Sperm DNA fragmentation on the day of fertilization is not associated with embryologic or clinical outcomes after IVF/ICSI.

PURPOSE: To evaluate if sperm DNA fragmentation (SDF) in the sample used for intracytoplasmic sperm injection (ICSI) impacts outcomes after euploid blastocyst transfer. METHODS: Prospective cohort study of couples undergoing IVF with preimplantation genetic testing for aneuploidy from December 2014-June 2017. Sperm collected on the day of ICSI was analyzed for SDF using the sperm chromatin structure assay (SCSA®). Semen analysis parameters, embryologic outcomes, and clinical outcomes after euploid blastocyst transfer were compared between groups with DNA fragmentation index (DFI) ≤ 15% and DFI > 15% using Mann-Whitney U, t tests, and generalized linear mixed effects models. RESULTS: Two hundred thirty-four patients were included. One hundred seventy-nine men had DFI ≤ 15% (low DFI group) and 55 men had DFI > 15% group (high DFI group). Total motile sperm and sperm concentration were significantly lower in the group with DFI > 15% vs. DFI ≤ 15%. There was no difference in fertilization (86.3 vs. 84.2%, adjusted OR (95% CI) 0.86 (0.63-1.18)), blastulation (49.5 vs. 48.8%, adjusted OR 1.02 (0.75-1.36)), or euploidy (55.7 vs. 52.1%, adjusted OR 0.96 (0.7-1.31)) between the low and high DFI groups, respectively. Clinical outcomes were similar between low and high DFI groups, including implantation rate (68.8 vs. 79.8%), ongoing pregnancy rate (65.9 vs. 72.6%), and miscarriage rate (4.2 vs. 8.8%), respectively. CONCLUSION: Sperm DNA fragmentation on the day of ICSI is not associated with embryologic or clinical outcomes after euploid blastocyst transfer. Increasing levels of SDF are associated with low sperm concentration and total motile sperm count.

Three-dimensional ultrasound diagnosis of T-shaped uterus is associated with adverse pregnancy outcomes after embryo transfer.

RESEARCH QUESTION: Is T-shaped uterine cavity morphology associated with adverse pregnancy outcomes after transfer of a single thawed euploid blastocyst? DESIGN: In this secondary analysis of a prospective cohort study, 648 patients with three-dimensional ultrasound (3D-US) data obtained on the day before embryo transfer were categorized into three groups according to uterine cavity morphology: normal (n = 472), intermediate (n = 166) and T-shaped (n = 10). Quantitative uterine cavity dimensions were used to evaluate uterine cavity morphology. Pregnancy outcomes, including live birth, clinical miscarriage and ectopic pregnancy, were compared among the groups. RESULTS: The prevalence of a T-shaped uterus in this cohort was 1.5%. Uterine cavity morphology was strongly associated with the ratio of interostial distance and isthmic diameter (P < 0.01). Live birth rates were 66.5% for normal, 65.7% for intermediate and 40.0% for T-shaped cavity morphology. Women with a T-shaped uterus had an increased risk of clinical miscarriage (40.0% versus 7.0% for normal and 9.0% for intermediate cavity morphology, P < 0.01) and ectopic pregnancy (10.0% versus 1.1% for normal and 1.9% for intermediate cavity morphology, P = 0.05). When evaluating interostial distance and isthmic diameter ratio to determine pregnancy outcomes, a cut-off value of 2 was noted to have weak predictive value for live birth, but not clinical miscarriage or ectopic pregnancy. CONCLUSIONS: T-shaped uterine cavity morphology is associated with adverse pregnancy outcomes after transfer of a single thawed euploid blastocyst. Given the low prevalence of this condition, quantifying the magnitude of risk will require a larger cohort of patients.

Expanded carrier screening in an infertile population: how often is clinical decision making affected?

PURPOSE: Options for preconception genetic screening have grown dramatically. Expanded carrier screening (ECS) now allows for determining carrier status for hundreds of genetic mutations by using a single sample, and some recommend ECS prior to in vitro fertilization. This study seeks to evaluate how often ECS alters clinical management when patients present for infertility care. METHODS: All patients tested with ECS at a single infertility care center from 2011 to 2014 were evaluated. The overall rate of positive ECS results and the number of couples who were carriers of the same genetic disorder were evaluated. RESULTS: A total of 6,643 individuals were tested, representing 3,738 couples; 1,666 (25.1%) of the individuals had a positive test result for at least one disorder. In 8 of the 3,738 couples, both members of the couple were positive for the same genetic disorder or had a test result that placed them at risk of having an affected child. Three of eight cases were cystic fibrosis. In this cohort, ECS affected clinical care eight times after 6,643 tests (0.12%, confidence interval: 0.05-0.24%) in 3,738 couples (0.21%, confidence interval: 0.09-0.42%). CONCLUSIONS: ECS is becoming more widespread. In a large case series, ECS affected clinical decision making for patients presenting for infertility care in 0.21% of cases. This information must be weighed when utilizing these tests and may be a helpful part of patient counseling.Genet Med 18 11, 1097-1101.

FMR1 gene CGG repeat variation within the normal range is not predictive of ovarian response in IVF cycles.

The relationship between FMR1 CGG premutation status and decreased ovarian responsiveness is well established. The association between FMR1 CGG repeat number in the currently defined normal range (less than 45 repeats) and ovarian reserve, however, is controversial. This retrospective study examined whether variation in CGG repeat number in the normal range was associated with markers of ovarian response in IVF cycles. The first IVF cycle of 3006 patients with FMR1 CGG repeat analysis was examined. Only patients carrying two alleles with less than 45 CGG repeats were included for analysis. The CGG repeat number furthest from the modal peak was plotted against number of mature oocytes retrieved and no correlation was identified. Patients were also separated into biallelic genotype groups, based on the recently proposed narrower "new normal" range of 26-34 CGG repeats. A linear regression showed that none of the biallelic genotype groups were associated with a decreased oocyte yield. The euploidy rates after comprehensive chromosomal screening were equivalent among the genotype groups. No difference was found in the rate of cycle cancellation for poor response. Despite increasing use, FMR1 CGG repeats in the normal range cannot be used as a predictor of ovarian response to gonadotrophin stimulation.

Vitamin D levels do not affect IVF outcomes following the transfer of euploid blastocysts.

OBJECTIVE: We sought to characterize the relationship between serum 25-hydroxy vitamin D (25-OH D) levels and implantation and clinical pregnancy rates in women who undergo a euploid blastocyst embryo transfer. STUDY DESIGN: This retrospective cohort study, conducted in an academic setting, included 529 cycles in which comprehensive chromosome screening was performed as part of routine infertility care with an autologous transfer of 1 or 2 euploid blastocysts. After excluding repeat cycles there were 517 unique cycles representing 517 women for evaluation. Vitamin D levels from serum samples obtained on the day of ovulation trigger in the fresh in vitro fertilization cycle were analyzed. The primary outcome was ongoing pregnancy rate as defined by sonographic presence of fetal heart rate at >8 weeks' gestation. RESULTS: For the population as a whole, serum vitamin D ranges and pregnancy outcomes did not correlate. Furthermore, pregnancy rates did not differ when comparing women in different strata of vitamin D levels (<20, 20-29.9, and ≥30 ng/mL). No meaningful breakpoint for vitamin D levels and ongoing pregnancy rate was identified using receiver operating characteristic analysis with the resultant line possessing an area under the curve of 0.502. Multivariate logistic regression controlling for age, transfer order, race, season, and body mass index did not yield a different result. The study was powered to detect an 18% difference in ongoing pregnancy rates between patients grouped by the 3 vitamin D ranges. CONCLUSION: In women undergoing euploid embryo transfer, vitamin D status was unrelated to pregnancy outcomes. Measuring serum 25-OH vitamin D levels does not predict the likelihood that euploid blastocysts will implant. These results may not apply to women who do not undergo extended embryo culture, blastocyst biopsy for comprehensive chromosome screening, and euploid embryo transfer.

24-chromosome PCR for aneuploidy screening.

PURPOSE OF REVIEW: The purpose of this study is to describe the many advantages of PCR-based comprehensive chromosome screening (CCS) methodologies and the importance of extensive preclinical validation. RECENT FINDINGS: The rigorous preclinical validation of quantitative real-time (q)PCR-based CCS involved an initial validation on cell lines, followed by a blinded evaluation on embryos. Comparison with alternative platforms and a prospective randomized clinical trial demonstrate superior precision and improved sustained implantation and delivery rates. Preclinical validation of targeted PCR-based next-generation sequencing (NGS) has also demonstrated consistency in positive controls, equivalent accuracy to commonly used techniques, high resolution, increased throughput, the simultaneous detection of single gene disorders and triploidy, and the potential to decrease costs. Prospective randomized controlled trials are ongoing to validate this technique for clinical use. SUMMARY: CCS using PCR-based methodology improves implantation and delivery rates and allows for fresh embryo transfers. Other platforms are available to select euploid embryos; however, there are meaningful differences between techniques. PCR-based NGS technology may further enhance the utility of CCS for patients with infertility.

Investigating the optimal preconception TSH range for patients undergoing IVF when controlling for embryo quality.

PURPOSE: The ideal thyroid-stimulating hormone (TSH) range for infertile women attempting conception has not been determined. Current recommendations include optimizing the preconception TSH value to ≤2.5 mIU/L, which is the established goal for pregnant women. The aim of this study was to determine if there is a distinct range of TSH ≤2.5 mIU/L for infertile women undergoing in vitro fertilization (IVF) that improves reproductive outcomes. METHODS: One thousand five hundred ninety-nine euploid blastocyst transfer cycles were evaluated in which TSH measurements were obtained 8 days after embryo transfer. Only euploid embryo transfers were included in an effort to control for embryo quality. Patients were separated into TSH groups utilizing 0.5 mIU/L increments. Implantation, live birth, and miscarriage rates among the TSH groups were compared. Outcomes for individuals on thyroid hormone supplementation and those not requiring supplementation were evaluated. RESULTS: There was no difference in implantation (p = 0.56), live birth (p = 0.36), or miscarriage rates (p = 0.10) between TSH groups. Receiver operating characteristic (ROC) curves for implantation, live birth, and miscarriage approached the line of no discrimination, signifying that there is no value of TSH within the recommended range for pregnancy (≤2.5 mIU/L) that predicts IVF outcomes better than other values in this range. Live birth rates for patients requiring thyroid hormone supplementation and those not on medication were similar (p = 0.86). CONCLUSIONS: The recommended TSH range for pregnancy (≤2.5 mIU/L) may be applied to infertile patients attempting conception without a need for further adjustment.

Endometrial disruption does not improve implantation in patients who have failed the transfer of euploid blastocysts.

PURPOSE: To assess the impact of single pass outpatient endometrial biopsy in patients at the highest risk for an endometrial cause for failed implantation; those that have failed to conceive despite the transfer of morphologically normal euploid embryos. METHODS: This is a retrospective cohort study consisting of all patients less than 42 years old who failed their first euploid blastocyst transfer and subsequently completed a second transfer cycle of euploid blastocysts. Cycles were analyzed to determine if a single pass endometrial biopsy, termed 'endometrial disruption', was performed in a cycle preceding their second embryo transfer. Transfer outcomes were analyzed and implantation rates calculated. Data analysis was performed to compare outcomes between patients who had endometrial disruption performed versus those that did not. RESULTS: Two hundred ninety patients failed their first euploid embryo transfer and subsequently completed a second euploid embryo transfer and were included. Thirty-nine patients underwent endometrial disruption and 251 did not. There were no statistical differences in clinical implantation rate or sustained implantation rate between the group with endometrial disruption and subjects without any intervention (Clinical IR, 43.6 % vs. 55.0 %, p = 0.13; 38.5 % vs. 42.6 %, p = 0.60). When controlling for transfer order there was no statistical difference noted in implantation rates. CONCLUSIONS: Single pass endometrial biopsy has no impact on endometrial receptivity in the highest risk subgroup- patient's that have failed to sustain the transfer of morphologically normal euploid embryos- as evidenced by equivalent implantation rates. It is possible that variations in technique may alter outcomes and randomized trials are needed to answer this question.

Aneuploidy across individual chromosomes at the embryonic level in trophectoderm biopsies: changes with patient age and chromosome structure.

PURPOSE: To characterize each chromosome's risk for being involved in embryonic aneuploidy. METHODS: This is a retrospective cohort study conducted at a single, academic center. The cohort consisted of 15,169 consecutive trophectoderm biopsies which then underwent comprehensive chromosome screening utilizing validated real-time polymerase chain reaction (RT-PCR) or single nucleotide polymosphism (SNP) array platforms. Analysis was done to determine probability of aneuploidy by chromosome, changes in that risk with increasing maternal age, and in relationship of aneuploidy to chromosomal structure as classified by prior cytogenetic literature. RESULTS: The highest prevalence of imbalances leading to aneuploidy was seen for chromosomes 13, 15, 16, 18, 19, 21, and 22. While elevated in all age groups, there was a disproportionate rise in aneuploidy rates for these chromosomes with increasing maternal age. When classic cytogenetic karyotype groups were compared, the overall smaller groups D, E, and G were associated with the highest rates. Similarly, when grouped based upon structure, acrocentric chromosomes exhibited the highest rates of aneuploidy, followed by the metacentric chromosomes, with the lowest prevalence of error in those with submetacentric structures. CONCLUSIONS: The highest rates of chromosomal aneuploidy were found in chromosomes known to be involved in clinically detectable, abnormal pregnancies, not just simply implantation failure. The rate of aneuploidy in these chromosomes rises disproportionately with age when compared to the other chromosomes which may provide information about chromosomal susceptibility to aging. The biological structure groupings did show varied aneuploidy rates which may provide insight into the biology of aneuploidy.

Embryology training for Reproductive Endocrine fellows in the clinical human embryology laboratory.

OBJECTIVE: To determine if comprehensive embryology training for clinical Reproductive Endocrinology fellows could be completed to a level of proficiency equivalent to that of experienced embryologists. METHOD: Clinical fellows were integrated into the clinical embryology team and were trained to perform all the various procedures utilized in clinical embryology. The fellows were trained to the same standards as the clinical embryology staff and underwent the same certification and sign off procedures. To determine if inclusion of clinical fellows on the embryology team impacted outcomes, outcomes for individual oocytes/embryos and the clinical cases where the fellows perform embryology procedures were compared to the outcomes of those oocytes/embryos and cases performed by the full time embryology staff. RESULTS: Clinical procedures performed by the fellows included isolation and processing of oocytes following retrieval, loading catheters for embryo transfer, and vitrification (N = 823 cases). Micromanipulation procedures compared included ICSI and assisted hatching (N = 650 cases). For each procedure, the outcomes in those cases performed by the RE fellows were equivalent to those done by the fully trained clinical embryology staff. CONCLUSIONS: When fellows are trained to perform embryology procedures as an integral part of their fellowship curricula, laboratory efficiencies and clinical outcomes are fully maintained. This experience provides valuable insight into the ART process critical to this subspecialty. It also empowers fellows to fully participate in research relating to the viability of gamete and embryos and optimization of the clinical ART laboratory.

The impact of contemporary preimplantation genetic screening and diagnosis on the detection of aneuploidy and inherited genetic diseases.

Pre-implantation genetic screening and diagnosis represent important tools for embryo selection in patients undergoing in vitro fertilization. Methods have evolved in recent years and it can be challenging to remain up to date on the current technology. This review article seeks to provide an overview of pre-implantation genetic screening and diagnosis methods, the associated clinical outcomes, and the limitations of this technology.

Preimplantation genetic testing for aneuploidy is cost-effective, shortens treatment time, and reduces the risk of failed embryo transfer and clinical miscarriage.

OBJECTIVE: To determine if preimplantation genetic testing for aneuploidy (PGT-A) is cost-effective for patients undergoing in vitro fertilization (IVF). DESIGN: Decision analytic model comparing costs and clinical outcomes of two strategies: IVF with and without PGT-A. SETTING: Genetics laboratory. PATIENTS: Women ≤ 42 years of age undergoing IVF. INTERVENTION(S): Decision analytic model applied to the above patient population utilizing a combination of actual clinical data and assumptions from the literature regarding the outcomes of IVF with and without PGT-A. MAIN OUTCOME MEASURE(S): The primary outcome was cumulative IVF-related costs to achieve a live birth or exhaust the embryo cohort from a single oocyte retrieval. The secondary outcomes were time from retrieval to the embryo transfer resulting in live birth or completion of treatment, cumulative live birth rate, failed embryo transfers, and clinical losses. RESULTS: 8,998 patients from 74 IVF centers were included. For patients with greater than one embryo, the cost differential favored the use of PGT-A, ranging from $931-2411 and depending upon number of embryos screened. As expected, the cumulative live birth rate was equivalent for both groups once all embryos were exhausted. However, PGT-A reduced time in treatment by up to four months. In addition, patients undergoing PGT-A experienced fewer failed embryo transfers and clinical miscarriages. CONCLUSION: For patients with > 1 embryo, IVF with PGT-A reduces healthcare costs, shortens treatment time, and reduces the risk of failed embryo transfer and clinical miscarriage when compared to IVF alone.

Investigating the impact of the timing of blastulation on implantation: management of embryo-endometrial synchrony improves outcomes.

STUDY QUESTION: Do embryos with delayed blastulation have inferior reproductive potential or poorer outcomes due in part to embryo and endometrial synchrony? SUMMARY ANSWER: Diminished outcomes in embryos with delayed blastulation undergoing fresh embryo transfer (ET) may be attributed to a loss of embryonic-endometrial synchrony. WHAT IS KNOWN ALREADY: Embryos that blastulate slowly have lower sustained implantation rates (SIR) than those which blastulate normally on Day 5 (D5). Traditionally this has been attributed to reduced embryo quality; however, dyssynchrony with the endometrium is also a possibility and has not been fully described. This convenient cohort composed of groups that resulted from a practice wide change in laboratory protocol allows for evaluation of embryo and endometrial synchrony as it related to blastocyst expansion. STUDY DESIGN SIZE DURATION: A retrospective cohort analysis was carried out from January 2009 to February 2013. Three cohorts were identified: D5 ET, D6 ET and frozen ET that comprised 822 patients, 763 patients and 718 patients, respectively. Each of these cohorts had slowly blastulating and normally blastulating embryos identified. PARTICIPANTS/MATERIALS SETTING METHODS: The study setting was academic affiliated private practice. All first fresh or cryopreserved ETs from 2010 to 2013 were studied. Non-biopsied embryos were classified into two groups on D5: slowly blastulating (Morula-Gardner 1) or normally blastulating (Gardner 2-6). Only single ETs or transfer of two embryos within the same classification group were included. Outcomes were compared between classification groups in embryos undergoing transfer on D5, D6, or after cryopreservation. This assesses the impact of transfer timing in fresh cycles as well as isolating a pure embryonic factor in frozen ET cycles. Sustained implantation was defined as heart beat detection at discharge sonogram at 8 weeks gestation. SIR was defined as the number of embryos transferred meeting criteria for sustained implantation divided by the total number of embryos transferred. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 3391 embryos were transferred to 1966 patients. On D5, SIRs were significantly lower with slowly blastulating embryos (44% versus 64% in women <35 years of age ( P < 0.001) and 18% versus 56% in women ≥35 years of age ( P < 0.001)). Fresh D6 ETs also had significantly lower SIRs for embryos that were slowly blastulating on D5 (52% versus 63% in <35 years of age (P < 0.05) and 32% versus 48% in ≥35 years of age (P < 0.005)) despite continued development to full blastocysts and being morphologically equivalent at the time of ET, suggesting dyssynchrony. However, when slowly blastulating embryos underwent vitrification and then ET, they had SIRs which were equivalent to their normally blastulating counterparts (57% versus 60% in <35 years of age (P = 0.5) and 37% versus 42% in ≥35 years of age (P = 0.3)). An intraclass correlation and a generalized estimating equation corrected for patient age was performed which confirmed these findings. The normalization in cryopreserved ETs indicates that dyssynchrony may be a major adverse factor limiting outcomes with late blastulating embryos in fresh cycles. LIMITATIONS REASONS FOR CAUTION: This is a retrospective study comprising cohorts from a convenient sample chosen due to a uniform change in embryology laboratory protocol regarding ET day, however, this was done independent of the management of embryo and endometrial synchrony. Although strict ultrasound and serum progesterone criteria were utilized to make endometrial receptivity uniform, pathologic states of pre-receptive and post-receptive endometrium cannot be ruled out. WIDER IMPLICATIONS OF THE FINDINGS: The data surrounding embryo and endometrial synchrony should be considered in patients undergoing IVF and attention to the variations in blastulation rates can be applied to any patient undergoing extended embryo culture. STUDY FUNDING/COMPETING INTERESTS: None.

Cumulus cell transcriptome profiling is not predictive of live birth after in vitro fertilization: a paired analysis of euploid sibling blastocysts.

OBJECTIVE: To compare the transcriptome of cumulus cells associated with a euploid embryo that resulted in live birth with that of a sibling euploid embryo without sustained implantation. DESIGN: Paired analysis. SETTING: Academic institution. PATIENT(S): Couples undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection with preimplantation genetic screening with female age ≤42 years and normal ovarian reserve. INTERVENTION(S): Transcriptome profiling of cumulus cells from sibling oocytes for correlation with live birth after euploid blastocyst transfer. Embryos were individually cultured to facilitate association with clinical outcomes. The cumulus cell transcriptome from the embryo resulting in live birth was compared with that of its sibling embryo without sustained implantation to investigate potential biomarkers that may aid in embryo selection. MAIN OUTCOME MEASURE(S): Differential gene expression in cumulus cells associated with a euploid embryo resulting in live birth and its sibling euploid embryo without sustained implantation using next-generation RNA sequencing (RNAseq). RESULT(S): Cumulus cell RNAseq of 34 samples (from 17 patients) generated an average of 10.4 ± 4 × 106 reads per sample. A total of 132 differentially expressed genes between sibling embryos that resulted in a live birth and those that did not were identified (P<.05). However, after correcting for multiple testing none of the genes remained significantly differentially expressed (false discovery rate <.05). CONCLUSION(S): The RNAseq profiles were similar between cumulus cells associated with a euploid embryo resulting in live birth and its sibling embryo that did not sustain implantation. The cumulus cell transcriptome is not predictive of live birth within an individual patient's cohort of euploid embryos.

High relative deoxyribonucleic acid content of trophectoderm biopsy adversely affects pregnancy outcomes.

OBJECTIVE: To evaluate the association between relative DNA content of the trophectoderm biopsy and pregnancy outcomes. DESIGN: Retrospective cohort study. SETTING: Academic-affiliated private practice. PATIENT(S): This study included patients undergoing their first single embryo transfer after trophectoderm biopsy and comprehensive chromosome screening (CCS) at a single center between January 2010 and February 2014. INTERVENTION(S): In phase 1 of the study, a standard curve was developed to estimate the relative DNA content of trophectoderm biopsies. Phase 2 of the study examined reproductive outcomes in patients undergoing single embryo transfer after trophectoderm biopsy and CCS. Samples were divided into quartiles according to their relative DNA content, and clinical outcomes were compared. MAIN OUTCOME MEASURE(S): Chemical pregnancy rate, clinical implantation rate, ongoing pregnancy rate, live birth rate. RESULT(S): The quartile of highest relative DNA content had a significantly lower live birth rate when compared with the other three quartiles (relative risk 0.84, 95% confidence interval 0.75-0.95). There was no difference between the quartiles regarding age, body mass index, ovarian response, or endometrial thickness. Among those patients who had a live birth, there was no difference in hCG levels, gestational age at delivery, or birth weight with respect to biopsy DNA content. CONCLUSION(S): Trophectoderm biopsies with the highest relative DNA content are associated with lower live birth rates after single embryo transfer. Possible explanations for this phenomenon include diminished accuracy of the euploid diagnosis vs. a mechanical impact of the biopsy. Regardless of the cause, the outcomes emphasize the importance of obtaining appropriately sized trophectoderm biopsies for CCS.

Sequential versus Monophasic Media Impact Trial (SuMMIT): a paired randomized controlled trial comparing a sequential media system to a monophasic medium.

OBJECTIVE: To determine whether sequential or monophasic media is the more optimal formulation for blastocyst development and sustained implantation rates (SIR) in IVF. DESIGN: Paired randomized controlled trials. SETTING: Academic. PATIENT(S): Infertile couples (N = 192) with female partner ≤42 years old and normal ovarian reserve. INTERVENTION(S): Fertilized zygotes from each patient were randomly divided into two groups: [1] cultured in sequential media and [2] cultured in monophasic medium. Sequential media consisted of Quinn's Advantage Cleavage Medium (SAGE) followed by Blast Assist (Origio). The monophasic medium used was Continuous Single Culture (Irvine Scientific). Paired ETs were accomplished by transferring the best euploid blastocyst from each media group. DNA fingerprinting was used to link outcomes. MAIN OUTCOME MEASURE(S): The primary outcome measure was the proportion of blastocysts suitable for clinical use. Secondary outcome measures included timing of blastulation, aneuploidy rates, and SIR. Sustained implantation rate is defined as the number fetal heart beats at 8-9 weeks of gestation, divided by the number of embryos transferred. RESULT(S): A total of 192 patients had their 2PN embryos (N = 2,257) randomized to each culture system. Sequential media had higher blastulation rate than monophasic medium (55.2% vs. 46.9%). No differences were found in the day of blastulation or aneuploidy rate. Of the 168 patients who had euploid blastocysts suitable for transfer, 126 completed a paired ET. Among the double ETs, there was no difference in implantation between groups. CONCLUSION(S): This is the first randomized controlled trial to examine paired euploid transfers of sibling zygotes cultured in sequential versus monophasic media. This study demonstrates that the usable blastocyst rate is greatest after culture in the sequential media tested in comparison with the monophasic formulation selected for study. However, no difference exists in timing of blastulation, aneuploidy, or SIR. Whether these observations are generalizable to other media systems remains to be determined. CLINICAL TRIAL REGISTRATION NUMBER: NCT01917240.

Blastocyst transfer is not associated with increased rates of monozygotic twins when controlling for embryo cohort quality.

OBJECTIVE: To compare monozygotic twinning (MZT) rates in patients undergoing blastocyst or cleavage-stage ET. DESIGN: Retrospective cohort. SETTING: Academic research center. PATIENT(S): Autologous, fresh IVF cycles resulting in a clinical pregnancy from 1999 to 2014. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Monozygotic twin pregnancy in blastocyst-stage transfer vs. cleavage-stage transfer when controlling for patient prognosis and embryo cohort quality factors. RESULT(S): There were a total of 9,969 fresh transfer cycles resulting in a pregnancy during the study period. Of these pregnancies, 234 monozygotic twin pregnancies were identified (2.4%). Of all transfers, 5,191 were cleavage-stage and 4,778 were blastocyst-stage transfers. There were a total of 99 MZT identified in the cleavage-stage group (1.9%) and 135 MZT in the blastocyst ET group (2.4%), which was significant. Multivariable logistic regression revealed that increasing age was associated with a significant reduction in MZT, regardless of transfer order. Embryo cohort quality factors, including the number and proportion of six- to eight-cell embryos and availability of supernumerary embryos, were also significant. When controlling for patient age, time period during which the cycle took place, the number and proportion of six- to eight-cell embryos, and availability of supernumerary embryos, there was no longer a difference in MZT rate between blastocyst and cleavage transfer. CONCLUSION(S): Patient prognosis and embryo cohort quality seem to be major factors in MZT rate in women undergoing blastocyst transfer. Although technology-based effects cannot be excluded, patient and embryo characteristics play an important role.

Endometrial infusion of human chorionic gonadotropin at the time of blastocyst embryo transfer does not impact clinical outcomes: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To determine whether endometrial hCG infusion at the time of human blastocyst transfer impacts implantation rates. DESIGN: Randomized double-blinded placebo-controlled trial. SETTING: Academic. PATIENT(S): Infertile couples with the female partner less than 43 years old (n = 300) undergoing fresh or frozen ET of one or two blastocysts. INTERVENTION(S): Patients undergoing ET were randomized into either a treatment or a control group. The treatment group received an infusion of 500 IU of hCG diluted in ET media. The control group received a sham infusion of ET media. Infusions were done using a separate catheter less than 3 minutes before actual ET. MAIN OUTCOME MEASURE(S): Sustained implantation rate: ongoing viable gestation (primary outcome) and ongoing pregnancy rate (secondary outcome). RESULT(S): A total of 473 blastocysts were transferred into 300 patients. There were no differences between the two groups in sustained implantation rate (48.1% in the hCG group, 44.2% in the control group) or ongoing pregnancy rate (58.8% in the hCG group, 52.0% in the control group). CONCLUSION(S): Endometrial infusion of hCG at the time of blastocyst ET does not improve sustained implantation rates. CLINICAL TRIAL REGISTRATION NUMBER: NCT01643993.