Assisted reproductive technology in Europe, 2004: results generated from European registers by ESHRE

Children born to subfertile couples, how are they doing? Evidence from research

More than 10 million children have been born with assisted reproductive technology (ART) as we begin to enter the third generation of individuals conceived by ART. Here we summarise key messages from an enlarging body of literature regarding their health. Earlier research had pointed towards increases in perinatal, neonatal and neurological risks, such as preterm birth, low birth weight, congenital malformations and cerebral palsy. Many of these risks have continued to persist in most recent work but have shown reduction. Newer research proposes long-term cardiometabolic and endocrine concerns. Fortunately, most reports conclude there is little or no risk of increased childhood malignancy or abnormal neurodevelopment. Moving forward, new research may benefit from changes in comparator groups and a better understanding of infertility per se in ART, and the confounding role it probably plays in many of the known risk associations, to reliably scan the horizon for health threats for individuals born after ART.

Comparative efficacy of acupuncture-related interventions for tubal obstructive infertility: A systematic review and Bayesian meta-analysis of randomized controlled trials

BACKGROUND

Tubal obstructive infertility (TOI) is a challenging condition affecting many women worldwide. Acupuncture and herbal medicine have emerged as potential therapeutic options for enhancing fertility outcomes in these patients. However, the evidence regarding their efficacy remains inconclusive, necessitating a comprehensive systematic review and meta-analysis.

METHOD

Computer searches were conducted in PubMed, Cochrane, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), VIP Information, Wanfang Database, and China Biology Medicine (CBM) databases to retrieve relevant literature on the efficacy and safety of acupuncture and related therapies for the treatment of tubal obstructive infertility. The search period extended from the inception of the databases to December 2022. Two researchers independently screened the literature based on strict inclusion criteria, extracted relevant data, and utilized Cochrane Collaboration tools and the Jadad scale to comprehensively assess the quality of the included studies. Subsequently, pairwise meta-analysis and network meta-analysis were performed using statistical software such as StataSE and Rstudio, and graphical representations were generated to present the results.

RESULT

The network meta-analysis included 1580 articles, with 23 meeting the criteria. These studies involved 2355 patients and explored 13 intervention measures. Acupuncture-related therapies outperformed control interventions in improving pregnancy rates, tubal patency rates, and overall effectiveness while demonstrating a lower incidence of adverse events. EA+CHM was identified as the most effective for pregnancy rates, MOX for tubal patency rates, and MOX+AP for overall effectiveness. The safety profile of acupuncture-related interventions was acceptable. These findings support acupuncture-related therapies as effective and safe options for tubal obstructive infertility management. Further high-quality research is needed to validate and expand upon these results.

CONCLUSION

These findings offer novel treatment strategies for acupuncture-related interventions, providing practitioners with evidence-based guidance. Addressing limitations through future research is crucial, including diverse literature, emphasizing higher-quality RCTs, and exploring a broader range of interventions with long-term follow-up data. Systematic assessment of adverse events, standardized techniques, and robust ranking methods should be considered.

Research progress of time-lapse imaging technology and embryonic development potential: A review

Cultivation and selection of high-quality human embryos are critical for the success of in vitro fertilization-embryo transfer. Time-lapse imaging technology (TLI) provides a stable culture environment for embryos, which can continuously observe and record the development process of early embryos, so that doctors can record embryo development time parameters more accurately. In this study, we review the current observation and research on the main embryo dynamics parameters in TLI and discusses their significance and development for embryo development potential. To analysis and summary, the application and research situation of TLI, we searched PubMed, Web of Science, and China National Knowledge Infrastructure, using TLI, embryo dynamics parameters, embryo development potential as Keywords, cited 50 out of the initial 89 selected literatures and summarized. With comparative analysis and research, we found that the embryo dynamic parameters provided by TLI has been intensively studied in clinical empirical and observational research, extensive experimental data verified its effectiveness and advantages in embryo development potential assessment. TLI provides technical support of embryo dynamic parameters, which may become the quantitative indicators for superior embryos and pregnancy prediction as well. Existing studies have shown that certain kinetic parameters provided by TLI culture can predict embryo implantation, but no parameter has been confirmed as the absolute correlation biological indicators yet. In this review we believe that further research is needed to verify these preliminary and sometimes contradictory results, and explore the predictive significance of various embryo kinetic parameters relying on TLI technology for embryo development potential.

Promising Perinatal Outcome after Using a Simplified Low-Cost IVF Culture System Specifically Designed for Resource-Poor Countries

Background: Assisted reproductive techniques services are often not accessible to the majority of infertile couples in Low and Middle Income Countries (LMIC) due to high costs. Lowering IVF laboratory costs is a crucial step to make IVF affordable for a larger part of the world population. We developed a simplified culture system (SCS) which has proven to be effective, and the next step is to prove its safety.Methods: Preterm birth (PTB) and low birthweight (LBW) of 176 singletons born after using the SCS, 105 after fresh embryo transfer (fresh ET), and 71 after frozen embryo transfer (frozen ET) were compared with all IVF/ICSI singletons born in Belgium between 2013 and 2018. When comparing our 105 SCS babies born after fresh ET with all Belgian babies born after conventional IVF only, we also adjusted for 7 risk factors known to influence perinatal outcome, namelythe mother’s age, day of transfer, pituitary inhibition protocol, rank of cycles, number of oocytes retrieved, number of embryos transferred, and gender of the baby.Findings: Before adjustment, we found a significantly higher PTB (10.2% vs. 3.8%, OR 2.852, 95% CI [1.042–7.803], p-value 0.0413) and LBW (9.8% vs. 2.9%, OR 3.692, 95% CI [1.163–11.721], p-value 0.0267) in the conventional IVF group versus SCS after fresh ET. After adjusting for seven risk parameters, these differences remained significant (PTB: OR 2.627, 95% CI [1.013–6.816], p-value 0.0471) and LBW: OR 3.267, 95% CI [1.118–9.549], p-value 0.0305). PTB and LBW between both groups was not significantly different for singletons born after frozen ET. Interpretation: Taking into account the small series, PTB and LBW rates in SCS singletons in FRET cycles are very reassuring and significantly lower compared to babies born after conventional IVF in Belgium. Being aware of its effectiveness, our results offer a good perspective for SCS to become an important tool to implement low-cost IVF in LMIC.

A Cohort Study Comparing the Growth and Neurodevelopmental Outcome of Babies Conceived by Assisted Reproductive Technology with Those of Naturally Conceived Babies from Birth till 24 Months

OBJECTIVE

To compare the growth and neurodevelopmental outcome of term, singleton babies conceived by assisted reproduction with those of naturally conceived babies.

METHODS

A cohort study evaluating the growth delay in terms of proportion of babies with wasting (W/L < -2SD) at 6, 12 and 24 mo follow-up. Developmental delay was defined as either motor or mental developmental quotient < 70 in DASII.

RESULTS

Amongst the 128 artificially conceived babies, at 6 and 12 mo, the proportions of babies with wasting (21.1% and 17.2%), motor (7.03%, 6.3%), and mental developmental delays (5.5% and 3.9%) were significantly higher (p < 0.05) compared to the naturally conceived babies (10.94%, 8.6%, 1.6%, 0.8%, 0.8% and 0%, respectively). However, at 24 mo, the difference in outcomes were not statistically significant (p > 0.05).

CONCLUSION

The growth and neurodevelopment of artificially conceived babies may be delayed in early infancy but they normalize to catch up with their naturally conceived peers by 24 mo.

The low fetal fraction at the first trimester is associated with adverse pregnancy outcomes in IVF singleton pregnancies with single embryo transfer from frozen cycles

PURPOSE

To study the associations between fetal fraction at the first trimester and subsequent adverse pregnancy outcomes (APOs) in IVF singleton pregnancies with single embryo transfer from frozen cycles.

METHODS

This is a single-center retrospective cohort study on IVF singleton pregnancies with single embryo transfer from frozen cycles. A total of 8457 women were collected between March 2015 and September 2018 from the Center for Reproductive Medicine, Shandong University, China. Participants underwent cell-free DNA (cfDNA) sequencing at 11-13 weeks' gestation. Multivariable logistic regressions were performed with the risk of APOs based on various predictor variables.

RESULTS

A total of 8457 women were included in the analysis of which 1563 (18.48%) women developed one or more APOs. The hypertensive disorders of pregnancy (HDP) (N = 515), gestational diabetes mellitus (GDM) (N = 684), preterm birth (PTB) (N = 567), and low birth weight (LBW) (N = 306) groups had lower fetal fraction compared with the no pregnancy complication (NPC) group (all p values < 0.05). Based on the multivariable logistic regression results, the optimal cutoff values of fetal fraction were 9.30%, 12.54%, 9.10%, 12.65%, and 13.83% for at least one APO, HDP, GDM, PTB, and LBW, respectively. After adjustment for potential maternal confounders, women in the low fetal fraction (LFF) group had a higher risk for the APOs compared with high fetal fraction (HFF) group.

CONCLUSIONS

The fetal fraction in HDP, GDM, PTB, and LBW groups were lower than NPC group in IVF singleton pregnancies with single embryo transfer from frozen cycles in China.

Outcomes of embryo vitrification at different developmental stages: Evaluation of 2412 warming cycles

INTRODUCTION

Advances in cell culture media have led to a shift from cleavage stage embryo transfer to blastocyst stage transfer. Extended embryo culture to the blastocyst stage provides some theoretical advantages and disadvantages. There has been controversy. This study is sought to evaluate the clinical outcomes of vitrified-warmed cleavage-stage and blastocyst-stage embryo transfers in patients undergoing Artificial Reproductive Technique treatments.

MATERIAL AND METHOD

The study was performed on 2740 women undergoing frozen embryo thawing transfer. Patients' basic situation, status of frozen embryo transfer cycle, clinical pregnancy rate, early abortion rate, sex ratio of birth, and birth weight were retrospectively analyzed. We compared the main clinical results of recovery of frozen embryo on the cleavage stage and blastocyst stage. Furthermore, we evaluated the clinical outcomes of blastocyst cryopreservation on Day 5, 6, or 7 after oocyte retrieval according to the day of blastocyst expansion were evaluated.

RESULTS

The implantation ratio of cleavage stage embryos was 21.62% compared with 43.52% on D5 (P < .05). The D5, D6, and D7 implanting rates were statistically different. The pregnancy rates were 57.56%, 51.76%, and 35.95% versus 37.79%, respectively for embryos cryopreserved on D5, D6, D7, and D3. The ectopic pregnancy rate and early abortion rate were statistically different between D5 and D3. The sex ratio, the birth weight, and birth defect were not statistically different among the four groups.

CONCLUSIONS

Blastocyst transfer achieved a higher implantation rate than vitrified cleavage stage embryo and decreased ectopic pregnancy rate. With increased incubation days before expansion blastocyst formed, the implantation rate is reduced and the early abortion rate increases.

Live-Birth Prediction of Natural-Cycle In Vitro Fertilization Using 57,558 Linked Cycle Records: A Machine Learning Perspective

BACKGROUND

Natural-cycle in vitro fertilization (NC-IVF) is an in vitro fertilization (IVF) cycle without gonadotropins or any other stimulation of follicular growth. Previous studies on live-birth prediction of NC-IVF were very few; the sample size was very limited. This study aims to construct a machine learning model to predict live-birth occurrence of NC-IVF using 57,558 linked cycle records and help clinicians develop treatment strategies.

DESIGN AND METHODS

The dataset contained 57,558 anonymized register patient records undergoing NC-IVF cycles from 2005 to 2016 filtered from 7bsp;60,732 records in the Human Fertilisation and Embryology Authority (HFEA) data. We selected matching records and features through data filtering and feature selection methods. Two groups of twelve machine learning models were trained and tested. Eight metrics, e.g., F1 score, Matthews correlation coefficient (MCC), the area under the receiver operating characteristic curve (AUC), etc., were computed to evaluate the performance of each model.

RESULTS

Two groups of twelve models were trained and tested. The artificial neural network (ANN) model performed the best in the machine learning group (F1 score, 70.87%; MCC, 50.37%; and AUC score, 0.7939). The LogitBoost model obtained the best scores in the ensemble learning group (F1 score, 70.57%; MCC, 50.75%; and AUC score, 0.7907). After the comparison between the two models, the LogitBoost model was recognized as an optimal one.

CONCLUSION

In this study, NC-IVF-related datasets were extracted from the HFEA data, and a machine learning-based prediction model was successfully constructed through this largest NC-IVF dataset currently. This model is universal and stable, which can help clinicians predict the live-birth success rate of NC-IVF in advance before developing IVF treatment strategies and then choose the best benefit treatment strategy according to the patients' wishes. As "use less stimulation and back to natural condition" becomes more and more popular, this model is more meaningful in the decision-making assistance system for IVF.

Predictive Factors and ICSI Results for Sperm Retrieval by Microdissection Testicular Sperm Extraction (micro-TESE) in Patients with Klinefelter Syndrome

OBJECTIVE

To determine the predictive factors for successful retrieval of sperm from testicles before microdissection-testicular sperm extraction (micro-TESE) in patients with Klinefelter syndrome (KS) in order to counsel these patients regarding the likelihood of findings sperm.

MATERIALS AND METHODS

The study is a retrospective analysis of the records of 67 men with KS between April 2016 and August 2020. Serum luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, prolactin, and estradiol levels were investigated. Testicular volumes were measured by ultrasonography. TESE was noted as positive or negative.

RESULTS

There were 32 (47.8%) micro-TESE-negative patients and 35 (52.2%) m-TESE positive patients. The age of the micro-TESE-negative (34.9 ± 5.1 years) patient group was significantly higher than the micro-TESE-positive (32.3 ± 4.7 years) group (p = 0.035).The left testicular volume values were significantly higher in the micro-TESE-positive group (p = 0.019). FSH, LH, and prolactin levels were higher in m-TESE-negative patients compared to micro-TESE-positive patients, and testosterone levels and testicular volume were lower in micro-TESE-negative patients compared to micro-TESE-positive patients. However, these differences were not significant. As a result of intracytoplasmic sperm injection (ICSI) performed on 31 couples, 20 pregnancies and 16 live births were obtained (51.06%).

CONCLUSION

Among the parameters examined in this study, the age of the patient with KS may be predictive for micro-TESE success. Counseling should be given that some patients with KS may have a child via micro-TESE-ICSI.

A robust metabolomics approach for the evaluation of human embryos from in vitro fertilization

The identification of the most competent embryos for transfer to the uterus constitutes the main challenge of in vitro fertilization (IVF). We established a metabolomic-based approach by applying Fourier transform infrared (FTIR) spectroscopy on 130 samples of 3-day embryo culture supernatants from 26 embryos that implanted and 104 embryos that failed. On examining the internal structure of the data by unsupervised multivariate analysis, we found that the supernatant spectra of nonimplanted embryos constituted a highly heterogeneous group. Whereas ∼40% of these supernatants were spectroscopically indistinguishable from those of successfully implanted embryos, ∼60% exhibited diverse, heterogeneous metabolic fingerprints. This observation proved to be the direct result of pregnancy's multifactorial nature, involving both intrinsic embryonic traits and external characteristics. Our data analysis strategy thus involved one-class modelling techniques employing soft independent modelling of class analogy that identified deviant fingerprints as unsuitable for implantation. From these findings, we could develop a noninvasive Fourier-transform-infrared-spectroscopy-based approach that represents a shift in the fundamental paradigm for data modelling applied in assisted-fertilization technologies.

Single blastocyst stage versus single cleavage stage embryo transfer following fresh transfer: A systematic review and meta-analysis

OBJECTIVES

To compare the available evidence of the effectiveness of single blastocyst stage transfer against the effectiveness of single cleavage stage embryo transfer.

STUDY DESIGN

A systematic research based on Pubmed, Embase and the Cochrane Library was performed until May 2, 2020 to identify all relevant studies. The Cochrane Collaboration's Review Manager (RevMan) 5.0.2 software was used for statistical analysis.

RESULTS

Five randomized controlled trials (RCTs) were included in analysis, involving 1784 patients in total, who were divided into 2 groups, which were the single blastocyst stage transfer (SBT) group of 932, and the single cleavage stage transfer (SCT) group of 852. Our meta-analysis concluded that SBT group had a significantly higher clinical pregnancy rate (RR 1.26; 95%CI: 1.14-1.39), ongoing pregnancy rate (RR 1.19; 95%CI: 1.05-1.35) and delivery rate (RR 1.4; 95%CI: 1.13-1.75) than SCT group during the fresh transfer. While miscarriage rate (RR 0.93; 95% CI: 0.66-1.33), multiple pregnancy rate (RR, 1.12; 95% CI, 0.51-2.45) and ectopic pregnancy rate (RR, 0.5; 95% CI: 0.13-1.90) between two groups showed no significant difference. However, the SCT group contained notably more cryopreserved embryos than the SBT group. (RR -0.68, 95% CI: -0.95 to -0.41).

CONCLUSIONS

Our results indicate that single blastocyst stage transfer is associated with higher ongoing pregnancy rate and delivery rate comparing to single cleavage stage transfer in the clinical practice. Due to the low quality of the evidence of the primary outcomes, other higher-quality lager RCTs are necessary before a fully informed decision is made.

The experience of in vitro fertilization data collection in Turkey

Collecting and reporting data is a crucial aspect of in vitro fertilization (IVF) practice. During the following two decades after the first report of the European IVF-monitoring Consortium (EIM) on IVF data, the number of contributing countries increased gradually reaching nearly forty. For the first seven years of publication, between 2001 and 2007, Turkey did not provide IVF data to the European registry. Turkey first took part in the European registry in 2008 and thus also in the World registry. The addition of Turkish data to EIM was an important milestone, since Turkey appeared as the country with the sixth highest number of cycles, performing nearly eight percent of all European assisted reproductive technology (ART) cycles. Turkey continued contributing to the European registry for the following four years consecutively but after 2012 the input of Turkish IVF data stopped. Strikingly, between 2008-2012 Turkey became one of the main contributors to the registry with an ability to give a full report. So far, we do not have a complete European set of data and the number of cycles reported by European Society for Human Reproduction and Embryology (ESHRE) EIM can easily be said to be an underestimation of the actual number of cycles. IVF data from Turkey - a country having the 17th highest population in the World and appearing among the first six countries in Europe in terms of the number of ART cycles per year- will definitely contribute very much to ESHRE EIM database. It is now time to turn the tide and restart submitting Turkish data to European registry, but this time regularly and in a systematic method. Such an achievement will greatly contribute to the aim of EIM of achieving a complete data set.

Applications of noninvasive prenatal testing in vanishing twin syndrome pregnancies after treatment of assisted reproductive technology in a single center

OBJECTIVE

The objective of the study is to assess the clinical application of noninvasive prenatal testing (NIPT) for VTS pregnancies after the treatment of assisted reproductive technology (ART).

METHOD

This was a retrospective study on VTS pregnancies through ART treatment. Participants underwent NIPT at 11 to 13 weeks gestation by sequencing. Resampling was recommended for both positive and testing failure cases. For NIPT positive results, participants were advised to have invasive testing. Clinical outcomes were obtained by telephone interview.

RESULTS

In total of 579 cases, testing failure rates after first sampling and resampling were 7.6% and 1.4%, respectively. Twelve positive results were reported by NIPT. But only one true positive was confirmed, giving a PPV of 8%. A total of 576 cases completed the follow-up (including 533 NIPT negative, 12 positive, and 31 testing failure) and three cases lost follow-up. Among the 536 cases with NIPT negative results, 504 (94.0%) resulted in live-birth and 29 (5.4%) resulted in miscarriage or stillbirths. No false-negative result was reported.

CONCLUSION

NIPT has the potential to be used in prenatal screening for VTS pregnancies. For the pregnant women who obtained positive and testing failure results, resampling after 15 weeks of gestation is recommended.

Success of in vitro fertilization and its association with the levels of psychophysiological stress before and during the treatment

Despite the advance of assisted reproduction, high rates of failure in treatment are still observed. Herein, we investigated how the psychophysiological stress profiles of patients can modulate the in vitro fertilization treatment (IVF) outcome. The women who had failure in IVF (n = 13; 65%) had higher baseline salivary cortisol awakening response and anxiety-state during treatment than patients who became pregnant (n = 7; 35%). Patients with major stress levels and religious coping style showed lower social support, which was correlated with higher anxiety. Therefore, we appointed stress modulators that negatively affect IVF and should be improved aiming to increase its success.

Consequences of assisted reproductive technologies for offspring function in cattle

Abnormal fetuses, neonates and adult offspring derived by assisted reproductive technologies (ART) have been reported in humans, rodents and domestic animals. The use of ART has also been associated with an increased likelihood of certain adult diseases. These abnormalities may arise as a result of an excess of or missing maternally derived molecules during invitro culture, because the invitro environment is artificial and suboptimal for embryo development. Nonetheless, the success of ART in overcoming infertility or improving livestock genetics is undeniable. Limitations of invitro embryo production (IVEP) in cattle include lower rates of the establishment and maintenance of pregnancy and an increased incidence of neonatal morbidity and mortality. Moreover, recent studies demonstrated long-term effects of IVEP in cattle, including increased postnatal mortality, altered growth and a slight reduction in the performance of adult dairy cows. This review addresses the effects of an altered preimplantation environment on embryo and fetal programming and offspring development. We discuss cellular and molecular responses of the embryo to the maternal environment, how ART may disturb programming, the possible role of epigenetic effects as a mechanism for altered phenotypes and long-term effects of ART that manifest in postnatal life.

The demographics of assisted reproductive technology births in a Nordic country

STUDY QUESTION

What are the socio-demographic characteristics of families in Norway who have children after assisted reproductive technology (ART), and have these characteristics changed over time?

SUMMARY ANSWER

Parents who conceive through ART in Norway tend to be advantaged families, and their socio-demographic profile has not changed considerably over the period 1985-2014.

WHAT IS KNOWN ALREADY

A small number of studies show that couples who conceive through ART tend to be socio-economically advantaged.

STUDY DESIGN, SIZE, DURATION

Norwegian Population Register, the Medical Birth Register and the national data bases were linked to study all live births in Norway between 1985 and 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The sample consisted of 1 757 768 live births. Simple bivariate analyses were performed to describe the socio-demographic characteristics of parents who conceived through ART and changes in these characteristics over the time period 1985-2014. We used linear probability models to estimate the association between parental income and giving birth after ART from 2000 to 2014, before and after adjustment for maternal age at delivery, education and area of residence.

MAIN RESULTS AND THE ROLE OF CHANCE

Parents conceiving through ART were more likely to be older, with the highest levels of income and education, and married. Their socio-demographic profiles did not change considerably during the period 1985-2014. In the unadjusted model, parents belonging to the top income quartile were 4.2 percentage points more likely (95% CI: 4.1 to 4.3) to have conceived through ART than parents who belonged to the bottom income quartile. Adjustment for maternal age only partially reduced the income disparities (for the top income quartile by 35% (β = 2.7 with 95% CI: 2.5 to 2.8)). Additional adjustment for maternal education, marital status and area of residence did not further attenuate the associations.

LIMITATIONS, REASONS FOR CAUTION

The data does not enable us to tell whether the lower numbers of children conceived through ART amongst more disadvantaged individuals is caused by lower success rates with ART treatment, lower demand of ART services or barriers faced in access to ART. The study focuses on Norway, a context characterised by high subsidisation of ART services.

WIDER IMPLICATIONS OF THE FINDINGS

Even though in Norway access to ART services is highly subsidised, the results highlight important and persisting social inequities in use of ART. The results also indicate that children born after ART grow up in resourceful environments, which will benefit their development and well-being.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by European Research Council agreement n. 803959 (to A.G.), by Economic and Social Research Council grant ES/M001660/1 and by the Research Council of Norway through its Centres of Excellence funding scheme, project number 262700. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

School performance and long-term outcomes of very preterm children conceived via in vitro fertilization

Objective

To assess the impact of in vitro fertilization (IVF) on school performance and long-term outcomes in very preterm children aged 8-16 years.

Methods

Seventy-nine children born after IVF were compared with 79 randomly selected matched controls born after spontaneous conception (SC). Information was obtained from parents via a questionnaire administered through telephone interviews looking into school performance, including preschool education, repeated grades, extra lessons, special education needs, and learning difficulties; long-term status, including incidence of attention deficit hyperactivity disorder and autism; and family profile. Gross motor function was assessed against the gross motor function classification system based on information given by the subjects' families.

Results

Mothers of IVF children were more likely to have a high educational level than mothers of SC children. Moreover, a greater proportion of IVF children had received preschool education than SC children. After adjusting for potential confounders, there was no difference in the school performance or long-term outcomes between IVF and SC children.

Conclusion

In our study, the school performance and long-term outcomes of very preterm children born after IVF and of their spontaneously conceived peers were comparable. This information can help provide guidance to families and educators.

Effects of different polyvinylpyrrolidone concentrations on intracytoplasmic sperm injection

To explore whether different polyvinylpyrrolidone (PVP) concentrations affect the results of intracytoplasmic sperm injection (ICSI), a prospective study was conducted for 194 couples undergoing 210 ICSI therapy cycles. These cycles were divided into three groups (10, 7 and 5% groups) using the corresponding concentration of PVP for sperm immobilization. The main outcome measures were analyzed. Results indicated that, with a decrease in PVP concentrations, all of the main outcome measures increased. In particular, the high-quality cleavage embryo rate in the 7% group was significantly lower than in the 5% group (P < 0.01), and the cleavage, high-quality cleavage embryo, and high-quality blastocyst rates in the 5% group were significantly higher than those in the 10% group (all P < 0.001). For high-/intermediate-quality semen, all of the main outcome measures were significantly increased with 5% PVP. For the poor-quality semen, only the high-quality cleavage embryo and high-quality blastocyst rates were significantly higher in the 5% group. Therefore, lowering PVP concentrations greatly promoted the development of embryos in ICSI cycles, with an optimal concentration of 5% for ICSI.

Assessing the impact of delayed blastulation using time lapse morphokinetics and preimplantation genetic testing in an IVF patient population

PURPOSE

There is clinical evidence that early cleavage timing parameters predictive of blastocyst development also correlate with embryo implantation potential. The aim of this study is to determine the developmental competency of embryos with delayed blastulation.

METHODS

Retrospective study performed from 2015 to 2016 at the Division of Reproductive Endocrinology and Infertility at Northwestern University.

RESULTS

A total of 2,292 embryos from 524 patients were included. Day 6 blastocysts had statistically significant longer times for every time point analyzed than day 5 blastocysts (p < 0.001). We found no statistically significant difference in euploidy rates between day 5 (44%) and day 6 (41%) embryos (p = 0.573). t7 and t8 time points were independent predictors of euploidy after controlling for day of biopsy (p < 0.015 and p < 0.014, respectively). Intrauterine pregnancy (IUP) and live birth (LB) were less likely to occur after transferring day 6 embryos (p = 0.0033 and p = 0.0359) without previous genetic testing. However, in embryos that undergo preimplantation genetic testing for aneuploidy (PGT-A), there were no significant differences in IUP or LB rates.

CONCLUSION

Early time-lapse points can be used to predict embryo development. Day of blastulation may be an independent predictor IUP, with day 6 blastocysts having lower pregnancy and live birth rates. Our data suggests that day 5 and day 6 PGT-A tested embryos show similar rates of euploidy, suggesting that differences in PR seen in the non-PGT-A tested group may be caused by factors other than aneuploidy. Genetic testing technologies in combination with time-lapse microscopy may provide further information to improve IVF outcomes.

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

BACKGROUND

Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are present in 10% to 15% of women seeking treatment for subfertility.

OBJECTIVES

To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

SEARCH METHODS

We searched the following databases from their inception to 16 April 2018; The Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies Online, ; MEDLINE, Embase , CINAHL , and other electronic sources of trials including trial registers, sources of unpublished literature, and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from 1 January 2014 to 12 May 2018) and we contacted experts in the field.

SELECTION CRITERIA

Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Two studies met the inclusion criteria.1. Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.In women with otherwise unexplained subfertility and submucous fibroids, we were uncertain whether hysteroscopic myomectomy improved the clinical pregnancy rate compared to expectant management (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17; P = 0.06, 94 women; very low-quality evidence). We are uncertain whether hysteroscopic myomectomy improves the miscarriage rate compared to expectant management (OR 1.54, 95% CI 0.47 to 5.00; P = 0.47, 94 women; very low-quality evidence). We found no data on live birth or hysteroscopy complication rates. We found no studies in women with endometrial polyps, intrauterine adhesions or uterine septum for this randomised comparison.2. Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.The hysteroscopic removal of polyps prior to IUI may have improved the clinical pregnancy rate compared to diagnostic hysteroscopy only: if 28% of women achieved a clinical pregnancy without polyp removal, the evidence suggested that 63% of women (95% CI 45% to 89%) achieved a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96; P < 0.00001, 204 women; low-quality evidence). We found no data on live birth, hysteroscopy complication or miscarriage rates in women with endometrial polyps prior to IUI. We found no studies in women with submucous fibroids, intrauterine adhesions or uterine septum prior to IUI or in women with all types of suspected uterine cavity abnormalities prior to IVF/ICSI.

AUTHORS' CONCLUSIONS

Uncertainty remains concerning an important benefit with the hysteroscopic removal of submucous fibroids for improving the clinical pregnancy rates in women with otherwise unexplained subfertility. The available low-quality evidence suggests that the hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may improve the clinical pregnancy rate compared to simple diagnostic hysteroscopy. More research is needed to measure the effectiveness of the hysteroscopic treatment of suspected major uterine cavity abnormalities in women with unexplained subfertility or prior to IUI, IVF or ICSI.

Do the children born after assisted reproductive technology have an increased risk of birth defects? A systematic review and meta-analysis

Background: Assisted reproductive technologies (ARTs) have made great progress. However, whether tube baby born after ART were at an increased risk of birth defects is not clear.Objective: To assess whether the ART increases the risk of birth defects in children born after ART.Search strategy: Medline, Google Scholar, and the Cochrane Library were searched.Selection criteria: Clinical trials that evaluate the risk of birth defect in children born after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) and natural conceptions (NC) were included. The primary outcome was the prevalence of birth defects.Data collection and analysis: The relative risk was used as the summary measure with random effects model. We assessed heterogeneity between studies using the I² index.Main results: Totally 46 studies were included. The pooled relative risk (RR) estimated suggested there was an increased risk of birth defects in ART compared with the NC group (RR: 1.40; 95% CI 1.31-1.49). Twenty and fifteen studies were included to compare the risk of birth defects between NC and IVF/ICSI, respectively. The results indicated that both IVF and ICSI increase the risk of birth defects (IVF: RR 1.25; 95% CI 1.12-1.40; ICSI: RR 1.29; 95% CI 1.14-1.45). When subgroup according to plurality, 22 studies assessed the risk of birth defects after ART or NC in singletons and 15 studies evaluated the risk of birth defects in twins. The pooled RRs were 1.41 (95% CI 1.30-1.52) and 1.18 (95% CI 0.98-1.42), respectively.Conclusions: Children born after ART were at an increased risk of birth defects compared with NC. There was no difference in birth defects risk between ART twins and NC twins.

The impact of ovarian stimulation on the outcome of intrauterine insemination treatment: an analysis of 8893 cycles

OBJECTIVE

To evaluate the impact of ovarian stimulation on the outcome of intrauterine insemination (IUI).

DESIGN

Retrospective analysis.

SETTING

A single university-based centre.

POPULATION

A total of 5109 couples with 8893 cycles.

METHODS

The outcome of IUI with different protocols for ovarian stimulation was examined.

MAIN OUTCOME MEASURES

The live birth rate (LBR), twin pregnancy rate and ovarian hyperstimulation syndrome (OHSS).

RESULTS

In ovulatory women without ovarian stimulation, the LBR was 7.6%. Stimulation with clomifene citrate (CC), letrozole (LE), human menopausal gonadotrophin (HMG), CC or LE combined with HMG achieved LBRs of 6.1, 5, 7.9, 8 and 12.2%, respectively. LE combined with HMG achieved a significantly improved LBR compared with no stimulation. HMG stimulation was associated with a higher rate of twins (7.4%) than no stimulation (0%, P < 0.01). In ovulatory women, the LBR appeared lower in CC and LE compared with no stimulation (P > 0.05). In anovulatory women, ovarian stimulation with CC, LE, HMG, CC or LE combined with HMG achieved LBRs of 11.3, 5.1, 11.8, 12.6 and 13.6%, respectively. No significant difference was observed. There were no triplet pregnancies or OHSS in stimulated cycles.

CONCLUSIONS

In ovulatory women, ovarian stimulation with LE combined with HMG achieved a significantly improved live birth rate. HMG stimulation resulted in a high risk for twins.

TWEETABLE ABSTRACT

In ovulatory women, ovarian stimulation with letrozole and HMG resulted in a significantly improved LBR.

Feasibility of Transabdominal Electrohysterography for Analysis of Uterine Activity in Nonpregnant Women

PURPOSE

Uterine activity plays a key role in reproduction, and altered patterns of uterine contractility have been associated with important physiopathological conditions, such as subfertility, dysmenorrhea, and endometriosis. However, there is currently no method to objectively quantify uterine contractility outside pregnancy without interfering with the spontaneous contraction pattern. Transabdominal electrohysterography has great potential as a clinical tool to characterize noninvasively uterine activity, but results of this technique in nonpregnant women are poorly documented. The purpose of this study is to investigate the feasibility of transabdominal electrohysterography in nonpregnant women.

METHODS

Longitudinal measurements were performed on 22 healthy women in 4 representative phases of the menstrual cycle. Twelve electrohysterogram-based indicators previously validated in pregnancy have been estimated and compared in the 4 phases of the cycle. Using the Tukey honest significance test, significant differences were defined for P values below .05.

RESULTS

Half of the selected electrohysterogram-based indicators showed significant differences between menses and at least 1 of the other 3 phases, that is the luteal phase.

CONCLUSION

Our results suggest transabdominal electrohysterography to be feasible for analysis of uterine activity in nonpregnant women. Due to the lack of a golden standard, this feasibility study is indirectly validated based on physiological observations. However, these promising results motivate further research aiming at evaluating electrohysterography as a method to improve understanding and management of dysfunctions (possibly) related to altered uterine contractility, such as infertility, endometriosis, and dysmenorrhea.

The effect of laser-assisted hatching on pregnancy outcomes of cryopreserved-thawed embryo transfer: a meta-analysis of randomized controlled trials

It is well known that laser-assisted hatching (LAH) is the most popular and ideal embryo hatching technology, but the relevance to pregnancy outcomes of cryopreserved-thawed embryo transfer (ET) is controversial. The purpose of this meta-analysis was to evaluate the effects of LAH on pregnancy outcomes of cryopreserved-thawed ET. We searched for relevant studies published in the PubMed, EMBASE, and Cochrane Central databases up to March 2017. This meta-analysis was primarily used to evaluate the effect of laser-assisted hatching on assisted reproductive outcomes: clinical pregnancy, embryo implantation, multiple pregnancy, miscarriage, and live birth. Using the Mantel-Haenszel fixed effects model and random effects model, we determined the summary odds ratios (OR) with 95% confidence intervals (CIs). There were 12 randomized controlled trials (more than 2574 participants) included in our analysis. The rates of clinical pregnancy (OR = 1.65, 95% CI = 1.24-2.19, I ² = 49), implantation (OR = 1.59, 95% CI = 1.06-2.38, I ² = 82%), multiple pregnancy (OR = 2.30, 95% CI = 1.30-4.07, I ² = 33%), miscarriage (OR = 0.86, 95% CI = 0.50-1.48, I ² = 0%), and live birth (OR = 1.09, 95% CI = 0.77-1.54, I ² = 0%) revealed comparable results for both groups. In summary, this meta-analysis demonstrates that LAH is related to a higher clinical pregnancy rate, embryo implantation rate, and multiple pregnancy rate in women with cryopreserved-thawed embryos. However, LAH is unlikely to increase live birth rates and miscarriage rates. Due to the small sample evaluated in the pool of included studies, large-scale, prospective, randomized, controlled trials are required to determine if these small effects are clinically relevant.

Trends over 15 years in ART in Europe: an analysis of 6 million cycles

STUDY QUESTION

Was the European IVF Monitoring (EIM) Consortium, established in 1999 by ESHRE, able to monitor the trend over time of ART in Europe?

SUMMARY ANSWER

The initial aims of the EIM programme (to collect and publish regional European data on census and trends on ART utilization, effectiveness, safety and quality) have been achieved.

WHAT IS ALREADY KNOWN

ART data in Europe have been collected and reported annually in Human Reproduction.

STUDY DESIGN SIZE DURATION

A retrospective data analysis and summary of the first 15 years of ART activity in Europe (1997-2011) was carried out, using the key figures from the annual ESHRE reports and focusing on how the practice of ART has evolved over the years.

PARTICIPANTS/MATERIALS SETTING METHOD

A total of 5 919 320 ART cycles are reported, including IVF, ICSI, frozen embryo relacment and egg donation, resulting in the birth of more than 1 million infants. A total of 1 548 967 IUIs are also reported, including husband/partner's semen and donor semen cycles. The most relevant and complete data are analysed and discussed.

MAIN RESULTS AND THE ROLE OF CHANCE

With some fluctuations, the number of countries and clinics reporting to EIM increases significantly from 1997 to 2011. A constant increase was also registered in the number of annual cycles reported. Since 2005, the estimation of the EIM coverage on the total European activity was >80%. In countries with 100% of coverage, the mean availability of ART increased from 765 cycles per million inhabitants in 1997 to 1269 cycles per million inhabitants in 2011, and the proportion of ART infants of the total number of infants born in the country increased from 1.3% to 2.4%. The proportion of women aged > 39 years undergoing IVF and ICSI cycles gradually increased. For 12 consecutive years, the proportion of ICSI versus IVF cycles showed a marked increase before reaching a plateau from 2008. The proportion of transfers with three or more embryos decreased constantly and the proportion of SETs increased over the time period. The triplets deliveries were reduced from 3.7% in 1997 to less than 1% since 2005 (0.6% in 2011). The effectiveness (evaluated as clinical pregnancy rate per aspiration and per embryo transfer) increased until 2007, then the figure remained stable. The cumulative percentage of documented pregnancy losses was 17%. No differences have been noted in terms of outcomes in the IUI cycles.

LIMITATIONS REASONS FOR CAUTION

The data presented are accumulated from countries with different collection systems, regulations, insurance coverage and different practices. Each year a number of countries have been unable to provide some of the data.

WIDER IMPLICATIONS OF THE FINDINGS

The first summary of 15 years of the EIM reports offers interesting data on census and trends on ART utilization, safety and quality in Europe. The primary aim of the ESHRE effort in supporting European data collection has been reached. Owing to its importance inside and outside the professional community, European data collection and publication on ART have to be supported and implemented.

STUDY FUNDING/COMPETING INTERESTS

None.

Relationship between apoptosis and survival molecules in human cumulus cells as markers of oocyte competence

To select from a single patient the best oocytes able to reach the blastocyst stage, we searched for valuable markers for oocytes competence. We evaluated the DNA fragmentation index (DFI) and the level of some survival molecules, such as AKT, pAKT and pERK1/2, in individual cumulus cell-oocyte complexes (COC). The study included normo-responder women. The average age of the patients was 34.3. DFI in cumulus cells was evaluated using the terminal deoxynucleotidyl transferase (TdT) dUTP nick-end labelling (TUNEL) assay in situ. AKT, pAKT and pERK1/2 were measured by immunological assay and densitometric analysis of fluorescent signals using NIS-Elements BR 3.10 image software. Statistical analysis was performed using STATA SE/14.1. The study focused on 53 patients involved after informed consent. Out of 255 MII oocytes, 197 were fertilized and the derived embryos had the following evolution: 117 completed the development to blastocyst and were transferred to uterus; 57 were vitrified at the blastocyst stage; and 23 were arrested during in vitro culture at different stages of cleavage. We found a significant statistical difference between the DFI of cumulus cells of the arrested embryos and the transferred blastocysts (P = 0.004), confirming that DFI could be considered as a valuable marker of oocyte competence. In addition, the pAKT/DFI ratio was higher in cumulus cells of oocytes able to produce blastocysts, indicating that DFI is significantly lower when pAKT is higher (P = 0.043). This study demonstrates for the first time that the relationship between apoptosis and survival molecules can be used as a marker to select the best oocytes.

[Ovarian hyperstimulation syndrome after stimulation with highly purified hMGfor in vitro fertilization: Observational study SHOview]

OBJECTIVE

Data on the incidence and severity of ovarian hyperstimulation syndrome (OHSS) in France are limited.

METHODS

Prospective observational multicentric study (23 French centers of IVF) in a cohort of 421 women treated with highly purified hMG (HP-hMG) for the first or second cycle of IVF with or without ICSI. The primary objective was to assess the incidence of moderate to severe OHSS in this cohort.

RESULTS

At inclusion, 172 patients (40.9%) were considered at risk of OHSS by the physicians. The main measures for risk minimization taken by the physicians rested on initial dose of HP-hMG and protocol choice. At the end of the follow-up (4 months in average), the rate of OHSS moderate to severe was 2.4% (confidence interval 95%: 1.1-4.3%) for the studied IVF cycle. OHSS was severe for 3 women (0.7%) and moderate for 7 women (1.7%).

CONCLUSION

This rate of OHSS after IVF is at the lower limit of the rates reported in the literature for OHSS. This study brings reassuring epidemiological data on the rate of OHSS in women at risk. The measures taken by the physicians to minimize the risk of OHSS could have contributed to this low incidence.

Fatal ovarian hyperstimulation syndrome in an anonymous egg donor

Ovarian hyperstimulation syndrome is a rare, but potentially life-threatening iatrogenic disorder arising from ovulation induction or ovarian hyperstimulation for assisted reproduction techniques. We report a case of a 26-year-old multiparous woman, an anonymous egg donor, who died a few hours after undergoing a procedure to donate eggs at an in vitro fertilization clinic. Her husband alleged that medical negligence had led to her death. The autopsy confirmed death due to ovarian hyperstimulation syndrome. We know of no previous descriptions of fatal ovarian hyperstimulation syndrome in an anonymous egg donor in medico-legal literature.

Biodemographic Analysis of Factors Related to Perinatal Mortality in Portugal (1988-2011)

Background. The purpose of this paper is to determine the relative mortality risks at delivery and during the first week of life with regard to maternal and foetal characteristics. Methods. Yearly individual digital records on live births and early neonatal mortality were used to infer the possible factors involved in perinatal deaths. Results. The results show that the number of births per year declined with time throughout the period studied. At the same time, rates decreased in 66.4% for stillbirths and in 70.2% for early neonatal mortality. Logistic regressions modelled the interaction of the two mortality indicators and covariables such as birth weight and the duration of gestation. Conclusions. This research provides a first biodemographic approach to the knowledge of factors influencing perinatal mortality in Portugal based on a set of foetal and maternal variables. Although the magnitude of the different perinatal mortality rates may be affected by the criteria used for selecting cases (multiple-singletons; minimum birth weight or minimum duration of gestation), one of the conclusions of the present analysis is that the relationship among the maternal and foetal variables that determine the relative risk remains unaltered. Certain resemblance with the factors determining negative birth outcomes in Spain is appreciated.

Maternal and Live-birth Outcomes of Pregnancies following Assisted Reproductive Technology: A Retrospective Cohort Study

This study was carried out to explore associations between assisted reproductive technology (ART) and maternal and neonatal outcomes compared with similar outcomes following spontaneously conceived births. We conducted a retrospective cohort study of pregnancies conceived by ART (N = 2641) during 2006–2014 compared to naturally conceived pregnancies (N = 5282) after matching for maternal age and birth year. Pregnancy complications, perinatal complications and neonatal outcomes of enrolled subjects were investigated and analysed by multivariate logistic regression. We found that pregnancies conceived by in vitro fertilization (IVF) were associated with a significantly increased incidence of gestational diabetes mellitus, gestational hypertension, preeclampsia, intrahepatic cholestasis of pregnancy, placenta previa, placental abruption, preterm premature rupture of membranes, placental adherence, postpartum haemorrhage, polyhydramnios, preterm labour, low birth weight, and small-for-date infant compared with spontaneously conceived births. Pregnancies conceived by intracytoplasmic sperm injection (ICSI) showed similar elevated complications, except some of the difference narrowed or disappeared. Singleton pregnancies or nulliparous pregnancies following ART still exhibited increased maternal and neonatal complications. Therefore, we conclude that pregnancies conceived following ART are at increased risks of antenatal complications, perinatal complications and poor neonatal outcomes, which may result from not only a higher incidence of multiple pregnancy, but also the manipulation involved in ART processes.

Protein expression in human cumulus cells as an indicator of blastocyst formation and pregnancy success

PURPOSE

The goal for the present study was to implement a technique for protein extraction and identification in human cumulus cells (CCs).

METHODS

Forty samples of CCs were collected after ovum pick-up from patients undergoing intracytoplasmic sperm injection (ICSI). Samples were split into the blastocyst group (n = 10), including patients in which all embryos converted into blastocysts, and the non-blastocyst group (n = 10), including patients in which none of the embryos reached the blastocyst stage or the positive-pregnancy (n = 10) and negative-pregnancy group (n = 10). Proteins were extracted and injected into a liquid chromatography system coupled to a mass spectrometer. The spectra were processed and used to search a database.

RESULTS

There were 87 different proteins in samples from the blastocyst and non-blastocyst groups, in which 30 were exclusively expressed in the blastocyst group and 17 in the non-blastocyst group. Among the 72 proteins detected in the pregnancy groups, 19 were exclusively expressed in the positive, and 16 were exclusively expressed in the negative-pregnancy group.

CONCLUSIONS

CC proteomics may be useful for predicting pregnancy success and the identification of patients that should be included in extended embryo culture programs.

Outcomes of vitrified-warmed cleavage-stage embryo hatching after in vitro laser-assisted zona pellucida thinning in patients

The aim of the present study was to determine whether the size of the zona pellucida (ZP) thinning area by laser-assisted hatching affected the potential development of vitrified-warmed embryos. A total of 196 vitrified-warmed cleavage-stage embryos (from 49 patients, four sister embryos per patient) were used in the study, i.e., four sister embryos from each patient were randomly assigned to four groups: a control group of embryos that were not zona-manipulated (zona intact, group A); one experimental group of embryos in which a quarter of the zona pellucida was thinned using laser-assisted ZP thinning (group B); a second experimental group of embryos in which half of ZP was thinned (group C); and a third group in which two-thirds of the ZP was thinned (group D). Subsequent blastocyst development was assessed. Microscopy was performed to study the hatching process of the embryos after zona thinning. The blastocyst formation rates were 71.43% in group A, 67.35% in group B, 65.31% in group C, and 51.02% in group D (groups B-D vs. group A, P=0.661, P=0.515, P=0.038, respectively). The rates of complete hatching were 30.61% in group A, 38.78% in group B, 61.22% in group C, and 48.98% in group D (groups B-D vs. group A, P=0.396, P=0.002, P=0.063, respectively). For a subgroup of patients, there was a significant difference in the complete hatching in all the groups for women aged <35 years (P=0.011), and there was a significant difference in the complete hatching in all the groups for secondary infertility women (P=0.022). There was no significant difference in the blastocyst formation rates in the different groups of women aged ≥35 years (P=0.340). In addition, there was no significant difference in the complete hatching in the different groups among women aged ≥35 years (P=0.492). The results of the present study showed that in vitrified-warmed embryo transfers at the cleavage-stage, and the two-thirds zona pellucida thinning group demonstrated a significantly decreased blastocyst formation rate compared with the control group, while the half zona pellucida thinning group demonstrated a significantly increased complete hatching rate compared with the control group, which may have a high value in clinical application.

Luteal phase support in intrauterine insemination cycles

Intrauterine insemination (IUI) treatment aims to increase the rate of conception by increasing the chances that the maximum number of healthy sperm reach the site of fertilization. IUI with controlled ovarian stimulation is frequently used in assisted reproduction practice. Although widely used, the efficacy of luteal support in IUI remains controversial. In this article, we aimed to review what we know regarding luteal support in IUI cycles and to adjudicate about the clinical use and benefits of this treatment. Based on the study results available in the literature, it appears to be beneficial to supplement the luteal phase in gonadotropin-stimulated IUI cycles that yield more than one follicle.

Does a strategy to promote shared decision-making reduce medical practice variation in the choice of either single or double embryo transfer after in vitro fertilisation? A secondary analysis of a randomised controlled trial

OBJECTIVES

The hypothesis that shared decision-making (SDM) reduces medical practice variations is increasingly common, but no evidence is available. We aimed to elaborate further on this, and to perform a first exploratory analysis to examine this hypothesis. This analysis, based on a limited data set, examined how SDM is associated with variation in the choice of single embryo transfer (SET) or double embryo transfer (DET) after in vitro fertilisation (IVF). We examined variation between and within hospitals.

DESIGN

A secondary analysis of a randomised controlled trial.

SETTING

5 hospitals in the Netherlands.

PARTICIPANTS

222 couples (woman aged <40 years) on a waiting list for a first IVF cycle, who could choose between SET and DET (ie, ≥2 embryos available).

INTERVENTION

SDM via a multifaceted strategy aimed to empower couples in deciding how many embryos should be transferred. The strategy consisted of decision aid, support of IVF nurse and the offer of reimbursement for an extra treatment cycle. Control group received standard IVF care.

OUTCOME MEASURE

Difference in variation due to SDM in the choice of SET or DET, both between and within hospitals.

RESULTS

There was large variation in the choice of SET or DET between hospitals in the control group. Lower variation between hospitals was observed in the group with SDM. Within most hospitals, variation in the choice of SET or DET appeared to increase due to SDM. Variation particularly increased in hospitals where mainly DET was chosen in the control group.

CONCLUSIONS

Although based on a limited data set, our study gives a first insight that including patients' preferences through SDM results in less variation between hospitals, and indicates another pattern of variation within hospitals. Variation that results from patient preferences could be potentially named the informed patient rate. Our results provide the starting point for further research.

TRIAL REGISTRATION NUMBER

NCT00315029; Post-results.

Expression of factors involved in the regulation of angiogenesis in the full-term human placenta: Effects of in vitro fertilization

The effects of assisted reproductive technologies (ARTs) on the safety of pregnancy and the resulting offspring remain controversial. Studies of placental functions, especially vasculogenesis and angiogenesis, in pregnancies established through ART are helpful for furthering our understanding of the safety of ART. This study compares the expression profiles of angiogenic factors in human term placentas obtained from natural (NAT) pregnancies vs. placentas obtained from pregnancies that resulted from ART. Term placentas were obtained from women who underwent an ART procedure (n=4), and these were compared with term placentas that were obtained from women who had experienced a spontaneous pregnancy (controls, n=4). An array analysis was performed using the Human Angiogenesis Antibody Array to detect 43 angiogenic factors and to identify which of these factors were differentially expressed between the two groups. The expression of six of these factors was greater in the ART group than in the NAT group. The levels of four of them, including vascular endothelial growth factor receptor-3 (VEGFR3), basic fibroblast growth factor (bFGF), interferon gamma (IFNG) and matrix metalloproteinase 1 (MMP1), were quantified using western blot analysis. These factors were examined using immunohistochemistry and microscopy in vascular endothelial cells or the cytoplasm and membranes of syncytiotrophoblast cells. Our finding that selected angiogenic factors exhibit altered expression profiles in ART placentas might be significant when evaluating ART safety.

Analysis of uterine activity in nonpregnant women by electrohysterography: A feasibility study

With an overall effectiveness below 30%, in vitro fertilization (IVF) is in urgent need for improvements, especially in view of the increasing trend in postponing childbirth in developed societies. Abnormal contraction of the uterus may underlie impaired fertility and unsuccessful IVF. However, currently, there is no method for quantitative assessment of uterine activity and guidance of dedicated intervention. Analysis of the electrohysterogram (EHG) has been extensively used in pregnancy for quantifying uterine contractions. In this paper, we evaluate, for the first time, the use of EHG analysis for characterizing contractions in women in two different phases of the menstrual cycle, when the uterus is expected to be active and quiescent. In this preliminary study, by estimating the time evolution of the EHG signal energy, we derive the contraction frequency, fC, as a possible marker for quantifying the activity of the uterus and discriminate between active and quiescent status. Ultrasound (US) image sequences are simultaneously recorded and visually analyzed for a qualitative validation of the results. The high correlation (0.91) between fC obtained by EHG and US analysis and the measured different values of fC in the two phases motivate further research to confirm the value of EHG analysis for contraction quantification in nonpregnant women.

Assisted reproductive technology in Europe, 2011: results generated from European registers by ESHRE

STUDY QUESTION

The 15th European IVF-monitoring (EIM) report presents the results of treatments involving assisted reproductive technology (ART) initiated in Europe during 2011: are there any changes in the trends compared with previous years?

SUMMARY ANSWER

Despite some fluctuations in the number of countries reporting data, while the overall number of ART cycles has continued to increase year by year, the pregnancy rates in 2011 decreased slightly to those reported in 2010, and the number of transfers with multiple embryos (3+) and the multiple delivery rates declined.

WHAT IS KNOWN ALREADY

Since 1997, ART data in Europe have been collected and reported in 14 manuscripts, published in Human Reproduction.

STUDY DESIGN, SIZE, DURATION

Retrospective data collection of European ART data by the EIM Consortium for the European Society of Human Reproduction and Embryology (ESHRE); cycles started between 1 January and 31 December 2011 are collected on a yearly basis. The data are collected by National Registers, when existing, or on a voluntary basis by personal information.

PARTICIPANTS/MATERIALS SETTING, METHODS

From 33 countries (+2 compared with 2010), 1064 clinics reported 609 973 treatment cycles including: IVF 138 592, ICSI 298 918, frozen embryo replacement (FER) 129 693, egg donation (ED) 30 198, in vitro maturation 511, preimplantation genetic diagnosis/screening 6824 and frozen oocyte replacements 5237. European data on intrauterine insemination (IUI) using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 861 IUI laboratories in 24 countries. A total of 174 390 IUI-H and 41 151 IUI-D cycles were included.

MAIN RESULTS AND THE ROLE OF CHANCE

In 17 countries where all clinics reported to the ART register, a total of 361 972 ART cycles were performed in a population of 285 million inhabitants, corresponding to 1269 cycles per million inhabitants. For all IVF cycles, the clinical pregnancy rates per aspiration and per transfer were stable with 29.1 and 33.2%, respectively, and for ICSI, the corresponding rates also were stable with 27.9 and 31.8%, respectively. In FER cycles, the pregnancy rate per thawing increased to 21.3% if compared with previous years. In ED cycles, the pregnancy rate per fresh transfer decreased to 45.8% (47.4% in 2010) and increased to 33.6% (33.3% in 2010) per thawed transfer. The delivery rate after IUI-H decreased to 8.3 (8.9 in 2010), and to 12.2% (13.8% in 2010) after IUI-D. In IVF and ICSI cycles, 1, 2, 3 and 4+ embryos were transferred in 27.5, 56.7, 14.5 and 1.3% of cycles, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (added together) were 80.8, 18.6 and 0.6%, respectively, resulting in a total multiple delivery rate of 19.2% compared with 20.6% in 2010, 20.2% in 2009, 21.7% in 2008, 22.3% in 2007 and 20.8% in 2006. In FER cycles, the multiple delivery rate was 13.2% (12.8% twins and 0.4% triplets). Twin and triplet delivery rates associated with IUI cycles were 9.7/0.6% and 7.3/0.3%, following IUI-H and IUI-D treatment, respectively.

LIMITATIONS, REASONS FOR CAUTION

The method of reporting varies among countries, and registers from a number of countries have been unable to provide some of the relevant data such as initiated cycles and deliveries. As long as data are incomplete and generated through different methods of collection, results should be interpreted with caution.

WIDER IMPLICATIONS OF THE FINDINGS

The 15th ESHRE report on ART shows a continuing expansion of the number of treatment cycles in Europe, with more than 600 000 cycles reported in 2011. Since 2006, the proportion of IVF to ICSI cycles has reached a plateau after a small decrease in 2009. Pregnancy and delivery rates after IVF remained relatively stable compared with 2010 and 2009. The pregnancy rate per aspiration in ICSI cycles declined for the first time by 0.9%. The multiple delivery rate is lower than ever before.

STUDY FUNDING/COMPETING INTERESTS

The study had no external funding; all costs are covered by ESHRE. There are no competing interests.

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

BACKGROUND

Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility.

OBJECTIVES

To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (8 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 9), MEDLINE (1950 to 12 October 2014), EMBASE (inception to 12 October 2014), CINAHL (inception to 11 October 2014) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2013 to October 2014) and we contacted experts in the field.

SELECTION CRITERIA

Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We retrieved 12 randomised trials possibly addressing the research questions. Only two studies (309 women) met the inclusion criteria. Neither reported the primary outcomes of live birth or procedure related complications. In women with otherwise unexplained subfertility and submucous fibroids there was no conclusive evidence of a difference between the intervention group treated with hysteroscopic myomectomy and the control group having regular fertility-oriented intercourse during 12 months for the outcome of clinical pregnancy. A large clinical benefit with hysteroscopic myomectomy cannot be excluded: if 21% of women with fibroids achieve a clinical pregnancy having timed intercourse only, the evidence suggests that 39% of women (95% CI 21% to 58%) will achieve a successful outcome following the hysteroscopic removal of the fibroids (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17, P = 0.06, 94 women, very low quality evidence). There is no evidence of a difference between the comparison groups for the outcome of miscarriage (OR 0.58, 95% CI 0.12 to 2.85, P = 0.50, 30 clinical pregnancies in 94 women, very low quality evidence). The hysteroscopic removal of polyps prior to IUI can increase the chance of a clinical pregnancy compared to simple diagnostic hysteroscopy and polyp biopsy: if 28% of women achieve a clinical pregnancy with a simple diagnostic hysteroscopy, the evidence suggests that 63% of women (95% CI 50% to 76%) will achieve a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96, P < 0.00001, 204 women, moderate quality evidence).

AUTHORS' CONCLUSIONS

A large benefit with the hysteroscopic removal of submucous fibroids for improving the chance of clinical pregnancy in women with otherwise unexplained subfertility cannot be excluded. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.

Pregnancy Complications and Neonatal Outcomes in Multiple Pregnancies: A Comparison between Assisted Reproductive Techniques and Spontaneous Conception

Background

This study compared neonatal outcome and maternal complications in multiple pregnancies after assisted reproductive technologies (ART) to spontaneous pregnancies.

Materials and Methods

In this cross-sectional study, we reviewed medical records of 190 multiple pregnancies and births conceived by ART or spontaneous conceptions between 2004 and 2009 in Women Hospital. Obstetric history and outcomes were recorded and compared between these two groups. SPSS version 13 was used for data analysis. The results were analyzed using student’s t test, chi square and logistic regression (p<0.05).

Results

There were 106 deliveries from spontaneous conceptions and 84 that resulted from ART. Parity history and mode of delivery significantly differed between the two groups (p<0.001). The ART group had significantly higher preterm labor and premature rupture of membranes (PROM) whereas pregnanc-induced hypertension (PIH) was higher in the spontaneous group (p=0.01). Newborn intensive care unit (NICU) admission, duration of hospitalization, still birth and low gestational age were significantly higher in the ART group while neonatal jaundice was higher in the spontaneous group. Logistic regression analysis by considering neonatal complications as the dependent variable showed that respiratory distress syndrome (RDS), NICU admission and Apgar score were independent predictors for neonatal complications.

Conclusion

Obstetric and neonatal outcomes must be considered in multiple pregnancies conceived by ART.

The effect of single embryo transfer on perinatal outcomes in Japan

OBJECTIVE

In 2007 and 2008, the Japan Society for Reproductive Medicine and the Japan Society of Obstetrics and Gynecology issued a recommendation for single embryo transfer (SET). Thereafter, SET was implemented in 73% of in vitro fertilization (IVF) cases in Japan. The purpose of this study was to evaluate the effects of compliance with the SET recommendation on perinatal outcomes.

METHODS

An electronic audit of the perinatal database of the Japanese Society of Obstetrics and Gynecology was conducted from 2001 through 2010. The database comprised data of 610,726 women. Totally, 20,923 women conceived through IVF. To compare perinatal outcomes, these women were categorized into two study groups depending on whether they conceived before (2004-2005, n=3,865) or after (2009-2010, n=6,842) the SET recommendation statement was issued.

RESULTS

The proportion of women who conceived through IVF increased from 1.3% in 2001 to 4.8% in 2010. Compliance with the SET recommendation led to a decrease in the incidence of twin pregnancies (33.9% versus 13%, p<0.01), incidence of preterm delivery (odds ratio [OR]: 0.54, 95% confidence interval [CI]: 0.50-0.59), low birth weight (OR: 0.42, 95% CI: 0.39-0.45), and neonatal intensive care unit admission (OR 0.70, 95% CI 0.65-0.76), but an increase in the incidence of monochorionic twins (1.6% versus 2.5%, p<0.01).

CONCLUSION

Compliance with the SET recommendation improved perinatal outcomes by reducing the incidence of twin pregnancies.

Identification and functional analysis of long non-coding RNAs in mouse cleavage stage embryonic development based on single cell transcriptome data

Background

Long non-coding RNAs (lncRNAs) regulate embryonic development and cell fate decision in various ways, such as modulation of chromatin modification and post-transcription regulation of gene expression. However, the profiles and roles of lncRNAs in early mammalian development have not yet been demonstrated. Here, we reported a comprehensive analysis of mouse cleavage stage embryonic lncRNA profiles based on public single-cell RNA-seq data.

Results

We reconstructed 50,006 high-confidence transcripts in 22,827 loci, and identified 5563 novel lncRNAs from 3492 loci expressed in mouse cleavage stage embryos. These lncRNAs share similar characteristics with previously reported vertebrate lncRNAs, such as relatively short length, low exon number, low expression level and low sequence conservation. Expression profile analysis revealed that the profiles of lncRNA vary considerably at different stages of cleavage stage embryos, suggesting that many lncRNAs in cleavage stage embryos are stage-specifically expressed. Co-expression network analysis suggested many lncRNAs in cleavage stage embryos are associated with cell cycle regulation, transcription, translation and oxidative phosphorylation to regulate the process of cleavage stage embryonic development.

Conclusions

This study provides the first catalog of lncRNAs expressed in mouse cleavage stage embryos and gives a revealing insight into the molecular mechanism responsible for early embryonic development.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2164-15-845) contains supplementary material, which is available to authorized users.

The frozen-thawed embryo transfer timing determined by serum progesterone level: a retrospective follow-up study

OBJECTIVE

To compare the reproductive outcomes of frozen-thawed embryo transfer (FET) in nature cycle utilizing monitoring ovulation regimen (MOR) and monitoring progesterone (P) level regimen (MPR).

STUDY DESIGN

A retrospective analysis of records of 224 women who received FET procedures.

RESULT(S)

MPR was used in 60.3% (135/224) of cycles and MOR in 39.7% (89/224) of cycles. The clinical pregnancy rate per transfer was 63.0% in the MPR group and 48.3% in the MOR group (p=0.030). The implantation rates were 42.6% and 35.1%, respectively (p=0.001). The ongoing pregnancy rates per transfer (at 12 weeks' gestation) were 54.1% and 41.6%, respectively (p>0.05). A logistic regression analysis showed that the type of natural cycle regimen was a predictor of clinical pregnancy rate (odds ratio, 1.996; 95% confidence interval, 1.123-3.549; p=0.019). Other significant variables affecting clinical pregnancy rate was number of top-quality embryos transferred.

CONCLUSION(S)

Performing FET using MPR could achieve higher clinical pregnancy rate compared with MOR in a group of patients with the comparable demographic and cycle characteristics profile.

Possible selection of viable human blastocysts after vitrification by monitoring morphological changes

PURPOSE

Morphological assessment of human blastocysts has been effective for selecting embryos with high potential. However, they often show repeated shrinkage and expansion toward their hatching. Here we assessed whether capturing morphological changes over time of vitrified-warmed blastocysts could lead to a better selection of viable embryos from shrunken blastocysts.

METHODS

The implantation rates of vitrified-warmed blastocysts that were shrunken or expanded (developing) at the time of loading for transfer were compared among 2,729 cycles that were subjected to single blastocyst transfer. Vitrified (107) and fresh blastocysts (17) were donated for the experimental study. To assess the relationship between morphology (expanded vs. shrunken) and the mitochondrial respiration of blastocysts, the oxygen consumption rate (OCR) was analyzed for 55 specimens using an uncoupler of oxidative phosphorylation. The remaining 69 blastocysts were used for recording morphological changes every 15 min for 48 h after warming.

RESULTS

Because there were no surplus embryos, 7 % of the vitrified-warmed blastocysts were shrunken and transferred. The shrunken embryos had sufficient implantation ability (40 %). The OCR of the shrunken embryos was significantly lower than that of their expanded counterparts. Upon exposure to the uncoupler, the OCR of some shrunken embryos increased to levels similar to the expanded specimens. Time-lapse images revealed some shrunken embryos which formed blastocoel by 5 h following warming exhibited developmental competence to the hatched stage.

CONCLUSIONS

Data of the present study suggest a group of shrunken blastocysts contains many viable and clinically available embryos and time-lapse observation of vitrified-warmed blastocysts is a potential method to distinguish viable embryos from shrunken blastocysts.

Auricular acupressure reduces anxiety levels and improves outcomes of in vitro fertilization: a prospective, randomized and controlled study

The study was to explore whether auricular acupressure (AA) can relieve anxiety during the period from trans-vaginal oocyte retrieval to the embryo transfer in IVF treatment and whether AA can improve the outcomes of IVF. 305 infertile patients with tubal blockage who were referred for IVF were included. The women were randomized into a control group with 102 cases, a Sham-AA group with 102 cases and an AA group with 101 cases. The anxiety levels were rated with Spielberger's State Trait Anxiety Inventory and the Amsterdam Preoperative Anxiety and Information Scale. Data of clinical pregnancy rate (CPR), implantation rate (IR) and live birth rate (LBR) were obtained. The levels of neuropeptide Y (NPY) and transforming growth factor alpha (TGF-alpha) in the follicular fluids were detected with ELISA. After treatment, in AA group, the levels of state anxiety, preoperative anxiety and need-for-information were significantly lower, whereas CPR, IR, LBR and NPY levels in the follicular fluids were markedly higher than Sham-AA group and control group. We concluded that AA could help to reduce anxiety levels associated with IVF and improves the outcomes of IVF partly through increasing the levels of NPY in the follicular fluids.