Objective assessments of temperature maintenance using in vitro culture techniques

Clinical pregnancy rates after blastocyst culture at a stable temperature of 36.6°C versus 37.1°C: a prospective randomized controlled trial

STUDY QUESTION

Is there a difference in clinical pregnancy rates (CPRs) in good prognosis patients after single embryo transfer (SET) on Day 5, in case of stable culture at 36.6°C or 37.1°C?

SUMMARY ANSWER

CPR (with heartbeat at 7 weeks) after blastocyst transfer do not differ after culturing at 36.6°C or 37.1°C.

WHAT IS KNOWN ALREADY

Since the beginning of IVF, embryo culture has been performed at 37.0°C; however, the optimal culture temperature remains unknown. Changes in incubator types have led to significant improvements in temperature control. Stable temperature control, i.e. with temperature differences of max. 0.1°C between chambers, is possible in some incubators. A previous prospective pilot study showed that embryo development on Day 5/6 was not affected when embryos were cultured at a stable temperature of 36.6°C or 37.1°C, but culture at 37.1°C resulted in an increased CPR when compared to culture at 36.6°C (74.2% vs 46.4%).

STUDY DESIGN, SIZE, DURATION

A prospective randomized controlled trial was performed in a tertiary fertility centre between February 2017 and November 26, 2022. A sample size of 89/89 patients with fresh single embryo transfer (SET) was required to achieve 80% power to detect a difference of 0.22 between group proportions (0.43-0.65) at a significance level of 0.05 using a two-sided z-test with continuity correction.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients were recruited on the day of oocyte retrieval based on inclusion criteria with final randomization after denudation once six mature oocytes were present. The primary endpoint was CPR (heartbeat at 7 weeks); secondary endpoints were fertilization rate, blastocyst development, biochemical pregnancy rate, live birth rate (LBR), and cumulative live birth rate (CLBR).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 304 patients were eligible for the study; of these 268 signed the consent, 234 (intention-to-treat) were randomized and 181 (per-protocol) received a SET on Day 5: 90 received culture at 36.6°C and 91 at 37.1°C. Patients were on average 32.4 ± 3.5 versus 32.5 ± 4.2 years old, respectively. No differences were observed in embryological outcomes per cycle between culture at 36.6°C versus 37.1°C: 12.0 ± 3.8 vs 12.1 ± 3.8 COCs retrieved (P = 0.88), 10.0 ± 3.1 versus 9.9 ± 2.9 mature oocytes inseminated (P = 0.68), with a maturation rate of 84.2% (901/1083) versus 83.5% (898/1104) (P = 0.87); and 8.0 ± 3.1 versus 7.9 ± 2.7 normally fertilized oocytes with a fertilization rate of 79.7% (720/901) vs 80.5% (718/898) (P = 0.96), respectively. On average 1.5 ± 1.7 versus 1.4 ± 1.9 (P = 0.25) and 1.1 ± 1.1 versus 0.9 ± 1.0 (P = 0.45) supernumerary blastocysts were vitrified on Day 5 and Day 6, respectively. The utilization rate per fertilized oocyte was 46.1% vs 41.5% (P = 0.14). A SET was performed for 181 patients, leading to a biochemical pregnancy rate of 72.2% (65/90) versus 62.7% (57/91) (P = 0.17), respectively. The CPR per fresh transfer cycle was 51.1% (46/90) versus 48.4% (44/91) [OR (95% CI) 1.11 (0.59-2.08), P = 0.710]. To date, a CLBR of 73.3% (66/90) versus 67.0% (61/91) (P = 0.354) has been observed, respectively. In each group, seven patients without live birth have remaining blastocysts frozen. The CPR for the intention-to-treat groups were 38.3% vs 38.6% [OR (95% CI) 0.98 (0.56-1.73), P = 0.967], respectively, for culture at 36.6°C versus 37.1°C.

LIMITATIONS, REASONS FOR CAUTION

Only selected patients with expected good prognosis were eligible for the study.

WIDER IMPLICATIONS OF THE FINDINGS

Embryos tend to tolerate small changes in temperature deviations during culture to the blastocyst stage, as demonstrated by their similar implantation potential at two slightly different temperatures.

STUDY FUNDING/COMPETING INTEREST(S)

There is no funding or conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

NCT03548532.

TRIAL REGISTRATION DATE

23 October 2017.

DATE OF FIRST PATIENT’S ENROLMENT

10 November 2017.

A propensity score-based, comparative study assessing humid and dry time-lapse incubation, with single-step medium, on embryo development and clinical outcomes

STUDY QUESTION

Does culture in a high relative humidity atmosphere improve clinical outcomes when using a time-lapse integrated incubator and single-step culture medium?

SUMMARY ANSWER

Using an integrated time-lapse system and single-step culture medium, culture in a high relative humidity atmosphere increases the likelihood of embryos, especially those subjected to preimplantation genetic testing for aneuploidies, to achieve a pregnancy compared to those cultured in dry conditions.

WHAT IS KNOWN ALREADY

The use of a humid atmosphere inside incubators can reduce changes in culture media osmolality, which has been reported to have a significant effect on embryo quality and morphokinetics. Studies assessing the effect of humid culture (HC) in clinical outcomes are, however, scarce and inconclusive, mostly due to a high variability in culture conditions and reduced sample size.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study performed over 1627 ICSI cycles performed during 3 consecutive years in which embryo cohorts were cultured in a time-lapse incubator with three dry and three humidified chambers, and using single-step culture medium. Clinical outcomes were compared between treatments in which embryo cohorts were cultured in either humid (n = 833) or dry (n = 794) conditions.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study includes autologous treatments, with (N = 492) and without (N = 372) preimplantation genetic testing for aneuploidies (PGT-A) and ovum donation treatments (N = 763), performed in three university-affiliated private IVF centres. Stimulation, oocyte pickup and fertilization were performed according to the standard procedures of the clinic. All embryo cohorts were cultured in the same model of time-lapse incubator, distributed to either a dry or humidified chamber, while the rest of the culture variables remained equal. The population was weighted by the inverse probability of treatment to control for all measured confounders. The association between HC and the main outcome was assessed by logistic regression over the weighted population. The E-value was reported as a way of considering for unmeasured confounders. Differences in embryo development and other secondary outcomes between the study groups were assessed by Pearson Chi-squared test, ANOVA test and Kaplan-Meier survival analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

An univariable logistic regression analysis, weighted by the inverse probability of treatment, determined that embryos cultured in humid conditions are more likely to achieve a clinical pregnancy than those cultured in dry conditions (odds ratio (OR) = 1.236 (95% CI 1.009-1.515), P = 0.041, E = 1.460). Through stratification, it was determined that said effect is dependent on the type of treatment: no improvement in clinical pregnancy was present in ovum donation or autologous treatments, but a statistically significant positive effect was present in treatments with preimplantation genetic testing (OR = 1.699 (95% CI 1.084-2.663), P = 0.021, E = 1.930). Said increase does not relate with an improvement in later outcomes. Differences were also found in variables related to embryo developmental morphokinetics.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature of the study makes it susceptible to some bias linked to the characteristics of the treatments. To lessen the effect of possible biases, cases were weighted by the inverse probability of treatment prior to the evaluation of the outcome, as means to assess for measured confounders. In addition, the E-value of the weighted OR was calculated as a sensitivity analysis for unmeasured confounders. A randomized prospective study could be performed for further assessing the effect of humid conditions in clinical outcome.

WIDER IMPLICATIONS OF THE FINDINGS

These results support that embryo culture under conditions of high relative humidity contributes to optimize clinical results in undisturbed culture in a time-lapse incubator with single-step medium. To our knowledge, this is the largest study on the matter and the first performing a propensity score-based analysis.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the ''Centro para el Desarrollo Tecnologico Industrial'' from the Spanish Ministry of Science, Innovation, and Universities (CDTI-20170310) and Generalitat Valenciana and European Social Fund (ACIF/2019/264). None of the authors have any competing interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

The effect of different temperature conditions on human embryosin vitro: two sibling studies

RESEARCH QUESTION

What temperature is optimal for human embryo development up to day 5 or 6?

DESIGN

Two prospective sibling oocyte studies on culture temperature were conducted in a university-based tertiary referral centre. Eligibility critera for both studies: Study 1: 50 cycles between August and October 2015, with culture at a stable temperature (37.0°C ± 0.3°C) or culture using a circadian temperature rhythm (CTR) (1 am to 6 am: 36.6°C, gradual increase to 37.5°C; 11 am to 9 pm: 37.5°C; gradual decrease to 36.6°C); study 2: 99 cycles between April and November 2016, with stable culture at 36.6°C or 37.1°C.

PRIMARY OUTCOME MEASURES

fertilization and embryo development (top and good quality) up to day 5 or 6, and utilization rate (number of embryos transferred and cryopreserved per zygote). Secondary outcome measure: clinical pregnancy (number of pregnancies with at least one gestational sac).

RESULTS

An incubator with CTR was used for culture. An effect was found on embryo development (utilization rate: 42.1% versus 32.6%; P = 0.014), but not on clinical pregnancy rate (60.0% versus 45.5%; P = 0.670). Stable culture at 36.6°C or 37.1°C did not affect embryo development (utilization rate: 40.0% versus 40.4%; P = 0.905); clinical pregnancy rate was improved by culture at 37.1°C (46.4% versus 74.2%; P = 0.036).

CONCLUSION

Culture in an incubator with CTR does not improve fertilization rate or embryo quality. Embryo culture at 36.6°C or 37.1°C showed similar embryo development.

[Impact of air quality on practices and results in the IVF laboratory]

The concept of Air Quality often refers to particulate and microbiological contamination of ambiant air. European Directive 2006/86/CE encompass the IVF process and specify a class A air quality for manipulation of tissue and cells, in a class D environment (A over D rule). Recognizing the paramount importance of ensuring the highest microbiological and particulate safety in the IVF laboratory, it is equally important to take into account practicability issues and the financial burden of these recommendations, as well as the utter need to protect gametes and embryo viability during their IVF journey. The usefulness of such stringent recommendations may also be questionned given the absence of published cases of airborne contaminations and related patients infections after embryo transfer. The European directive stems from pharmaceutical standards and were not specifically designed for human IVF. Gametes and embryos are indeed extremely sensitive to physical and chemical stress and require strict temperature, osmolarity and pH control, as well as an absence of chemical contamination during manipulation and culture. These conditions are hardly obtained when using laminar flow hoods. Following concerns raised by many experts in the field, exceptions to the A over D rule were added in the 2006/86/CE Directives. This narrative review discusses all these aspects in a critical way and compare scientific and legal requirements applying to IVF practices in different regions of the world.

Impact of oxygen concentrations on fertilization, cleavage, implantation, and pregnancy rates of in vitro generated human embryos

The aim of the present study was to determine the impact of oxygen concentration during in vitro culture of human oocytes and embryos on fertilization, cleavage, implantation, pregnancy, multiple gestation and abortion rates. Women 20-48 years old presenting for infertility treatment and accounting for 3484 in vitro fertilization/intracytoplasmic sperm injection cycles were included in the study. Oocytes/embryos were randomly allocated to be incubated under three different oxygen tension environments: (1) 20% O2 in air; (2) initially 20% O2 in air, followed on day 2 (2-4 cells stage) by 5% CO2, 5% O2 and 90% N2; and (3) 5% CO2, 5% O2 and 90% N2 throughout. Interestingly, IVF-derived embryos cultured in 5% O2 yielded higher rates of fertilization and implantation as compared to those incubated in 20% O2 (P < 0.05). Conversely, embryos in 20% O2 yielded higher rates of fertilization, high quality embryo and implantation than those in the 20%-5% O2 group (P < 0.05). Moreover, ICSI-derived embryos cultured in 20% O2 resulted in lower rates of cleavage as compared to those from the 20%-5% O2 group (P < 0.05). These results are consistent with in vitro and subsequent in vivo embryo development being more susceptible to O2 tension fluctuations rather than the degree of O2 tension itself during culture.

The heat is on: room temperature affects laboratory equipment--an observational study

OBJECTIVE

To evaluate the effect of ambient room temperature on equipment typically used in in vitro fertilization (IVF).

DESIGN

We set the control temperature of the room to 20 °C (+/-0.3) and used CIMScan probes to record temperatures of the following equipment: six microscope heating stages, four incubators, five slide warmers and three heating blocks. We then increased the room temperature to 26 °C (+/-0.3) or decreased it to 17 °C (+/-0.3) and monitored the same equipment again. We wanted to determine what role, if any, changing room temperature has on equipment temperature fluctuation.

RESULTS

There was a direct relationship between room temperature and equipment temperature stability. When room temperature increased or decreased, equipment temperature reacted in a corresponding manner. Statistical differences between equipment were found when the room temperature changed. What is also noteworthy is that temperature of equipment responded within 5 min to a change in room temperature.

CONCLUSIONS

Clearly, it is necessary to be aware of the affect of room temperature on equipment when performing assisted reproductive procedures. Room and equipment temperatures should be monitored faithfully and adjusted as frequently as needed, so that consistent culture conditions can be maintained. If more stringent temperature control can be achieved, human assisted reproduction success rates may improve.

Assisted reproductive technology and major birth defects in Western Australia

OBJECTIVE

To estimate the prevalence of major birth defects diagnosed by 6 years of age in all births and terminations of pregnancy for fetal anomaly conceived by assisted reproductive technology (when this included intracytoplasmic sperm injection and in vitro fertilization [IVF]) and the remainder of nonassisted reproductive technology-conceived children born in Western Australia from 1994 to 2002.

METHODS

This retrospective cohort study used data linkage between three population-based registers (Reproductive Technology Register, Western Australian Register of Developmental Anomalies, and Midwives' Notification of Birth System) to identify all assisted reproductive technology (n=2,911) and nonassisted reproductive technology (n=210,997) births with and without birth defects diagnosed by age 6 and all terminations of pregnancy for fetal anomaly.

RESULTS

A major birth defect was diagnosed in 8.7% of assisted reproductive technology and 5.4% of nonassisted reproductive technology singletons (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.30-1.79), as well as 7.1% of assisted reproductive technology twins and 5.9% of nonassisted reproductive technology twins of unlike sex (OR 1.08, 95% CI 0.77-1.51). The prevalence of birth defects in assisted reproductive technology singletons and twins decreased markedly over the study period. This change was evident across all three clinics contributing data over the whole study and was particularly marked for children conceived as a result of IVF.

CONCLUSION

There has been a decrease in the prevalence of birth defects over time in children born as a result of assisted reproductive technology in Western Australia; however, the prevalence of major birth defects in assisted reproductive technology singletons remains increased compared with nonassisted reproductive technology singletons.

LEVEL OF EVIDENCE

II.

IVF/ICSI outcomes after culture of human embryos at low oxygen tension: a meta-analysis

BACKGROUND

Improved pregnancy, implantation, and birth rates have been reported after the use of reduced O2 concentration during embryo culture, mainly due to a reduction of the cumulative detrimental effects of reactive oxygen species. However, some studies have failed to report any positive effects. The objective of this meta-analysis was to evaluate the effect of a low-O2 environment on IVF/intracytoplasmic sperm injection (ICSI) outcomes.

METHODS

All available published and ongoing randomised trials that compared the effects of low (~5%; OC~5) and atmospheric (~20%; OC~20) oxygen concentrations on IVF/ICSI outcomes were included. Search strategies included online surveys of databases from 1980 to 2011. The outcomes measured were fertilisation rate, implantation rate and ongoing pregnancy rates. The fixed effects model was used to calculate the odds ratio.

RESULTS

Seven studies were included in this analysis. The pooled fertilisation rate did not differ significantly (P=0.54) between the group of oocytes cultured at low O2 tension and the group at atmospheric O2 tension. Concerning all cycles, the implantation (P=0.06) and ongoing pregnancy (P=0.051) rates were not significantly different between the group receiving transferred sets containing only OC~5 embryos and the group receiving transferred sets with only OC~20 embryos. In a meta-analysis performed for only those trials in which embryos were transferred on day 2/3, implantation (P=0.63) and ongoing pregnancy (P=0.19) rates were not significantly different between the groups. In contrast, when a meta-analysis was performed using only trials in which embryos were transferred on days 5 and 6 (at the blastocyst stage), the group with transferred sets of only OC~5 embryos showed a statistically significantly higher implantation rate (P=0.006) than the group receiving transferred sets with only OC~20 embryos, although the ongoing pregnancy (P=0.19) rates were not significantly different between the groups.

CONCLUSIONS

Despite some promising results, it seems too early to conclude that low O2 culture has an effect on IVF outcome. Additional randomised controlled trials are necessary before evidence-based recommendations can be provided. It should be emphasised that the present meta-analysis does not provide any evidence that low oxygen concentration is unnecessary.

Quality Management Issues in the Assisted Reproduction Laboratory

In the United States, the Clinical Laboratory Improvement Act (CLIA) of 1988 describes requirements and guidelines for implementing a quality control/quality assurance (QC/QA) program for moderate and high complexity laboratories. These requirements and guidelines apply to Assisted Reproductive Technology (ART) laboratories as well. The general topic of QC and QA as it pertains to in vitro fertilization (IVF) and embryo transfer (ET) is extensively reviewed. This review summarizes many of the QC and QA events that contribute to the advancement of knowledge in this biotechnological field. These events include control of the culture environment inside and outside of the incubator, as well as factors that affect culture media. This review also discusses, in considerable detail, the QC and the QA that pertain to equipment used within the laboratory and how to control for potential contaminants, which reside within the laboratory. This review provides evidence to indicate the need for laboratory personnel to monitor quality improvement issues on a continuous basis. Personnel must be willing to change as improvements in technology occur in order to meet the ever-evolving demands of a more difficult patient population. Suggestions for meeting these demands are offered.

To QC or not to QC: the key to a consistent laboratory?

A limiting factor in every embryology laboratory is its capacity to grow ‘normal’ embryos. In human in vitro fertilisation (IVF), there is considerable awareness that the environment of the laboratory itself can alter the quality of the embryos produced and the industry as a whole has moved towards the implementation of auditable quality management systems. Furthermore, in some countries, such as Australia, an established quality management system is mandatory for clinical IVF practice, but such systems are less frequently found in other embryology laboratories. Although the same challenges of supporting consistent and repeatable embryo development are paramount to success in all embryology laboratories, it could be argued that they are more important in a research setting where often the measured outcomes are at an intracellular or molecular level. In the present review, we have outlined the role and importance of quality control and quality assurance systems in any embryo laboratory and have highlighted examples of how simple monitoring can provide consistency and avoid the induction of artefacts, irrespective of the laboratory’s purpose, function or species involved.

Meiotic spindle and zona pellucida characteristics as predictors of embryonic development: a preliminary study using PolScope imaging

This study assesses meiotic spindle and zona pellucida characteristics using the PolScope, and analyses their relationship to embryonic development potential. A total of 205 matured oocytes retrieved from 25 patients undergoing ovarian stimulation were imaged for meiotic spindle and zona pellucida characteristics using the PolScope. After intracytoplasmic sperm injection, the oocytes were cultured and assessed for progression to blastocysts. Meiotic spindles were visualized in 78.0% of oocytes. Significantly more oocytes with visible spindles fertilized and progressed to blastocysts compared with oocytes without visible spindles. Oocytes with spindle retardance of >3 nm showed a greater progression to blastocysts compared with those with a retardance of 2-3 nm or <2 nm. More blastocysts were obtained from oocytes with spindle lengths of >12 nm than from oocytes with spindle lengths 10-12 nm or <10 nm. A difference in progression to blastocyst was observed in oocytes with a zona inner layer retardance of >3 nm compared with oocytes with retardance of 2-3 nm or <2 nm. Oocytes with an inner layer zona of 10-12 nm thickness showed better progression compared with those with a thickness of 8-10 nm or <8 nm. Quantitative measurement of length and retardance of the meiotic spindle and zona pellucida has a positive predictive value in relation to embryonic development.

Effect of micro-environment maintenance on embryo culture after in-vitro fertilization: comparison of top-load mini incubator and conventional front-load incubator

PURPOSE

To investigate the effect of microenvironment maintenance on embryo culture and clinical results using two types of incubators.

METHODS

Temperature and oxygen concentration in a mini-incubator and a conventional incubator were compared following a 5-s door opening/closing procedure. Embryos of 30 in-vitro fertilization embryo transfer (IVF-ET) cases were randomly allocated to either one of the incubator, cultured, and the early-stage good embryo formation rate and the good blastocyst formation rate were compared, as indicators for micro-environment maintenance ability.

RESULTS

Temperature recovery after a 5-s door opening/closing procedure was approximately 5 min for the mini-incubator and 30 min for the conventional incubator. The oxygen concentration return was significantly improved in the mini-incubator (3.0 +/- 0 min) compared with the conventional incubator (7.8 +/- 0.9 min). Both the early-stage good embryo formation rate and the good blastocyst formation rate were significantly higher in the mini-incubator (39.5% and 15.1%) than the conventional incubator (28.4% and 7.8%).

CONCLUSION

The microenvironment maintenance ability of incubators appears to significantly influence the formation of good embryos.

Duration and temperature of culture medium equilibration affect frequency of blastocyst development

Hamster 2-cell embryos were cultured in 50 microl drops of chemically defined medium (HECM-9) under oil in 60 mm Petri dishes. In the first experiment, the dishes were equilibrated with 5% O(2) /10% CO(2) /85% N(2) for 2 h either within sealed plastic bags or exposed directly to the same gas mixture in a tissue culture incubator. After culture of embryos for 48 h, there was no difference in development to the blastocyst stage. In the second experiment, the dishes were first equilibrated with 5% O(2) /10% CO(2) / 85% N(2) within sealed plastic bags, (A) at 4 degrees C overnight (16-18 h), or (B) at 37.5 degrees C overnight or (C) at 37.5 degrees C for 2 h. Dishes in treatment A were placed in the incubator at 37.5 degrees C for 2 h next day just before use. Two-cell embryos from a superovulated, mated female were equally distributed among the three treatments, then the dishes were sealed in fresh bags containing the same gas mixture and incubated at 37.5 degrees C for 48 h. This experiment was replicated 13 times with a total of 20 females and 268-275 embryos/treatment. There was no significant difference among the treatments for development to the (combined) morula/blastocyst stages. However, the percentage of blastocysts that developed in culture dishes that had been equilibrated overnight at 37.5 degrees C (treatment B) was significantly lower [50 +/- 14% (SEM)] than in treatments A and C, which were not different from one another (67 +/- 11 and 60 +/- 17% respectively). These results indicate that when culture medium is incubated at 37.5 degrees C overnight, chemical deterioration occurs that is detrimental to embryo development, and that this can be avoided by equilibrating dishes at 4 degrees C overnight, followed by a brief period at 37.5 degrees C to warm the medium before inserting embryos. This finding may have clinical relevance for human embryo culture. The study also demonstrates the utility and advantages of the sealed bag system for embryo culture.

The efficacy of test tube warming devices used during oocyte retrieval for IVF

PURPOSE

To investigate whether commonly used test tube warming devices maintain a constant temperature in follicular fluid aspirates.

METHODS

By using a digital thermocouple, temperature was measured and comparisons were made between an analog dry block heater, a digital dry block heater, and a thermostatic test tube heater.

RESULTS

For small fluid volumes, temperature in the block heaters increased above 37 degrees C after being in the block for over 2 min. The thermostatic heater maintained a constant temperature, but this was below the factory setting of 36.9 degrees C. Temperature maintenance was influenced by fluid volume in each tube.

CONCLUSIONS

One of the key factors in the handling of gametes and embryos is the maintenance of constant temperature. Test tube warming devices require verification of their ability to maintain fluid at the desired temperature. Temperature may vary with fluid volume and the type of test tube warming device used.