Extended embryo culture to increase implantation rate

Benefits of Blastocyst Transfer With at Least Three Good-Quality Cleavage-stage Embryos in Women of Advanced Maternal Age: A Retrospective Analysis

OBJECTIVES

Limited studies on the benefits of blastocyst transfer in advanced maternal age (AMA) (≥40 years) have been reported. Our objective was to find whether blastocyst-stage embryo transfer improves pregnancy and live birth rates in women ≥40 years who have 3 or more good-quality cleavage-stage embryos.

METHODS

All fresh in vitro fertilization-intracytoplasmic sperm injection cycles performed from January 2020 to December 2021 in AMA women that progressed to transfer were considered for analysis. We compared fresh and cumulative ongoing pregnancy rates in AMA women of those who had a cleavage-stage transfer, while meeting the criteria for extended culture (≥3 high-quality embryos, group 1), and those who underwent blastocyst transfer (group 2). Demographic parameters, stimulation, embryology, fresh and cumulative ongoing pregnancy rates, and clinical miscarriage rates were compared.

RESULTS

During the study period, 255 cycles were analyzed including group 1 (n = 99) and group 2 (n = 156). Group 1 participants were older and had a greater number of embryos for transfer. Fresh and cumulative ongoing pregnancy rates per transfer were higher in group 2 compared to group 1 (23.4% vs. 13.1%, P = 0.04; 25.5% vs. 14.1%, P = 0.03), while overall miscarriage rates were higher in group 1 than group 2 (51.7% vs. 25%, P = 0.01).

CONCLUSIONS

Blastocyst culture provides a benefit to AMA women who have at least 3 good-quality embryos on day 3 resulting in significantly higher fresh and cumulative ongoing pregnancy rates and lower miscarriage compared to cleavage-stage transfers.

Overweight and obesity significantly reduce pregnancy, implantation, and live birth rates in women undergoing In Vitro Fertilization procedures

OBJECTIVE

The objective of this study was to evaluate the effects of overweight and obesity on fertility outcomes in IVF procedures.

METHODS

This was a retrospective and nonrandomized study that included 191 IVF/ICSI cycles using non-donor oocytes performed between July 2016 and December 2018 that were allocated according to Body Mass Index (BMI) in three groups: Normal group: 18.5-24.9 (n=67 women), Overweight group: 25.0-29.9 (n=86 women) and Obesity group: ≥30.0 (n=38 women). We compared fertilization rates, embryo quality at day 3, development and quality of blastocyst, pregnancy rates, implantation rates, and live birth rates.

RESULTS

Patients from all groups had similar stimulation days, but those women with overweight and obesity used more hormones compared to women with normal weight (p<0.05). Fertilization rates, zygotes that underwent cleavage and good-quality embryos at Day 3 were similar between the three evaluated groups. The groups of overweight and obesity had embryos at Day 3 with significantly less cells, compared to those from the normal group (p<0.05). The blastocyst development rate was significantly lower in women with overweight and obesity compared to women with normal BMI (p<0.05); but, the percentages of good blastocysts were similar in all studied patients. Pregnancy, implantation and live birth rates were significantly lower in the group of women with overweight and obesity, compared to those women with normal weight (p<0.05). Obese women had significantly more miscarriages compared to those in the other groups (p<0.05).

CONCLUSIONS

Our data shows that an increased BMI affects embryo development and significantly reduces the pregnancy, implantation and live birth rates.

Vitrification of the human embryo: a more efficient and safer in vitro fertilization treatment

Cryopreservation has become a central pillar in assisted reproduction, reflected in the exponential increase of "freeze all" cycles in the past few years. Vitrification makes it possible to cool and warm human eggs and embryos with far less cryo-damage than 'slow-freeze' and allows nearly intact survival of embryos with very high survival rates for eggs as well. This has resulted in a complete transformation how we manage treatment for in vitro fertilization patients. Fresh transfers can be avoided without compromising outcomes, and in fact, cumulative pregnancy/delivery rates may be improved by performing sequential elective "frozen" single embryo transfers. Some recent evidence suggests that previously vitrified embryos give better perinatal outcomes than fresh embryo transfers. Frozen embryo transfer, especially when coupled with preimplantation genetic testing allows for highly efficient single embryo transfers that translate to more singleton and therefore safer pregnancies, as well as healthier babies. Additionally, vitrification has also opened new options for patients, most notably fertility preservation (through oocyte cryopreservation), and donor egg banking.

In vitro versus In vivo: Development-, Apoptosis-, and Implantation- Related Gene Expression in Mouse Blastocyst

Background

While mammalian embryos can adapt to their environments, their sensitivity overshadows their adaptability in suboptimal in vitro conditions. Therefore, the environment in which the gametes are fertilized or to which the embryo is exposed can greatly affect the quality of the embryo and consequently its implantation potential.

Objectives

Since providing an optimal culture condition needs a deep understanding of the environmental effects, and regarding the fact that normal morphology fails to be a reliable indicator of natural embryo development, the current study aimed at comparing in vivo- and in vitro-derived blastocysts at the molecular level.

Materials and Methods

In vivo and in vitro mouse blastocysts were obtained by flushing the uterine horns and in vitro fertilization/culture, respectively. Normal blastocysts of both groups were evaluated in terms of hatching rate and expression of three lineage-differentiation-, apoptosis-, and implantation-related genes.

Results

The hatching rate was lower in In vitro fertilization (IVF)-produced blastocysts in comparison with that of the in vivo counterparts. More importantly, the study results indicated significant changes in the expression levels of eight out of ten selected genes, especially Mmp-9 (about -10.7-fold). The expression of Mmp-9 in trophoblast cells is required for successful implantation and trophoblast invasion.

Conclusions

The current study, in addition to confirming that the altered gene expression pattern of in vitro-produced embryos resulted in normal morphology, provided a possible reason for lower implantation rate of in vitro-produced blastocysts regarding the Mmp-9 expression.

Embryo selection or uterine environment: which plays the greater role in blastocyst transfer cycles?

AIM

Blastocyst stage embryo transfer (BET) leads to higher pregnancy rates when compared to cleavage stage transfer. Better embryo selection and a more physiologic stage of transfer are possible explanations. We assessed the significance of embryo selection in achieving an improved outcome.

METHODS

Retrospective analysis of all BETs from our 2007 IVF database was performed. The BET cycles were grouped based on the number of top-quality cleavage stage embryos (≤3 or >3). A cut-off of ≤3 embryos was chosen, because with ≤3 embryos those that will likely make it to the blastocyst stage have already been identified, therefore embryo selection becomes less important. Baseline characteristics, stimulation and embryology parameters, as well as treatment outcome, were compared. The T-test and χ(2)-test were used where appropriate. P < 0.05 was considered significant.

RESULTS

A total of 251 cycles where at least one blastocyst was transferred on day 5 were identified and included in the analysis (≤3 top-quality cleavage embryos, n = 32; >3 top-quality cleavage embryos, n = 219). The number of follicles >14 mm and the number of eggs/mature eggs were higher in the group with >3 good quality day 3 embryos. Slightly more embryos were transferred in the ≤3 embryo group. Pregnancy rates (14/32 [43.8%] vs 96/219 [43.8%]; P = NS) and ongoing pregnancy rates (10/32 [31.2%] vs 80/219 [36.5%]; P = NS) were comparable.

CONCLUSION

Based on the analysis of our data, the number of top-quality cleavage stage embryos did not significantly influence BET outcome. Besides embryo selection, other factors such as improved embryo-endometrium synchrony probably play an important role in the higher implantation and pregnancy rates.

Making the blastocyst: lessons from the mouse

Mammalian preimplantation development, which is the period extending from fertilization to implantation, results in the formation of a blastocyst with three distinct cell lineages. Only one of these lineages, the epiblast, contributes to the embryo itself, while the other two lineages, the trophectoderm and the primitive endoderm, become extra-embryonic tissues. Significant gains have been made in our understanding of the major events of mouse preimplantation development, and recent discoveries have shed new light on the establishment of the three blastocyst lineages. What is less clear, however, is how closely human preimplantation development mimics that in the mouse. A greater understanding of the similarities and differences between mouse and human preimplantation development has implications for improving assisted reproductive technologies and for deriving human embryonic stem cells.

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.

Embryonic factors affecting outcome from single cryopreserved embryo transfer

Multiple pregnancy minimization by single embryo transfer is becoming more prevalent, but is less common in the case of cryopreserved embryos. This study defines embryonic characteristics in single cryopreserved embryo transfers associated with success rates equivalent to those achieved when transferring two cryopreserved embryos. In a retrospective analysis of 6916 cryopreserved day-2 embryo transfer procedures, transfer of two cryopreserved embryos resulted in higher clinical pregnancy rates when compared with transfer of a single thawed embryo but was also associated with elevated multiple pregnancy rates (26.7% in women under 36). Optimal outcome (implantation rate of 30.9%) from single cryopreserved embryo transfer (SCET) in women under 36 was associated with cryopreservation at the 4-cell stage, loss of fewer than two blastomeres and subsequent cleavage of at least two surviving blastomeres. In comparison, transfer of two cryopreserved embryos in women under 36 resulted in pregnancy and implantation rates of 25.5 and 16.1% respectively. Interestingly, in cryopreserved 4-cell stage embryos, loss of a single blastomere did not reduce implantation potential and cleavage of only a single post-thaw blastomere was not indicative of increased implantation potential. Establishment of these critical thresholds provides a rational basis for SCET.