Faculty Bibliography

OBJECTIVE: With increased availability of genetic testing, particularly expanded carrier screening (ECS) and hereditary cancer (HC) testing, the scope of conditions for which PGT-M is performed is expanding. Our aim was to report on indications for PGT-M from the past decade in our large academic practice. MATERIALS AND METHODS: All PGT-M cases occurring between January 2010 and April 2021 were reviewed.
RESULT(S): A total of 331 patients were identified for which PGT-M was performed for 124 different genes over 582 cycles. Eighteen patients tested for two genes and one patient tested for three genes; therefore, there were a total of 351 unique PGT-M cases. Of the 124 genes tested, 82 (66.1%) were of childhood onset while 16 (12.9%) were of adult onset, and the remaining 26 (21.0%) were of variable onset. Over the entire study period, 70/351 patients (19.9%) tested for 16 genes related to HC syndromes; between 2010-2017, HC-related PGT-M accounted for 12.6% (20/159) of our total PGT-M volume, and since 2018, it rose to 26.0% (50/192). Overall, BRCA1 was the most common gene tested in our practice, and hereditary breast and ovarian cancer syndrome (BRCA1 and BRCA2) accounted for 15.1% (53/351) of our total PGT-M patient population. 181/351 patients (51.6%) tested for 49 genes that are commonly found on ECS, with cystic fibrosis (CFTR) being the most common (34/351) followed by fragile X (FMR1; 32/351); these represented the second and third most common genes tested in our practice (9.7% and 9.1% respectively). Of all patients doing PGT-M for ECS-related conditions, 46.4% (84/181) tested for 41 genes that are not detected by traditional or ethnicity-based carrier screening, with the most common being GJB2-related nonsyndromic hearing loss (the fourth most common condition tested in our practice, representing 6.6% of our total PGT-M volume), followed by 21-hydroxylase deficient congenital adrenal hyperplasia (CYP21A2) and familial Mediterranean fever (MEFV). There were eight patients (2.3%) who either were or could have been identified on our current 283-disease ECS panel but would have been missed on our prior 176-disease ECS panel. Eight patients did PGT-M for HLA matching, and three did non-disclosure PGT-M (two for Huntington's disease/HTT and one for CADASIL/NOTCH3). 80/124 genes tested (64.5%) were unique to a single patient.
CONCLUSION(S): PGT-M is performed for a wide range of genetic conditions, and nearly two-thirds of genes tested in our clinic were unique to a single patient. While most conditions tested are childhood-onset, BRCA1 is the most common gene tested by our patient population, and the proportion of patients testing for HC syndromes has doubled over the past three years. More than half of patients pursued PGT-M for conditions detectable through ECS but not through traditional carrier screening; however, increasing the ECS panel size by more than 100 conditions has only had a minor effect on PGT-M uptake. IMPACT STATEMENT: This large dataset from a single IVF clinic highlights the impact of HC testing and ECS on PGT-M utilization over the past decade

OBJECTIVE: Oocyte cryo is widely used for fertility preservation, but the value of M1 cryo remains unclear. We evaluated the utility and efficiency of M1 compared to M2 cryo. MATERIALS AND METHODS: Patients (pts) who thawed autologous oocytes at our academic center from 2004-2020 were reviewed. Pts were excluded if cryo was performed for a medical indication, as research, due to no sperm or a natural disaster, in combination with embryos or for use with a gestational carrier. At our center, all M1s retrieved from 2004-2015 were cryopreserved; after 2015, M1s were only cryopreserved if <15 M2s were retrieved during the same cryo cycle. Outcomes included survival rate, useable embryo rate and embryo transfer (ET) results.Auseable embryo was defined as an embryo that was transferred, biopsied or cryopreserved for future use. Statistics included Fisher's exact test.
RESULT(S): 543 pts (median age at 1st cryo 38y, interquartile range 37-40y) underwent 800 cryo, 605 thaw and 416 ET cycles. Cryo was performed with vitrification for 72%, slow freezing for 4% and both technologies for 24% of pts. In total, 8511 oocytes (1019M1s + 7492 M2s)were thawed.All pts thawed >=1 M2, and 60% (n=327) thawed >=1 M1. See table for thaw outcomes of M1s vs. M2s. For 30 pts, >=1 M1 led to a useable embryo (n=32 useable embryos). Vitrification was used for 69% of these M1s (n=22) and slow freezing was used for 31% (n=10). Of the 32 useable embryos from M1s, 69% (n=22) underwent PGTand 4were euploid (17 aneuploid, 1 mosaic). Therewere 3 single ETs of euploid embryos from M1s, which led to 1 spontaneous abortion (SAB) and 2 biochemical pregnancies. Therewere 3 single ETs of untested embryos from M1s, which led to 1 negative result, 1 SAB and 1 singleton ongoing pregnancy. The ongoing pregnancy is from an ETof a day 5 morula and is now in the third trimester. There were 6 ETs in which untested embryos from M1s were transferred alongwith untested embryos fromM2s, resulting in 3 negative results, 1 SAB, 1 singleton live birth and 1 unknown outcome (ongoing singleton pregnancy at last contact).
CONCLUSION(S): Cryopreserved M1s can result in useable embryos and pregnancies, but are less likely to survive or form useable embryos than cryopreserved M2s. To our knowledge, this is the first report of an ongoing third trimester pregnancy from a cryopreserved M1. This information may be helpful for pt counselling and designing oocyte cryo protocols for embryology labs. IMPACT STATEMENT: Cryopreserved M1s may be a viable option for pts with a low M2 yield. (Table Presented)

OBJECTIVE: Many preimplantation genetic testing (PGT) labs require intracytoplasmic sperm injection (ICSI) for PGT for aneuploidy (PGT-A) due to concern for paternal cell contamination. We sought to determine if sperm lysis occurs during PGT-A and assess the rate of paternal cell contamination in trophectoderm (TE) biopsies in embryos from insemination. MATERIALS AND METHODS: Sixty-two tripronuclear (3PN) embryos donated to research were collected from IVF with either insemination or ICSI from January - April, 2021. Embryos were cultured and assessed for development to blastocyst stage on days 5, 6 and 7 of culture. Embryos that developed into blastocysts underwent two separate TE biopsies. Biopsy procedure consisted of zona ablation on day 4 followed by TE biopsy using 2-3 pulses of laser beam at the cell junction. Biopsy samples were washed with drops of buffer 2-3 times and placed in a PCR tube. Arrested embryos were collected and assessed for approximate cell number. One group of arrested embryos was collected without washing (unwashed) and a second group was collected after removal of the zona (washed). TE biopsies, arrested embryos, and maternal and paternal samples were sent to a PGT lab to determine the genetic ploidy composition of the embryo biopsies and arrested embryos including the parent of origin. Testing included PGT-A using the PGTseq platform and SNP allele sharing that can detect parental origin of abnormalities and contamination.
RESULT(S): Of the 62 3PN embryos cultured, 17 developed into blastocysts with 4 from ICSI and 13 from insemination. There were 45 arrested embryos with 6 from ICSI (2 washed, 4 unwashed) and 39 from insemination (14 washed, 25 unwashed). PGT analysis showed varying degrees of paternal cell contamination in unwashed arrested embryos from insemination, and no paternal cell contamination in washed arrested embryos (ICSI or insemination) or unwashed ICSI embryos. Two washed arrested embryos from insemination showed no amplification. There was no paternal cell contamination in TE biopsies from either ICSI or insemination.
CONCLUSION(S): Analysis of unwashed arrested embryos from insemination demonstrates that excess sperm can lyse and cause paternal cell contamination during PGT-A. However, TE biopsies of embryos from insemination showed no evidence of paternal cell contamination, indicating that when properly washed and processed, paternal cell contamination is unlikely in inseminated embryos undergoing PGT-A. While this study was not powered to draw definitive conclusions or assess levels of contamination that interfere with PGT-A, preliminary results indicate that ICSI is not necessary for PGT-A. It should be noted that these findings are specific to the PGTseq platform, and may not translate to other methods. IMPACT STATEMENT: This study demonstrates that sperm have the ability to lyse and are a potential source of paternal cell contamination in PGT-A. However, this study also showed a 0% rate of paternal cell contamination in inseminated embryos when embryo biopsies were washed and processed as described, suggesting that ICSI is not necessary for patients desiring PGT-A

OBJECTIVE: OC is widely used for fertility preservation. Many models predict the live birth (LB) rate of OC, but real-world data is lacking. We reviewed our LBs from OC to develop an OC counseling tool based on real outcomes. MATERIALS AND METHODS: We reviewed patients (pts) who thawed autologous oocytes (AOs) at our academic fertility center from 2004-2020. We included pts who: 1) had a LB or ongoing pregnancy (OP) >12 weeks at last contact, or 2) consumed all AOs and resultant embryos. Pts were excluded if they transferred AOs or resultant embryos to another center or if OC was performed for a medical reason, as research, due to no sperm or a natural disaster, combined with embryos or for use with a gestational carrier. We calculated OP + LB rate (LBR) based on number of AOs and metaphase II oocytes (M2s) thawed. Data were stratified by age (<38y vs. >=38y). For pts who underwent OC at <38y and >=38y, a weighted age was calculated (for each OC cycle, #AOs thawed was multiplied by age at OC; the sum of these numbers was then divided by total #AOs thawed). Statistics included Fisher's exact test (p<0.05 significant).
RESULT(S): We included 462 pts (median age at 1st OC 38.5y). Weighted ages were used for 21 pts (5%). Our pts underwent 650 OCs (90% our center, 9% elsewhere, 1% both), 512 thaws and 385 embryo transfers. OC involved vitrification for 72%, slow freezing for 4% and both for 24% of pts. A total of 7050 AOs and 6178 M2s were thawed. 38% of pts (n=176) have >=1 LB or OP from AO thaw. See table for outcomes. Pts who thawed 0-10 AOs had a lower LBR than pts who thawed 11-20, 21-30, or >30 AOs (p<=0.03). Pts who thawed 0-10 M2s had a lower LBR than pts who thawed 11-20 or 21- 30 M2s (p<=0.02). LBR was not significantly different between pts who thawed 11-20, 21-30, or >30 AOs or M2s.
CONCLUSION(S): Pts who thawed 0-10 AOs had a lower LBR (27%) than pts who thawed >10 AOs (LBR >= 43%), and pts who thawed 0-10 M2s had a lower LBR (30%) than pts who thawed > 10 M2s (LBR >= 42%), but LBR was not different with >10 thawed AOs. IMPACT STATEMENT: Our real-world OC outcomes are not consistent with LBRs in published models. These results provide more realistic expectations about OC outcomes and may help pts decide how many AOs to freeze

OBJECTIVE: Morphologic evaluation of embryos after fertilization is the first step in embryo assessment, with two pronuclei (2PN) indicating normal fertilization. Deviations from 2PN are considered consistent with abnormal fertilization and genetic ploidy, and may be discarded instead of cultured. The aim of this study was to determine the genetic ploidy of three pronuclei (3PN) embryos diagnosed by morphology. MATERIALS AND METHODS: Sixty-two 3PN embryos donated to research that underwent IVF with either insemination or ICSI were collected from January - April, 2021. 3PN embryos were identified at time of fertilization check and vitrified. Batched 3PN embryos were subsequently warmed and cultured. Embryos were assessed for development to the blastocyst stage on days 5, 6 and 7 of culture, and embryos that developed into blastocysts underwent two separate trophectoderm (TE) biopsies. TE biopsies, along with maternal and paternal samples were sent to a pre-implantation genetic testing (PGT) lab to determine the genetic ploidy composition of the morphological based 3PN embryos. Testing included PGT for aneuploidy (PGT-A) using the PGTseq platform that routinely includes triploidy detection via single nucleotide polymorphism (SNP) B allele ratio. Testing was also performed using a second method, SNP allele sharing, with the maternal and paternal DNA samples. This method can detect both triploidy and parental of origin of abnormalities.
RESULT(S): Of the 62 3PN embryos cultured, 17 (27%) developed into blastocysts that underwent TE biopsy. In all cases paired biopsies were concordant. Three of the 17 biopsied embryos were diploid (18%) and 14 were triploid (82%). All 3 diploid embryos were the result of insemination and were aneuploid on PGT-A; no euploid embryos were identified. The overall rate of diploid tested blastocysts was 4.8% (3/62) among all 3PNs collected. Of the 14 triploid embryos, 10 were the result of IVF with traditional insemination and 4 were from ICSI. All triploid embryos from insemination were consistent with paternal origin while all triploid embryos from ICSI were consistent with maternal origin. Both methods for detecting triploidy were concordant.
CONCLUSION(S): Embryos morphologically diagnosed as 3PN are typically discarded as they are likely the result of abnormal fertilization consistent with triploidy. This study demonstrates that a small percentage of 3PN embryos have the potential to develop into blastocysts with a diploid genetic complement. While none of the diploid 3PN embryos in this study were found to be euploid, this could be due to the small sample size and it is possible that a larger number of embryos may result in 3PN euploid embryos which could impact a labs decision on what tissue to discard or culture. It should be noted that due to the inherently subjective component of morphologic assessment, these findings may not translate to other laboratories. IMPACT STATEMENT: While 3PN embryos are typically discarded in IVF after both insemination and ICSI, our study shows that a small proportion have the potential to develop into diploid blastocysts where reproductive potential remains to be seen

OBJECTIVE: COVID-19 has affected nearly every facet of modern life, and has left many wondering what implications, if any, the virus has on reproductive health. Increased levels of psychological stress, concern for viral contamination in embryology labs, and reports of decreased male fertility following COVID infection, have also been thought to contribute negatively to ART outcomes.We sought to determine whether the pandemic resulted in any differences in IVF/OOF outcomes. MATERIALS AND METHODS: Patients who tested negative for COVID-19 and underwent GnRH-antagonist IVF and OOF cycles from January 2020 through December 2020 at NYU Fertility Center, a period marked by the COVID-19 pandemic, were separated by month of treatment and compared with patients from the corresponding month in the prior year. In patients with multiple cycles over this time period, only the first cycle was used. Patient age, AMH, #oocytes retrieved, #oocytes matured, #fertilized, #blastocysts, and #euploid embryos were compared using Student's T-test.
RESULT(S): 2,467 patients were compared. While the number of cycles were remarkably decreased over March and April of 2020 (59 and 25 respectively), the total number of cycles were very similar for the entire year (1,239 in 2019; 1,228 in 2020). There were no consistently significant differences in age, AMH, #oocytes retrieved, #oocytes matured, #blastocysts formed, or #euploid embryos formed, between the two years.
CONCLUSION(S): Despite initial concerns, and prior research suggesting otherwise, we did not detect any consistent quantitative or qualitative differences in retrieval outcomes amongst COVID negative patients receiving care during the pandemic. IMPACT STATEMENT: These results can reassure patients and their providers that IVF/OOF cycles can be continued safely during the pandemic without compromising outcomes

Study question: To explore the effect of chromosomal mosaicism detected in preimplantation genetic testing (PGT-A) on prenatal and postnatal outcome of mosaic embryo pregnancies Summary answer: No significant difference between euploid and mosaic embryos was observed in terms of weeks of gestation, average weight, and developmental defect of the babies born What is known already: Mosaic embryos have the potential to implant and develop into healthy babies.Transfer of these embryos is now offered as an option for women who undergo IVF resulting in no euploid embryos. While, prenatal diagnosis has shown the depletion of chromosomal mosaicism in mosaic embryos, several concerns remain. For instance, the direct effects of different kind of mosaicism on prenatal/postnatal outcome and the possibility that intra-biopsy mosaicism in the TE is a poor predictor of the ploidy status of the ICM. Thus, there is certainly a need for comprehensive analyses of obstetrical and neonatal outcome data of transferred mosaic embryos. Study design, size, duration: Compiled analysis from multicenter data on transfers of mosaic embryos (n=1,000) and their outcome, with comparison to a euploid control group (n=5,561). To explore the effect of embryonic mosaicism on newborns, we matched mosaic embryos resulting in a birth with a euploid embryo by a series of parameters (maternal age, embryo morphology, and indication for PGT-A). Prenatal tests and birth characteristics of >200 neonates from mosaic embryo transfers were compared to >200 euploid embryos. Participants/materials, setting, methods: PGT-A was performed on blastocyst- stage embryos with 24-Chromosome whole genome amplification (WGA)-based Next Generation Sequencing (NGS). In accordance with established guidelines, embryos were categorized as mosaic when PGT-A results indicated 20-80% aneuploid content. Prenatal testing where performed in 30% of pregnancies with amniocentesis, 4% did an extra analysis for potential UPD for the suspected mosaic chromosome, and an additional 16% performed chorionic villus sampling (CVS) and 9.5% performed noninvasive prenatal testing (NIPT). Main results and the role of chance: Of the 465 mosaic embryos that implanted, about 20% miscarried, and out of those, 75% were early spontaneous abortions. Of the pregnancies, 3 out of 368 were stillborn (2 out of them were twins that were extremely premature at 23 weeks, and the other died during pregnancy from a heart defect). The remaining 99% of those have been born or are late ongoing pregnancies at the time of analysis. Prenatal tests were performed in >200 pregnancies and the vast majority tested normal. All 5 abnormal cases were amniocentesis tests showing microdeletions or insertions of sizes smaller than the resolution used during PGT-A, so they were unrelated to the mosaicism detected with PGT-A. In fact, in none of the cases did the prenatal test reflect the mosaicism detected at the embryonic stage. Matching each of the 162 mosaic embryos resulting in a birth with a euploid embryo, we found that the length of gestation was similar on average, and so was the average weight of the babies at birth. We also gathered information on the routine physical examination performed on babies at birth, and of those 162 babies from mosaic embryo transfers, none had obvious developmental defects or gross abnormalities. Limitations, reasons for caution: Even though newborns resulting from mosaic embryo transfers in this study invariably appeared healthy by routine examination, concerns for long-term health cannot yet be entirely dispelled. The question must therefore be carefully considered by each clinic and patient situation. Wider implications of the findings: Prenatal testing of >200 pregnancies from mosaic embryo transfers showed no incidence of mosaicism that matched the PGT-A findings, indicating the involvement of self-corrective mechanisms. Pregnancy and obstetric data indicates that mosaic embryos prevailing through gestation and birth have similar chromosomal and physiological health compared to euploid embryos

Objective/UNASSIGNED:To determine if recent evolutions in laboratory protocols, including the increased use of natural cycles and the use of a hyaluronan-containing transfer medium, affected the rate of monozygotic twin (MZT) pregnancies after single frozen embryo transfer (FET). Design/UNASSIGNED:Retrospective cohort study. Setting/UNASSIGNED:Urban university-based fertility center. Patients/UNASSIGNED:Patients who underwent single FET between January 2016 and December 2018 resulting in an intrauterine pregnancy. Interventions/UNASSIGNED:Transition to a transfer protocol with a hyaluronan-containing transfer medium in July 2017. Main Outcome Measures/UNASSIGNED:Number of MZT pregnancies. Results/UNASSIGNED:There were 1,619 cycles that met the inclusion criteria and 31 (1.9%) resulted in MZT pregnancies. A hyaluronan-containing transfer medium was used in 875 (54.1%) cycles. Programmed cycles were used for 1,385 (85.5%) FETs and 234 (14.5%) cycles were natural. The mean age at FET, oocyte age, endometrial echo thickness, inner cell mass grade, trophectoderm grade, expansion, and day of blastocyst vitrification were similar between the groups. The use of a hyaluronan-containing transfer medium resulted in fewer MZTs. After controlling potential confounders with a multivariate regression, the use of the hyaluronan-containing medium still resulted in fewer MZTs. Monozygotic twins were colinear with preimplantation genetic testing (PGT), so PGT was excluded as a variable in our regression. A regression of PGT only cycles showed that the use of the hyaluronan-containing medium was still associated with a reduction in MZT pregnancies. Conclusions/UNASSIGNED:The use of a hyaluronan-containing transfer medium was associated with a lower rate of MZTs. Other clinical parameters, including cycle type, were not associated with changes in the number of MZTs. The use of PGT needs to be further investigated as a risk factor for MZTs.

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.

OBJECTIVE:To evaluate the prevalence of coronavirus disease 2019 (COVID-19) and efficacy of a universal screening program in patients undergoing controlled ovarian stimulation (COS). DESIGN:Single-center retrospective cohort study. SETTING:Academic fertility center in an epicenter of the COVID-19 pandemic. PATIENT(S):All patients undergoing COS from June 17, 2019, to February 28, 2021. INTERVENTION(S):Universal COVID-19 screening starting June 17, 2020, with SARS-CoV-2 polymerase chain reaction testing within 5 days of oocyte retrieval, patient-reported symptom screening, and temperature monitoring. MAIN OUTCOMES MEASURE(S):The primary outcome was the number of positive COVID-19 cases in patients undergoing COS cycles. The secondary outcomes were cycle outcomes compared with before COVID-19 COS cycles, adverse outcomes in COVID-canceled cycles, and center-specific COVID-19 detection rates compared with New York City cases. RESULT(S):From June 17, 2020, to February 28, 2021, 1,696 COS cycles were initiated with only seven positive COVID-19 cases for an overall positivity rate of 0.4%. When compared with before COVID cycles from June 17, 2019, to February 28, 2020, the volume of COS cycles were higher, while the overall cycle cancelation rate was lower during COVID-19. Cycle outcomes including oocyte yield and blast utilization rates were unchanged from pre-COVID cycles. Cases of COVID-19, while very low, occurred more frequently during surges in New York City rates. CONCLUSION(S):Assisted reproductive technology can be performed during the COVID-19 pandemic utilizing frequent universal screening and safe practices with low SARS-CoV-2 positivity, low cycle cancelation rates, and positive patient outcomes.