Objective To determine both the negative and positive predictive values of comprehensive chromosome screening (CCS) results for clinical outcome. Design Data obtained from two prospective, ...double-blinded, nonselection studies. Setting Academic center for reproductive medicine. Patient(s) One hundred forty-six couples with a mean maternal age of 34.0 ± 4.4 years and a mean paternal age of 37.3 ± 5.8 years. Intervention(s) Embryo biopsy for DNA fingerprinting and aneuploidy assessment. Main Outcome Measure(s) Failure rate of embryos predicted aneuploid by CCS (negative predictive value) and success rate of embryos predicted euploid by CCS (positive predictive value). Result(s) A total of 255 IVF-derived human embryos were cultured and selected for transfer without influence from CCS analysis. Embryos were biopsied before transfer, including 113 blastomeres at the cleavage stage and 142 trophectoderm biopsies at the blastocyst stage. Comprehensive chromosome screening was highly predictive of clinical outcome, with 96% of aneuploid predicted embryos failing to sustain implantation and 41% sustained implantation from embryos predicted to be euploid. Conclusion(s) These nonselection data provide the first prospective, blinded, clinical study directly measuring the predictive value of aneuploidy screening for clinical outcome. The clinical error rate of an aneuploidy designation is very low (4%), whereas implantation and delivery rates of euploid embryos are increased relative to the entire cohort of transferred embryos.
Objective To determine if cleavage- or blastocyst-stage embryo biopsy affects reproductive competence. Design Paired randomized clinical trial. Setting Academic-assisted reproduction program. ...Patient(s) Attempting conception through IVF. Intervention(s) After selecting two embryos for transfer, one was randomized to biopsy and the other to control. Both were transferred within shortly thereafter. The biopsy was submitted for microarray analysis and single-nucleotide polymorphism (SNP) profiling. Buccal DNA obtained from the neonate after delivery had microarray analysis and SNP profile compared with that of the embryonic DNA. A match confirmed that the biopsied embryo implanted and developed to term, whereas a nonmatch indicated that the control embryo had led to the delivery. Main Outcome Measure(s) Paired analysis of the delivery rates of the transferred embryos. Either twin delivery or failure to deliver represents equivalent outcomes for the biopsied and control embryos. In contrast, singletons were determined to be from the biopsied or the control embryo. Result(s) Blastomere biopsy on day 3 of development resulted in a significant reduction in sustained implantation. Only 30% of biopsied embryos had sustained implantation and ultimately developed into live-born infants versus 50% of unbiopsied controls, a relative reduction of 39%. In contrast, sustained implantation rates were equivalent (51% vs. 54%) for biopsied and control blastocysts. Conclusion(s) Cleavage-stage biopsy markedly reduced embryonic reproductive potential. In contrast, trophectoderm biopsy had no measurable impact and may be used safely when embryo biopsy is indicated. Clinical Trial Registration Number NCT01219504.
A consistent requirement for all preimplantation genetic testing is the need to obtain DNA from the oocyte or embryo. Currently this sample is attained through biopsy of one or both polar bodies, ...blastomere biopsy at the cleavage stage, or trophectoderm biopsy after blastulation. Selecting the optimal time for biopsy requires careful consideration. Polar body biopsy is less invasive and provides more time for analysis but fails to capture as many as one in three embryonic aneuploidies. Additionally, the inability to readily distinguish nondysjunction from premature separation of sister chromatids greatly limits the predictive value of the technique and may lead to an overdiagnosis of aneuploidy in as many as 45% of cases with first polar-body errors. Cleavage-stage biopsy provides adequate samples but is detrimental to the embryo. The adverse effect of blastomere biopsy may result in approximately two of every five reproductively competent embryos losing their ability to implant and sustain development. Trophectoderm biopsy does not adversely impact the embryos. However, for the majority of clinical programs without a genetics laboratory, vitrification would be necessary to allow time for the genetic analysis. Although this extends the time required for treatment, clinical outcomes are equivalent after transfer of euploid blasts during fresh IVF and cryopreserved embryo transfer cycles, so that excellent outcomes are maintained. At present the blastocyst stage is the optimal time to perform biopsies for preimplantation genetic testing.
Significant progress has been made in the understanding of embryonic competence and endometrial receptivity since the inception of assisted reproductive technology. The endometrium is a highly ...dynamic tissue that plays a crucial role in the establishment and maintenance of normal pregnancy. In response to steroid sex hormones, the endometrium undergoes marked changes during the menstrual cycle that are critical for acceptance of the nascent embryo. There is also a wide body of literature on systemic factors that impact assisted reproductive technology outcomes. Patient prognosis is impacted by an array of factors that tip the scales in her favor or against success. Recognizing the local and systemic factors will allow clinicians to better understand and optimize the maternal environment at the time of implantation. This review will address the current literature on endometrial and systemic factors related to impaired implantation and highlight recent advances in this area of reproductive medicine.
Objective To determine whether performing comprehensive chromosome screening (CCS) and transferring a single euploid blastocyst can result in an ongoing pregnancy rate that is equivalent to ...transferring two untested blastocysts while reducing the risk of multiple gestation. Design Randomized, noninferiority trial. Setting Academic center for reproductive medicine. Patient(s) Infertile couples (n = 205) with a female partner less than 43 years old having a serum anti-Müllerian hormone level ≥1.2 ng/mL and day 3 FSH <12 IU/L. Intervention(s) Randomization occurred when at least two blastocysts were suitable for trophectoderm biopsy. The study group (n = 89) had all viable blastocysts biopsied for real-time, polymerase chain reaction–based CCS and single euploid blastocyst transfer. The control group (n = 86) had their two best-quality, untested blastocysts transferred. Main Outcome Measure(s) The ongoing pregnancy rate to ≥24 weeks (primary outcome) and the multiple gestation rate. Result(s) The ongoing pregnancy rate per randomized patient after the first ET was similar between groups (60.7% after single euploid blastocyst transfer vs. 65.1% after untested two-blastocyst transfer; relative risk RR, 0.9; 95% confidence interval CI, 0.7–1.2). A difference of greater than 20% in favor of two-blastocyst transfer was excluded. The risk of multiple gestation was reduced after single euploid blastocyst transfer (53.4% to 0%), and patients were nearly twice as likely to have an ongoing singleton pregnancy (60.7% vs. 33.7%; RR, 1.8; 95% CI, 1.3–2.5). Conclusion(s) In women ≤42 years old, transferring a single euploid blastocyst results in ongoing pregnancy rates that are the same as transferring two untested blastocysts while dramatically reducing the risk of twins. Clinical Trial Registration Number NCT01408433.
Objective To develop and validate a quantitative real-time polymerase chain reaction (qPCR)–based method for blastocyst trophectoderm comprehensive chromosome screening (CCS) of aneuploidy. Design ...Prospective, randomized, and blinded. Setting Academic center for reproductive medicine. Patient(s) Nine cell lines were obtained from a commercial cell line repository, and 71 discarded human blastocysts were obtained from 24 IVF patients that underwent preimplantation genetic screening. Intervention(s) None. Main Outcome Measure(s) Consistency of qPCR diagnosis of aneuploidy compared with either conventional karyotyping of cell lines or microarray-based diagnoses of human blastocysts. Result(s) Samples from nine cell lines with well characterized karyotypes were diagnosed by qPCR with 97.6% (41/42) consistency. After applying a minimum threshold for concurrence, 100% consistency was achieved. Developmentally normal blastocysts designated as aneuploid or arrested blastocysts designated as euploid by single-nucleotide polymorphism microarray analyses were assigned identical 24 chromosome diagnoses by qPCR in 98.6% of cases (70/71). Overall euploidy (n = 37) and aneuploidy (n = 34) were assigned with 100% consistency. Data was obtained for both sample types in 4 hours. Conclusion(s) These data demonstrate the first qPCR technology capable of accurate aneuploidy screening of all 24 chromosomes in 4 hours. This methodology provides an opportunity to evaluate trophectoderm biopsies with subsequent fresh euploid blastocyst transfer. Randomized controlled trials to investigate the clinical efficacy of qPCR-based CCS are currently underway.
Objective To determine whether blastocyst biopsy and rapid quantitative real-time polymerase chain reaction (qPCR)–based comprehensive chromosome screening (CCS) improves in vitro fertilization (IVF) ...implantation and delivery rates. Design Randomized controlled trial. Setting Academic reproductive medicine center. Patient(s) Infertile couples in whom the female partner (or oocyte donor) is between the ages of 21 and 42 years who are attempting conception through IVF. Intervention(s) Embryonic aneuploidy screening. Main Outcome Measure(s) Sustained implantation and delivery rates. Result(s) We transferred 134 blastocysts to 72 patients in the study (CCS) group and 163 blastocysts to 83 patients in the routine care (control) group. Sustained implantation rates (probability that an embryo will implant and progress to delivery) were statistically significantly higher in the CCS group (89 of 134; 66.4%) compared with those from the control group (78 of 163; 47.9%). Delivery rates per cycle were also statistically significantly higher in the CCS group. Sixty one of 72 treatment cycles using CCS led to delivery (84.7%), and 56 of 83 (67.5%) control cycles ultimately delivered. Outcomes were excellent in both groups, but use of CCS clearly improved patient outcomes. Conclusion(s) Blastocyst biopsy with rapid qPCR-based comprehensive chromosomal screening results in statistically significantly improved IVF outcomes, as evidenced by meaningful increases in sustained implantation and delivery rates. Clinical Trial Registration Number NCT01219283.
To determine if preimplantation genetic testing for aneuploidy (PGT-A) is cost-effective for patients undergoing in vitro fertilization (IVF).
Decision analytic model comparing costs and clinical ...outcomes of two strategies: IVF with and without PGT-A.
Genetics laboratory.
Women ≤ 42 years of age undergoing IVF.
Decision analytic model applied to the above patient population utilizing a combination of actual clinical data and assumptions from the literature regarding the outcomes of IVF with and without PGT-A.
The primary outcome was cumulative IVF-related costs to achieve a live birth or exhaust the embryo cohort from a single oocyte retrieval. The secondary outcomes were time from retrieval to the embryo transfer resulting in live birth or completion of treatment, cumulative live birth rate, failed embryo transfers, and clinical losses.
8,998 patients from 74 IVF centers were included. For patients with greater than one embryo, the cost differential favored the use of PGT-A, ranging from $931–2411 and depending upon number of embryos screened. As expected, the cumulative live birth rate was equivalent for both groups once all embryos were exhausted. However, PGT-A reduced time in treatment by up to four months. In addition, patients undergoing PGT-A experienced fewer failed embryo transfers and clinical miscarriages.
For patients with > 1 embryo, IVF with PGT-A reduces healthcare costs, shortens treatment time, and reduces the risk of failed embryo transfer and clinical miscarriage when compared to IVF alone.
La fecundación in vitro (FIV) con test genético preimplantacional para aneuploidías es coste-efectivo, acorta el tiempo de tratamiento y reduce el riesgo de transferencia embrionaria fallida y aborto clínico en pacientes seleccionadas comparado con FIV solo
Determinar si el test genético preimplantacional para aneuploidías (TGP-A) es coste-efectivo para pacientes que se someten a fecundación in vitro (FIV).
Modelo analítico de decisión comparando costes y resultados clínicos de dos estrategias: FIV con y sin TGP-A.
Laboratorio de genética.
Mujeres ≤ 42 años de edad que se someten a FIV.
Modelo analítico de decisión aplicado a la población de pacientes antedicha utilizando una combinación de datos clínicos reales y suposiciones de la literatura con respecto a los resultados de FIV con y sin TGP-A.
El resultado primario fue el coste acumulado relacionado con FIV para lograr un nacido vivo o agotar la cohorte embrionaria de una única captación ovocitaria. Los resultados secundarios fueron tiempo desde la captación ovocitaria hasta la transferencia embrionaria que resultara en un nacido vivo o terminación del tratamiento, tasa acumulada de nacido vivo, transferencias embrionarias fallidas y pérdidas clínicas.
8998 pacientes de 74 centros de FIV fueron incluídas. Para pacientes con más de un embrión, el diferencial de costes favoreció el uso de TGP-A, desde $931-2411 y dependiendo del número de embriones estudiados. Como se esperaba, la tasa acumulada de nacido vivo fue equivalente en ambos grupos una vez que todos los embriones fueron agotados. Sin embargo, el TGP-A redujo el tiempo en tratamiento hasta cuatro meses. Además, las pacientes sometidas a TGP-A experimentaron menos transferencias embrionarias fallidas y abortos clínicos.
Para pacientes con más de un embrión, FIV con TGP-A reduce los costes sanitarios, acorta el tiempo de tratamiento y reduce el riesgo de transferencia embrionaria fallida y aborto clínico comparado con FIV solo.
Objective To determine the relationship between the age of the female partner and the prevalence and nature of human embryonic aneuploidy. Design Retrospective. Setting Academic. Patient(s) ...Trophectoderm biopsies. Intervention(s) Comprehensive chromosomal screening performed on patients with blastocysts available for biopsy. Main Outcome Measure(s) Evaluation of the impact of maternal age on the prevalence of aneuploidy, the probability of having no euploid embryos within a cohort, the complexity of aneuploidy as gauged by the number of aneuploid chromosomes, and the trisomy/monosomy ratio. Result(s) Aneuploidy increased predictably after 26 years of age. A slightly increased prevalence was noted at younger ages, with >40% aneuploidy in women 23 years and under. The no euploid embryo rate was lowest (2% to 6%) in women aged 26 to 37, was 33% at age 42, and was 53% at age 44. Among the biopsies with aneuploidy, 64% involved a single chromosome, 20% two chromosomes, and 16% three chromosomes, with the proportion of more complex aneuploidy increasing with age. Finally, the trisomy/monosomy ratio approximated 1 and increased minimally with age. Conclusion(s) The lowest risk for embryonic aneuploidy was between ages 26 and 30. Both younger and older age groups had higher rates of aneuploidy and an increased risk for more complex aneuploidies. The overall risk did not measurably change after age 43. Trisomies and monosomies are equally prevalent.
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