Faculty Bibliography

OBJECTIVE:To study the effect of frozen embryo transfer (FET) preparation protocol on incidence of subchorionic hematoma (SCH) and serum hormone levels. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:University-affiliated fertility center. PATIENT(S)/METHODS:Patients who underwent FET at the New York University Langone Fertility Center. INTERVENTION(S)/METHODS:None. MAIN OUTCOME MEASURE(S)/METHODS:The primary outcome was incidence of SCH by protocol in FET cycles. RESULT(S)/RESULTS:There were 1,273 FET cycles that met criteria for inclusion. The frequency of SCH was lower in natural compared with programmed cycles (P<.05; relative risk = 0.4 [0.27-0.78]; odds ratio = 0.4 [0.23-0.75]). Serum estrogen level was higher in programmed compared with natural cycles on day of progesterone initiation (P<.001) and cycle day 28 (P<.001). However, serum estrogen levels at the same time points were not associated with formation of SCH in programmed or natural cycles. CONCLUSION(S)/CONCLUSIONS:This is the first study to evaluate the formation of SCHs by FET protocol type. Our results highlight that high serum estradiol levels do not independently lead to an increase in rate of SCH. Further research must be done to understand other clinical, or perhaps molecular, differences between natural and programmed FET cycle preparations that can be better associated with SCH formation.

PURPOSE/OBJECTIVE:To examine fertility-related social media accounts and influencers on two social media platforms. METHODS:The search function of Twitter (TW) and Instagram (IG) was used to generate a list of accounts with the terms: fertility, infertility, ttc, egg freezing, ivf, endometriosis, and reproductive. Accounts not in English, in private, with no posts in > 1 year, or with content unrelated to search terms were excluded. Accounts were assessed for author type; REI board certification (REI-BC); influencer (INF) status (> 10 K followers on IG; verified check mark on TW); account demographics; and content in last 5 posts. Statistical analysis included unpaired t tests, a classification and regression tree (CART) analysis, and stepwise multiple logistic regression. RESULTS:Seven hundred ten accounts were identified and 537 (278 TW, 259 IG) were included. Account types included societies, clinics, physicians, patients, groups, and "other." Instagram content (1290 posts reviewed) was primarily personal stories (31.7%) or inspiration/support (23.7%). Twitter content (1390 posts reviewed) was mostly promotion (28.2%) and research/education (20.2%). Thirty-nine accounts (12.5%) were influencers. Fertility influencers were most often awareness/support accounts (59.8% TW, 25.0% IG), patients (12.8% TW, 25% IG), or other (17.9% TW, 21.0% IG). Only 7.7% TW and 7.1% IG INFs were board-certified REI physicians. The best predictor for classification as an influencer was high activity (> 50 posts/month TW, > 10 posts/month IG). CONCLUSION/CONCLUSIONS:As patients increasingly utilize social media to obtain and engage with health information, it is critical to understand the fertility-related SM landscape. This understanding may help to successfully enhance relationships with patients and ensure dissemination of accurate information.

PURPOSE/OBJECTIVE:To assess the accuracy and reliability of comprehensive chromosome screening by next-generation sequencing (NGS) of human trophectoderm (TE) biopsy specimens. METHODS:The reliability and accuracy of diagnoses made by preimplantation genetic testing for aneuploidy (PGT-A) from TE biopsy were tested. Repeat biopsies of TE and inner cell mass (ICM) samples were obtained from thawed blastocysts previously tested by NGS. To test for the reliability of the NGS assay, biopsy samples were compared with the original PGT-A results. Prior NGS testing classified the TE samples as euploid, aneuploid, or aneuploid-mosaic. The resulting re-biopsied samples underwent SurePlex whole genome amplification followed by NGS via the MiSeq platform, with copy number value (CNV) determined using BlueFuse Multi Software. The primary outcome measure was reliability, defined as concordance between initial TE result and the repeat biopsies. Accuracy was determined by concordance between the TE and ICM samples, and compared between three chromosome types (disomic, aneuploid, and mosaic). RESULTS:Re-biopsies were performed on 32 embryos with prior PGT-A showing euploidy (10 embryos), aneuploidy of one or two chromosomes (4 embryos), or aneuploid-mosaic with one aneuploid chromosome and one mosaic chromosome (18 embryos). One hundred twenty-nine biopsy samples completed NGS (90 TE and 39 ICM biopsies) and 105 biopsy results were included in the analysis. TE biopsies provide a highly accurate test of the future fetus, with the ICM disomic concordance rate of 97.6%. Clinical concordance rates indicate that TE biopsies provide a reliable test when the result is euploid (99.5%) or aneuploid (97.3%), but less reliable when the result is mosaic (35.2%). CONCLUSION/CONCLUSIONS:TE biopsies predict euploidy or aneuploidy in the ICM with a high degree of accuracy. PGT-A with NGS of TE biopsies is shown to be highly reliable, with clinically relevant concordance rates for aneuploidy and euploidy over 95%. TE biopsies indicating mosaicism were less reliable (35.2%), presumably because mitotic non-disjunction events are not uniformly distributed throughout the blastocyst. However, classification of TE biopsy of PGT-A with NGS results as either aneuploid or euploid provides a highly reliable test.

We investigated clinical error rates with single thawed euploid embryo transfer (STEET) diagnosed by next generation sequencing (NGS) and array comparative genomic hybridization (aCGH). A total of 1,997 STEET cycles after IVF with preimplantation genetic testing for aneuploidy (PGT-A) from 2010 to 2017 were identified; 1,151 STEET cycles utilized NGS, and 846 STEET cycles utilized aCGH. Any abortions, spontaneous or elective, in which products of conception (POCs) were collected were reviewed. Discrepancies between chorionic villus sampling, amniocentesis, or live birth results and PGT-A diagnosis were also included. Primary outcomes were clinical error rate per: ET, pregnancy with gestational sac, live birth, and spontaneous abortion with POCs available for analysis. Secondary outcomes included implantation rate (IR), spontaneous abortion rate (SABR), and ongoing pregnancy/live birth rate (OPR/LBR). The clinical error rates in the NGS cohort were: 0.7% per embryo, 1% per pregnancy with gestational sac, and 0.1% rate per OP/LB. The error rate per SAB with POCs was 13.3%. The IR was 69.1%, the OPR/LBR was 61.6%, and the spontaneous abortion rate was 10.2%. The clinical error rates in the aCGH cohort were: 1.3% per embryo, 2% per pregnancy with gestational sac, and 0.4% rate per OP/LB. The error rate per SAB with POCs was 23.3%. The IR was 63.8%, the OPR/LBR was 54.6%, and the SAB rate was 12.4%. Our findings demonstrate that, although NGS and aCGH are sensitive platforms for PGT-A, errors still occur. Appropriate patient counseling and routine prenatal screening are recommended for all patients undergoing IVF/PGT-A.

OBJECTIVE:To investigate the use of preimplantation genetic testing for aneuploidy (PGT-A) among patients pursuing embryo banking (EB) for medically indicated fertility preservation (FP). DESIGN/METHODS:Retrospective cohort. SETTING/METHODS:University-affiliated fertility center. PATIENTS/METHODS:All patients who underwent in vitro fertilization with or without PGT-A for medically indicated FP between January 2014 and April 2018. INTERVENTIONS/METHODS:None MAIN OUTCOME MEASURES: EB cycle characteristics, subsequent cycle pursuit/outcomes, and frozen embryo transfer (FET) outcomes. RESULTS:A total of 58 medical EB cycles were compared; 34 cycles used PGT-A. Of the EB patients with breast cancer, 67% used PGT-A; other indications were evenly divided between PGT-A (FP/PGT-A) and no PGT-A (FP). PGT-A use increased over the study period. Groups were similar in age, days of stimulation, and days from initial FP consultation to treatment initiation. Number of oocytes (14.5 [2-63] FP vs. 17.5 [1-64] FP/PGT-A), 2PN zygotes (7 [1-38] FP vs. 9 [0-36] FP/PGT-A), and blastocysts (5.5 [0-22] FP vs. 5 [0-18] FP/PGT-A) cryopreserved were similar between groups. Equal numbers cryopreserved both oocytes and embryos (5 vs. 3). Five FP/PGT-A patients underwent a second EB cycle. Among FP/PGT-A patients, an average of 6.7 ± 5 blastocysts underwent PGT-A, with 3.5 ± 3 (48.2%) euploid embryos cryopreserved for future FET compared to an average of 7.2 ± 7 untested embryos in the FP group. CONCLUSION/CONCLUSIONS:PGT-A in medical EB cycles increased over time and did not limit the use of other FP methods such as oocyte cryopreservation. In some cases, poor PGT-A results informed patients to pursue a second EB cycle. When counseling patients, the prognostic benefits of PGT-A must be weighed against the financial costs and potential for "terminal" fertility diagnosis.

OBJECTIVE: The use of PGT-A and vitrification to select euploid embryos for transfer has led to improved live birth success in IVF; however, some euploid embryos fail to implant. Our objective was to compare parameters from 1) the retrieval cycle (IVF) in which blastocysts were biopsied and vitrified, 2) the frozen embryo cycle (FETu) during which the uterus was prepared for transfer, 3) the embryo transfer (FETt), and 4) the embryology (Lab) records all consolidated to determine what best predicts implantation following single thawed euploid embryo transfer (STEET). DESIGN: Multivariate analysis of 45 parameters from IVF, FETu, FETt and Lab and their association with a positive pregnancy test (+hCG). MATERIALS AND METHODS: Data were collected from our electronic records for patients with transfers of thawed single euploid embryos diagnosed as euploid by Next Generation Sequencing during the IVF cycle. Parameters from IVF (17), FETu (5), FETt (4), and Lab (19) were considered. All 908 cases of STEET using NGS prior to 2018 with the required fields were examined. There were 704 STEETs (77.5%) with +hCG. All +hCGs were considered implantations since 1) patients believe they are pregnant when they have a +hCG result and 2) no interfering hCG was administered to these patients. Stepwise multiple logistic regression (197 combinations of parameters) was performed using the Akaike Information Criterion (AIC) to select significant parameters.
RESULT(S): Parameters associated with better implantation (in descending magnitude of standard partial regression coefficient) were: Thicker Endometrium (FETu); higher endogenous serum Estradiol at Start of the IVF Cycle (IVF); higher Progesterone on day of embryo transfer (FETu); more embryos vitrified (IVF); the re-expansion of the blastocyst afterwarming (Lab); and less expansion of blastocysts prior to biopsy (Lab).Age at retrieval, embryo grades, as well as many other parameters were not associated with implantation.
CONCLUSION(S): Parameters from3 of the 4 treatment categories were associated with establishment of +hCG. Of these, some may be under our control: Thicker endometrium, higher Progesterone levels on day of embryo transfer, and less expansion of the blastocyst prior to biopsy. However, the possibility remains that these parameters may be aliases for other features such as rate of uterine proliferation, rate of blastocyst development, patient weight. FETt (embryo transfer) was the category with no parameter associated with implantation. Also notable was the lack of association between embryo grades and +hCG.
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Objective: It is now well-established that embryos diagnosed as chromosomally mosaic can result in healthy live births. Our aim was to report on our clinic's outcomes associated with mosaic embryo transfer (MET), determine which parameters predict MET success, and compare MET outcomes to single thawed euploid embryo transfer (STEET).
Design(s): Retrospective cohort study.
Material(s) and Method(s): All STEET cycles after in vitro fertilization, trophectoderm biopsy, and preimplantation genetic testing for aneuploidy (PGT-A) by next-generation sequencing were identified as controls. Cases included all MET cycles. Statistical analysis included chi-square, with p<0.05 considered significant.
Result(s): A total of 645 PGT-A frozen embryo transfer cycles occurred during the selection period. STEET occurred in 569 cycles (mean age = 35.8), and MET occurred in 70 cycles (mean age = 39.6) with 76 embryos. 47 embryos were diagnosed as segmental mosaic (SM) and 29 embryos were diagnosed as whole chromosome mosaic (WCM; including monosomies and trisomies). 28/47 (59.6%) SM embryos and 10/29 (38.5%) WCM embryos implanted, compared to 408/569 (71.7%) euploid embryos. The ongoing pregnancy/live birth rate was significantly higher in SM embryos (22/47; 46.8%) compared to WCM embryos (5/29; 19.2%; p<0.01). STEET resulted in significantly more ongoing pregnancies (358/569; 62.9%) than both SM (p=0.03) and WCM (p<0.01) embryos. For SM embryos, there was no significant difference in outcomes when stratified by the percentage of mosaicism in the biopsy; however, WCM embryos with 20-40% mosaicism in the biopsy had significantly higher ongoing pregnancy rates compared to those with 41-80% mosaicism (p=0.03). 8/8 WCM embryos with more than 1 chromosome involved failed to implant. There were no significant differences when comparing embryos with a deletion vs. a duplication or a monosomy vs. a trisomy. Maternal age at testing was not associated with differences in pregnancy outcomes in the MET or STEET groups. 15/27 fetuses conceived by MET were reported to be tested by amniocentesis (including 9 with chromosomal microarray), and none were found to have evidence of mosaicism involving the chromosome in question.
Conclusion(s): In the absence of euploid embryos, MET may be considered. While embryos diagnosed as SM have higher reproductive potential compared to those diagnosed as WCM, both categories have inferior outcomes when compared to STEET. While neonatal outcomes are reassuring, additional studies are needed to explore long-term outcomes from babies born following MET.
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Objective: Morphologic grading of embryos has been an ART standard for nearly 4 decades. More recently, PGT-A has improved embryo selection. Data conflicts regarding whether morphological evaluation improves outcomes of euploid embryo transfers [1, 2, 3]. Our objective was to determine whether morphology is predictive of pregnancy outcomes among single thawed euploid embryo transfers (STEETs).
Design(s): Retrospective cohort study.
Material(s) and Method(s): We reviewed all STEETs at a university-based ART center from 2014-2018. STEETs were excluded if oocytes were cryopreserved, embryos were created at another facility, embryos were frozen or biopsied twice, PGT-M or -SR was used, or an oocyte donor or gestational carrier was used. Only the first STEET during the study period that did not meet any exclusion criterion from each patient was included. Embryo morphology was graded according to Gardner [4]. Outcomes included implantation rate of all transfers and live birth (LB) rate, excluding 154 ongoing pregnancies and 28 pregnancies with unknown birth outcomes. Statistical analysis included chi-square, one-way ANOVA, and 2 multivariable log-binomial regression models to determine the association of predictors (age, expansion, ICM, TE) with implantation and LB.
Result(s): We reviewed 1323 STEETs (mean age 37y; range 24-46y). Overall, implantation was 69% and LB (n=1141) was 55%. ICM and TE were bivariately associated with both implantation and LB (p<0.01), but age and expansion were not. ICM significantly predicted implantation, but TE did not. Both ICM and TE independently predicted LB (see Table for adjusted predicted probabilities of implantation and LB based on ICM and TE grades at mean levels of all covariates in the models).
Conclusion(s): Ploidy status is not the sole determinant of embryo competence. ICM and TE are strong predictors of LB and can improve selection among euploid embryos. Poor ICM is the greatest negative morphological predictor of implantation and LB. Our model can serve as a counseling tool for patients banking embryos. [Figure presented] References: 1) Chen, M., et al. (2015). "Can Comprehensive Chromosome Screening Technology Improve IVF/ICSI Outcomes? A Meta-Analysis." PLoS One10(10): e0140779. 2) Capalbo, A., et al. (2014). "Correlation between standard blastocyst morphology, euploidy and implantation: an observational study in two centers involving 956 screened blastocysts." Hum Reprod29(6): 1173-1181. 3) Irani, M., et al. (2017). "Morphologic grading of euploid blastocysts influences implantation and ongoing pregnancy rates." Fertil Steril107(3): 664-670. 4) Gardner DK, Lane M, Stevens J, Schlenker T, Schoolcraft WB. Blastocyst score affects implantation and pregnancy outcome: towards a single blastocyst transfer. Fertility and Sterility (2000) 73 (6):1155-1158.
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