Management strategies following implantation failure of euploid embryos

Background

Euploid blastocyst implantation failure may result from embryonic factors undetectable by preimplantation genetic testing for aneuploidy (PGT-A); however, various nonembryonic factors can also intricately interfere with implantation. This review seeks to clarify evidence-based testing and treatments for implantation failure after euploid embryo transfer.

Methods

We conducted a review of the literature on implantation failure after euploid embryo transfer or multiple embryo transfer cycles, which mainly included systematic reviews and meta-analyses.

Results

The recommended tests for implantation failure include (1) hysteroscopy, (2) endometrial CD138 immunohistochemistry and bacterial culture, (3) serum 25-hydroxyvitamin D3, and (4) thrombophilia screening. Based on diagnostic findings, the following treatments have been recommended: (1) antibiotics for chronic endometritis, (2) vitamin D replacement, (3) lifestyle modification, and (4) low-dose aspirin starting from the postimplantation period for thrombophilia. Moreover, frozen-thawed single euploid blastocyst transfer using assisted hatching and hyaluronan-enriched transfer medium may support embryo implantation.

Conclusion

To ensure a successful pregnancy in subsequent embryo transfers, simple, inexpensive, and evidence-based tests and treatments should be selected.

Impact of Homocysteine as a Preconceptional Screening Factor for In Vitro Fertilization and Prevention of Miscarriage with Folic Acid Supplementation Following Frozen-Thawed Embryo Transfer: A Hospital-Based Retrospective Cohort Study

Homocysteine is an amino acid naturally produced in the body and metabolized via the methionine cycle. High homocysteine levels can increase the risk of infertility and pregnancy complications, such as preeclampsia, preterm delivery, miscarriage, and low birth weight. Preconceptional homocysteine levels may be reduced by taking folic acid supplements to reduce the risk of such complications. This cross-sectional, hospital-based study was conducted to examine the role of homocysteine in 1060 infertile women with a history of IVF/intracytoplasmic sperm injection (ICSI) failure. We analyzed whether folic acid intervention altered homocysteine levels and influenced reproductive outcome. We found that a higher homocysteine level was statistically associated with a lower fertilization rate in patients with a history of IVF/ICSI failure. There was an inverse relationship between homocysteine levels and serum 25(OH)VD, and a trend towards lower anti mullerian hormone in the group with higher homocysteine levels. This is the first interventional study to identify that folic acid supplementation improved pregnancy outcomes following freeze embryo transfer (FET) in women with a history of FET failure by monitoring the reduction in homocysteine levels. Therefore, folic acid supplementation and homocysteine level monitoring may constitute a novel intervention for improving IVF/ICSI pregnancy outcomes.

Beyond body mass index: a synthesis of lifestyle factors that may influence in vitro fertilisation outcomes

There are several lifestyle factors that are thought to potentially impact in vitro fertilisation outcomes, including body mass index, smoking, alcohol consumption, caffeine, dietary patterns and physical activity. Eligibility criteria for in vitro fertilisation in England often require individuals to be non-smokers, drug free and have a body mass index <30kg/m2. Some researchers have questioned the scientific and ethical basis for the use of body mass index thresholds in fertility treatment, citing evidence that other factors may have a greater effect on the chance of success of in vitro fertilisation. This article aims to briefly synthesise the current evidence on how other factors such as smoking, alcohol, recreational drugs, smoking, caffeine, dietary patterns and physical activity may impact in vitro fertilisation outcomes.

Adherence to the Mediterranean diet and the risk of unexpected poor response to ovarian stimulation in IVF cycles

RESEARCH QUESTION

Can preconception adherence to a Mediterranean diet influence the rate of poor response to ovarian stimulation in IVF cycles?

DESIGN

The impact of dietary habits on the success of IVF is controversial. Inconsistencies may be explained by confounders associated with the use of pregnancy as an outcome as well as by a reductionist view of diet that focuses on single components rather than on food patterns. This cross-sectional study analysed adherence to a Mediterranean diet in women with unexpected poor response to ovarian stimulation. Main inclusion criteria were: age 18-39 years, normal weight, preserved ovarian reserve and starting dose of gonadotrophins of 150-225 IU/day. Adherence to the Mediterranean diet was assessed through a Mediterranean diet score (MDS). Unexpected poor ovarian response was defined as the retrieval of ≤3 suitable oocytes.

RESULTS

A total of 296 women were included, of whom 47 (15.9%) showed an unexpected poor response. A clear dose-related association with tertiles of MDS was not observed in the univariate analysis. However, in the multivariate analysis, the risk of unexpected poor response was significantly lower for women in the second tertile of MDS compared with the first tertile (adjusted odds ratio [OR] 0.29, 95% confidence interval [CI] 0.11-0.76) and for women in the second and third tertiles, grouped together, compared with the first tertile (adjusted OR 0.34, 95% CI 0.14-0.82).

CONCLUSIONS

Low adherence to a Mediterranean diet could be a risk factor for unexpected poor ovarian response.

ESHRE good practice recommendations on recurrent implantation failure

STUDY QUESTION

How should recurrent implantation failure (RIF) in patients undergoing ART be defined and managed?

SUMMARY ANSWER

This is the first ESHRE good practice recommendations paper providing a definition for RIF together with recommendations on how to investigate causes and contributing factors, and how to improve the chances of a pregnancy.

WHAT IS KNOWN ALREADY

RIF is a challenge in the ART clinic, with a multitude of investigations and interventions offered and applied in clinical practice, often without biological rationale or with unequivocal evidence of benefit.

STUDY DESIGN SIZE DURATION

This document was developed according to a predefined methodology for ESHRE good practice recommendations. Recommendations are supported by data from the literature, if available, and the results of a previously published survey on clinical practice in RIF and the expertise of the working group. A literature search was performed in PubMed and Cochrane focussing on 'recurrent reproductive failure', 'recurrent implantation failure', and 'repeated implantation failure'.

PARTICIPANTS/MATERIALS SETTING METHODS

The ESHRE Working Group on Recurrent Implantation Failure included eight members representing the ESHRE Special Interest Groups for Implantation and Early Pregnancy, Reproductive Endocrinology, and Embryology, with an independent chair and an expert in statistics. The recommendations for clinical practice were formulated based on the expert opinion of the working group, while taking into consideration the published data and results of the survey on uptake in clinical practice. The draft document was then open to ESHRE members for online peer review and was revised in light of the comments received.

MAIN RESULTS AND THE ROLE OF CHANCE

The working group recommends considering RIF as a secondary phenomenon of ART, as it can only be observed in patients undergoing IVF, and that the following description of RIF be adopted: 'RIF describes the scenario in which the transfer of embryos considered to be viable has failed to result in a positive pregnancy test sufficiently often in a specific patient to warrant consideration of further investigations and/or interventions'. It was agreed that the recommended threshold for the cumulative predicted chance of implantation to identify RIF for the purposes of initiating further investigation is 60%. When a couple have not had a successful implantation by a certain number of embryo transfers and the cumulative predicted chance of implantation associated with that number is greater than 60%, then they should be counselled on further investigation and/or treatment options. This term defines clinical RIF for which further actions should be considered. Nineteen recommendations were formulated on investigations when RIF is suspected, and 13 on interventions. Recommendations were colour-coded based on whether the investigations/interventions were recommended (green), to be considered (orange), or not recommended, i.e. not to be offered routinely (red).

LIMITATIONS REASONS FOR CAUTION

While awaiting the results of further studies and trials, the ESHRE Working Group on Recurrent Implantation Failure recommends identifying RIF based on the chance of successful implantation for the individual patient or couple and to restrict investigations and treatments to those supported by a clear rationale and data indicating their likely benefit.

WIDER IMPLICATIONS OF THE FINDINGS

This article provides not only good practice advice but also highlights the investigations and interventions that need further research. This research, when well-conducted, will be key to making progress in the clinical management of RIF.

STUDY FUNDING/COMPETING INTERESTS

The meetings and technical support for this project were funded by ESHRE. N.M. declared consulting fees from ArtPRED (The Netherlands) and Freya Biosciences (Denmark); Honoraria for lectures from Gedeon Richter, Merck, Abbott, and IBSA; being co-founder of Verso Biosense. He is Co-Chief Editor of Reproductive Biomedicine Online (RBMO). D.C. declared being an Associate Editor of Human Reproduction Update, and declared honoraria for lectures from Merck, Organon, IBSA, and Fairtility; support for attending meetings from Cooper Surgical, Fujifilm Irvine Scientific. G.G. declared that he or his institution received financial or non-financial support for research, lectures, workshops, advisory roles, or travelling from Ferring, Merck, Gedeon-Richter, PregLem, Abbott, Vifor, Organon, MSD, Coopersurgical, ObsEVA, and ReprodWissen. He is an Editor of the journals Archives of Obstetrics and Gynecology and Reproductive Biomedicine Online, and Editor in Chief of Journal Gynäkologische Endokrinologie. He is involved in guideline developments and quality control on national and international level. G.L. declared he or his institution received honoraria for lectures from Merck, Ferring, Vianex/Organon, and MSD. He is an Associate Editor of Human Reproduction Update, immediate past Coordinator of Special Interest Group for Reproductive Endocrinology of ESHRE and has been involved in Guideline Development Groups of ESHRE and national fertility authorities. D.J.M. declared being an Associate Editor for Human Reproduction Open and statistical Advisor for Reproductive Biomedicine Online. B.T. declared being shareholder of Reprognostics and she or her institution received financial or non-financial support for research, clinical trials, lectures, workshops, advisory roles or travelling from support for attending meetings from Ferring, MSD, Exeltis, Merck Serono, Bayer, Teva, Theramex and Novartis, Astropharm, Ferring. The other authors had nothing to disclose.

DISCLAIMER

This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation. ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type. Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.

Impact of COVID-19 Pandemic on Women's Health and Obstetric Outcomes after Assisted Reproduction: A Survey from an Italian Fertility Center

BACKGROUND

the restrictive measures that were adopted during three waves of the COVID-19 pandemic had an impact on both the emotional state and lifestyle of the general population. We evaluated the impact of COVID-19 pandemic on lifestyles and emotional states of women planning assisted reproductive technology (ART), and whether these changes affected ART outcomes.

METHODS

quantitative research, using a web-based survey, was performed on 289 Caucasian women.

RESULTS

In preconception, we observed higher percentage of women with positive obstetric outcomes who reduced body weight (52.4% vs. 27.2%, p = 0.09). Over 60% of women with positive outcomes practiced physical activity vs. 47% of women with negative outcomes (p = 0.03), as well as having better quality of sleep (45% vs. 35%), and a more solid relationships with their partners (65.1% vs. 51.7%, p = 0.03). Women who increased their intake of whole grains, fruits, vegetables, and legumes (p < 0.05), according to the Mediterranean diet, showed positive outcomes. We observed that participants who experienced "very much" or "extreme" anxiety, sadness, and fear (p < 0.05) during pandemic were clearly more numerous in the group with negative pregnancy outcomes.

CONCLUSIONS

healthy lifestyle together with a positive emotional state in preconception can positively influence the obstetric outcomes after ART.

Preconception paternal alcohol exposure decreases IVF embryo survival and pregnancy success rates in a mouse model

Increasingly, couples struggling with fertility turn to assisted reproductive techniques, including IVF, to have children. Despite the demonstrated influence of periconception male health and lifestyle choices on offspring development, studies examining IVF success rates and child health outcomes remain exclusively focused on maternal factors. Using a physiologically relevant mouse model, we tested the hypothesis that chronic paternal preconception alcohol intake adversely affects IVF success and negatively impacts IVF offspring fetoplacental growth. Using a voluntary, binge-like mouse model, we exposed sexually mature C57BL/6J males to three preconception treatments (0% (Control), 6% EtOH or 10% EtOH) for 6 weeks, isolated and cryopreserved caudal sperm from treated males, and then used these samples to fertilize oocytes before assessing IVF embryo developmental outcomes. We found that preconception paternal alcohol use reduced IVF embryo survival and pregnancy success rates in a dose-dependent manner, with the pregnancy success rate of the 10% EtOH treatment falling to half those of the Controls. Mechanistically, we found that preconception paternal alcohol exposure disrupts embryonic gene expression, including Fgf4 and Egfr, two critical regulators of trophectoderm stem cell growth and placental patterning, with lasting impacts on the histological organization of the late-term placenta. The changes in placental histoarchitecture were accompanied by altered regulation of pathways controlling mitochondrial function, oxidative phosphorylation and some imprinted genes. Our studies indicate that male alcohol use may significantly impede IVF success rates, increasing the couple's financial burden and emotional stress, and highlights the need to expand prepregnancy messaging to emphasize the reproductive dangers of alcohol use by both parents.

Effects of air pollution on clinical pregnancy rates after in vitro fertilisation (IVF): a retrospective cohort study

OBJECTIVE

To evaluate the effect of air pollution, from oocyte retrieval to embryo transfer, on the results of in vitro fertilisation (IVF) in terms of clinical pregnancy rates, at two fertility centres, from 2013 to 2019.

DESIGN

Exploratory retrospective cohort study.

SETTING

This retrospective cohort study was performed in the Reproductive Biology Department of Bordeaux University Hospital localised in Bordeaux, France and the Jean Villar Fertility Center localised in Bruges, France.

PARTICIPANTS

This study included 10 763 IVF attempts occurring between January 2013 and December 2019, 2194 of which resulted in a clinical pregnancy.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome of the IVF attempt was recorded as the presence or absence of a clinical pregnancy; exposure to air pollution was assessed by calculating the cumulative exposure of suspended particulate matter, fine particulate matter, black carbon, nitrogen dioxide and ozone (O₃₎, over the period from oocyte retrieval to embryo transfer, together with secondary exposure due to the presence of the biomass boiler room, which was installed in 2016, close to the Bordeaux University Hospital laboratory. The association between air pollution and IVF outcome was evaluated by a random-effects logistic regression analysis.

RESULTS

We found negative associations between cumulative O₃ exposure and clinical pregnancy rate (OR=0.92, 95% CI = (0.86 to 0.98)), and between biomass boiler room exposure and clinical pregnancy rate (OR=0.75, 95% CI = (0.61 to 0.91)), after adjustment for potential confounders.

CONCLUSION

Air pollution could have a negative effect on assisted reproductive technology results and therefore precautions should be taken to minimise the impact of outdoor air on embryo culture.

Specific lifestyle factors and in vitro fertilization outcomes in Romanian women: a pilot study

Background

Infertility is an important health concern worldwide. Although lifestyle habits and behaviors have been widely reported as predictors of IVF outcomes by previous studies, they have not been reported for Romanian women undergoing IVF. In this regard, our pilot study aimed to begin to address the data gap by assessing lifestyle predictors of in vitro fertilization (IVF) outcomes in Romanian women.

Study design

Our pilot study included 35 participants who completed a first IVF cycle at a single infertility center. We evaluated individual self-reported lifestyle habits and behaviors as predictors of IVF outcomes, and employed principal component analysis (PCA) to characterize multiple lifestyle habits and behaviors into personal care product (PCP) use, and healthy diet and physical activity patterns as predictors of IVF outcomes.

Results

Our PCA analysis showed that greater use of PCPs was associated with lower probabilities of pregnancy (RR: 0.92, 95% CI [0.87-0.98]) and live birth (RR: 0.94, 95% CI [0.88-1.01]) while, the healthy dietary habits and physical activity were associated with a higher likelihood of pregnancy, although without statistical significance (RR: 1.10, 95% CI [0.93-1.30]).

Conclusions

In this pilot study we identified associations between IVF outcomes among Romanian women and certain lifestyle habits and behaviors including stress, diet and physical activity, and certain PCP use. We also estimated the joint effects of multiple lifestyle factors using PCA and found that PCP use, healthy dietary habits and physical activity were associated with IVF outcomes.

Influence of ambient air pollution on successful pregnancy with frozen embryo transfer: A machine learning prediction model

Numerous air pollutants have been reported to influence the outcomes of in vitro fertilization (IVF). However, whether air pollution affects implantation in frozen embryo transfer (FET) process is under debate. We aimed to find the association between ambient air pollution and implantation potential of FET and test the value of adding air pollution data to a random forest model (RFM) predicting intrauterine pregnancy. Using a retrospective study of a 4-year single-center design，we analyzed 3698 cycles of women living in Shanghai who underwent FET between 2015 and 2018. To estimate patients' individual exposure to air pollution, we computed averages of daily concentrations of six air pollutants including PM_2.5, PM₁₀, SO₂, CO, NO₂, and O₃ measured at 9 monitoring stations in Shanghai for the exposure period (one month before FET). Moreover, A predictive model of 15 variables was established using RFM. Air pollutants levels of patients with or without intrauterine pregnancy were compared. Our results indicated that for exposure periods before FET, NO₂ were negatively associated with intrauterine pregnancy (OR: 0.906, CI: 0.816-0.989). AUROC increased from 0.712 to 0.771 as air pollutants features were added. Overall, our findings demonstrate that exposure to NO₂ before transfer has an adverse effect on clinical pregnancy. The performance to predict intrauterine pregnancy will improve with the use of air pollution data in RFM.

More Live Births in Primary Subfertile Intracytoplasmic Sperm Injection-Treated Women with High Normal TSH Levels

OBJECTIVES

The aim of this study was to analyze the fertility outcome in intracytoplasmic sperm injection (ICSI)-treated women across normal range thyroid-stimulating hormone (TSH) levels. Published results are inconclusive about optimal TSH levels and fertility.

DESIGN

This is a retrospective cohort study in 752 ICSI-treated women with predominantly severe male factor subfertility, starting treatment between the first of January 2008 and the first of March 2012 with a follow-up until 2014. Participants/Materials, Setting, Methods: Women aged 22-45 years with TSH 0.3-4.5 mIU/L without thyroid hormone substitution were included in Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands, an iodine-sufficient area. Demographic and baseline characteristics were compared between groups of patients based on TSH, using one-way ANOVA, Kruskal-Wallis ANOVA, and χ2 test. The patient was the unit of analysis: all cumulative cycles per patient were analyzed up to and including the first ongoing pregnancy. The primary outcome was a cumulative live birth rate. Clinical pregnancy rate, pregnancy loss, and ongoing pregnancy rate were secondary outcomes. The χ2 test and logistic regression were used to compare interquartile groups while adjusting for confounders. Logistic regression was used with the natural logarithm of TSH as a continuous predictor. Primary and secondary subfertile women were analyzed separately.

RESULTS

Analysis of the total cohort (n = 752) showed no difference in fertility outcomes across the normal TSH range. The cumulative live birth rate for the 4 groups of primary subfertile women (n = 455) was 76% in the upper TSH quartile compared to 56%, 60%, and 59% in the lower TSH quartiles.

LIMITATIONS

Levels of thyroxine and presence of thyroid autoimmunity were not measured in this retrospective cohort study.

CONCLUSIONS

The observation that a higher live birth rate was found in primary subfertile ICSI-treated women with high but allegedly normal TSH levels contributes to the hypothesis that in certain subfertile women in addition to a male factor, female factors such as subtle hypothyroidism and/or thyroid autoimmunity may play a role in keeping them from conception, which can be overcome by the process of ICSI.

Pretreatment maternal lifestyle and outcomes of assisted reproduction: an Italian cohort study

OBJECTIVE

We investigated whether lifestyle affects assisted reproduction technology (ART) outcomes.

DESIGN

Cohort study.

SETTING

Italian fertility unit.

PARTICIPANTS

From September 2014 to December 2016, women from couples presenting for evaluation and eligible for ART were invited to participate. Information on alcohol intake, current smoking and leisure physical activity (PA) during the year before the interview was collected, using a structured questionnaire. We considered the ART outcomes of the cycle immediately following the interview.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was cumulative pregnancy rate per retrieval. Secondary measures were number of retrieved oocytes, embryo transfer and live birth.

RESULTS

In 492 women undergoing an ART cycle, 427 (86.8%) underwent embryo transfer, 157 (31.9%) had at least one clinical pregnancy and 121 (24.6%) had live birth. The cumulative pregnancy rate per retrieval was 33.3% (95% CI 28.5% to 38.7%). In women in the third tertile of alcohol intake, adjusted relative risk was 0.97 (95% CI 0.87 to 1.08), 0.90 (95% CI 0.62 to 1.30) and 0.89 (95% CI 0.57 to 1.37) for embryo transfer, clinical pregnancy and live birth, respectively. The corresponding figures in women currently smoking more than 5 cigarettes/day were 1.00 (95% CI 0.88 to 1.16), 0.94 (95% CI 0.60 to 1.48) and 1.14 (95% CI 0.68 to 1.90), and in women with PA ≥5 hours/week were 0.93 (95% CI 0.79 to 1.08), 0.44 (95% CI 0.22 to 0.90) and 0.48 (95% CI 0.22 to 1.05), respectively.

CONCLUSION

There were no significant differences in in vitro fertilisation outcomes among women who used alcohol or tobacco in the year prior to treatment. Conservatively, all women should be advised to limit substance abuse. Moreover, our study suggested that maintaining a moderate, but not high, level of PA could be beneficial.

Resuming Assisted Reproduction Services during COVID-19 Pandemic: An Initial Indian Experience

BACKGROUND

The pandemic of COVID-19 has affected many countries and medical services including assisted reproductive treatment (ART) have been hampered.

AIM

The study was conducted to assess the preparedness of ART clinics and staff to resume services; patients' reasons to initiate treatment; and key performance indicators (KPIs) of ART laboratories during the pandemic.

SETTING AND DESIGN

This was a semidescriptive, prospective study in two private in vitro fertilization (IVF) clinics in Maharashtra, India, when COVID-19 testing for asymptomatic people was unavailable.

MATERIALS AND METHODS

Time required for replenishing consumables and clinic preparedness to function under "new norms" of pandemic was documented. Infection mitigation measures and triaging strategy were evaluated. KPIs following resumption were analyzed. The Student's t-test was performed for comparing parameters.

RESULTS

Thirty percent of the patients consulted through telemedicine accepted or were eligible to initiate treatment on clinic resumption. Lack of safe transport and financial constraints prevented majority from undergoing IVF, and 9% delayed treatment due to fear of pandemic. With adequate training, staff compliance to meet new demands was achieved within a week, but procuring consumables and injections was time-consuming. Fifty-two cycles of IVF were performed including fresh and frozen embryo transfers with satisfactory KPIs even during pandemic. Conscious sedation and analgesia during oocyte retrieval were associated with reduced procedure time and no intervention for airway maintenance compared to general anesthesia. Self-reported pain scores by patients ranged from nil to mild on a graphic rating scale.

CONCLUSIONS

This study provides practical insight for the resumption of IVF services during the COVID-19 pandemic.

Adherence to healthy dietary patterns and outcomes of assisted reproduction: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the association between adherence to a healthy dietary pattern and outcomes of assisted reproductive techniques (ARTs). PubMed, Embase and Web of Science were searched for eligible studies through December 2019 according to the population, intervention, comparison, outcome and study design (PICOS) criteria. Eight prospective cohort studies (S) reporting pregnancy outcomes (O) of higher vs lower adherence to a healthy dietary pattern (I/C) in women undergoing ART treatment (P) were included, involving a total of 2229 women with 2067 embryo transfer cycles. The pooled odds ratio (OR) for positive pregnancy test, clinical pregnancy and ongoing pregnancy/live birth was 0.82 (95% confidence interval [CI] 0.65-1.03), 0.99 (95% CI 0.68-1.44) and 1.30 (95% CI 0.81-2.09), respectively. In conclusion, greater adherence to a healthy dietary pattern rich in vegetables, fruits, whole grains, legumes and fish, may not be significantly related to ART success.

Dietary Carbohydrate Intake, Dietary Glycemic Load and Outcomes of In Vitro Fertilization: Findings from an Observational Italian Cohort Study

In recent decades, increasing attention has been paid to the influence of diet on reproductive health. Carbohydrates in diet affect glucose metabolism and multiple evidences showed the key role of insulin sensitivity in regulating female fertility. We designed a prospective cohort study to investigate the relation between dietary carbohydrate intake, glycemic load (GL) and the outcomes of assisted reproduction. A population of 494 female partners of couples referring to an Italian Fertility Center and eligible for in vitro fertilization (IVF) were enrolled in the study. On the day of the oocyte retrieval, information on their diet was obtained using a validated food frequency questionnaire (FFQ). We calculated the relative risk and 95% confidence interval of embryo transfer, clinical pregnancy and live birth according to the following dietary exposures: GL, glycemic index (GI) as well as the daily carbohydrate and fiber intake. A multiple regression model was used to account for the confounders. After adjusting for age, college degree, body mass index (BMI), leisure physical activity and previous assisted reproduction techniques (ART) cycles, no significant association was observed between the considered dietary exposures and the IVF outcomes. The roles of GL, carbohydrate intake and GI were assessed in strata of the cause of infertility and body mass index and no relation emerged in this further analysis. We found no clear association between the dietary carbohydrate quantity and quality and IVF outcomes in a cohort of infertile Italian women.

Influence of polycyclic aromatic hydrocarbon exposure on IVF: now is the time to focus on women

RESEARCH QUESTION

Is polycyclic aromatic hydrocarbon (PAH) exposure associated with the reproductive outcomes of IVF treatment?

DESIGN

A prospective, small-scale monocentric cohort study of couples who underwent IVF treatment between January 2018 and June 2019. Both members of each couple answered a questionnaire on PAH exposure and provided urine samples to measure urinary 1-hydroxypyrene (1-OHP) the day before oocyte retrieval and semen collection for fertilization. To assess the specific PAH exposure of gamete cells, immunostaining was conducted on both spermatozoa and granulosa cells obtained during IVF with an anti-benzo(a)pyrene diol epoxide (BPDE) monoclonal antibody that recognizes BDPE-DNA adducts. To assess DNA damage, a comet assay on spermatozoa was conducted. The PAH exposure was compared between couples who had positive HCG and couples who had negative HCG on day 14 after embryo transfer.

RESULTS

Eighteen couples were included. The mean 1-OHP level in women whose HCG tests were positive (n = 6) was significantly lower than that in women with negative HCG tests (0.098 [0.042-0.170] versus 0.177 [0.067-0.812] μg/g creatinine; P = 0.048). The presence of BPDE-DNA adducts in granulosa cells of women with a negative (29.7 [16.2-57.5] arbitrary units) or positive HCG test (20.3 [9.3-23.3] arbitrary units) were not significantly different (P = 0.092). The urinary 1-OHP levels of men and BPDE-DNA adducts in spermatozoa showed no differences between groups.

CONCLUSIONS

This exploratory research should encourage further studies to determine the effect of women's exposure to PAHs on reproductive outcomes of IVF treatment.

Investigating the effect of lifestyle risk factors upon number of aspirated and mature oocytes in in vitro fertilization cycles: Interaction with antral follicle count

INTRODUCTION

There is evidence demonstrating that certain lifestyle factors have a detrimental effect on fertility. Since such factors often coexist, possible synergistic effects merit further investigation. Thus we aimed to examine the cumulative impact of lifestyle factors on in vitro fertilization (IVF) early reproductive treatment outcomes and their interaction with measures of ovarian reserve.

MATERIALS AND METHODS

By following women who were starting their first fresh IVF cycle in 2 cohorts, the "Lifestyle study cohort" (hypothesis generating cohort, n = 242) and the "UppSTART study" (validation cohort, n = 432) in Sweden, we identified two significant risk factors acting independently, smoking and BMI, and then further assessed their cumulative effects.

RESULTS

Women with both these risk factors had an Incidence Rate Ratio (IRR) of 0.75 [(95% CI 0.61-0.94)] regarding the number of aspirated oocytes compared to women without these risk factors. Concerning the proportion of mature oocytes in relation to the total number of aspirated oocytes, the interaction between BMI and Antral Follicle Count (AFC) was significant (p-value 0.045): the lower the value of AFC, the more harmful the effect of BMI with the outcome.

CONCLUSIONS

Data shows that there is an individual as well as a cumulative effect of smoking and BMI on the number of aspirated and mature oocytes in fresh IVF treatment cycles. AFC might modify associations between BMI and the proportion of mature oocytes in relation to the total number of aspirated oocytes. These results highlight the importance of lifestyle factors on IVF early reproductive outcomes and provide additional evidence for the importance of preconception guidance for the optimization of IVF cycle outcome.

A Practical Guide to Gynecologic and Reproductive Health in Women Undergoing Hematopoietic Stem Cell Transplant

Optimum care of female transplant recipients requires gynecologic care at several stages through the allogeneic hematopoietic stem cell transplantation (HCT) process. Sex-based considerations in women post-HCT span gynecologic sequelae of transplant along with assessment and maintenance of optimal sexual and gynecologic health. Pre-HCT, managing menstruation and abnormal uterine or genital bleeding, considering fertility preservation, and assessing for sexually transmitted infections, including human papillomavirus (HPV)-related disease and cervical cancer, enhance women's health. While inpatient during transplant when women are thrombocytopenic, menstrual bleeding requires suppression. Whenever graft-versus-host disease (GVHD) is assessed, screening for genital GVHD merits consideration. After the first 100 days, periodic assessments include obtaining a menstrual history, assessing ovarian function, and reviewing current hormonal use and contraindications to hormonal methods. Regular assessment for primary ovarian insufficiency, dyspareunia, and intimacy guides provision of contraception and hormone replacement options. As part of ongoing screening for genital GVHD and HPV-related disease, including sexually transmitted infections, periodic pelvic examinations are performed. Once successful long-term survival is achieved, planning for fertility may be considered. This article offers a comprehensive approach to these aspects of gynecologic care of patients throughout the trajectory of HCT and beyond into survivorship. We review the effects of HCT treatment on sexual health, ovarian function, and resulting menstrual changes and fertility challenges. Identification, treatment, and prevention of subsequent malignancies, including breast cancer, are discussed, with a focus on regular assessment of genital HPV disease and GVHD in long-term follow-up.

Body mass index in relation to extracellular vesicle-linked microRNAs in human follicular fluid

OBJECTIVE

To study whether increased body mass index is associated with altered expression of extracellular vesicle microRNAs (EV-linked miRNAs) in human follicular fluid.

DESIGN

Cross-sectional study.

SETTING

Tertiary-care university-affiliated center.

PATIENT(S)

One hundred thirty-three women undergoing in vitro fertilization (IVF) were recruited from January 2014 to August 2016.

INTERVENTIONS(S)

None.

MAIN OUTCOME MEASURE(S)

EV-linked miRNAs were isolated from follicular fluid and their expression profiles were measured with the use of the Taqman Open Array Human miRNA panel. EV-linked miRNAs were globally normalized and inverse-normal transformed. Associations between body mass index (BMI) and EV-linked miRNA outcomes were analyzed by means of multivariate linear regression and principal component analysis.

RESULT(S)

Eighteen EV-linked miRNAs were associated with an increase in BMI after adjusting for age, ethnicity, smoking status, and batch effects. Hsa-miR-328 remained significant after false discovery rate adjustments. Principal component analyses identified the first principal component to account for 40% of the variation in our EV-linked miRNA dataset, and adjusted linear regression found that the first principal component was significantly associated with BMI after multiple testing adjustments. Using Kyoto Encyclopedia of Genes and Genomes enrichment analyses, we predicted gene targets of EV-linked miRNA in silico and identified PI3K-Akt signaling, ECM-receptor interaction, focal adhesion, FoxO signaling, and oocyte meiosis pathways.

CONCLUSION(S)

These results show that a 1-unit increase in BMI is associated with altered follicular fluid expression of EV-linked miRNAs that may influence follicular and oocyte developmental pathways. Our findings provide potential insight into a mechanistic explanation for the reduced fertility rates associated with increased BMI.

Live birth rate after intrauterine insemination is not different between women with lower quartile versus higher quartile normal range thyroid stimulating hormone levels

STUDY QUESTION

Does lower quartile normal range thyroid stimulating hormone (TSH) compared to higher quartile normal range in women without thyroid hormone substitution affect live birth rate after a complete IUI treatment series?

SUMMARY ANSWER

Lower quartile normal range TSH, in women without thyroid hormone substitution, does not affect live birth rate after a complete intrauterine insemination treatment series compared to higher quartile normal range TSH.

WHAT IS KNOWN ALREADY

TSH is historically seen as the most sensitive test for thyroid function. Its distribution is right-skewed. Whether the preconceptional upper reference TSH values in subfertile women should be 2.5 or 4.5 mIU/L is under debate. Studies have shown that IUI patients treated with levothyroxine for TSH levels above 2.5 mIU/L show higher pregnancy rates. However, no adverse outcome is associated with untreated high normal TSH levels studied in first IUI cycles. Thyroid peroxidase antibodies have also impaired outcomes in some studies whereas others have shown an effect only in combination with high normal TSH levels. As a subgroup, patients with unexplained infertility showed increased levels of TSH. This article adds to the value of TSH evaluation and fertility outcome in four quartiles and in the context of a completed IUI treatment modus of a maximum of six inseminations.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study in 909 women undergoing 3588 IUI cycles starting treatment between the first of January 2008 and the first of March 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged 22–45 years with TSH 0.3–4.5 mIU/L without thyroid hormone substitution were included at Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands, an Iodine-sufficient area. The primary endpoint was live birth. Clinical pregnancy, pregnancy loss and ongoing pregnancy were secondary endpoints. Logistic regression was used with the natural logarithm of TSH as a continuous predictor. Chi-square tests and logistic regression were used to compare groups of patients based on TSH values in four quartile TSH groups (0.3–1.21 mIU/L; 1.22–1.75 mIU/L; 1.76–2.34 mIU/L; 2.35–4.5 mIU/L) on basic characteristics and on the endpoints while adjusting for confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Analysis with the natural logarithm of TSH as a continuous variable showed no association with live birth, pregnancy chance or pregnancy loss. There were no differences in any of the outcomes across the quartile TSH level ranges after regression analysis before and after adjusting for age, BMI, use of alcohol, tobacco, use or gonadotrophins, sperm count, diminished ovarian reserve, unexplained infertility and primary or secondary subfertility.

The distribution of primary and secondary subfertility and smoking characteristics were remarkably different across the four groups, with proportionally the lowest prevalence of primary subfertility and the highest rate of smoking in the lowest TSH group (0.3–1.20 mIU/L).

LIMITATIONS, REASONS FOR CAUTION

Unknown values of free thyroxine and thyroid peroxidase antibodies, as well as the retrospective character of the study, limit the clinical interpretability.

WIDER IMPLICATIONS OF THE FINDINGS

TSH in the highest quartile range (2.35–4.5 mIU/L) in subfertile women preceding IUI is not associated with a lower live birth rate or rate of clinical and ongoing pregnancy, or with loss of pregnancies, compared to subfertile women with TSH in the lower three quartile groups after complete intrauterine insemination treatment.

STUDY FUNDING/COMPETING INTEREST(s)

The department of Obstetrics and Gynaecology, division of Reproductive Medicine, and of Internal Medicine, division of Endocrinology provided support. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Adherence to the Mediterranean diet and IVF success rate among non-obese women attempting fertility

STUDY QUESTION

Is adherence to the Mediterranean diet (MedDiet) associated with better IVF performance in women attempting fertility?

SUMMARY ANSWER

Greater adherence to the MedDiet, defined using the validated Mediterranean diet score (MedDietScore), was associated with a higher likelihood of achieving clinical pregnancy and live birth among non-obese women <35 years of age.

WHAT IS KNOWN ALREADY

Diet impacts fertility and certain nutrients and food groups appear to have a greater effect on reproductive health, but there are relatively few published data on the role of dietary patterns, and the MedDiet in particular, on assisted reproductive performance.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study included 244 non-obese women (22-41 years of age; BMI < 30 kg/m2) who underwent a first IVF treatment in an Assisted Conception Unit in Athens, Greece, between November 2013 and September 2016. The study was designed to evaluate the influence of habitual dietary intake and lifestyle on fertility outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Diet was assessed before the IVF treatment via a validated food-frequency questionnaire. Adherence to the MedDiet was assessed through the MedDietScore (range: 0-55), with higher scores indicating greater adherence. Intermediate outcomes (oocyte yield, fertilization rate and embryo quality measures) and clinical endpoints (implantation, clinical pregnancy and live birth) were abstracted from electronic medical records. Associations between MedDietScore and IVF outcomes were analysed using generalized linear models adjusting for age, ovarian stimulation protocol, BMI, physical activity, anxiety levels, infertility diagnosis, caloric intake and supplements use.

MAIN RESULTS AND THE ROLE OF CHANCE

No association of MedDietScore with any of the intermediate outcomes or with implantation was found. However, compared with women in the highest tertile of the MedDietScore (≥36, n = 86), women in the lowest tertile (≤30, n = 79) had significantly lower rates of clinical pregnancy (29.1 vs 50.0%, P = 0.01) and live birth (26.6 vs 48.8%, P = 0.01). The multivariable-adjusted relative risk (95% CI) for clinical pregnancy comparing women in the lowest with women in the highest tertile of the MedDietScore was 0.35 (0.16-0.78; P-trend=0.01), and for live birth it was 0.32 (0.14-0.71; P-trend = 0.01). These associations were significantly modified by women's age (P-interaction <0.01 for both outcomes). MedDietScore was positively related to clinical pregnancy and live birth among women <35 years old (P ≤ 0.01) but not among women ≥35 years. Among women <35 years, a beneficial 5-point increase in the MedDietScore was associated with ~2.7 times higher likelihood of achieving clinical pregnancy and live birth.

LIMITATIONS, REASONS FOR CAUTION

Our finding cannot be generalized to the whole reproductive population nor to obese women nor to women attending infertility clinics around the world. In addition, due to the observational study design, causal inference is limited.

WIDER IMPLICATIONS OF THE FINDINGS

The results suggest that diet modifications and greater compliance to the Mediterranean diet may help increase the chances of a successful pregnancy and delivering a live baby for women undergoing IVF treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This work was partially supported by a grand from Harokopio University (KE321). All authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

NCT03050944.

Women undergoing assisted fertilisation and high-intensity interval training: a pilot randomised controlled trial

OBJECTIVES

Overweight and obese women often seek assisted fertilisation. In the obese population, pregnancy rates are 30%-75% below that of normal weight women who undergo assisted fertilisation. We hypothesised that high-intensity interval training (HIT) would improve fertility by improving insulin sensitivity and thus affect the hypothalamic-pituitary-ovarian axis and ovarian androgen production. Our aim was to assess whether HIT prior to assisted fertilisation would increase pregnancy rate.

METHODS

Eighteen overweight and obese women (body mass index>25.0 kg/m2) were randomised to HIT (n=8) or usual care (control, n=10) before assisted fertilisation. HIT was undertaken three times weekly for 10 weeks; two sessions of 4×4 min HIT and one session of 10×1 min HIT. Primary outcome was ongoing pregnancy. Secondary outcomes included insulin sensitivity, reproductive hormones, oxygen uptake and body composition.

RESULTS

Four women got pregnant in both the HIT group (50%) and in the control group (44%), no between-group difference (p=0.6). Insulin sensitivity (glucose infusion rate) improved significantly after HIT, from 264.1 mg/m2/min (95% CI 193.9 to 334.4) at baseline to 324.7 mg/m2/min (95% CI 247.2 to 402.2) after 10 weeks (between-group difference, p=0.04). Fasting glucose, visceral fat, waist circumference and VO2peak were significantly improved in the group that undertook HIT.

CONCLUSIONS

HIT significantly improved insulin sensitivity, VO2peak and abdominal fat. Low statistical power makes it difficult to conclude on whether HIT prior to assisted fertilisation could increase pregnancy rate. Larger trials are needed to determine if improvements in insulin sensitivity are clinically relevant for assisted fertilisation success rates in this population.

Association between preconception maternal beverage intake and in vitro fertilization outcomes

OBJECTIVE

To study whether maternal intake of beverage type affects IVF outcomes.

DESIGN

A prospective study.

SETTING

Tertiary, university-affiliated center.

PATIENT(S)

Three hundred forty women undergoing IVF from 2014 through 2016 for infertility as well as for pregenetic diagnosis for autosomal recessive diseases were enrolled during ovarian stimulation and completed a questionnaire describing their usual beverage consumption.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

IVF outcomes were abstracted from medical records. Total caffeine intake was estimated by summing the caffeine content for specific beverages multiplied by frequency of intake. Associations between specific types of beverages and IVF outcomes were analyzed using Poisson and logistic regression models adjusting for possible confounders.

RESULT(S)

Higher intake of sugared soda was associated with lower total, mature, and fertilized oocytes and top-quality embryos after ovarian stimulation. Women who consumed sugared soda had, on average, 1.1 fewer oocytes retrieved, 1.2 fewer mature oocytes retrieved, 0.6 fewer fertilized oocytes, and 0.6 fewer top-quality embryos compared with women who did not consume sugared soda. Furthermore, compared with women who did not drink sugared soda, the adjusted difference in percent of cycles resulting in live birth for women consuming 0.1-1 cups/day and >1 cup/day were -12% and -16%, respectively. No associations were found between consumption of coffee, caffeine, or diet sodas and IVF outcome.

CONCLUSION(S)

Sugared beverages, independent of their caffeine content, may be a bigger threat to reproductive success than caffeine and caffeinated beverages without added sugar.