In-vitrofertilisation treatment: Factors affecting its results and outcome

Association Between MitoScore, BMI, and Body Fat Percentage as a Predictive Marker for the Outcome of In-Vitro Fertilization (IVF)

Background

Infertility is defined as the inability to establish a pregnancy within 12 months of regular and unprotected sexual intercourse. In response to these problems, assisted reproductive techniques (ARTs) have made profound impacts on the therapeutic management of infertility. However, in-vitro fertilization (IVF) success rates are confounded by several internal and external factors. A relatively new approach to embryo assessment is known as MitoScore (Igenomix, Miami, USA). As a result, we sough to evaluate whether MitoScore can help in predicting in IVF outcomes, and to assess the relationship between MitoScore, BMI, and body fat percentage in determining the success of ARTs.

Methods

Using retrospective cohort, a study population consisting of 166 women aged 26-43 who were undergoing ART with pre-implantation genetic testing for aneuploidy (PGT-A) was assessed to determine if MitoScore, BMI, and body fat percentage impacted IVF outcomes.

Results

MitoScore, BMI, and body fat percentage were significantly lower in pregnant women as compared to non-pregnant women. Furthermore, MitoScore was correlated with subclasses of IVF outcomes (delivery, biochemical pregnancy, and spontaneous abortion) and was found to be positively correlated with BMI in patients with biochemical pregnancies.

Conclusion

Our findings suggest that MitoScore, BMI, and body fat percentage could act as critical parameters in determining the success of ART. However, the association between MitoScore, BMI, and body fat percentage does not appear to be a significant confounding factor to determine pregnancy outcome at this stage. Still, many factors need to be considered to establish the correlation reliably.

Demographic determinants and outcome of in vitro fertilization (IVF) services in Saudi Arabia

Objectives

To assess the demographic characteristics and outcomes of couples undergoing in vitro fertilisation (IVF) treatment at a private hospital in Al Qassim district, Saudi Arabia.

Methods

For this retrospective study, information was extracted from the hospital electronic database and IVF unit medical records.

Results

2259 couples underwent 2703 IVF/ICSI cycles during 2014 to 2016. The utilization rate was approximately 1000 cycle per million of inhabitants. Mean ages ± standard deviation (SD) for women and men were 32.9 ± 5.7 and 39.2 ± 7.4 years, respectively. More couples were diagnosed with secondary infertility (55.2%) than primary infertility (44.8%). Male factor was the commonest single indication for IVF (36.2%). Mean ± SD infertility duration was 4.70 ± 4.03 years. Overall, 949 couples had a successful pregnancy. Age-specific pregnancy rates (PR) were highest for women <35 years (39.8%) and lowest for women >40 years (11.6%). Male age and infertility duration had no effect on PR but sperm source (fresh vs. frozen) and female age had significant impacts. However, fresh sperm was used in 90.6% cycles whereas frozen sperm was used in 9.4% cycles.

Conclusions

IVF treatment outcomes in the Al Qassim district are within the boundaries of average international success rates. Infertile couples seeking IVF services should be counselled with regard to important prognostic factors

Reduced Protein C Global Assay Levels in Infertile Women with in vitro Fertilization Failure: A Pilot Study

Protein C global is a global dotting assay that evaluates abnormalities in the protein C anticoagulant pathway. A few studies have examined this assay in relation to assisted reproductive technology (ART), but its role in infertile women with in vitro fertilization (IVF) failure remains unclear. In this study, we assessed protein C in infertile women with a history of IVF failure who were undergoing ART. We examined 45 healthy fertile women who conceived naturally, and 45 infertile women with 2 or more implantation failures undergoing ART. Both protein C and activated protein C resistance (APC-R) were evaluated. The results showed that mean protein C expressed as a normalized ratio (PCAT-NR) was significantly lower in the study group compared to the control group (0.76 ± 0.15 vs. 0.91 ± 0.14, respectively; p = 0.0001). Follow-up on ART outcomes showed that women who failed ART had significantly lower PCAT-NR compared to successful cases. PCAT-NR did not correlate with APC-R levels in the study (r = 0.125, p < 0.5) or failed ART subgroups. Using logistic regression analysis, patients with lower PCAT-NR levels showed an elevated risk of implantation failure (p = 0.04, OR 0.50, 95% CI 0.26-0.84). In conclusion, protein C global assay may play a role in the etiology of IVF failure, which might be independent of APC-R. Larger studies are encouraged to validate these findings and explore the underlying pathophysiological mechanisms.

Which are the most common thrombophilic genetic nucleotide polymorphisms in infertile women undergoing an IVF cycle?

INTRODUCTION

Thrombophilia is considered one of the causes of infertility, especially after repeated failures of IVF techniques. The aim of this work is to evaluate the incidence of thrombophilia in women who underwent IVF cycles and assess the outcome of the techniques.

METHODS

In vivo study. The study sample was composed of 262 women undergoing a fresh cycle of in vitro fertilization (IVF) cycle of Intracytoplasmatic Sperm Injection (ICSI) from July 2012 to December 2014 in the Center of Physiopathology of Human Reproduction. Amongst these patients, we have selected 96 patients with indication for thrombophilia screening.

RESULTS

Thrombophilia screening detects that only 8% (n = 8) of the patients was negative to all the studied mutations, while the remaining 92% (n = 88) was positive to at least one mutation. The most common mutations were MTHFR gene (C677T) (91,84%), ACE gene (54,88%) and PAI-1 gene (69,44%).

CONCLUSION

Our results showed an increased frequency of genetic nucleotide polymorphisms in women reporting failures in IVF techniques. Differently from scientific literature data, in our work, the most frequent mutation affects the enzyme gene MTHFR, particularly the C667T mutation; on the other side, mutations of factor V and II are less common.

Association between Thrombophilia and Repeated Assisted Reproductive Technology Failures

PURPOSE

This study was performed to investigate the incidence of thrombophilic gene mutations in repeated assisted reproductive technology (ART) failures.

METHODS

The prevalence of mutated genes in the patients with a history of three or more previous ART failures was compared with the patients with a history of successful pregnancy following ARTs. The study group included 70 patients, 34 with three or more previously failed ARTs (A) and control group consisted of 36 patients with successful pregnancy following ARTs (B). All patients were tested for the presence of mutated thrombophilic genes including factor V Leiden (FVL), Methylenetetrahydrofolate reductase (MTHFR) and Prothrombin (G20210A) using real-time polymerase chain reaction (RT- PCR).

RESULTS

Mutation of FVL gene was detected in 5.9% women of group A (2 of 34) compared with 2.8% women (1 of 36) of control group (P = 0.6). Mutation of MTHFR gene was found in 35.3% (12 cases) as compared with 50% (18 cases) of control (35.3% versus 50%; P = 0.23). Regarding Prothrombin, only control group had 5.6% mutation (P = 0.49). No significant differences were detected in the incidences of FVL, Prothrombin and MTHFR in the study group A compared with the control group B.

CONCLUSION

The obtained results suggest that thrombophilia does not have a significant effect in ART failures.

Female infertility following restorative proctocolectomy

AIM

Females of child-bearing age have been reported to have a two to three-fold increase in infertility after restorative proctocolectomy (RPC). This study aimed to assess aspects of infertility and pregnancy.

METHOD

A postal questionnaire was sent to 790 females who had undergone primary RPC in two tertiary centres. Infertility, the number and outcome of pregnancies, delivery method and the use of fertility treatments were determined.

RESULTS

Three hundred and six (38.5%) females responded (median age 47.9 years at follow up; 35.3 years at the time of RPC). Eighty-two per cent (n=250) had ulcerative colitis. Forty-five per cent (n=138) had conceived prior to RPC, 5.2% (n=16) conceived both before and after RPC, 5.5% (n=17) conceived after RPC only and 44.1% (n=135) had never conceived. Females delivering before RPC had significantly more vaginal deliveries than those conceiving after (pre-RPC 69.6%, n=96 vs post-RPC 35.3%, n=6; P=0.001). Fifty-seven patients stated they had attempted to conceive after RPC, with 25 (45.5%) being successful. Eighteen females had been referred to a fertility specialist, of whom 16 received in vitro fertilization (IVF). Four (30.7%) females conceived using IVF.

CONCLUSION

While RPC is known to be associated with infertility, only a small proportion of patients are referred for fertility management. IVF outcomes and success rates after RPC are similar to the general population. Patients are more likely to have a Caesarean section following RPC.

Thrombophilia and outcomes of assisted reproduction technologies: a systematic review and meta-analysis

Thrombophilia has been associated with pregnancy complications and recurrent miscarriage. The aim of this systematic review was to evaluate the controversial association between thrombophilia and failures of assisted reproduction technology (ART). A systematic search of the literature for studies reporting on thrombophilia in women undergoing ART up to April 2011 yielded 33 studies (23 evaluating anti-phospholipid antibodies, 5 inherited thrombophilia, and 5 both) involving 6092 patients. Overall, methodologic quality of the studies was poor. Combined results from case-control studies showed that factor V Leiden was significantly more prevalent among women with ART failure compared with fertile parous women or those achieving pregnancy after ART (odds ratio = 3.08; 95% confidence interval, 1.77-5.36). The prothrombin mutation, methylenetetrahydrofolate reductase mutation, deficiency of protein S, protein C, or anti-thrombin were all not associated with ART failure. Women with ART failure tested more frequently positive for anti-phospholipids antibodies (odds ratio = 3.33; 95% confidence interval, 1.77-6.26) with evidence of high degree of between-study heterogeneity (I2 = 75%; P < .00001). Prospective cohort studies did not show significant associations between thrombophilia and ART outcomes. Although case-control studies suggest that women experiencing ART failures are more frequently positive for factor V Leiden and anti-phospholipid antibodies, the evidence is inconclusive and not supported by cohort studies.

Fertility, Infertility and Thrombophilia

Hypercoagulation has been reported in some studies to be associated with reproductive failures, such as unexplained infertility, IVF implantation failure and recurrent fetal losses. Many pregnancy-related disorders have been interpreted as consequences of impaired microvascular function and might be viewed as a mild form of venous thromboembolic disease. In the absence of clinical guidelines, there is a need for an evidence base regarding thrombophilic screening and antithrombotic therapy in cases of reproductive failure. This article will focus on the controversial effect of congenital and acquired thrombophilia on human fertility, and will review the English literature for relevant studies identified by searching PubMed® results between January 1966–November 2010 using the key words: ‘thrombophilia‘, ‘fertility’ and ‘infertility‘.

Predictive factors in in vitro fertilization (IVF): a systematic review and meta-analysis

BACKGROUND

Various models have been developed for the prediction of pregnancy after in vitro fertilization (IVF). These models differ from one another in the predictors they include. We performed a systematic review and meta-analysis to identify the most relevant predictors for success in IVF.

METHODS

We systematically searched MEDLINE and EMBASE for studies evaluating IVF/ICSI outcome. Studies were included if they reported an unconditional odds ratio (OR) or whenever one could be calculated for one or more of the following factors: age, type of infertility, indication, duration of infertility, basal FSH, number of oocytes, fertilization method, number of embryos transferred and embryo quality.

RESULTS

Fourteen studies were identified. A summary OR could be calculated for five factors. We found negative associations between pregnancy and female age [OR: 0.95, 95% confidence interval (CI): 0.94-0.96], duration of subfertility (OR: 0.99, 95% CI: 0.98-1.00) and basal FSH (OR: 0.94, 95% CI: 0.88-1.00). We found a positive association with number of oocytes (OR 1.04, 95% CI: 1.02-1.07). Better embryo quality was associated with higher pregnancy chances. No significant association was found for the type of infertility and fertilization method. A summary OR for IVF indication and number of embryos transferred could not be calculated, because studies reporting on these used different reference categories.

CONCLUSIONS

Female age, duration of subfertility, bFSH and number of oocytes, all reflecting ovarian function, are predictors of pregnancy after IVF. Better quality studies are necessary, especially studies that focus on embryo factors that are predictive of success in IVF.

Previous tubal ectopic pregnancy raises the incidence of repeated ectopic pregnancies in in vitro fertilization-embryo transfer patients

PURPOSE

To investigate the incidence of Tubal Ectopic Pregnancies (TEP) in IVF-ET patients with respect to the status of the fallopian tubes after a previous TEP.

MATERIAL AND METHODS

This retrospective study compares patients undergoing 481 IVF-ET cycles after conservatively or surgically treated TEP(s) with a Control Group (idiopathic or male factor for IVF-ET indication). Medical reports of surgery and/or hysterosalpingograms prior to the IVF cycles classified the status of the fallopian tubes.

RESULTS

12 TEPs (8.95%/Pregnancies (PR)) occurred in the Study Group. In the Control Group one TEP (0.75%/PR; p < 0.001) was found. Smoking increased the probability of TEPs (p = 0.0028) and of pathological pregnancies (abortion, biochemical and ectopic PR; (p = 0.0411)). For statistic evolution logistic regression (PROC GENMOD) and a repeated measure model were applied.

CONCLUSION

Women with a previous TEP should be informed about the significantly increased risk for a further TEP in IVF-ET treatment, especially if they are smoking.

The accuracy of multivariate models predicting ovarian reserve and pregnancy after in vitro fertilization: a meta-analysis

BACKGROUND To review the accuracy of multivariate models for the prediction of ovarian reserve and pregnancy in women undergoing IVF compared with the antral follicle count (AFC) as single test. METHODS We performed a computerized MEDLINE and EMBASE search to identify articles published on multivariate models for ovarian reserve testing in patients undergoing IVF. In order to be selected, articles had to contain data on the outcome of IVF in terms of either pregnancy and/or poor response and on the prediction of these events based on a multivariate model. For the selected studies, sensitivity and specificity of the test in the prediction of poor ovarian response and non-pregnancy were calculated. Overall performance was assessed by estimating a summary receiver operating characteristic (ROC) curve, which was compared with the ROC curve for the AFC as the current best single test. RESULTS We identified 11 studies reporting on the predictive capacity of multivariate models in ovarian reserve testing. All studies reported on the prediction of poor ovarian response, whereas none reported on the occurrence of pregnancy. The sensitivity for prediction of poor ovarian response varied between 39% and 97% and the specificity between 50% and 96%. Logistic regression analysis indicated that cohort studies provided a significantly better discriminative performance than case-control studies. As cohort studies are superior to case-control studies, further analysis was limited to the cohort studies. For the cohort studies, a summary ROC curve could be estimated, which had a shape similar to that previously made for the AFC. CONCLUSIONS The accuracy of multivariate models for the prediction of ovarian response in women undergoing IVF is similar to the accuracy of AFC. No data are available on the capacity of these models to predict pregnancy, let alone live birth. On the basis of these findings, the use of more than one single test for the assessment of ovarian reserve cannot currently be supported.

The impact of obesity on female reproductive function

Obesity may be described as the new worldwide epidemic, and its serious impact on morbidity and mortality are well known. As more and more women become obese, the reproductive problems associated with obesity present an ever-growing challenge to physicians involved in their fertility care. The spectrum of reproductive problems associated with obesity encompasses a wide range of disorders including infertility problems, miscarriage and pregnancy complications. In this review, we aim to discuss the impact of obesity on the various aspects of female reproductive function with focus on the clinical aspects of fertility problems in obese women. We finally comment on the available therapeutic options available to this group of women.

Aneuploidy rates in embryos from women with prematurely declining ovarian function: a pilot study

OBJECTIVE

Prematurely declining ovarian function (PDOF) affects approximately 10% of infertile females, and has been suggested to represent a shift of the normal ovarian aging curve toward younger age. Whether women with PDOF demonstrate an increased level of aneuploidy in their embryos, based on increasing aneuploidy rates with advancing female age, is unknown, and was the subject of this study.

DESIGN

Retrospective, case-control study.

SETTING

Academically affiliated private IVF center.

PATIENT(S)

Twenty women with PDOF, and 20 age-matched controls with age-appropriate ovarian function (AAOF), underwent IVF cycles and preimplantation genetic diagnosis (PGD) by fluorescence in situ hybridization for chromosomes X, Y, 13, 16, 18, 21, and 22 on day 3 after fertilization, and ET on day 5.

INTERVENTION(S)

None.

MEAN OUTCOME MEASURE(S)

Oocyte and embryo numbers, embryonic aneuploidy rates, pregnancies, and miscarriages.

RESULT(S)

Pregnancy rates (PRs) after initial fresh ET did not differ between patients with PDOF and those with AAOF. Among a total of 258 embryos analyzed by PGD, aneuploidy rates in PDOF and AAOF cycles were 52.6% and 52.2%, respectively. A trend toward lower ongoing PRs was noted in patients with PDOF (21% versus 41%), primarily attributable to higher clinical miscarriage rates (50% versus 13%) after detection of fetal heart motion.

CONCLUSION(S)

In this pilot study, the observation that PDOF is not characterized by an increased aneuploidy rate (controlled for age) suggests that PDOF does not represent a simple shift of the physiologically declining ovarian function curve toward younger age. This observation, indeed, suggests that the underlying pathophysiology of PDOF may vary from that of AAOF.

South Asian women with polycystic ovary syndrome exhibit greater sensitivity to gonadotropin stimulation with reduced fertilization and ongoing pregnancy rates than their Caucasian counterparts

Polycystic ovary syndrome (PCOS) is a heterogeneous syndrome. In vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) is required for PCOS cases that are refractory to standard ovulation induction or have co-existing infertility factors in women with PCOS and Tubal factor subfertility.

OBJECTIVES

Assess ethnic variations in response to IVF/ICSI treatment.

STUDY DESIGN

Observational Comparative study in a University hospital fertility clinic in women with PCOS and Tubal factor subfertility. Women with PCOS (Asians: AP=104; Caucasians: CP=220) and those with tubal factor infertility seeking fertility treatment were assessed (Asians: AC=84; Caucasians: CC=200). Six hundred and eight fresh IVF or ICSI cycles using long protocol of GnRHa suppression and resulting in a fresh embryo transfer were compared. The primary endpoint was to assess the dose of gonadotropins used in the cycles. The secondary outcomes were: total number of oocytes retrieved, fertilization and ongoing clinical pregnancy rates.

RESULTS

We found that the South Asian women presented at a younger age for the management of sub-fertility. An extended stimulation phase and Caucasian ethnicity showed an inverse correlation with the number of oocytes retrieved in the PCOS subgroup. Caucasian ethnicity was associated with a higher fertilization rate however increase in body mass index (BMI) and the laboratory technique of IVF appeared to have a negative impact on fertilization rates in the PCOS subgroup. Commencing down regulation on day 1 of the cycles was negatively associated with fertilization rates in the tubal group. In terms of clinical pregnancy rates, the Caucasian PCOS had a 2.5 times (95% CI: 1.25-5) higher chance of an ongoing clinical pregnancy as compared with their Asian counterpart. Also, a unit increase in the basal FSH concentration reduced the odds of pregnancy by 18.6% (95% CI: 1.8-32.6%) in the PCOS group.

CONCLUSIONS

The Asian PCOS have a greater sensitivity to gonadotropin stimulation with lower fertilization and ongoing clinical pregnancy rates as compared with their Caucasian counterparts.

Acquired and inherited thrombophilia: implication in recurrent IVF and embryo transfer failure

BACKGROUND

The objective of this study was to determine the incidence of undiagnosed thrombophilic factors and its relation to IVF and embryo transfer failure in women who have had three or more previous IVF-embryo transfer cycles.

METHODS

The study group comprised of 90 consecutive women with three or more previously failed IVF-embryo transfer cycles (group A). Two control groups were enrolled: group B (n=90) included women who have had successful pregnancy after their first IVF-embryo transfer cycle, and group C (n=100) included women who conceived spontaneously with at least one uneventful pregnancy and no previous history of miscarriage. All women were tested for the presence of inherited [factor V Leiden (FVL) mutation, prothrombin mutation, methylenetetrahydrofolate reductase (MTHFR) mutation and deficiencies in proteins S and C and antithrombin III] or acquired (lupus anticoagulant and anticardiolipin) thrombophilic factors.

RESULTS

An increase in the incidences of FVL, MTHFR and antiphospholipid antibodies was found in the study group compared with the two control groups. At least one inherited or acquired thrombophilic factor was detected in 68.9% of women with repeated IVF failure compared with 25.6 and 25% in the groups B and C, respectively (P<0.01). Combined thrombophilia (two or more thrombophilic factors) was significantly higher in women who have had repeated IVF failure as compared with the two control groups (35.6 versus 4.4 and 3%) (P<0.0001).

CONCLUSION

Thrombophilia has a significant role in IVF-embryo transfer implantation failure. Women with repeated IVF-embryo transfer failure should be screened for thrombophilia.