Faculty Bibliography

OBJECTIVE: It is well known that the embryo aneuploidy rate increases with women's age [1], but the effect of age on complex chromosomal abnormality (CCA) is less clear. Here, we addressed the relationship between maternal age and CCA with a retrospective cohort study. MATERIALS AND METHODS: We reviewed results of preimplantation genetic testing (PGT) by aCGH or NGS of embryo biopsies performed in an academic IVF unit between 2010 and 2019. We excluded PGT results from single gene disorder and egg donation cycles. CCA was defined as>=3 chromosome abnormalities (whole, partial and/or mosaic). Maternal age was categorized according to SART age groups: <35, 35-37, 38-40, 41-42, and >42 years. Statistical analyses were conducted using GraphPad Prism 8.
RESULT(S): 27,423 embryos were biopsied from 3,501 women aged 23 to 48 years. 4,740 embryos (16%) has CCA. Consistent with prior study [2], the most frequent chromosomes involved in CCA were 22, 16, 21 and 15, with incidences of 30.6%, 29.1%, 26.1% and 25.8% respectively. The number of chromosomal errors (from 3 to 42) involved in CCA did not correlate with maternal age (Spearman r = -0.0149, P = 0.3352). However, the rate of complex abnormal embryos tended to increase with advancing maternal age (9.7%, 11.2%, 10.9%, 24.8% and 43.6% in women aged < 35, 35-37, 38-40, 41-42, and > 42 years, respectively). Women over 40 years old had significantly higher rates of CCA compared to those under 40 years (Chisquare test, P < 0.0001). Surprisingly, the relationship between maternal age and CCA followed a U-shaped curve, decreasing from the 25 to 30 year old group (Pearson r = -0.831, P = 0.04) to the 30 to 35 year old group (Pearson r = 0.093, P = 0.861), then increased markedly in the 35 to 48 year old group (Pearson r = 0.921, P < 0.0001).
CONCLUSION(S):We found that CCA embryos share common features of aneuploidy, such as association with maternal age and preferential involvement of shorter chromosomes i.e. 22, 16, 21 and 15. Unexpectedly, our data showed that the relationship between CCA and maternal age assumes a U shape with increased rates at very young and very old ages. Both meiotic and mitotic errors contribute to chromosomal abnormality, and the contribution of each to CCA merits further investigation. IMPACT STATEMENT: The complex relationship between maternal age and embryo aneuploidy, which approximates a U-shape, may inform optimal timing of elective oocyte freezing and oocyte donation

OBJECTIVE: The use of a GnRH trigger in COH cycles has increased due to an improved safety profile but not all patients have adequate response1.We sought to investigate the utility of using serum GN levels to predict response to GnRH trigger. MATERIALS AND METHODS: We performed a retrospective cohort study of all GnRH-antagonist COH cycles at an urban university affiliated fertility center from 2017-2020. Cycles that utilized GnRH-agonist (GnRH-a) alone or in combination with human chorionic GN (hCG) for trigger were included. Patient and cycle characteristics were collected from the electronic medical record, including day 2 baseline follicle stimulating hormone (B-FSH) and earliest in-cycle luteinizing hormone (EIC LH). An optimal response to GnRH-a trigger was defined as a LH R40 mIU/mL on the morning after trigger. Descriptive statistics (median +/- range for continuous variables; frequencies and percentages for categorical variables) were calculated by GnRH-a response. Statistical analyses were performed on SAS (v9.4) and included the chi-square test, Fisher's exact test, or Mann Whitney U test, as appropriate with a p<0.05 considered significant.
RESULT(S): A total of 3,865 COH antagonist cycles were included. Ninetyone percent of patients had an optimal response to GnRH-a trigger. Optimal responders had higher B-FSH levels than those with poor response (6.52 mIU/ml vs 4.36 mIU/ml, p<0.001). Similarly, the EIC LH was higher for optimal responders (4.66 mIU/ml vs 2.16 mIU/ml, p<0.001). Optimal response had a positive association with older age (p<0.00001), lower BMI (p<0.0001), less days of stimulation (p<0.001), lower starting serum estradiol (p<0.0007), and lower total gonadotropin dose (p<0.001). Optimal response was also associated with B-FSH >5 mIU/ml (p<0.0001), EIC LH >1 (p<0.0001), and Clomiphene citrate use (p< 0.009). Asian race was associated with poor response (p<0.006). There was no difference in oocyte maturity rate (p=0.6) or fertilization rate (p=0.5) for optimal or poor response. Cutoffs for B-FSH (>5 mIU/mL) and EIC LH ( >1 mIU/mL) were chosen to be reasonable clinical cutoffs to create a tool or aid to predict patient response to GnRH-a trigger. The incidence of patients with B-FSH >5 IU/ ml who had a poor response was 4.9% compared to 16.0% in patients with B-FSH <5 (p<0.0001). Twenty-four percent of patients with an EIC LH <1 had a poor response, compared to 4% of patients with EIC LH >1 (p<0.0001). The combination of B-FSH >5 IU/ml and EIC LH >1 IU/ml had a 71% sensitivity and 96% PPV in predicting an optimal response. When individually compared to a B-FSH >5 mIU/ml, an EIC LH>1 mIU/ ml had a higher sensitivity (91% vs 76%) and higher PPV (96% vs 95%) in predicting optimal response.
CONCLUSION(S): A B-FSH>5 and EIC LH>1 may be an appropriate threshold and helpful guide for physicians when determining trigger medicine for GnRH-antagonist COH cycles. Further studies are needed to understand predictors of poor response above these thresholds. IMPACT STATEMENT: In an era of personalized medicine, cycle and patient characteristics, such as GN levels, may improve cycle outcomes and provide further individualized care

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: Mosaic embryo transfer (MET) following preimplantation genetic testing for aneuploidy (PGT-A) has become more commonplace, particularly among patients who do not have any euploid embryos available for transfer. Our aim was to report on uptake and results of prenatal diagnosis (PND) following MET. MATERIALS AND METHODS: All MET cases occurring at our clinic between September 2015 and February 2021 in which an ongoing pregnancy was documented were reviewed. Patients received genetic counseling prior to MET, including discussion of prenatal testing options, and a summary letter was provided upon discharge. Medical records were reviewed to determine whether PND was performed, and the types of analyses performed on amniotic fluid (AF) or chorionic villi (CV).
RESULT(S): Sixty-five patients had an ongoing pregnancy following MET. Eight patients were excluded from the analysis due to gestational age too early for PND, and we were able to obtain PND results for 33 of the 57 patients (57.9%). Of the remaining patients, 9/57 (15.8%) declined PND, and we were unable to obtain information about whether PND was performed for 15/57 (26.3%). Since 2/33 patients were carrying twins both originating from MET, there were a total of 35 conceptuses with PND results; 34 on AF and 1 on CV. In one case, spontaneous abortion (SAB) occurred following attempted amniocentesis and was attributed to an infection caused by the procedure. In 35/35 cases (100%), karyotype results were normal (46,XY or 46,XX). In 28/35 cases (80.0%), chromosomal microarray was also performed, and there were no cases in which segmental mosaicism identified in the embryo was detected. In 6/28 cases (21.4%), a variant of uncertain significance (VUS) was identified on a different chromosome; 5/6 of which were inherited from a parent and were below the resolution of PGT-A (mean size 206.6 kb). Two out of 35 cases (5.7%) involved additional uniparental disomy (UPD) analysis; one result was normal while the other was inconclusive due to lack of informative parental markers.
CONCLUSION(S): There were no cases identified in which PND results confirmed mosaicism detected by PGT-A; therefore, this risk appears to be low. Genetic counseling about MET should address benefits, limitations, and risks of PND, including potential of an unrelated VUS and procedurerelated risk of SAB. Currently, it remains unclear as to whether the benefits of PND outweighs these risks, and whether additional analyses such as UPD testing are warranted. Future studies are necessary to determine whether specific types of mosaic results are associated with different risks, as well as the psychological impact of PND after MET on patients. IMPACT STATEMENT: Our study provides evidence that the risks associated with METare likely overestimated, as we did not identify any cases of abnormal PND consistent with the mosaic PGT-A result. These data are necessary for accurate patient counseling and informed consent, as well as evidence-based clinical policy development

OBJECTIVE: To determine the prognostic utility of day of biopsy on mosaic embryo (ME) transfer outcomes. MATERIALS AND METHODS: Sub-analysis was performed of data collected in the 2021 study by Viotti et al 1. Descriptive statistics (mean +/- standard deviation for continuous variables; frequencies and percentages for categorical variables) were calculated separately by biopsy day (5, 6, or 7). The three groups were compared using the chi-square test or Fisher's exact test, as deemed appropriate, for categorical variables, and analysis of variance (ANOVA) for continuous data. A result was considered statistically significant at p<0.05. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).
RESULT(S): Of the 1000 ME transfers documented, 825 specified day of biopsy (day 5, 6, or 7). There was a significant difference in mosaic type by biopsy day (p<0.0001); day 7 MEs resulted in significantly more complex and single monosomy/trisomy types. Day 6 MEs resulted in significantly more double monosomy/trisomy type. Day 5 MEs resulted in significantly more segmental types overall, including single, double, and complex segmental. There were also significant differences in outcomes; day 7 MEs were significantly less likely to result in pregnancy (p=0.0015), while day 5 MEs were significantly more likely to result in implantation (p= 0.0005) and ongoing pregnancy/live birth (p <0.0001). There was no significant difference in biochemical pregnancy (p= 0.717) or spontaneous abortion (p=0.757) based on biopsy day. There was no significant difference in maternal age (p= 0.455) or percent mosaicism (p=0.319) based on biopsy day. Day 5 MEs had significantly better morphology (p< 0.0001). The difference in ongoing pregnancy rate among the three biopsy days remained statistically significant after adjusting for mosaic type (p<0.0005). However, there was no significant difference in ongoing pregnancy rate between mosaic types after adjusting for biopsy day (p=0.1369).
CONCLUSION(S): MEs biopsied on day 5 are more likely to have segmental type mosaicism, better morphology, and better transfer outcomes. The mechanism for these differences are unclear; however, a hypothesis is that embryos with mosaicism associated with poorer outcomes may be slower to develop into blastocysts. These data can be incorporated into ME prioritization decisions. Further studies are needed to determine whether larger sample sizes would show similar findings, and how biopsy day can be combined with embryo morphology and mosaic type to continue improving ME selection and better inform patient counseling. IMPACT STATEMENT: Day of embryo biopsy is an important predictor of ME transfer success

OBJECTIVE: The rise of the SARS-CoV-2 pandemic and temporary closures of fertility centers made the effect on POC cycles uncertain but garnered national attention1,2. We sought to assess the impact of the pandemic on POC cycles in a pandemic epicenter. MATERIALS AND METHODS: This is a retrospective cohort study of all POC cycles at an academic fertility center in New York City from 1/1/2019- 12/31/2020. Primary outcomes were number of POC patients (pts) and cycles. Secondary outcomes were pt relationship status, payment method, AMH, and cycle parameters; with subgroup analyses by age groups. We also examined the relationship between monthly number of POC cycles and national SaRS-CoV-2 cases. Statistical analyses included z-score analysis, Mann-Whitney, and Chi-squared, with p<0.05 significant.
RESULT(S): Despite a 5.5 week center closure in 2020, POC pts increased 14% and POC cycles increased 16% from 2019 to 2020 (Table), with a 32% increase seen between June-Dec, 2020 . There was a 28% increase in POC pts <37yo in 2020 (252 pts vs. 323 pts, p<0.04) and no change in pts >37yo in 2020 (p=0.9). Relationship status did not differ between years (16% partnered, 76% single, 8% unknown in 2019 vs. 16% partnered, 73% single, 11% unknown in 2020; p=0.6). Fewer patients in 2020 had insurance coverage (16% vs. 24%, p<0.001). AMH was higher in 2020 (2.3 vs. 2.1, p<0.03), but days of stimulation, oocytes retrieved, oocytes frozen, total gonadotropins, and maximum estradiol (E2) were not different (Table). While national SARS-CoV-2 cases peaked in April, July, and November 2020, monthly POC cycles at our center did not decrease with surges in SARS-CoV-2 after our center reopened in May (p=0.24). In 2020 there were 23 cycles cancelled, none due a positive SARS-CoV-2 test.
CONCLUSION(S): POC volume increased at our center in 2020, especially in young patients, despite center closures and SARS-CoV-2 surges. IMPACT STATEMENT: More young people pursued POC despite the SARS-CoV-2 pandemic. Further research is needed to understand POC pt motivations and experiences during a pandemic. (Table Presented)

OBJECTIVE: AO cryopreservation (cryo) is widely used, but published thaw data is scarce. We reviewed our elective AO thaws. MATERIALS AND METHODS: Pts who thawed AOs at our FC in 2004- 2020 were reviewed. Pts were excluded if AO cryo was performed for a medical reason, as research, due to no sperm or a natural disaster, with embryo cryo or for use with a gestational carrier. Outcomes included implantation (IR), spontaneous abortion (SABR) and ongoing pregnancy + live birth (LBR) rates / embryo transfer (ET). We calculated a final LBR (FLBR) defined as LBR / pt; FLBR only included pts who a) had live birth (LB) or ongoing pregnancy (OP), or b) consumed all AOs and resultant embryos. Statistics included Mann-Whitney U and Fisher's exact test.
RESULT(S): 543 pts (median age at 1st cryo 38y) underwent 800 cryos (89% our FC, 9% elsewhere, 2% both), 605 thaws and 416 ETs. Cryo used vitrification for 72%, slow freezing for 4% and both for 24% of pts. Median time from 1st cryo to 1st thaw was 4y. In total, we thawed 8511 AOs (7492 M2s). AO survival was 79%, M2 survival was 80% and 2PN fertilization was 66%. When pts returned for thaw, 25% pursued fresh ET, 73% pursued preimplantation genetic testing (PGT), and 2% pursued a combination of both. In pts who pursued fresh ET, 92% had >=1 embryo for ET. In pts who pursued PGT, 57% had >=1 euploid. 13% of pts had no useable embryos (embryos for fresh ET, PGT, cryo). 59% of pts had >=1 ET. 37% of ETs were fresh, with 2% using rush-PGT. 63% of ETs were frozen, with 97% using PGT. In non-biopsied ETs, IR was 29%, SABR was 19% and LBR was 31%. In euploid ETs, IR was 64%, SABR was 10% and LBR was 55%. In our cohort, FLBR was 38%. In total, 178 babies (11 twin, 1 triplet) and 24 OPs resulted. 176 pts have >=1 LB or OP, and 23 pts have >=2 LBs or OPs from AO thaw. 33% of pts have remaining AOs or euploid or untested embryos; 45% of these pts do not have a LB or OP from AO thaw. See table for outcomes by age.
CONCLUSION(S): AO thaw leads to a FLBR of 38%, comparable to our FC's 34% LBR per intended retrieval in pts of similar age1 . IMPACT STATEMENT: Our real thaw data may be more useful than models in pt counseling

OBJECTIVE: There has been significant uncertainty surrounding the COVID-19 pandemic and its effect on human reproduction which resulted in a temporary suspension of ART treatments in early stages of the pandemic. The ACE2 receptor used by the virus to infect pulmonary cells is also found in reproductive organs and has fueled speculation as to whether the disease can be sexually transmitted and whether it can cause infertility. Non-viral issues (e.g., pandemic related psychological stress, alternate methods of communication and interaction, and new clinic procedures) may also worsen outcomes. We sought to determine whether clinical outcomes following the frozen embryo transfer (FET) of a euploid embryo were different during the COVID-19 pandemic in 2020 when compared to prior to the pandemic in 2019. MATERIALS AND METHODS: Patients who tested negative for COVID-19 and underwent FET of a single euploid embryo at NYU Fertility Center in NYC over January 2020 through September 2020 were separated by treatment month and compared with patients from the corresponding month in 2019. Patient's age at cycle start and age at freeze were compared using Student's T-Test. Potential cycle outcomes included intrauterine pregnancy (IUG), biochemical pregnancy (Biochem), and no pregnancy, and outcomes were compared between the two years using contingency Chi Square.
RESULT(S): 1,044 patients were compared over the corresponding months. 558 transfers from 2019 and 486 patients from 2020, with no patients in April of 2020. There were no differences noted in patient's age at cycle start, or age at cryopreservation, between any of the months across the two years. Analysis of outcomes following FET further revealed no statistically significant differences between any of the months over the two years, X² = 14.64, p > 0.05. Post hoc analyses comparing the combined months of March, April and May, or the combined 9-month periods, were also not statistically significant (X² = 0.042, p > 0.05; X² = 1.68, p > 0.05; respectively).
CONCLUSION(S): In patients who tested negative for COVID-19, there were no differences in treatment outcomes following FET's when comparing patients treated during the COVID pandemic with those who were treated prior to the pandemic. IMPACT STATEMENT: Providers and patients can be reassured that with proper testing and sanitizing techniques FET outcomes remained unaffected by the pandemic. (Table Presented)

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: The causes of spontaneous abortion (SAB) following euploid embryo transfer (EET) remain poorly understood. Here we describe the frequency of aneuploidy in products of conception (POC) and endometrial dysfunction in women who miscarried after EET. MATERIALS AND METHODS: Between 1/2018 - 8/2020, 255 dilation and curettage (D&C) procedures were performed at a large academic IVF center for SAB following EET. Retrospective chart review was performed to identify D&Cs followed with genetic analysis of POCs. Information collected from the medical record included assessments of endometrial dysfunction based on Endometrial Receptivity Assay (ERA), CD138 for chronic endometritis (CE), and/or BCL6 for endometriosis. Exclusion criteria included an abnormal endometrial cavity on imaging. Demographic factors, clinical parameters and IVF/FET outcomes were reviewed. Additionally, retrospective chart review was performed of all ERAs completed at our institution from 12/2018-9/2020.
RESULT(S): Genetic analysis of 67 POCs after D&C following EET were identified. Fifty-nine POCs (88%) were euploid by SNP microarray. Eight (12%) of the POCs displayed genetic abnormalities: 3 trisomies, 2 partial duplications, 2 mosaic trisomies and 1 triploidy of paternal origin. Of the 51 patients who had endometrial biopsy (EMB), 28 (55%) had normal results. Twenty-three (45%) had abnormal results: 18 with CE, 2 with elevated BCL6 and 3 with pre-receptive ERA. The proportion of SABs unexplained by endometrial dysfunction or genetically abnormal POCs was 38% (26). A total of 44 patients underwent repeat EET. Eleven live births (LB) occurred, six after correction of endometrial dysfunction. Eight patients currently have ongoing pregnancy, 2 after treatment for CE. Three patients experienced repeat SAB, 1 following correction of pre-receptive ERA, and 1 after CE treatment. Four patients had implantation failure, 3 following normal EMB and 1 after treatment of CE. Two patients conceived spontaneously and delivered, 1 after treatment for CE, the other after a normal EMB. Upon review of all ERAs, 82 single EET following ERA guidance were identified. Fifty-nine percent (n=48) resulted in ongoing pregnancy or LB. There was no significant difference in ERA result or post ERA transfer outcome based on ethnicity (p= 0.7, p=0.4) or BMI (p= 0.8, 0.9), respectively. There was also no difference in post ERA transfer outcome based on blastocyst age (day 5 or 6) (p=0.5)
CONCLUSION(S): Aneuploidy and/or endometrial factor can contribute to SAB following EET. Aneuploid POCs could have arisen de novo and/or have passed undetected by trophectoderm biopsy and NGS. Our results are consistent with the 1-2% false negative rate reported for PGT-A. Further studies are needed to characterize the sub-chromosomal genetic variations associated with euploid embryo SABs, as well as endometrial function testing. IMPACT STATEMENT: The etiology behind failed EET may involve more discrete entities such as sub-chromosomal abnormalities in addition to aneuploidy and endometrial dysfunction