Clinical outcomes from ART in predicted hyperresponders: in vitro maturation of oocytes versus conventional ovarian stimulation for IVF/ICSI

STUDY QUESTION

Do ongoing pregnancy rates (OPRs) differ in predicted hyperresponders undergoing ART after IVM of oocytes compared with conventional ovarian stimulation (OS) for IVF/ICSI?

SUMMARY ANSWER

One cycle of IVM is non-inferior to one cycle of OS in women with serum anti-Müllerian hormone (AMH) levels ≥10 ng/ml.

WHAT IS KNOWN ALREADY

Women with high antral follicle count and elevated serum AMH levels, indicating an increased functional ovarian reserve, are prone to hyperresponse during ART treatment. To avoid iatrogenic complications of OS, IVM has been proposed as a mild-approach alternative treatment in predicted hyperresponders, including women with polycystic ovary syndrome (PCOS) who are eligible for ART. To date, inferior pregnancy rates from IVM compared to OS have hampered the uptake of IVM by ART clinics. However, it is unclear whether the efficiency gap between IVM and OS may differ depending on the extent of AMH elevation.

STUDY DESIGN, SIZE, DURATION

This study is a retrospective cohort analysis of clinical and laboratory data from the first completed highly purified hMG (HP-hMG) primed, non-hCG-triggered IVM or OS (FSH or HP-hMG stimulation in a GnRH antagonist protocol) cycle with ICSI in predicted hyperresponders ≤36 years of age at a tertiary referral university hospital. A total of 1707 cycles were included between January 2016 and June 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Predicted hyperresponse was defined as a serum AMH level ≥3.25 ng/ml (Elecsys® AMH, Roche Diagnostics). The primary outcome was cumulative ongoing pregnancy rate assessed 10-11 weeks after embryo transfer (ET). The predefined non-inferiority limit was -10.0%. The analysis was adjusted for AMH strata. Time-to-pregnancy, defined as the number of ET cycles until ongoing pregnancy was achieved, was a secondary outcome. Statistical analysis was performed using a multivariable regression model controlling for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 463 IVM cycles were compared with those from 1244 OS cycles. Women in the IVM group more often had a diagnosis of Rotterdam PCOS (434/463, 93.7%) compared to those undergoing OS (522/1193, 43.8%), were significantly younger (29.5 years versus 30.5 years, P ≤ 0.001), had a higher BMI (25.7 kg/m2 versus 25.1 kg/m2, P ≤ 0.01) and higher AMH (11.6 ng/ml versus 5.3 ng/ml, P ≤ 0.001). Although IVM cycles yielded more cumulus-oocyte complexes (COCs) (24.5 versus 15.0 COC, P ≤ 0.001), both groups had similar numbers of mature oocytes (metaphase II (MII)) (11.9 MII versus 10.6 MII, P = 0.9). In the entire cohort, non-adjusted cumulative OPR from IVM was significantly lower (198/463, 42.8%) compared to OS (794/1244, 63.8%), P ≤ 0.001. When analysing OPR across different serum AMH strata, cumulative OPR in both groups converged with increasing serum AMH, and OPR from IVM was non-inferior compared to OS from serum AMH levels >10 ng/ml onwards (113/221, 51.1% (IVM); 29/48, 60.4% (OS)). The number of ETs needed to reach an ongoing pregnancy was comparable in both the IVM and the OS group (1.6 versus 1.5 ET's, P = 0.44). Multivariable regression analysis adjusting for ART type, age, BMI, oocyte number, and PCOS phenotype showed that the number of COCs was the only parameter associated with OPR in predicted hyperresponders with a serum AMH >10 ng/ml.

LIMITATIONS, REASONS FOR CAUTION

These data should be interpreted with caution as the retrospective nature of the study holds the possibility of unmeasured confounding factors.

WIDER IMPLICATIONS OF THE FINDINGS

Among subfertile women who are eligible for ART, IVM, and OS resulted in comparable reproductive outcomes in a subset of women with a serum AMH ≥10 ng/ml. These findings should be corroborated by a randomised controlled trial (RCT) comparing both treatments in selected patients with elevated AMH.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. P.D. has been consultant to Merck Healthcare KGaA (Darmstadt, Germany) from April 2021 till June 2023 and is a Merck employee (Medical Director, Global Medical Affairs Fertility) with Merck Healthcare KGAaA (Darmstadt, Germany) since July 2023. He declares honoraria for lecturing from Merck KGaA, MSD, Organon, and Ferring. The remaining authors declared no conflict of interest pertaining to this study.

TRIAL REGISTRATION NUMBER

N/A.

Mouse oocytes restore antral stage partial mechanical denudation in vitro

In brief

Partially denuded mouse cumulus-oocyte complexes restore likely functional transzonal projections in culture, under meiotic inhibition, with no detectable impact on oocyte competence. This proof-of-concept study constitutes positive premises for improving the developmental competence of human capacitation (CAPA)-in vitro maturation (IVM) oocytes with inadequate somatic cell connections.

Abstract

In vitro oocyte culture might be the sole option for fertility preservation in some patients. This relies on constant oocyte-somatic bidirectional communication, and its precocious disruption alters oocyte competence. In non-human chorionic gonadotropin-triggered human in vitro maturation (IVM), retrieval of cumulus-oocyte complexes (COCs) by needle aspiration from the targeted small follicles (2-8 mm) leads to the collection of some partially denuded (PD) COCs with poor developmental competence. Hypothetically, re-establishing connectivity in these COCs could rescue oocyte quality. To test this, we used a well-characterized mouse preantral follicle culture system. On day 8, at antral stage, in part of the follicles, the oocytes were mechanically denuded while in other follicles in vitro grown oocytes were replaced with age matched fully stripped in vivo grown ones. The denuded oocytes were cultured on top of the somatic compartment until day 12, when oocyte-somatic reconnection was assessed. Furthermore, to better mimic the current biphasic IVM setup, fully surrounded (FS) COCs were collected from 19- to 21- day-old unprimed mice. Following partial mechanical denudation, COCs were cultured under meiotic inhibition for 2-4 days, to test oocyte-cumulus cell (CC) reconnection. Meiotic and developmental competence endpoints were compared between reconnected and FS-cultured COCs. We concluded that (i) in vivo- and in vitro- grown antral oocytes reconnect with in vitro-grown somatic companions; (ii) PD-COCs restore the FS morphology in culture, under meiotic inhibition; and (iii) oocyte quality from reconnected and intact cultured COCs is comparable. These observations encourage translational work to rescue partially denuded oocytes in human IVM.

Electronic witnessing in the medically assisted reproduction laboratory: insights and considerations after 10 years of use

STUDY QUESTION

What have we learnt after 10 years of electronic witnessing?

SUMMARY ANSWER

When applied correctly, an electronic witnessing system can replace manual witnessing in the medically assisted reproduction lab to prevent sample mix-up.

WHAT IS KNOWN ALREADY

Electronic witnessing systems have been implemented to improve the correct identification, processing, and traceability of biological materials. When non-matching samples are simultaneously present in a single workstation, a mismatch event is generated to prevent sample mix-up.

STUDY DESIGN, SIZE, DURATION

This evaluation investigates the mismatch and administrator assign rate over a 10-year period (March 2011-December 2021) with the use of an electronic witnessing system. Radiofrequency identification tags and barcodes were used for patient and sample identification. Since 2011, IVF and ICSI cycles and frozen embryo transfer cycles (FET) were included; IUIs cycles were included since 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The total number of tags and witnessing points were recorded. Witnessing points in a particular electronic witnessing system represent all the actions that have been performed from gamete collection through embryo production, to cryopreservation and transfer. Mismatches and administrator assigns were collected and stratified per procedure (sperm preparation, oocyte retrieval, IVF/ICSI, cleavage stage embryo or blastocyst embryo biopsy, vitrification and warming, embryo transfer, medium changeover, and IUI). Critical mismatches (such as mislabelling or non-matching samples within one work area) and critical administrator assigns (such as samples not identified by the electronic witnessing system and unconfirmed witnessing points) were selected.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 109 655 cycles were included: 53 023 IVF/ICSI, 36 347 FET, and 20 285 IUI cycles. The 724 096 used tags, led to a total of 849 650 witnessing points. The overall mismatch rate was 0.251% (2132/849 650) per witnessing point and 1.944% per cycle. In total, 144 critical mismatches occurred over the different procedures. The yearly mean critical mismatch rate was 0.017 ± 0.007% per witnessing point and 0.129 ± 0.052% per cycle. The overall administrator assign rate was 0.111% (940/849 650) per witnessing point and 0.857% per cycle, including 320 critical administrator assigns. The yearly mean critical administrator assign rate was 0.039 ± 0.010% per witnessing point and 0.301 ± 0.069% per cycle. Overall mismatch and administrator assign rates remained fairly stable during the evaluated time period. Sperm preparation and IVF/ICSI were the procedures most prone to critical mismatch and administrator assigns.

LIMITATIONS, REASONS FOR CAUTION

The procedures and methods of integration of an electronic witnessing system may vary from one laboratory to another and result in differences in the potential risks related to sample identification. Individual embryos cannot (yet) be identified by such a system; this makes extra manual witnessing indispensable at certain critical steps where potential errors are not recorded. The electronic witnessing system still needs to be used in combination with manual labelling of both the bottom and lid of dishes and tubes to guarantee correct assignment in case of malfunction or incorrect use of radiofrequency identification tags.

WIDER IMPLICATIONS OF THE FINDINGS

Electronic witnessing is considered to be the ultimate tool to safeguard correct identification of gametes and embryos. But this is only possible when used correctly, and proper training and attention of the staff is required. It may also induce new risks, i.e. blind witnessing of samples by the operator.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was either sought or obtained for this study. J.S. presents webinars on RIW for CooperSurgical. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

A systematic review and evidence assessment of monogenic gene-disease relationships in human female infertility and differences in sex development

BACKGROUND

As in other domains of medicine, high-throughput sequencing methods have led to the identification of an ever-increasing number of gene variants in the fields of both male and female infertility. The increasing number of recently identified genes allows an accurate diagnosis for previously idiopathic cases of female infertility and more appropriate patient care. However, robust evidence of the gene-disease relationships (GDR) allowing the proper translation to clinical application is still missing in many cases.

OBJECTIVE AND RATIONALE

An evidence-based curation of currently identified genes involved in female infertility and differences in sex development (DSD) would significantly improve both diagnostic performance and genetic research. We therefore performed a systematic review to summarize current knowledge and assess the available GDR.

SEARCH METHODS

PRISMA guidelines were applied to curate all available information from PubMed and Web of Science on genetics of human female infertility and DSD leading to infertility, from 1 January 1988 to 1 November 2021. The reviewed pathologies include non-syndromic as well as syndromic female infertility, and endocrine and reproductive system disorders. The evidence that an identified phenotype is caused by pathogenic variants in a specific gene was assessed according to a standardized scoring system. A final score (no evidence, limited, moderate, strong, or definitive) was assigned to every GDR.

OUTCOMES

A total of 45 271 publications were identified and screened for inclusion of which 1078 were selected for gene and variant extraction. We have identified 395 genes and validated 466 GDRs covering all reported monogenic causes of female infertility and DSD. Furthermore, we present a genetic diagnostic flowchart including 105 genes with at least moderate evidence for female infertility and suggest recommendations for future research. The study did not take into account associated genetic risk factor(s) or oligogenic/polygenic causes of female infertility.

WIDER IMPLICATIONS

We have comprehensively reviewed the existing research on the genetics of female infertility and DSD, which will enable the development of diagnostic panels using validated genes. Whole genome analysis is shifting from predominantly research to clinical application, increasing its diagnostic potential. These new diagnostic possibilities will not only decrease the number of idiopathic cases but will also render genetic counselling more effective for infertile patients and their families.

P-253 Shorter duration of compaction during human in-vitro preimplantation embryo development is associated with a higher clinical pregnancy rate

Study question

Is the duration of compaction, KID- (Known Implantation Data) and iDAScore (Intelligent Data Analysis for embryo evaluation) associated to clinical pregnancy rate?

Summary answer

Duration of compaction, KID- or iDAScore can be used to select the best embryo for transfer to increase clinical pregnancy rate.

What is known already

The development of human preimplantation embryos follows a programmed timeline in which a series of critical events occur. Compaction is a typical event at 3 to 4 days post fertilisation that is characterised by flattening of the blastomeres and the formation of tight junctions between the blastomeres. It is considered the first morphological event in the differentiation process of the embryo. Time-lapse technology introduced continuous monitoring of the embryo throughout development in the IVF laboratory. Evaluation of the developmental events combined with calculating KID- and iDAScore can optimise the selection of the most competent embryos for transfer and/or cryopreservation.

Study design, size, duration

This single-centre retrospective observational study included 158 IVF/ICSI cycles with fresh single embryo transfer (SET) was performed between December 2018 and November 2021. Embryos were cultured during 5 days in cleavage/blastocyst medium (Coopersurgical) in the EmbryoScope + (Vitrolife). Transferred embryos were evaluated for start of compaction, time to full compaction and duration of compaction. Embryo quality was calculated using KID- and iDAScore. These parameters were compared between the clinically pregnant and non-pregnant group (primary outcome).

Participants/materials, setting, methods

Only IVF/ICSI cycles with ejaculated sperm and fresh SET on day 5 were included. MNC, IVM and PGT cycles were excluded. Time zero was the start of injection or insemination. Pregnancy was confirmed by hCG and clinical pregnancy was defined by gestational sac visualisation at ultrasound.

GraphPad Prism and R-studio were used for statistical analysis. For prediction of clinical pregnancy, univariate logistic regression was used. Other significant differences were determined using t-test.

Main results and the role of chance

Out of 158 fresh ET, 101 (63.9%) had a positive hCG, of which 88 (55.6%) achieved clinical pregnancy. All 158 transferred blastocysts were annotated to calculate KID- and iDAScore.

There was no statistical difference in age between the two groups (34.7 years vs 35.0 years; p = 0.69).

Start of compaction was heterogeneous (between 50.9 and 98.3 hours post injection/insemination; mean=76.5±7.7), as well as the blastomere number at its initiation (between 4 and 16 blastomeres; mean=11.8±2.1).

Univariate logistic regression showed that each individual parameter, i.e. duration of compaction (p = 0.02), KID-score (p = 0.001) and iDAScore (p = 0.0006) was different between the clinically pregnant and non-pregnant group.

The total duration of compaction was significantly shorter in the clinical pregnant group (mean=8.6±3.4 hours vs 10.2±4.7 hours; p = 0.01; t-test). In the pregnant group the KIDscore (mean=7.7±1.4 vs 6.7±2.3; p = 0.0007) and iDAScore (mean=8.9±0.7 vs 8.3±1.3; p = 0.0002) were significantly higher.

During partial compaction, cells were rather excluded (93%) than extruded from the process; 17 embryos underwent this process, 10 of which resulted in a clinical pregnancy.

Limitations, reasons for caution

As this is a retrospective study, the influence of uncontrolled variables cannot be excluded. In the future, different models will be applied that can combine duration of compaction, KID- and iDAScore in a larger study.

Wider implications of the findings

Our analysis confirms previous findings that KID- and iDAScore are good predictors of clinical pregnancy.

We also show that duration of compaction can be used as a potential predictor for pregnancy, especially in IVF clinics that have no access to KID- or iDAScore.

Trial registration number

not applicable

First live birth after fertility preservation using vitrification of oocytes in a woman with mosaic Turner syndrome

PURPOSE

To report the case of a young woman diagnosed with Turner syndrome (TS) who achieved a live birth using her own oocytes that had been vitrified for fertility preservation.

METHODS

A 25-year-old woman with mosaic (45,X/46,XX) TS was referred for fertility preservation (FP) counseling. Serum anti-Müllerian hormone (AMH) level was normal (6.4 µg/L). In view of the unpredictable rate of follicle loss in TS individuals, she requested FP and underwent two cycles of ovarian stimulation (OS) for oocyte cryopreservation (OoC) using a GnRH antagonist protocol and recombinant follicle stimulating hormone (rFSH), 200-250 IU daily for 8 resp. 12 days.

RESULTS

In total, 29 metaphase II oocytes (MII) were vitrified after OS. After conceiving spontaneously and achieving a live birth, she returned to the clinic five years after OoC with a desire for pregnancy using in vitro fertilization (IVF) of her cryopreserved oocytes and preimplantation genetic testing (PGT-A). All 29 MII oocytes were thawed; 23 oocytes survived (79.3%) and were inseminated with partner sperm using intracytoplasmic sperm injection (ICSI). Thirteen oocytes were fertilized resulting in three good quality blastocysts which were vitrified after trophectoderm biopsy for PGT-A using array-CGH. Two blastocysts were found to be euploid. One was thawed and transferred to the uterus using a HRT priming protocol. An uneventful pregnancy occurred. The patient delivered a healthy baby girl weighing 3490 g at 40 weeks of gestation.

CONCLUSIONS

We report the first live birth achieved using cryopreserved oocytes in a woman diagnosed with mosaic TS. Cryopreservation of oocytes after ovarian stimulation is a realistic option for FP in selected post menarche individuals with mosaic TS. Whether PGT-A may reduce the risk of pregnancy loss in TS has to be confirmed by further studies.

Cumulative live birth rate after ovarian stimulation with freeze-all in women with polycystic ovaries: does the polycystic ovary syndrome phenotype have an impact?

RESEARCH QUESTION

Do cumulative live birth rates (CLBR) differ between polycystic ovary syndrome (PCOS) phenotypes when a freeze-all strategy is used to prevent OHSS after ovarian stimulation?

DESIGN

A single-centre, retrospective cohort study of 422 women with PCOS or polycystic ovarian morphology (PCOM), in whom a freeze-all strategy was applied after GnRH agonist triggering because of hyper-response in their first or second IVF/ICSI. Primary outcome was CLBR; multivariate logistic regression analysis was used.

RESULTS

Phenotype A (hyperandrogenism + ovulation disorder + PCOM [HOP]) (n = 91/422 [21.6%]); phenotype C (hyperandrogenism + PCOM [HP]) (33/422 [7.8%]; phenotype D (ovulation disorder + PCOM [OP]) (n = 161/422 [38.2%]); and PCOM (n = 137/422 [32.5%]. Unadjusted CLBR was similar among the groups (69.2%, 69.7%, 79.5% and 67.9%, respectively; P = 0.11). According to multivariate logistic regression analysis, the phenotype did not affect CLBR (OR 0.72, CI 0.24 to 2.14 [phenotype C]; OR 1.55, CI 0.71 to 3.36 [phenotype D]; OR 0.84, CI 0.39 to 1.83 [PCOM]; P = 0.2, with phenotype A as reference).

CONCLUSIONS

In women with PCOS, hyper-response after ovarian stimulation confers CLBR of around 70%, irrespective of phenotype, when a freeze-all strategy is used. This contrasts with unfavourable clinical outcomes in women with hyperandrogenism and women with PCOS who underwent mild ovarian stimulation targeting normal ovarian response and fresh embryo transfer. The results should be interpreted with caution because the study is retrospective and cannot be generalized to all cycles as they pertain to those in which hyper-response is observed.

P–462 First live birth after fertility preservation using vitrified oocytes in a woman with mosaic Turner syndrome

Study question

Is oocyte vitrification an option for preserving the fertility of women diagnosed with Turner syndrome (TS)?

Summary answer

We report the first live birth achieved using cryopreserved oocytes in a woman diagnosed with mosaic Turner syndrome.

What is known already

Women with TS are at extremely high risk for premature ovarian insufficiency (POI) and infertility. Although the desire of becoming parents may be fulfilled through egg donation or adoption, fertility preservation using ovarian tissue cryopreservation or oocyte vitrification has been offered to adolescents with TS before complete exhaustion of their follicular stockpile. However, women with TS exhibit higher rates of pregnancy loss and obstetric complications, and the feasibility of fertility preservation in TS is hampered by the reduced follicular pool and by concerns about the X chromosomal content of oocytes and follicular cells.

Study design, size, duration

Case report in a university hospital.

Participants/materials, setting, methods

A 25-year-old woman with Turner syndrome mosaicism (45,X0[14]/46,XX[86]) was referred for fertility preservation (FP) counseling. Serum antimüllerian hormone (AMH) level was normal (6.4 µg/L). In view of parenthood postponement and because of the unpredictable rate of follicle loss, the woman underwent two cycles of ovarian stimulation using recombinant follicle stimulating hormone (rFSH), 200–250 IU/day for 8 resp. 12 days, in a GnRH antagonist protocol.

Main results and the role of chance

In total, 29 metaphase II oocytes (MII) were vitrified. Five years later, the patient returned to the clinic with a desire for pregnancy. Because of evidence of considerable AMH decline (–56% in an interval of four years), the patient was advised to utilize her cryopreserved oocytes for in-vitro fertilization with preimplantation genetic testing for aneuploidy screening (PGT-A). All 29 MII oocytes were thawed; 26 oocytes survived (89.7%) and were inseminated using intracytoplasmic sperm injection (ICSI). Thirteen oocytes were fertilized normally. Three good quality blastocysts ensued and were vitrified after trophectoderm biopsy for PGT-A using array-CGH. Two blastocysts were found euploid. One was thawed and transferred into the uterus using a HRT priming protocol. An uneventful pregnancy occurred. The patient delivered a healthy baby girl weighing 3490 g at 40 weeks of gestation.

Limitations, reasons for caution

Cryopreservation of oocytes and/or ovarian tissue in selected postmenarchal girls or young women with Turner syndrome is an investigational FP approach that may result in genetic parenthood. The feasibility of FP in TS individuals is limited to those with evidence of ovarian function, before POI occurs.

Wider implications of the findings: Cryopreservation of mature oocytes after ovarian stimulation is a realistic option for FP in selected postmenarchal individuals with mosaic TS. Whether PGT-A may reduce the risk of pregnancy loss in TS has to be confirmed by further studies.

Trial registration number

Not applicable

O-161 Cumulative live birth rate after a freeze-all approach in women with polycystic ovaries: does the PCOS phenotype have an impact?

Study question

Do cumulative live birth rates (CLBR) differ between PCOS phenotypes when a freeze-all strategy is used to prevent OHSS after ovarian stimulation (OS)?

Summary answer

When conventional-dose OS resulted in high response, a CLBR of ∼ 70% was observed after “freeze-all” in women with PCOS, irrespective of their phenotype.

What is known already

Previous observational studies have shown that CLBR in women with PCOS who undergo assisted reproductive technologies (ART) may depend on their phenotype. When OS was performed with caution to avoid ovarian hyperresponse, CLBR was lower in women with a hyperandrogenic PCOS phenotype. However, when women with PCOS do exhibit hyperresponse and a freeze-all strategy is used, the impact of the PCOS phenotype on the clinical outcome of the ART cycle is unclear.

Study design, size, duration

This is a single-centre, retrospective cohort study including 422 women with polycystic ovary syndrome (PCOS) as defined by Rotterdam criteria or PCO-like ovarian morphology-only (PCOM) in whom a freeze-all strategy was applied after GnRH agonist triggering in the context of hyperresponse defined as ³19 follicles of ³11mm in their first or second IVF-ICSI cycle between January 2015 and December 2019 in a tertiary referral hospital.

Participants/materials, setting, methods

PCOS phenotype was based on hyperandrogenism (H), ovulatory dysfunction (O) and PCO-like ovarian morphology (P). Ovarian stimulation was performed with rFSH or HPhMG, adjusted to BMI. The primary outcome was cumulative live birth rate (CLBR) resulting from the transfer of all cryopreserved embryos from the same IVF-ICSI cycle. Patient and cycle characteristics and laboratory and clinical data were analysed. Data were analysed by multivariate logistic regression adjusting for covariates.

Main results and the role of chance

In total, 91/422 (21.6%) patients had PCOS phenotype A (HOP); 33 (7.8%) had phenotype C (HP), 161/422 (38.2%) had phenotype D (OP) and 137/422 (32.5%) had PCOM (n = 137). BMI, AMH and AFC were significantly different between phenotype groups (p < 0.001), and highest in PCOS phenotype A. The type of gonadotropin used, as well as the mean daily and total stimulation dose were comparable for all groups. The mean number of retrieved oocytes was comparable among groups (22.4±10.8 for phenotype A, 21.4±7.1 for phenotype C, 20.4±7.8 for phenotype D and 22.2±9.7 for PCOM; p = 0.46). The mean number of embryos available for vitrification differed significantly (4.4±3.7, 5.7±3.4, 5.7±3.4 and 5.2±3.6, respectively; p = 0.005). Following the first frozen embryo transfer, LBR was comparable among groups (41.5%, 43.3%, 49.3% and 38.5%, respectively; p = 0.31). Unadjusted CLBR was also similar (69.2%, 69.7%, 79.5% and 67.9%, respectively; p = 0.11). The multivariate logistic regression model adjusting for age, BMI, number of oocytes and embryo stage (cleavage vs. blastocyst stage) confirmed that the PCOS/PCOM phenotype did not have any impact on CLBR (OR 0.80, CI 0.28-2.29 (phenotype C); OR 1.40, CI 0.67-2.90 (phenotype D); OR 0.65, CI 0.31-1.34 (PCOM); p = 0.1, with phenotype A as reference).

Limitations, reasons for caution

These data should be interpreted with caution as the retrospective nature of the study holds the possibility of unmeasured confounding factors. The results cannot be generalised to all ART cycles in women with polycystic ovaries as they pertain to those cycles where OS leads to hyperresponse.

Wider implications of the findings

In subfertile women with PCOS eligible for ART, hyperresponse after OS confers excellent cumulative live birth rates when a freeze-all strategy is used, eliminating unfavourable clinical outcomes that had previously been observed in hyperandrogenic PCOS women after mild OS targeting normal ovarian response and fresh embryo transfer.

Trial registration number

not applicable

Early pregnancy loss in patients with polycystic ovary syndrome after IVM versus standard ovarian stimulation for IVF/ICSI

STUDY QUESTION

Is the incidence of early pregnancy loss (EPL) in patients with polycystic ovary syndrome (PCOS) higher after IVM of oocytes than after ovarian stimulation (OS) for IVF/ICSI?

SUMMARY ANSWER

Women with PCOS who are pregnant after fresh embryo transfer have a higher probability of EPL following IVM, but after frozen embryo transfer (FET), no significant difference in the incidence of EPL was observed following IVM compared to OS.

WHAT IS KNOWN ALREADY

There is conflicting evidence in the current literature with regard to the risk of EPL after IVM of oocytes when compared with OS. Because of the limited sample size in previous studies, the use of different IVM systems and the possible bias introduced by patient characteristics and treatment type, firm conclusions cannot be drawn.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study evaluating 800 women, with a diagnosis of infertility and PCOS as defined by Rotterdam criteria, who had a first positive pregnancy test after fresh or FET following IVM or OS between January 2010 and December 2017 in a tertiary care academic medical centre.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pregnancies after non-hCG triggered IVM following a short course of highly purified human menopausal gonadotropin were compared with those after conventional OS. The primary outcome was EPL, defined as a spontaneous pregnancy loss before 10 weeks of gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 329 patients with a positive pregnancy test after IVM and 471 patients with a positive pregnancy test after OS were included. Women who were pregnant after IVM were younger (28.6 ± 3.4 years vs 29.3 ± 3.6 years, P = 0.005) and had higher serum anti-Mullerian hormone levels (11.5 ± 8.1 ng/ml vs 7.2 ± 4.1 ng/ml, P < 0.001) compared to those who were pregnant after OS. The distribution of PCOS phenotypes was significantly different among women in the IVM group compared to those in the OS group and women who were pregnant after OS had previously suffered EPL more often (28% vs 17.6%, P = 0.003). EPL was significantly higher after fresh embryo transfer following IVM compared to OS (57/122 (46.7%) vs 53/305 (17.4%), P < 0.001), while the results were comparable after FET (63/207 (30.4%) vs 60/166 (36.1%), respectively, P = 0.24). In the multivariate logistic regression analysis evaluating fresh embryo transfer cycles, IVM was the only independent factor (adjusted odds ratio (aOR) 4.24, 95% CI 2.44-7.37, P < 0.001)) significantly associated with increased odds of EPL. On the other hand, when the same model was applied to FET cycles, the type of treatment (IVM vs OS) was not significantly associated with EPL (aOR 0.73, 95% CI 0.43-1.25, P = 0.25).

LIMITATIONS, REASONS FOR CAUTION

The current data are limited by the retrospective nature of the study and the potential of bias due to unmeasured confounders.

WIDER IMPLICATIONS OF THE FINDINGS

The increased risk of EPL after fresh embryo transfer following IVM may point towards inadequate endometrial development in IVM cycles. Adopting a freeze-all strategy after IVM seems more appropriate. Future studies are needed to ascertain the underlying cause of this observation.

STUDY FUNDING/COMPETING INTEREST(S)

The Clinical IVM research has been supported by research grants from Cook Medical and Besins Healthcare. All authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Outcome of in-vitro oocyte maturation in patients with PCOS: does phenotype have an impact?

STUDY QUESTION

Does the phenotype of patients with polycystic ovary syndrome (PCOS) affect clinical outcomes of ART following in-vitro oocyte maturation?

SUMMARY ANSWER

Cumulative live birth rates (CLBRs) after IVM were significantly different between distinct PCOS phenotypes, with the highest CLBR observed in patients with phenotype A/HOP (= hyperandrogenism + ovulatory disorder + polycystic ovaries), while IVM in patients with phenotype C/HP (hyperandrogenism + polycystic ovaries) or D/OP (ovulatory disorder + polycystic ovaries) resulted in lower CLBRs (OR 0.26 (CI 0.06-1.05) and OR 0.47 (CI 0.25-0.88), respectively, P = 0.03).

WHAT IS KNOWN ALREADY

CLBRs in women with hyperandrogenic PCOS phenotypes (A/HOP and C/HP) have been reported to be lower after ovarian stimulation (OS) and ART when compared to CLBR in women with a normo-androgenic PCOS phenotype (D/OP) and non-PCOS patients with a PCO-like ovarian morphology (PCOM). Whether there is an influence of the different PCOS phenotypes on success rates of IVM has been unknown.

STUDY DESIGN, SIZE, DURATION

This was a single-centre, retrospective cohort study including 320 unique PCOS patients performing their first IVM cycle between April 2014 and January 2018 in a tertiary referral hospital.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Baseline patient characteristics and IVM treatment cycle data were collected. The clinical outcomes following the first IVM embryo transfer were retrieved, including the CLBR defined as the number of deliveries with at least one live birth resulting from one IVM cycle and all appended cycles in which fresh or frozen embryos were transferred until a live birth occurred or until all embryos were used. The latter was considered as the primary outcome. A multivariate regression model was developed to identify prognostic factors for CLBR and test the impact of the patient's PCOS phenotype.

MAIN RESULTS AND THE ROLE OF CHANCE

Half of the patients presented with a hyperandrogenic PCOS phenotype (n = 140 A/HOP and n = 20 C/HP vs. n = 160 D/OP). BMI was significantly different between phenotype groups (27.4 ± 5.4 kg/m2 for A/HOP, 27.1 ± 5.4 kg/m2 for C/HP and 23.3 ± 4.4 kg/m2 for D/OP, P < 0.001). Metformin was used in 33.6% of patients with PCOS phenotype A/HOP, in 15.0% of C/HP patients and in 11.2% of D/OP patients (P < 0.001). Anti-müllerian hormone levels differed significantly between groups: 12.4 ± 8.3 µg/l in A/HOP, 7.7 ± 3.1 µg/l in C/HP and 10.4 ± 5.9 µg/l in D/OP patients (P = 0.01). The number of cumulus-oocyte complexes (COC) was significantly different between phenotype groups: 25.9 ± 19.1 COC in patients with phenotype A/HOP, 18.3 ± 9.0 COC in C/HP and 19.8 ± 13.5 COC in D/OP (P = 0.004). After IVM, patients with different phenotypes also had a significantly different number of mature oocytes (12.4 ± 9.3 for A/HOP vs. 6.5 ± 4.2 for C/HP vs. 9.1 ± 6.9 for D/OP, P < 0.001). The fertilisation rate, the number of usable embryos and the number of cycles with no embryo available for transfer were comparable between the three groups. Following the first embryo transfer, the positive hCG rate and LBR were comparable between the patient groups (44.7% (55/123) for A/HOP, 40.0% (6/15) for C/HP, 36.7% (47/128) for D/OP, P = 0.56 and 25.2% (31/123) for A/HOP, 6.2% (1/15) for C/HP, 26.6% (34/128) for D/OP, respectively, P = 0.22). However, the incidence of early pregnancy loss was significantly different across phenotype groups (19.5% (24/123) for A/HOP, 26.7% (4/15) for C/HP and 10.2% (13/128) for D/OP, P = 0.04). The CLBR was not significantly different following univariate analysis (40.0% (56/140) for A/HOP, 15% (3/20) for C/HP and 33.1% (53/160) for D/OP (P = 0.07)). When a multivariable logistic regression model was developed to account for confounding factors, the PCOS phenotype appeared to be significantly correlated with CLBR, with a more favourable CLBR in the A/HOP subgroup (OR 0.26 for phenotype C/HP (CI 0.06-1.05) and OR 0.47 for phenotype D/OP (CI 0.25-0.88), P = 0.03)).

LIMITATIONS, REASONS FOR CAUTION

These data should be interpreted with caution as the retrospective nature of the study holds the possibility of unmeasured confounding factors and misassignment of the PCOS phenotype. Moreover, the sample size for phenotype C/HP was too small to draw conclusions for this subgroup of patients.

WIDER IMPLICATIONS OF THE FINDINGS

Caucasian infertile patients with a PCOS phenotype A/HOP who undergo IVM achieved a higher CLBR than their counterparts with C/HP and D/OP. This is in strong contrast with previously reported outcomes following OS where women with PCOS and hyperandrogenism (A/HOP and C/HP) performed significantly worse. For PCOS patients who require ART, the strategy of OS followed by an elective freeze-all strategy remains to be compared with IVM in a prospective fashion; however, the current data provide support for IVM as a valid treatment option, especially in the most severe PCOS phenotypes (A/HOP). Our data suggest that proper patient selection is of utmost importance in an IVM programme.

STUDY FUNDING/COMPETING INTEREST(S)

The clinical IVM research has been supported by research grants from Cook Medical and Besins Healthcare. All authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Combining fertility preservation procedures to spread the eggs across different baskets: a feasibility study

STUDY QUESTION

What is the reproductive potential following combinations of ovarian stimulation, IVM and ovarian tissue cryopreservation (OTC) in female patients seeking fertility preservation (FP)?

SUMMARY ANSWER

In selected patients, combining different FP procedures is a feasible approach and reproductive outcomes after FP in patients who return to attempt pregnancy are promising.

WHAT IS KNOWN ALREADY

FP is increasingly performed in fertility clinics but an algorithm to select the most suitable FP procedure according to patient characteristics and available timeframe is currently lacking. Vitrification of mature oocytes (OV) and OTC are most commonly performed, although in some clinical scenarios a combination of procedures including IVM, to spread the sources of gametes, may be considered in order to enhance reproductive options for the future.

STUDY DESIGN, SIZE, DURATION

Retrospective, observational study in a university-based, tertiary fertility centre involving all female patients who underwent urgent medical FP between January 2012 and December 2018. Descriptive analysis of various FP procedures, either stand-alone or combined, was performed, and reproductive outcomes of patients who attempted pregnancy in the follow-up period were recorded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 207 patients underwent medical FP. Patient-tailored strategies and procedures were selected after multidisciplinary discussion. When deemed feasible, FP procedures were combined to cryopreserve different types of reproductive tissue for future use. The main primary outcome measure was the number of mature oocytes. Live birth rates were evaluated in patients who returned for reproductive treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

Among patients seeking FP, 95/207 (46%) had breast cancer, 43/207 (21%) had haematological malignancies and 31/207 (15%) had a gynaecological tumour. Mean ± SD age was 27.0 ± 8.3 years. Eighty-five (41.1%) patients underwent controlled ovarian stimulation (COS), resulting in 10.8 ± 7.1 metaphase II (MII) oocytes for vitrification. Eleven (5.3%) patients had multiple COS cycles. Transvaginal oocyte retrieval for IVM was performed in 17 (8.2%) patients, yielding 9.2 ± 10.1 MII oocytes. Thirty-four (16.4%) patients underwent OTC combined with IVM of oocytes retrieved from ovarian tissue 'ex vivo' (OTO-IVM), yielding 4.0 ± 4.3 MII oocytes in addition to ovarian fragments. Seventeen (8.2%) patients had OTC combined with OTO-IVM and transvaginal retrieval of oocytes for IVM from the contralateral ovary, resulting in 13.5 ± 9.7 MII oocytes. In 13 (6.3%) patients, OTC with OTO-IVM was followed by controlled stimulation of the contralateral ovary, yielding 11.3 ± 6.6 MII oocytes in total. During the timeframe of the study, 31/207 (15%) patients have returned to the fertility clinic with a desire for pregnancy. Of those, 12 (38.7%) patients had preserved ovarian function and underwent ART treatment with fresh oocytes, resulting in nine (75%) livebirth. The remaining 19 (61.3%) patients requested warming of their cryopreserved material because of ovarian insufficiency. Of those, eight (42.1%) patients had a livebirth, of whom three after OTO-IVM. To date, 5/207 patients (2.4%) achieved an ongoing pregnancy or livebirth after spontaneous conception.

LIMITATIONS, REASONS FOR CAUTION

Our FP programme is based on a patient-tailored approach rather than based on an efficiency-driven algorithm. The data presented are descriptive, which precludes firm conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

Combining different FP procedures is likely to enhance the reproductive fitness of patients undergoing gonadotoxic treatment but further follow-up studies are needed to confirm this.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study and the authors have no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Live births following fertility preservation using in-vitro maturation of ovarian tissue oocytes

STUDY QUESTION

Can oocytes extracted from excised ovarian tissue and matured in vitro be a useful adjunct for urgent fertility preservation (FP)?

SUMMARY ANSWER

Ovarian tissue oocyte in-vitro maturation (OTO-IVM) in combination with ovarian tissue cryopreservation (OTC) is a valuable adjunct technique for FP.

WHAT IS KNOWN ALREADY

Despite the impressive progress in the field, options for FP for cancer patients are still limited and, depending on the technique, clinical outcome data are still scarce.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study conducted at a university hospital-affiliated fertility clinic between January 2012 and May 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included 77 patients who underwent unilateral oophorectomy for OTC. Cumulus-oocyte complexes (COCs) obtained during ovarian tissue processing were matured in vitro for 28-42 h. Oocytes reaching metaphase II stage were vitrified or inseminated for embryo vitrification.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 1220 COCs were collected. The mean oocyte maturation rate was 39% ± 23% (SD). There were 64 patients who had vitrification of oocytes (6.7 ± 6.3 oocytes per patient). There were 13 patients who had ICSI of mature oocytes after IVM, with 2.0 ± 2.0 embryos vitrified per patient. Twelve patients have returned to the clinic with a desire for pregnancy. For seven of these, OTO-IVM material was thawed. Two patients had OTO-IVM oocytes warmed, with survival rates of 86% and 60%. After ICSI, six oocytes were fertilised in total, generating three good quality embryos for transfer, leading to a healthy live birth for one patient. In five patients, for whom a mean of 2.0 ± 0.8 (SD) embryos had been vitrified, seven embryos were warmed in total: one embryo did not survive the warming process; two tested genetically unsuitable for transfer; and four were transferred in separate cycles to three different patients, resulting in two healthy babies. In this small series, the live birth rate per patient after OTO-IVM, ICSI and embryo transfer was 43%.

LIMITATIONS, REASONS FOR CAUTION

The retrospective study design and the limited sample size should be considered when interpreting results.

WIDER IMPLICATIONS OF THE FINDINGS

The results of the study illustrate the added value of OTO-IVM in combination with OTC. We report the first live birth following the use of this appended technique combined with oocyte vitrification.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. M.D.V. reports honoraria for lectures in the last 2 years from MSD and Ferring, outside the submitted work, as well as grant support from MSD. The other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Live births after in vitro maturation of oocytes in women who had suffered adnexal torsion and unilateral oophorectomy following conventional ovarian stimulation

PURPOSE

To report the first successful application of in vitro maturation (IVM) of oocytes resulting in live births in two anovulatory women who had suffered oophorectomy following ovarian torsion after stimulation with gonadotropins.

METHODS

Data abstraction was performed from medical records of two subfertile women with excessive functional ovarian reserve. Both women had previously received gonadotropins for ovulation induction or ovarian stimulation, resulting in ovarian torsion. They were offered IVM of oocytes retrieved from antral follicles after mild ovarian stimulation, insemination of mature oocytes using ICSI, and embryo transfer. Outcome measures were the incidence of complications and live birth after fertility treatment.

RESULTS

Transvaginal retrieval of cumulus-oocyte complexes from a unique ovary was conducted. One patient had a singleton live birth after vitrified-warmed embryo transfer in the second IVM cycle. The other patient had a singleton live birth after transfer of a fresh blastocyst in her first IVM cycle.

CONCLUSIONS

Although approaches have been developed to prevent ovarian hyperstimulation syndrome (OHSS) and to increase the safety profile of fertility treatment in predicted high responders, women with an excessive functional ovarian reserve may have a non-negligible risk of ovarian torsion. For these patients, IVM should be considered as a safer alternative approach.

Reversing complete mechanical transzonal projections disruption during mouse in vitro follicle culture with unaltered oocyte competence†

In vitro oocyte growth is widely studied as an alternative fertility preservation approach. Several animal models are used to generate extensive information on this complex process regulated by the constant and dynamic interaction between the oocyte and its somatic compartment throughout follicle growth and maturation. A two-dimensional attachment mouse secondary follicle culture system was used to assess the oocyte's capacity to overcome disconnection from its somatic companions at different developmental stages for final competence acquisition. To test this, complete mechanical denudation of oocytes from preantral (PA) and early antral (EA) follicles was performed. Established endpoints were the oocyte's potential to reconnect with somatic cells and the impact of connectivity disruption on mature oocyte quality. This study proves that oocytes from PA and EA cultured mouse follicles can overcome complete denudation, restoring likely functional transzonal projections with no significant differences in meiotic and developmental competence compared with those from intact cultured follicles. These novel findings constitute good premises for developing successful strategies to rescue human oocyte competence in the context of in vitro culture approaches such as nonhuman chorionic gonadotropin triggered in vitro maturation.

Fertility preservation does not delay the initiation of chemotherapy in breast cancer patients treated with adjuvant or neo-adjuvant chemotherapy

PURPOSE

To investigate whether fertility preservation (FP) in adult women diagnosed with breast cancer (BC) may impact the time interval between diagnosis and start of chemotherapy in an adjuvant or neo-adjuvant setting.

METHODS

Retrospective cohort study of breast cancer patients diagnosed between January 2012 and December 2017 undergoing FP at a tertiary-care academic fertility centre before neo-adjuvant (NAC) or adjuvant chemotherapy (AC), and matched control breast cancer patients who had no FP. FP interventions included oocyte vitrification following ovarian stimulation or after in-vitro maturation (IVM) of immature oocytes, and/or ovarian tissue cryopreservation. Controls from the patient database of the affiliated Breast Cancer Clinic were matched for tumour characteristics and type of treatment. Time intervals between cancer diagnosis and the start of chemotherapy were analysed.

RESULTS

Fifty-nine BC patients underwent FP: 29 received NAC and 30 received AC. The average interval between diagnosis and chemotherapy in BC patients with NAC was 28.5 days (27.3 (range: 14.0-44.0) days in cases and 29.6 (range: 14.0-62.0) days in controls (NS)); this interval was 58.9 days in BC patients with AC (57.2 (range: 36.0-106.0) days in cases and 60.7 (range: 31.0-105.0) days in controls (NS)).

CONCLUSION

Fertility preservation does not delay the start of chemotherapy in breast cancer patients.

Influence of ultra-low oxygen (2%) tension on in-vitro human embryo development

STUDY QUESTION

Is a reduction in the oxygen tension from 5 to 2% during extended culture from Day 3 onwards beneficial for human blastocyst development in vitro?

SUMMARY ANSWER

A reduction in oxygen concentration from 5 to 2% O2 after Day 3 did not improve embryo development, quality and utilization rate.

WHAT IS KNOWN ALREADY

The human embryo leaves the fallopian tube to reach the uterine cavity around Day 3-4 post-ovulation. As the oxygen concentration ranges from 5 to 7% in the fallopian tube and decreases to 2% in the uterus, reducing the oxygen tension during extended culture from Day 3 onwards seems more physiological. We aim to mimic the in-vivo environment during in-vitro embryo culture. Therefore, we compared the effect of extended culture performed at 5% (control arm) or 2% oxygen (O2; study arm) tension on blastocyst formation and quality.

STUDY DESIGN, SIZE, DURATION

Between December 2016 and September 2017, in two prospective studies, sibling embryos were randomized on Day 3 to either 5% O2 (control) or 2% O2 (study) for extended culture. In the control arms of both studies 1 and 2, the dishes with blastocyst medium were pre-equilibrated overnight in 5% O2, 6% CO2 and 89% N2 at 37°C. In the 2% study groups, the overnight pre-equilibration of blastocyst media was performed in either 2% O2 (study 1, 99 cycles) or 5% O2 (study 2, 126 cycles). The latter provides a gradual transition from 5 to 2% O2 environment for the study arm.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Embryo culture until Day 3 was always performed in 5% O2; if at least four embryos of moderate to excellent quality were obtained on Day 3, the sibling embryos were randomized to either 5% O2 or 2% O2 for extended culture. The endpoints were embryo development and quality on Day 5/6 and the utilization rate (embryos transferred and cryopreserved). Statistical analysis was performed using the chi-square test, a P-value of <0.05 was considered significantly different.

MAIN RESULTS AND THE ROLE OF CHANCE

In study 1, 811 embryos were randomized on Day 3: 405 to the 2% O2 and 406 to the 5% O2 condition. No differences were observed in the blastulation rate (68.6 versus 71.9%; P = 0.319) and the proportion of good quality blastocysts on Day 5 (55.8 versus 55.2%; P = 0.888), nor in the utilization rate (53.1 versus 53.2%; P = 1.000). In study 2, 1144 embryos were randomized: 572 in each arm. Similarly, no significant difference was demonstrated in terms of the blastulation rate (63.6 versus 64.7%; P = 0.758), the proportion of good quality blastocysts (46.9 versus 48.8%; P = 0.554) or the utilization rate (49.8 versus 48.1%; P = 0.953).

LIMITATIONS, REASON FOR CAUTION

This study evaluated embryo development only until Day 5/6. The effect of oxidative stress on the developing embryo may only become evident at later stages (i.e. during implantation) and should therefore be studied in an RCT. The question also remains as to whether the switch to ultra-low oxygen tension from Day 4 onwards, when the embryo arrives in the uterus in vivo, would be preferential.

WIDER IMPLICATIONS OF THE FINDINGS

Based on the present study results, there is no benefit in lowering the oxygen tension from 5 to 2% from Day 3 onwards during extended human embryo culture.

STUDY FUNDING/COMPETING INTEREST(s)

No funding was received for this study and the authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Obstetric and neonatal outcome of ART in patients with polycystic ovary syndrome: IVM of oocytes versus controlled ovarian stimulation

STUDY QUESTION

Does IVM of immature oocytes retrieved from small antral follicles in women with polycystic ovary syndrome (PCOS) have an impact on obstetric and neonatal outcomes compared to controlled ovarian stimulation (COS)?

SUMMARY ANSWER

Obstetric and neonatal outcomes after IVM appear to be similar to those after COS.

WHAT IS KNOW ALREADY

Women with PCOS have an increased risk of adverse pregnancy outcomes and congenital malformations in their offspring. For patients with PCOS who require IVF, IVM of germinal vesicle (GV)-stage oocytes retrieved from antral follicles has been adopted as a mild approach ART, with improved pregnancy rates over the last two decades. Although reports of obstetrical and neonatal outcomes after IVM have been reassuring, the limited sample sizes in previous studies preclude firm conclusions, and further study is warranted.

STUDY DESIGN, SIZE, DURATION

This is a retrospective observational study analysing obstetric and neonatal data from 1036 clinical pregnancies in unique patients with PCOS who conceived following a cycle of IVM or COS between January 2010 and December 2016 in a tertiary reproductive centre. In total, 393 singleton pregnancies with a gestational age beyond 20 weeks were included. A phenotypic approach was used for the diagnosis of PCOS. Pregnancies following oocyte donation, standard IVF (as opposed to ICSI) or preimplantation genetic testing and pregnancies requiring testicular biopsy in the male partners were excluded.

PARTICIPANTS/MATERIALS,SETTING, METHODS

Pregnancy outcomes were analysed in women with PCOS phenotype A, C or D, as defined by different combinations of the Rotterdam criteria. Data from 164 pregnancies beyond 20 weeks after IVM were compared with those from 229 pregnancies after COS. Pregnancies in the IVM group were obtained after minimal ovarian stimulation and IVF with ICSI of transvaginally collected GV oocytes that had reached the metaphase II stage in vitro after 28 to 40 h of culture. No hCG trigger was administered before oocyte retrieval. Outcome measures were analysed or reported in singleton pregnancies only and included adverse obstetric events and neonatal health parameters, in particular birthweight, prematurity, small-for-gestational age, large-for-gestational age, perinatal death and major/minor malformation rates. The incidence of hypertensive disorders of pregnancy (HDP) and birthweight was analysed by multiple linear and logistic regression, adjusted for relevant treatment variables and maternal characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

The IVM and the COS groups differed significantly (P < 0.001) for maternal circulating AMH levels and PCOS phenotype distribution, with more of the PCOS phenotype A in the IVM group. Pregnant women in the IVM group were younger than pregnant women in the COS group (P = 0.05). With regard to obstetric complications in singleton pregnancies, in the unadjusted analysis, mothers of infants in the IVM group more often had HDP (29/164 (17.9%) vs 22/229 (9.6%), P = 0.02) compared with mothers in the COS group. Singletons born after IVM and COS had a similar birthweight standard deviation score (SDS) (0.51 ± 0.94 after IVM vs 0.33 ± 1.05 after COS, P = 0.19). Preterm birth rate (32–36.9 weeks) and early preterm birth rate (<32 weeks) were also similar in both groups. The total malformation rate was 4.1% in singletons after IVM and 2.4% in singletons after COS. Multivariate linear regression analysis accounting for relevant confounders demonstrated that parity was the only independent predictive factor (P = 0.04) for birthweight SDS. Multivariate logistic regression analysis showed that BMI, parity and type of ART (IVM as opposed to COS) were significantly correlated with the incidence of HDP. Only patients with the PCOS phenotype A showed a tendency towards a higher risk of HDP in those who underwent IVM compared to those who had COS.

LIMITATIONS, REASONS FOR CAUTION

The study is limited by its retrospective nature and loss to follow-up of a subset of children with no information regarding congenital malformations. Furthermore, the paediatricians who assessed the children after birth were not blinded for the type of ART procedure.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides further evidence that, compared to COS, IVM of oocytes derived from small antral follicles does not adversely affect the neonatal health of the offspring of patients with PCOS. The observed increased risk of HDP in patients with PCOS phenotype A following IVM treatment warrants further scrutiny.

STUDY FUNDING/COMPETING INTEREST(S)

Translational IVM research at Universitair Ziekenhuis Brussel (UZ Brussel) and Vrije Universiteit Brussel (VUB) has been supported by grants from the Institute for the Promotion of Innovation by Science and Technology in Flanders (Agentschap voor Innovatie door Wetenschap en Technologie—IWT, project 110680), the Fund for Research Flanders (Fonds Wetenschappelijk Onderzoek–Vlaanderen—FWO, project G.0343.13) and the Belgian Foundation Against Cancer (HOPE project, Dossier C69). Clinical IVM research was supported by research grants from Cook Medical and Besins Healthcare. M.D.V. reports honoraria for lectures from Cook Medical and Besins Healthcare outside the submitted work. S.S.R. reports honoraria for lectures by MSD and Besins and research grants by MSD, Ferring and Merck Serono outside of the submitted work. C.B. reports personal fees from Merck-Serono, Ferring, IBSA, Finox, MSD and Abbott outside the submitted work. H.T. reports grants from Merck, MSD, Goodlife, Cook, Roche, Besins, Ferring, Mithra (now Allergan) and the Research Fund of Flanders (FWO) and consultancy fees from Finox, Abbott, Obseva and Ovascience outside the submitted work. The other authors have nothing to disclose.

Cumulus-corona gene expression analysis combined with morphological embryo scoring in single embryo transfer cycles increases live birth after fresh transfer and decreases time to pregnancy

PURPOSE

Clinical pregnancy rate after IVF with eSET stagnates between 30 and 40%. In order to increase pregnancy and live birth rates, multiple embryo transfer is still common practice. Providing additional non-invasive tools to choose the competent embryo for transfer could avoid multiple pregnancy and improve time to pregnancy. Cumulus mRNA analysis with quantitative PCR (QPCR) is a non-invasive approach. However, so far, no gene sets have been validated in prospective interventional studies.

METHODS

A prospective interventional single-center pilot study with two matched controls (day-3 and day-5 eSET) was performed in 96 patients consenting to the analysis of the cumulus-corona of their oocytes. All patients were super-ovulated for ICSI and eSET at day 3. All oocytes were denuded individually and cumulus was analyzed by quantitative PCR using three predictive genes (EFNB2, SASH1, CAMK1D) and two housekeeping genes (UBC and β2M). Patients (n = 62) with 2 or more day-3 embryos (good or excellent morphology) had their embryo chosen following the normalized expression of the genes.

RESULTS

Corona testing significantly increased the clinical pregnancy and live births rates (63% and 55%) compared to single embryo transfer (eSET) on day 3 (27% and 23%: p < 0.001) and day 5 (43% and 39%: p = 0.022 and p = 0.050) fresh transfer cycle controls with morphology-only selection. Time-to-pregnancy was significantly reduced, regardless of the number of good-quality embryos available on day 3.

CONCLUSION

Combining standard morphology scoring and cumulus/corona gene expression analysis increases day-3 eSET results and significantly reduces the time to pregnancy.

TRIAL REGISTRATION NUMBER

This is not an RCT study and was only registered by the ethical committee of the University Hospital UZBRUSSEL of the Vrije Universiteit Brussel VUB (BUN: 143201318000).

In vitro maturation (IVM) of oocytes recovered from ovariectomy specimens in the laboratory: a promising "ex vivo" method of oocyte cryopreservation resulting in the first report of an ongoing pregnancy in Europe

PURPOSE

We present our center's experience with 34 consecutive cases who underwent in vitro maturation (IVM) of oocytes obtained from ovariectomy specimens and compare our data with updated literature data.

METHODS

Feasibility and efficiency of oocyte collection during ovarian tissue processing was assessed by the recovery rate, maturation rate, and embryological development after IVM.

RESULTS

On average, 14 immature oocytes were retrieved per patient during ovarian tissue processing in 33/34 patients. The overall maturation rate after IVM was 36%. The maturation rate correlated with the age of the patient and the duration of IVM. Predominately, oocyte vitrification was performed. Eight couples preferred embryo cryopreservation. Here, a 65% fertilization rate was obtained and at least one good-quality day 3 embryo was cryopreserved in 7/8 couples. The retrieval of oocytes ex vivo resulted in mature oocytes or embryos available for vitrification in 79% of patients. One patient with ovarian insufficiency following therapeutic embolization of the left uterine and the right ovarian artery because of an arteriovenous malformation had an embryo transfer of one good-quality warmed embryo generated after IVM ex vivo, which resulted in an ongoing clinical pregnancy.

CONCLUSIONS

IVM of oocytes obtained ex vivo during the processing of ovarian cortex prior to cryopreservation is a procedure with emerging promise for patients at risk for fertility loss, as illustrated by the reported pregnancy. However, more data are needed in order to estimate the overall success rate and safety of this novel approach.

Gene expression differences induced by equimolar low doses of LH or hCG in combination with FSH in cultured mouse antral follicles

In a natural cycle, follicle growth is coordinated by FSH and LH. Follicle growth stimulation in Assisted Reproductive Technologies (ART) requires antral follicles to be exposed to both FSH and LH bioactivity, especially after GNRH analog pretreatment. The main aim was to detect possible differences in gene expression in granulosa cells after exposing the follicle during antral growth to LH or hCG, as LH and hCG are different molecules acting on the same receptor. Effects of five gonadotropin treatments were investigated for 16 genes using a mouse follicle culture model. Early (day 6) antral follicles were exposed to high recombinant FSH combined or not with equimolar concentrations of recombinant LH (rLH) or recombinant hCG (rhCG) and to highly purified human menopausal gonadotropin (HP-hMG) for 6 h, 12 h, or 3 days. Expression differences were tested for genes involved in steroidogenesis: Mvk, Lss, Cyp11a1, Hsd3b1, Cyp19a1, Nr4a1, and Timp1; final granulosa differentiation: Lhcgr, Oxtr, Pgr, Egfr, Hif1a, and Vegfa; and cytokines: Cxcl12, Cxcr4, and Sdc4. Lhcgr was present and upregulated by gonadotropins. Nr4a1, Cxcl12, and Cxcr4 showed a different expression pattern if LH bioactivity was added to high FSH in the first hours after exposure. However, no signs of premature luteinization were present even after a 3-day treatment as shown by Cyp19a1, Oxtr, Pgr, and Egfr and by estrogen and progesterone measurements. The downstream signaling by rhCG or rLH through the LHCGR was not different for this gene selection. Granulosa cells from follicles exposed to HP-hMG showed an enhanced expression level for several genes compared with recombinant gonadotropin exposure, possibly pointing to enhanced cellular activity.

New candidate genes to predict pregnancy outcome in single embryo transfer cycles when using cumulus cell gene expression

OBJECTIVE

To relate the gene expression in cumulus cells surrounding an oocyte to the potential of the oocyte, as evaluated by the embryo morphology (days 3 and 5) and pregnancy obtained in single-embryo transfer cycles.

DESIGN

Retrospective analysis of individual human cumulus complexes using quantitative real-time polymerase chain reaction for 11 genes.

SETTING

University hospital IVF center.

PATIENT(S)

Thirty-three intracytoplasmic sperm injection patients, of which 16 were pregnant (4 biochemical and 12 live birth).

INTERVENTION(S)

Gene expression analysis in human cumulus complexes collected individually at pickup, allowing a correlation with the outcome of the corresponding oocyte. Multiparametric models were built for embryo morphology parameters and pregnancy prediction to find the most predictive genes.

MAIN OUTCOME MEASURE(S)

Gene expression profile of 99 cumulus complexes for 11 genes.

RESULT(S)

For embryo morphology prediction, TRPM7, ITPKA, STC2, CYP11A1, and HSD3B1 were often retained as informative. Models for pregnancy-biochemical or live birth-complemented or not with patient and cycle characteristics, always retained EFNB2 and CAMK1D together with STC1 or STC2. Positive and negative predictive values of the live birth models were >85%.

CONCLUSION(S)

EFNB2 and CAMK1D are promising genes that could help to choose the embryo to transfer with the highest chance of a pregnancy.

Cumulus cell gene expression predicts better cleavage-stage embryo or blastocyst development and pregnancy for ICSI patients

BACKGROUND

Cumulus cell (CC) gene expression is suggested as a non-invasive analysis method to predict oocyte competence. There are, however, important between-patient differences in CC gene expression. These can be compensated when expression results are combined with patient and cycle characteristics using a multiple regression analysis model.

METHODS

From ICSI patients stimulated with GnRH antagonist and recombinant FSH (n= 25) or GnRH agonist and highly purified menotrophin (n= 20), CC were collected and oocytes were individually fertilized and cultured. CC were analyzed for the expression of Syndecan 4 (SDC4), Prostaglandin-endoperoxide synthase 2 (PTGS2), Versican (VCAN), Activated leukocyte cell adhesion molecule, Gremlin 1, transient receptor potential cation channel, subfamily M, member 7 (TRPM7), Calmodulin 2 and Inositol 1,4,5-trisphosphate 3-kinase A (ITPKA) using quantitative PCR. Results were analyzed in relation to the stimulation protocol. Within-patient variation in gene expression was related to oocyte maturity and developmental potential. Models predictive for normal embryo or blastocyst development and pregnancy in single embryo transfer cycles were developed.

RESULTS

Mature oocytes have higher PTGS2 and lower VCAN expression in their cumulus. All genes except VCAN had a positive correlation with good embryo or blastocyst morphology and were used to develop predictive models for embryo or blastocyst development (P< 0.01). Specific models were obtained for the two stimulation protocols. In both groups, better cleavage-stage embryo prediction relied on TRPM7 and ITPKA expression and pregnancy prediction relied on SDC4 and VCAN expression. In the current data set, the use of CC expression for pregnancy prediction resulted in a sensitivity of >70% and a specificity of >90%.

CONCLUSIONS

Multivariable models based on CC gene expression can be used to predict embryo development and pregnancy.

Cumulus cell gene expression is associated with oocyte developmental quality and influenced by patient and treatment characteristics

BACKGROUND

Gene expression of cumulus cells (CC) could predict oocyte developmental quality. Knowledge of the genes involved in determining oocyte quality is scanty. The aim was to correlate clinical and biological characteristics during ovarian stimulation with the expression of 10 selected genes in CC.

METHODS

Sixty-three ICSI patients were stimulated with GnRH-agonist plus highly purified hMG (n = 35) or recombinant FSH (n = 28). Thirteen variables were analyzed: Age, BMI, duration of stimulation, serum concentrations of progesterone, 17beta-estradiol, FSH and LH on day of hCG, Ovarian Response, Oocyte Maturity, 2 pronuclei and three embryo morphology related variables: > or =7 cells, Low Fragmentation, Good Quality Embryos score. Expression of HAS2, VCAN, SDC4, ALCAM, GREM1, PTGS1, PTGS2, DUSP16, SPROUTY4 and RPS6KA2 was analyzed in pooled CC using quantitative PCR, and the relationship to the 13 variables was evaluated by multivariable analysis.

RESULTS

All 10 genes are expressed at oocyte retrieval, with PTGS1, SPROUTY4, DUSP16 and RPS6KA2 described in human ovary for the first time. The three variables that correlated most often with differential expression were Age, BMI and serum FSH level. Significant correlation was found with Oocyte Maturity (VCAN, P < 0.005), Low Fragmentation (RPS6KA2, P < 0.05), Embryos with > or =7 cells (ALCAM and GREM1, P < 0.05). The expression of the other genes was also correlated to oocyte developmental quality but to a less extent. SDC4, VCAN, GREM1, SPROUTY4 and RPS6KA2 showed gonadotrophin preparation-dependent expression and/or interactions (all P < 0.05).

CONCLUSION

The expression of ovulation related genes in CC is associated with patient and treatment characteristics, oocyte developmental potential and differs with the type of gonadotrophin used.

A differential cytokine expression profile is induced by highly purified human menopausal gonadotropin and recombinant follicle-stimulating hormone in a pre- and postovulatory mouse follicle culture model

OBJECTIVE

To compare the differential effects of highly purified (HP) hMG or recombinant FSH (rFSH) on cytokine expression before and after ovulation in an in vitro mouse ovarian follicle model.

DESIGN

A prospective laboratory in vitro study.

SETTING

A university-based reproductive biology laboratory. MATERIAL(S): Mechanically isolated mouse preantral follicles from 14-day-old prepubertal mouse ovaries (F1 hybrids: C57BL/6JxCBA/ca).

INTERVENTION(S)

Randomly distributed mouse early preantral follicles were exposed to two hyperstimulation conditions with either HP-hMG or rFSH. An ovulatory stimulus was given using hCG/epidermal growth factor. Conditioned media from the two culture conditions were collected on the days before and after in vitro ovulation. Conditioned media were compared for their relative cytokine profile content as measured by a cytokine antibody array analysis.

MAIN OUTCOME MEASURE(S)

Relative concentrations of 62 cytokines in conditioned media before and after ovulation.

RESULT(S)

Statistically significant increase in the production of a number of cytokines was found after HP-hMG stimulation compared with rFSH: 14 and 24 pre- and post-rhCG, respectively. Cytokines with the largest significant difference (more than 5 times) before and after ovulation included thymus-expressed cytokine (TECK), sTNFRI, and SDF-1alpha. The cytokines that are most strongly related to oocyte and embryo quality and implantation and that have been related to oocyte yield and maturation were significantly higher with HP-hMG.

CONCLUSION(S)

The significant differences in follicular cytokine production induced by HP-HMG and rFSH before and after in vitro ovulation might explain the difference in treatment outcome.

Differences in collagen expression in cumulus cells after exposure to highly purified menotropin or recombinant follicle-stimulating hormone in a mouse follicle culture model

Extracellular matrix (ECM) formation by cumulus cells is an important process that determines fertilization and embryo quality. Several collagen types are present in the ovarian follicular ECM and are related to proliferation, steroidogenesis, and luteinization. In vitro mouse follicles can optimally grow and provide developmentally competent oocytes with 10 IU/L recombinant follicle-stimulating hormone (rFSH). As a model for superovulation, experiments with 100 IU/L rFSH or 100 IU/L highly purified menotropin (HP-hMG) exposure during antral growth were undertaken. Col4a1, Col4a2, and Col6a2 expression levels were analyzed at three time points during antral growth and at a 4-h interval up to 16 h after ovulation induction using quantitative PCR. The presence and induction of the collagen mRNA and protein were confirmed in cumulus from in vivo- and in vitro-grown follicles, and TGFBs 1 and 2 were assayed as potential regulators. The study revealed that exposure to 100 IU/L FSH, as in both superovulation conditions, significantly influenced the follicle morphology and slowed down nuclear maturation and mucification (P < 0.05). This coincided with an increased expression of the three collagens in the cumulus-oocyte complex at the end of antral growth and in the first hours following the ovulatory dose of human chorionic gonadotropin (P < 0.05). The increased expression might reflect a differentiation but is most likely due to a precocious luteinization of the cumulus. Growth in HP-hMG resulted in higher Tgfb1 mRNA and protein levels, fewer COCs with an increased collagen expression and with a more synchronous nuclear maturation. This suggests that the presence of luteinizing hormone activity tempered the effect of the elevated FSH dose.

Transcriptional regulation of iodothyronine deiodinases during embryonic development

A single dose of chicken growth hormone (cGH) or dexamethasone acutely increases circulating T(3) levels in 18-day-old chicken embryos through a reduction of hepatic type III iodothyronine deiodinase (D3). The data in the present study suggest that this decrease in D3 is induced by a direct downregulation of hepatic D3 gene transcription. The lack of effect of cGH or dexamethasone on brain and kidney D3 activity, furthermore suggests that both hormones affect peripheral thyroid hormone metabolism in a tissue specific manner. Dexamethasone administration also results in an increase in brain type II iodothyronine deiodinase (D2) activity and mRNA levels that is also regulated at a transcriptional level. In contrast, however, cGH has no effect on brain D2 activity, thereby suggesting that either GH cannot pass through the blood-brain barrier in chicken or that cGH and dexamethasone regulate thyroid hormone deiodination by different mechanisms. In addition, the very short half-life of D2 and D3 (t(1/2)<1 h) in comparison with the longer half life of type I iodothyronine deiodinase (D1, t(1/2)>8 h), allows for D2 and D3 to play a more prominent role in the acute regulation of peripheral thyroid hormone metabolism than D1.