Impact of Caesarean section on pregnancy outcomes in ART after transfer of one or more frozen blastocysts

INTRODUCTION

The prevalence of Caesarean delivery is rising steadily worldwide, and it is important to identify its future impact on fertility. A number of articles have been published on this subject, but the impact of Caesarean section on reproductive outcomes is still under debate, and none of these articles focus exclusively on frozen blastocysts.

OBJECTIVE

The aim of this study was to evaluate the impact of a previous Caesarean delivery compared with a previous vaginal delivery on the chances of a live birth following the transfer of one or more frozen embryos at the blastocyst stage.

METHODS

This was a retrospective, bicentric study at the University Hospitals of Nîmes and Montpellier, conducted between January 1st, 2016 and February 1st, 2021. Three hundred and ninety women with a history of childbirth and a transfer of one or more frozen embryos at blastocyst stage were included in the analysis. The primary outcome was the number of live births. Secondary outcomes were: the rate of positive HCG, miscarriage, ectopic pregnancy and clinical pregnancy, as well as the live birth rate according to the presence or absence of an isthmocele.

RESULTS

Of the 390 patients included, 118 had a previous Caesarean delivery and 272 a vaginal delivery. No statistically significant differences were found for the primary (p = 0.9) or secondary outcomes. A trend towards lower live birth rates was observed in patients with isthmoceles, but this did not reach significance (p>0.9). On the other hand, transfers were more often described as difficult in the Caesarean delivery group (p = 0.011).

CONCLUSION

Our study found no effect of previous Caesarean delivery on the chances of live birth after transferring one or more frozen blastocysts. However, further prospective studies are needed to confirm these results.

Incidence of obstetric anal sphincter injuries following breech compared to cephalic vaginal births

INTRODUCTION

Obstetric anal sphincter injuries (OASIs) at the time of childbirth can lead to serious consequences including anal incontinence, dyspareunia, pain and rectovaginal fistula. These types of lesions and their incidence have been well studied after cephalic presentation deliveries, but no publications have specifically addressed this issue in the context of vaginal breech delivery. The goal of our study was to evaluate the incidence of OASIs following breech deliveries and compare it with cephalic presentation births.

METHODS

This was a retrospective cohort study involving 670 women. Of these, 224 and 446 had a vaginal birth of a fetus in the breech (breech group) and cephalic (cephalic group) presentations respectively. Both groups were matched for birthweight (± 200 g), date of delivery (± 2 years) and vaginal parity. Main outcome of interest was to evaluate the incidence of OASIs following breech vaginal birth compared to cephalic vaginal births. Secondary endpoints were the incidence of intact perineum or first-degree tear, second-degree perineal tear and rates of episiotomies in each group.

RESULTS

There was no statistically significant difference in OASIs incidence between the breech and cephalic groups (0.9% vs. 1.1%; RR 0.802 (0.157; 4.101); p = 0.31). There were more episiotomies in the breech group (12.5% vs. 5.4%, p = 0.0012) and the rate of intact or first-degree perineum was similar in both groups (74.1% vs. 75.3%, p = 0.7291). A sub-analysis excluding patients with episiotomy and history of OASIs did not show any statistically significant difference either.

CONCLUSION

We did not demonstrate a significant difference in the incidence of obstetric anal sphincter injuries between women who had a breech vaginal birth compared to cephalic.

P-219 Does artificial shrinkage prior to fresh blastocyst transfer improve ongoing pregnancy rate? A prospective double blind randomized controlled trial

Study question

Does artificial shrinkage (AS) of blastocoelic cavity (BC) prior to fresh elective single blastocyst transfer (SBET) increase ongoing pregnancy rate?

Summary answer

Ongoing pregnancy rates were similar with or without AS of blastocoelic cavity. AS does not seem to provide benefit before fresh blastocyst transfer.

What is known already

AS of the vitrified blastocysts enhances success rate in frozen embryo transfer cycles.

In vitro cultured embryos suffer changes in temperature, pH and osmotic pressure. Moreover, manipulations such as pipetting, fertilization, microscopic observations and changes of dishes can induce oxidative stress and apoptosis. The presence of cell free DNA (cfDNA) in blastocyst fluids could be the consequence of its release from dead cells. The quantity of cfDNA in blastocyst fluids could possibly be related to the rate of cell death. It is thus interesting to estimate whether AS of BC could improve the implantation rate in cycles with fresh blastocyst transfer.

Study design, size, duration

Prospective, randomized, double blind controlled study. From May 20th 2018 to June 30th 2021, 150 couples elected for fresh SBET were included in the study and were randomly selected as “AS +” group (n = 100), where AS of blastocoel was performed by laser pulse before fresh blastocyst transfer, and “AS -” group (n = 50), where fresh blastocysts were transferred without any additional intervention.

Participants/materials, setting, methods

On day 5 after fertilization, one blastocyst with a grade of expansion B3, B4, B5 or B6 and type A or B quality trophectoderm (Gardner and Schoolcraft classification, 1999) was selected for transfer. After replacement, the droplet that contained the embryo from day 3 was collected for cfDNA level quantification.

Ongoing pregnancy rate was determined by the visualization of a gestational sac with a foetal heartbeat 6 weeks later and cfDNA was assessed by ALU-qPCR.

Main results and the role of chance

The two groups were similar for age, BMI, infertility duration and cause, stimulation characteristics and embryological parameters. The global ongoing pregnancy rate per transfer after SBET was 49.7 %. The pregnancy rate in the AS + group was slightly higher than in the control group but not significantly (respectively 50.00 % and 48,9 %, p = 0,91).

cfDNA median value in the AS+ group was comparable to the control group (0.493 (0.219; 0.915) mg/ml and 0.595 (0.271; 1.129) mg/ml respectively (p = 0.45)). No link was found between cfDNA rate and clinical pregnancy rate.

Limitations, reasons for caution

Patients included in the study are still followed to evaluate the impact of AS on live birth rate, wastage rate, obstetrical and neonatal complications. cfDNA rate was evaluated in spent culture media and not by blastocentesis, which could provide a more accurate quantification.

Wider implications of the findings

To our knowledge, this is the first prospective randomized controlled study assessing the benefit of AS of BC before fresh blastocyst transfer. The inclusion of live birth rate is crucial to ascertain the interest of this technique and more studies are needed to improve the use of cfDNA in routine.

Trial registration number

NCT02988544

Isolated tubal twist: A case series of a rare event occurring at different times in reproductive life

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Isolated fallopian tube torsion is a rare but potentially serious event occurring at different times in reproductive life.

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This diagnosis is often overlooked before surgery.

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It should be evoked in front acute pelvic pain in patients with history of hydrosalpinx or paratubal cyst.

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Conservative management must be privileged especially in woman of childbearing age and in a pediatric population.

Introduction and importance

Isolated fallopian tube torsion (IFTT) is a rare but potentially serious cause of pelvic pain in women. Despite being a surgical emergency, this diagnosis is often overlooked before surgery. To raise awareness of this diagnosis among clinicians, we describe here five cases, which occurred at different times in reproductive life.

Cases presentation

We present five cases of isolated fallopian tube torsion at different ages (13–54 years). It often manifests with sudden onset of acute pelvic pain in four cases and chronic pelvic pain in one case.

At admission, patients were suspected of adnexal torsion (3 cases), genital infection (1 case), and renal pain (1 case). CT-scan showed IFTT in only one patient. Laparoscopic surgical management, performed by experienced surgeons, consisted of salpingectomy in 4 cases and conservative treatment in one case. The latter was complicated with hydrosalpinx 6 years later. All patients were followed in outpatient clinic at least one time after surgery and had favorable outcomes.

Clinical discussion

Given the rarity of the pathology and the lack of pathognomonic imaging, IFTT is rarely diagnosed before surgery. Its etiology is still unknown but hydrosalpinx following an infectious process seems to be a major risk factor.

Conclusion

Increasing awareness of this rare entity is advocated, especially in woman of reproductive age. Torsion should be evoked in front acute pelvic pain in patients with hydrosalpinx or paratubal cyst. Conservative management must be privileged especially in women of childbearing age and in pediatric population.

[Endometrial receptivity in assisted reproductive techniques: An aspect to investigate in embryo implantation failure]

Infertility affects between 8 and 12% of reproductive-age couples worldwide. Despite improvements in assisted reproductive techniques (ART), live birth rates are still limited. In clinical practice, imaging and microscopy are currently widely used, but their diagnostic effectiveness remains limited. In research, the emergence of innovative techniques named OMICS would improve the identification of the implantation window, while progressing in the understanding of the pathophysiological mechanisms involved in embryo implantation failures. To date, transcriptomic analysis seems to be the most promising approach in clinical research. The objective of this review is to present the results obtained with the different approaches available in clinical practice and in research to assess endometrial receptivity in patients undergoing ART.

[Comparison of birth weights of children born after slow frozen embryo replacement versus fresh embryo transfer]

OBJECTIVE

It is already known that children born after slow frozen embryo replacement have a significantly higher birth weight compared to children born after fresh embryo transfer. Similar data have been reported related to frozen embryo transfer using an open vitrification system. However, few data relative to birth weight using a complete embryo closed vitrification system has been reported. The purpose of this study was to know if frozen embryo in closed vitrification system is associated with a higher birth weight compared to fresh embryo replacement.

DESIGN

This was a monocentric retrospective cohort study, 371 children were issued from fresh embryo replacement and 127 from vitrified embryo transfer.

MATERIALS AND METHODS

All singletons born after fresh or vitrified embryo transfer between January 2011 and April 2015 were included. Births from the vitrified or fresh transfers of egg or sperm donation, and preimplantation genetic diagnosis were excluded. In addition, pregnancies with more than one gestational sac at the first ultrasound were excluded. An analysis of covariance (ANCOVA) was used for multivariate analysis.

RESULTS

Mean birth weight was 205g higher in the frozen embryo compared with fresh embryos transfer groups (3368g vs. 3163g respectively, P<0.001). This difference remained after multivariate analysis adjusted on confounding factors such as gestational age, maternal age, maternal body mass index (BMI), tobacco exposure, number of embryo transferred and birth order (P<0.001)..

CONCLUSIONS

Embryo frozen in closed vitrification system is associated with a higher birth weight compared to fresh embryo replacement. Our findings are consistent with the previous studies related to slow freezing and open vitrification systems data. The effects of controlled ovarian stimulation (COS), ex vivo culture conditions and cryopreservation systems on birth weight of children born should be further explored.

[Birth weight and frozen embryo transfer: State of the art]

The aim of this study was to update our acknowledgment if there is a link between assisted embryo cryopreservation and epigenetics in human? Animal studies have demonstrated epigenetics consequence and especially imprinting disorders due to in vitro culture. In human, it is important to note that after frozen embryo transfer birth weight is significantly increased by 81 to 250g. But these studies cannot identify the reasons of such difference. This review strongly suggests that embryo cryopreservation is responsible for birth weight variations but mechanisms not yet elucidated. Epigenetics is probably one of these but to date, none study is able to prove it. We have to be attentive on a possible link between assisted reproductive technology (ART) and epigenetics reprogrammation.

Sperm quality and paternal age: effect on blastocyst formation and pregnancy rates

Background

Several studies suggest a decrease in sperm quality in men in the last decades. Therefore, the aim of this work was to assess the influence of male factors (sperm quality and paternal age) on the outcomes of conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

Methods

This retrospective study included all couples who underwent IVF or ICSI at Montpellier University Hospital, France, between 1 January 2010 and 31 December 2015. Exclusion criteria were cycles using surgically retrieved sperm or frozen sperm, with pre-implantation genetic diagnosis or using frozen oocytes. The primary outcomes were the blastulation rate (number of blastocysts obtained at day 5 or day 6/number of embryos in prolonged culture at day 3) and the clinical pregnancy rate. The secondary outcomes were the fertilization and early miscarriage rates.

Results

In total, 859 IVF and 1632 ICSI cycles were included in this study. The fertilization rate after ICSI was affected by oligospermia. Moreover, in ICSI, severe oligospermia (lower than 0.2 million/ml) led to a reduction of the blastulation rate. Reduced rapid progressive motility affected particularly IVF, with a decrease of the fertilization rate and number of embryos at day 2 when progressive motility was lower than 32%.

Paternal age also had a negative effect. Although it was difficult to eliminate the bias linked to the woman’s age, pregnancy rate was reduced in IVF and ICSI when the father was older than 51 and the mother older than 37 years.

Conclusions

These results allow adjusting our strategies of fertilization technique and embryo transfer. In the case of severe oligospermia, transfer should be carried out at the cleaved embryo stage (day 2–3) due to the very low blastulation rate. When the man is older than 51 years, couples should be aware of the reduced success rate, especially if the woman is older than 37 years. Finally, promising research avenues should be explored, such as the quantification of free sperm DNA, to optimize the selection of male gametes.

[Effects of artificial shrinkage prior to vitrification in a closed system: a randomized controlled trial]

OBJECTIVE

To evaluate the effect of induced blastocoele shrinkage before vitrification in a closed carrier device.

PATIENTS AND METHODS

Prior to vitrification, blastocyst cavity was artificially shrinked by laser pulse or not treated according to a 2:1 randomized procedure. A total of 185 warming cycles from April 2011 to March 2013 have been analyzed. Clinical pregnancy rate and survival rate were compared between the two groups. The mean (±SD) women age was 33.5±5.7 years for both groups.

RESULTS

The pregnancy rate in the group with artificial reduction of the cavity was higher ([32/67] 47.7%) than in the control group but not significantly ([43/113] 38%). The survival rate in the artificial shrinkage group was significantly higher compared with the control group : 99% (102/103) and 91.8% (168/183) respectively (P=0.01).

DISCUSSION AND CONCLUSION

This study reveals that artificial shrinkage of blastocoelic cavity by laser pulse before vitrification in a closed carrier device improves survival rate after warming.

[Oncofertility program at the Montpellier university hospital 2 years after]

OBJECTIVE

Female fertility preservation in the context of cancer management is crucial for patient's health care. The aim of this study was to evaluate the oncofertility practice at our university hospital of Montpellier since 2011.

PATIENTS AND METHODS

The evaluation of management of young patients referred to Montpellier University Hospital from September 2011 to September 2013 for oncofertility counselling before cancer treatment.

RESULTS

Seventy-one patients were referred to a specialized oncofertility center. Forty-two patients (59.1%) were included in the oncofertility program. Twenty-two patients (31%) were proposed for oocyte vitrification after COS protocol, eight patients (11.3%) for ovarian tissue cryoconservation, seven patients (9.9%) for GnRH injections, three patients (4.2%) ovarian transposition and two patients (2.8%) for embryo cryopreservation. Among the 42 indications of fertility preservation, only 18 will have finally taken place.

CONCLUSION

Oncofertility counselling for young patients should now be part of the cancer management. It involves multidisciplinary teams. Further information of both oncologists and patients is needed to improve this new approach in the field of cancer treatments.