Clinical outcomes of uninterrupted embryo culture with or without time-lapse-based embryo selection versus interrupted standard culture (SelecTIMO): a three-armed, multicentre, double-blind, randomised controlled trial

BACKGROUND

Time-lapse monitoring is increasingly used in fertility laboratories to culture and select embryos for transfer. This method is offered to couples with the promise of improving pregnancy chances, even though there is currently insufficient evidence for superior clinical results. We aimed to evaluate whether a potential improvement by time-lapse monitoring is caused by the time-lapse-based embryo selection method itself or the uninterrupted culture environment that is part of the system.

METHODS

In this three-armed, multicentre, double-blind, randomised controlled trial, couples undergoing in-vitro fertilisation or intracytoplasmic sperm injection were recruited from 15 fertility clinics in the Netherlands and randomly assigned using a web-based, computerised randomisation service to one of three groups. Couples and physicians were masked to treatment group, but embryologists and laboratory technicians could not be. The time-lapse early embryo viability assessment (EEVA; TLE) group received embryo selection based on the EEVA time-lapse selection method and uninterrupted culture. The time-lapse routine (TLR) group received routine embryo selection and uninterrupted culture. The control group received routine embryo selection and interrupted culture. The co-primary endpoints were the cumulative ongoing pregnancy rate within 12 months in all women and the ongoing pregnancy rate after fresh single embryo transfer in a good prognosis population. Analysis was by intention to treat. This trial is registered on the ICTRP Search Portal, NTR5423, and is closed to new participants.

FINDINGS

1731 couples were randomly assigned between June 15, 2017, and March 31, 2020 (577 to the TLE group, 579 to the TLR group, and 575 to the control group). The 12-month cumulative ongoing pregnancy rate did not differ significantly between the three groups: 50·8% (293 of 577) in the TLE group, 50·9% (295 of 579) in the TLR group, and 49·4% (284 of 575) in the control group (p=0·85). The ongoing pregnancy rates after fresh single embryo transfer in a good prognosis population were 38·2% (125 of 327) in the TLE group, 36·8% (119 of 323) in the TLR group, and 37·8% (123 of 325) in the control group (p=0·90). Ten serious adverse events were reported (five TLE, four TLR, and one in the control group), which were not related to study procedures.

INTERPRETATION

Neither time-lapse-based embryo selection using the EEVA test nor uninterrupted culture conditions in a time-lapse incubator improved clinical outcomes compared with routine methods. Widespread application of time-lapse monitoring for fertility treatments with the promise of improved results should be questioned.

FUNDING

Health Care Efficiency Research programme from Netherlands Organisation for Health Research and Development and Merck.

O-003 The SelecTIMO study - clinical outcomes of uninterrupted embryo culture with or without time-lapse based embryo selection versus interrupted standard culture: a randomized controlled trial

Study question

Does uninterrupted embryo culture with or without the application of a time-lapse monitoring (TLM) selection algorithm lead to higher (cumulative) ongoing pregnancy rates?

Summary answer

Uninterrupted embryo culture with or without a TLM selection algorithm and interrupted culture with morphological embryo selection all resulted in comparable (cumulative) ongoing pregnancy rates.

What is known already

The application of TLM for embryo development has been claimed to improve success rates of IVF and ICSI treatments. Systematic reviews, however, show that evidence supporting the routine clinical use of TLM in IVF laboratories is limited and well-designed RCTs are needed to assess its clinical value. The uninterrupted and stable culture conditions in a TLM incubator may cause an increase of the clinical success rate independent from a possible improvement mediated by TLM based embryo selection procedures. Therefore, three study groups were needed to distinguish these two mechanisms.

Study design, size, duration

In this multicenter, double-blind, superiority RCT, women were prospectively randomized in three groups between 2017-2020: 1) TLE (Time-Lapse Eeva): embryo selection based on the Eeva® Test (a day three TLM algorithm, used adjunctively with morphology) and uninterrupted culture. 2) TLR (Time-Lapse Routine): routine morphological embryo selection and uninterrupted culture. 3) CON (Control): routine morphological embryo selection and interrupted culture. Embryos were cultured in Geri+ incubators. Randomization was stratified for laboratory-site and ovum pickup number.

Participants/materials, setting, methods

Women scheduled for day three single embryo transfer (SET) during their first, second or third ovum pickup were included. Primary endpoints were: 1) cumulative ongoing pregnancy rate (cOPR) including fresh SET and associated cryo transfers within 12 months of all women; 2) ongoing pregnancy rate (OPR) after fresh SET in a good-prognosis population: women <41.0 years, ≥5 oocytes, ≥4 fertilized oocytes. Odds ratios (OR) with 95% CI were adjusted for laboratory-site and ovum pickup number.

Main results and the role of chance

A total of 1731 women were randomly assigned to TLE (577), TLR (579) or CON (575). The 12 month cOPR did not differ significantly between the groups (p = 0.85) with a cOPR of 50.8% (293/577) in TLE, 50.9% (295/579) in TLR and 49.4% (284/575) in CON (TLE vs TLR: OR 0.99, 95% CI 0.79 – 1.25; TLE vs CON: OR 1.06, 95% CI 0.84 – 1.33; CON vs TLR: OR 0.94, 95% CI 0.75 – 1.19). In the good-prognosis population, the OPR after fresh SET was 38.2% (125/327) in TLE, 36.5% (118/323) in TLR and 37.8% (123/325) in CON (p = 0.90). Consistent results were found for pregnancy and live birth rates after fresh embryo transfer and cumulatively within one year. A planned subgroup analysis of three female age groups revealed interaction between age group and treatment on cOPR (p = 0.02). In women of 39 years and older (n = 245), the cOPR was higher in TLE compared to TLR (40.0% vs 23.7%: OR 2.10, 95% CI 1.05-4.21) with no difference between TLE vs CON (40.0% vs 31.5%: OR 1.44, 95% CI 0.76-2.71).

Limitations, reasons for caution

This study investigated embryo culture in the Geri+ incubator and the Eeva® Test algorithm, which predicts blastocyst formation on day three and was used in combination with morphology for embryo selection, while more TLM systems and algorithms are currently available.

Wider implications of the findings

Neither embryo selection based on a TLM selection algorithm in combination with morphology (TLE) nor the uninterrupted culture conditions in the Geri+ incubator (TLR) improved (cumulative) ongoing pregnancy and live birth rates after IVF or ICSI. Widespread application for fertility treatments with the promise of improved outcomes should be questioned.

Trial registration number

NL5314

Urinary gonadotropin measurements in neonates: a valuable non-invasive method

Background: To measure low neonatal gonadotropin levels, a sensitive non-invasive method is optimal. The aim of the current study was to validate the Architect i2000SR, an automated immunoassay analyser for the measurement of gonadotropins in unextracted neonatal urine samples against serum gonadotropin levels as a gold standard.

Methods: Blood and urine were sampled from 30 approximately six-week-old male and female neonates undergoing elective paediatric surgery. Follicle stimulating hormone (FSH) and luteinizing hormone (LH) were measured and the urine results were corrected for creatinine.

Results: The agreement between neonatal serum and urinary FSH was 0.904 (3-5 h between samples) and 0.704 (18-20 h). For LH, the correlation coefficients were 0.785 and 0.507, respectively.

Conclusion: We conclude that gonadotropins can be reliably measured using the Architect on randomly voided, non-extracted urine samples collected from neonates by an adhesive device. Urinary gonadotropin levels are a proper reflection of the serum levels.

Frequency distribution of polymorphisms in the FSH receptor gene in infertility patients of different ethnicity

Studies on the frequency distribution of follicle-stimulating hormone receptor (FSHR) polymorphisms report conflicting results. It has been suggested that ethnicity might influence these outcomes. Therefore, the aim of this study was to determine the frequency distribution of FSHR polymorphisms at position 680 of exon 10 within a large group of women with fertility problems from different ethnic backgrounds. A total of 1771 women of different ethnic origin (Caucasian, Asian, Hindustani, Creole and Mediterranean) were studied. FSHR single-nucleotide polymorphisms at codon 680 of exon 10 were determined by restriction fragment length polymorphism of amplicons generated by polymerase chain reaction. Genotypes were compared with serum FSH concentrations and between different ethnic groups. A significantly lower number of Asians (10.5%) were found to have the Ser680Ser receptor variant compared with Caucasians (21.5%) and Mediterraneans (22.3%) (P=0.010). FSH concentrations did not differ between the various ethnic groups, or the different FSHR polymorphisms. In conclusion, the Ser680Ser receptor variant is less common in the Asian subgroup compared with Caucasians and Mediterraneans. This indicates that, when comparing allelic frequency distributions of the FSHR polymorphism variants, ethnic background should be accounted for. FSH concentrations did not differ between FSHR polymorphisms or between ethnic groups.

Clomiphene citrate resistance in relation to follicle-stimulating hormone receptor Ser680Ser-polymorphism in polycystic ovary syndrome

BACKGROUND

Clomiphene citrate (CC) response in anovulatory women is difficult to predict and patient-tailored treatment would benefit patient care and time-management. The objective of this study was to evaluate the role of the follicle-stimulating hormone receptor (FSHR) Ser680Ser-polymorphism as a predictor for CC response.

METHODS

In this retrospective study, 193 patients, diagnosed with polycystic ovary syndrome (PCOS) according to Rotterdam criteria and treated with ovulation induction, were included over a 5-year period in a university hospital in the Netherlands. Data on demographics, BMI, menstrual cycle, laboratory screening (including FSHR genotyping), transvaginal ultrasonography of ovaries and ovulation parameters were collected. Main outcome measures were response to CC and FSHR genotype.

RESULTS

The frequency distribution of the 680-polymorphism was 26% (Asn/Asn), 50% (Asn/Ser) and 24% (Ser/Ser). No significant differences in basal characteristics were found. Significantly more patients with Ser/Ser-polymorphism were resistant to CC (28%) compared with Asn/Ser (14%) and Asn/Asn group (15%), with an odds ratio for ovulation of 0.44 (95% CI, 0.21-0.97). Patients with higher FSH levels, higher age and lower BMI were significantly more likely to ovulate in univariate analysis. In a multivariate logistic regression model, corrected for age, BMI, mean ovarian, volume, hyperandrogenism, and amenorrhoea, only FSHR and basal FSH levels were predictive for ovulation.

CONCLUSIONS

Chance of resistance to CC is almost double in women with PCOS harbouring the Ser/Ser genotype.

Clomiphene citrate resistance in relation to follicle-stimulating hormone receptor Ser680Ser-polymorphism in polycystic ovary syndrome

BACKGROUND

Clomiphene citrate (CC) response in anovulatory women is difficult to predict and patient-tailored treatment would benefit patient care and time-management. The objective of this study was to evaluate the role of the follicle-stimulating hormone receptor (FSHR) Ser680Ser-polymorphism as a predictor for CC response.

METHODS

In this retrospective study, 193 patients, diagnosed with polycystic ovary syndrome (PCOS) according to Rotterdam criteria and treated with ovulation induction, were included over a 5-year period in a university hospital in the Netherlands. Data on demographics, BMI, menstrual cycle, laboratory screening (including FSHR genotyping), transvaginal ultrasonography of ovaries and ovulation parameters were collected. Main outcome measures were response to CC and FSHR genotype.

RESULTS

The frequency distribution of the 680-polymorphism was 26% (Asn/Asn), 50% (Asn/Ser) and 24% (Ser/Ser). No significant differences in basal characteristics were found. Significantly more patients with Ser/Ser-polymorphism were resistant to CC (28%) compared with Asn/Ser (14%) and Asn/Asn group (15%), with an odds ratio for ovulation of 0.44 (95% CI, 0.21-0.97). Patients with higher FSH levels, higher age and lower BMI were significantly more likely to ovulate in univariate analysis. In a multivariate logistic regression model, corrected for age, BMI, mean ovarian, volume, hyperandrogenism, and amenorrhoea, only FSHR and basal FSH levels were predictive for ovulation.

CONCLUSIONS

Chance of resistance to CC is almost double in women with PCOS harbouring the Ser/Ser genotype.

Heritability of reproductive hormones in adult male twins

BACKGROUND

Proper functioning of the male reproductive axis depends on complex feedback systems between several hormones. In this study, the genetic contribution of various endocrine components of the hypothalamic-pituitary-testicular axis is evaluated and previously observed differences in FSH and inhibin B levels between mono- (MZ) and dizygotic (DZ) twins are re-investigated.

METHODS

Inhibin B, FSH, LH, sex hormone-binding globulin (SHBG) and testosterone levels were assayed in 128 adult males (20 MZ twin pairs, 7 single MZ twins, 10 DZ twin pairs, 27 single DZ twins and 34 siblings of twins, constituting 10 sibling pairs), aged 15.6-68.7 years. Hormone levels were compared across zygosity groups and heritability estimates were obtained using maximum likelihood variance component analysis.

RESULTS

Heritability estimates ranged from 56% (testosterone) to 81% (inhibin B and SHBG). For LH and FSH, the heritability was estimated at 68% and 80% respectively. No mean differences in hormone levels were observed across groups.

CONCLUSIONS

All measured hormones are highly heritable. A difference in the FSH-inhibin B feedback system between DZ twin males and MZ twin males could not be confirmed.