Faculty Bibliography

Objective: To determine the incidence of euploidy and implantation and delivery of Blastocysts derived from 0PN and 1PN compared with 2PN embryos.
Design(s): Single center retrospective review of PGT-A cases over a 4 year period (2015-2018) where a biopsy and ploidy determination was performed on blastocysts (blasts) derived from zygotes where pronuclei (PNs) were either not evident (0 PN) or only 1 pronucleus (1 PN) was evident at the time of fertilization check.
Material(s) and Method(s): At our center fertilization checks are routinely conducted ~18 hours post insemination or ICSI. The number of PN in each egg is recorded and zygotes cultured individually. Cases where < 50% of the mature eggs exhibit 2PN are routinely rechecked later on Day 1 and omitted from this study if additional PNs seen. In cases for PGT-A, all viable inseminated eggs excluding those with > 3 PN remain in culture to Day 6/7. Good quality blastocysts with a distinct Inner cell mass and cohesive trophectoderm are considered for PGT-A regardless of whether they were 0PN, 1PN or 2PN at fertilization check. PGT-A results are shown in Table 1 along with PGT-A sex of blasts derived from each group.
Result(s): [Figure presented]
Conclusion(s): Prior to utilization of PGT-A and/or timelapse zygotes not exhibiting 2PN at fertilization check were routinely discarded. However, it is now obvious that a percentage of these, albeit small, are fertilized normally and are euploid. Though they account for only a small percentage these may be the only euploid blasts available. Implantation rates and LB rates following transfer of these blasts are similar to those for 2PN blastocysts. Of interest, ratios of XX:XY blasts derived from 1PN and 0PN zygotes were skewed towards female while those from 2PN zygotes were ~1:1. It should be noted that NGS cannot detect pure haploidy (23, X) or triploidy (69, XXX) thereby possibly misdiagnosing these as euploid although our IR and LB results indicate otherwise. Support: None References: None
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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 progress following implantation. 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 is prepared for transfer, 3) the embryo transfer (FETt), and 4) the embryology (Lab) records all consolidated to determine what best predicts pregnancy loss following establishment of pregnancy by euploid embryos.
Design(s): Multivariate analysis of 45 parameters from IVF, FETu, FETt and Lab and their association with loss of pregnancies after a positive pregnancy test (+hCG).
Material(s) and Method(s): Data were collected from our electronic records for patients with transfers of thawed single euploid embryos diagnosed as euploid by NGS during the IVF cycle. Parameters from IVF (17), FETu (5), FETt (4), and Lab (19) were considered. All cases of STEET using euploid embryos tested with Next Generation Sequencing (908) were considered for analysis. Transfers without +hCG (204) and clinical pregnancies without final outcomes (205) at the time of analysis were excluded. Those 499 remaining cases with a positive pregnancy test (hCG > 5 mIU/mL) and all the required fields. 144 cases failed to progress (75 biochemical pregnancies and 69 SAbs). Stepwise multiple logistic regression (152 combinations of parameters) was performed using the Akaike Information Criterion (AIC) to select parameters associated with loss of pregnancy precluding live birth following +hCG. +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.
Result(s): Parameters associated with increased pregnancy loss after positive hCG (in descending magnitude of standard partial regression coefficient) were: more expansion of the trophectoderm prior to biopsy (IVF); more serum estrogen on the day prior to progesterone administration (FETu) and more difficulty of the embryo transfer procedure (FETt ). Age at retrieval, embryo grades, as well as many other parameters were not associated with pregnancy loss.
Conclusion(s): Parameters from 3 categories were associated with loss of pregnancy as biochemical pregnancies or spontaneous abortions. Of these, some are under our control: serum estradiol levels on the day prior to progesterone administration and possibly the difficulty of the transfer and the expansion of the blastocyst prior to biopsy. However, it is possible that these parameters may be aliases for other features such as rate of blastocyst development, patient weight, and/or uterine contractions or presence of blood in the cervix or uterus. No Lab parameters were associated with pregnancy loss. Also notable was the lack of association between embryo grades and pregnancy loss.
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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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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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PURPOSE/OBJECTIVE:To assess the experiences of two large fertility clinics in which embryos with positive results following preimplantation genetic testing for monogenic disorders (PGT-M) were transferred upon patient request, in order to explore the nature of the conditions for which these requests have been made and review ethical considerations. METHODS:Retrospective review of previous embryo transfers at the NYU Langone Fertility Center and ORM Fertility was performed. Embryo transfers prior to May 2019 in which embryo biopsy and PGT-M occurred were reviewed, and transferred embryos that were positive for a monogenic disorder (excluding autosomal recessive carriers) were identified. RESULTS:Seventeen patients were identified who elected to transfer 23 embryos that tested positive for nine different monogenic disorders. Most of the embryos transferred were positive for disorders that are autosomal dominant (15/23), are adult-onset (14/23), are associated with reduced penetrance (16/23), and have available management to lessen symptom severity (22/23). Transfer of positive embryos most commonly occurred for hereditary cancer susceptibility syndromes (9/23 embryos), particularly hereditary breast and ovarian cancer syndrome. CONCLUSIONS:When unaffected embryos are not produced following in vitro fertilization with PGT-M, some patients request to transfer embryos with positive test results. The majority of transfers were for embryos positive for adult-onset, reduced penetrance diseases. As these requests will likely increase over time, it is essential to consider the practical and ethical implications.

Objective: A previous study by our group¹ showed a higher incidence of subchorionic hematoma (SCH) formation in pregnancies from programmed (PRG) frozen embryo transfer (FET) cycles; compared to natural (NAT) FETs where estradiol (E2) levels were lower. We analyzed whether E2 levels were associated with an increased incidence of SCH formation.
Design(s): Retrospective cohort study of all single thawed euploid embryo transfer cycles resulting in clinical pregnancy from 1/2016 to 12/2018 at our center.
Material(s) and Method(s): All single euploid (by Next Generation Sequencing) FETs resulting in clinical pregnancy (presence of a gestational sac) were included. FET cycles with ploidy determined by aCGH, or cycles in which untested, mosaic, or multiple embryos were transferred were excluded. PRG cycles were defined by treatment of oral E2 daily followed by progesterone (P4); either 50-75mg intramuscular in oil or vaginal suppository. A NAT cycle, with and without with letrozole, was defined by monitoring until a dominant follicle reached >18mm and ovulation was confirmed, followed by supplementation with vaginal P4 suppository. SCH was defined as a measurable clot behind the gestational sac at time of luteal ultrasound. The primary outcome was E2 levels in patients with SCH. Statistical analysis included Shapiro-Wilk test for normality for continuous variable, Mann-Whitney U and Fisher's Exact tests where appropriate. Median values are presented, as continuous variables were not parametric. A p-value <0.05 was considered significant.
Result(s): 1273 cycles were identified and included; 213 NAT and 1060 PRG. Age (p=0.73), endometrial thickness (p=0.65), P4 level on cycle day (CD) 28 (p=0.82) and CD of SCH diagnosis (p=0.78) were similar between groups, though first hCG levels were lower in PRG cycles (196 vs 164 mIU/mL, p<0.001). The formation of SCH was significantly lower in NAT cycles compared to PRG (RR 0.4 (0.24 - 0.78), p < 0.001). There was no association with SCH incidence by P4 type (IM vs vaginal, p=0.40) in PRG cycles. Additionally, E2 levels were significantly higher in PRG cycles on day of P4 start (351.5 vs 268.5, p<0.001) and CD 28 (356.5 vs 249, p<0.001). However, there was no relationship between SCH formation and continuous E2 levels on day of P4 start (NAT p=0.76 PRG p=0.44) or on CD 28 (NAT p=0.71, PRG p=0.11) in either protocol. Within PRG cycles, SCH incidence was not associated with the change in E2 from day of P4 initiation to CD28 (p=0.25). E2 levels were then re-classified as high (>249pg/mL) or low based on the median E2 at day of P4 initiation (249 pg/mL). There was no association between rate of SCH formation in PRG cycles with high E2(RR 0.75 (0.51-1.10), p = 0.09) or with high E2s on CD 28 (RR 1.10 (0.72-1.65), p= 0.38). Interestingly, in NAT FET cycles, patients with high E2 levels were more likely to have SCH formation (RR 3.23 (1.0-10.83), p<0.04).
Conclusion(s): Both SCH formation and serum E2 levels are higher in PRG FETs. However, high E2 levels was not associated with SCH formation. Further analysis is needed to determine the physiologic cause for an increased rate of SCH formation in PRG cycles and an estimation of obstetrical risk. References: 1. Edison, N., Blakemore, J. K., Goldman, K. N., Hodes-Wertz, B., & Grifo, J. A. (2018). Behind the bleed: analysis of the formation of subchorionic hematomas (SCH) in single euploid embryo transfer cycles by protocol.A Fertility and Sterility,A 110(4), e260-e261.
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Objective: Use of a combination trigger (low dose hCG with GnRH-a) is commonly used as part of controlled ovarian hyperstimulation in good responders as it lowers the risk of OHSS compared to hCG alone as well as triggering oocyte maturation. We sought to determine the effects of a second dose of GnRH-a 12 hours after the first, as part of the combination trigger on oocyte and blastocyst quality and risk of OHSS.
Design(s): Retrospective cohort study of all cycles utilizing a combination trigger between 1/1/2017 and 12/31/2018 at our center.
Material(s) and Method(s): Primary outcomes were the number and maturity of oocytes retrieved and incidence of OHSS, as defined by the ASRM practice committee. A subgroup analysis of all cycles utilizing pre-implantation genetic testing for aneuploidy (PGT-A) was performed for the secondary outcomes of number of 2PN, percent of 2PN biopsied as blastocysts and number euploid. Statistical analysis included student t-test, a chi-squared test with and without adjustments for age.
Result(s): 1892 cycles were included in the study, 1394 utilizing a single GnRH-a (G1) and 498 utilizing a double GnRH-a (G2) as part of the combination trigger. Demographics were not different between groups (Table 1). Cycles utilizing G2 had more oocytes retrieved (20.5 v 19.4, p < 0.03), however maturity was not different between groups. The incidence of OHSS was not different between groups, even when controlled for by age and use of cabergoline. Groups were then made by comparing low (<3500pg/mL) v high (>3500pg/mL) E2. The incidence of OHSS was higher in the high E2 group but lower with G2 (11.0% v 14.7%, p = 0.14). A subgroup analysis of cycles utilizing PGT-A was then performed comparing G1 (n=703) vs G2 (n=463). The number of 2PN zygotes was higher in G2 (12.3 v 11.2, p < 0.01) and there was a trend towards more %2pn of all eggs in G2 (60.0% v 59.8% p=0.05). The % of blastocysts biopsied from M2 was not different between groups (45.5% v 46.2%, p = 0.75), however, the total number of euploid embryos was higher with G2 compared to G1 (2.6 v 2.2, p < 0.02).
Conclusion(s): Use of G2 results in more oocytes retrieved and more euploid embryos. While there was no statistically decreased incidence of OHSS in G2 vs G1 overall, when stratified into low vs. high estradiol, there may be a clinically important reduction in OHSS for patients receiving G2 over G1. [Figure presented] Reference: None.
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