P-773 Assessment of the putative impact of culture strategies, oocyte/embryo manipulations, and operators: a retrospective analysis of 3705 blastocyst culture cycles and 2604 single blastocyst transfers

Study question

Do the culture strategies, oocyte/embryo manipulations, and operators impact blastulation-rates per cohort of metaphase-II oocytes (BR per MII-oocytes) and/or live-birth-rates per single-embryo-transfer (LBR per SET)?

Summary answer

Undisturbed culture improved the BR per MII-oocytes, while culture drop volumes ≥80ml in the well-of-the-well system were associated with increased LBR per untested/euploid blastocyst SET.

What is known already

IVF lab performance is critical to achieve success in IVF. Yet, while a consensus exists on the main key-performance-indicators (KPIs), namely BR and LBR, and their inherent benchmark values, the strategies to fulfil them are still poorly standardized. The plasticity of human embryos along with the disparities in the patient populations might mask even largely different outcomes across clinics. Therefore, clear guidelines shall outline which procedures to standardize and carefully monitor in IVF laboratories. Here we investigated different embryo culture strategies, manipulations, and operators for their effect on BR and LBR per SET, adjusting the results for all main confounders.

Study design, size, duration

Retrospective analysis of 3705 cycles with ≥1 MII-oocyte and 2604 SETs (January2019-March2021). BR per MII-oocytes and LBR per SET were the main outcomes. Embryo-twinning was also assessed. The putative impact of culture strategies, manipulations, and operators’ expertise (0-5yr,6-11yr or > 12yr) was determined via regression analyses adjusted for possible confounders (autologous/donated oocytes, age, primary/secondary infertility and duration, sperm factor; for SET: also endometrial preparation, age at transfer, number of consecutive transfer, untested/euploid blastocyst, quality, and day).

Participants/materials, setting, methods

In donation cycles, only vitrified oocytes were used. In Preimplantation-Genetic-Testing (PGT) cycles, no assisted-hatching was performed and only euploid non-mosaic vitrified-warmed blastocysts were transferred. The culture strategies assessed were undisturbed (Embryoscope, Geri and Embryoscope-plus)/disturbed (KSystems), volume and approach (drops ≤30ml with single-culture or ≥ 80ml with well-of-the-well approaches), humidified/non-humidified atmosphere and media refreshed/not-refreshed. The manipulations assessed were oocyte/blastocyst vitrification (performed/not-performed), oocyte retrieval and denudation performed with oil overlay (yes/not), laser-assisted artificial-shrinkage (performed/not-performed), trophectoderm biopsy (performed/not-performed).

Main results and the role of chance

The only confounders on BR per MII-oocytes (overall:39.1±26.6%) were sperm factor and oocyte age. The linear regressions showed benefits for humidified atmosphere (unstandardized B-coefficient:+2.9%, p = 0.01), manipulations with oil overlay (+3.9%, p = 0.03) and drops≥80ml with a well-of-the-well approach (+4.3%, p < 0.01). However, only the positive effect of undisturbed incubators was significant when adjusting for confounders [41.7±27.8% (N = 1440 cycles) versus 37.5±25.7% in a disturbed incubator (N = 2265 cycles); unstandardized B-coefficient:+5.6%, 95%CI +3.9% to + 7.3%, standardized beta-coefficient:-0.103,p<0.01].

The main confounders on LBR per SET (overall: N = 1044/2604, 40.1%) were oocyte age, number of consecutive transfer, blastocyst chromosomal status (untested/euploid), quality and day. The univariate logistic regressions showed a benefit for undisturbed incubators (OR:1.3, 95%CI 1.1-1.5, p < 0.01), humidified atmosphere (OR:1.4, 95%CI 1.1-1.7, p < 0.01) and media refresh (OR:1.3, 95% 1.01-1.8, p = 0.05). However, only the use of drops ≥80ml with a well-of-the-well approach rather than drops ≤30ml with a single-culture approach involved an improvement when adjusting for confounders (untested SETs: N = 71/171, 41.5% versus N = 434/1284, 33.8%; euploid SETs: N = 170/316, 53.8% versus N = 369/833, 44.3%; multivariate-OR:1.33, 95%CI 1.12-1.58, adjusted p-value<0.01). This result was confirmed in a sub-analysis across only first patients’ SETs.

Lastly, no feature under investigation was associated with embryo-twinning (overall: N = 23/1243, 1.9% and N = 14/1044, 1.3% per pregnancy and delivery, respectively).

Limitations, reasons for caution

Retrospective single center study. Only ICSI cycles and continuous culture media were assessed. Cleavage stage SETs were excluded. All operators had at least 3yr of experience. Perinatal and gestational outcomes were not evaluated.

Wider implications of the findings

Real-life data adjusted for confounders may unveil fluctuations in critical KPIs mainly imputable to culture strategies. An impact seldom derives from oocyte/embryo manipulations if experienced operators adopt validated protocols. An accurate interpretation of these evidence shall lead to properly designed studies with problem-solving/progress-building purposes, and guidelines to standardize culture practices.

Trial registration number

Not applicable

[Unaffected child born following preimplantation genetic diagnosis with karyomapping]

Preimplantation genetic diagnosis for single gene defects is a well established method in assisted reproductive technologies. Karyomapping is a genome wide parental haplotyping using a high density single nucleotide polymorphism array that allows the diagnosis of any single gene defects. A couple with an affected child with primary congenital glaucoma attended at our clinic. Six oocyte-cumulus-complex was retrieved and all three mature oocytes were inseminated. One zygote showed the signs of normal fertilization and was cultured for five days. Trophectoderm biopsy and karyomapping analysis were carried out. Result showed a heterozygous carrier for primary congenital glaucoma. Embryo was thawed and transferred and a healthy girl was delivered at term. Here we report the first live birth following in vitro fertilization combined with preimplantation genetic diagnosis using karyomapping in Hungary. Karyomapping is able to accurately detect single gene disorders from a limited amount of samples without a significant preclinical workup. Orv. Hetil., 2016, 157(51), 2048-2050.

Higher risk of orofacial clefts in children born to mothers with angina pectoris: a population-based case-control study

Previously an unexpected association of maternal angina pectoris (MAP) during pregnancy with a higher risk of orofacial clefts in their children was found. There were three objectives of this study: (i) to evaluate the validity of MAP-diagnoses in the previous study and the recent history of mothers with MAP in a follow-up study; (ii) to estimate the prevalence of other congenital abnormalities in the offspring of mothers with MAP; and (iii) to analyze the possible effect of confounders for the risk of orofacial clefts. The large dataset of population-based Hungarian Case-Control Surveillance System of Congenital Abnormalities, 1980-1996 was evaluated including 22 843 cases with congenital abnormalities and 38 151 controls without any defect. Twenty-two cases (0.10%) and 12 controls (0.03%) were born to mothers with medically recorded MAP (odds ratio [OR] with 95% confidence interval [CI]: 3.7, 1.8-7.3). Of 22 cases, six had isolated cleft lip ± palate (OR with 95% CI: 13.3, 4.9-35.9) and two were affected with isolated cleft palate (OR with 95% CI: 10.5, 2.3-47.6). The diagnosis of MAP was confirmed in seven women visited at home in 2009-2010, two had recent myocardial infarction and five were smokers. There was no higher risk for other congenital abnormalities. In conclusion the higher risk of orofacial clefts was confirmed in the children of mothers with MAP and smoking may trigger the genetic predisposition of both MAP and orofacial clefts. However, the number of cases was limited and therefore further studies are needed to confirm or reject this theoretically and practically important observation.

Association of certain chronic maternal diseases with the risk of specific congenital heart defects: a population-based study

OBJECTIVE

Previous epidemiological studies have evaluated cases with all congenital heart defects (CHDs), rather than analysing different types of CHD. The objective of this study was to evaluate the possible association of certain chronic maternal diseases with the risk of different types of CHD, because the role of possible environmental factors in the origin of CHDs is unclear in the vast majority of patients.

STUDY DESIGN

Different types of CHD, diagnosed after lethal outcome (autopsy report) or after surgical intervention (catheter or correction), were evaluated in order to estimate the possible role of chronic maternal diseases in their origin. This analysis was based on the rates of medically recorded chronic maternal diseases in 3562 live-born cases with CHDs, 38,151 population controls without any birth defects, and 16,602 malformed controls with other isolated congenital abnormalities, using the data set of the population-based Hungarian Case-Control Surveillance of Congenital Abnormalities (1980-1996).

RESULTS

Maternal epilepsy treated with carbamazepine and migraine were found to be associated with higher risk of ventricular septal defect; panic disorders were associated with higher risk of hypoplastic left heart; type I diabetes mellitus was associated with higher risk of coarctation of the aorta; chronic hypertension was associated with higher risk of ventricular septal defect, common atrioventricular canal and common truncus; and paroxysmal supraventricular tachycardia was associated with higher risk of atrial septal defect secundum, common atrioventricular canal and ventricular septal defect.

CONCLUSION

In conclusion, certain chronic maternal diseases were found to be associated with higher risk of specific CHDs. Appropriate treatment of these diseases may help to prevent these CHDs.

Birth outcomes of cases with conotruncal defects of heart - a population-based case-control study

OBJECTIVE

The aim of this study was to evaluate the birth outcomes of cases with four types of conotruncal defects (CTDs), i.e. common truncus, transposition of great arteries, tetralogy of Fallot and double-outlet right ventricle.

METHODS

Birth outcomes of 597 live-born cases with CTD and 38,151 population controls without any defects were compared in the population-based large dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities completed by socio-demographic variables of their mothers.

RESULTS

There was a male excess in cases with CTD (56.8%) with the same mean gestational age (39.4 versus 39.4 weeks) and preterm birth rate (8.2 versus 9.2%), but their mean birth weight was smaller (3077 versus 3276 g) with a high rate of low birthweight (14.6 versus 5.7%) compared to the birth outcomes of population controls. These data indicate intrauterine growth restriction of fetuses affected with transposition of great arteries, tetralogy of Fallot and double-outlet right ventricle particularly in females, while there were a shorter mean gestational age and smaller mean birth weigh in cases with common truncus.

CONCLUSIONS

In general CTD, except common truncus, had no effect for gestational age but associated with a high risk for intrauterine fetal growth restriction particularly in female cases.

Risk and protective factors in the origin of atrial septal defect secundum--national population-based case-control study

The aim of this study was to assess the risk factors in the origin of lethal or surgically corrected isolated atrial septal defect secundum. The population-based Hungarian Case-Control Surveillance of Congenital Abnormalities (conducted between 1980 and 1996) comprised 472 atrial septal defect secundum cases, 678 matched controls and 38,151 available controls without any defects; in addition, 21,022 malformed controls with other isolated defects. Medically recorded chronic disorders in the prenatal maternity logbook were evaluated, while acute maternal diseases, drug treatments and pregnancy supplements were analyzed on the basis of both prospective medically recorded data and retrospective maternal information. Acute pelvic inflammatory disease, paroxysmal supraventricular tachycardia and phenolphthalein treatment due to severe constipation of mothers were shown to contribute to the development of atrial septal defect secundum of their children. High doses of folic acid in early pregnancy had positively influenced a minor part of isolated atrial septal defect secundum in foetuses. In conclusion, the obvious genetic predisposition for atrial septal defect secundum is connected with maternal paroxysmal supraventricular tachycardia and triggered by acute pelvic inflammatory diseases and phenolphthalein treatment, while the manifestation of atrial septal defect secundum can be reduced by high doses of folic acid supplementation in early pregnancy.

Vitamin D and pre-eclampsia: original data, systematic review and meta-analysis

BACKGROUND/AIMS

Vitamin D may protect from pre-eclampsia through influences on immune modulation and vascular function. To evaluate the role of vitamin D in the development of pre-eclampsia, we conducted a systematic review and meta-analysis including novel data from 2 large-scale epidemiological studies.

METHODS

PubMed, EMBASE and the Cochrane Central Register of Controlled Trials were searched for prospective observational studies of association between vitamin D supplementation or status (measured by maternal 25-hydroxyvitamin D, 25(OH)D) with a subsequent risk of pre-eclampsia, or randomised controlled trials using vitamin D supplementation to prevent pre-eclampsia. The Hungarian Case-Control Surveillance of Congenital Abnormalities (HCCSCA) and the Avon Longitudinal Study of Parents and Children (ALSPAC) were included in meta-analyses with published studies.

RESULTS

Mothers receiving vitamin D supplementation earlier in pregnancy had lower odds of pre-eclampsia [pooled odds ratios (OR) 0.81 and 95% confidence interval (CI) 0.75-0.87, p = 2.4 × 10(-8), 2 studies] in the meta-analysis of published studies with HCCSCA. The meta-analysis of published studies with ALSPAC suggested an association between higher serum 25(OH)D levels and a reduced risk of pre-eclampsia (pooled OR 0.52 and 95% CI 0.30-0.89, p = 0.02, 6 studies). Randomised trials of supplementation were suggestive of protective association (pooled OR 0.66 and 95% CI 0.52-0.83, p = 0.001, 4 studies).

CONCLUSIONS

This study suggests that low maternal serum 25(OH)D concentrations increase pre-eclampsia risk and that vitamin D supplementation lowers this risk. The quality of evidence is insufficient to determine a causal association, which highlights the need for adequately powered clinical trials.

Maternal hypertension with nifedipine treatment associated with a higher risk for right-sided obstructive defects of the heart: a population-based case-control study

OBJECTIVE

To establish possible aetiological factors contributing to congenital heart defects (CHD) overall and separately for different types of CHD, as causes are unknown for the vast majority of patients.

DESIGN

To estimate a possible association with maternal diseases and related drug treatments as exposures in the mothers of cases with right-sided obstructive defects of the heart (RSODH).

SETTING

A large population-based Hungarian Case-Control Surveillance of Congenital Abnormalities data set.

PATIENTS

Newborn infants with four types of RSODH based on autopsy or surgical records.

INTERVENTIONS

Comparison of 200 live-born cases with RSODH including 72 (36.0%) with pulmonary valve stenosis, 13 (6.5%) with tricuspid atresia/stenosis, 7 (3.5%) with Ebstein's anomaly and 108 (54.0%) with pulmonary atresia, with 304 matched controls and 38 151 population controls without any defects.

MAIN OUTCOME MEASURES

Risk of any RSODH and risk of each type of RSODH.

RESULTS

High blood pressure, particularly chronic hypertension with nifedipine treatment, was associated with a risk for RSODH (OR 7.03, 95% CI 3.13 to 13.84). High doses of folic acid reduced the birth prevalence of pulmonary atresia (OR 0.29, 95% CI 0.16 to 0.53).

CONCLUSIONS

The multifactorial threshold model provides the best explanation for the origins of RSODH. Genetic predisposition may be triggered by maternal hypertension with nifedipine treatment, while the risk for pulmonary atresia is reduced by high doses of folic acid in early pregnancy.

Folate deficiency and folic acid supplementation: the prevention of neural-tube defects and congenital heart defects

Diet, particularly vitamin deficiency, is associated with the risk of birth defects. The aim of this review paper is to show the characteristics of common and severe neural-tube defects together with congenital heart defects (CHD) as vitamin deficiencies play a role in their origin. The findings of the Hungarian intervention (randomized double-blind and cohort controlled) trials indicated that periconceptional folic acid (FA)-containing multivitamin supplementation prevented the major proportion (about 90%) of neural-tube defects (NTD) as well as a certain proportion (about 40%) of congenital heart defects. Finally the benefits and drawbacks of three main practical applications of folic acid/multivitamin treatment such as (i) dietary intake; (ii) periconceptional supplementation; and (iii) flour fortification are discussed. The conclusion arrived at is indeed confirmation of Benjamin Franklin's statement: "An ounce of prevention is better than a pound of care".

Risk and protective factors in the origin of conotruncal defects of heart--a population-based case-control study

Congenital heart defect (CHD) cases have been evaluated together as a group in some previous epidemiological studies. However, different CHD entities have different etiologies, and the underlying causes are unclear in the vast majority of patients. Thus the aim of this study was to analyze the possible association of different maternal diseases with the risk of four types of conotruncal defects (CTD), that is, truncus arteriosus, d-transposition of the great arteries, tetralogy of Fallot, and double-outlet right ventricle based on autopsy or surgical report diagnosis. Acute and chronic diseases with related drug treatments and peri-conceptual folic acid or multivitamin supplementations were compared in mothers of 598 CTD cases, of 902 matched controls, and 38,151 population controls without any defects, and with 20,896 malformed controls with other isolated non-cardiac defects in the population-based large dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities. Mothers who had medically recorded influenza and the common cold with secondary complications in the prenatal maternity logbook during the second and/or third gestational months were associated with a higher risk of CTD (OR with 95% CI: 2.22, 1.19-3.88). The common denominator of these maternal diseases may be high fever, which could be prevented by antifever therapies. On the other hand, high doses of medically recorded folic acid in early pregnancy were able to reduce the birth prevalence of CTD (OR with 95% CI: 0.54, 0.39-0.73), and this reduction was significant in transposition of the great arteries (0.46, 0.29-0.71) as well. In conclusion, high fever related maternal diseases may have a role in the origin of CTD, while high doses of folic acid in early pregnancy were able to reduce of CTD, particularly transposition of great vessels.

The participation of prospective fathers in preconception care

We present the data of male participants in the Coordinating Center of the Hungarian Preconception Service (HPS), Budapest, 1984–2010. One of main objectives of the HPS was the incorporation of male partners of female participants into the preparation of childbirth. The HPS is based on three steps: (I) Reproductive health check-up. (II) A 3-month preparation for conception with the major determinants of the development of new life such as sex, health and/or some diseases. Smoking and illicit drug use cessation and limitation of alcohol intake was suggested in the male participants (III) to achieve optimal conception and better protection of early pregnancy. Pregnant women usually visit prenatal care clinics between the 7th and 12th gestational week when it is too late to reduce the risk of congenital abnormalities. Male participation in HPS will help to enhance use of appropriate preconception methods at the appropriate time.

Birth outcomes of cases with isolated atrial septal defect type II--a population-based case-control study

OBJECTIVES

In general, epidemiological studies have evaluated cases with congenital cardiovascular abnormalities together. The aim of this study is to describe the birth outcomes of cases with isolated/single atrial septal defect type II (ASD-II, i.e. only a fossa ovalis defect) after surgical correction or lethal outcome in the light of maternal sociodemographic data.

DESIGN

Comparison of birth outcomes and maternal characteristics of cases with ASD-II and controls without defect.

SETTING

The population-based Hungarian Case-Control Surveillance of Congenital Abnormalities.

POPULATION

Hungarian newborn infants with or without ASD-II.

METHODS

Medically recorded birth outcomes, maternal age and birth order were evaluated. Marital and employment status was based on maternal information. The lifestyle factors were analyzed in a subsample of mothers visited at home based on a personal interview with mothers and their close relatives, and the family consensus was accepted.

MAIN OUTCOME MEASURES

Mean gestational age at delivery and birthweight, rate of preterm birth and low birthweight, maternal age, birth order, marital and employment status.

RESULTS

The evaluation of 471 cases with ASD-II and 38,151 controls without any defects showed a female excess in cases with ASD-II, having shorter gestational age and lower mean birthweight, and thus a higher rate of preterm births and low birthweight.

CONCLUSIONS

Intrauterine growth restriction and shorter gestational age were found in cases with ASD-II, particularly in female children. These factors may have a general developmental process in which there was not closure of the foramen ovale, thus echocardiographic screening of these babies might be of value.