Randomized study comparing day 2 versus day 3 elective transfer of two good-quality embryos

Prolonged blastomere movement induced by the delay of pronuclear fading and first cell division adversely affects pregnancy outcomes after fresh embryo transfer on Day 2: a time-lapse study

RESEARCH QUESTION

What is the incidence, origin and clinical significance of blastomere movement after the first cell division in the human embryo?

DESIGN

A total of 1096 embryos, cultured in the EmbryoScope+ ® time-lapse system and subjected to a single fresh cleaved embryo transfer, were retrospectively analysed. Type and duration of blastomere movement (dBMov) between the first (t2) and second cell division (t3) was monitored, and the ratio of dBMov during the 2-cell stage [dBMov/(t3-t2)] was calculated. Morphological evaluation of embryos was performed by referring to the size of the blastomere and fragmentation after first division in addition to Veeck's criteria on Day 2. The correlation between dBMov and ongoing pregnancy was evaluated and the association of dBMov with patient and embryonic characteristics was determined.

RESULTS

Both movement type and the value of dBMov/(t3-t2) were significantly associated with asymmetrical first division, fragment formation and morphological grade on Day 2. Multivariate logistic regression analysis revealed that a higher value of dBMov/(t3-t2) significantly correlated with a decreased ongoing pregnancy rate, even after adjustment for co-founders (odds ratio 0.399, P = 0.0419). The time intervals of pronuclear (PN) alignment and PN fading were significantly correlated with the dBMov/(t3-t2) value.

CONCLUSIONS

Embryos with extended blastomere movement after the first cell division, which is associated with the delay of PN fading and first cell division, have a lower competence to initiate an ongoing pregnancy after fresh embryo transfer on Day 2. Thus, blastomere movement could be a useful predictive parameter for selecting embryos at the early cleavage stage.

Efficacy of embryo transfer on day 2 versus day 3 according to maternal age in patients with normal ovarian response

Objective

Delaying embryo transfer (ET) enables us to select among the embryos available for transfer and is associated with positive effects on implantation and pregnancy outcomes. However, the optimal day for ET of human cleavage-stage embryos remains controversial.

Methods

A retrospective study of 3,124 in vitro fertilization/intracytoplasmic sperm injection cycles (2,440 patients) was conducted. We compared the effects of day 2 and 3 ET on rates of implantation and pregnancy outcomes between young maternal age (YMA; <38 years old, n=2,295) and old maternal age (OMA; ≥38 years old, n=829) patient groups.

Results

The YMA and OMA groups did not differ in terms of patient characteristics except for the proportion of unexplained factor infertility, which was significantly greater in the OMA group, and the proportion of arrested embryos, which was significantly greater in the YMA group. However, the biochemical pregnancy, clinical pregnancy, ongoing pregnancy, abortion, and implantation rates per cycle were not significantly different between day 2 and 3 ET in the YMA group or the OMA group.

Conclusion

We suggest that offering patients the opportunity to decide which day would be suitable for ET could be part of a patient-friendly protocol that takes into consideration an infertile woman's circumstances and work schedule by allowing ET to be performed on day 2 instead of the traditional transfer on day 3.

Day three versus day two embryo transfer following in vitro fertilization or intracytoplasmic sperm injection

BACKGROUND

Embryo transfer (ET) was traditionally performed two days after oocyte retrieval; however, developments in culture media have allowed embryos to be maintained in culture for longer periods. Delaying transfer from Day two to Day three would allow for further development of the embryo and might have a positive effect on pregnancy outcomes.

OBJECTIVES

To determine if there are any differences in live birth and pregnancy rates when embryo transfer is performed on day three after oocyte retrieval, compared with day two, in infertile couples undergoing treatment with in vitro fertilisation (IVF), including intracytoplasmic sperm injection (ICSI).

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) from the inception of the databases to 26th April 2016. We also searched ClinicalTrials.gov and the WHO portal for ongoing trials plus citation lists of relevant publications, review articles and included studies, as well as abstracts of appropriate scientific meetings.

SELECTION CRITERIA

Randomised controlled trials that compared Day 3 versus Day 2 embryo transfer after oocyte retrieval during an IVF or ICSI treatment cycle in infertile couples.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. The primary outcome measures were live birth rate and ongoing pregnancy rate.

MAIN RESULTS

We included 15 studies. Fourteen studies reported data per woman (2894 women) and one study reported data per cycle (969 cycles). The quality of the evidence using the GRADE approach ranged from moderate quality to very low quality. The main reasons for downgrading evidence were poor methodological reporting, selective reporting, inconsistency and imprecision. Live birth per woman - Overall, there was no evidence of a difference in live birth rate between Day three and Day two embryo transfer (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.23; three studies, n = 1200 women; I2 = 63%; very low quality evidence). The data suggest that if 32% of women who underwent a Day two embryo transfer had a live birth, then between 28% to 39% of women undergoing a Day three embryo transfer would have a live birth. Ongoing pregnancy per woman - There was no evidence of a difference between Day three and Day two embryo transfer for ongoing pregnancy (RR 0.98, 95% CI 0.85 to 1.12; six studies, n = 1740 women; I2 = 52%; very low quality of evidence). The data suggest that if 33% of women undergoing a Day two embryo transfer had an ongoing pregnancy then between 28% to 37% of women undergoing a Day three embryo transfer would have an ongoing pregnancy. Clinical pregnancy per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the chance of a clinical pregnancy (RR 1.08, 95% CI 0.98 to 1.19; 12 studies, n = 2461, I2 = 51%; very low quality evidence). The data suggest that if 39% of women undergoing Day two embryo transfer had a clinical pregnancy, then between 38% to 46% of women undergoing a Day three embryo transfer would have a clinical pregnancy. Multiple pregnancy per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the risk of a multiple pregnancy (RR 1.12, 95% CI 0.86 to 1.44; eight studies, n = 1837; I2 = 0%; moderate quality evidence). The data suggest that if 11% of women undergoing Day two embryo transfer had a multiple pregnancy, then between 9% to 15% of women undergoing a Day three embryo transfer would have a multiple pregnancy. Miscarriage rate per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the risk of miscarriage (RR 1.16, 95% CI 0.84 to 1.60; nine studies, n = 2153 women, I2 = 26%; moderate quality evidence). The data suggest that if 6% of women undergoing Day two embryo transfer had a miscarriage, then between 5% to 10% of women undergoing a Day three embryo transfer would have a miscarriage. Ectopic pregnancy rate per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the risk of ectopic pregnancy (RR 0.99, 95% CI 0.29 to 3.40; six studies, n = 1531 women, I2 = 0%; low quality evidence). The data suggest that if 0.7% of women undergoing Day two embryo transfer have an ectopic pregnancy, then between 0.2% to 2% of women undergoing Day three embryo transfer would have an ectopic pregnancy.Subgroup analysis for pregnancy outcomes did not identify any differential effect between IVF and ICSI.None of the included studies prespecified complication rate (e.g. OHSS), fetal abnormality or women's evaluation of the procedure as outcomes in their studies.

AUTHORS' CONCLUSIONS

Twelve of 15 studies contributed data that could be included in meta-analyses. The quality of the evidence ranged from moderate to very low. Only three of the 15 studies reported data for live birth, although the data for ongoing pregnancy and clinical pregnancy are consistent with the live birth data, suggesting no difference between Day three and Day two embryo transfer for these outcomes. There was no evidence of a difference identified between Day three and Day two embryo transfer for multiple pregnancy, miscarriage or ectopic pregnancy per woman randomised. No data were reported for complication rate, fetal abnormality or woman's evaluation of the procedure. The current evidence has not identified any evidence of differences in pregnancy outcomes between Day two and Day three embryo transfers. Any further studies comparing these timings of embryo transfer are unlikely to alter the findings and we suggest that this review no longer be updated.

Establishment of criteria for elective single embryo transfer at day 2 or day 3 by analyzing cases with successful implantation of all embryos transferred

AIM

Elective transfer of two good-quality embryos has been used to avoid triplet or high-order multiple pregnancies. However, the rate of twin pregnancies has remained fairly unchanged. In the present study, criteria for elective single embryo transfer (eSET) at day 2 or day 3 were established by analyzing cases with successful implantation of all embryos transferred.

METHODS

A total of 685 fresh or frozen-thawed embryo transfers following in vitro fertilization/intracytoplasmic sperm injection between April 2002 and March 2006 were performed. Only embryo transfers at day 2 or day 3, but not at blastocyst stage, were included. Successful implantation of all embryos transferred was obtained in 17 pregnancy cycles.

RESULTS

Thirty-one gestational sacs with fetal heartbeats were obtained by a total of 31 embryo transfers in 17 infertile women. The average age was 32.6 years (23-38), and 14 (82.3%) of the 17 women were <36 years old. Fifteen (88.2%) of the 17 pregnancies were established at the first attempt of assisted reproductive technology (ART). Of the 17 women, eight (47.1%) women were multigravida and four (23.5%) women were multipara. The indications for ART or insemination methods did not seem to be related to the pregnancy results. Twenty-nine (93.5%) of 31 embryos implanted were considered good-quality embryos. Of the 17 fresh embryos transferred at day 2, 15 were at the 4-cell stage and two were at the 5-cell stage. Of the 11 fresh embryos transferred at day 3, one was at the 6-cell stage, two were at the 7-cell stage and eight were at the 8-cell stage.

CONCLUSION

The criteria for eSET at day 2 or day 3 were established as follows: <36 years of age, a first treatment cycle and more than two good-quality embryos developed at least to the 4-cell stage at day 2, or 6-cell stage at day 3. Additionally, the past history of pregnancy or delivery should be considered, as patients positive for such history might have better implantation ability. eSET can be highly recommended to avoid twin pregnancies in subjects with the established criteria.

Increase of multiple pregnancies caused by ovulation induction with gonadotropin in combination with metformin in infertile women with polycystic ovary syndrome

Metformin appears to be an effective medicine to induce ovulation in women with polycystic ovary syndrome and insulin resistance. After the introduction of metformin treatment for such cases, the use of gonadotropin in combination with metformin significantly increased the incidence of multiple pregnancies.

Serum matrix metalloproteinase and tissue inhibitor of metalloproteinase concentrations in infertile women achieved pregnancy following IVF-ET

PROBLEM

Matrix metalloproteinase (MMP) and tissue inhibitor of metalloproteinase (TIMP) play important roles throughout various stages of pregnancy, including embryo implantation, trophoblastic invasion, placentation in early gestation, and cervical dilatation in later gestation, and feto-maternal membrane lysis. It would be beneficial if assessment of serum concentrations of MMP and TIMP could predict successful implantation following in vitro fertilization-embryo transfer (IVF-ET). This study was performed to compare serum MMP and TIMP concentrations between patients with and without the establishment of pregnancy following ET.

METHOD OF STUDY

Ten patients who conceived and 10 patients who did not after IVF-ET were entered in the present study. Only intra-uterine single pregnancies with uneventful courses to term were included in the study subjects. Blood samples were obtained at 7, 14 and 21 days after oocyte retrieval. Serum concentrations of MMP-1, MMP-2, MMP-3, and TIMP-1 were measured using enzyme-linked immunosorbent assay. These variables were compared with estradiol (E(2)), progesterone (P(4)), and betahCG levels in the patients' sera. Clinical pregnancies were diagnosed only when fetal heartbeat was visualized on ultrasound.

RESULTS

There were no significant differences in serum MMP concentrations between the pregnant group and the non-pregnant group. However, serum TIMP-1 concentrations on Days 14 and 21 in the pregnant group were significantly higher than those in non-pregnant group [Day 14: 223.1 +/- 11.9 versus 177.5 +/- 20.6 ng/mL (P = 0.004); Day 21: 215.4 +/- 27.8 versus 181.5 +/- 27.4 ng/mL (P = 0.03)]. Serum TIMP-1 concentrations were also correlated with serum E(2) and P(4) levels (P < 0.0001), but not with those of the MMPs. None of MMP nor TIMP-1 were correlated with serum betahCG level.

CONCLUSIONS

It was demonstrated that the patients who successfully conceived after IVF-ET showed significantly higher levels of TIMP-1 at 14 and 21 days after IVF-ET, but not at day 7; further work will be required to determine if serum TIMP-1 can be used to improve prediction of pregnancy outcome in these patients.

Effects of in vivo exposure to eggs with sperm-immobilizing antibodies in follicular fluid on subsequent fertilization and embryo development in vitro

Aims:  It has been shown that supplementation of patients' sera that contains sperm-immobilizing antibodies results in failure of fertilization and embryo development in vitro. The present study was carried out to investigate if exposing retrieved eggs to a high number of sperm-immobilizing antibodies in the follicular fluid (FF) in vivo affected subsequent fertilization and embryo development in vitro, even if they were washed with an antibody-free culture medium. Methods:  Patients' sera and their FF were collected in 15 in vitro fertilization-embryo transfer (IVF-ET) or intracytoplasmic sperm injection-embryo transfer (ICSI-ET) treatment cycles from 11 infertile women with sperm-immobilizing antibodies in their sera. Quantitative sperm-immobilizing antibody titers (SI₅₀ titers) in the sera and FF were evaluated. The fertilization rate, good-quality embryo rate and implantation rate by IVF-ET were compared between infertile patients having higher (10≤) SI₅₀ titers and lower (<10) SI₅₀ titers in their FF. Results:  There was a significant correlation in the SI₅₀ titers between the patients' sera and their FF (P < 0.0001). After thoroughly washing the collected eggs in culture medium without the patient's serum before IVF, there was no difference in the fertilization rate in the patients with high (10≤) and low (<10) SI₅₀ titers in their FF (P = 0.62). However, the good-quality embryo rate in the patients with a high SI₅₀ titer was significantly lower than patients with a low antibody titer (P < 0.05). There was no significant difference in the implantation rate between the two groups (P = 0.33). Conclusions:  Similar amounts of sperm-immobilizing antibodies existed in the patients' FF and in their sera. ICSI did not seem to be necessary in patients having the antibodies if their sera were not supplemented in the culture media. Even with careful manipulation of eggs, it might be suggested that the harmful effects of sperm-immobilizing antibodies on embryo development cannot be completely avoided, especially in patients with high SI₅₀ titers in the FF. (Reprod Med Biol 2006; 5: 137-143).

Effects of in vivo exposure to eggs with sperm-immobilizing antibodies in follicular fluid on subsequent fertilization and embryo development in vitro

Aims:  It has been shown that supplementation of patients' sera that contains sperm-immobilizing antibodies results in failure of fertilization and embryo development in vitro. The present study was carried out to investigate if exposing retrieved eggs to a high number of sperm-immobilizing antibodies in the follicular fluid (FF) in vivo affected subsequent fertilization and embryo development in vitro, even if they were washed with an antibody-free culture medium. Methods:  Patients' sera and their FF were collected in 15 in vitro fertilization-embryo transfer (IVF-ET) or intracytoplasmic sperm injection-embryo transfer (ICSI-ET) treatment cycles from 11 infertile women with sperm-immobilizing antibodies in their sera. Quantitative sperm-immobilizing antibody titers (SI₅₀ titers) in the sera and FF were evaluated. The fertilization rate, good-quality embryo rate and implantation rate by IVF-ET were compared between infertile patients having higher (10≤) SI₅₀ titers and lower (<10) SI₅₀ titers in their FF. Results:  There was a significant correlation in the SI₅₀ titers between the patients' sera and their FF (P < 0.0001). After thoroughly washing the collected eggs in culture medium without the patient's serum before IVF, there was no difference in the fertilization rate in the patients with high (10≤) and low (<10) SI₅₀ titers in their FF (P = 0.62). However, the good-quality embryo rate in the patients with a high SI₅₀ titer was significantly lower than patients with a low antibody titer (P < 0.05). There was no significant difference in the implantation rate between the two groups (P = 0.33). Conclusions:  Similar amounts of sperm-immobilizing antibodies existed in the patients' FF and in their sera. ICSI did not seem to be necessary in patients having the antibodies if their sera were not supplemented in the culture media. Even with careful manipulation of eggs, it might be suggested that the harmful effects of sperm-immobilizing antibodies on embryo development cannot be completely avoided, especially in patients with high SI₅₀ titers in the FF. (Reprod Med Biol 2006; 5: 137-143).

Severe ovarian hyperstimulation syndrome in a 42-year-old woman with successful pregnancy after intracytoplasmic sperm injection embryo transfer

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of ovulation induction for infertile women. It has been shown that patients suffering from OHSS are generally young because OHSS depends on the patient's ovarian reserve. Therefore, women ≥40 years of age seldom suffer from the severe form of OHSS. In the present study, we report a case of severe OHSS that occurred in a 42-year-old woman with a successful pregnancy after intracytoplasmic sperm injection (ICSI)-embryo transfer. She had been diagnosed as having polycystic ovary syndrome (PCOS). After 5 cycles of unsuccessful treatment with gonadotropins plus intrauterine insemination for her husband's asthenozoospermia, the treatment with assisted reproductive technology (ART) was indicated. In the third ART attempt, the patient was treated by ICSI-embryo transfer (ET) and she developed severe OHSS at 4 weeks' gestation. On admission, marked hemoconcentration, oligouria and hypo-albuminemia were diagnosed. A continuous autotransfusion system of ascites, which was developed to expand circulating plasma volume without exogenous albumin, was carried out for 5 h at a rate of 100-200 mL/h once a day for a total of 5 days. The course of the pregnancy was uneventful. At 37 weeks' gestation, a healthy baby boy weighing 3336 g was born by cesarean section when the patient was 43 years of age. The postoperative course was also uneventful. To the best of our knowledge, the present report describes the oldest woman showing severe OHSS. (Reprod Med Biol 2005; 4: 265-269).