Optimal endometrial preparation for frozen embryo transfer (FET) of screened embryos is independent of follicular phase length

Embryo Transfer Practices and Outcomes in Mandated States.

CT

HI

IL

MD

MA

NJ

P Value

Day 5 transfer (%) 30.0 34.4 52.5 44.8 17.8 42.7 <0.0001 ——————————————————————————————DAY 3 TRANSFER——————————————————————— Mean # embryos transferred 2.2 3.0 2.4 2.2 2.0 2.4 <0.0001 eSET rate/transfer (%) 1.1 0.0 1.0 0.5 12.1 0.5 <0.0001 Implantation rate/embryo transferred (%) 30.0 16.0 19.0 23.0 28.0 25.0 <0.0001 Multiple birth rate/live birth (%) 30.2 27.2 24.5 24.9 25.3 29.9 <0.0001 ——————————————————————————————DAY 5 TRANSFER——————————————————————— Mean # embryos transferred 1.7 2.1 1.9 1.6 1.5 2.0 <0.0001 eSET rate/transfer (%) 28.1 1.5 13.8 31.6 34.9 6.6 <0.0001 Implantation rate/embryo transferred (%) 43.0 36.0 38.0 47.0 46.0 45.0 <0.0001 Multiple birth rate/live birth (%) 26.6 37.4 32.0 24.5 19.0 38.7 <0.0001

W. W. Hurd,a J. L. Eaton.a aDivision of Reproductive Endocrinology & Infertility, Duke University Medical Center, Durham, NC; bDepartment of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, NC. OBJECTIVE: Insurance mandates for in vitro fertilization (IVF) vary with respect to eligibility criteria and the maximum number of covered cycles. Our objective was to examine associations among embryo transfer practices and multiple birth rates in states with mandated insurance coverage for IVF. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We utilized the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SARTCORS) database to identify fresh, autologous IVF cycles performed between 2007 and 2011 in women aged 20-42 years. Cycles were included if they were performed in one of 6 states with legislation requiring insurance coverage for at least one IVF cycle: CT, HI, IL, MA, MD, or NJ. Only first IVF cycles performed in each woman’s state of residence were included in the analysis. Cycles were excluded if the indication for IVF was ‘‘non-infertile’’ or ‘‘preimplantation genetic diagnosis,’’ if they were performed in a state with only one reporting clinic, or if embryo transfer occurred on days other than 3 or 5. Analysis of variance and the X2 test were used to compare continuous and categorical variables, respectively. P < 0.00019 was considered statistically significant after Bonferroni adjustment for multiple comparisons. Multivariate regression models were used to examine factors associated with multiple birth and elective single embryo transfer (eSET). RESULTS: A total of 45,011 cycles were included in the analysis. Embryo transfer practices and multiple birth rates differed significantly among the 6 states with IVF insurance mandates (Table). After adjustment for potential confounders, there was a significant association between day-5 embryo transfer and multiple birth (OR ¼ 1.56, 95% CI 1.43-1.71). Elective single embryo transfer was more common on day 5 than day 3 (17% vs. 4%, P < 0.0001; adjusted OR ¼ 3.64, 95% CI 3.16-4.19); however, the vast majority (83%) of day-5 transfers still involved more than 1 embryo (mean 1.80  0.54). CONCLUSIONS: Among states with mandated insurance coverage for IVF, day-5 embryo transfer is associated with a 56% increased odds of multiple birth compared to embryo transfer on day 3. This association is driven by the transfer of multiple embryos with higher implantation rates. O-120 Tuesday, October 20, 2015 12:30 PM RESISTANCE OF CUMULUS CELL (CC) MITOCHONDRIA TO STRESS IN VITRO AS A PREDICTOR OF OOCYTE COMPETENCE DURING OVARIAN STIMULATION FOR IN VITRO FERTILIZAA. A. Guedikian,a D. L. Hill,b TION (IVF). J. P. Alvarez,a G. D. Chazenbalk,a D. A. Dumesic.a aOB/GYN, UCLA, Los Angeles, CA; bART Reproductive Center, Beverly Hills, CA. OBJECTIVE: To establish a CC mitochondria in vitro bioassay based upon mitochondrial resistance to stress to predict oocyte competence during ovarian stimulation for IVF. DESIGN: Prospective cohort study MATERIALS AND METHODS: Eighteen women (ages, 34.51.1 years; body mass index [BMI], 23.20.9 kg/m2 [mean SEM]) undergoing ovarian stimulation for IVF were studied. Pooled CC from each woman were collected

FERTILITY & STERILITYÒ

at oocyte retrieval and immediately analyzed. A CC mitochondrial resistance bioassay was developed by measuring mitochondrial potential to the membrane-permeable JC-1 dye in the presence of mitochondrial membrane potential disrupter, carbonyl cyanide 3-chlorophenylhydrazone (CCCP). For bioassay optimization, human T Lymphocyte Jurkat cells were incubated with varying CCCP doses (0.02 - 2.0 mM) and then exposed to JC-1 (1.0 mM). Exposure of CC to 1.0 mM CCCP reduced mitochondrial potential to 50% of untreated cells; thus 1.0 mM CCCP was used in all CC studies. Regression analysis compared 1) CC mitochondrial resistance to CCCP and amount of follicle-stimulating hormone (FSH) administered with total and mature oocyte numbers, and also 2) correlated CC mitochondrial resistance to CCCP with numbers of 2-pronuclear (2PN), 6-8 cell cleavage and blastocyst embryos, before and after adjusting for mature oocyte number. RESULTS: CC mitochondrial resistance to CCCP positively correlated with numbers of total (r¼0.78, P<0.0001) and mature (r¼0.83, P<0.00001) oocytes, while negatively correlating with the amount of FSH administered (r¼-0.67, P<0.0022). The amount of FSH administered, in turn, negatively correlated with numbers of total (r¼-0.75, P<0.0005) and mature (r¼-0.83, P<0.0001) oocytes. Adjusting for FSH administered, CC mitochondrial resistance to CCCP remained a positive predictor of mature oocyte number (r¼0.60, P<0.025). During pre-implantation embryogenesis, CC mitochondrial resistance to CCCP positively correlated with numbers of 2 PN (r ¼ 0.79, P<0.0002), 6-8 cell cleavage (r ¼ 0.84, P<0.0001) and blastocyst (r ¼ 0.63, P<0.01) embryos. However, mature oocyte number also positively correlated with numbers of 2 PN (r¼0.94, P<0.0001), 6-8 cell cleavage (r¼0.87, P<0.0001) and blastocyst (r¼0.73, P<0.001) embryos. Adjusting for mature oocyte number (mitochondrial resistance X mature oocytes interaction, P<0.05), CC mitochondrial resistance to CCCP remained a positive predictor of 6-8 cell cleavage embryo number, with higher values of mitochondrial bioassay-predicted cleaving embryos accompanying higher numbers of mature oocytes retrieved. CONCLUSIONS: Resistance of CC mitochondria to stress in vitro predicts oocyte competence based upon ovarian responsiveness to FSH administration during IVF. Reference: 1. Dumesic DA, Meldrum D, Katz-Jaffe MG, Krisher RL, Schoolcraft WB. The Oocyte Environment: Follicular Fluid and Cumulus Cells are Critical for Oocyte Health. Fertil Steril 2015;103:303-15 Supported by: David Geffen School of Medicine, Stein/Oppenheimer Endowment Award. CRYOPRESERVATION AND FROZEN EMBRYO TRANSFER CLINICAL: ART O-121 Tuesday, October 20, 2015 11:15 AM OPTIMAL ENDOMETRIAL PREPARATION FOR FROZEN EMBRYO TRANSFER (FET) OF SCREENED EMBRYOS IS INDEPENDENT OF FOLLICULAR PHASE LENGTH. J. Bardos,a J. Rodriguez-Purata,b M. C. Whitehouse,b J. A. Lee,b B. Sandler,b D. E. Stein,b A. B. Copperman.c aObstetrics, Gynecology and Reproductive

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Science, Icahn School of Medicine at Mount Sinai, New York, NY; bReproductive Medicine Associates of New York, New York, NY; cRMANY-Mount Sinai, New York, NY. OBJECTIVE: The modern treatment of the infertile patient often includes ovarian stimulation, oocyte retrieval, fertilization, biopsy and chromosomal analysis (CCS), and vitrification. Embryos found to be normal can be transferred in a subsequent FET cycle. We were able to control for embryo quality by using only screened embryos and for synchronization by initiating progesterone treatment five days prior to embryo transfer and were able to ask the question of whether the number of days of estradiol preparation impacts the likelihood of implantation. DESIGN: Retrospective MATERIALS AND METHODS: Patients who underwent an IVF cycle with qPCR-based CCS that had R1 euploid embryo available for FET were included. Fresh ETs were excluded from this analysis. Patients started oral estradiol 2 mg twice daily for four days, then 2 mg three times daily. Endometrial thickness was assessed weekly until a thickness of R7mm was observed. Progesterone supplementation was then initiated, and five days later, re-warming and ultrasound guided transfer was performed. A Poisson regression model was used to predict if the total number of days of estradiol impacted implantation rates. Statistical difference of p<0.05 was considered significant. RESULTS: A total of 511 euploid FET cycles were included in this analysis. Estrace administration ranged from 13 to 23 days (17.7  2.5). We observed similar implantation rates regardless of the number of days estradiol was administered. In addition, there was no difference in implantation rates when analyzing the number of days of estrogen use following achievement of a 7mm endometrial lining and prior to progesterone initiation. After applying the Poisson regression model, there was no correlation between the number of days with estradiol and implantation rates. CONCLUSIONS: In synthetic FET cycles, estrogen and progesterone are administered in a sequential regimen that mimics the endocrine exposure of the endometrium in the normal cycle. This is the first study to analyze if different durations of a synthetically manipulated follicular phase had any impact on implantation rates of euploid embryos. This analysis revealed no impact on implantation rates in the context of number of days of estradiol administration. Similar to a physiologic state, the length of the follicular phase seems to not influence the possibility of an embryo to implant.

Estradiol exposure and Implantation Rate.

Days under Estradiol 13 14 15 16 17 18 19 20 21 22 23

Count

Average number of Embryos Transferred

Implantation Rate

20 30 44 78 64 55 60 34 49 23 13

1.2 1.1 1.1 1.2 1.2 1.3 1.3 1.3 1.2 1.1 1.2

46% 64% 55% 55% 67% 52% 49% 55% 58% 64% 63%

O-122 Tuesday, October 20, 2015 11:30 AM PERI-IMPLANTATION WHOLE-BLOOD GENE EXPRESSION IN IN-VITRO FERTILIZATION (IVF) COMPARED TO FROZEN EMBRYO TRANSFER (FET) CYCLES. B. L. Maslow,a,b J. George,b J. Nulsen,a J. Banchereau.b aUniversity of Connecticut Health Center, Farmington, CT; bThe Jackson Laboratory for Genomic Medicine, Farmington, CT. OBJECTIVE: Observed differences in perinatal outcomes between IVF and FET have been attributed to alterations in the maternal environment dur-

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ASRM Abstracts

ing the peri-implantation period. The immune system plays a vital role in allowing implantation of the semi-allogeneic embryo during this period. While whole-blood gene expression has been utilized to evaluate immune system activity, this technology has not yet been applied to the peri-implantation time period.This study aims to characterize differences in wholeblood gene expression before and after implantation between IVF and FET cycles. DESIGN: Ongoing, prospective, cohort study of whole-blood gene expression in women undergoing treatment at a large university-based infertility center. MATERIALS AND METHODS: Women <37 years old with normal ovarian function were eligible for recruitment on the day of their blastocyst (fresh or frozen) transfer. Whole-blood was collected in TempusÔ (Applied Biosciences) tubes on the day of embryo transfer (ET) and 9 days later, at the first pregnancy test. RNA was extracted using the TempusÔ Spin RNA Isolation Kit. RNA Sequencing was performed on the Illumina HiSeq 2500 sequencing system. Raw data was processed with a validated computational pipeline. Differentially expressed genes were identified using R Package ‘‘edgeR’’ and a false discovery rate of <5% was considered significant. Downstream statistical analyses were performed using the R statistical platform. RESULTS: To date, 26 subjects have enrolled in this study. Complete RNA sequencing data from 12 subjects (5 IVF, 7 FET) were available for initial analysis. 9/12 subjects conceived (3 IVF, 6 FET) and were included in the post-implantation analysis.We observed significant differences in whole-blood gene expression between IVF and FET on the day of ET, with 6767 genes significantly differentially expressed between the IVF and FET subjects.After implantation, only 26 genes were significantly differentially expressed between the IVF and FET subjects. Gene set analysis of these 26 genes identified significant differences in T-cell receptor signaling and NK-cell mediated cytotoxicity pathways (p<0.01). CONCLUSIONS: Whole-blood gene expression on the day of ET differs drastically between IVF and FET cycles. Surprisingly, once implantation has occurred, gene expression is remarkably similar. Nevertheless, the few genes that are differentially expressed participate in critical immune function pathways.Genomic analysis offers a novel way to explore the potential impact of cycle type on the maternal peri-implantation environment. This study is the first to demonstrate alterations in peri-implantation immune activity between IVF and FET cycles, which may in part explain observed differences in perinatal outcomes. Associations with perinatal outcomes in this cohort will be investigated as additional sequencing and clinical follow up data become available. Supported by: The Jackson Laboratory for Genomic Medicine.

O-123 Tuesday, October 20, 2015 11:45 AM ARE WE TAKING TECHNOLOGY TOO FAR? COMPARISON OF TROPHECTODERM BIOPSY (TEBX) WITH PREIMPLANTATION GENETIC SCREENING (PGS) IN CYCLES USING PREVIOUSLY FROZEN VS. FRESH AUTOLOGOUS OOCYTES. N. Noyes,a H. Lee,a S. Druckenmiller,b P. Labella,a E. Ampeloquio,a K. N. Goldman,a J. Grifo.a aNYU Fertility Center, New York, NY; bNYU School of Medicine, New York, NY. OBJECTIVE: Independent usage of oocyte cryopreservation (OC) and TEBX-PGS has rapidly increased over the past 5 y as these technologies have become more reliable and mainstream. Importantly, they afford women the opportunity to have children when ready and to limit embryo transfer (ET) to a single euploid blastocyst (BL) even at advanced ages. Our center has performed >1500 independent cycles of each technology and now uses the two in complement. Here, we assessed whether adding TEBXPGS to OC negatively impacted cycle outcomes by comparing TEBX-PGS cycles where fresh (FR) vs. previously cryopreserved oocytes served as the female gamete. DESIGN: Retrospective case-control. MATERIALS AND METHODS: 69 OC (n¼47, age<40 + 22, age>39) and 814 FR (n¼407, age<40 + 407, age>39) treatment cycles with intention for ploidy analysis using TEBX-PGS were assessed (mean age of both groups: 392y). In OC cycles, ICSI was performed on thawed mature (MII) oocytes while in FR cycles, ICSI or insemination was used based on

Vol. 104, No. 3, Supplement, September 2015