Nucleation status of Day 2 pre-implantation embryos, acquired by time-lapse imaging during IVF, is associated with live birth.

The primary purpose of this time-lapse data analysis was to identify the association between the nucleation status of a Day 2 preimplantation embryo and live births following in vitro fertilization (IVF). The retrospective data analysis was based on 2769 transferred embryos from 1966 treatment cycles and utilised only Known Implantation Data (KID) for live births. Nucleation errors (NE) such as micronucleation, binucleation, multinucleation and minor error groups, were annotated in the time-lapse images which were taken every 15 minutes for a minimum of 44 hours post insemination. Further, factors that may impact NE and the relationship of early morphological attributes and morphokinetic variables with NE occurrence were explored. The frequency of NE among the transferred embryos was 23.8%. The reversibility of NE evidenced by their presence at the two-cell stage, but absence at the four-cell stage was 89.6%. Embryos exhibiting nucleation errors at the two-cell stage had significantly lower live birth rates compared to embryos with no nucleation errors, constituting a significant predictor. A Generalized Additive Mixed Model was used to control for confounders and for controlling clustering effects from dual embryo transfers. Increased incidences of NE were observed with increasing age, with delayed occurrence of cell divisions and in oocytes inseminated with surgically retrieved spermatozoa. NE assessment and their impact on live birth provides valuable markers for early preimplantation embryo selection. In addition, the high incidence of reversibility of NE and their possible impact on live birth suggest that incorporating two-cell nuclear status annotations in embryo selection, alongside morphology and morphokinetics, is of value.

Time-lapse imaging derived morphokinetic variables reveal association with implantation and live birth following in vitro fertilization: A retrospective study using data from transferred human embryos.

The purpose of this retrospective time-lapse data analysis from transferred preimplantation human embryos was to identify early morphokinetic cleavage variables that are related to implantation and live birth following in vitro fertilization (IVF). All embryos were monitored from fertilization check until embryo transfer for a minimum of 44 hours. The study was designed to assess the association between day 2 embryo morphokinetic variables with implantation and live birth based on Known Implantation Data (KID). The kinetic variables were subjected to quartile-based analysis. The predictive ability for implantation and live birth was studied using receiver operator characteristic (ROC) curves. Three morphokinetic variables, time to 2-cells (t2), duration of second cell cycle (cc2) below one threshold and cc2 above another threshold had the highest predictive value with regards to implantation and live birth following IVF treatment. The predictive pre-transfer information has little divergence between fetal heartbeat and live birth data and therefore, at least for early morphokinetic variables up to the four-cell stage (t4), conclusions and models based on fetal heartbeat data can be expected to be valid for live birth datasets as well. The three above mentioned variables (t2, cc2 below one threshold and cc2 above another threshold) may supplement morphological evaluation in embryo selection and thereby improve the outcome of in vitro fertilization treatments.

Validation of Assisted Reproductive Technology in the Medical Birth Registry of Norway Versus the Norwegian Prescription Database.

BACKGROUND: Increasing attention has been given to the long-term effects of assisted reproductive technology (ART). This study assessed the validity and completeness of ART as registered in the Medical Birth Registry of Norway (MBRN) using drug prescription data from the Norwegian Prescription Database (NorPD) as reference. METHODS: In this nationwide registry validation study, we included all pregnancies recorded in the MBRN between 2005 and 2017. We estimated sensitivity, specificity, and positive and negative predictive value (PPV and NPV) of the MBRN, using data from the NorPD as reference. We obtained the total percentage of ART pregnancies that could be identified (completeness) from both registries using the capture-recapture method. We analyzed subgroups by maternal age, gestational length, mode of ART treatment, health region, and mode of registration of ART (ART institution or birth notification form). RESULTS: Twenty-three thousand seven hundred eighteen of a total 765,789 pregnancies were registered as ART pregnancies through the MBRN and 20,807 as ART pregnancies through the NorPD. The sensitivity of the MBRN was 85.1% (95% confidence interval [CI] = 84.7, 85.6) and the PPV was 74.7% (74.1-75.2). Sensitivity declined with increasing maternal age: 71.5% (69.4-73.7) in the age group 40-44 years, and 40.7% (22.2-59.3) in the ages above 45 years. Completeness when combining data was 96.2% (96.0-96.5). CONCLUSIONS: Our analysis shows that, when identifying women pregnant through ART, NorPD data complemented MBRN data to obtain a more complete count of all women giving birth after ART in Norway.

Cancer risk in mother and child after fertility treatment. / Kreftrisiko hos mor og barn etter fertilitetsbehandling.

BAKGRUNN: I Norge fødes nå om lag 2 500 barn årlig etter fertilitetsbehandling. Hvorvidt behandlingen er forbundet med økt kreftrisiko, er fremdeles usikkert. KUNNSKAPSGRUNNLAG: Oversikten inkluderer kohortstudier om kreftrisiko hos kvinner behandlet med fertilitetsbehandling og barn unnfanget etter slik behandling. Et systematisk søk etter artikler ble gjort i EMBASE og Medline for perioden 2006-17. RESULTATER: Resultatene viser ingen generell økning i kreft hos kvinner som har fått fertilitetsbehandling. Hos barn antyder resultatene en tendens til økt risiko for hematologisk kreft, men ingen generell økt kreftrisiko. FORTOLKNING: Det er ingen entydige funn av forhøyet risiko for kreft hos kvinner som har gjennomgått fertilitetsbehandling, eller hos barn unnfanget etter slik behandling. Oppfølgingstiden er foreløpig kort, og det er behov for store befolkningsbaserte kohortstudier med lengre oppfølgingsperioder.

Cancer Risk in Women Treated with Fertility Drugs According to Parity Status-A Registry-based Cohort Study.

Background: Long-term safety of assisted reproductive techniques (ART) is of interest as their use is increasing. Cancer risk is known to be affected by parity. This study examined the risk of cancer after fertility treatment, stratified by women's parity.Methods: Data were obtained from all women (n = 1,353,724) born in Norway between 1960 and 1996. Drug exposure data (2004-2014) were obtained from the Norwegian Prescription Database (drugs used in ART and clomiphene citrate). The Medical Birth Registry of Norway provided parity status. HRs were calculated for all site cancer, breast, cervical, endometrial, ovarian, colorectal, central nervous system, thyroid cancer, and malignant melanoma.Results: In 12,354,392 person-years of follow-up, 20,128 women were diagnosed with cancer. All-site cancer risk was 1.14 [95% confidence interval (95% CI), 1.03-1.26] and 1.10 (95% CI, 0.98-1.23) after clomiphene citrate and ART exposure, respectively. For ovarian cancer, a stronger association was observed for both exposures in nulliparous (HR, 2.49; 95% CI, 1.30-4.78; and HR, 1.62; 95% CI, 0.78-3.35) versus parous women (HR, 1.37; 95% CI, 0.64-2.96; and HR, 0.87; 95% CI, 0.33-2.27). Elevated risk of endometrial cancers was observed for clomiphene citrate exposure in nulliparous women (HR, 4.49; 95% CI, 2.66-7.60 vs. HR, 1.52; 95% CI, 0.67-3.42). Risk was elevated for breast cancer in parous women exposed to clomiphene citrate (HR, 1.26; 95% CI, 1.03-1.54) for thyroid cancer and among nulliparous women after ART treatment (HR, 2.19; 95% CI, 1.08-4.44).Conclusions: Clomiphene citrate appears associated with increased risk of ovarian and endometrial cancer. Elevations in risks of breast and thyroid cancer were less consistent across type of drug exposure and parity.Impact: Continued monitoring of fertility treatments is warranted. Cancer Epidemiol Biomarkers Prev; 26(6); 953-62. ©2017 AACR.

Literature review on cancer risk in children born after fertility treatment suggests increased risk of haematological cancers.

Medically assisted fertility treatment, including assisted reproductive technology (ART), is increasingly being used and the subsequent child health outcomes are of interest. Some studies have suggested an elevated risk of somatic morbidity, while others have reported an elevated cancer risk. This review summarises the literature on fertility treatments and childhood cancer, based on 23 cohort and case-control studies. CONCLUSION: The findings varied, but reassuring results on overall childhood cancer and fertility treatment were observed. However, some studies suggested an elevated risk of haematological cancers. More large population-based studies are needed, and the growing population of ART children should be monitored.

Risk of Cancer in Children Conceived by Assisted Reproductive Technology.

BACKGROUND AND OBJECTIVE: An increasing number of children are born after assisted reproductive technology (ART), and monitoring their long-term health effects is of interest. This study compares cancer risk in children conceived by ART to that in children conceived without. METHODS: The Medical Birth Registry of Norway contains individual information on all children born in Norway (including information of ART conceptions). All children born between 1984 and 2011 constituted the study cohort, and cancer data were obtained from the Cancer Registry of Norway. Follow-up started at date of birth and ended on the date of the first cancer diagnosis, death, emigration, or December 31, 2011. A Cox proportional hazards model was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) of overall cancer risk between children conceived by ART and those not. Cancer risk was also assessed separately for all childhood cancer types. RESULTS: The study cohort comprised 1 628 658 children, of which 25 782 were conceived by ART. Of the total 4554 cancers, 51 occurred in ART-conceived children. Risk of overall cancer was not significantly elevated (HR 1.21; 95% CI 0.90-1.63). However, increased risk of leukemia was observed for children conceived by ART compared with those who were not (HR 1.67; 95% CI 1.02-2.73). Elevated risk of Hodgkin's lymphoma was also found for ART-conceived children (HR 3.63; 95% CI 1.12-11.72), although this was based on small numbers. CONCLUSIONS: This population-based cohort study found elevated risks of leukemia and Hodgkin's lymphoma in children conceived by ART.

Autotransplantation of cryopreserved ovarian tissue after treatment for malignant disease - the first Norwegian results.

INTRODUCTION: With increasing survival rates after treatment for cancer in prepubertal girls and women of reproductive age, an increasing focus on quality of life has emerged. Both irradiation and cytotoxic drugs can be detrimental to future fertility, consequently several treatment alternatives have been developed to spare or restore fertility in young females diagnosed with cancer. One of these options is cryopreservation of ovarian tissue before treatment and autotransplantation at a later time. MATERIAL AND METHODS: We present the Norwegian experience after 11 years of practice with ovarian tissue cryopreservation. A total of 164 patients have had ovarian tissue cryopreserved during the period 2004-2014. Fifteen patients died during the observation period. Six patients requested autotransplantation, which was performed in two women. RESULTS: Both patients conceived, one spontaneously and one after assisted reproduction due to a concomitant male factor. The pregnancies were uneventful and they each gave birth to a healthy child. CONCLUSIONS: Cryopreservation with later autotransplantation of ovarian tissue should be offered to a selected group of young women with cancer.

Risk of breast cancer following fertility treatment--a registry based cohort study of parous women in Norway.

Despite increasing numbers of women availing themselves of assisted reproductive technology (ART), effects on cancer risk remain unresolved. Given hormonal exposures, breast cancer risk is of particular concern. The aim of this study is to investigate breast cancer risk amongst women giving birth following ART as compared to that amongst women who gave birth without ART. Data on all women who gave birth in Norway with or without ART, between 1984 and 2010 were obtained from the Medical Birth Registry of Norway (MBRN). 808,834 women eligible for study were linked to the Cancer Registry of Norway. Cox proportional models computed hazard ratios (HR) and 95% confidence intervals (CI) of breast cancer between the two groups, adjusting for age, parity, age at first birth, calendar period and region of residence. In total, 8,037 women were diagnosed with breast cancer during the study period, 138 ART women and 7,899 unexposed. Total follow-up time was 12,401,121 person-years (median 16.0); median age at entry was 32.5 years (range 18.6-49.9) for ART women and 26.3 (range 10.5-54.6) for unexposed. Women exposed to ART had an elevated risk of breast cancer (adjusted HR 1.20, 95% CI 1.01-1.42). Subgroup analyses gave an HR of 1.30 (95% CI 1.07-1.57) for women treated with IVF and 1.35 (95 % CI 1.07-1.71) for women with follow-up >10 years, compared with controls. Our findings of increased risk in the study population warrant continued monitoring of women treated with ART as this population advances into more typical cancer age ranges.

Fragmentation of human cleavage-stage embryos is related to the progression through meiotic and mitotic cell cycles.

OBJECTIVE: To study whether fragmentation of human embryos is related to the progression through meiotic and mitotic cell cycles. DESIGN: This report consists of two observational studies. SETTING: Not applicable. PATIENT(S): A total of 1,943 oocytes from 297 patients and 372 embryos from 100 patients were imaged in the Polscope instrument and monitored in the Embryoscope, respectively. INTERVENTION(S): Completion of the first meiotic division was determined by visualization of the meiotic metaphase II spindle in human oocytes, and the duration of the first three mitotic cell cycles was determined with time-lapse microscopy. The percentage of embryo fragmentation was recorded 42-45 hours after insemination. MAIN OUTCOME MEASURE(S): Appearance of the meiotic spindle; durations of the first, second, and third mitoses. RESULT(S): Human embryos with a low degree of fragmentation (<10%) at 42-45 hours after insemination originated from oocytes with an early appearance of the meiotic spindle (mean 35.5 hours after hCG injection), early first mitosis (28.2 hours after insemination), late start of the second mitosis (38.0 hours after insemination), and a shorter duration of the third mitosis (1.1 hours). Highly fragmented embryos (>50% fragmentation) originated from oocytes with a late-appearing meiotic spindle (36.5 hours after hCG injection), delayed initiation of the first mitosis (29.8 hours after insemination), early start of the second mitosis (36.4 hours after insemination), and a longer duration of the third mitotic cell cycle (4.1 hours). CONCLUSION(S): The observed associations suggest that the process of fragmentation of in vitro-derived embryos was related to the progress of the meiotic and the mitotic cell cycles.

Advanced glycation end products and their receptor contribute to ovarian ageing.

STUDY QUESTION: Do advanced glycation end products (AGE) and the receptor for advanced glycation end products (RAGE) affect the cells of the human ovarian follicle? SUMMARY ANSWER: AGE accumulate on the surface of ovarian granulosa-lutein (GL) cells and monocytes by binding to RAGE and other receptors with possible functional effects on these cells. WHAT IS KNOWN ALREADY: AGE and RAGE are expressed in granulosa and theca cells, as well as in luteinized cells derived from the ovary. STUDY DESIGN, SIZE, DURATION: In this prospective cohort study, human follicle fluid-derived cells were isolated from aspirates of ovarian follicles of women who underwent assisted reproduction treatment. PARTICIPANTS/MATERIALS, SETTING, METHODS: Immunofluorescence microscopy and multi-colour flow cytometry were used to determine the presence of AGE and RAGE on the surface of follicular fluid-derived cells and to characterize downstream effects of RAGE activation. MAIN RESULTS AND THE ROLE OF CHANCE: GL cells and ovarian monocytes were found to contain AGE and RAGE and to bind AGE-bovine serum albumin (BSA) in correlation with the patients' chronological age. AGE-BSA and BSA failed to induce significantly the cleavage of caspase-3, phosphorylation of nuclear factor-κB or the binding of annexin V (the latter was marginally increased). AGE-fibronectin was found to induce detachment of cultured GL cells in vitro. LIMITATIONS, REASONS FOR CAUTION: The impact of AGE and RAGE in the ovary, shown here in cells in culture, remains to be affirmed in clinical settings. WIDER IMPLICATIONS OF THE FINDINGS: The ligands of RAGE and their effects in the ovary remain uncertain but this study implies that AGEs in the form of structural long-lived extracellular matrix proteins, rather than soluble AGEs, may play a role in the decline of ovarian function during ageing. STUDY FUNDING/COMPETING INTEREST(S): The project was funded by the Norwegian Resource Centre for Women's Health, Oslo University Hospital. The authors have no conflicts of interests.

Infertility treatment and the risk of cancer.

BACKGROUND: A possible correlation between hormonal stimulation during treatment of infertility and the risk of cancer of the breast, the ovaries, the cervix or the uterus has been investigated in a number of epidemiological studies. The purpose of this article is to review the relevant literature and summarise the findings. KNOWLEDGE BASE: This review article is based on literature searches in the databases MEDLINE, Cochrane and EMBASE. RESULTS: No studies showed a specific general correlation between hormonal ovulatory stimulation used as pre-treatment to assisted fertilisation and an increased risk of cancer of the breast, the ovaries, the cervix or the uterus. Most studies detected no increased risk. Some studies, however, showed an increased risk of cancer among certain sub-groups, such as women who have received repeated treatment with clomiphene citrate. INTERPRETATION: On the basis of the studies reviewed, the conclusions are ambiguous. It is therefore necessary to monitor the long-term effects of infertility treatment on women's health. Further good-quality large-scale population studies are necessary, with longer follow-up periods and better adjustment for confounding factors.

Preconceptional paternal glycidamide exposure affects embryonic gene expression: single embryo gene expression study following in vitro fertilization.

Recognition of early determinants of disease onset has sparked an interest in paternally transmitted factors and their impact on the developing embryo. Acrylamide (AA), a widely distributed xenobiotic compound, is converted to its active metabolite glycidamide (GA) by the CYP2E1 enzyme. Based on its capacity to induce dominant lethal mutations, we hypothesized that paternal GA exposure would have a negative impact on embryonic genome activation, via GA-DNA and protamine adducts persisting in the fertilizing sperm. Using a combination of in vitro fertilization (IVF) techniques and RT-qPCR single embryo gene expression (SEGE), we studied the expression of key DNA repair genes and genes important for embryo development, at the 1-, 2-, 4- and 8-cell stage of the developing mouse embryo. Compared to controls paternal GA-exposure gave rise to an altered pattern of embryonic gene expression, with an initial reduced expression at early stages followed by increased expression at the 8-cell stage.

Routine morphological scoring systems in assisted reproduction treatment fail to reflect age-related impairment of oocyte and embryo quality.

Routine morphological scoring systems in assisted reproduction treatment are based on parameters that presumably correlate with the biological quality of gametes and embryos, including chromosome abnormalities. Maternal age is a key factor predicting pregnancy and live birth, and it is therefore of considerable interest to identify age-related indicators of oocyte and embryo quality in assisted reproduction treatment. The purpose of this study was to examine whether routine morphological scoring systems reflect age-related impact on oocyte and embryo quality among 4587 couples undergoing their first assisted reproduction treatment. This study assessed over 43,000 oocytes, 25,000 embryos and 7900 transferred embryos and analysed the associations among the following parameters: number of oocytes retrieved, oocyte quality, including maturity, fertilization rates, embryo quality, based on morphological features, and treatment outcome. Advanced chronological age was found to be associated with fewer oocytes retrieved, fewer embryos available for cryopreservation, as well as lower pregnancy, implantation, live birth rates and a higher miscarriage rate. No age-related correlation was found between fertilization rates, oocyte or embryo quality. Routinely-used morphological scoring systems, such as assessment of blastomere count, shape and fragmentation, fail to reflect age-related impact on oocyte and embryo quality.

[Cryopreservation of ovarian tissue]. / Kryopreservering av ovarialvev.

BACKGROUND: Unfertilized oocytes, embryos and ovarian issue can be cryopreserved before cancer treatment of post-pubertal women. Fertility may be restored by retransplantation in women who are pronounced healthy. MATERIAL AND METHODS: The article is based on relevant literature and our own clinical experience since 2004, when the procedure was first allowed in Norway. RESULTS AND INTERPRETATION: Cryopreservation of ovarian tissue is an established procedure in Norway. As of January 2007, ovarian tissue from 22 women, aged 14-35 years, has been cryopreserved at Rikshospitalet. There is an upper age limit of 35 years because of age-related follicular loss. The treating oncologist and a gynaecologist should be responsible for informing patients about the possibility of preserving fertility by ovarian cryopreservation before chemo- and/or radiation therapy. The patient should, at the same time, be told about the limited world-wide experience with this procedure.

Characterization and depletion of leukocytes from cells isolated from the pre-ovulatory ovarian follicle.

BACKGROUND: Cells isolated from the periovulatory ovarian follicle are often used as a model of ovarian steroidogenesis and corpus luteum formation. The follicular fluid-derived cell (FFDC) population is, however, heterogeneous and in addition to granulosa-lutein cells, non-steroidogenic cells are also present. These non-steroidogenic cells, especially the immune cells, may have important biological functions in this model. Here, we describe a method to isolate FFDC, characterize the phenotype of the immune cells and deplete immune cells from FFDC. METHODS AND RESULTS: Follicular fluid aspirated transvaginally during IVF was clarified by centrifugation and enzymatic dispersion, labelled for leukocyte-specific markers and analysed by flow cytometry. Leukocytes constituted 22% of FFDC and expressed macrophage/dendritic cell, monocyte and lymphocyte markers. Leukocytes were depleted with anti-CD45-conjugated immunobeads, resulting in an FFDC population with <1.9% leukocytes. Leukocyte-containing FFDC secreted more interleukin-8 in culture than leukocyte-depleted FFDC. CONCLUSION: Leukocyte-depleted FFDC may serve as a useful model to study the interaction of immune cells and luteinizing cells during corpus luteum formation.

Intracytoplasmic sperm injection (ICSI) in unexplained and stage I endometriosis-associated infertility after fertilization failure with in vitro fertilization (IVF).

PURPOSE: To investigate possible differences between unexplained and stage I endometriosis-associated infertility in ICSI cycles conducted after low fertilization (<20%) in preceding IVF cycles with normal semen parameters. METHODS: Retrospective cohort study consisting of patients with unexplained (n=48) and stage I endometriosis-associated infertility (n=43) with a minimum of one IVF cycle with <20% fertilized oocytes and normal semen quality, treated with ICSI from January 1997 to January 2006. Age matched male factor infertility patients (n=91) were used as controls. RESULTS: Diploid fertilization rate was significantly lower in the stage I endometriosis-associated infertility group compared to the unexplained infertility group. Score of the transferred embryos, implantation rate, pregnancy rate and outcome were similar in the two groups. CONCLUSIONS: ICSI appears to be an efficient treatment option after fertilization failure with IVF in unexplained and stage I endometriosis-associated infertility.

Impact of overweight and underweight on assisted reproduction treatment.

BACKGROUND: Underweight and overweight may affect reproduction and interfere with treatment of infertility. The purpose of this report is to describe the independent effect of body weight on treatment with IVF and ICSI. METHODS: Records of 5019 IVF or ICSI treatments in 2660 couples were reviewed. The influence of body mass index (BMI) on treatment outcome was examined, after accounting for differences in age and infertility diagnosis. RESULTS: The cumulative live birth rate within three treatment cycles was 41.4% [95% confidence interval (CI) 32.1-50.7] in obese women with BMI > or =30 kg/m2 and 50.3 (95% CI 47.0-53.7) in normal weight women with BMI 18.5-24.9 kg/m2. Obesity was associated with an increased risk of early pregnancy loss occurring before 6 weeks gestation. Positive correlation between BMI and gonadotrophin requirement during stimulation and negative correlation between BMI and number of collected oocytes were observed. Underweight (BMI <18.5 kg/m2) was not related to an impaired outcome of IVF or ICSI. CONCLUSIONS: Obesity is associated with lower chances for live birth after IVF and ICSI and with an impaired response to ovarian stimulation.