Human-induced pluripotent stem cell-derived ovarian support cell co-culture improves oocyte maturation in vitro after abbreviated gonadotropin stimulation

STUDY QUESTION

Can in vitro maturation (IVM) and developmental competence of human oocytes be improved by co-culture with ovarian support cells (OSCs) derived from human-induced pluripotent stem cells (hiPSCs)?

SUMMARY ANSWER

OSC-IVM significantly improves the rates of metaphase II (MII) formation and euploid Day 5 or 6 blastocyst formation, when compared to a commercially available IVM system.

WHAT IS KNOWN ALREADY

IVM has historically shown highly variable performance in maturing oocytes and generating oocytes with strong developmental capacity, while limited studies have shown a positive benefit of primary granulosa cell co-culture for IVM. We recently reported the development of OSCs generated from hiPSCs that recapitulate dynamic ovarian function in vitro.

STUDY DESIGN, SIZE, DURATION

The study was designed as a basic science study, using randomized sibling oocyte specimen allocation. Using pilot study data, a prospective sample size of 20 donors or at least 65 oocytes per condition were used for subsequent experiments. A total of 67 oocyte donors were recruited to undergo abbreviated gonadotropin stimulation with or without hCG triggers and retrieved cumulus-oocyte complexes (COCs) were allocated between the OSC-IVM or control conditions (fetal-like OSC (FOSC)-IVM or media-only IVM) in three independent experimental design formats. The total study duration was 1 April 2022 to 1 July 2023.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Oocyte donors between the ages of 19 and 37 years were recruited for retrieval after informed consent, with assessment of anti-Mullerian hormone, antral follicle count, age, BMI and ovarian pathology used for inclusion and exclusion criteria. In experiment 1, 27 oocyte donors were recruited, in experiment 2, 23 oocyte donors were recruited, and in experiment 3, 17 oocyte donors and 3 sperm donors were recruited. The OSC-IVM culture condition was composed of 100 000 OSCs in suspension culture with hCG, recombinant FSH, androstenedione, and doxycycline supplementation. IVM controls lacked OSCs and contained either the same supplementation, FSH and hCG only (a commercial IVM control), or FOSCs with the same supplementation (Media control). Experiment 1 compared OSC-IVM, FOSC-IVM, and a Media control, while experiments 2 and 3 compared OSC-IVM and a commercial IVM control. Primary endpoints in the first two experiments were the MII formation (i.e. maturation) rate and morphological quality assessment. In the third experiment, the fertilization and embryo formation rates were assessed with genetic testing for aneuploidy and epigenetic quality in blastocysts.

MAIN RESULTS AND THE ROLE OF CHANCE

We observed a statistically significant improvement (∼1.5×) in maturation outcomes for oocytes that underwent IVM with OSCs compared to control Media-IVM and FOSC-IVM in experiment 1. More specifically, the OSC-IVM group yielded a MII formation rate of 68% ± 6.83% SEM versus 46% ± 8.51% SEM in the Media control (P = 0.02592, unpaired t-test). FOSC-IVM yielded a 51% ± 9.23% SEM MII formation rate which did not significantly differ from the media control (P = 0.77 unpaired t-test). Additionally, OSC-IVM yielded a statistically significant ∼1.6× higher average MII formation rate at 68% ± 6.74% when compared to 43% ± 7.90% in the commercially available IVM control condition (P = 0.0349, paired t-test) in experiment 2. Oocyte morphological quality between OSC-IVM and the controls did not significantly differ. In experiment 3, OSC-IVM oocytes demonstrated a statistically significant improvement in Day 5 or 6 euploid blastocyst formation per COC compared to the commercial IVM control (25% ± 7.47% vs 11% ± 3.82%, P = 0.0349 logistic regression). Also in experiment 3, the OSC-treated oocytes generated blastocysts with similar global and germline differentially methylated region epigenetic profiles compared commercial IVM controls or blastocysts after either conventional ovarian stimulation.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

While the findings of this study are compelling, the cohort size remains limited and was powered on preliminary pilot studies, and the basic research nature of the study limits generalizability compared to randomized control trials. Additionally, use of hCG-triggered cycles results in a heterogenous oocyte cohort, and potential differences in the underlying maturation state of oocytes pre-IVM may limit or bias findings. Further research is needed to clarify and characterize the precise mechanism of action of the OSC-IVM system. Further research is also needed to establish whether these embryos are capable of implantation and further development, a key indication of their clinical utility.

WIDER IMPLICATIONS OF THE FINDINGS

Together, these findings demonstrate a novel approach to IVM with broad applicability to modern ART practice. The controls used in this study are in line with and have produced similar to findings to those in the literature, and the outcome of this study supports findings from previous co-culture studies that found benefits of primary granulosa cells on IVM outcomes. The OSC-IVM system shows promise as a highly flexible IVM approach that can complement a broad range of stimulation styles and patient populations. Particularly for patients who cannot or prefer not to undergo conventional gonadotropin stimulation, OSC-IVM may present a viable path for obtaining developmentally competent, mature oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

A.D.N., A.B.F., A.G., B.P., C.A., C.C.K., F.B., G.R., K.S.P., K.W., M.M., P.C., S.P., and M.-J.F.-G. are shareholders in the for-profit biotechnology company Gameto Inc. P.R.J.F. declares paid consultancy for Gameto Inc. P.C. also declares paid consultancy for the Scientific Advisory Board for Gameto Inc. D.H.M. has received consulting services from Granata Bio, Sanford Fertility and Reproductive Medicine, Gameto, and Buffalo IVF, and travel support from the Upper Egypt Assisted Reproduction Society. C.C.K., S.P., M.M., A.G., B.P., K.S.P., G.R., and A.D.N. are listed on a patent covering the use of OSCs for IVM: U.S. Provisional Patent Application No. 63/492,210. Additionally, C.C.K. and K.W. are listed on three patents covering the use of OSCs for IVM: U.S. Patent Application No. 17/846,725, U.S Patent Application No. 17/846,845, and International Patent Application No.: PCT/US2023/026012. C.C.K., M.P.S., and P.C. additionally are listed on three patents for the transcription factor-directed production of granulosa-like cells from stem cells: International Patent Application No.: PCT/US2023/065140, U.S. Provisional Application No. 63/326,640, and U.S. Provisional Application No. 63/444,108. The remaining authors have no conflicts of interest to declare.

P-556 Younger maternal age as a factor associated with embryonic mosaicism. Analysis of 3222 blastocyst by Next Generation Sequencing

Study question

Is there an association between healthy younger women under 30 years old and blastocyst mosaicism rate evaluated by NGS analysis?

Summary answer

Embryo mosaicism is independent to younger maternal age. However, morphological embryo quality is associated with embryo mosaicism.

What is known already

Embryo aneuploidy rate is strongly associated with maternal age, increasing in women older than 36y. On the contrary, the aneuploidy rate remains lower in women between 22 to 35y. However, the mosaicism rate in younger women seems to be slightly higher compared to older women. Although, there is still controversy on the relationship with maternal age and others factors.

Study design, size, duration

This retrospective study include 786 oocytes donation cycles were performed from 2016 to 2020. These IVF cycles generated 3222 blastocyst that were analyzed with PGT-A(NGS. Veryseq-Illumina). Mosaic embryos were call when variation was between 20-80%. Mosaic embryos were also sub-classify as a whole or segmental chromosome mosaicism. Mosaic embryos were according to the impact level as a: high Mosaic level (>50%) and low mosaic level (≤50%). Data was classified by donor age: group-1(18-22y)(n = 288) and group-2(23-30y)(n = 498).

Participants/materials, setting, methods

All donors had a normal ovarian reserve and without any pathological or chromosome translocation. Donors had conventional oocyte stimulation with antagonist protocol trigger with agonist GnRH. Embryos were cultured with Lifeglobal media family under 7% CO2 and 5%O2.

A multilevel model was made and associations between variables by logistic regression were adjusted according to paternal age, morphological blastocyst quality, fertilization method, biopsy operator, day of embryo biopsy, number of chromosomes impacted per embryo and sperm quality.

Main results and the role of chance

Oocyte donation cycles generated 3222 blastocyst that were analyzed by NGS. The euploidy rate was 60.4% (n = 723) and 58.6% (n = 1186). Aneuploidy rate was 22.6% (n = 271) and 26.2% (n = 531) (p = 0.04). Mosaicism rate was 17% (n = 204) and 15.1% (n = 309) in group 1 and 2 respectively (p = 0.4)

Mosaic embryos were also further studied and classified according to the impact level. Interestingly, a vast majority of mosaic embryos have low mosaicism level (86.1%) compared to high mosaic level (13.9%) (p < 0.001).

The multilevel model shows that embryo quality correlated with embryo mosaicism where good quality embryos have a lower mosaicism rate compared to fair and poor quality blastocyst.

Finally, the chromosomes 21, 22 and 14 were the most frequent chromosome affect in whole chromosome mosaicism while the chromosomes 1, 2 and 5 were affected by segmental chromosome mosaicism and it was independent of maternal age.

Limitations, reasons for caution

The analysis was limited only for healthy women under 30 year old and it should not be extrapolate to patients with other pathologies.

Wider implications of the findings

The present study revealed that embryo mosaicism remains at similar percentage in younger healthy women. The mosaic embryos generated from young women have a lower chromosome impact, which according to other studies has a good implantation potential.

Trial registration number

N.A

P–581 The day of blastocyst biopsy and the chromosomal constitution. Evaluation of 5125 embryos by Next Generation Sequency (NGS)

Study question

Is there a relationship between the day of blastocyst biopsy and the results NGS analysis?

Summary answer

Embryos biopsied on day 6 or 7 are associated with the increased probability of being an aneuploidy embryo and less likely to be mosaic embryo.

What is known already

There is controversy about whether an embryo that reaches the blastocyst stage on day 5 has a higher chance of being euploid than embryos which are biopsied later. In our study, chromosome constitution was evaluated by next-generation sequencing (NGS)-based preimplantation genetic testing for aneuploidy (PGT-A) and confounding factors were eliminated.

Study design, size, duration

Data was collected retrospectively from June 2016 to January 2020

Participants/materials, setting, methods

In total, 5125 blastocyst (day 5=2914, day 6 N = 2154 and day7 N = 57), generated from 1318 cycles were analysed with PGT-A. The chromosome constitution for each embryo was classified as euploid, aneuploid and mosaic. A multilevel model was made and associations betwwen variables by logistic regression were adjusted according to maternal age, SART blastocyst grade, fertilization method, biopsy operator and blastocyst stage.

Main results and the role of chance

The mean maternal age was 36.2 ± 4.2. Euploid rate was 62.1% and 37.9% (day 5 and day 6–7 respectively), aneuploidy rate was 47.0% and 53.0% (day 5 and day 6–7, respectively), mosaicism rate was 59.6% and 40.4% (day 5 and day 6–7, respectively) (p < 0.001).

Embryos biopsied on day 6–7 have a significantly lower probability to be euploid and mosaicism than embryos biopsied on day 5 ((OR = 0.76 [0.68–0.86]); (OR = 0.84 (0.73 – 0.96) respectively) (p < 0.001). On the contrary, embryos biopsy on day 5 were significantly more likely to be euploid than day 6–7 (OR = 1.63[1.42–1.86]) (p < 0.001).

Limitations, reasons for caution

The results observed in this study should be confirmed using a larger number of samples. For the NGS analysis, a chromosome with a variation between 20 to 80% was considered mosaic.

Wider implications of the findings: The present study revealed that embryos that reach blastocyst classified as full to hatched on day 5 are more like to be euploid compared to slow growing embryos.

Trial registration number

non-clinical trials

Long-term outcomes of percutaneous or surgical treatment in left main disease

INTRODUCTION

Long-term efficacy and safety of either surgical or percutaneous treatment left main coronary artery disease treatment is lacking.

EVIDENCE ACQUISITION

We conducted a systematic review and meta-analysis of the most updated randomized clinical trials that compared the efficacy of coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the Left Main Coronary Artery (LMCA) disease. It was also conducted a systematic search of PubMed, Google Scholar, reference lists of relevant articles, and Medline. The search utilized the following terms: "left main PCI versus CABG," "drug-eluting stents," "bypass surgery" and "left main stenting." The search of articles compatible with our inclusion and exclusion criteria was performed from inception through April 2020 and returned a combined total of 304 articles.

EVIDENCE SYNTHESIS

We identified 6 studies, providing data on 5812 patients. The mean follow-up was 6.7 years. PCI was associated with an increased risk of major vascular events (MACE) (IRR 1.24, 95% CI [1.03-1.67], P<0.01), and coronary revascularization (IRR 1.69, 95% CI [1.42-2.03], P<0.01) compared to CABG. Furthermore, all-cause death, MI and stroke events were not statistically different between the two therapeutic revascularization methodologies (IRR 1.06, 95% CI [0.90-1.24], P=0.47, IRR 1.35, 95% CI [0.84-2.16], P=0.03 and IRR 0.66, 95% CI [0.43-1.01], P=0.05, respectively).

CONCLUSIONS

LMCA PCI has an overall same survival compared to CABG in the long term follow-up. Nevertheless, MACE and revascularization events were more frequent in PCI compared to CABG.

Long-term outcomes of percutaneous or surgical treatment in left main disease

INTRODUCTION

Long-term efficacy and safety of either surgical or percutaneous treatment left main coronary artery disease treatment is lacking.

EVIDENCE ACQUISITION

We conducted a systematic review and meta-analysis of the most updated randomized clinical trials that compared the efficacy of coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the Left Main Coronary Artery (LMCA) disease. It was also conducted a systematic search of PubMed, Google Scholar, reference lists of relevant articles, and Medline. The search utilized the following terms: "left main PCI versus CABG," "drug-eluting stents," "bypass surgery" and "left main stenting." The search of articles compatible with our inclusion and exclusion criteria was performed from inception through April 2020 and returned a combined total of 304 articles.

EVIDENCE SYNTHESIS

We identified 6 studies, providing data on 5812 patients. The mean follow-up was 6.7 years. PCI was associated with an increased risk of major vascular events (MACE) (IRR 1.24, 95% CI [1.03-1.67], P<0.01), and coronary revascularization (IRR 1.69, 95% CI [1.42-2.03], P<0.01) compared to CABG. Furthermore, all-cause death, MI and stroke events were not statistically different between the two therapeutic revascularization methodologies (IRR 1.06, 95% CI [0.90-1.24], P=0.47, IRR 1.35, 95% CI [0.84-2.16], P=0.03 and IRR 0.66, 95% CI [0.43-1.01], P=0.05, respectively).

CONCLUSIONS

LMCA PCI has an overall same survival compared to CABG in the long term follow-up. Nevertheless, MACE and revascularization events were more frequent in PCI compared to CABG.

Clinical Experience with the Use of Neoadjuvant Hormone Therapy for Breast Cancer in a Latin American Cancer Center

Introduction: The most frequent subtype of breast cancer is the luminal one, in 70 to 80% of cases; the poor response to neoadjuvant chemotherapy of these tumors positions neoadjuvant hormone therapy as a treatment option. Materials and Methods: An observational, descriptive, historical cohort study was conducted in patients with hormone receptor (HR positive and HER2-positive breast cancer, managed with neoadjuvant hormone therapy in the INC (National Cancer Institute, for its initials in Spanish), with the aim of evaluating their clinical and pathological response. Results: 57 patients were managed with neoadjuvant hormone therapy. Most stage IIA patients (40.3%, n = 23). 86% (n = 49) had luminal A tumors. Letrozole was the most widely used drug, in 78.9% (n = 45). The overall response rate (ORR) was reached in 94.6% (n = 53); and 10.7% of the patients (n = 6) achieved complete clinical response (cCR). Complete pathological response (pCR) was achieved only in one patient. Conservative surgery was possible in 56.9% (n = 29) of the patients. There was no difference between the type of aromatase inhibitor (AI) and the duration of neoadjuvant hormonal treatment with the clinical response. With a median follow-up of 3 years (0.6 and 6 years), no disease progression was reported in any of the patients in the study. Conclusion: The results of this study support the neoadjuvant hormone therapy recommendations for postmenopausal patients older than 65 years with luminal breast cancer, with well or moderately differentiated tumors, strongly HR positive and low Ki 67.

A multidisciplinary, video-based, curriculum for management of the intubated and surgical airway patient for a pediatric hospital in El Salvador

OBJECTIVE

Primary objective is to determine the rate of intubation with inappropriately sized endotracheal tubes (ETTs) in a pediatric intensive care unit (PICU) in El Salvador. Secondary objective is to determine effectiveness of a video-based curriculum to teach local providers on pediatric advanced airway management and surgical approach to patients requiring airway reconstruction.

METHODS

Data for 296 intubated pediatric patients was collected over a six month period in a 16-bed PICU in El Salvador. Results of a learning behavior assessment survey completed by local healthcare workers informed a curriculum to complement on-site education during annual surgical airway mission trips. The video-based curriculum addressed proper sizing and use of cuffed endotracheal tubes, care of the intubated child and perioperative considerations of the surgical airway patient. Providers completed pre and post-curriculum quizzes to measure knowledge acquisition.

RESULTS

Over 6-months, 281 patients were intubated. Sixty-three percent had improperly sized ETTs. Thirty-one percent had a failed or accidental extubation. All-cause mortality was 24%. One hundred and fifty-nine Salvadorian providers completed a learning behavior survey informing a video-based curriculum. Sixty-four providers completed the curriculum. Post-curriculum quiz scores increased by 18.7%. Surgeons, anesthesiologist, intensivists and speech pathologists demonstrated significant improvement (p < 0.05).

CONCLUSION

Nearly two-thirds of intubated patients in a PICU in El Salvador have improperly sized ETTs and one-third require reintubation following planned or accidental extubation. The development of this first of its kind video-based curriculum for critical care and surgical training regarding how to properly care for the intubated child is coupled with the development of a longitudinal database to record pediatric airway related morbidity and mortality in the largest pediatric hospital in El Salvador. This model and system can be used to track the reduction in airway related morbidity and mortality directly related to a systems based intervention both in El Salvador and then elsewhere.

P5752Which is the best stenting technique for coronary bifurcation lesions? Evidence from a network meta-analysis of randomized clinical trials

Background

Bifurcation lesions represent 20% of all coronary lesions treated by percutaneous coronary interventions (PCI). Although provisional technique with 1 stent in the main branch and balloon angioplasty of the side branch is considered the standard approach, the implantation of 2 stents is often being pursued with a wide variety of bifurcation stenting techniques. We thus conducted a systematic review and network meta-analysis of randomized clinical trials (RCTs) to compare clinical cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions.

Methods

We searched on Pubmed, Google Scholar, Embase and Cochrane Library, up to October 2018 for published and unpublished RCTs that compared clinical cardiovascular outcomes in patients with bifurcation lesions treated with 7different techniques (crush [Cr]; culotte [Cu]; double kissing crush [DKCr], mini-crush [mCr], routine T-stenting [RTS], T-stenting and small protrusion [TAP], and provisional (1 stent technique)). We performed a frequentist fixed-effect network meta-analysis to estimate relative risks (RR) of major adverse cardiovascular events (“MACE”, typically defined as death, myocardial infarction and target vessel revascularization), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST).

Results

We identified 14 studies, yielding data on 4285 patients. DKCr and mCr yielded significant reductions in MACE, TVR, and TLR when compared with the 1-stent technique (RR 0.31–0.55 [all P<0.01] and RR 0.42–0.45 [all P<0.02], respectively) and with the rest of the bifurcation techniques (RR 0.44–0.55 [all P<0.05] for DKCr and RR 0.37–0.45 [all P<0.05] for mCr). On the other hand, Cu and Cr were associated with an increased risk for ST compared to 1-stent technique (RR 3.25–4.27 [both P<0.05]) and to DKCr (RR 3.02–3.99 [both P<0.05]). We found no heterogeneity nor inconsistency between studies.

Conclusions

The various PCI bifurcation stenting techniques are associated with different cardiovascular outcomes, with double kissing crush and mini crush being more effective than others, including the 1-stent approach, whereas culotte and crush are associated with increased risk of stent thrombosis.

Acknowledgement/Funding

None

Aberrant endometrial steroid receptor expression in in-vitro maturation cycles despite hormonal luteal support: A pilot study

Clinical outcomes of fresh embryo transfer in non-hCG triggered in vitro maturation (IVM) cycles are inferior compared to vitrified-warmed embryo transfer. This is a prospective observational pilot study in a consecutive cohort of 31 polycystic ovary syndrome (PCOS) patients and 37 normo-ovulatory egg donors who underwent IVM without fresh embryo transfer between July 2009 and June 2014. All subjects received 150 IU of highly purified menotropin (HP-hMG) daily for three days. On cycle day 6, all patients started transdermal oestradiol (E2) at a daily dose of 9 mg. There was no human chorionic gonadotropin (hCG) trigger before oocyte retrieval (OR). Vaginal micronized progesterone was commenced on the evening after OR, at a daily dose of 600 mg. Additional luteal phase support (LPS) was administered as follows: Group A: no additional LPS; Group B: 1500 IU of hCG administered 4 h after OR and Group C: 5000 IU of hCG administered 4 h after OR + an additional injection of 5000 IU of hCG 1 day before endometrial biopsy. Endometrial biopsy for histology and immunohistochemistry (IHC) was performed on day 5 or 6 after OR. Instead of being downregulated, both PR-B and ERα in endometrial glands and stroma were moderately to strongly expressed in all three protocols, suggesting that the mid-luteal histological signature of endometrial receptivity is deficient in a non-hCG-triggered IVM cycle. Poor clinical outcomes after fresh embryo transfer following IVM are probably related to inappropriate endometrial development which may be linked to the short follicular phase of IVM cycles.

What advice should we give our patients to preserve their fertility and avoid needing oocyte donation in the future? - A Social Fertility Preservation program

OBJECTIVE

To describe our fertility preservation program focusing on the number of oocytes vitrified by age.

METHODS

From January 2015 to December 2016, 686 oocyte vitrification cycles were performed in our units for the social fertility preservation program. In total, 288 were donors who donated their oocytes for our oocyte-banking program, and 398 were patients who underwent elective fertility preservation.

RESULTS

The mean numbers of COCs retrieved and vitrified oocytes were similar among the donor cycles (women under 30 years). In those patients over 36 years of age the mean numbers of COCs retrieved and vitrified oocytes were significantly lower. We also estimated the association between age and cancelation rates. Odd ratios (OR) for total cancelation was calculated between patients of 31-35 years and 41-45 years; the OR was 5.17 (95% CI 1.89 - 14.17) and increased up to 25.67 (95% CI 5.01 - 131.42) between patients 31-35 y and those older than 45 years. No differences were found between patients of 31-35 years and 36-40 years. The OR for total cancellation increased 3.83 (95% CI 2.06 - 7.11) and 19.00 (95% CI 4.56 - 79.11) between women 36-40 years and 41-45 years, and those older than 45 years, respectively. Finally, the oocyte survival rate in patients under 36 years of age was similar to that of our donor program (94% vs. 95%).

CONCLUSIONS

Based on this study, we encouraged our patients under than 36 years of age to preserve their fertility for the future.

Dissection of Ascending Aorta: A Complication of Transradial Artery Access of Coronary Procedure

Iatrogenic acute dissection of ascending aorta following coronary angiography and percutaneous intervention is a rare complication. Most reports involve localized aortic dissections as a complication of cannulation of a coronary artery with propagation into the ascending aorta. It is usually treated by sealing the intima with a stent in the ostium of the coronary artery or conservative management, while extensive dissections may require a surgical intervention. We describe a case of the subclavian dissection extending into the ascending aorta that occurred during diagnostic catheterization using the radial approach. The patient was successfully treated utilizing conservative management.

The number of biopsied trophectoderm cells may affect pregnancy outcomes

OBJECTIVE

To study if the number of trophectoderm (TE) biopsied cells has an impact on implantation rates.

DESIGN

A retrospective cohort study in a single-center study.

SETTING

In vitro fertilization center.

PATIENTS

Patients who underwent PGT-A from January 2013 to March 2016. In total, 482 vitrified/warmed single embryo transfers were included.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Clinical pregnancies rate, implantation rate.

RESULTS

Overall, clinical pregnancies per embryo transfer were higher when a regular TE were biopsied compared to larger size biopsy cells (66% (175/267) vs 53% (115/215) (p < 0.005) respectively). Pregnancy rates were also analyzed according to embryo morphology at the moment of embryo biopsy, when a good-quality embryo was transferred the clinical outcome was 75% (81/108) in group 1 and 61% (60/99) in group 2 (p < 0.05). Data was also stratified by age in patients ≤ 35 years and > 35 years. The clinical pregnancy was 67% (51/76) in women ≤ 35 years and 65% (124/191) in women > 35 years when a regular size biopsy was performed. These results significantly reduced when a larger size biopsy was performed 54% (49/91) and 53% (66/124), respectively (p < 0.05). Further investigation indicated that miscarriage rate was similar between these groups (4% (7/182) in group 1 and 5% (6/121) in group 2).

CONCLUSIONS

These findings underscore that when a large amount of TE cells are biopsied, it may negatively affect implantation rates, but once implanted, the embryos have the same chance to miscarry or reach term.

Novel Alkylimidazolium Ionic Liquids as an Antibacterial Alternative to Pathogens of the Skin and Soft Tissue Infections

Keeping in mind the concept of green chemistry, this research aims to synthesize and characterize new ionic liquids (ILs) derived from N-cinnamyl imidazole with different sizes of alkyl chains (1, 6, 8, and 10 carbon atoms), and evaluate their antibacterial activity against Skin and soft tissue infections (SSTIs) causative bacteria. The antibacterial screening was carried out by agar well diffusion and the Minimum Inhibitory Concentration (MIC) and Half Maximum Inhibitory Concentration (IC₅₀) of the different ILs were determined by microdilution in broth, also Molecular dynamics simulations were performed to study the interaction mechanism between ILs and membranes. The MIC value in Gram-positive bacteria showed that as the hydrocarbon chain increases, the MIC value decreases with a dose-dependent effect. Furthermore, Gram-negative bacteria showed high MIC values, which were also evidenced in the antibacterial screening. The molecular dynamics showed an incorporation of the ILs with the longer chain (10 C), corresponding to a passive diffusion towards the membrane surface, for its part, the ILs with the shorter chain due to its lack of hydrophobicity was not incorporated into the bilayer. Finally, the new ILs synthesized could be an alternative for the treatment of Gram-positive bacteria causative of SSTIs.

Risk factors for Clostridium difficile infection in intestinal transplant recipients during the first year post-transplant

BACKGROUND

Clostridium difficile is the most common cause of healthcare-associated infectious diarrhea. Risk factors for C. difficile infections (CDI) in intestinal transplant recipients (ITR) are not well-defined. The aim of our study was to assess specific risk factors for CDI in ITR.

METHODS

This is a 1:3 case-control study that included 29 ITR who developed CDI (cases) and 87 ITR without CDI (controls) observed during the first year post-transplantation. Wilcoxon rank sum and Fisher's exact tests were used to compare variables. Univariate and multivariable conditional logistic regressions analysis were performed to identify risk factors for CDI.

RESULTS

The multivariable conditional logistic regression analysis showed that proton pump inhibitors (PPI) administration (odds ratio [OR] = 0.06; 95% confidence interval [CI]: 0.007-0.52; P = .01) was the only factor associated with lower rates of CDI. Outcomes for cases vs controls: rejection episodes 24.14% vs 20.69% (P = .7), graft loss 0% vs 2.3% (P = .99), and survival rate 1 year post-transplantation 79.3% (59.6-90.1%) vs 87.2% (78.1-92.7%) (P = .38).

CONCLUSIONS

Proton pump inhibitor administration might be protective for CDI in ITR. Risks factors for CDI might be different in ITR compared to other populations; anatomical differences and medications administered in the post-transplantation period may affect intestinal microbiota.

Coronary artery disease in decompensated patients undergoing liver transplantation evaluation

Coronary artery disease (CAD) is an important contributor to morbidity and mortality in patients undergoing liver transplantation (LT). However, the current literature is limited by sampling bias and nondefinitive assessment of CAD. The current study examines the prevalence of CAD via per protocol coronary angiography and its relationship to etiology of liver disease in patients undergoing liver transplantation evaluation (LTE). Data on 228 patients were prospectively collected who had coronary angiography as part of LTE between 2011 and 2014. Coronary angiography was done in all patients age ≥50 years or with CAD risk factors. CAD was defined as any coronary artery stenosis, whereas stenosis ≥ 70% in distribution of 1 or 3 major coronary arteries was considered as single- or triple-vessel disease. CAD was detected in 36.8% of patients, with the highest prevalence among nonalcoholic steatohepatitis (NASH) patients with cirrhosis (52.8%). Prevalence of single-vessel disease was higher among patients with NASH compared with hepatitis C virus (HCV) and alcoholic cirrhosis (15.1% versus 4.6% versus 6.6%; P = 0.02). Similarly, patients with NASH were more likely to have triple-vessel disease when compared with HCV and alcoholic cirrhosis (9.4% versus 0.9% versus 0%; P = 0.001). While adjusting for traditional risk factors for CAD, only NASH as etiology of liver disease remained significantly associated with CAD. Complications from diagnostic coronary angiography or percutaneous coronary intervention were low (2.6%). In conclusion, patients undergoing LTE have a high prevalence of CAD, which varies widely depending on etiology of liver cirrhosis. The procedural complications from coronary angiography are low. Liver Transplantation 24 333-342 2018 AASLD.

A healthy HLA-matched baby born by using a combination of aCGH and Karyomapping: the first latin american case

PGD for HLA typing is a procedure that can be performed when an affected child requires a transplant to treat a non-hereditary disorder related to the hematopoietic and/or immune system. Hematopoietic stem cell transplantation from an HLA-identical donor provides the best treatment option. Three conventional ovarian stimulation procedures for IVF were performed in a couple with a 10-year-old child diagnosed with T-cell acute lymphoblastic leukemia of high risk. Trophectoderm biopsy and aCGH examination were performed on 15 blastocysts, three on the first IVF procedure, four on the second cycle, and eight on the third. Three euploid blastocysts HLA-compatible with the genome of the affected child were identified. One euploid blastocyst HLA-compatible with the affected child was warmed and transferred, resulting in an HLA-matched live birth. In conclusion, combined aCGH for aneuploidy screening and Karyomapping may be performed in a single biopsy procedure.

Pharmacodynamic effects of standard dose prasugrel versus high dose clopidogrel in non-diabetic obese patients with coronary artery disease

Increased body weight is independently associated with impaired clopidogrel pharmacodynamic (PD) response. Prasugrel has more potent PD effects compared with clopidogrel, although its PD effects in obese patients are unknown. The aim of this prospective, randomised, study was to compare the PD effects of standard-dose prasugrel [60 mg loading dose (LD)/10 mg daily maintenance dose (MD)] with highdose clopidogrel (900 mg LD/150 mg daily MD) in non-diabetic obese [body mass index (BMI) ≥30 kg/m2] patients, with coronary artery disease (CAD) on aspirin therapy. PD assessments (baseline, 2 hours post-LD and 6 ± 2 days after MD) were conducted using four platelet function assays, and the platelet reactivity index (PRI) assessed by VASP was used for sample size estimation. A total of 42 patients with a BMI of 36.42 ± 5.6 kg/m2 completed the study. There were no differences in baseline PD measures between groups. At 2 hours post-LD, prasugrel was associated with lower PRI compared with clopidogrel (24.3 ± 5.5 vs 58.7 ± 5.7, p≤0.001), with consistent findings for all assays. At one-week, PRI values on prasugrel MD were lower than clopidogrel MD without reaching statistical significance (34.7 ± 5.8 vs 42.9 ± 5.8, p=0.32), with consistent findings for all assays. Accordingly, rates of high on-treatment platelet reactivity were markedly reduced after prasugrel LD, but not after MD. In conclusion, in non-diabetic obese patients with CAD, standard prasugrel dosing achieved more potent PD effects than high-dose clopidogrel in the acute phase of treatment, but this was not sustained during maintenance phase treatment. Whether an intensified prasugrel regimen is required in obese patients warrants investigation.

Laryngospasm, central and obstructive apnea during seizures: Defining pathophysiology for sudden death in a rat model

Seizure spread into the autonomic nervous system can result in life-threatening cardiovascular and respiratory dysfunction. Here we report on a less-studied consequence of such autonomic derangements-the possibility of laryngospasm and upper-airway occlusion. We used parenteral kainic acid to induce recurring seizures in urethane-anesthetized Sprague Dawley rats. EEG recordings and combinations of cardiopulmonary monitoring, including video laryngoscopy, were performed during multi-unit recordings of recurrent laryngeal nerve (RLN) activity or head-out plethysmography with or without endotracheal intubation. Controlled occlusions of a tracheal tube were used to study the kinetics of cardiac and respiratory changes after sudden obstruction. Seizure activity caused significant firing increases in the RLN that were associated with abnormal, high-frequency movements of the vocal folds. Partial airway obstruction from laryngospasm was evident in plethysmograms and was prevented by intubation. Complete glottic closure (confirmed by laryngoscopy) occurred in a subset of non-intubated animals in association with the largest increases in RLN activity, and cessation of airflow was followed in all obstructed animals within tens of seconds by ST-segment elevation, bradycardia, and death. Periods of central apnea occurred in both intubated and non-intubated rats during seizures for periods up to 33s and were associated with modestly increased RLN activity, minimal cardiac derangements, and an open airway on laryngoscopy. In controlled complete airway occlusions, respiratory effort to inspire progressively increased, then ceased, usually in less than 1min. Respiratory arrest was associated with left ventricular dilatation and eventual asystole, an elevation of systemic blood pressure, and complete glottic closure. Severe laryngospasm contributed to the seizure- and hypoxemia-induced conditions that resulted in sudden death in our rat model, and we suggest that this mechanism could contribute to sudden death in epilepsy.

Causes and estimated incidences of sex-chromosome misdiagnosis in preimplantation genetic diagnosis of aneuploidy

Preimplantation genetic diagnosis of aneuploidy (PGD-A) with comprehensive chromosome analysis has been known to improve pregnancy outcomes. Accuracy in detecting sex chromosomes becomes important when selecting against embryos at risk for sex-linked disorders. A total of 21,356 PGD-A cycles consisting of day-3 (cleavage) or day-5 (blastocyst) biopsies were received at the same laboratory for PGD-A via fluorescence in situ hybridization (FISH) or array comparative genome hybridization (aCGH) from multiple fertility centres. The misdiagnosis rates were 0.12% (Wilson 95% CI 0.05 to 0.25%) in day-3 FISH cycles, 0.48% (Wilson 95% CI 0.19 to 1.22%) in day-3 aCGH cycles and 0.0% (Wilson 95% CI 0 to 0.26) in day-5 aCGH cycles. Although rare, the likely causative biological event for true misdiagnosis is embryonic XX/XY mosaicism. Reanalysis of 1219 abnormal cleavage-stage research embryos revealed a 73% incidence of minor and major mosaicism. Only four (0.3%) embryos were found to be diploid and contained XX and XY cells that could potentially account for the misdiagnosis of sex. Our investigation identified errors leading to misdiagnosis and their attribution to specific events during PGD-A testing. The reported misdiagnosis rates suggest that PGD-A for sex determination is highly accurate, particularly when using aCGH applied to blastocyst biopsies.

Prognosis of status epilepticus (SE): Relationship between SE duration and subsequent development of epilepsy

In animal models, SE duration is related to epileptogenesis. Data in humans are scarce, mainly in NCSE; therefore, we aimed to study the prognosis of SE de novo and which factors may influence subsequent development of epilepsy.

METHODS

We evaluated patients with SE without previous epilepsy at our hospital (February 2011-February 2014), including demographics, etiology, number of AEDs, duration of SE, mortality, and occurrence of seizures during follow-up.

RESULTS

Eighty-nine patients were evaluated. Median age was 69 (19-95) years old. Among them, 33.7% were convulsive. Regarding etiology, 59 were considered acute symptomatic (41 lesions, 18 toxic-metabolic), 17 remote or progressive symptomatic, and 13 cryptogenic. The median recovery time was 24h (30 min-360 h). In-hospital mortality was 29% (n = 26). After a median follow-up of 10 months, 58.7% of survivors (n = 37) showed seizures. Subsequently, we analyzed which factors might be related to the development of epilepsy, and we found that epilepsy development was more frequent with longer SE duration (37 vs. 23 h, p = 0.004); furthermore, patients with a toxic-metabolic etiology developed epilepsy less frequently (33% vs. 67%; p = 0.022). Epilepsy was also correlated (tendency) with focal SE (p = 0.073), a lesion in neuroimaging (p = 0.091), and the use of 2 or more AEDs (p = 0.098). Regarding SE duration, a cutoff of above 24h was clearly related to chronic seizures (p = 0.014); however, combining etiology and duration, the association of longer SE and epilepsy was significant in acute lesional SE (p = 0.034), but not in epilepsy with cryptogenic or remote/progressive etiology. After a logistic regression, only a duration longer than 24h (OR = 3.800 (1.277-11.312), p = 0.016) was found to be an independent predictor of the development of epilepsy.

CONCLUSION

In patients with SE, the longer duration is associated with an increased risk of subsequent epilepsy at follow-up, mainly in symptomatic SE due to an acute lesion. It is unclear if it might be the result of a more severe injury causing both prolonged seizures and subsequent epilepsy, and therefore whether more aggressive treatment in this group might avoid this possibility. Most of the patients with cryptogenic or remote/progressive SE developed epilepsy regardless of SE duration. This article is part of a Special Issue entitled "Status Epilepticus".

Chromosome constitution of human embryos generated after in vitro maturation including 3-isobutyl-1-methylxanthine in the oocyte collection medium

STUDY QUESTION

Do cleavage-stage embryos obtained from oocytes matured in vitro after pre-incubation with a phosphodiesterase inhibitor (IBMX) carry more chromosomal abnormalities than those generated from oocytes matured in vivo?

SUMMARY ANSWER

The rate and type of chromosomal abnormalities in normally developing cleavage-stage embryos generated with an in vitro maturation (IVM) system including pre-incubation with IBMX are not different from those observed in supernumerary embryos obtained from oocytes matured in vivo.

WHAT IS KNOWN ALREADY

Very limited information is available about the chromosomal constitution of IVM embryos. Previous studies were carried out using FISH on single biopsied blastomeres or arrested whole embryos and only provided fragmentary information on chromosomal abnormalities in IVM embryos. There is no systematic study of chromosomal abnormalities in all blastomeres of human Day 3 embryos with good morphology.

STUDY DESIGN, SIZE, DURATION

Between July 2012 and December 2012, 16 young (age <35 years old) egg donors underwent 18 IVM cycles for the generation of research embryos. Eighteen embryos developed to Day 3 and were analysed using array comparative genomic hybridization (aCGH).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Immature oocytes were retrieved from 2 to 10 mm follicles after mild ovarian stimulation with gonadotrophins but without hCG ovulation trigger. At collection, oocytes were pre-incubated with 3-isobutyl-1-methylxanthine (IBMX), a phosphodiesterase inhibitor and matured in vitro. After IVM culture, mature oocytes were microinjected with sperm from a single donor. Embryos were cultured to Day 3 after ICSI and all blastomeres of 18 good-morphology embryos were collected individually for aCGH.

MAIN RESULTS AND THE ROLE OF CHANCE

Oocyte maturation rate in vitro was 50.2% (120/239). The mean fertilization rate was 68.3% (82/120) and 30.5% (25/82) of fertilized oocytes developed into a morphologically good quality embryo on Day 3 after ICSI. Of these, 18 embryos that developed well up to Day 3 were analysed using aCGH. Eighty of the 123 blastomeres analysed showed at least one chromosomal abnormality. Three out of eighteen embryos had completely normal cells. A single embryo carried a meiotic abnormality, 11 embryos were mosaic and three were chaotic. Although the aneuploidy data of this study are too limited to allow statistical analysis, these data are comparable to our own published data on the chromosome constitution of whole day 3 and day 4 embryos after conventional ART.

LIMITATIONS, REASONS FOR CAUTION

Array CGH technology determines relative quantification of chromosomal domains but does not allow for the visualization of chromosomal rearrangements, assessment of ploidy or detection of uniparental isodisomy. Conclusions drawn on segmental abnormalities should be treated with caution. Although the limited number of embryos analysed here precludes firm conclusions, they provide valuable data on possible causes of the reduced potential of IVM embryos.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to describe the complete chromosome complement of all single blastomeres of good-morphology day 3 embryos obtained with IVM (including the presence of IBMX in a pre-incubation medium). The results demonstrate that a high proportion of good-morphology embryos are aneuploid and that there is no obvious increase in aneuploidies as a result of IVM which seems to suggest that the reduced efficiency of IVM technology compared with standard IVF may be accounted for by factors other than aneuploidy, such as cytoplasmic defects or reduced endometrial receptivity.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the TBM (Applied Biomedical Research with Societal Finality) programme of the IWT (Agency for Innovation through Science and Technology - Flanders, 110680) and by a Methusalem grant of the Vrije Universiteit Brussel. C.S. is a post-doctoral fellow of the Fund for Scientific Research Flanders (FWO - Vlaanderen). K.J. is a PhD student funded by the FWO. The University of Adelaide owns a patent family associated with IVM technologies that is licensed to Cook Medical. R.B.G. and J.G.T. are inventors. The remaining authors have no conflict of interest to declare.

Vitamin D deficiency and pregnancy rates in women undergoing single embryo, blastocyst stage, transfer (SET) for IVF/ICSI

STUDY QUESTION

What is the influence of vitamin D deficiency on pregnancy rates among women undergoing IVF/ICSI and Day 5 (blastocyst stage) single embryo transfer (SET)?

SUMMARY ANSWER

Vitamin D deficiency results in significantly lower pregnancy rates in women undergoing single blastocyst transfer.

WHAT IS KNOWN ALREADY

Preliminary experiments have identified the presence of vitamin D receptors in the female reproductive system. However, results regarding the effect of vitamin D deficiency on clinical outcomes are conflicting. None of the previous studies adopted a SET strategy.

STUDY DESIGN, SIZE, DURATION

Serum vitamin D concentration was measured retrospectively in patients who underwent SET on Day 5. Overall 368 consecutive infertile women treated within a period of 15 months were included in the study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients underwent ovarian stimulation for IVF/ICSI and Day 5 SET. Serum samples were obtained 7 days prior to embryo transfer and stored frozen at -20°C. Samples were collectively analyzed for their 25-OH vitamin D content. Vitamin D deficiency was defined as serum 25-OH vitamin D levels <20 ng/ml in accordance with the Institute of Medicine and the Endocrine Society clinical practice guidelines.

MAIN RESULTS AND THE ROLE OF CHANCE

Clinical pregnancy rates were significantly lower in women with vitamin D deficiency compared with those with higher vitamin D values (41 versus 54%, P = 0.015).Logistic regression analysis was performed to identify whether vitamin D deficiency is independently associated with clinical pregnancy rates after controlling for 16 potential confounding factors. According to our results vitamin D deficiency was independently associated with lower clinical pregnancy rates, odds ratios [ORs (95% confidence interval (CI) 0.61 (0.39-0.95)] for vitamin D deficiency (deficient versus non-deficient women), P = 0.030. Finally, even when restricting our analysis to women undergoing elective SET (274 patients), vitamin D deficiency was again independently associated with pregnancy rates [OR (95% CI) 0.56 (0.33-0.93), P = 0.024].

LIMITATIONS, REASONS FOR CAUTION

Our results refer only to patients undergoing Day 5 SET. Although vitamin D deficiency appears to compromise pregnancy rates in this population, no guidance can be provided regarding a potential relationship between vitamin D deficiency and ovarian reserve or response to ovarian stimulation.

WIDER IMPLICATIONS OF THE FINDINGS

Vitamin D deficiency impairs pregnancy rates in women undergoing single blastocyst transfer. Future prospective confirmatory studies are needed to validate our results and examine the exact underlying mechanism by which vitamin D levels may impair pregnancy rates in infertile women undergoing IVF/ICSI.

STUDY FUNDING/COMPETING INTERESTS

None declared.

The effect of ovarian puncture on the endocrine profile of PCOS patients who undergo IVM

BACKGROUND

To examine whether ovarian puncture for immature oocyte retrieval and in-vitro maturation (IVM) has an effect on the endocrine profile of patients with polycystic ovary syndrome (PCOS).

METHODS

Twenty-two consecutive patients with PCOS undergoing IVM treatment were included. Serum anti-Müllerian hormone (AMH), sex hormone-binding globulin (SHBG), total testosterone (TT) and luteinized hormone (LH) levels were analyzed at the start of the cycle, on the day of immature oocyte retrieval (OR) and at fixed intervals thereafter, for up to three months after OR.

RESULTS

Five days after OR circulating AMH, TT, calculated free testosterone (FTc), and LH levels were significantly reduced and circulating SHBG was significantly increased. Two weeks after OR, TT, FTc and LH remained reduced, whereas circulating AMH and SHBG levels recovered to pre-puncture values. Three months after OR, all circulating hormone levels had recovered to baseline values.

CONCLUSION

Ovarian puncture for the retrieval of immature oocytes and IVM in patients with PCOS has a significant impact on the ovarian endocrine profile, but this impact is brief and transient.

Predictors of ovarian response in women treated with corifollitropin alfa for in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

To identify predictors of ovarian response in women undergoing ovarian stimulation with corifollitropin alfa in a GnRH antagonist protocol and determine specific thresholds for the prediction of low and excessive responders.

DESIGN

Retrospective cohort study.

SETTING

University-based tertiary care center.

PATIENT(S)

Infertile women undergoing ovarian stimulation for in vitro fertilization/intracytoplasmic sperm injection.

INTERVENTION(S)

Controlled ovarian hyperstimulation with corifollitropin alfa in a GnRH antagonist protocol.

MAIN OUTCOME MEASURE(S)

Relationship between ovarian reserve tests and ovarian response.

RESULT(S)

Antimüllerian hormone (AMH) and antral follicle count (AFC) were the only independent predictors for low and excessive ovarian response. In prediction of excessive response, the area under the receiver operating characteristic curve [AUC (95% CI)] for AMH was 0.890 (0.832-0.947) and 0.897 (0.829-0.964) for AFC. The optimal thresholds for identifying excessive responders were 3.52 ng/mL for AMH (sensitivity 89.5, specificity 83.8) and 16 for AFC (sensitivity 80.0, specificity 84.5). AMH and AFC also predicted low ovarian response: AUCs AMH 0.836 (0.783-0.889) and AFC 0.830 (0.767-0.894). The optimal thresholds for predicting low response were 1.37 ng/mL for AMH (sensitivity 74.1, specificity 77.5) and 8 for AFC (sensitivity 72.2, specificity 84.6). For both excessive and low ovarian responses, a logistic regression model combining the biomarkers was associated with improved discrimination.

CONCLUSION(S)

AMH and AFC are the best predictors for low and excessive response in women treated with corifollitropin alfa in an antagonist protocol. Using AMH and AFC to select suitable candidates for treatment with corifollitropin alfa may result in a safe and convenient stimulation.