A randomized controlled trial of laser-assisted ICSI.

STUDY QUESTION: Does the use of a laser to open the zona pellucida during ICSI (laser assisted or LA-ICSI) improve oocyte survival, embryo development and clinical outcomes? SUMMARY ANSWER: Compared to conventional ICSI, LA-ICSI increased rates of oocyte survival and some aspects of embryo development but it did not alter the ongoing pregnancy rate; after adjusting for oocyte survival, there was no beneficial effect of LA-ICSI on embryo development and utilization. WHAT IS KNOWN ALREADY: Oocyte degeneration occurs in a 10th of mature oocytes after ICSI. Pilot studies suggest that LA-ICSI may improve oocyte survivability. STUDY DESIGN, SIZE, DURATION: In a randomized controlled trial, 966 couples (16 122 metaphase II oocytes) were allocated to receive LA-ICSI (intervention) or conventional ICSI (control) between 17 September 2018 and 5 August 2019. Oocyte survival (primary endpoint), embryo development and ongoing pregnancy rates were compared. PARTICIPANTS/MATERIALS, SETTING, METHODS: Couples included in this study were recommended for ICSI due to female or male factor, unexplained infertility or a combination of factors. Patients were ineligible to participate in the study if they had uterine abnormality including thin endometrium, recurrent pregnancy loss, endometriosis or a severe medical condition. Concealed randomization to LA-ICSI or conventional ICSI, allocated in a 1:1 ratio, took place on stimulation Day 1 with replacement of blastocysts on only Day 5. The primary endpoint was oocyte survival with membrane integrity 24 h after the ICSI procedure. The sample size was estimated to detect a 3% increase in oocyte survival after LA-ICSI with 99% power at a 1% significance level. This also permitted the detection of 10% increase in ongoing pregnancy rate after LA-ICSI with 85% power at 5% alpha level. We used Poisson regression with zero-inflation for count data to estimate relative risk (RR) with 95% CI and logistic regression for clinical outcomes to estimate odds ratio (OR) with 95% CI. Both models adjusted for age as a covariate. MAIN RESULTS AND THE ROLE OF CHANCE: Compared with conventional ICSI, LA-ICSI resulted in a higher number of surviving oocytes (RR 1.08, 95% CI 1.05-1.12, P < 0.001), as well as a higher number of fertilized oocytes (RR 1.08, 95% CI 1.04-1.13, P < 0.001) and utilizable blastocysts (RR 1.09, 95% CI 1.04-1.15, P < 0.001). Sensitivity analyses adjusted for oocyte survival showed no between-group difference in utilizable blastocysts (OR 1.01, 95% CI 0.95-1.08, P = 0.73) and by calculating the mean rate, a reduction in utilizable blastocysts was shown (RR 0.95, 95% CI 0.94-0.97, P < 0.001). Ongoing pregnancy showed no between-group difference (LA-ICSI 179/489 (37%) vs ICSI 201/477 (42%), OR 0.79, 95% CI 0.61-1.03, P = 0.09). LIMITATIONS, REASONS FOR CAUTION: It was not possible to blind the embryologists involved in the ICSI procedure. However, there was concealment of randomization and blinding of outcome assessments reducing the risk of selection and measurement bias. WIDER IMPLICATIONS OF THE FINDINGS: A beneficial effect of LA-ICSI on oocyte survival should be shown to improve clinical outcomes, before its use in clinical practice is justified. STUDY FUNDING/COMPETING INTEREST(S): The study received no funding, and the authors declare that there are no conflicts of interest. TRIAL REGISTRATION NUMBER: NCT03665103. TRIAL REGISTRATION DATE: 11 September 2018. DATE OF FIRST PATIENT'S ENROLMENT: 17 September 2018.

Triple-arm trial of pH (Tri-pH) effect on live birth after ICSI in Egyptian IVF facilities: protocol of a randomised controlled trial.

INTRODUCTION: One potential stressor that can affect preimplantation and postimplantation embryonic growth after in vitro fertilisation (IVF) is the pH of the human embryo culture medium, but no evidence exists to indicate which pH level is optimal for IVF. Based on anecdotal evidence or mouse models, culture media manufacturers recommend a pH range of 7.2 to 7.4, and IVF laboratories routinely use a pH range of 7.25 to 7.3. Given the lack of randomised trials evaluating the effect of pH on live birth rate after IVF, this trial examines the effect of three different pH levels on the live birth rate. METHODS AND ANALYSIS: This multicentre randomised trial will involve centres specialised in IVF in Egypt. Eligible couples for intracytoplasmic sperm injection (ICSI) will be randomised for embryo culture at pH 7.2, 7.3 or 7.4. The study is designed to detect 10 percentage points difference in live birth rate between the best and worst performing media with 93% power at a 1% significance level. The primary outcome is the rate of live birth (delivery of one or more viable infants beyond the 20th week of gestation) after ICSI. Secondary clinical outcomes include biochemical pregnancy, clinical pregnancy, ongoing pregnancy, miscarriage, preterm births, birth weight, stillbirth, congenital malformation and cumulative live birth (within 1 year from randomisation). Embryo development outcomes include fertilisation, blastocyst formation and quality, and embryo cryopreservation and utilisation. ETHICS AND DISSEMINATION: The study was reviewed and approved by the Ethics Review Boards of the participating centres. Eligible women will sign a written informed consent before enrolment. This study has an independent data monitoring and safety committee comprised international experts in trial design and in vitro culture. No plan exists to disseminate results to participants or health communities, except for the independent monitoring and safety committee of the trial. TRIAL REGISTRATION NUMBER: NCT02896777.

Cytokines hold promise for human embryo culture in vitro: results of a randomized clinical trial.

OBJECTIVE: To evaluate the effects of cytokine enrichment of culture medium on embryological and clinical outcomes after intracytoplasmic sperm injection (ICSI). DESIGN: A randomized clinical trial. SETTING: In vitro fertilization centers. PATIENT(S): This trial included 443 ICSI cycles randomized into two groups. INTERVENTION(S): This study evaluated the influence of integration of granulocyte-macrophage colony-stimulating factor, heparin-binding epidermal growth factor-like growth factor, and leukemia inhibitory factor into culture media on human embryo development after ICSI. MAIN OUTCOME MEASURE(S): Ongoing pregnancy rate per a randomized participant. RESULT(S): Cytokine enrichment of culture medium showed improvement in ongoing pregnancy rate compared with no cytokines (106/224 [47%] vs. 78/219 [36%]; absolute rate difference [ARD] = 12; 95% confidence interval [CI], 2.5-21). This integration of cytokines also showed better rates of live birth (101/224 [45%] vs. 71/219 [33%]; ARD = 13; 95% CI, 4-21) and cumulative live birth (132/224 [60%] vs. 97/219 [44%]; ARD = 12; 95% CI, 4-20) and lower rate of pregnancy loss (27/124 [22%] vs. 37/103 [36%]; ARD = -14; 95% CI, -26 to -2) than conventional medium. Embryos developed in the cytokine-supplemented medium showed better blastocyst formation, quality, cryopreservation, and use than control medium. CONCLUSION(S): Integration of cytokines into human embryo culture media showed improvement in embryological and clinical outcomes after ICSI. However, the long-term effect of cytokine enrichment of a medium is still unclear and warrants further studies with longitudinal follow-up. CLINICAL TRIAL REGISTRATION NUMBER: NCT02420886 at ClinicalTrials.gov.

Artificial oocyte activation with SrCl2 or calcimycin after ICSI improves clinical and embryological outcomes compared with ICSI alone: results of a randomized clinical trial.

STUDY QUESTION: Are pregnancy and birth rates affected by artificial oocyte activation (AOA) with SrCl2 or calcimycin after ICSI for couples with male-factor infertility linked to abnormal sperm morphology or for couples with previous ICSI cycles of unexplained low fertilization or inadequate fertilization associated with impaired oocyte morphology? SUMMARY ANSWER: AOA with either SrCl2 or calcimycin can improve the rates of clinical pregnancy, ongoing pregnancy and live birth compared with ICSI alone, and the two agents have diverse effects for different subgroups of patients. WHAT IS KNOWN ALREADY: ICSI is a successful treatment for infertility, but not in all individuals. AOA has potential to overcome inadequate fertilization in ICSI. Calcimycin and SrCl2 are candidate agents for AOA, but their effectiveness remains to be compared. STUDY DESIGN, SIZE, DURATION: This study was a randomized, open-label, three-arm, parallel-group, double-centre, superiority trial conducted between April 2015 and January 2016. The study evaluated the effects of AOA with calcimycin or SrCl2 for clinical pregnancy rates after ICSI and included 343 couples divided into three groups. PARTICIPANTS/MATERIALS, SETTING, METHODS: Couples were included if they had two previous ICSI cycles of no or low fertilization (0-30%) with unknown causes or impaired oocyte morphology. Male-factor infertility cycles (frozen-thawed sperm, surgically retrieved sperm or ejaculates contained <10 millions spermatozoa/ml) undergoing their first ICSI attempt were also included if they had 100% abnormal sperm morphology (including globozoospermia and tapered-head). Couples were randomized to undergo ICSI with SrCl2 AOA, ICSI with calcimycin AOA or ICSI alone, with clinical pregnancy as the primary endpoint. Effect sizes were summarized as absolute rate differences (ARDs) and odds ratios (ORs), with precision evaluated by 95% CIs. MAIN RESULTS AND THE ROLE OF CHANCE: Both SrCl2 and calcimycin AOA improved clinical pregnancy rates compared to ICSI alone (49, 42 and 27%; ARD 22, 95% CI: 9-33; P = 0.0007 and ARD 16, 95% CI: 3-27; P = 0.014). SrCl2 and calcimycin AOA were also superior to ICSI alone on the rates of ongoing pregnancy (42, 36 and 23%; P = 0.0019 and P = 0.023) and live birth (40, 33 and 18%; P = 0.0002 and P = 0.012). Among couples with previous ICSI cycles of low fertilization, AOA with SrCl2 (but not with calcimycin) was superior to ICSI alone for rates of clinical pregnancy (ARD 35 percentage points (pp), P = 0.0007), ongoing pregnancy (ARD 27 pp, P = 0.009) and live birth (ARD 37 pp, P = 0.002). Among couples affected by male-factor infertility, AOA with calcimycin (but not with SrCl2) was superior to ICSI alone for rates of clinical pregnancy (ARD 22 pp, P = 0.006), ongoing pregnancy (ARD 19 pp, P = 0.013) and live birth (ARD 17 pp, P = 0.02). LIMITATIONS, REASONS FOR CAUTION: This study was an open-label trial, and this design might have introduced bias, although randomization methods were used. The study did not include a longitudinal follow-up, so further evidence is required to demonstrate the safety of AOA. WIDER IMPLICATIONS OF THE FINDINGS: The decision to use SrCl2 or calcimycin for AOA after ICSI may depend on whether the activation failure originates in the oocyte or the sperm. STUDY FUNDING/COMPETING INTEREST(S): The study received no funding and the authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: NCT02424214. TRIAL REGISTRATION DATE: 22 April 2015. DATE OF FIRST PATIENT'S ENROLMENT: 27 April 2015.

Impact of 3.5% O2 culture on embryo development and clinical outcomes: a comparative study.

OBJECTIVE: To evaluate the effect of culturing human embryos in vitro in 3.5% oxygen (O2) concentration. DESIGN: Comparative study. SETTING: Private IVF center. PATIENT(S): The study included 558 women in two groups. INTERVENTION(S): After intracytoplasmic sperm injection (ICSI), women's oocytes were assigned to undergo cultivation in either 3.5% O2 concentration (intervention) or 5% O2 level (control group), continuously, from day 0 through day 5 or 6. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate (PR) after ET. RESULT(S): There were significantly higher fertilization and cleavage rates in the 3.5% O2 group (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.53-1.93) and (OR 3.74, 95% CI 2.30-6.07) than in the 5% O2 group. The compaction rate on day 3, and the number of formed, high-quality and cryopreserved blastocysts on day 5 were significantly lower in 3.5% O2 than in 5% O2 concentration ([OR 0.81, 95% CI 0.69-0.91], [OR 0.40, 95% CI 0.36-0.46], [OR 0.32, 95% CI 0.28-0.37] and [OR 0.47, 95% CI 0.40-0.54]), respectively. Culturing embryos in 3.5% O2 concentration led to significantly lower rates of biochemical pregnancy, clinical PR, and implantation ([OR 0.66, 95% CI 0.47-0.92], [OR 0.60, 95% CI 0.43-0.84] and [OR 0.61, 95% CI 0.46-0.81]), respectively. CONCLUSION(S): Culturing human embryos, continuously from day 0 to 5 or 6, in 3.5% O2 concentration is associated with significantly lower blastocyst formation rate and clinical outcomes parameters, but rather with significantly higher rates of fertilization and cleavage. Whether these findings hold true for other patient populations and culture media brands remain unknown.

Humid versus dry incubator: a prospective, randomized, controlled trial.

OBJECTIVE: To evaluate the efficacy of a dry versus humidified incubator on human embryo development ex vivo. DESIGN: Prospective, double-blind, randomized, controlled trial. SETTING: Private fertility centers. PATIENT(S): A total of 297 women undergoing in vitro fertilization randomized into two groups. INTERVENTION(S): From days 0 to day 5 or 6 of culture, intervention group embryos exposed to dry culture and control group embryos exposed to humidified culture. MAIN OUTCOME MEASURE(S): Subsequent ongoing pregnancy rate. RESULT(S): After transfer of embryos, there were statistically significantly lower rates of clinical and ongoing pregnancy in the dry culture arm than in the humidified culture arm (odds ratio [OR] 0.57; 95% confidence interval [CI], 0.36-0.91; versus OR 0.54; 95% CI, 0.34-0.85). On day 3 of culture, embryo quality and compaction were lower in the dry culture group (OR 0.38; 95% CI, 0.32-0.45) than in the group exposed to humidified culture (OR 0.23; 95% CI, 0.19-0.27). On day 5 of culture, embryos in dry culture had a lower rate of blastocyst formation (OR 0.39; 95% CI, 0.33-0.46), quality (OR 0.34; 95% CI, 0.29-0.40), and cryopreservation (OR 0.41; 95% CI, 0.35-0.48). CONCLUSION(S): In this study, human embryos cultivated ex vivo in a dry incubator had statistically significantly decreased implantation and clinical and ongoing pregnancy rates. Our findings indicate the need for larger multicenter, randomized, controlled trials. CLINICAL TRIAL REGISTRATION NUMBER: NCT01695096.

Integrating insulin into single-step culture medium regulates human embryo development in vitro.

OBJECTIVE: To evaluate the effect of supplementing single-step embryo culture medium with insulin on human embryo development. DESIGN: Comparative study. SETTING: Two private centers. PATIENT(S): The study involved a sibling oocyte split of 5,142 retrieved oocytes from 360 patients. INTERVENTION(S): Sibling oocytes split after intracytoplasmic sperm injection for culture from day 0 through day 5 or 6 in insulin-supplemented or control medium. Women were split to receive their embryos from insulin-supplemented or control medium. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate. RESULT(S): There were significantly higher rates of clinical, ongoing, and twin pregnancies in the insulin-supplemented arm than in the control arm. On day 3, embryo quality and compaction were higher in insulin-supplemented medium. On day 5, insulin supplementation showed higher rates of blastocyst formation, quality, and cryopreservation. CONCLUSION(S): Insulin supplementation of single-step embryo culture medium from day 0 through day 5 or 6 improved clinical pregnancy rate and human embryo development. However, these findings need further confirmation through a multicenter randomized controlled trial that may include other patient populations and different culture media.

Major Placenta Previa: Rate, Maternal and Neonatal Outcomes Experience at a Tertiary Maternity Hospital, Sohag, Egypt: A Prospective Study.

INTRODUCTION: Major degree placenta is a serious health issue and is associated with high fetal-maternal morbidity and mortality. Literature from developing countries is scant. AIM: To determine the prevalence and maternal and neonatal outcomes among women with major placenta previa (PP). MATERIALS AND METHODS: A prospective descriptive study of 52 singleton pregnancies with PP was evaluated in this study. The study was conducted at Sohag University Hospital, Egypt from January through June 2014. Outcome measures, including the prevalence of PP, maternal and neonatal outcomes, and case-fatality rate. RESULTS: The total number of deliveries performed during the study period was 3841, of them, 52 cases were placenta previa. Thus, the prevalence of PP was 1.3%. The mean of previous cesarean scars was 2.2±1.4. Of women with PP, 26.4% (n=14) had placenta accreta. In total, 15.1% (n=8) of women underwent an obstetric hysterectomy. From the total no. of babies, 13.2% (n=7) were delivered fresh stillborn babies. Of the surviving babies (n=45), 20% (n=9) required admission to NICU. The frequencies of bowel and bladder injuries were 3.8% (n=2) and 13.2% (n=7) respectively. There was no maternal death in this study. CONCLUSION: The rate of PP is comparable to previous studies, however, the rate of placenta accreta is high. Also, there are high rates of neonatal mortality and intraoperative complications which can be explained by accreta. The study highlights the need to revise maternity and child health services.