ESHRE good practice recommendations on recurrent implantation failure.

STUDY QUESTION: How should recurrent implantation failure (RIF) in patients undergoing ART be defined and managed? SUMMARY ANSWER: This is the first ESHRE good practice recommendations paper providing a definition for RIF together with recommendations on how to investigate causes and contributing factors, and how to improve the chances of a pregnancy. WHAT IS KNOWN ALREADY: RIF is a challenge in the ART clinic, with a multitude of investigations and interventions offered and applied in clinical practice, often without biological rationale or with unequivocal evidence of benefit. STUDY DESIGN SIZE DURATION: This document was developed according to a predefined methodology for ESHRE good practice recommendations. Recommendations are supported by data from the literature, if available, and the results of a previously published survey on clinical practice in RIF and the expertise of the working group. A literature search was performed in PubMed and Cochrane focussing on 'recurrent reproductive failure', 'recurrent implantation failure', and 'repeated implantation failure'. PARTICIPANTS/MATERIALS SETTING METHODS: The ESHRE Working Group on Recurrent Implantation Failure included eight members representing the ESHRE Special Interest Groups for Implantation and Early Pregnancy, Reproductive Endocrinology, and Embryology, with an independent chair and an expert in statistics. The recommendations for clinical practice were formulated based on the expert opinion of the working group, while taking into consideration the published data and results of the survey on uptake in clinical practice. The draft document was then open to ESHRE members for online peer review and was revised in light of the comments received. MAIN RESULTS AND THE ROLE OF CHANCE: The working group recommends considering RIF as a secondary phenomenon of ART, as it can only be observed in patients undergoing IVF, and that the following description of RIF be adopted: 'RIF describes the scenario in which the transfer of embryos considered to be viable has failed to result in a positive pregnancy test sufficiently often in a specific patient to warrant consideration of further investigations and/or interventions'. It was agreed that the recommended threshold for the cumulative predicted chance of implantation to identify RIF for the purposes of initiating further investigation is 60%. When a couple have not had a successful implantation by a certain number of embryo transfers and the cumulative predicted chance of implantation associated with that number is greater than 60%, then they should be counselled on further investigation and/or treatment options. This term defines clinical RIF for which further actions should be considered. Nineteen recommendations were formulated on investigations when RIF is suspected, and 13 on interventions. Recommendations were colour-coded based on whether the investigations/interventions were recommended (green), to be considered (orange), or not recommended, i.e. not to be offered routinely (red). LIMITATIONS REASONS FOR CAUTION: While awaiting the results of further studies and trials, the ESHRE Working Group on Recurrent Implantation Failure recommends identifying RIF based on the chance of successful implantation for the individual patient or couple and to restrict investigations and treatments to those supported by a clear rationale and data indicating their likely benefit. WIDER IMPLICATIONS OF THE FINDINGS: This article provides not only good practice advice but also highlights the investigations and interventions that need further research. This research, when well-conducted, will be key to making progress in the clinical management of RIF. STUDY FUNDING/COMPETING INTERESTS: The meetings and technical support for this project were funded by ESHRE. N.M. declared consulting fees from ArtPRED (The Netherlands) and Freya Biosciences (Denmark); Honoraria for lectures from Gedeon Richter, Merck, Abbott, and IBSA; being co-founder of Verso Biosense. He is Co-Chief Editor of Reproductive Biomedicine Online (RBMO). D.C. declared being an Associate Editor of Human Reproduction Update, and declared honoraria for lectures from Merck, Organon, IBSA, and Fairtility; support for attending meetings from Cooper Surgical, Fujifilm Irvine Scientific. G.G. declared that he or his institution received financial or non-financial support for research, lectures, workshops, advisory roles, or travelling from Ferring, Merck, Gedeon-Richter, PregLem, Abbott, Vifor, Organon, MSD, Coopersurgical, ObsEVA, and ReprodWissen. He is an Editor of the journals Archives of Obstetrics and Gynecology and Reproductive Biomedicine Online, and Editor in Chief of Journal Gynäkologische Endokrinologie. He is involved in guideline developments and quality control on national and international level. G.L. declared he or his institution received honoraria for lectures from Merck, Ferring, Vianex/Organon, and MSD. He is an Associate Editor of Human Reproduction Update, immediate past Coordinator of Special Interest Group for Reproductive Endocrinology of ESHRE and has been involved in Guideline Development Groups of ESHRE and national fertility authorities. D.J.M. declared being an Associate Editor for Human Reproduction Open and statistical Advisor for Reproductive Biomedicine Online. B.T. declared being shareholder of Reprognostics and she or her institution received financial or non-financial support for research, clinical trials, lectures, workshops, advisory roles or travelling from support for attending meetings from Ferring, MSD, Exeltis, Merck Serono, Bayer, Teva, Theramex and Novartis, Astropharm, Ferring. The other authors had nothing to disclose. DISCLAIMER: This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation. ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type. Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.

Is it worth it to cryopreserve embryos with blastulation delay at day 5?

This is a retrospective study over a 5-year period. In total, 3139 embryos were individually cryopreserved (Cryotop®) and warmed using the Kitazato vitrification/warming kit. They were classified into three categories based on their expansion degree. Transfer, implantation and pregnancy rates were assessed for each embryo category and compared using SPSS (Statistical Package for the Social Sciences) software. In total, 1139 couples enrolled in infertility treatment programme benefitted from embryo vitrification at day 5. After warming, embryos belonging to the three categories showed similar success rates. Although there was a trend towards better outcomes when grade 3 embryos were transferred, the differences did not reach statistical significance: implantation rates (n fetal sac/n embryo transferred) grade 1: 21.9%, grade 2: 22.7% and grade 3: 30.3% (=0.19). Pregnancy rate (n clinical pregnancy/n transfer) (21.9%, 22.7%, 30.3%, respectively; P=0.11). Miscarriage rate was not statistically different in the three categories (14.5%, 20.4%, 20%, respectively, P=0.51). Our overall results show that it is worth vitrifying slow kinetics embryos as they provide a non-negligible chance to give rise to a pregnancy.

[Satisfaction survey on the use of autologous oocyte vitrification in Assisted Reproductive Technologies]. / Enquête de satisfaction des couples à propos de la vitrification ovocytaire autologue en assistance médicale à la procréation.

OBJECTIVES: We organized a survey for in-vitro fertilization couples who beneficiated on self-preservation of part of the oocyte cohort. The main objective was to measure couples' satisfaction. Secondary objectives were; to identify how patients had been informed; to verify that the use of the ART technique met their expectations, and how they felt about oocyte or embryo freezing. METHODS: The data were collected by a questionnaire sent electronically to couples who had undergone partial vitrification of the oocyte cohort and at least one warming cycle. The questionnaire consisted of 2 components; one for the women and another one for their husband. RESULTS: Eighty-eight women and 62 men responded to the survey respectively, representing 50.86% and 35.84% of the targeted patients. They were satisfied with a 90% rate, men and women combined. The information we give in the center is heard by couples and is part of the trust in the medical staff. Men are more worried than women about the risks of stimulation or ovarian pick-up and are not displeased to be called upon for sperm recovery for every attempt at oocyte warming. The ambiguity of the answers on the representation of the embryo confirms what is already described, but is independent of the acceptance of freezing whether it is oocyte or embryo. CONCLUSION: In the same way as evaluating the results, the evaluation of patient satisfaction is useful for the implementation of therapeutic strategies and care pathways.

Longitudinal growth of French singleton children born after in vitro fertilization and intracytoplasmic sperm injection. Body mass index up to 5 years of age.

BACKGROUND: The literature presents conflicting results on the epigenetic effect of in vitro fertilization (IVF) on the short-term and mid-term growth of children. These contradictory results may be related to the use of heterogeneous methodologies and non-longitudinal data. The goal of this study was to compare the body mass index (BMI) of children conceived via IVF and spontaneous conception (SC) children, using longitudinal data from birth to 5 years. METHODS: This study compared 118 singleton children born after in vitro fertilization, with or without intracytoplasmic sperm injection (ICSI), selected from a pre-existing single-center cohort to 320 SC children from the same geographic area. BMI and its evolution were analyzed using the mixed-effect model during three periods: before standing acquisition (from birth to 1 year of age), during standing acquisition, and the following period from 2 to 5 years of age. RESULTS: BMI means were not significantly different between groups regardless of the period, when adjusting for confounding factors related to parents, pregnancy, and children's characteristics and lifestyle. Nevertheless, during the standing acquisition period, children born after IVF-ICSI presented a less significant decrease in BMI (P<0.05). In addition, for each period we identified influencing factors (maternal BMI, level of wealth indicator) associated with BMI. CONCLUSION: In the study population, the suspected epigenetic influence of IVF reported in the literature was not observed for BMI from birth to 5 years of age. Further investigations need to be conducted to determine if the suspected influence of IVF on adiposity could be expressed through other parameters.

Morphokinetics analysis of embryos derived from vitrified/warmed oocytes.

PURPOSE: Oocyte vitrification is a worldwide used technique that has proved its worth. Although it was shown not to alter oocyte integrity, a recent study concluded that it may affect oocyte embryo development. As the morphology and kinetics of embryos derived from sibling fresh and vitrified oocytes have not been described previously, the present study evaluates cleavage rate, blastomeres size, fragmentation rate, and blastocyst formation in vitrified/warmed oocyte derived embryos (VODE) as compared with sibling fresh oocytes derived embryos (FODE). METHODS: This investigation included 90 infertility cases displaying large cohort of mature oocytes at pick up, divided into 2 groups after denudation. A part of oocytes underwent ICSI while others were vitrified. Oocyte warming cycles were performed when no pregnancy was achieved using fresh eggs. Zygote to blastocyst development was recorded prospectively in an image database up to day 5. RESULTS: VODE did not show major difference as compared with FODE in terms of cleavage rate, number of blastomeres, fragmentation rate, and blastomeres size. Furthermore, percentage of morulae at day 4 and blastocysts at day 5 are not affected by oocyte vitrification. CONCLUSION: Although our results show that embryo development is not altered by oocyte vitrification, offspring follow-up is essential to exclude any adverse developmental effect of the technique.

Sperm global DNA methylation level: association with semen parameters and genome integrity.

Sperm DNA methylation abnormalities have been detected in oligozoospermic men. However, the association between sperm DNA methylation defects, sperm parameters and sperm DNA, and chromatin integrity remains poorly understood. This study was designed to clarify this issue. We recruited a cohort of 92 men (62 normozoospermic and 30 oligoasthenozoospermic) presenting for infertility evaluation during a 1-year period. Sperm global DNA methylation was evaluated by an ELISA-like method, DNA fragmentation was evaluated by flow cytometry-based terminal transferase dUTP nick end-labeling (TUNEL) assay (reported as DNA fragmentation index or DFI), and sperm denaturation was evaluated by aniline blue staining (reported as sperm denaturation index or SDI, a marker of chromatin compaction). We found a significant positive association between sperm global DNA methylation level and conventional sperm parameters (sperm concentration and motility), supported by the results of methylation analysis on H19-DMR. We also identified significant inverse relationships between sperm global DNA methylation, and, both DFI and SDI. However, sperm global DNA methylation level was not related to sperm vitality or morphology. Our findings suggest that global sperm DNA methylation levels are related to conventional sperm parameters, as well as, sperm chromatin and DNA integrity.

Normal live birth after vitrified/warmed oocytes intracytoplasmic sperm injection with immotile spermatozoa in a patient with Kartagener's syndrome.

The present article is a report on two cases of male Kartagener's syndrome enrolled in intraconjugal IVF programme due to akinetospermia. Viable spermatozoa were selected using a hypo-osmotic swelling test (HOST) and pentoxifylline activation and subsequently microinjected into vitrified/warmed oocytes. The treatment enabled one of these two couples to achieve a pregnancy and to give birth to a healthy baby girl.

[Oocyte vitrification in an ART laboratory]. / Apport de la vitrification ovocytaire dans un laboratoire d'AMP. Vitrification des ovocytes : l'âge mûr.

Oocyte vitrification has been authorized in France after the modification of French bioethics law in July 2011. This evolution will bring a dramatic change in patients' management since, from 2011, infertile couples, oocyte donation and fertility preservation programs will benefit this technique in France. We have introduced oocyte vitrification in our ART laboratory through a validation of the method using Evidence-Based Medicine model: open system Cryotop, Ethylène-glycol 15% and DMSO 15%. Based on our 1-year experience, oocyte vitrification upgrades our daily practice while also minimizing embryo cryoconservation as recommended by the law.

Effect of temozolomide on male gametes: an epigenetic risk to the offspring?

INTRODUCTION: Temozolomide is an oral alkylating agent with proven efficacy in recurrent high-grade glioma. The antitumour activity of this molecule is attributed to the inhibition of replication through DNA methylation. However, this methylation may also perturb other DNA-dependent processes, such as spermatogenesis. The ability to father a child may be affected by having this treatment. Here we report a pregnancy and a baby born after 6 cures of temozolomide. METHODS: The quality of gametes of the father has been studied through these cures and after the cessation of treatment. Sperm parameters, chromosomal content and epigenetic profiles of H19, MEST and MGMT have been analysed. RESULTS: Sperm counts decrease significantly and hypomethylation of the H19 locus increase with time even staying in the normal range. CONCLUSION: This is the first report of an epigenetic modification in sperm after temozolomide treatment suggesting a potential risk for the offspring. A sperm cryopreservation before the initiation of temozolomide treatment should be recommended.