Mary D Hinckley

Incidence of monozygotic twinning with blastocyst transfer compared to cleavage-stage transfer

OBJECTIVE To evaluate the incidence of monozygotic twinning (MZT) in pregnancies conceived after blastocyst transfer compared to cleavage-stage transfer. DESIGN Retrospective study. SETTING University IVF program. PATIENT(S) All IVF patients with viable pregnancies conceived during a 4-year period. INTERVENTION(S) Blastocyst transfer or day 3 ET. MAIN OUTCOME MEASURE(S) Incidence of MZT assessed by transvaginal ultrasound. RESULT(S) There were 11 incidences of MZT in 197 viable pregnancies (5.6%) with blastocyst transfer compared to 7 of 357 viable pregnancies (2%) with day 3 ET. In 10 of 18 pregnancies, MZT was observed in the setting of a higher order multiple gestation (6 of 11 for blastocyst transfer and 4 of 7 for day 3 ET). In the day 3 ET group, assisted hatching or intracytoplasmic sperm injection (ICSI) did not increase MZT (4 of 213, 1.9%) compared to cycles without zona breaching (3 of 144, 2.1%). Similarly, in the blastocyst-transfer group, ICSI did not increase the incidence of MZT (4 of 74, 5.5% for ICSI and 7 of 123, 5.7% for non-ICSI IVF). CONCLUSION(S) Compared to day 3 ET, blastocyst transfer appears to significantly increase the incidence of gestations with MZT. This information should be taken into account when counseling patients about the pros and cons of extended culture.

Comparison of blastocyst transfer with day 3 embryo transfer in similar patient populations

OBJECTIVE To compare implantation and pregnancy rates (PRs) achieved with blastocyst transfer (BT) and day 3 ET in similar patient populations. DESIGN Retrospective analysis. SETTING Academic infertility center. PATIENT(S) One hundred consecutive patients <40 years undergoing IVF, each with more than three eight-cell embryos on day 3. INTERVENTION(S) Patients used their own eggs for IVF or IVF and intracytoplasmic sperm injection. Embryos were cultured in P1 medium (Irvine Scientific, Santa Ana, CA) until day 3, when they were either transferred or, in the case of embryos for BT, incubated in Blastocyst Medium (Irvine Scientific), followed by transferring on day 5. MAIN OUTCOME MEASURE(S) Implantation and PRs. RESULT(S) There were no statistically significant differences in patient age, FSH level, or number of oocytes or zygotes. The BT group had fewer embryos transferred (mean, 2.4) compared with the day 3-ET group (mean, 4.6). The viable PR (cardiac activity at 6-7 weeks was considered indicative of a viable pregnancy) was higher with BT (68%, 34/50) than with day 3 ET (46%, 23/50). The implantation rate was increased with BT (47%, 56 sacs/120 embryos) compared with day 3 ET (20%, 46 sacs/231 embryos). CONCLUSION(S) The BT group in our study had higher implantation and PRs compared with the day 3-ET group. Better embryo selection, improved embryo-uterine synchrony, and decreased cervical mucus on day 5 may have accounted for the enhanced outcome. Our data support the use of BT to limit the number of embryos transferred while improving PRs.

Rodent oocytes express an active adenylyl cyclase required for meiotic arrest

The intracellular levels of cAMP play a critical role in the meiotic arrest of mammalian oocytes. However, it is debated whether this second messenger is produced endogenously by the oocytes or is maintained at levels inhibitory to meiotic resumption via diffusion from somatic cells. Here, we demonstrate that adenylyl cyclase genes and corresponding proteins are expressed in rodent oocytes. The mRNA coding for the AC3 isoform of adenylyl cyclase was detected in rat and mouse oocytes by RT-PCR and by in situ hybridization. The expression of AC3 protein was confirmed by immunocytochemistry and immunofluorescence analysis in oocytes in situ. Cyclic AMP accumulation in denuded oocytes was increased by incubation with forskolin, and this stimulation was abolished by increasing intraoocyte Ca(2+) with the ionophore A23187. The Ca(2+) effects were reversed by an inhibitor of Ca(2+), calmodulin-dependent kinase II. These regulations of cAMP levels indicate that the major cyclase that produces cAMP in the rat oocyte has properties identical to those of recombinant or endogenous AC3 expressed in somatic cells. Furthermore, mouse oocytes deficient in AC3 show signs of a defect in meiotic arrest in vivo and accelerated spontaneous maturation in vitro. Collectively, these data provide evidence that an adenylyl cyclase is functional in rodent oocytes and that its activity is involved in the control of oocyte meiotic arrest.

Accuracy of day 3 criteria for selecting the best embryos

OBJECTIVE To assess the accuracy of day 3 morphologic criteria in identifying the best embryos. DESIGN Prospective observational study. SETTING University IVF program. PATIENT(S) One hundred cycles in women desiring blastocyst transfer who had > or =3 eight-cell embryos on day 3. INTERVENTION(S) On day 3, the embryologist chose the two embryos that would have been transferred that day. On day 5, embryos were examined to determine the best and second-best blastocysts. MAIN OUTCOME MEASURE(S) Accuracy of day 3 picks as measured in culture on day 5, outcome of nontransferred picks, and cryopreservation rate. RESULT(S) All cycles reached the blastocyst stage and 73% had cryopreservation. The mean number of blastocysts was 4.8 (3.2 on day 5 and 1.6 on day 6). Neither pick was chosen in 39% of cycles; one pick was transferred in 38%; and both picks were transferred in 23%. Of 116 nontransferred picks, 51 were frozen and 65 arrested, with both picks arresting in 9 cycles. The single best blastocyst was chosen from the picks in 39% of cycles. CONCLUSION(S) Morphologic criteria for cleavage-stage embryo selection may fall short when the transfer is limited to two embryos. Culture to blastocyst is warranted in this population to avoid high-order multiples and still be able to choose the two embryos with the highest implantation potential.

Comparison of the sex ratio with blastocyst transfer and cleavage stage transfer.

AbstractPurpose: To evaluate the sex ratio in births conceived with blastocyst transfer compared to day 3-ET. Methods: A retrospective analysis of IVF patients who became pregnant after blastocyst or cleavage stage transfer at Stanford University Hospital and a literature review were performed. Result(s): In the day 3-ET group, the male-to-female (M/F) ratio was 157/139 (53%/47%) compared to 97/66 (59.5%/40.5%) in the blastocyst group (P = 0.18). Similar trends have been found in individual studies in the literature but reached statistical significance in only one out of six reports reviewed. The combined data from our study and the literature show a male-to-female ratio of 797/594 (57.3%/42.7%) in blastocyst transfer compared to 977/932 (51.2%/48.8%) in day 3-ET (P = 0.001). Conclusion(s): Although individual studies may lack power to show an altered sex ratio with blastocyst transfer, the combined data presented in this report do suggest that the M/F ratio is higher with blastocyst transfer compared to cleavage stage transfer.

Rapid reaccumulation of hydrometra after drainage at embryo transfer in patients with hydrosalpinx

OBJECTIVE To report the occurrence and management of hydrometra at the time of scheduled embryo transfer in two patients who underwent drainage of hydrosalpinges at oocyte retrieval. DESIGN Case report. University IVF clinic. PATIENT(S) Two patients with hydrosalpinges visible on ultrasonography who deferred tubal surgery. Although no fluid was seen at the time of oocyte retrieval, hydrometra was noticed and drained before planned embryo transfer (ET). MAIN OUTCOME MEASURE(S) Reoccurrence of hydrometra after drainage. RESULT(S) Rapid reaccumulation of hydrometra despite drainage was seen in both patients, one of whom had reoccurrence in 1 hour. Embryo transfer was deferred until after tubal surgery, and all embryos were cryopreserved. CONCLUSION(S) In patients with hydrosalpinges, ultrasonography before ET is useful to detect newly developed hydrometra. Aspiration of the uterine fluid is unlikely to help because of rapid reaccumulation of hydrometra. Cryopreservation of the embryos for future transfer after the hydrosalpinx is removed or ligated is recommended.

Effect of ICSI on subsequent blastocyst development and pregnancy rates

AbstractPurpose: To investigate whether ICSI (intracytoplasmic sperm injection)results in decreased blastocyst formation and pregnancy compared to IVF (in vitro fertilization). Methods: We performed a retrospective analysis of blastocyst transfer (BT)offered routinely to patients under age 40 with ≥ three 8-cell embryos on day 3 and compared IVF to ICSI cycles. Sequential media were used with P1 until day 3, then Blastocyst Medium until day 5/6. Results: There were 131 IVF and 75 ICSI cycles. There was no difference in age, number of oocytes, zygotes, 8-cell embryos, blastocysts on days 5 and 6, or embryos transferred. Progression to blastocyst was similar (78% for IVF and 73% for ICSI) as was the viable pregnancy rate (51.4% for IVF and 55% for ICSI). No cycles failed to form blastocysts. Conclusions: The progression to blastocyst and the likelihood of conceiving aviable pregnancy were unaltered by ICSI. Thus it seems appropriate for programs to offer BT to patients undergoing ICSI using the same inclusion criteria applied to their IVF patients.

Comparison of blastocyst transfer to day 3 transfer with assisted hatching in the older patient.

OBJECTIVE To compare cycle outcomes in similar populations of women over 40 who underwent blastocyst transfer compared with women who had day 3 embryo transfer with assisted hatching (ET/AH). DESIGN Retrospective study. STTING: University hospital-based program. PATIENT(S) Eighty-six IVF cycles in women ages 40 to 43 years who had more than three eight-cell embryos on day 3. On day 3 of embryo culture, patients chose either to undergo blastocyst transfer or day 3 ET/AH. MAIN OUTCOME MEASURE(S) Pregnancy and cryopreservation rates were recorded. RESULT(S) In 48 cycles, blastocyst transfer was performed, and in 38 cycles day 3 ET/AH was performed. There was no statistically significant difference between the blastocyst transfer group and the day 3 ET/AH group with respect to age (41.1 +/- 0.9 years vs. 41.6 +/- 0.8 years), percentage of intracytoplasmic sperm injection cycles (29.2% vs. and 27.6%), number of oocytes (14.9 +/- 5.6 vs. 12.8 +/- 4.0), or number of eight-cell embryos (6.1 +/- 2.2 vs. 5.4 +/- 1.5). Significantly fewers embryos were transferred per cycle with blastocyst transfer (2.6 +/- 1.0) compared with day 3 ET/AH (5.9 +/- 2.0). The viable pregnancy rate was similar in the blastocyst transfer group (29.2%) and in the day 3 ET/AH group (26.3%). Embryos for cryopreservation were available in significantly more cycles in the blastocyst transfer group (52.1%) than in the day 3 ET/AH group (21.1%). Cleavage stage arrest occurred only in one cycle. CONCLUSIONS Blastocyst transfer appears to be as effective as day 3 ET/AH in older patients with good embryos. Higher cryopreservation rate in the blastocyst transfer group may represent an advantage over day 3 ET/AH. Older women may also benefit from the information that extended culture provides them regarding their oocyte quality.

Percutaneous oocyte retrieval from an inguinal ovary

Ectopic locations of the ovary are rare, but should be considered when an ovary is absent on traditional imaging studies. The images presented are of a patient with recurrent pregnancy loss and infertility. Of note, she also had a corrected tetralogy of Fallot and normal karyotype. Hysterosalpingogram revealed a right unicornuate uterus with the presence and patency of only the right fallopian tube. Magnetic resonance imaging showed an absent left kidney and ovary and a left inguinal hernia. The left ovary was discovered on the seventh day of ovarian stimulation for in vitro fertilization when a mass was seen in the inguinal region (Fig. 1) with follicles visualized by transabdominal ultrasound. The risk of ovarian torsion was discussed with the patient who elected to continue the cycle. Oocyte retrieval was performed from the right ovary transvaginally. Then, using a transvaginal ultrasound probe with needle guide (Figs. 2 and 3), the needle was advanced percutaneously through the abdominal wall into the inguinal ovary allowing aspiration of normal-appearing oocytes. The patient did not conceive with the fresh transfer of a single blastocyst but conceived after a thaw transfer of a single embryo and delivered a healthy female at 34 weeks’ gestation. She plans to undergo corrective surgery to repair the inguinal hernia and reposition the ovary into the pelvic cavity.

High gonadotropin dosage does not affect euploidy and pregnancy rates in IVF PGS cycles with single embryo transfer

STUDY QUESTION Does high gonadotropin dosage affect euploidy and pregnancy rates in PGS cycles with single embryo transfer? SUMMARY ANSWER High gonadotropin dosage does NOT affect euploidy and pregnancy rates in PGS cycles with single embryo transfer. WHAT IS KNOWN ALREADY PGS has been proven to be the most effective and reliable method for embryo selection in IVF cycles. Euploidy and blastulation rates decrease significantly with advancing maternal age. In order to recruit an adequate number of follicles, the average dosage of gonadotropins administered during controlled ovarian stimulation in IVF cycles often increases significantly with advancing maternal age. STUDY DESIGN, SIZE, AND DURATION A retrospective study of SNP (Single Nucleotide Polymorphism) PGS outcome data from blastocysts biopsied on day 5 or day 6 was conducted to identify differences in euploidy and clinical pregnancy rates. Seven hundred and ninety four cycles of IVF treatment with PGS between January 2013 and January 2017 followed by 651 frozen embryo transfers were included in the study (506 patients, maternal age (y.o.) - 37.2 ± 4.31). PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 4034 embryos were analyzed (5.1 ± 3.76 per case) for euploidy status. All embryos were vitrified after biopsy, and selected embryos were subsequently thawed for a hormone replacement frozen embryo transfer cycle. All cycles were analyzed by total gonadotropin dosage (<3000 IU, 3000-5000 IU and >5000 IU), by number of eggs retrieved (1-5, 5-10, 10-15 and >15 eggs) and patients age (<35, 35-37, 38-40 and ≥41 y.o.). Clinical pregnancy rate was defined by the presence of a fetal heartbeat at 6-7 weeks of gestation. MAIN RESULTS AND THE ROLE OF CHANCE Euploidy rates within the same age group were not statistically different regardless of the total dosage of gonadotropins used or the number of eggs retrieved. In the youngest group of patients (<35 y.o. - 187 IVF cycles) euploidy rates ranged from 62.3% (<3000 IU were used in the IVF cycle) to 67.5% (>5000 IU were used in the IVF cycle) (OR = 0.862, 95% CI 0.687-1.082, P = 0.2) and from 69.5% (1-5 eggs retrieved) to 60.0% (>15 eggs retrieved) (OR = 0.658, 95% CI 0.405-1.071, P = 0.09). Similar data were obtained in the oldest group of patients (≥41 y.o. - 189 IVF cycles): euploidy rates ranged from 30.7 to 26.4% (OR = 0.811, 95% CI 0.452-1.454, P = 0.481) when analyzed by total dosage of gonadotropins used in the IVF cycle and from 40.0 to 30.7% (OR = 0.531, 95% CI 0.204-1.384, P = 0.19), when assessed by the total number of eggs retrieved. Ongoing pregnancy rates were similar, not only within particular age groups, but also between different age groups regardless of the total dosage of gonadotropins used: ranging from to 63.6% (<3000 IU, < 35 y.o.) to 54.8% (>5000 IU, ≥41 y.o) (OR = 0.696, 95% CI 0.310-1.565, P = 0.38). LIMITATIONS, REASONS FOR CAUTION Retrospective study and heterogeneity of patients included. WIDER IMPLICATIONS OF THE FINDINGS These data are reassuring for the common practice of increasing gonadotropin dosages in PGS cycles, particularly in older woman. STUDY FUNDING/COMPETING INTEREST(S) No formal funding has been received for this study. TRIAL REGISTRATION NUMBER N/A.