A.P. Melnick

Morphologic grading of euploid blastocysts influences implantation and ongoing pregnancy rates

OBJECTIVE To determine whether blastocyst grading can predict pregnancy outcomes in the frozen-thawed embryo transfer (FET) of euploid blastocysts. DESIGN Retrospective cohort study. SETTING Academic medical center. PATIENT(S) Women who underwent FET of euploid embryo(s) between January 2013 and December 2015, with blastocysts were divided into four groups based on their morphologic grading before cryopreservation: excellent (≥3AA), good (3-6AB, 3-6BA, 1-2AA), average (3-6BB, 3-6AC, 3-6CA, 1-2AB, 1-2BA), and poor (1-6BC, 1-6CB, 1-6CC, 1-2BB). INTERVENTION(S) FET. MAIN OUTCOMES MEASURE(S) Ongoing pregnancy rate (OPR). RESULT(S) A total of 417 FET cycles (477 embryos) were included. Excellent-quality embryos (n = 38) yielded a statistically significantly higher OPR than poor-quality embryos (n = 106) (84.2% vs. 35.8%; adjusted odds ratio 11.0; 95% confidence interval, 3.8-32.1) and average-quality embryos (n = 197) (84.2% vs. 55.8%; adjusted odds ratio 4.8; 95% confidence interval, 1.7-13.3). Good-quality embryos (n = 76) were associated with a statistically significantly higher OPR than poor-quality embryos (61.8% vs. 35.8%). These odds ratios were adjusted for patients age, body mass index, number of transferred embryos, type of frozen cycle, peak endometrial thickness, day of trophectoderm biopsy (5 or 6), and total number of euploid embryos for each patient. An inner cell mass grade of A yielded a statistically significantly higher OPR than ICM grade C (76.2% vs. 13.5%) or grade B (76.2% vs. 53.6%) after controlling for all confounders. CONCLUSION(S) Contrary to prior published studies, the current data suggest that blastocyst morphologic grading and particularly inner cell mass grade is a useful predictor of OPR per euploid embryo. Morphologic grading should be used to help in the selection among euploid blastocysts.

Sliding scale HCG trigger yields equivalent pregnancy outcomes and reduces ovarian hyperstimulation syndrome: Analysis of 10,427 IVF-ICSI cycles

Objective To evaluate pregnancy outcomes and the incidence of ovarian hyperstimulation syndrome (OHSS) using a sliding scale hCG protocol to trigger oocyte maturity and establish a threshold level of serum b-hCG associated with optimal oocyte maturity. Design Retrospective cohort. Setting Academic medical center. Patients Fresh IVF cycles from 9/2004–12/2011. Intervention 10,427 fresh IVF-ICSI cycles met inclusion criteria. hCG was administered according to E2 level at trigger: 10,000IU vs. 5,000IU vs. 4,000IU vs. 3,300IU vs. dual trigger (2mg leuprolide acetate + 1,500IU hCG). Serum absorption of hCG was assessed according to dose and BMI. Main outcome measures Oocyte maturity was analyzed according to post-trigger serum b-hCG. Fertilization, clinical pregnancy, live birth and OHSS rates were examined by hCG trigger dose. Results Post-trigger serum b-hCG 20–30, 30–40, and 40–50 mIU/mL was associated with reduced oocyte maturity as compared b-hCG >50 (67.8% vs. 71.4% vs. 73.3% vs. 78.9%, respectively, P<0.05). b-hCG 20–50 mIU/mL was associated with a 40.1% reduction in live birth (OR 0.59, 95% CI 0.41–0.87). No differences in IVF outcomes per retrieval were seen for varying doses of hCG or dual trigger when controlling for patient age. The incidence of moderate to severe OHSS was 0.13% (n = 14) and severe OHSS was 0.03% (n = 4) of cycles. Conclusions Moderate stimulation with sliding scale hCG at trigger and fresh transfer is associated with low rates of OHSS and favorable pregnancy rates. Doses as low as 3,300IU alone or dual trigger with 1,500IU are sufficient to facilitate oocyte maturity.

Spontaneous bilateral torsion of fallopian tubes presenting as primary infertility

Background: Spontaneous torsion of the fallopian tubes is a rare condition, usually seen in acute settings or as incidental findings during laparoscopy. Presentation of the case: A 34-year-old nulligravid woman with inability to conceive for 7 months presented to our center. Her hysterosalpingography revealed a blind-ending right fallopian tube, and a blocked and dilated left fallopian tube. Laparoscopy showed a long, auto-amputated right fallopian tube, disconnected from the fimbriae and a long, dilated left fallopian tube, with several twists around its axis. Bilateral salpingectomy was performed. The patient subsequently underwent IVF, resulting in an ongoing pregnancy. Conclusion: Spontaneous torsion of the fallopian tubes can manifest as primary infertility without any antecedent symptoms and should be considered in the differential diagnosis of bilateral tubal obstruction.

Autologous endometrial coculture biopsy: is timing everything?

OBJECTIVE To determine whether endometrial biopsy timing affects implantation rates and pregnancy outcomes in patients undergoing in vitro fertilization (IVF) with autologous endometrial coculture (AECC). DESIGN Retrospective cohort study. SETTING Academic medical center. PATIENT(S) All patients with a history of at least one failed IVF cycle who underwent an IVF-AECC cycle at our center from May 2004 to November 2013 were included. INTERVENTION(S) Patients underwent luteal-phase endometrial biopsy in preparation for IVF. Biopsy samples were used for IVF in either the subsequent menstrual cycle or a future cycle. Embryos were cultured in AECC media and transferred on day 3. MAIN OUTCOME MEASURE(S) A total of 2,533 cycles of 1,719 patients who underwent an IVF-AECC cycle were identified. Cycles were stratified by endometrial biopsy timing. Clinical outcomes, including implantation, pregnancy, and live birth rates, were analyzed and compared between the two groups. RESULT(S) A total of 1,416 coculture biopsies were performed in the menstrual cycle before IVF and 1,117 were performed more than one cycle before IVF. The two groups were similar in age, body mass index, number of mature oocytes retrieved, and best embryo grade. There were no significant differences in implantation, clinical pregnancy, or live birth rates, with adjusted relative risks of 1.02 (95% confidence interval [CI] 0.92-1.13), 1.02 (95% CI 0.91-1.14), and 0.99 (95% CI 0.86-1.16), respectively. CONCLUSION(S) Coculture biopsy in the cycle preceding IVF does not increase implantation, clinical pregnancy, or live birth rates compared with biopsies performed more than one cycle before IVF. Previously demonstrated improvements in embryo quality and pregnancy outcomes in patients undergoing IVF with AECC are probably not attributable to biopsy-induced endometrial injury.