Prospective evaluation of blastocyst stage transfer vs. zygote intrafallopian tube transfer in patients with repeated implantation failure

Efficacy of therapies and interventions for repeated embryo implantation failure: a systematic review and meta-analysis

The aim of the present systematic review and meta-analysis was to assess the effect of the different therapeutic options for repeated embryo implantation failure (RIF) on a subsequent IVF cycle outcome. Twenty-two RCTs and nineteen observational studies were included. Pooling of results showed a beneficial effect of intrauterine PBMC infusion on both CPR (RR 2.18; 95% CI 1.58-3.00; p < 0.00001; OR 2.03; 95% CI 1.22-3.36; p = 0.006) and LBR (RR 2.41; 95% CI 1.40-4.16; p = 0.002; OR 3.73; 95% CI 1.13-12.29; p = 0.03), of subcutaneous G-CSF administration on CPR (RR 2.29; 95% CI 1.58-3.31; p < 0.0001) and of intrauterine PRP infusion on CPR (RR 2.45; 95% CI 1.55-3.86; p = 0.0001). Observational studies also demonstrated a positive effect of IVIG and intrauterine hCG infusion on both CPR and LBR and of atosiban on CPR. Studies investigating intrauterine G-CSF infusion, LMWH, intravenous intralipid, hysteroscopy, blastocyst-stage ET, ZIFT, PGT-A and AH failed to observe an impact on IVF outcome. The quality of the evidence that emerged from RCTs focused on intrauterine PBMC infusion and subcutaneous G-CSF administration was moderate. For all other therapies/interventions it varied from low to very low. In conclusion, intrauterine PBMC infusion and subcutaneous G-CSF administration are the most promising therapeutic options for RIF. However, further well conducted RCTs are necessary before their introduction into clinical practice.

Effects of Melatonin Administration on Chemical Pregnancy Rates of Polycystic Ovary Syndrome Patients Undergoing Intrauterine Insemination: A Randomized Clinical Trial

Background

Oxidative stress as a potential cause of poor oocyte quality can influence a female's reproductive system. This study aimed to investigate the effects of melatonin on chemical pregnancy rates of a significant number of polycystic ovary syndrome (PCOS) patients undergoing intrauterine insemination (IUI).

Materials and Methods

In this double-blinded randomized clinical trial (RCT) study, the samples included 198 PCOS patients fulfilling the inclusion criteria and undergoing the IUI treatment. On the third day of menstruation, a 3-mg melatonin tablet or its placebo was given to the patients according to the randomized study protocol; this prescription was continued until the day of human chorionic gonadotropin (hCG) administration. The current study attempted primarily to scrutinize the effect of melatonin administration on the rate of chemical pregnancy and mature follicles during the IUI treatment cycle, and secondarily to determine the endometrial thickness (ET) on the day of IUI.

Results

The mean age of the participants in the study was 28.9 ± 5.5 years. The chemical pregnancy rate in the group receiving melatonin was about 32%, when it was 18% in the control group (P=0.012). Furthermore, it was concluded that the addition of melatonin to the treatment cycle of PCOS individuals could significantly improve the ET after the treatment (P<0.001).

Conclusion

The results of this study demonstrated that the treatment of PCOS patients undergoing IUI with melatonin significantly improves the rate of chemical pregnancy (Registration number: IRCT2017021132489N1).

Frozen blastocyst embryo transfer vs. frozen cleavage-stage embryo transfer in couples with recurrent implantation failure: a cohort study

The objective of this prospective cohort study was to investigate whether cryopreservation of cleavage or blastocyst stage embryos improves in vitro fertilization outcomes in recurrent implantation failure (RIF) patients. The study comprised 575 patients who were allocated to receive either single frozen/thawed blastocyst-stage transfer (SBT) or frozen/thawed double-cleavage-stage embryo transfer (DET). The clinical pregnancy rate, implantation rate, and ongoing pregnancy rate were higher in the SBT group compared with the DET group (41.15% vs. 27.11%, p < 0.001; 41.15% vs. 19.28%, p < 0.001; 40.03% vs. 25.9%, p < 0.001), but the miscarriage rate did not differ between the two groups. It was concluded that frozen/thawed SBT could be a preferred strategy for RIF patients.

Zygote intrafallopian tube transfer versus intrauterine cleavage or blastocyst stage transfer after intracytoplasmic sperm injection cycles in patients with repeated implantation failure: A prospective follow-up study

AIM

This study aimed to compare the outcomes between zygote intrafallopian transfer (ZIFT) with intrauterine day-3 (cleavage stage) embryo transfer and intrauterine day-5 (blastocyst stage) embryo transfer in patients undergoing intracytoplasmic sperm injection.

MATERIAL AND METHODS

This prospective study was performed at Royan Institute, Tehran, Iran, between January 2012 and January 2014. Two hundred fifty women with more than three unexplained implantation failures were divided non-randomly into three groups according to embryonic age and methods used as follows: (i) intrauterine cleavage-stage embryo transfer (n = 100); (ii) intrauterine blastocyst-stage embryo transfer (n = 50); and (iii) ZIFT (n = 100). Implantation, clinical pregnancy, miscarriage and live birth rates were our main outcomes.

RESULTS

Patients' characteristics and ovarian response were comparable among the three groups. Implantation rate (56.1% vs 27.9%) was significantly higher in the blastocyst group as compared to the ZIFT group; however, clinical pregnancy rate (38% vs 23%) was not statistically significantly different between the two groups, but due to the significantly higher miscarriage rate (34.7% vs 5.3%) in the ZIFT group, the live birth rate was significantly higher in the blastocyst group (P = 0.04). No significant differences were found between the cleavage-stage and blastocyst-stage groups in terms of implantation, clinical pregnancy, miscarriage and live birth rates.

CONCLUSION

We do not recommend the use of the ZIFT procedure for patients with repeated implantation failures. It seems that replication of cleavage- or blastocyst-stage embryo transfer is more efficient and affordable.

Should zygote intrafallopian transfer be offered to all patients with unexplained repeated in-vitro fertilization cycle failures?

BACKGROUND

One of the suggest strategy for patients with repeated implantation failure (RIF) is zygote intrafallopian transfer (ZIFT). However, no data exist regarding to the issue of when and under which circumstances should ZIFT be offered to patients with RIF? We therefore aimed to examine whether repeated implantation failure (RIF) patients characteristics or their previous controlled ovarian hyperstimulation (COH) variables may differentiate between those who will conceive following a ZIFT cycle and those who will not.

METHODS

Forty seven consecutive women admitted to our IVF unit during a 7 year period, who underwent ZIFT for RIF, were included. Ovarian stimulation characteristics, number of oocytes retrieved and number and quality of zygotes/embryos transferred were assessed and compared between the ZIFT cycle and the previous IVF/ICSI cycle and between those who conceived following the ZIFT cycle and those who did not.

RESULTS

Twelve clinical pregnancies (clinical pregnancy rate- 25.5%) were recorded following the ZIFT cycle. Those who benefit from ZIFT were young patients (≤31 yrs), who underwent ≤6 cycle attempts, yielding over eight 2PN embryos with low (≤0.4) ratio of number of top-quality embryos to total 2PN embryos. Moreover, in those destined for a ZIFT cycle, only those with >7 2PN embryo should undergo a transfer of at least five 2PN embryos.

CONCLUSIONS

Further large prospective studies are needed to identify the specific characteristics of RIF women who may benefit from ZIFT.

Spontaneous ovulation versus HCG triggering for timing natural-cycle frozen-thawed embryo transfer: a randomized study

In ovulatory patients, frozen-thawed embryo transfer (FET) is commonly performed during a natural cycle (NC). The objective was to compare serial monitoring until documentation of ovulation with human chorionic gonadotrophin (HCG) triggering, for timing NC-FET. Sixty women with regular menstrual cycles undergoing NC-FET were randomized into two groups: group A (n=30) had FET in a natural cycle after ovulation triggering with HCG; group B (n=30) had FET in a natural cycle after detection of spontaneous ovulation. The main outcome measure was the number of monitoring visits at the clinic per cycle. Secondary outcome measures included implantation rate, clinical pregnancy and live-birth rates. Both groups were similar in terms of demographic characteristics and reproductive history. Clinical and laboratory characteristics of fresh and frozen cycles and pregnancy and delivery rates were comparable for both groups. The number of monitoring visits in group A (3.2 ± 1.4) was significantly lower than in group B (4.7 ± 1.6) (P=0.002). In patients undergoing NC-FET, triggering ovulation by HCG can significantly reduce the number of visits necessary for cycle monitoring without an adverse effect on cycle outcome. Ovulation triggering can increase both patient convenience and cycle cost effectiveness.

Blastocyst culture and transfer: lessons from an unselected, difficult IVF population

Blastocyst-stage transfer has yielded excellent results in good prognosis IVF patients, but its efficacy in the general IVF population has not been clearly demonstrated. The objective of this study was to compare cleavage-stage and blastocyst-stage transfer in a mixed, general IVF population. In a prospective, quasi-randomized study, 152 patients underwent 164 treatment cycles. Patients were allocated to cleavage-stage (group 1; n = 94) or blastocyst-stage (group 2; n = 70) transfer. Main outcome measures included implantation, clinical pregnancy and live birth rates. Implantation (11.2% versus 15.5%), clinical pregnancy (34% versus 21%) and live birth rates per transfer (21.3% versus 13.8%) and per started cycle (21.3% versus 11.4%) were all comparable for groups 1 and 2, respectively. Logistic regression analysis revealed that blastocyst culture and transfer reduced the odds for pregnancy in the general IVF population and defined a good prognosis group for blastocyst transfer. Introducing blastocyst culture and transfer to all IVF patients is not advantageous. Blastocyst transfer should be offered primarily to good prognosis patients, and this group should be specifically defined in each clinical set-up.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

Recent advances in cell culture media have led to a shift in IVF practice from early cleavage embryo transfer to blastocyst stage transfer. The rationale for blastocyst culture is to improve both uterine and embryonic synchronicity and self selection of viable embryos thus resulting in higher implantation rates.

OBJECTIVES

To determine if blastocyst stage embryo transfers (ETs) affect live birth rate and associated outcomes compared with cleavage stage ETs and to investigate what factors may influence this.

SEARCH STRATEGY

Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and Bio extracts. The last search date was January 2007.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 50 trials that were identified, 18 randomised controlled trials (RCTs) met the inclusion criteria and were reviewed. The primary outcome was rate of live birth. Secondary outcomes were rates per couple of clinical pregnancy, multiple pregnancy, high order pregnancy, miscarriage, failure to transfer embryos and cryopreservation. Quality assessment, data extraction and meta-analysis were performed following Cochrane guidelines.

MAIN RESULTS

Evidence of a significant difference in live-birth rate per couple between the two treatment groups was detected in favour of blastocyst culture (9 RCTs; OR 1.35, 95% CI 1.05 to 1.74 (Day 2/3: 29.4% versus Day 5/6: 36.0%)). This was particularly for trials with good prognosis patients, equal number of embryos transferred (including single embryo transfer) and those in which the randomisation took place on Day 3. Rates of embryo freezing per couple was significantly higher in Day 2 to 3 transfers (9 RCTs; OR 0.45, 95% CI 0.36 to 0.56). Failure to transfer any embryos per couple was significantly higher in the Day 5 to 6 group (16 RCTs; OR 2.85, 95% CI 1.97 to 4.11 (Day 2/3: 2.8% versus Day 5/6: 8.9%)) but was not significantly different for good prognosis patients (9 RCTs; OR 1.50, 95% CI 0.79 to 2.84).

AUTHORS' CONCLUSIONS

This review provides evidence that there is a significant difference in pregnancy and live birth rates in favour of blastocyst transfer with good prognosis patients with high numbers of eight-cell embryos on Day three being the most favoured in subgroup for whom there is no difference in cycle cancellation. There is emerging evidence to suggest that in selected patients, blastocyst culture maybe applicable for single embryo transfer.

Timing intra-Fallopian transfer procedures

With the gradual decline in the use of zygote intra-Fallopian transfer (ZIFT), current practice is to offer ZIFT almost exclusively to patients with repeated implantation failure (RIF). For practical reasons, the procedure is sometimes deferred by 1 day and embryo intra-Fallopian transfer (EIFT) is performed. The aim of the present study was to compare the reproductive outcome of ZIFT versus EIFT. In a retrospective analysis, 176 patients who failed in 7.65 +/- 3.7 previous IVF cycles underwent 200 ZIFT and 73 EIFT procedures. Implantation and live birth rates were compared for both groups. Patients in both groups were found comparable for demographic and clinical parameters. Similar numbers of oocytes were retrieved and fertilized in both groups, and 5.2 +/- 1.2 zygotes/embryos were transferred. Implantation and live birth rates (10.5 and 26.5% versus 10.9 and 24.7% for ZIFT and EIFT respectively) were comparable. It is concluded that tubal transfer of zygotes and day-2 cleavage stage embryos are equally effective.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

In the past decade, advances in the understanding of nutrient requirements of embryos, has led to the evolution of culture media designed to support extended culture of embryos in vitro from the standard procedure of 2 to 3 days (for early cleavage embryo transfer) to 5 to 6 days (blastocyst culture). The rationale for blastocyst culture is to improve the synchronicity of uterine and embryonic development and provide a mechanism for self-selection of viable embryos. Since the initial widespread introduction of blastocyst culture in 1998, there has been conflicting reports about the clinical benefits of this technique.

OBJECTIVES

To determine if blastocyst stage embryo transfers (ETs) affects success rates compared with cleavage stage ETs and investigate what factors may influence this.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials. We also searched the Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and Bio extracts. Attempts were made to identify trials from the National Research Register, the Clinical Trials Register and the citation lists of review articles and included trials. The last search date was May 2005. The first or corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 45 trials that were identified, 16 trials met the inclusion criteria and were reviewed. Primary outcomes were rates of live birth, clinical pregnancy and multiple-pregnancy rates per couple. Secondary outcomes were rates of miscarriage, failure to transfer embryos, freezing, implantation and high order pregnancy and per cycle data. Quality assessment and data extraction were performed independently by two review authors. Meta-analysis was performed using odds ratios (OR) for dichotomous outcomes and weighted mean differences for binary outcomes with 95% confidence intervals (CI).

MAIN RESULTS

There was no evidence of a difference in live-birth rate per couple between the two treatment groups (7 RCTs; OR 1.16, 95% CI 0.74 to 1.44 [Day 2/3 34.3% vs. Day 5/6 35.4%]); in the clinical pregnancy rate per couple (15 RCTs; OR 1.05, 95% CI 0.88 to 1.26 [Day 2/3 38.8% vs. 40.3%]) even for good prognosis patients (6 RCTs: OR 96% 1.06 CI 0.83 to 1.34). There was also no difference in multiple-pregnancy rate per couple (12 RCTs; OR 0.85, 95% CI 0.63 to 1.13) particularly in trials where equal numbers of embryos were transferred in both groups (6 RCTs: OR 0.91, 95% CI 0.63 to 1.32). There was no evidence of a difference in high order multiple-pregnancy rates per couple (5 RCTs; OR 0.44, 95% CI 0.15 to 1.33) or miscarriage rate per couple between the two groups (9 RCTs; OR 1.33, 95% CI 0.89 to 2.01). Rates of embryo freezing per couple was significantly higher in Day 2 to 3 transfers (9 RCTs; OR 0.45, 95% CI 0.36 to 0.57). Failure to transfer any embryos per couple was significantly higher in the Day 5 to 6 group (10 RCTs: OR 3.21, 95% CI 2.15 to 4.81[Day 2/3 3.5% vs D 5/6 10.1%]), but was not significantly different for good prognosis patients (7RCTs, OR 1.58 95% CI 0.65 to 3.82).

AUTHORS' CONCLUSIONS

There is no evidence of a difference in live birth or pregnancy outcomes between Day 2 to 3 and Day 5 to 6 transfer of embryos. Blastocyst transfer was associated with an increase in failure to transfer any embryos in a cycle and a decrease in embryo freezing rates. In the absence of data on cumulative live birth rates resulting from fresh and thawed cycles, it is not possible to determine if this represents an advantage or disadvantage.

The role of aromatase inhibitors in ameliorating deleterious effects of ovarian stimulation on outcome of infertility treatment

Clinical utilization of ovulation stimulation to facilitate the ability of a couple to conceive has not only provided a valuable therapeutic approach, but has also yielded extensive information on the physiology of ovarian follicular recruitment, endometrial receptivity and early embryo competency. One of the consequences of the use of fertility enhancing agents for ovarian stimulation has been the creation of a hyperestrogenic state, which may influence each of these parameters. Use of aromatase inhibitors reduces hyperestrogenism inevitably attained during ovarian stimulation. In addition, the adjunct use of aromatase inhibitors during ovarian stimulation reduces amount of gonadotropins required for optimum stimulation. The unique approach of reducing hyperestrogenism, as well as lowering amount of gonadotropins without affecting the number of mature ovarian follicles is an exciting strategy that could result in improvement in the treatment outcome by ameliorating the deleterious effects of the ovarian stimulation on follicular development, endometrial receptivity, as well as oocyte and embryo quality.

Comparison of zygote intrafallopian tube transfer and transcervical uterine embryo transfer in patients with repeated implantation failure

OBJECTIVE

This study was designed to evaluate the role of zygote intrafallopian transfer (ZIFT) procedure in patients with repeated failure of implantation.

STUDY DESIGN

A total of 141 ZIFT cycles of 132 women and 145 embryo transfer (ET) cycles of 97 women in whom five or more embryos were transferred were included in this study. Transcervical uterine embryo transfer and ZIFT cycle outcome in patients with five or more previous implantation failure were compared. Embryos were transferred by laparoscopy into the fallopian tube 24-27 h following oocytes retrieval in the ZIFT group. In the ET group, embryos were transferred transcervically on the third day following oocytes retrieval.

RESULTS

The mean age was 34+/-4.9 and 34.9+/-5.0 years in ZIFT and ET group, respectively. No difference was determined between the two groups regarding the basal FSH, E2 value on the day of HCG injection and the number of oocytes retrieved or fertilized. The implantation rate was 6.5% versus 7.2%, clinical pregnancy rate was 22.7% versus 24.8% and live birth rate was 21.2% versus 16.5% in ZIFT and ET groups, respectively.

CONCLUSIONS

Implementation of ZIFT procedure in patients with repeated implantation failure is not superior to transcervical uterine embryo transfer.

Recurrent implantation failure in assisted reproduction: how to counsel and manage. B. Treatment options that have not been proven to benefit the couple

The success of assisted reproduction, although gradually increasing over the years, is still less than satisfactory. Many couples have benefited from this treatment; however, many have also been left frustrated following multiple failed attempts. Couples who fail to conceive after multiple IVF/intracytoplasmic sperm injection (ICSI) treatments often seek treatment options that are new and that have not been offered before. Some of these include immunological testing and treatment, allogenic lymphocyte therapy, intratubal transfer of zygotes and embryos, blastocyst transfer, sequential embryo transfer, assisted hatching, co-cultures, and preimplantation genetic screening for aneuploidy. Although the evidence behind some of these is more robust, most suffer from lack of well designed randomized trials comparing them with other treatment options. Randomized studies are extremely difficult to conduct, as couples will resist being randomized into a treatment group where previously failed procedures will be repeated. In the mean time, assisted reproduction programmes should resist offering treatment options that are not evidence based, or at least they should share with the couple the information that is available and should stress that none of these is a panacea for their problem.

Efficacy of blastocyst transfer after implantation failure

Clinicians who treat unsuccessful couples despite repeated transfers of good quality embryos face a challenge. Among the various strategies that have been described, embryo transfer at the blastocyst stage has been postulated to improve implantation. A prospective non-randomized analysis was performed in 276 IVF patients who failed to conceive after at least two early embryo transfers of at least two grade 1-2 embryos per cycle. For the next attempt, couples chose between day 2 embryo transfer (D2 group; n = 147) and day 5/6 blastocyst transfer (D5/D6 group; n = 129) before starting the following attempt. Embryo quality was assessed and results were expressed as clinical pregnancy, live birth and implantation rates per cycle. Embryo grade 1 number was similar between both groups, whereas mean embryo score of the whole cohort was slightly higher in the D2 group. The live birth rates per cycle (27.9 versus 19.7%) and implantation rates per cycle (25.4 versus 12.4%) were higher in the D5/D6 group compared with the D2 group. Improved embryo selection and uterine receptivity may explain the additional benefit of embryo transfer at the blastocyst stage for couples with repeated implantation failures.

Outcome of blastocyst transfer according to availability of excess blastocysts suitable for cryopreservation

The purpose of this study was to assess the outcome of blastocyst transfer in relation to the presence or absence of excess blastocysts available for cryopreservation. The study was designed as a retrospective case series in a tertiary care private hospital. The study group consisted of 450 blastocyst stage embryo transfer cycles. In 139 cycles there were excess freezeable blastocysts (group 1), in 78 cycles there were excess but unfreezeable blastocysts (group 2), and in 233 cycles there were no excess blastocysts (group 3). A mean of three blastocysts was replaced in all groups. Treatment cycle characteristics, implantation and pregnancy rates following fresh and cryopreserved blastocyst transfer were assessed in each group. More embryos reached the blastocyst stage in group 1 and more blastocysts were of good quality. In group 1, clinical pregnancy and implantation rates (71 and 41%) were significantly higher compared with groups 2 (56 and 27%) and 3 (43 and 19%). Embryos that were selected for transfer among a cohort of good quality blastocysts yielded the highest implantation and pregnancy rates. Given a clinical pregnancy rate of 71%, an implantation rate per embryo of 41%, and a multiple pregnancy rate of 58%, serious consideration should be given to a single blastocyst transfer in these patients.

Embryo culture as a diagnostic tool

Embryo culture can serve as a strong diagnostic tool, yielding useful information regarding the implantation potential of the human embryo. The information thus gained is useful for quality control of the embryology laboratory, success rates of the IVF/intracytoplasmic sperm injection (ICSI) programme, and counselling of the couple following failed cycles. Zygotes can be scored and zygote quality has been associated with further embryonic development and cleavage stage embryo quality. Early cleavage, cleavage rate, cleavage stage embryo grade and subsequent progression of these embryos to the blastocyst stage have all been shown to be individual and collective markers for the implantation-competent human embryo. This manuscript discusses embryonic markers of normality/quality throughout in-vitro culture starting with the zygote and ending with the blastocyst.