RBMO Insights Issue 28: September 2024

A warm welcome to September’s RBMO Insights - your monthly newsletter from Reproductive Biomedicine Online bringing you behind-the-scenes news, Affiliated Society updates, special article selections, and in-depth commentary on pertinent themes of the field.

The Summer is drawing to a close and the weather is getting cooler, but conference season is getting a second wind. In this issue we look to several forthcoming events over the coming months, including our own RBMO Live webinar on September 10.

Our Talking Points section unpacks the inconsistency of non-invasive PGT-A, advantages of blastocyst over cleavage-stage transfer, and the risks around prolonged third stage of labour.Elsewhere in this issue we also give you some details of our new and improved article website pages on rbmojournal.com, look at some recent article highlights from the journal, and showcase our Reproduction, Technology and Society section, with a profile from Section Editor, and one of the founding partners of RBMO, Dr Kamal Ahuja.

If you are not yet subscribed to this newsletter by email and you like what you read, click this link to see all back issues and sign up to our mailing list to receive Insights, our quarterly Digest and occasional RBMO news direct to your inbox.

With that, we will leave you to enjoy this packed issue of Insights.

Non-invasive PGT-A remains constrained by inconsistent results

It’s now a decade since Dagan Wells and colleagues in Italy reported in the pages of this journal that genomic DNA was present in about 90% of blastocoele fluid samples taken during embryo vitrification, which raised the possibility of screening embryos for an X-linked disorder. The following year, Gianaroli’s group in Bologna tested the proposal in a small study of 17 couples which detected DNA in 76% of blastocoele fluid samples taken, and in almost all these cases the ploidy condition of the samples was confirmed in trophectoderm cells. Blastocoele fluid, the authors proposed, could represent ‘a possible alternative source of material for chromosomal analysis’.

Since then, the progress of a non-invasive - or minimally invasive - means of testing embryos for aneuploidy has been reported with ever promising conclusions, but never with any certainty that the technique is ready for primetime. And that remains the conclusion of a new review published in the October issue of RBMO, by GERARD CAMPOS GUILLAUMES, MSc and Liesl Nel-Themaat .

‘Although blastocentesis remains a promising area for future research,’ conclude the authors, ‘several technical and methodological limitations are currently constraining its consideration for clinical practice.’

The term ‘non-invasive’ has inevitable implications that trophectoderm biopsy for PGT-A is by definition ‘invasive’ and thereby less preferable than the alternative. Thus, while the authors of this latest RBMO review propose that trophectoderm biopsy is ‘considered safe and has minimal impact on the embryo’, they do suggest that its alternative ‘could represent a simpler, safer and more consistent approach to PGT’, with both cost benefit to the patient and technical benefits to the lab. A 2023 review of health outcomes following embryo biopsy described its effect on implantation and live birth as ‘unclear’, although an RCT in 2013 had appeared to demonstrate the safety of the procedure.

Over the past decade - and with the additional promise of DNA detected in spent culture medium - milestone reports have hailed non-invasive PGT-A as the next phase in embryonic genetic screening. Is non-invasive genetic testing ‘the next revolution in reproductive genetics?’, asked a review in 2020.

But today, as then, the answer seems not yet. The latest RBMO review identifies several reasons why non-invasive tests are still a definite maybe, and not yet a definite yes. First is the question of the source of the DNA in blastocoele fluid and whether it accurately represents the genetic status of the embryo. The authors propose - without evidence in humans - that release of DNA into the blastocoele fluid cavity during embryonic cell apoptosis may compromise the integrity of the DNA remnants detected, as resulting from cells which the embryo preferentially eliminated under its ‘self-correction’ mechanism. Any compromised integrity of blastocoele fluid DNA with likely apoptotic origination, the authors propose, would constrain amplification, leading to low concordance and reproducibility rates for both aneuploidy screening and monogenic testing.

However, the biggest test remains with establishing concordance between those amplification results and gold standard from trophectoderm samples. But, the review concludes, the concordance and reproducibility of minimally invasive PGT-A remain ‘mostly inconsistent’, with high variability in DNA amplification (35–87%) and correlation between blastocoele fluid and trophectoderm samples (38–100%). And if, as they emphatically propose, the genetic composition of blastocoele fluid ‘most likely contains genetic material from cells eliminated during development’ (ie, degraded and fragmented), such low correlation might ‘reasonably be expected’ between the ploidy status inferred from the blastocoele fluid and the embryo karyotype. Thus, as ever, ‘data do not support the use of blastocoele fluid DNA as a reliable and consistent replacement for PGT’ - and the promise of those earlier milestone studies seems as far off now as then.

Cumulative LBR advantage less evident in day 5/6 transfers than in day 2/3

A 2022 Cochrane review of cleavage-stage vs blastocyst embryo transfer spoke of ‘a shift’ in IVF practice from the former to the latter, no doubt explained by developments in culture media and by irrefutable evidence of blastocyst transfer’s superior outcome in fresh cycles. Indeed, the third of seven Cochrane reviews on the subject had already concluded in 2007 that ‘there is a significant difference in pregnancy and live birth rates in favour of blastocyst transfer with good prognosis patients’, adding that patients with ‘high numbers of eight‐cell embryos on Day three being the most favoured’.

The advantage of blastocyst over cleavage-stage transfers in fresh cycles was reaffirmed in a Cochrane update in 2022, which included 32 RCTs and almost 6000 women and found a positive odds ratio of 1.27. However, that review noted as had the earlier versions that any advantage in cumulative LBRs remained ‘uncertain’, largely because of limited evidence (just five RCTs) and the higher risks of transfer cancellation in frozen blastocyst cycles. Thus, the 2022 Cochrane review concluded that ‘more evidence is needed to know whether the stage of transfer impacts on cumulative live birth and pregnancy rates’.

A team led by Pr Patricia Fauque (MD-PhD) have published a registry study from the large French national database that goes some way to providing that evidence - but now without obvious benefit from extended culture. The study, which is currently available as an in-press article in RBMO, was based on data from the French national registry including cycles reported from 2016 to 2019 with at least one cleaved embryo at day 2. Cycles were divided into short (day 2/3) or extended (day 5/6) embryo culture - and as in current everyday practice any supernumerary embryos following the initial fresh transfer were all vitrified. More than 133,000 cycles met the inclusion criteria.

After one year of follow-up the cumulative LBR per cycle in the day 2/3 and day 5/6 groups was 30.3% and 33.4%, respectively, but with substantial differences found according to patient age, the number of day 2 embryos and fertilisation method. When these variables were included in a multivariate regression analysis, the cumulative LBR per cycle at one year became significantly lower in the day 5/6 group than in the day 2/3 group. However, because the rate of fresh ET cancellation in the day 5/6 group was substantially higher (19.9% vs 3.0%), the cumulative LBR per transfer was found to be significantly higher in the blastocyst group.

This was a complicated study in its design but there does seem some clarity in a higher cumulative LBR per transfer but a lower cumulative LBR per cycle in the extended culture patients. As the authors report: ‘The cumulative outcomes evaluated per cycle in multivariate analysis taking into account patient and cycle characteristics significantly favoured day-2/3 group in the overall cohort, even if the difference was small . . . This finding reinforces the hypothesis that extended embryo culture does not yield an improved probability of birth.’

So, despite Cochrane in fresh cycles, where does that leave short or longer culture in everyday transfers? A similar registry study from the HFEA database of non-donor treatments between 1999 and 2010 concluded that blastocyst-stage transfer ‘may offer an improved chance of live birth’ in both the first fresh and the first complete cycle of ART compared to cleavage-stage transfer (56.5% vs 34.8%). ‘Where possible,’ advised the authors, ‘offering blastocyst transfer to a wider range of couples may increase cumulative success rates.’

However, while these latter results and the traditional arguments in favour of blastocyst transfer - more physiological, better embryo selection, more conducive to SET - make a strong case, extended culture remains associated with cycle cancellation and fewer blastocysts for freezing. Indeed, the Cochrane review of 2022 found embryo freezing rates lower in the blastocyst group (OR 0.48) and cycle cancellations higher (OR 2.50). Thus, while benefit from extended culture seems clear in fresh transfers, inconclusive and conflicting results in studies of cumulative outcomes suggest that more evidence will be needed to know how or if the stage of transfer has an effect.

ART associated with added risk of postpartum hemmorhage from prolonged third stage of labour

The third stage of labour, that short time after birth when the uterus contracts and expels the placenta, carries risk for the mother in its association with postpartum hemorrhage. Postpartum hemorrhage is said to explain around 25% of all maternal deaths and it’s for this reason that the active management of the third stage of labour is well established over physiological management. The former through uterine-active drugs (oxytocin, ergometrine) and umbilical cord control aims to speed up this stage of labour, while the latter simply allows delivery of the placenta without intervention.

Now, with some evidence that ART conceptions are associated with several obstetric complications including postpartum hemorrhage, a new paper published online by RBMO has concluded that ART pregnancies (and particularly those from frozen embryo transfers) are indeed a significant risk factor for a prolonged third stage of labour, highlighting the need for vigilant monitoring and active management of this third stage.

The study by Akihito Kato and colleagues in Nagoya, analysed data from all term deliveries at 12 maternity hospitals in Japan between 2012 and 2018 (n=25,336). ART conceptions accounted for 4.5% of them, with multivariate analysis applied to detect a prolonged third stage of labour (defined as ≥20 min). This analysis identified ART pregnancy (OR 4.38), a history of abortion (OR 1.40) and prolonged labour (OR 1.52) as independent risk factors when compared to natural conceptions.

However, among the types of ART, further stratified analysis identified FET, FET in a programmed HRT cycle and blastocyst transfer as each significantly associated with a prolonged third stage of labour (ORs 4.07, 4.11 and 2.13 respectively). And as expected, the duration of the third stage of labour was closely associated with total blood loss and the prevalence of postpartum hemorrhage in ART pregnancies.

The study analysed data from all term deliveries at 12 maternity hospitals in Japan between 2012 and 2018 (n=25,336). ART conceptions accounted for 4.5% of them, with multivariate analysis applied to detect a prolonged third stage of labour (defined as ≥20 min). This analysis identified ART pregnancy (OR 4.38), a history of abortion (OR 1.40) and prolonged labour (OR 1.52) as independent risk factors when compared to natural conceptions. However, among the types of ART, further stratified analysis identified FET, FET in a programmed HRT cycle and blastocyst transfer as each significantly associated with a prolonged third stage of labour (ORs 4.07, 4.11 and 2.13 respectively). And as expected, the duration of the third stage of labour was closely associated with total blood loss and the prevalence of postpartum hemorrhage in ART pregnancies.

Theirs, say the authors, is the first study to demonstrate that ART is an independent risk factor for a prolonged third stage of labour, which in itself is closely related to several placental disorders already associated with ART. However, they report that a ‘precise biological mechanism’ for the findings remains unclear, although they - as have many other recent studies - note the effect of FET cycles programmed with HRT, where in this study the greatest increased odds for an extended third stage of labour were found. The authors thus suggest that hormonal effects - such as the absence of a corpus luteum rather than the embryo transfer itself - ‘may be partly responsible for the delay of the detachment phase during placental delivery’. This is a finding much applied to pre-eclampsia and other hypertensive disorders of pregnancy in recent FET studies, and already behind a large-scale change in practice in favour of non-programmed cycles.

Of course, the finding of this Japanese study is association, not causation, and as in all such studies will raise questions whether this third stage of labour is per se more complicated in ART pregnancies or if some of the women needing ART have pre-existing conditions anyway associated with complications during delivery (such as adenomyosis).

Derivative and non-derivative aneuploidy rates in PGT tested blastocysts from carriers of structural rearrangements

Lauren Walters-Sen, PhD, FACMG , Dana Neitzel, MS, CGC , Rachel Ellsworth, Sarah Poll, Nicole Faulkner, Swaroop Aradhya

Evaluation of a large cohort of PGT-SR data allowed the authors of this study to generate likelihood of transfer estimates for different types of structural rearrangements stratified by parent-of-origin and number of biopsies. These data allow for a more accurate risk assessment when counseling couples with chromosomal rearrangements.

Impact of different progesterone timings on live birth rates for blastocyst frozen embryo transfer cycles

Ruiqiong Zhou, Mei Dong, Zhaoyi Wang, Li Huang, Songlu Wang, Ye Chen, Zhenghong Zhu, Xiqian Zhang, Fenghua Liu

This study provides a new perspective on the timing of progesterone administration prior to frozen embryo transfer. Slower-developing day 6 blastocysts may have a different window of implantation (WOI) compared with day 5 blastocysts, and day 6 blastocysts may require a longer period of progesterone administration and may have a narrower optimal WOI.

Growing evidence that endometriosis is a systemic disease

Togas Tulandi & Paola Vercellini

The pathophysiology of endometriosis remains unclear. Retrograde menstruation could be a phenomenon that initiates the process, but may not explain the entire pathophysiology of endometriosis. Current evidence suggests that endometriosis is a type of chronic inflammatory disease. In this new Commentary paper, Togas Tulandi and Paolo Vercellini emphasize the importance of pursuing research for novel and safer anti-inflammatory and immunomodulatory drugs that can be used by patients with endometriosis on a long-term basis.

Patient satisfaction with telemedicine and in-person visits in reproductive endocrinology and infertility clinics

Anne Kim, Jake Anderson-Bialis , Lauren Citro , Clarisa Gracia

The impact of telemedicine in the fertility setting is garnering interest, and this survey study shows a majority of patients are satisfied with their telemedicine care. Although most still preferred in-person visits, the high satisfaction rating supports the continued use of telemedicine as supplement or viable alternatives to in-person services.

Exploring the effect of PRP on vascularization and survival of follicles in human ovarian tissue transplanted to immunodeficient mice

Cristina Subiran Adrados , Hanna ?rnes Olesen , Sophie Vernimmen Olesen , Susanne Elisabeth Pors, Susanne Holtze , Thomas Hildebrandt, Claus Yding Andersen , Stine Gry Kristensen

Ovarian tissue transplantation could be improved by increasing vascularization after transplantation and reducing hypoxia. Platelet-rich plasma solutions have been shown to increase vascularization in different models including murine ovarian autotransplantation. This paper shows that local injections of hPL do not increase vascularization in human ovarian tissue xenografting after 3 and 6 days. Furthermore, neither hPL, nor UCP increased follicle density after 4 weeks.

RBMO’s article pages get an update

The RBMOjournal.com website has a new and improved journal article page. The page has been given a more compact cleaner design, and the presentation of key information has been streamlined making it easier to see more details at a glance, and highlight the important features of each article.

Author and article information - At the top of the page dropdowns now hold all the author affiliations and notes, with an article information tab for the publication milestones, footnotes, DOI, copyright and other details.

Outline - The left hand navigation bar can now be collapsed, to make the text windows wider when not in use, or slide out to reveal hyperlinks to key article sections such as the Methods and Results, or the subheading titles in review articles and our more editorial style articles such as Countercurrent Contributions.

Journal issue - To the right-hand side of the page, the journal cover image is a clearer sign to reach the current table of contents, or click on 'Download full issue' to save all the article PDFs you have access to for later; i.e., if you have full subscription or access, the full issue will be downloaded. If you have no subscription, all the free and open access papers will be downloaded.

Article tools - The set of article management actions have been simplified and reorganised with easier location and identification of buttons to download the PDF, get a citation, share to your favourite social media platform, or quickly link to other key journal pages.

Key previews - Finally, the right hand column features figure thumbnails, overviews of article metrics, related articles, and supplemental materials, to give you an indication of additional context and further reading around the article itself.

Many of these changes are a result of reader feedback and we hope you like the new design, but we are always keen to hear more of your thoughts on the accessibility and functionality of our site, so please do let us know if you have any.

Peer Review Week

September brings with it the annual Peer Review Week , a global awareness initiative which this year runs from 23-27 September, exploring the ‘Intersection of Innovation and Technology’.

Now in its ninth year, the week is a valuable platform that brings together researchers, publishers, editors, and other members of the scholarly community over a range of activities to foster discussion, discuss future developments, exchange insights, and acknowledge significant contributions made to the peer review process. These events are a great way to learn more about how and why article submissions are handled in the ways they are, and where peer review is headed in the future, with the chance to make your voice heard at one (or perhaps several) of the many events that run over the week.

Check the Peer Review Week website for listings of events, including ORCID hosted session ‘Navigating Challenges in Peer Review: Perspectives from University Presses and Associations’ and tech company World Brain Scholar for a ‘Demonstration of Eliza, the AI-supported peer-review tool’ with more to be added as we get nearer to the week itself.

We have recently published guidelines from two of our Affiliated Society partners.

Turkish Society of Reproductive Medicine

Affiliated Society Guideline: Turkish Society of Reproductive Medicine good laboratory practice guide for PGT-M https://doi.org/10.1016/j.rbmo.2024.104378

This new guideline from the Turkish Society of Reproductive Medicine defines the conditions and requirements for an outsourced PGT program in line with the experience and needs of practitioners.

It is intended to be a reference document for ART centres, genetic diagnosis centres, non-governmental organisations working on reproductive health, legal experts, consultants working on laboratory accreditation, academicians specialising in ethical issues, and policy makers.

The document specifically includes challenges and recommendations regarding PGT-M and aims to identify and prevent errors leading to misdiagnosis. Though developed in the context of Turkish experiences, the recommendations can be modified to fit other locations as well.

Association of Reproductive & Clinical Scientists

Affiliated Society Guideline Laboratory Diagnostic Andrology UK Guidelines for Good Practice (2024) https://doi.org/10.1016/j.rbmo.2024.104373

This new guideline from the ARCS updates and clarifies items relating to diagnostic andrology in the 2012 Association of Biomedical Andrologists Laboratory Andrology Guidelines for Good Practice Version 3 (Tomlinson et al., 2012).

The main change separates diagnostic and therapeutic andrology into individual documents; post-vasectomy semen analysis still references the 2016 guideline (Hancock et al., 2016). These guidelines seek to incorporate and clarify internationally agreed methodology following the World Health Organisation laboratory manual for the examination and processing of human semen 6th edition (World Health Organization, 2021), and publication of ISO 23162:2021 (International Organization for Standardization (ISO), 2021).

Significant updates include: requiring four-category grading for motility (A: rapidly progressive; B: slowly progressive; C: non-progressive; D: immotile); 4-part morphology assessment (head, midpiece, tail, cytoplasmic droplets) as essential for quality assurance (even if only the percentage ‘normal’ are reported); and specifying sperm toxicity testing procedures for diagnostic andrology. ?We include a section on haematospermia, an observation requiring rapid onward referral.

RBMO LIVE final line-up announcement!

Final call for the ninth edition of RBMO Live, Tuesday 10th September! Register now through our Zoom form.

Chief Editor Nick Macklon and Editor Signe Altm?e will host this episode of our quarterly webinar, broadcast in association with the International IVF Initiative (I3)

The webinar will feature over 90 minutes of presentations, behind the scenes insights into the journal, panel discussion and audience questions, including:

• Munevver Serdarogullari with a review of the potential for platelet-rich-plasma as a promising approach in reproductive medicine, the importance of standardising PRP preparation protocols, and the patient populations that could benefit most from this treatment.
• Jemma Garratt presenting Britain’s largest ever study of egg freezing, reporting on the outcomes of almost 30,000 eggs. The results show consistent, predictable and reliable success rates comparable to routine IVF that challenge sceptical perceptions of egg freezing.
• a showcase of our Periconception, Pregnancy, Children Outcomes section with overview and insights from Section Editor Catherine Aiken…
• …and a featured article presentation from Melissa van der Windt and Melek Rousian on their recent landmark paper ‘Periconceptional maternal and paternal alcohol consumption and embryonic and foetal development: the Rotterdam periconception cohort.’

Register online now to add it to your calendars, and share the link with your colleagues - the event is free and open to all. We look forward to seeing you there.

ARCS symposium, September 13, 2024, Birmingham, UK

https://uobevents.eventsair.com/arcs-2024/

The annual Symposium of the The Association of Reproductive and Clinical Scientists comprises a full day of specialist presentations and poster exhibitions, including Rod Mitchell (University of Edinburgh) presenting ‘20 years of fertility preservation for pre-pubertal boys’, Kelly Tilleman (UZGent) on ‘Embracing Diversity: Navigating Transgender Fertility Care’, Hannah Newby (ARCS), with an ARCS Policy and Practice Update, among other sessions.

CFAS 70th Annual Meeting: Past Present and Future, Celebrating 70 Years of Innovation and ScienceSeptember 12-14, 2024, Vancouver, Canada

https://cfas.ca/CFAS_70th_Annual_Meeting.html

This September, Canadian Fertility and Andrology Society hold their 70th annual conference at The Westin Bayshore in Vancouver, British Columbia. The event is themed on the ‘Past, Present and Future, Celebrating 70 Years of Innovation and Science’.

The programme features a keynote from RBMO founding Editor, Dr Jacques Cohen discussing the change of laboratory processes, from artisanal craft to automated technologies since the inception of IVF, presentation from Col. Jordon Swain discussing leadership in IVF, Alyse Goldberg on ‘Obesity and Fertility’, Dr. Tom Hannam ‘Optimizing REI Practice’ and much more.

This month we highlight our Reproduction, Technology and Society (RTS) section, with a profile from Section Editor, and one of the founding partners of RBMO, Dr Kamal Ahuja. RTS is a section of RBMO focusing on societal aspects and implications of developments in reproductive science, assessment of the impact of developments in ART on policymakers, commercial companies and the public as a whole, rather than on individual patient clinical outcomes.

Dr Kamal Ahuja, London Women's Clinic RBMO Reproduction, Technology and Society Section Editor

‘Family formations in the modern world are increasingly complex. The Reproductive, Technology and Society section of RBMO provides a high-quality platform for academic discussions to occur at the interface between technology, ART and Society. I am very proud to apply my dedication to enhancing the opportunities for ethicists, reproductive scientists and lawmakers across disciplines with this section of the journal, and I welcome the submission of cutting-edge manuscripts that will further the development of these thematic relationships across this progressive field.’

Some recent highlights from the Reproduction, Technology and Society section:

Guido Pennings - Elective egg freezing and women's emancipation

Sophie Zadeh et al. - Searching for and making genetic connections: recommendations for practice from donor conceived adults in the UK

Kirsty Horsey - The future of surrogacy: a review of current global trends and national landscapes

Ann Korkidakis et al. - Decision-Making in Women Considering Planned Oocyte Cryopreservation: Decision Satisfaction or Regret?

Lucy Frith et al. - Direct-to-consumer genetic testing and the changing landscape of gamete donor conception: key issues for practitioners and stakeholders

Michal Youngster et al. - An artificial intelligence based approach for selecting the optimal day for triggering in antagonist protocol cycles

David Klein et al. - Reproductive healthcare providers’ perceptions regarding their involvement in offering expanded carrier screening in fertility clinics: a qualitative study

Randi Sylvest et al. - How to talk to young adults about fertility

Dr Rasha Bayoumi et al. - A critical systematic review and meta-analyses of risk factors for fertility problems in a globalized world

Jo Lysons et al. - Families created via identity-release egg donation: disclosure and an exploration of donor threat in early childhood

That brings us to the end of another Insights Newsletter. We hope you enjoyed this edition.

If you have any thoughts or ideas you’d like to share with us about the newsletter, please do leave us a comment below, send us a message here, or an email.

The RBMO Editorial Team