Jamie Grifo

Diminished effect of maternal age on implantation after preimplantation genetic diagnosis with array comparative genomic hybridization.

OBJECTIVEnTo assess the relationship between maternal age, chromosome abnormality, implantation, and pregnancy loss.nnnDESIGNnMulticenter retrospective study.nnnSETTINGnIVF centers in the United States.nnnPATIENT(S)nIVF patients undergoing chromosome screening.nnnINTERVENTION(S)nEmbryo biopsy on day 3 or day 5/6 with preimplantation genetic diagnosis (PGD) by array comparative genomic hybridization.nnnMAIN OUTCOME MEASURE(S)nAneuploidy, implantation, pregnancy, and loss rates.nnnRESULT(S)nAneuploidy rates increased with maternal age from 53% to 93% for day 3 biopsies and from 32% to 85% for blastocyst biopsies. Implantation rates for euploid embryos for ages <35-42 years did not decrease after PGD: ranges 44%-32% for day 3 and 51%-40% for blastocyst. Ongoing pregnancy rates per transfer did not decrease for maternal ages <42 years after PGD with day 3 biopsy (48.5%-38.1%) or blastocyst biopsy (64.4%-54.5%). Patients >42 years old had implantation rates of 23.3% (day 3), 27.7% (day 5/6), and the pregnancy rate with day 3 biopsy was 9.3% and with day 5 biopsy 10.3%.nnnCONCLUSION(S)nSelective transfer of euploid embryos showed that implantation and pregnancy rates were not significantly different between reproductively younger and older patients up to age 42 years. Some patients who start an IVF cycle planning to have chromosome screening do not have euploid embryos available for transfer, a situation that increases with advancing maternal age. Mounting data suggests that the dramatic decline in IVF treatment success rates with female age is primarily caused by aneuploidy.

Elevated day 3 serum follicle stimulating hormone and/or estradiol may predict fetal aneuploidy

OBJECTIVEnTo determine whether baseline serum FSH and/or E2 concentrations can predict the risk for fetal chromosomal abnormalities.nnnDESIGNnCase control study.nnnSETTINGnReproductive technology program at a university hospital.nnnPATIENT(S)nPatients who underwent dilation and curettage (D + C), and whose products of conception were karyotyped.nnnINTERVENTION(S)nPatients underwent natural conception or controlled ovarian hyperstimulation followed by intrauterine insemination, in vitro fertilization and embryo transfer, gamete intrafallopian transfer, or zygote intrafallopian transfer.nnnMAIN OUTCOME MEASURE(S)nBaseline serum FSH and E2 concentrations and fetal karyotype.nnnRESULT(S)nGenetic evaluation of 78 D + C specimens revealed 34 normal and 44 abnormal fetal karyotypes. A significantly greater proportion of women with abnormal fetal karyotype had elevated baseline serum FSH (> or =15 mIU/mL [RIA] or 10 mIU/mL [Immulite]) and/or E2 > or = 50 pg/mL [Immulite]) compared with women of normal fetal karyotype. Among karyotypically abnormal abortuses, autosomal trisomy was the most common abnormality noted (79.5%), followed by mosaicism (6.8%), triploidy (6.8%), monosomy XO (4.5%), and balanced translocation (2.3%).nnnCONCLUSION(S)nBaseline serum FSH and/or E2 concentrations may be valuable as predictors of fetal aneuploidy.

Idiopathic recurrent miscarriage is caused mostly by aneuploid embryos.

OBJECTIVEnTo determine any beneficial effects of preimplantation genetic screening (PGS) of all chromosomes by array comparative genomic hybridization (aCGH), with either day 3 or blastocyst biopsy, for idiopathic recurrent pregnancy loss (RPL) patients compared with their expected loss rate.nnnDESIGNnCase series report.nnnSETTINGnMultiple fertility centers.nnnPATIENT(S)nA total of 287 cycles of couples with idiopathic RPL (defined as two or more losses).nnnINTERVENTION(S)nPGS was done with day 3 biopsy (n = 193) or blastocyst biopsy (n = 94), followed by analysis with aCGH.nnnMAIN OUTCOME MEASURE(S)nSpontaneous abortion rate, euploidy rate.nnnRESULT(S)nA total of 2,282 embryos were analyzed, of which 35% were euploid and 60% were aneuploid. There were 181 embryo transfer cycles, of which 100 (55%) became pregnant with an implantation rate of 45% (136 sacs/299 replaced embryos) and 94 pregnancies (92%) were ongoing (past second trimester) or delivered. The miscarriage rate was found to be only 6.9% (7/102), compared with the expected rate of 33.5% in an RPL control population and 23.7% in an infertile control population.nnnCONCLUSION(S)nCurrent PGS results with aCGH indicate a significant decrease in the miscarriage rate of idiopathic RPL patients and high pregnancy rates. Furthermore, this suggests that idiopathic recurrent miscarriage is mostly caused by chromosomal abnormalities in embryos.

Preembryo biopsy and analysis of blastomeres by in situ hybridization

We developed a method for the biopsy of preimplantation mouse embryos (preembryos) at the four- to eight-cell stage, which uses partial zona pellucida dissection. The preembryos were collected in calcium- and magnesium-free phosphate-buffered saline solution with 0.01% ethylenediaminetetraacetic acid, 0.1 mol/L sucrose, and 4 mg/ml of bovine serum albumin to facilitate removal of blastomeres. This allows entry of a fine micropipette into the perivitelline cavity with subsequent removal of a single blastomere by gentle suction. The majority of embryos (75%) from which biopsy specimens were obtained in this fashion developed to the blastocyst stage. The blastomeres obtained were mainly intact and they were fixed to glass slides. After permeabilization, in situ hybridization was performed with chromosome X- and chromosome 3-specific probes. Human unfertilized eggs and blastomeres from human polyspermic embryos also have been analyzed by in situ hybridization with chromosome specific probes. The combination of nondestructive embryo biopsy and in situ hybridization is a possible approach for preimplantation genetic diagnosis.

Aldose reductase inhibition prevents galactose-induced ovarian dysfunction in the Sprague-Dawley rat

OBJECTIVEnOur objective was to determine whether impaired ovarian function induced by short-term creation of a galactosemic state in the rat might be prevented by the coadministration of an aldose reductase inhibitor.nnnSTUDY DESIGNnPrepubertal Sprague-Dawley rats were fed four different diets including (1) control, (2) 40% galactose, (3) 40% galactose and an aldose reductase inhibitor, and (4) an aldose reductase inhibitor with the control diet. Percentage germinal vesicle breakdown, postovulatory oocyte quantities, hormonal parameters, ovarian histologic evaluation, and ovarian galactitol concentrations were determined.nnnRESULTSnThe galactose-fed animals (group 2) had decreased germinal vesicle breakdown (47%) versus control (69%, p < 0.05). Galactose-exposed animals had significantly decreased quantities of postovulatory eggs (6.4 per animal) after menotropin ovarian stimulation in comparison with controls (14.1, p < 0.01). In rats exposed to high dietary levels of galactose (group 2) ovarian galactitol concentrations were significantly higher (protein 42.12 mumol/gm versus 0.0 for controls, p < 0.005). When galactose-fed animals received the aldose reductase inhibitor, ovarian accumulation of galactitol was significantly reduced and the observed detrimental effects on the oocyte were prevented.nnnCONCLUSIONnGalactitol accumulation or metabolic flux through aldose reductase in galactosemic rodents may be involved in the demonstrated ovarian dysfunction.

Poor embryo quality: The answer lies (mostly) in the egg.

A 37-year-old gravida 0 infertility patient presented for evaluation. Her clinical workup was entirely normal, including a serum FSH level of 9 IU/L on day 3 and a good response to gonadotropin stimulation. This was her first IVF cycle. Three embryos were transferred, and three were frozen (Fig. 1). She did not conceive during the fresh or frozen transfer cycle. More importantly, her embryos were especially disappointing, being characterized by slow division rate, poor cellular morphology, and significant fragmentation.

Serum progesterone levels greater than 20 ng/dl on day of embryo transfer are associated with lower live birth and higher pregnancy loss rates

BackgroundProgesterone (P4) is essential for support of the endometrium and implantation of an embryo in the normal menstrual cycle. In programed frozen embryo transfer cycles using exogenous P4 is necessary, as the endogenous production of P4 requires a functioning corpus luteum that is not present in programed cycles. To date, there is continuing debate about ideal serum estradiol and P4 values in frozen embryo transfer cycles.MethodsPatients underwent single euploid embryo frozen transfer cycles from 2010 to 2013 at a single large academic center. Patients using donor oocytes and patients with changes in progesterone dose during the cycles in question were excluded. All cycles were programed and intramuscular P4 was used exclusively. Only patients administering the same daily dose of P4 throughout the cycle were included (Nu2009=u2009213 patients). Main outcomes were ongoing pregnancy/live birth rates (OPR/LBR), clinical pregnancy rates (CPR), and spontaneous abortions/biochemical pregnancies. CPR was defined by the presence of a sac on 1st trimester ultrasound. Missed abortions were calculated per pregnancy with a sac. Receiver operator characteristic curves (ROC curves) and chi-squared tests were performed for statistical analysis.ResultsTwo groups based on day 19 P4 levels were compared (group A, P4u2009<u200920xa0ng/ml; group B, P4u2009>u200920xa0ng/ml). OPR/LBRs were 65 vs. 49xa0%, group A vs. B, p valueu2009=u20090.02, RRu2009=u20091.33 (1.1–1.7). Missed abortion and biochemical rates were higher in group B as opposed to group A, 27 vs. 12xa0%, pu2009=u20090.01, RRu2009=u20090.45(0.24–0.86). When P4 was stratified into five groups based on nanogram per milliliter of progesterone on day 19 (10–15, 15–20, 20–30, 30–40, and >40), there was a trend downward in OPR/LBR (70, 62, 52, 50, and 33xa0%, respectively). There was also an increase in missed abortion/biochemical rates (7, 15, 27, 32, and 20xa0%, respectively). Multiple logistic regression showed an increase in OPR/LBR when accounting for age, day 2 FSH, weight, number of embryos biopsied, and number of euploid embryos.ConclusionP4 levels >20xa0ng/ml on the day of transfer (during frozen single euploid embryo transfer cycles) were associated with decreased OPR/LBR.

Baseline ovarian cysts do not affect clinical response to controlled ovarian hyperstimulation for in vitro fertilization

OBJECTIVEnTo evaluate the effect of baseline ovarian cysts at the onset of controlled ovarian hyperstimulation for in vitro fertilization (IVF) on cycle outcome.nnnDESIGN, PATIENTSnA review of 82 IVF cycles in 29 women in which each patient served as her own control. The stimulation regimen for each patient remained constant over time. Each woman had at least one cycle in which an ovarian cyst measuring 14 to 53 mm was present at baseline and one cycle in which no such cyst was present.nnnSETTINGnThe In Vitro Fertilization Program at Yale University School of Medicine.nnnRESULTSnThere was no statistically significant difference in cycle cancellation rates, baseline serum estradiol (E2), peak serum E2, number of follicles present at retrieval, number of oocytes retrieved, or fertilization rate between groups. Stimulation regimen, cyst size, and age were unrelated to outcome. The number of cysts present at baseline correlated positively with the number of follicles present at retrieval.nnnCONCLUSIONnBaseline ovarian cysts in the setting of a low baseline E2 level do not affect the clinical response to controlled ovarian hyperstimulation in IVF cycles.

A greater number of euploid blastocysts in a given cohort predicts excellent outcomes in single embryo transfer cycles.

PurposeThis multicentered retrospective study analyzed whether the quantity of euploid blastocysts in a given cohort after comprehensive chromosomal screening can be used to identify candidates for single embryo transfer.MethodsBlastocysts from 437 patients underwent trophectoderm biopsy followed by array comparative genomic hybridization. Embryos were then selected for single or double embryo transfer. The number of euploid blastocysts produced and transferred for each patient was recorded, as was clinical pregnancy rate and multiple gestation rate.ResultsIn patients with ≤3 euploid blastocysts, clinical pregnancy rate was higher in double, compared to single embryo transfers. However, in patients with ≥4 euploid blastocysts, clinical pregnancy rate was not reduced with single embryo transfer was performed, whereas the multiple gestation rate was greatly reduced.ConclusionsSize of the euploid embryo cohort is a marker for success in single embryo transfer cycles. Patients who produce at least four euploid blastocysts are outstanding candidates for single embryo transer.

UPDATE IN PREIMPLANTATION GENETIC DIAGNOSIS : SUCCESSES, ADVANCES, AND PROBLEMS

The field of preimplantation genetic diagnosis has undergone significant advances since the report of the first birth from this method in 1990. The first birth in the USA was reported in 1992, as was the first successful diagnosis and delivery of a baby free of a single gene defect disorder (cystic fibrosis and then Tay Sachs). Investigators have now reported approximately 40 births worldwide from preimplantation genetic diagnosis using the polymerase chain reaction and fluorescent in-situ hybridization methods to analyze single cells removed from early cleavage stage preimplantation embryos. The International Working Group on Preimplantation Genetics meets annually to discuss progress and pitfalls in this field. Although preimplantation genetic diagnosis offers hope to patients at risk of transmitting disease, there are many technical hazards of this experimental procedure. Technical difficulties must be overcome in order for preimplantation genetic diagnosis to become a standard clinical tool. This review will highlight some of the recent advances and problems in the field of preimplantation genetic diagnosis.