Jason M. Franasiak

The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening

OBJECTIVE To determine the relationship between the age of the female partner and the prevalence and nature of human embryonic aneuploidy. DESIGN Retrospective. SETTING Academic. PATIENT(S) Trophectoderm biopsies. INTERVENTION(S) Comprehensive chromosomal screening performed on patients with blastocysts available for biopsy. MAIN OUTCOME MEASURE(S) Evaluation of the impact of maternal age on the prevalence of aneuploidy, the probability of having no euploid embryos within a cohort, the complexity of aneuploidy as gauged by the number of aneuploid chromosomes, and the trisomy/monosomy ratio. RESULT(S) Aneuploidy increased predictably after 26 years of age. A slightly increased prevalence was noted at younger ages, with >40% aneuploidy in women 23 years and under. The no euploid embryo rate was lowest (2% to 6%) in women aged 26 to 37, was 33% at age 42, and was 53% at age 44. Among the biopsies with aneuploidy, 64% involved a single chromosome, 20% two chromosomes, and 16% three chromosomes, with the proportion of more complex aneuploidy increasing with age. Finally, the trisomy/monosomy ratio approximated 1 and increased minimally with age. CONCLUSION(S) The lowest risk for embryonic aneuploidy was between ages 26 and 30. Both younger and older age groups had higher rates of aneuploidy and an increased risk for more complex aneuploidies. The overall risk did not measurably change after age 43. Trisomies and monosomies are equally prevalent.

Endometrial microbiome at the time of embryo transfer: next-generation sequencing of the 16S ribosomal subunit

PurposeCharacterization of the human microbiome has become more precise with the application of powerful molecular tools utilizing the unique 16S ribosomal subunit’s hypervariable regions to greatly increase sensitivity. The microbiome of the lower genital tract can prognosticate obstetrical outcome while the upper reproductive tract remains poorly characterized. Here, the endometrial microbiome at the time of single embryo transfer (SET) is characterized by reproductive outcome.MethodsConsecutive patients undergoing euploid, SET was included in the analysis. After embryo transfer, performed as per routine, the most distal 5-mm portion of the transfer catheter was sterilely placed in a DNA free PCR tube. Next-generation sequencing of the bacteria specific 16S ribosome gene was performed, allowing genus and species calls for microorganisms.ResultsTaxonomy assignments were made on 35 samples from 33 patients and 2 Escherichia coli controls. Of the 33 patients, 18 had ongoing pregnancies and 15 did not. There were a total of 278 different genus calls present across patient samples. The microbiome at time of transfer for those patients with ongoing pregnancy vs. those without ongoing pregnancy was characterized by top genera by sum fraction. Lactobacillus was the top species call for both outcomes.ConclusionsThe data presented here show the microbiome at the time of embryo transfer can successfully be characterized without altering standard clinical practice. This novel approach, both in specimen collection and analysis, is the first step toward the goal of determining physiologic from pathophysiologic microbiota. Further studies will help delineate if differences in the microbiome at the time of embryo transfer have a reliable impact on pregnancy outcome.

Defining the “sweet spot” for administered luteinizing hormone-to-follicle-stimulating hormone gonadotropin ratios during ovarian stimulation to protect against a clinically significant late follicular increase in progesterone: an analysis of 10,280 first in vitro fertilization cycles

OBJECTIVE To determine whether different ratios of administered LH-to-FSH influence the risk of clinically relevant late follicular P elevations and whether there is an optimal range of LH-to-FSH to mitigate this risk. DESIGN Retrospective cohort. SETTING Private academic center. PATIENT(S) A total of 10,280 patients undergoing their first IVF cycle. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The ratio of exogenous LH-to-FSH throughout stimulation and association with absolute serum P level≥1.5 ng/mL on the day of hCG administration. RESULT(S) Stimulations using no administered LH (N=718) had the highest risk of P elevation≥1.5 ng/mL (relative risk [RR]=2.0; 95% confidence interval [CI] 1.8-2.2). The lowest risk of P increase occurred with an LH-to-FSH ratio of 0.30:0.60 (20%; N=4,732). In contrast, ratios<0.30, reflecting proportionally less administered LH (N=4,847) were at increased risk for premature P elevation (32%, RR=1.6; 95% CI 1.5-1.7) as were ratios>0.60 (23%, RR 1.1; 95% CI 1.0-1.3). This pattern of lowest risk in the 0.30-0.60 range held true for cycles characterized by low, normal, and high response. When performing a logistic regression to control for multiple confounding variables this relationship persisted. CONCLUSION(S) Absent or inadequate LH dosing is associated with a risk for a late follicular elevation in P sufficient to induce suboptimal outcomes. A total LH-to-FSH ratio of 0.30:0.60 was associated with the lowest risk of P elevation. Optimization of this parameter should be considered when making gonadotropin dosing decisions.

Blastocyst transfer is not associated with increased rates of monozygotic twins when controlling for embryo cohort quality

OBJECTIVE To compare monozygotic twinning (MZT) rates in patients undergoing blastocyst or cleavage-stage ET. DESIGN Retrospective cohort. SETTING Academic research center. PATIENT(S) Autologous, fresh IVF cycles resulting in a clinical pregnancy from 1999 to 2014. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Monozygotic twin pregnancy in blastocyst-stage transfer vs. cleavage-stage transfer when controlling for patient prognosis and embryo cohort quality factors. RESULT(S) There were a total of 9,969 fresh transfer cycles resulting in a pregnancy during the study period. Of these pregnancies, 234 monozygotic twin pregnancies were identified (2.4%). Of all transfers, 5,191 were cleavage-stage and 4,778 were blastocyst-stage transfers. There were a total of 99 MZT identified in the cleavage-stage group (1.9%) and 135 MZT in the blastocyst ET group (2.4%), which was significant. Multivariable logistic regression revealed that increasing age was associated with a significant reduction in MZT, regardless of transfer order. Embryo cohort quality factors, including the number and proportion of six- to eight-cell embryos and availability of supernumerary embryos, were also significant. When controlling for patient age, time period during which the cycle took place, the number and proportion of six- to eight-cell embryos, and availability of supernumerary embryos, there was no longer a difference in MZT rate between blastocyst and cleavage transfer. CONCLUSION(S) Patient prognosis and embryo cohort quality seem to be major factors in MZT rate in women undergoing blastocyst transfer. Although technology-based effects cannot be excluded, patient and embryo characteristics play an important role.

Prospective assessment of midsecretory endometrial leukemia inhibitor factor expression versus ανβ3 testing in women with unexplained infertility.

OBJECTIVE To evaluate endometrial leukemia inhibitor factor (LIF) expression as a marker of endometrial receptivity in women with unexplained infertility (UI). DESIGN Prospective case-control study. SETTING University-associated infertility clinics. PATIENT(S) Women with UI for more than 1 year and healthy control women. INTERVENTION(S) Endometrial biopsy. MAIN OUTCOME MEASURE(S) Time to pregnancy was compared between patients with UI who were evaluated for endometrial LIF protein as well as ανβ3 integrin expression. Endometrium was evaluated using immunohistochemistry (IHC) and messenger RNA by real time reverse transcriptase-polymerase chain reaction (PCR) (quantitative real-time reverse transcriptase-PCR) in samples from women with UI as well as healthy control women. RESULT(S) Leukemia inhibitor factor was expressed in epithelial cells in a cyclic fashion in controls, and overall expression in the secretory phase was similar between controls and women with UI, whereas ανβ3 integrin expression was reduced. However, using quantitative real-time PCR, LIF messenger RNA abundance was 4.4-fold lower in women with low levels of ανβ3 integrin expression compared with samples with normal integrins. By immunohistochemistry, ανβ3 integrin expression was always lacking when the histology was out of phase, whereas LIF expression was only negative in a subset of those samples. Reduced endometrial LIF expression was strongly associated with poor reproductive outcomes. CONCLUSION(S) Endometrial LIF expression peaks in the midsecretory phase and is reduced in some women with UI. The use of LIF in combination with ανβ3 integrin as biomarkers appears to be superior to integrin testing alone when evaluating endometrial receptivity, primarily because of its earlier pattern of expression during the secretory phase.

Aneuploidy across individual chromosomes at the embryonic level in trophectoderm biopsies: changes with patient age and chromosome structure

PurposeTo characterize each chromosome’s risk for being involved in embryonic aneuploidy.MethodsThis is a retrospective cohort study conducted at a single, academic center. The cohort consisted of 15,169 consecutive trophectoderm biopsies which then underwent comprehensive chromosome screening utilizing validated real-time polymerase chain reaction (RT-PCR) or single nucleotide polymosphism (SNP) array platforms. Analysis was done to determine probability of aneuploidy by chromosome, changes in that risk with increasing maternal age, and in relationship of aneuploidy to chromosomal structure as classified by prior cytogenetic literature.ResultsThe highest prevalence of imbalances leading to aneuploidy was seen for chromosomes 13, 15, 16, 18, 19, 21, and 22. While elevated in all age groups, there was a disproportionate rise in aneuploidy rates for these chromosomes with increasing maternal age. When classic cytogenetic karyotype groups were compared, the overall smaller groups D, E, and G were associated with the highest rates. Similarly, when grouped based upon structure, acrocentric chromosomes exhibited the highest rates of aneuploidy, followed by the metacentric chromosomes, with the lowest prevalence of error in those with submetacentric structures.ConclusionsThe highest rates of chromosomal aneuploidy were found in chromosomes known to be involved in clinically detectable, abnormal pregnancies, not just simply implantation failure. The rate of aneuploidy in these chromosomes rises disproportionately with age when compared to the other chromosomes which may provide information about chromosomal susceptibility to aging. The biological structure groupings did show varied aneuploidy rates which may provide insight into the biology of aneuploidy.

Multiple thrombophilic single nucleotide polymorphisms lack a significant effect on outcomes in fresh IVF cycles: an analysis of 1717 patients

PurposeThe aim of the study is to determine if thrombophilic single nucleotide polymorphisms (SNPs) affect outcomes in fresh in vitro fertilization (IVF) cycles in a large general infertility population.MethodsA prospective cohort analysis was performed at a university-affiliated private IVF center of female patients undergoing fresh non-donor IVF cycles. The effect of the following thrombophilic SNPs on IVF outcomes were explored: factor V (Leiden and H1299R), prothrombin (G20210A), factor XIII (V34L), β-fibrinogen (-455G → A), plasminogen activator inhibitor-1 (4G/5G), human platelet antigen-1 (a/b9L33P), and methylenetetrahydrofolate reductase (C677T and A1298C). The main outcome measures included positive pregnancy test, clinical pregnancy, embryo implantation, live birth, and pregnancy loss.ResultsPatients (1717) were enrolled in the study, and a total of 4169 embryos were transferred. There were no statistically significant differences in positive pregnancy test, clinical pregnancy, embryo implantation, live birth, or pregnancy loss in the analysis of 1717 patients attempting their first cycle of IVF. Receiver operator characteristics and logistic regression analyses showed that outcomes cannot be predicted by the cumulative number of thrombophilic mutations present in the patient.ConclusionsIndividual and cumulative thrombophilic SNPs do not affect IVF outcomes. Therefore, initial screening for these SNPs is not indicated.

Embryonic aneuploidy: overcoming molecular genetics challenges improves outcomes and changes practice patterns.

Since its inception, in vitro fertilization (IVF) has pursued molecular technology to improve patient outcomes, leading to enhanced methods of embryo selection. Comprehensive chromosomal screening (CCS) is a powerful tool that decreases maternal and neonatal morbidity due to multiple gestations by allowing the transfer of fewer embryos while maintaining success rates. To optimize this genetic test, physiological principles limiting the timing and type of cells to be removed had to be realized. Molecular barriers involved in genome amplification and ensuring the accuracy and validity of the CCS platform required a multistep approach to ensure that this technology was not used prematurely. Only after ensuring that the potential for harm was minimized and benefit maximized could clinicians use this technology to improve patient care.

Demographics of Cancer in the Reproductive Age Female

Cancer in reproductive age women represents a significant source of morbidity and mortality. The treatment of cancer in this age group whether it entails chemotherapy, radiotherapy, or surgical resection often results in survivors with impaired or absent reproductive potential without assisted reproductive technologies (ART). Although primary treatment goals are swift diagnosis, treatment, and follow-up of the primary malignancy, a strong factor in long-term emotional well-being of cancer survivors is the ability to parent a child. To achieve this goal requires a working knowledge of common malignancies faced in this age group, their treatments at various stages of disease, the treatment’s impact on fertility, and the therapeutic options available to patients for fertility preservation and restoration. Ultimately, a collaborative, multidisciplinary team approach will provide optimal management. This chapter reviews the epidemiology of common cancers in women of reproductive age and includes: breast cancer, lung cancer, colorectal cancer, cervical cancer, uterine cancer, and ovarian cancer. Their prevalence and common treatment strategies are discussed.

Curbside consultations in the era of social media connectivity and the creation of the Society for Reproductive Endocrinology and Infertility Forum

Social media, as defined by Wikipedia, the social encyclopedia, is a computer-mediated tool that allows people to create, share, or exchange information, career interests, ideas, and pictures/videos in virtual communities and networks. A Google search for the term yields 1.2 billion hits and you are hard pressed to get through your morning coffee without being asked to give or receive information through one of the many outlets that fall under this umbrella. Given its meteoric rise, it was only a matter of time before electronic connectivitys impact on the medical field was felt. A Pubmed search for ‘‘social media’’ as the keyword in 2007 would have yielded zero search results, although ‘‘social networks’’ were noted to have ‘‘considerable opportunity to advance the public health’’ (1). The first four results for ‘‘social media’’ were listed the ensuing year in 2008 followed by an exponential rise culminating in nearly 4,000 results in the medical literature as of January 2016. Not only is it being studied in terms of patient and physician interaction, it has also become a ‘‘hallway forum’’ for the old curbside consultation. There is little doubt that the way the world electronically communicates is changing, and the medical field is no exception. This evolution in medical communication brings along with it some significant concerns. Many question the validity or trustworthiness of information dispersed on social media given the lack of requirements or disclosure of user qualifications. Most platforms require only an internet connection, circumventing the traditional gatekeepers previously in place in the media. A second concern is the existence of disparities in social media, less having to do with access in modern society, and more having to do with the desire to learn the new skills required to function in this quickly evolving environment— the so called ‘‘digital divide.’’ These issues take a backseat to privacy which is of paramount concern when discussing social media in the medical community. In the era of big datamining, electronicfingerprints are constantly being captured, processed, and analyzed. Indeed, electronic tracking via third party applications allow data miningwithout user consent or knowledge. Socialmedia integration in the work environment can lead to conflicts with employees and employers as popular platforms, such as Facebook, Twitter, Instagram, and others, are used to fulfill professional roles when they are better suited for social communication. These concerns over both patient and personal confidentiality, reputation, and risk management need to be acknowledged and squarely addressed. In a study of 57 general surgery residency programs in 2014, 32% of residents had publically identifiable Facebook profiles that contained unprofessional content ranging from binge drinking and sexually suggestive photographs to clear violations of the Health Insurance Portability and Accountability Act (HIPAA) in 26% of cases (2). In response to this growth and in an attempt to establish guidelines for its membership, the American Congress of Obstetricians and Gynecologists issued Committee Opinion 622 in February 2015, which addressed the use of