Should all embryos be cultured to blastocyst for advanced maternal age women with low ovarian reserve: a single center retrospective study

Does conventional morphological evaluation still play a role in predicting blastocyst formation?

BACKGROUND

Advanced models including time-lapse imaging and artificial intelligence technologies have been used to predict blastocyst formation. However, the conventional morphological evaluation of embryos is still widely used. The purpose of the present study was to evaluate the predictive power of conventional morphological evaluation regarding blastocyst formation.

METHODS

Retrospective evaluation of data from 15,613 patients receiving blastocyst culture from January 2013 through December 2020 in our institution were reviewed. Generalized estimating equations (GEE) were used to establish the morphology-based model. To estimate whether including more features regarding patient characteristics and cycle parameters improve the predicting power, we also establish models including 27 more features with either LASSO regression or XGbosst. The predicted number of blastocyst were associated with the observed number of the blastocyst and were used to predict the blastocyst transfer cancellation either in fresh or frozen cycles.

RESULTS

Based on early cleavage and routine observed morphological parameters (cell number, fragmentation, and symmetry), the GEE model predicted blastocyst formation with an AUC of 0.779(95%CI: 0.77-0.787) and an accuracy of 74.7%(95%CI: 73.9%-75.5%) in the validation set. LASSO regression model and XGboost model based on the combination of cycle characteristics and embryo morphology yielded similar predicting power with AUCs of 0.78(95%CI: 0.771-0.789) and 0.754(95%CI: 0.745-0.763), respectively. For per-cycle blastocyst yield, the predicted number of blastocysts using morphological parameters alone strongly correlated with observed blastocyst number (r = 0.897, P < 0.0001) and predicted blastocyst transfer cancel with an AUC of 0.926((95%CI: 0.911-0.94).

CONCLUSION

The data suggested that routine morphology observation remained a feasible tool to support an informed decision regarding the day of transfer. However, models based on the combination of cycle characteristics and embryo morphology do not increase the predicting power significantly.

Extended embryo culture is effective for patients of an advanced maternal age

The aim of this study was to determine the effectiveness of extended embryo culture in advanced maternal age (AMA) patients (37–43 years). In this retrospective analysis, 21,301 normally fertilized zygotes from 4952 couples were cultured until the blastocyst stage. Blastocyst development, including kinetics and morphology, transfer rate, implantation and live birth rates, were measured. In AMA patients, the blastocyst rate was significantly decreased as compared to that in younger women. On day 5, blastocysts underwent growth retardation in AMA patients, which was highlighted by a decreased rate of full/expanded blastocysts. Organization of the cells (trophectoderm and inner cell mass) was unaffected by age. However, in AMA patients, a ‘good’ morphology blastocyst had a decreased probability to implant compared with an ‘average’ morphology blastocyst in younger women. While the rates of blastocyst transfer and useful blastocysts were similar to younger patients, in AMA patients, both implantation and live birth rates were significantly reduced. Our results support the idea that extended embryo culture is not harmful for AMA patients. However, embryo selection allowed by such culture is not powerful enough to avoid chromosomal abnormalities in the developed blastocysts and therefore cannot compensate for the effect of a woman’s age.

Cumulative live birth rates do not increase after 4 complete cycles in women with poor ovarian response: a retrospective study of 1,825 patients

Objective

To investigate whether the cumulative clinical pregnancy rates (CCPR) and cumulative live birth rates (CLBR) increase as the oocyte retrieval cycle increases in women with poor ovarian response.

Design

Retrospective cohort study.

Setting

Not applicable.

Patient(s)

Women diagnosed of poor ovarian response (POR) according to the Bologna criteria and who completed in vitro fertilization or intracytoplasmic sperm injection cycles between January 2014 and December 2018.

Intervention(s)

Not applicable.

Main Outcome Measure(s)

The conservative and optimistic estimations of CCPR and CLBR.

Result(s)

The conservative and optimistic estimates of CCPR peaked at the 6th complete cycle, reaching 36.44% and 71.61%, respectively. However, the conservative and optimistic estimates of CLBR peaked at the 4th complete cycle, reaching 20.22% and 38.31%, respectively. The live birth rate per complete cycle of mild stimulation protocol was comparable to other protocols after adjusting for the confounding factors. For patients ≤35 years, the live birth rate per complete cycle of progestin-primed ovarian stimulation (adjusted odds ratio = 0.51, 95% confidence interval: 0.30–0.87) and gonadotropin-releasing hormone antagonist protocol (adjusted odds ratio=0.45, 95% confidence interval: 0.24–0.81) were significantly lower than that of the mild stimulation.

Conclusion(s)

It is not advisable to initiate more than four complete cycles for POR patients since CLBR do not increase after that. For POR patients ≤35 years, the live birth rate per complete cycle increased in women with mild stimulation protocol.

A comparison of embryo culture strategies for women of advanced age with four or fewer available D3 embryos: a single centre retrospective analysis of 556 patients

The purpose of this study was to compare two embryo culture strategies in older women with four or fewer D3 embryos. A total of 556 eligible patients aged >38 years in a single reproductive centre underwent IVF/ICSI leading to the generation of four or fewer D3 embryos from April 2016 to October 2018. Patients whose D3 embryos were all cultured to blastocyst were classified as group A; those in which none of their embryos was cultured to blastocysts were classified as group B. Cumulative biochemical pregnancy rate, clinical pregnancy rate and live birth rate were similar between the two groups (p = 0.582, 0.426 and 0.546, respectively). Though more embryo transfer cycles were achieved in group B, significantly higher biochemical and clinical pregnancy rate per embryo transfer cycle were found in group A (p = 0.001 and 0.003). In patients with blastocyst culture, the clinical conditions of those who had a successful outcome were better than those who failed. Blastocyst culture and transfer can significantly increase pregnancy rate per embryo transfer cycle and may be appropriate in some older patients with a good clinical prognosis.

Clinical and neonatal outcomes of patients of different ages following transfer of thawed cleavage embryos and blastocysts cultured from thawed cleavage-stage embryos

BACKGROUND

Frozen-thawed embryo transfer (FET) has become a routine procedure in assisted reproductive technology (ART). In FET, although blastocysts cultured from thawed cleavage-stage embryos are associated with better perinatal outcomes. it may increase cycle cancellation due to no suitable embryo to transfer. The overall clinical outcomes following transfer of thawed cleavage-stage FET and blastocysts cultured from thawed cleavage-stage embryos in young and advanced age patients remains unclear. Therefore, we aimed to identify the optimal FET strategy in young and advanced age women who undergo FET.

METHODS

This retrospective study included 16,387 thaw cycles. We retrospectively analyzed data of couples who had completed the first FET cycle. Two FET strategies were studied: transfer of thawed cleavage-stage embryos (strategy A) or blastocysts cultured from thawed cleavage-stage embryos (strategy B). The clinical and neonatal outcomes of two FET strategies were compared in young (<35 years) and advanced (≥35 years) age women.

RESULTS

In young women, the clinical outcomes per transfer cycle were better in strategy B than strategy A. While the clinical pregnancy (59.29%, 52.60%) and live birth rates (49.37%, 43.88%) per thaw cycle were significantly higher in strategy A than in B. In women of advanced age, the clinical outcomes per transfer cycle were still better in strategy B than in A, and the clinical pregnancy (36.44%, 39.66%) and live birth rates (25.70%, 30.00%) per thaw cycle were significantly higher in strategy B than in A.

CONCLUSIONS

FET of blastocysts cultured from cleavage-stage embryos showed higher efficiency for per transfer cycle whether in younger or advanced age women. Whereas, when cycle cancellations due to no suitable embryo to transfer were considered, cleavage-stage FET was found to be more suitable for younger women, while FET of blastocysts cultured from cleavage-stage embryos was better suited for women of advanced age.