMH for diagnosis of PCOS in Indian women.

Aim and Objectives:

The aim of this study is to determine a cutoff level for AMH that could facilitate diagnosis of PCOS and its phenotypes in women of Indian origin using the automated (Roche) assay and to compare the competence of oocytes in PCOS and non-PCOS women undergoing in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI).

Materials and Methodology:

A total of 367 women undergoing treatment at our fertility center between February 2017 and August 2017 were prospectively enrolled in this study. Of these, 133 were diagnosed with PCOS, 69 had isolated PCOM, and 165 (controls) had normal ovaries on ultrasound examination. Serum AMH levels were assessed using the fully automated Roche Elecsys^® immunoassay. Gonadotropin-releasing hormone antagonist protocol was used for IVF-ICSI in all patients.

Statistical Analysis Used:

Quantitative variables were compared using the Mann–Whitney test. Qualitative variables were correlated using the Chi-square test. P < 0.05 was considered to be statistically significant.

Results:

Mean AMH concentrations in women with PCOS was higher (7.56 ± 4.36 ng/mL) in comparison to PCOM and controls. Serum AMH concentration >5.03 ng/mL could facilitate diagnosis of PCOS (area under the curve = 0.826); sensitivity –70.68%, specificity of 79.91%. There was no difference in the ratio of mature to total oocytes retrieved in the three groups (P > 0.05). Mean number of mature oocytes was lower in controls than PCOS and PCOM (P < 0.001).

Conclusions:

Serum AMH concentration >5.03 ng/mL could be used as cutoff value for the diagnosis of PCOS in women of Indian origin.

Association between early embryo morphokinetics plus cumulus cell gene expression and assisted reproduction outcomes in polycystic ovary syndrome women

RESEARCH QUESTION

Can a combination of time-lapse morphokinetic parameters and cumulus cell gene expression in polycystic ovary syndrome (PCOS) women be used to predict assisted reproductive treatment outcome?

DESIGN

A total of 547 embryos from 100 intracytoplasmic sperm injection (ICSI) cycles were evaluated. Fifty women with PCOS and 50 women who were categorized as tubal factor infertility were recruited. Time-lapse records were annotated for time to pronuclear fading (tPNf), time to 2 to 8 cells (t2-t8), reverse cleavage, direct cleavage and also for the presence of multinucleation. Expression levels of three genes involved in mitotic divisions, diaphanous-related formin 2 (DIAPH2), nibrin (NBN) and NIMA-related protein kinase (NEK4), were measured in 100 associated cumulus cell samples using quantitative real-time polymerase chain reaction.

RESULTS

Expression of DIAPH2 and NBN was significantly higher in the embryos of PCOS patients that resulted in implantation, biochemical and clinical pregnancies as well as live birth compared with embryos that were negative for these outcomes (P <0.01). However, in the tubal factor group, NBN gene expression was significantly higher in embryos resulting in biochemical pregnancy, clinical pregnancy and live birth (P <0.01) only. Multivariate logistic regression analysis showed that tPNf together with DIAPH2 gene expression were independent prognostic factors of clinical pregnancy rate and live birth in both groups.

CONCLUSIONS

Some time-lapse embryo parameters may be related to cumulus gene expression and clinical outcome. Furthermore, the expressions of cumulus cell genes involved in mitotic divisions are significantly associated with ICSI outcome using Day 3 embryo transfer.

Assessing ICSI outcome by combining non-invasive indicators: Early time-lapse morphokinetics and apoptosis in associated cumulus cells among women with the polycystic ovarian syndrome

Cumulus cells features and embryo developmental events can be considered as noninvasive indicators for embryo selection and clinical outcomes. A combination of time-lapse morphokinetic parameters and cumulus cell apoptosis in women with polycystic ovarian syndrome (PCOS) was evaluated for predicting pregnancy outcome. We assessed a total of 547 embryos from 100 intracytoplasmic sperm injection (ICSI) cycles. Time-lapse records were interpreted in time to pronuclear fading (tPNf), time to 2 to 8 cells (t2-t8), direct cleavage, reverse cleavage, and also for the presence of multinucleation. Percentages of apoptosis were identified in 100 associated cumulus cell samples using the TDT-mediated dUTP-biotin nick end-labeling assay. The significant decrease of apoptotic cumulus cells was detected in patients with chemical and clinical pregnancies as well as live birth among patients PCOS and in the tubal infertility group (p > 0.05). Furthermore, significantly higher implantation rate and also significantly lower cases of early pregnancy loss were observed in the group of oocytes with less apoptotic cumulus cells. Multivariate logistic regression analysis showed that tPNf together with cumulus cell apoptosis were independent prognostic factors of chemical pregnancy, clinical pregnancy rate, and live birth. Time-lapse embryo parameters may not reflect the cumulus cell apoptosis rate. However, the rate of apoptotic cumulus cells is significantly associated with ICSI outcome using Day 3 embryo transfer.

Transcriptome analysis of PCOS arrested 2-cell embryos

In an attempt to explore the early developmental arrest in embryos from polycystic ovarian syndrome (PCOS) patients, we sequenced the transcriptome profiles of PCOS arrested 2-cell embryos, non-PCOS arrested 2-cell embryos and non-arrested 2-cell embryos using single-cell RNA-Seq technique. Differential expression analysis was performed using the DEGSeq R package. Gene Ontology (GO) enrichment was analyzed using the GOseq R package. Data revealed 62 differentially expressed genes between non-PCOS arrested and PCOS arrested embryos and 2217 differentially expressed genes between PCOS arrested and non-arrested 2-cell embryos. A total of 49 differently expressed genes (DEGs) were annotated with GO terms in the up-regulated genes between PCOS arrested and non-PCOS arrested embryos after GO enrichment. A total of 29 DEGs were annotated with GO terms in the down-regulated genes between PCOS arrested and non-arrested 2-cell embryos after GO enrichment. These data can provide a reference for screening specific genes involved in the arrest of PCOS embryos.

Impact of polar body biopsy on embryo morphokinetics-back to the roots in preimplantation genetic testing?

Purpose

Polar body biopsy (PBB) is a common technique in preimplantation genetic testing (PGT) to assess the chromosomal status of the oocyte. Numerous studies have been implemented to investigate the impact of biopsies on embryo development; however, information on embryo morphokinetics is still lacking. Hence, we investigated the impact of PBB on morphokinetic parameters in early embryo development.

Methods

Four hundred four embryos (202 PBB, 202 control) were retrospectively analyzed. Patients were stimulated with a gonadotropin-releasing hormone antagonist ovarian hyperstimulation protocol. After fertilization check, embryos were incubated in a time-lapse incubator. The groups were matched for maternal age at time of oocyte retrieval.

Results

Mean group times for reaching specific developmental time points showed no significant difference comparing embryos with PBB conducted and without. Likewise, further subdivision of the PBB group in euploid and aneuploid embryos revealed no differences in the early embryo morphokinetic development compared to the control group. Aneuploidy testing revealed a high prevalence of chromosomal aberrations for chromosomes 21, 4, 16, and 19.

Conclusions

In conclusion, PBB does not impact the morphokinetic parameters of the embryo development. PBB can be safely applied without the risk of impairing the reproductive potential of the embryo and can be highly recommended as safe and practicable PGT approach, especially in countries with prevailing restrictions regarding PGT analysis.

Relative Morphokinetics Assessed by Time-Lapse Imaging Are Altered in Embryos From Patients With Endometriosis

INTRODUCTION

Time-lapse technology allows almost continuous noninvasive assessment of embryonic development. It was shown previously that relative kinetics defining cleavage synchronicity are better predictors of blastocyst quality than absolute time points. This study aims to compare relative kinetics in embryos from patients with and without endometriosis.

METHODS

Time-lapse data were collected retrospectively from 596 patients undergoing infertility treatment for in vitro fertilization from January 2011 to July 2016. Four hundred twenty-eight patients with confounding comorbidities (ie, polycystic ovary syndrome, pathological spermiogram in the included cycle, numerical/structural genetic abnormalities, preimplantation genetic screening performed) or incomplete data sets were excluded. Of the 168 included patients, 72 (42.9%) had endometriosis. Indications for in vitro fertilization of controls were tubal factor, unexplained infertility, or prolonged infertility. Relative kinetics were calculated as defined previously: cleavage synchronicity (CS)2-8=((t3-t2) + (t5-t4))/(t8-t2), CS4-8=(t8-t5)/(t8-t4), CS2-4=(t4-t3)/(t4-t2), DNA replication time ratio (DR)=(t3-t2)/(t5-t3). In women with more than one embryo, the median time was analyzed.

RESULTS

Median age, body mass index, smoking status, and AMH levels were similar in both groups. Embryos from patients with endometriosis showed poorer relative kinetics. The relative time CS2-8 was decreased in embryos from patients with endometriosis (0.7 [0.0-0.93] vs 0.8 [0.0-0.94], P < .05) and CS4-8 was increased (0.4 [0.0-1.0] vs 0.3 [0.0-1.0], P < .05). The less powerful diagnostic relative kinetic parameters (CS2-4 and DR) were not significantly different.

CONCLUSIONS

Embryos from patients with endometriosis presented with altered relative kinetics suggesting poorer embryo quality. These findings support recently published data demonstrating reduced oocyte quality in patients with endometriosis which is one possible explanation for their poor response to fertility treatment.

Comparison of the morphokinetic parameters of embryos according to ovarian reserve in IVF cycles

The aim of this study is to evaluate the impact of ovarian reserve and age of women on early morphokinetic parameters of embryos with a time-lapse monitoring system. In total, 197 infertile couples with poor ovarian reserve (Group 1, n = 41), normal ovarian reserve (Group 2, n = 59), or polycystic ovaries (Group 3, n = 97) were included. The time from insemination to the following events were analyzed: pronuclear fading (Pnf) and cleavage to 2, 3, 4 and 5 cells. The optimal ranges for morphokinetic parameters of t5, s2 and cc2 in each group were also evaluated. In total, 1144 embryos were evaluated. Morphokinetic parameters did not differ statistically between the groups. Data were analyzed according to different age groups (20-30, 30-40, >40). The morphokinetic parameters did not differ statistically in Group 1 and 3. In Group 2, the times from insemination to tPnf, t2, t3, t4 were significantly shorter in the younger age group than the older age group (p < 0.05). The percentages of optimal embryos, according to t5, s2 and cc2, did not differ statistically between the groups. In conclusion, ovarian reserve did not seem to affect the morphokinetic parameters of embryos.

[Quality of oocytes and embryos from women with polycystic ovaries syndrome: State of the art]

The frequency of polycystic ovary syndrome (PCOS) and the consequent fertility disorders cause many difficulties in the management of the assisted reproductive technics. Some studies are focused on different additional treatments, stimulation protocols or techniques that could optimize the in vitro fertilization cycles. The quality of the oocytes and embryos of these patients is also an outstanding issue. They remain difficult to actually evaluate during management, and none of the few published studies on this subject demonstrated any inferiority, compared to control patients. However, many differences have been highlighted, studying intra- and extra-ovarian factors. The advent of new genetic techniques could allow a better understanding of the pathophysiological mechanisms of the syndrome, as well as refining the evaluation of oocytes and embryos, in order to better predict the results of in vitro fertilization attempts. Pregnancy and birth rates, however, appear to be comparable to those of the general population.

High insulin impaired ovarian function in early pregnant mice and the role of autophagy in this process

Metabolic disorders, such as PCOS (polycystic ovarian syndrome) and T2DM (type 2 diabetes mellitus), are associated with menstrual dysfunction, anovulation, infertility, and early pregnancy loss. Ovarian dysfunction is not only related to low pregnancy rates but also to the increased risk of miscarriage. Women with PCOS or T2DM, characterized by hyperinsulinemia, commonly experience ovarian dysfunction. In this study, we first explored whether high insulin levels directly affected ovarian functioning during embryo implantation. Mice in the insulin-treated group were given a subcutaneous injection of human recombinant insulin. After insulin treatment, serum levels of E2 (estrogen), PROG (progesterone), LH (luteinizing hormone), and FSH (follicle-stimulating hormone) were obviously lower, and there was a significant decrement of ovarian GDF9 (growth differentiation factor 9) mRNA. H&E (hematoxylin and eosin) staining showed a greater number of immature follicles and less luteinization in the insulin group. Further autophagy was studied in this process. A significant increase of P62 (SQSTM1/Sequestosome1) and a decrease of Cathepsin B, BECN1 (Beclin 1), and ULK1 (Unc-51-like kinase 1) mRNA in ovary was found in the insulin group. Western blot analysis showed that the expressions of LC3 (microtubule-associated protein 1 light chain 3), BECN1, and Cathepsin B proteins in ovaries from insulin group were obviously reduced, while P62 proteins were significantly increased. All these results illustrated that insulin could directly impair ovarian function during embryo implantation and the imbalance of ovarian autophagy due to insulin. Autophagy could enhance the impaired ovarian function results from insulin.