Faculty Bibliography

Objective: Fragile X (FgX) is a recommended part of carrier screening with pre- and full mutations associated with a spectrum of disease including intellectual disability, tremor ataxia syndrome and premature ovarian insufficiency. Risk of expansion is categorized based on number of CGG repeats.¹ Testing for AGG interruptions can offer further risk assessment in some cases.¹ As these tests become more commonplace, our objective was to determine how often screened patients select PGT-M for FgX.
Material(s) and Method(s): This is a retrospective case series at a single academic fertility center. Electronic medical records were queried to identify patients with a positive carrier screen for FgX from 2008-2022 and those undergoing PGT-M for FgX. Assisted reproductive treatments and outcomes were reviewed. Kruskal Wallis and Chi-square statistical tests were performed (p<0.05 significant).
Result(s): 393 positive FgX reports were identified including 20 prospective oocyte donors. 63% (247/393) had an intermediate (INT) number of CGG repeats (45-54), 34% (133/393) had a premutation (PRE) (55-200 repeats) and 0.8% (3/393) had a full mutation (FUL) (>200 repeats). 61% (238/393) underwent fertility treatment at our center. PRE patients were younger (INT: 36 (17-47) vs PRE: 33 (21-44) vs FUL: 37 (37-39) years (Y), p<0.01). Anti-mullerian hormone levels were similar (INT: 1.9 (0.03-14) vs PRE: 1.5 (0.01-8.7) vs FUL: 3 (0.1-5) ng/mL, p=0.08). Only 37% (49/133) of PRE carriers underwent AGG testing to further risk stratify expansion potential, as did 2% (4/247) of INT. 25% (13/53) had 0 AGGs: 4 declined fertility treatment, 4 cryopreserved oocytes, 5 underwent PGT-M. 12% (49/393) in total underwent PGT-M: 4% INT (2/49), 73% PRE (36/49), 6% FUL (3/49). 27% (13/49) of PGT-M patients underwent AGG testing: 38% (5/13) had 0 AGG, 38% (5/13) had 1 AGG, and 23% (3/13) had 2 AGGs. 8% (4/49) additional patients were offered but declined AGG testing. 18% (9/49) of PGT-M patients had terminated an affected pregnancy prior to PGT-M. 10% (5/49) had documented family members affected or PRE carriers. Patients underwent median 2 retrieval cycles (range 0-5) and 1 embryo transfer cycle (range 0-5). 31% (14/45) of patients with completed treatment did not achieved an autologous euploid unaffected embryo for transfer; two of these patients transferred non-euploid unaffected embryos and 71% (10/14) had AMH <0.8ng/mL. 1 INT and 2 PRE female embryos were also transferred. 46% (13/28) of transfers resulted in a live birth.
Conclusion(s): PGT-M is most commonly used for PRE carriers and with a history of prior affected pregnancy or family member, with varied use of AGG testing. Patients with low ovarian reserve are less likely to achieve an autologous live birth of an unaffected embryo from PGT-M. Impact Statement: FgX premutation carriers do not have uniform uptake of AGG testing or PGT-M and require individualized counseling due to differences in risk assessment and varied assisted reproductive technology outcomes. Support: None REFERENCES:: 1. Monaghan KG, Lyon E, Spector EB; American College of Medical Genetics and Genomics. ACMG Standards and Guidelines for fragile X testing: a revision to the disease-specific supplements to the Standards and Guidelines for Clinical Genetics Laboratories of the American College of Medical Genetics and Genomics. Genet Med. 2013 Jul;15(7):575-86.
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Objective: Historically, PGT-A results were applied in a binary fashion: embryos categorized as normal were transferred, and those categorized as abnormal were not. While embryos with euploid results have consistent reproductive outcomes, it has now become evident that "abnormal" results can be subcategorized, depending on whether an intermediate copy number is observed ("mosaic"), range of intermediate copy number (estimated percentage of biopsied cells with the abnormality), and type of abnormality (segmental or full monosomy/trisomy).
Material(s) and Method(s): Frozen embryo transfers at our clinic in which PGT-A was performed by next-generation sequencing (NGS) were reviewed. Biopsies from embryos transferred were categorized as either euploid (<20% undetectable abnormal cells), low level segmental mosaic (LL-SM; 20-40% abnormal), high level segmental mosaic (HL-SM; 40-80% abnormal), low level whole chromosome mosaic (LL-WCM), high level whole chromosome mosaic (HL-WCM), or aneuploid (80-100% abnormal). Primary outcomes were implantation rate (IR; defined as presence of gestational sac), ongoing pregnancy rate at 7 weeks gestation (OPR), and spontaneous abortion rate (SABR; defined as loss of gestational sac). Contingency Chi-square (X²; 6x2) analysis with post hoc (2x2)'s were used for comparisons.
Result(s): Table 1 lists the primary outcomes for each PGT-A category. For IR and OPR, euploid and LL-SM embryos were indistinguishable; however, HL-SM, LL-WCM, HL-WCM, and aneuploid embryos were significantly different (p<0.001). While the limited sample size of spontaneous abortions was too small to make accurate comparisons between all 6 groups, a significantly higher SABR was observed for non-euploid embryos (p<0.001). There were no cases in which a non-euploid PGT-A result was confirmed by amniocentesis or in the newborn. [Formula presented]
Conclusion(s): Embryos with euploid and LL-SM results have the highest chance of producing a viable pregnancy. Those with other types of mosaic results can produce viable pregnancies, but at lower rates, and aneuploid embryos are least likely to be viable. Therefore, a spectrum of PGT-A results can help to predict reproductive potential. These data can be used to guide patient counseling about embryo transfer after PGT-A. Impact Statement: The amount and type of mosaicism in embryos correlates with OPR and SABR. Trophectoderm biopsy with NGS is a powerful tool in predicting reproductive outcomes. Support: None
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Objective: The use of sequencing-based genetic testing has resulted in increasingly complex results interpretation. In contrast to diagnostic testing, only variants believed to be pathogenic or likely pathogenic (LP) are reported in carrier screening, while variants believed to be benign, likely benign (LB), or of unknown clinical significance (VUS) are not typically reported by the testing laboratory. However, laboratories frequently disagree on variant classification, and classifications may also change over time, as more data is compiled. Therefore, the same patient may have different results depending on the laboratory used and time of results reporting. The objective of this study was to assess the impact of discrepant variant classifications on use of PGT-M.
Material(s) and Method(s): Known cases in which discrepant variant classification impacted PGT-M utilization were reviewed. Cases were selected due to complicated genetic counseling and perceived or stated burden to patients.
Result(s): Ten cases were identified in which discrepant variant classification complicated PGT-M decision-making. Nine cases were identified through carrier screening, and one involved both carrier screening and diagnostic testing. The condition involved was X-linked in six cases, and autosomal recessive in four cases. The variant in question was initially reported as LP in 6/10 cases, and as pathogenic in 4/10 cases by the carrier screening laboratory. In 8/10 cases, at least one other laboratory disagreed with the initial classification and instead classified the variant as VUS, LB, or benign. In one case, the laboratory informed about a reclassification of an LP variant to VUS upon further inquiry, and in the last case, the laboratory reported a variant as pathogenic while omitting essential details about reduced penetrance and mild/variable expressivity. In the majority of cases (6/10), learning about discrepant variant information altered patient decision making regarding use of PGT-M; however, only one patient elected not to continue with PGT-M. Four other patients continued with PGT-M but planned to consider variant-positive embryos for transfer if needed, and in the last case, the patient was undecided between PGT-M or selecting a new gamete donor.
Conclusion(s): Discrepancies in variant classification between testing laboratories can pose challenges for decision-making about the use of PGT-M, and may lead to unnecessary use of this technology. Genetic counseling and thorough variant review is essential prior to PGT-M initiation, to ensure that both patients and clinicians have all necessary and current data to make informed reproductive decisions. The need for carrier screening laboratories to contribute variant-specific information to publicly available databases and include thorough variant-specific annotations on test reports is paramount to improving patient care and reducing both emotional and financial burdens of this costly and complex treatment. Impact Statement: This study is the first to demonstrate the impact of discrepant variant classification between carrier screening laboratories on PGT-M use.
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Objective: The use of GnRH-a trigger in antagonist controlled ovarian hyperstimulation (COH) cycles has increased due to its enhanced safety profile. However, response, as measured by the serum LH level post trigger, vary considerably^1-6. We investigated the impact of serum LH response to GnRH-a trigger in antagonist COH cycles on oocyte yield, oocyte maturity, blastocyst formation, PGT-A and pregnancy outcomes.
Material(s) and Method(s): This is a retrospective cohort study in a single university-based fertility center of all GnRH-antagonist COH cycles utilizing GnRH-a alone or in combination with 1000u of human chorionic gonadotropin (hCG) for trigger from 2017 to 2020. An optimal response to GnRH-a trigger was defined as LH >= 40 mIU/mL and suboptimal response was defined as LH < 40 mIU/mL on the morning after trigger. Subanalyses with responses of LH >= 15 mIU/mL and LH < 15 mIU/mL were also performed. Primary outcomes included oocyte yield, oocyte maturity rate, blastocyst formation rate, euploidy rate, aneuploidy rate and simple mosaic rate. Secondary outcomes included biochemical pregnancy rate (BPR), spontaneous abortion rate (SABR) and ongoing/pregnancy live birth rate (OP/LBR). Primary and secondary outcomes were also stratified by age, race and BMI. Descriptive statistics (median +/- range for continuous variables), Mann Whitey U and Fisher's Exact tests were performed accordingly with p<0.05 defined as significant.
Result(s): This study included 3,833 retrieval cycles with 1,435 single thawed euploid embryo transfers (STEET) among 2,618 patients. Ten percent (351/3446) of retrieval cycles had suboptimal and 90% (3446/3833) had optimal response to GnRH-a trigger. There was no difference in median oocyte yield (16 vs 17 oocytes per cycle, p=0.92), or oocyte maturity (77% vs 76%, p=0.43), fertilization (76% vs 77%, p=0.48) and blastocyst formation (51% vs 52%, p=0.88) rates by response. There were no significant differences in the rate of euploidy (35% vs 39%, p=0.55), aneuploidy (51% vs 47%, p=0.56) and simple mosaic (11% vs 11%, p=1) between groups. Seven percent (102/1435) of STEETs utilized embryos from a cycle with suboptimal response and 93% (1333/1435) from optimal response to GnRH trigger. There were no significant differences in BPR [19/44 (14%) vs 164/1907 (9%), p=0.2], SABR [11/144 (8%) vs 152/1907 (8%), p=1] and OP/LBR [85/144 (59%) vs 1127/1907 (59%), p=1]. No differences in pregnancy outcomes were found in the subanalyses of LH >= and < 15 mIU/mL and when data were stratified by SART age ranges, race and BMI.
Conclusion(s): A suboptimal response to GnRH-a trigger (LH < 40) is not associated with lower oocyte yield, oocyte maturity rate, blastocyst rate, euploidy rate or worse pregnancy outcomes compared to an optimal response (LH >= 40). Additional studies with larger cohorts are needed to further investigate these findings and with different thresholds of response. Impact Statement: A suboptimal LH response to GnRH-a trigger may not predict poor cycle outcomes. Providers should not hesitate to use GnRH-a trigger, especially in patients with identifiable risk factors for ovarian hyperstimulation syndrome (OHSS)⁷. Support: None.
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The American Society for Reproductive Medicine compels centers providing reproductive medicine care to develop and implement an emergency preparedness plan in the event of a disaster. Reproductive care is vulnerable to disruptions in energy, transportation, and supply chains as well as may have potential destructive impacts on infrastructure. With the relentless progression of events related to climate change, centers can expect a growing number of such disruptive events and must prepare to deal with them. This article provides a case study of the impact of Hurricane Sandy on one center in New York City and proposes recommendations for future preparedness and mitigation.

OBJECTIVE:To review the outcomes of patients who underwent autologous oocyte thaw after planned oocyte cryopreservation. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Large urban university-affiliated fertility center. PATIENT(S)/METHODS:All patients who underwent ≥1 autologous oocyte thaw before December 31, 2020. INTERVENTION(S)/METHODS:None. MAIN OUTCOME MEASURE(S)/METHODS:The primary outcome was the final live birth rate (FLBR) per patient, and only patients who had a live birth (LB) or consumed all remaining inventory (cryopreserved oocytes and resultant euploid/untested/no result embryos) were included. The secondary outcomes were laboratory outcomes and LB rates per transfer. RESULT(S)/RESULTS:A total of 543 patients underwent 800 oocyte cryopreservations, 605 thaws, and 436 transfers. The median age at the first cryopreservation was 38.3 years. The median time between the first cryopreservation and thaw was 4.2 years. The median numbers of oocytes and metaphase II oocytes (M2s) thawed per patient were 14 and 12, respectively. Overall survival of all thawed oocytes was 79%. Of all patients, 61% underwent ≥1 transfer. Among euploid (n = 262) and nonbiopsied (n = 158) transfers, the LB rates per transfer were 55% and 31%, respectively. The FLBR per patient was 39%. Age at cryopreservation and the number of M2s thawed were predictive of LB; the FLBR per patient was >50% for patients aged <38 years at cryopreservation or who thawed ≥20 M2s. A total of 173 patients (32%) have remaining inventory. CONCLUSION(S)/CONCLUSIONS:Autologous oocyte thaw resulted in a 39% FLBR per patient, which is comparable with age-matched in vitro fertilization outcomes. Studies with larger cohorts are necessary.

Embryos are diagnosed as mosaic if their chromosomal copy number falls between euploid and aneuploid. The purpose of this study was to investigate the impact of mosaicism on global gene expression. This study included 42 blastocysts that underwent preimplantation genetic testing for aneuploidy (PGT-A) and were donated for IRB approved research. Fourteen blastocysts were diagnosed as mosaic with Next-generation Sequencing (NGS). Three NGS diagnosed euploid embryos, and 25 aneuploid embryos (9 NGS, 14 array Comparative Genomic Hybridization, 2 Single Nucleotide Polymorphism array) were used as comparisons. RNA-sequencing was performed on all of the blastocysts. Differentially expressed genes (DEGs) were calculated using DESeq2/3.5 (R Bioconductor Package) with p < 0.05 considered significantly differentially expressed. Pathway analysis was performed on mosaic embryos using EnrichR with p < 0.05 considered significant. With euploid embryo gene expression used as a control, 12 of 14 mosaic embryos had fewer DEGs compared to aneuploid embryos involving the same chromosome. On principal component analysis (PCA), mosaic embryos mapped separately from aneuploid embryos. Pathways involving cell proliferation, differentiation, and apoptosis were the most disrupted within mosaic embryos. Mosaic embryos have decreased disruption of global gene expression compared to aneuploid embryos. This study was limited by the small sample size, lack of replicate samples for each mosaic abnormality, and use of multiple different PGT-A platforms for the diagnosis of aneuploid embryos.

Background: To evaluate whether the ongoing coronavirus disease 2019 (COVID-19) pandemic has had an impact on assisted reproductive technology (ART) outcomes and assess the possible role of geographic differences in the pandemic's trajectory on these outcomes. Methods: Multi-center retrospective cohort study involving patients who underwent oocyte cryopreservation, in vitro fertilization (IVF), embryo cryopreservation, or frozen euploid embryo transfer in 2019 and 2020 at two academic fertility centers located in regionally distinct areas of the US with high coronavirus infection rates. Patients were screened for infectious symptoms, exposure to sick contacts, and fevers, and tested with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction testing within 5 days of oocyte retrieval. The primary outcomes were the number of oocytes retrieved, embryos fertilized, blastocyst or euploid embryos produced in oocyte retrieval and IVF cycles, and rates of embryo implantation, biochemical pregnancy or no pregnancy following frozen embryo transfer (FET). Results: We found no consistent significant differences in the number of oocytes retrieved, embryos fertilized, blastocysts or euploid embryos produced at either institution over the study period. Furthermore, we did not detect any differences in FET outcomes, including rates of embryo implantation, biochemical pregnancy, or no pregnancy, at either institution during the study time period. Conclusions: There were no significant differences in ART outcomes in patients who received fertility treatment during the pandemic at our centers. Patients and providers can be reassured that with proper testing, sanitizing, and distancing measures, treatments can continue safely during the pandemic without compromising outcomes.

In vitro fertilization is typically associated with high failure rates per transfer, leading to an acute need for the identification of embryos with high developmental potential. Current methods are tailored to specific times after fertilization, often require expert inspection, and have low predictive power. Automatic methods are challenged by ambiguous labels, clinical heterogeneity, and the inability to utilize multiple developmental points. In this work, we propose a novel method that trains a classifier conditioned on the time since fertilization. This classifier is then integrated over time and its output is used to assign soft labels to pairs of samples. The classifier obtained by training on these soft labels presents a significant improvement in accuracy, even as early as 30 h post-fertilization. By integrating the classification scores, the predictive power is further improved. Our results are superior to previously reported methods, including the commercial KIDScore-D3 system, and a group of eight senior professionals, in classifying multiple groups of favorable embryos into groups defined as less favorable based on implantation outcomes, expert decisions based on developmental trajectories, and/or genetic tests.

Objective/UNASSIGNED:To characterize activity, text sentiment, and online community characteristics regarding "fertility" on Twitter before and during the COVID-19 pandemic using social network analysis. Design/UNASSIGNED:Cross-sectional analysis. Setting/UNASSIGNED:Publicly available Twitter data. Patients/UNASSIGNED:Not applicable. Interventions/UNASSIGNED:Not applicable. Main Outcome Measures/UNASSIGNED:Number of users (vertices); edges (connections, defined as unique and total); self-loops (tweet without connection to another user); connected components (groups of users communicating back and forth frequently); maximum vertices in a connected component (largest group size); maximum and average geodesic distance (number of tweets to connect two users in the network); graph density; positive and negative sentiment tweets; and top 5 hashtags and top 5 word pairs. Results/UNASSIGNED:There were 1426 unique users and 401 groups in the pre-COVID-19 data compared to 1492 unique users and 453 groups in the during COVID-19 data. There was no difference in the number of total connections (96.8% [1381/1426] vs. 96.0% [1433/1492]) or self-loops (20.0% [286/1426] vs. 22.1% [329/1492]) before and during the COVID-19 pandemic. The percentage of unique connections per user decreased during COVID-19 (91.6% [1381/1508] pre-COVID-19 vs. 83.3% [1433/1720] during COVID-19). The average and maximum distance between users in the community increased during COVID-19 (maximum: 5 pre-COVID-19, 8 during COVID-19; average 1.95 pre-COVID-19, 2.43 during COVID-19). The percentage of positive sentiments per total number of tweets increased during COVID-19 (58.1% pre-COVID-19 [773/1331] vs. 64.3% [1198/1863] during COVID-19). The top 5 hashtags changed during COVID-19 to include COVID-19. The top word pairs changed from "family, hereditary; parents, children" to "fertility, treatment; healthcare, decisions." Conclusions/UNASSIGNED:Despite the challenge to the fertility community amidst the COVID-19 pandemic, the overall Twitter sentiment regarding fertility was more positive during than before the pandemic. Top hashtags and word pairs changed to reflect the emergence of COVID-19 and the unique healthcare decision-making challenges faced. While the character, the number of users, and the total connections remained constant, the number of unique connections and the distance between users changed to reflect more self-broadcasting and less tight connections.