Infection precautions for severe acute respiratory syndrome coronavirus 2 in assisted reproduction centers: dodging an invisible bullet.

The coronavirus disease 2019 pandemic has resulted in many changes in how we interact in society, requiring that we protect ourselves and others from an invisible, airborne enemy called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Until a vaccine is developed, and it reaches high levels of distribution, everyone must continue to be diligent to limit the viral spread. The practice of assisted reproduction during this pandemic presents unique challenges in addition to the risks identified in general clinical care. The established good tissue practices employed in laboratories are not designed to protect gametes and embryos from an airborne virus, particularly one that may be shed by an asymptomatic staff member. Armed with theoretical risks but lacking direct evidence, assisted-reproduction teams must examine every aspect of their practice, identify areas at a risk of exposure to SARS-CoV-2, and develop a mitigation plan. Several professional fertility societies have created guidelines for the best practices in patient care during the coronavirus disease 2019 pandemic. As we learn more about SARS-CoV-2, updates have been issued to help adapt infection-control and -prevention protocols. This review discusses what is currently known about SARS-CoV-2 infection risks in assisted reproductive centers and recommends the implementation of specific mitigation strategies.

Successful treatment algorithm for evaluation of early pregnancy after in vitro fertilization.

OBJECTIVE: To evaluate a prospectively implemented clinical algorithm for early identification of ectopic pregnancy (EP) and heterotopic pregnancy (HP) after assisted reproductive technology (ART). DESIGN: Analysis of prospectively collected data. SETTING: Academic medical center. PATIENT(S): All ART-conceived pregnancies between January 1995 and June 2013. INTERVENTION(S): Early pregnancy monitoring via clinical algorithm with all pregnancies screened using human chorionic gonadotropin (hCG) levels and reported symptoms, with subsequent early ultrasound evaluation if hCG levels were abnormal or if the patient reported pain or vaginal bleeding. MAIN OUTCOME MEASURE(S): Algorithmic efficiency for diagnosis of EP and HP and their subsequent clinical outcomes using a binary forward stepwise logistic regression model built to determine predictors of early pregnancy failure. RESULT(S): Of the 3,904 pregnancies included, the incidence of EP and HP was 0.77% and 0.46%, respectively. The algorithm selected 96.7% and 83.3% of pregnancies diagnosed with EP and HP, respectively, for early ultrasound evaluation, leading to earlier treatment and resolution. Logistic regression revealed that first hCG, second hCG, hCG slope, age, pain, and vaginal bleeding were all independent predictors of early pregnancy failure after ART. CONCLUSION(S): Our clinical algorithm for early pregnancy evaluation after ART is effective for identification and prompt intervention of EP and HP without significant over- or misdiagnosis, and avoids the potential catastrophic morbidity associated with delayed diagnosis.

Human embryo cryopreservation-methods, timing, and other considerations for optimizing an embryo cryopreservation program.

The contribution of embryo cryopreservation to the birth rate per in vitro fertilization cycle has escalated from a rare subsidy to a vital tool that is called upon to augment the cycle outcome. Embryology laboratories must identify the embryo stage, quality criteria and methodology that will optimize their ability to preserve each embryo's reproductive potential. This chapter reviews the principles of cryopreservation, outcomes based on embryo stage and cryopreservation method and benchmarks that may be employed by the laboratory to measure the performance of their embryo cryopreservation program.

Human embryos secrete microRNAs into culture media--a potential biomarker for implantation.

OBJECTIVE: To determine whether human blastocysts secrete microRNA (miRNAs) into culture media and whether these reflect embryonic ploidy status and can predict in vitro fertilization (IVF) outcomes. DESIGN: Experimental study of human embryos and IVF culture media. SETTING: Academic IVF program. PATIENT(S): 91 donated, cryopreserved embryos that developed into 28 tested blastocysts, from 13 couples who had previously completed IVF cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Relative miRNA expression in IVF culture media. RESULT(S): Blastocysts were assessed by chromosomal comparative genomic hybridization analysis, and the culture media from 55 single-embryo transfer cycles was tested for miRNA expression using an array-based quantitative real-time polymerase chain reaction analysis. The expression of the identified miRNA was correlated with pregnancy outcomes. Ten miRNA were identified in the culture media; two were specific to spent media (miR-191 and miR-372), and one was only present in media before the embryos had been cultured (miR-645). MicroRNA-191 was more highly concentrated in media from aneuploid embryos, and miR-191, miR-372, and miR-645 were more highly concentrated in media from failed IVF/non-intracytoplasmic sperm injection cycles. Additionally, miRNA were found to be more highly concentrated in ICSI and day-5 media samples when compared with regularly inseminated and day-4 samples, respectively. CONCLUSION(S): MicroRNA can be detected in IVF culture media. Some of these miRNA are differentially expressed according to the fertilization method, chromosomal status, and pregnancy outcome, which makes them potential biomarkers for predicting IVF success.

Change in oocyte yield in repeated in vitro fertilization cycles: effect of ovarian reserve.

OBJECTIVE: To examine factors that affect variability in oocyte yield between consecutive IVF cycles. DESIGN: Retrospective cohort study. SETTING: University-based fertility clinic. PATIENT(S): A total of 292 women starting two IVF cycles within 12 months from 2005 to 2011. INTERVENTION(S): Variables evaluated included female age, body mass index, parity, infertility diagnosis, antral follicle count (AFC), ovarian stimulation protocol, change in stimulation protocol, total dose of gonadotropin used and change in dose between cycles. Possible associations were tested using a log linear regression model. MAIN OUTCOME MEASURE(S): Change in total and mature oocyte yield between cycles and factors that predict this change. RESULT(S): In cycle 1, total and mature oocyte yield were positively associated with increased AFC and negatively associated with total gonadotropin dose. In cycle 2, a significant increase was seen in both total and mature oocytes. There were no significant independent variables that predicted this change in oocyte yield. When stratified into groups based on ovarian reserve, change in oocyte yield between cycles was significant only in patients with normal ovarian reserve (AFC >10). In this group, the only independent variable associated with an increased oocyte yield was an increase in the total gonadotropin dose. CONCLUSION(S): An increase in oocyte yield between cycles was found in women with normal ovarian reserve and was associated with an increased total gonadotropin dose in the second cycle.

MicroRNA expression in the human blastocyst.

OBJECTIVE: To determine the most highly expressed microRNAs (miRNAs) in human blastocysts and to compare miRNAs in euploid versus aneuploid embryos and in male versus female embryos. DESIGN: Experimental study of human embryos: 14 blastocysts (four male, five female, and five aneuploid) were evaluated for miRNA expression with the use of an array-based quantitative real-time polymerase chain reaction (qPCR). Highly expressed and differentially expressed miRNAs were confirmed with the use of qPCR in an expanded set of 27 blastocysts (seven male, eleven female, and nine aneuploid). SETTING: Academic IVF program. PATIENT(S): Thirteen couples donated 91 cryopreserved embryos for this study. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Relative miRNA expression in individual blastocysts. RESULT(S): The most highly expressed miRNA in euploid embryos was miR-372. Many of the highly expressed miRNAs have been shown to be critical to mammalian embryo development and to maintenance of stem cell pluripotency. Several differentially expressed miRNAs were discovered based on chromosomal makeup, including sex of the embryo. CONCLUSION(S): Human blastocysts express miRNAs, which may be important to their survival. Differential miRNA expression based on sex implies some degree of differentiation at the blastocyst stage of development. Differential miRNA expression between euploid and aneuploid embryos may be an early indicator of their prognosis or a mechanism behind their eventual fate.

Clinical factors associated with live birth after single embryo transfer.

OBJECTIVE: To identify patient, cycle, and retrieval characteristics associated with embryo implantation and live birth in patients undergoing single embryo transfer (SET). DESIGN: Analysis of prospectively collected IVF database. SETTING: Academic IVF program. PATIENT(S): All patient cycles meeting criteria for SET between June 2004 and September 2010. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical pregnancy and live birth. RESULT(S): Single embryo transfer was performed in 438 cycles, resulting in a clinical pregnancy rate of 76.2% and a live birth rate of 66.8% per transfer. Clinical pregnancy was associated with younger female age, ≥ 58% mature (metaphase II) oocytes at the time of retrieval, and increasing blastocyst expansion. Ongoing pregnancy was associated with younger female age and more advanced blastocysts. A diagnosis of uterine factor was negatively associated with live birth. CONCLUSION(S): Even in a favorable prognosis population, younger female age is associated with clinical pregnancy and live birth. Although all patients underwent blastocyst transfer, expanded and hatching blastocysts were strongly associated with pregnancy and live birth. A diagnosis of uterine factor was the only infertility diagnosis found to affect live birth after SET. Obesity did not negatively affect SET outcome. These findings may assist physicians in determining the best candidates for SET.

In vitro fertilization patients support a single blastocyst transfer policy.

OBJECTIVE: To determine whether patients support a mandatory single blastocyst transfer (mSBT) policy in IVF. DESIGN: Prospective survey study. SETTING: Academic hospital-based infertility center. PATIENT(S): Two hundred sixty-two female patients presenting for fresh or cryopreserved/thawed ET after IVF. INTERVENTION(S): Internet-based in-clinic survey after ET. Follow-up at-home survey after pregnancy test results. MAIN OUTCOME MEASURE(S): Patient support for an mSBT policy and attitudes regarding patient input into IVF treatment. Logistic regression analyses tested associations among main outcome measures, patient characteristics, and treatment results. RESULT(S): Ninety-four percent of patients endorsed support for our mSBT policy; 95% and 87% felt they had the right amount of input in their IVF treatment and number of embryos transferred, respectively, and these subjects were more likely to support the mSBT policy. Other factors associated with stronger support were concern for multiples, availability of extra cryopreserved embryos, and shorter duration of infertility. Receiving a single blastocyst during treatment did not change the level of support. A negative pregnancy outcome decreased support, however. CONCLUSION(S): Policies restricting the number of embryos transferred may find wide patient acceptance.

Identification of apolipoprotein A1 in the human embryonic secretome.

OBJECTIVE: To identify factors secreted by the human embryo and correlate levels with embryo morphology and pregnancy outcome. DESIGN: A laboratory-based study of human embryo protein synthesis and secretion and a retrospective analysis of spent embryo culture media as it relates to pregnancy outcome. SETTING: University-based academic IVF program. PATIENT(S): IVF patients who had donated cryopreserved human pronuclear-stage embryos. Patients undergoing fresh IVF cycles resulting in a blastocyst transfer who donated spent media drops. INTERVENTION(S): In vitro embryo culture and collection of spent media. MAIN OUTCOME MEASURE(S): Protein analysis and identification by two-dimensional gel electrophoresis and mass spectrometry, ApoA1 quantification by ELISA, and mRNA analysis by quantitative reverse transcriptase-polymerase chain reaction. RESULT(S): By protein gel electrophoresis, apolipoprotein A1 (ApoA1) was increased in the culture media from good-quality blastocysts (n = 6 embryos) compared to either cleavage-arrested embryos (n = 6 embryos) or poor-quality blastocysts (n = 6 embryos) using spent media from culture days 4 and 5, respectively. Apolipoprotein A1 concentrations were 23.1% greater in day 5 spent culture media from good-grade blastocysts (n = 30) when compared to poor-grade embryos (n = 30). However, in a group of patients (n = 20) with transfer of two good-quality blastocysts, ApoA1 levels from day 5 spent media did not correlate with embryo implantation and pregnancy. Quantitative reverse transcriptase-polymerase chain reaction confirmed the presence of ApoA1 mRNA transcripts in human blastocysts. CONCLUSION(S): Apolipoprotein A1 is produced by human preimplantation embryos, and increased levels are present in spent culture media containing blastocysts of higher morphologic grade. These results suggest a role for lipoproteins in early embryologic development.

Skewed X inactivation and IVF-conceived infants.

The objective of this study was to investigate whether skewed X chromosome inactivation (XCI) is associated with IVF. A retrospective cohort study was performed comprising 30 female infants conceived by IVF and 44 naturally conceived control infants matched for gestational age and sex. Cord blood DNA samples were obtained and XCI patterns were analysed using a methylation-sensitive assay. Eight IVF samples and 13 control samples were excluded from the study because they were either homozygous or alleles were too similar for the assay to determine skewing. Mildly skewed XCI (80-90% inactivation of one allele) was present in two of 22 (9.1%) IVF samples and two of 31 (6.5%) control samples. Extremely skewed XCI (>90% inactivation of one allele) was found in two of 22 (9.1%) IVF samples and none of 31 control samples. Neither difference was statistically significant. However, the mean degree of skewed XCI in the IVF group was 72.0% and in the control group was 62.4% (P=0.002). Larger studies are needed to clarify the relationship between IVF and skewed XCI.

A mandatory single blastocyst transfer policy with educational campaign in a United States IVF program reduces multiple gestation rates without sacrificing pregnancy rates.

OBJECTIVE: To reduce the twin rate in our IVF program. DESIGN: A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING: University-based infertility center. PATIENT(S): One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S): A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S): Knowledge of twin risks and desired number of embryos transferred before and after education. Pregnancy rates, number of embryos transferred, and multiple-gestation rates before and after mSBT policy. RESULT(S): After education, knowledge of twin risks improved and a significant number of subjects changed their desired outcome to a lower gestational number. There was no change in ongoing pregnancy rates with blastocyst transfer before and after mSBT (63% vs. 58%; NS). Program-wide number of embryos transferred (2.1 +/- 0.6 vs. 1.9 +/- 0.7) and multiple-gestation rates (35% vs. 19%) decreased significantly while pregnancy rates were maintained. CONCLUSION(S): Simple educational materials can improve knowledge of twin pregnancy risks and affect decision making. In high-risk patients, mSBT results in pregnancy rates similar to two-blastocyst transfer, with decreased twin rates.

Supernumerary minute ring chromosome 14 in a man with primary infertility and left varicocele.

OBJECTIVE: To describe a case of supernumerary minute ring chromosome (SMRC) in an infertile man, with the concurrent finding of a left varicocele. DESIGN: Case report. SETTING: Urologic infertility clinic in a university hospital. PATIENT(S): Male patient presenting with primary infertility. INTERVENTION(S): Karyotyping, genetic counseling, and microsurgical left varicocelectomy. MAIN OUTCOME MEASURE(S): Sperm concentration and motility, chromosomal number and structure. RESULT(S): Fluorescence in situ hybridization revealing SMRC 14. Sperm concentration and motility improved after left varicocele repair. CONCLUSION(S): A karyotype should be included in the evaluation of severe oligospermia. Although SMRC 14 may be associated with fertility problems, repair of a coexisting varicocele should be considered in these patients.

In vitro fertilization is associated with an increase in major birth defects.

OBJECTIVE: To determine the risk of major birth defects in cohorts of children conceived through IVF or through IUI as compared with naturally conceived children. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): Children conceived by IVF or IUI at the University of Iowa from 1989 through 2002, compared with a matched cohort of naturally conceived children. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Outcome data were obtained from Iowa state birth and fetal death certificates and from the Iowa Birth Defects Registry. RESULT(S): Ninety of 1,462 IVF-conceived children (6.2%) and 17 of 343 IUI-conceived children (5.0%) had a major birth defect, compared with 369 of 8,422 naturally conceived children (4.4%). The adjusted odds ratio of a major birth defect in all IVF-conceived children was 1.30 (95% confidence interval [CI] 1.00-1.67) and 1.11 (95% CI 0.67-1.84) for IUI-conceived children. The birth defect rate was increased after IVF when the analysis was limited to term singletons. Cardiovascular and musculoskeletal defects and known birth defect syndromes were increased after IVF. Among IVF-conceived children, there was no difference in birth defect rates after intracytoplasmic sperm injection (ICSI) or after transfer of cryopreserved embryos. CONCLUSION(S): Infants conceived through IVF have a slightly higher rate of major birth defects. More birth defects are noted among children born to infertile couples treated with IUI, although this difference is not statistically significant. Larger studies of infants conceived by infertile couples after all types of infertility treatment are needed to definitively determine whether the increased risk of birth defects is secondary to problems inherent in the infertile couple and/or factors associated with some aspect of the treatment.

Computational models for prediction of IVF/ICSI outcomes with surgically retrieved spermatozoa.

IVF/intracytoplasmic sperm injection (ICSI) using surgically retrieved spermatozoa (SRS) is a key option in the treatment of severe male infertility. It was aimed to develop a computational model for the prediction of this modality's outcome. A dataset of 113 exemplars, derived from patients who underwent IVF/ICSI with SRS, was retrospectively analysed. The dataset, containing input features maternal age, sperm retrieval technique, type of spermatozoa used, type of male factor and output intrauterine pregnancy, was randomized into a modelling ('training') set of 83 and cross-validation ('test') set of 30. neUROn++, a set of C++ programs, was used to model the dataset using linear and quadratic discriminant function analysis, logistic regression, and neural computation. A 4-hidden node neural network was found to have the highest accuracy, with a test set receiver operator characteristic (ROC) curve area of 0.783. Reverse regression of this neural network showed maternal age to be the most significant feature in predicting pregnancy (P = 0.025), followed by sperm type (P = 0.076). Type of male factor (P = 0.47) and sperm retrieval technique (P = 0.88) did not predict outcome. In summary, a neural network of clinical relevance was found to be superior in terms of IVF/ICSI outcome prediction. Future media deployment is planned.

Hyperbaric oxygen and ovarian follicular stimulation for in vitro fertilization: a pilot study.

Our objective was to assess the safety and tolerability of hyperbaric oxygen therapy (HBO) as an adjunct to IVF therapy in women with a poor prognosis for pregnancy in a prospective observational pilot study. We conclude that HBO is well tolerated by women undergoing IVF treatment and that further study is required to determine whether this is an efficacious adjuvant therapy for women being treated by IVF.

Oral ovulation induction agents combined with low-dose gonadotropin injections and intrauterine insemination: cost- and clinical effectiveness.

OBJECTIVE: To compare the efficacy and cost-effectiveness of different induction protocols involving gonadotropins with intrauterine insemination (IUI). STUDY DESIGN: We performed a retrospective chart review of 648 IUI cycles. Some patients had gonadotropin injections alone before human chorionic gonadotropin (hCG) and IUI (human menopausal gonadotropin protocol); others were given oral medications, then gonadotropins before hCG and IUI (combination protocol). Outcomes included pregnancy rates, multiple birth rates, endometrial thickness, number of ovarian follicles, injection days, ampules of gonadotropins and cost. RESULTS: The combination protocol was more cost-effective. In first cycles, pregnancy rates, multiple birth rates, number of large follicles produced and cancellation rates were similar. The combination group had fewer days of injections and fewer ampules used. When all cycles were analyzed, the multiple birth rate was lower in the combination group. Comparing the different oral medications in the combination protocols, letrozole yielded higher pregnancy rates than tamoxifen or clomiphene. Multiple birth rates were similar for all oral medications. CONCLUSION: Combination protocols are less costly and equally effective, with potentially fewer multiple births than with gonadotropins alone. Letrozole may be more effective than clomiphene and tamoxifen in a combination protocol.