The effect of intralipid on pregnancy rates in in vitro fertilisation (IVF)

IMPLANTATION P-611 Wednesday, October 19, 2016 1+ 1 >2: A COST EFFECTIVENESS ANALYSIS OF SINGLE EMBRYO TRANSFER WITH PGS IN TWO SUCCESSIVE CYCLES VS A DOUBLE EMBRYO TRANSFER WITH PGS IN ONE. J. Rodriguez-Purata,a A. Santistevan,b L. Sekhon,a,c J. A. Lee,a K. Hunter Cohn,b T. Mukherjee,a B. Sandler,a P. Yurttas Beim,b A. B. Copperman.d,c a Reproductive Medicine Associates of New York, New York, NY; bCelmatix Inc, New York, NY; cObstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; dObstetrics and Gynecology, RMANY-Mount Sinai, New York, NY. OBJECTIVE: Infertile couples seek ART treatment with the goal of achieving the birth of a healthy child. A growing number of clinicians propose an IVF, PGS and freeze-all plan, a strategy that has shown to be efficient in improving the efficiency of the treatment process . Amid these benefits a pivotal question lingers when R2 embryos are available for ET: transfer 2 embryos in one cycle, or transfer 2 single embryos in sequential cycles. DESIGN: Retrospective. MATERIALS AND METHODS: A total of 1,907 IVF cycles were identified, and 832 met the inclusion criteria of use of a freeze-all protocol with PGS testing in 2010-2015. Cohorts were segregated into: Group 1) two SET cycles (n¼663); Group 2) one DET cycle (n¼169). Cycle outcome (no pregnancy, biochemical pregnancy, clinical loss (after detection of gestational sac) and ongoing pregnancy (OP)) and the multiples rate were calculated, along with the empirical cumulative percentage of patients who achieved OP on each treatment path. 95% CI were reported for all calculations. The average cost of live birth for each path was computed as the sum of the cumulative costs associated with having a singleton ($26,922) or twins ($115,238) weighted by their respective probabilities of occurring conditional on a live birth occurring, along with the weighted cost of miscarriages ($596), PGS use ($5,000), and the weighted cost of FETs ($2,800) required in each path. RESULTS: There was no statistical difference between age, BAFC, AMH, day 3 FSH and BMI between groups. The cumulative ongoing pregnancy rate (OPR) in Group 1 was 75% [71-80] with a 97.3% [96-99] singleton rate. Per cycle, the OPR in cycle 1 was 52% [48-56], and in cycle 2 was 49% [42-56]. The cumulatively achieved singleton OPR was 73% [69-78]. From the 48% that did not achieve a OP in the 1st cycle, 44% had a loss (biochemical loss 24% [19-28]; clinical loss 20.7% [17-25]) and 56% [51-61] were not pregnant. The expected cost for a live birth in this group was $38,063 and for no live birth: $10,852. In Group 2 59% [52%-66%] achieved OP, with 38% [31%-46%] of patients achieving a singleton gestation. Among those who had OP, 35% [26%-45%] had twins. The expected cost for a live birth was $65,910 and for no live birth: $7,911. CONCLUSIONS: It is well established that SET with PGS reduces multiple births and improves neonatal end points. However, there is a paucity of data when considering economic impact of such decisions. Compared to one DET cycle with PGS, this study showed patients who pursued two SET cycles with euploid embryos achieved 16% higher cumulative OPR, 35% higher singleton OPR, 32% lower multiple rate and $27,847 less dollars spent on a live birth when R2 euploid embryos were available for transfer. P-612 Wednesday, October 19, 2016 THE PREDICTIVE VALUE OF THE FIRST SERUM HCG LEVEL FOLLOWING TRANSFER OF A SINGLE, EUPLOID, FROZEN EMBRYO TRANSFER. L. Sekhon,a,b N. Herlihy,a,b J. Rodriguez-Purata,a J. A. Lee,a M. C. Whitehouse,a B. McAvey,a L. Grunfeld,a,b T. Mukherjee,a,b B. Sandler,a,b A. B. Copperman.a,b aReproductive Medicine Associates of New York, New York, NY; bObstetrics, Gynecology & Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY. OBJECTIVE: Despite the increasing utilization of single, euploid frozen blastocyst transfer (FET) as a treatment strategy, prognostic thresholds for the initial serum HCG level have yet to be established. This study seeks to identify the HCG thresholds correlative of successful intrauterine pregnancy. DESIGN: Retrospective cohort analysis. MATERIALS AND METHODS: Patients that underwent single, euploid FET resulting in a positive serum HCG (>2 mIU/ml), from June 2011 to March 2016, were included. Serum HCG levels (unit: mIU/ml) were measured 9 days post FET and analyzed with respect to maternal age, BMI, blastocyst expansion grade, implantation and clinical pregnancy rates.

FERTILITY & STERILITYÒ

All embryos were biopsied at the blastocyst stage, with ploidy determined by PCR. Data was analyzed by student’s t-test, Chi-square, Kruskal-Wallis, linear and binary logistic regression. RESULTS: Of the 876 single euploid FETs, 91% (n¼802) had a serum hCG >2 mIU/ml. Serum HCG levels were drawn 9 days after FET in 649 patients with 77.8% implantation (n¼505) and 71.8% clinical pregnancy rate (n¼466). Neither odds of implantation nor clinical pregnancy were influenced by maternal age, BMI or blastocyst expansion grade. Serum HCG levels were lower in patients with BMI>30 (OR -4.39 [95% CI (-6.3)(-2.46). p¼0.0012]. Serum HCG levels significantly predicted the probability of implantation (OR 1.02 [95% CI 1.02-1.03], p<0.0001) and clinical pregnancy (OR 1.03 [95% CI 1.02-1.04], p<0.0001. HCG thresholds for clinical pregnancy (Table) were not correlated with maternal age, degree of blastocyst expansion or BMI. CONCLUSIONS: Serum HCG levels measured 9 days after transfer are a predictive marker for implantation and clinical pregnancy. Half of patients with HCG <26.5 mIU/ml ultimately had an early pregnancy loss, while nearly 90% of those with initial HCG >100 mIU/ml had an ongoing clinical pregnancy. In a well controlled population if patients undergoing SET of euploid embryos, initial HCG level are a powerful prognostic indicator of embryonic health and of the likelihood of a positive reproductive outcome.

Modeled probability of ongoing clinical pregnancy in relation to serum HCG levels 9 days post-ET

Probability of Clinical Pregnancy (%)

Serum HCG 9 days post-transfer

50 75 80 90 95 >99

26.5 67.1 80.6 107.6 134.6 185.3

P-613 Wednesday, October 19, 2016 THE EFFECT OF INTRALIPID ON PREGNANCY RATES IN IN VIM. Healey,b,c,d TRO FERTILISATION (IVF). R. H. Shirlow,a a d ea M. Volovsky, V. B. MacLachlan, B. J. Vollenhoven. Monash University, Melbourne, Australia; bUniversity of Melbourne, Melbourne, Australia; c Royal Women’s Hospital, Melbourne, Australia; dMonash IVF, Melbourne, Australia; eMonash Health, Melbourne, Australia. OBJECTIVE: Poor uterine receptivity may be one reason for implantation failure in IVF. Some evidence [1-3] suggests an immunological role for reduced uterine receptivity hence many interventions targeted at achieving an ‘ideal’ immune environment are being investigated. One such therapy, intralipid, has been shown to be effective at suppressing natural kill cell cytotoxicity [4-5] but it remains unclear as to the actual effect in improving pregnancy rates. Thus, the objective of our study was to evaluate the effect of intralipid on chemical pregnancy, clinical pregnancy, live births and clinical pregnancy loss. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: The study evaluated all fresh and frozen embryo transfers (ETs) between 2011 and 2015 (N¼29,852) from a multi-site IVF clinic. In patients who had one or more ETs with intralipid, all other ETs were excluded and a randomly selected single ET cycle was chosen for each patient, leaving 11,028 ETs for analysis. This included 545 ETs where intralipid was used and 10,483 control ETs. Intervention and control groups were matched for: year, cycle number, age, number of embryos transferred, number of previous ETs without a live birth, and use of adjuvant therapies. Univariate comparison of proportions was performed using the Chi square test, while Mann Whitney U testing was used for univariate comparison of continuous variables. Logistic regression was used to allow for potential confounding variables. Analysis was performed initially on the full cohort and then on matched cases and controls. RESULTS: Analysis of the full cohort demonstrated reduced rates for the intralipid group of chemical pregnancy (crude OR 0.61 CI 0.50-0.70), clinical pregnancy (crude OR 0.58 CI 0.48-0.71) and live birth (crude OR 0.52 CI 0.42-0.65). Once confounding factors had been allowed for through logistic regression (adjusted ORs) no statistically significant differences were seen between ET cycles with or without intralipid.

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CONCLUSIONS: Intralipid has been introduced to improve pregnancy rates in women with implantation failure. Based on these results there is no difference in outcomes once confounding factors have been allowed for. Our study concludes that, at present, intralipid should not be advocated for as a beneficial therapy and future use should only be as part of a randomised controlled trial. The safety of intralipid also needs investigation. References: 1. Achache H, Revel A. Endometrial receptivity markers, the journey to successful embryo implantation. Hum Reprod Update 2006 NovDec;12(6):731-46. 2. Kwak-Kim J, Gilman-Sachs A. Clinical Implication of Natural Killer Cells and Reproduction. Am J Reprod Immunol 2008;59:388-400. 3. Miko E, Manfai Z, Meggyes M, Barakonyi A, et al. Possible role of natural killer and natural killer T-like cells in implantation failure after IVF. Reprod Biomed Online 2010 Dec:21(6):750-6. 4. Roussev RG, Ng SC, Coulam CB. Natural Killer Cell Functional Activity Suppression by Intravenous Immunoglobulin, Intralipid and Soluble Human Leukocyte Antigen-G. Am J Repro Immunol 2007;57:262-69. 5. Roussev RG, Acacio B. Ng SC, Coulam CB. Duration of Intralipid’s Suppressive Effect on NK Cell’s Functional Activity. Am J Repro Immunol 2008;60:258-63.

P-614 Wednesday, October 19, 2016 THE DEVELOPMENT RATE OF THE EUPLOID EMBRYO HAS A MORE SIGNIFICANT IMPACT ON IMPLANTATION THAN MORPHOLOGY. X. Yang, A. Runge, T. Leung, M. Cedars, M. Rosen. Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA. OBJECTIVE: The euploid embryo has on average a 50-60% implantation rate. The purpose of this study was to determine whether blastocyst development rate and/or morphology were independently associated with implantation of a euploid embryo. DESIGN: Retrospective study. MATERIALS AND METHODS: A total of 3,646 blastocysts were biopsied and analyzed. All embryos were biopsied once expanded and cryopreserved the same day. 1,475 blastocysts were biopsied on day 5 and 2,171 on day 6. Morphology was determined using Gardener’s classification and subsequently categorized into four groups: excellent (R3AA); good (AB/BA); fair (BB) and poor (C+). All embryos were vitrified after biopsy. 647 euploid blastocysts were warmed and transferred. Only the embryos with definite implantation outcome were included. Chi-square test was used to determine significance. RESULTS: The average patient age of day 5 and day 6 blastocyst transfer were 37.73.3 and 37.93.3 respectively. The percent of embryos that were euploid on day 5 and day 6 was 51% and 42% (P<0.001), respectively. The implantation rate for day 5 vs day 6 euploid embryos was 62%, and 45% (p <0.05), respectively. Table1. The association between euploidy implantation rate, day of biopsy and morphology

Blast grading

Day 5 IR

Day6 IR

0.67 0.60 0.64 0.40

0.58 0.43 0.46 0.33

AA AB/BA BB C+

CONCLUSIONS: This study indicates that the development rate is the most important predictor of implantation rate in a euploid embryo. These findings suggest that not all euploid embryos are equal. Thus, when determining which euploid embryo to transfer, the development rate should be the primary factor and morphology the secondary factor. P-615 Wednesday, October 19, 2016 EARLY GROWTH RESPONSE 1 (EGR1) IS REQUIRED FOR PROPER EPITHELIAL-STROMAL CROSS-TALKS TO RESPOND TO E2 AND P4 FOR SUCCESSFUL EMBRYO IMPLANTATION IN THE UTERUS. H. Kim,a Y. Kim,a K. Kang,b H. Choi,b M. Koong,b

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ASRM Abstracts

I. Kang,b T. K. Yoon,b H. Song.a,b aBiomedical Science, CHA University, Seongnam, Korea, Republic of; bCHA Seoul Fertility Center, CHA University, Seoul, Korea, Republic of. OBJECTIVE: Harmonized actions of ovarian estrogen (E2) and progesterone (P4) regulate cell proliferation and differentiation in the uterus with a spatiotemporal manner. Imbalance between the actions and levels of two major regulators often lead to infertility and gynecological diseases. While numerous works have shown that reduced expression and/or deletion of uterine factors participating in P4 signaling could disturb uterine physiology, a few local factor(s) to mediate E2 actions in the uterus has been revealed. Recently, we reported that Egr1 is an immediately early response gene induced by E2 in the uterus. In this study, we have examined whether early growth response 1 (Egr1) is required to maintain coordinated actions of E2 and P4 for successful embryo implantation by characterizing Egr1(-/-) female mice with multiple approaches. DESIGN: Animal study on mouse uterus with a series of experiments in cell culture. MATERIALS AND METHODS: real-time RT-PCR, Western blotting, immunostaining, histological analyses, hormone assays, epithelial-stromal cell co-culture were performed with wildtype and/or Egr1(-/-) mice. RESULTS: Given exogenous gonadotrophins to overcome LHb deficiency in the pituitary of Egr1(-/-) mice, ovulation, fertilization and embryo development normally occurred in these mice. However, they showed complete failure of embryo implantation with reduced uterine responses to artificial decidualization stimuli. While serum levels of E2 and P4 in Egr1(-/-) mice were comparable, genes regulated by E2 or P4 in uterine epithelial cells (ECs) were aberrantly expressed on day 4 of pregnancy. Impaired P4 signaling in ECs caused hypersensitive E2 responses shown as enhanced expression of E2-responsive genes such Muc1 and Ltf as well as reduced levels of P4-dependent genes, such as Ihh and Areg, in Egr1(-/-) ECs. This is consistent with persistent proliferation in ECs and severely compromised proliferation in stromal cells (SCs) in Egr1(-/-) mice treated with E2+P4. Furthermore, primary co-culture of Egr1(-/-) ECs with Egr1(+/+) SCs and vice versa supported a notion that Egr1 is required for epithelialstromal cross-talks with respect to proper responses to E2 and/or P4 in both uterine cell compartments. CONCLUSIONS: Egr1 is an essential transcription factor for epithelialstromal cross-talks with properly responses to E2 and P4 for successful embryo implantation in the uterus. Supported by: This work was supported in part by grants from the National Research Foundation of Korea (NRF) grant funded by the Korea government (MEST) (NRF-2012R1A2A2A01011274 and NRF-2015R1A2A2A010 06714).

P-616 Wednesday, October 19, 2016 IMPACT OF TRANSCRIPTOMIC BASIS OF LOCAL ENDOMETRIAL INJURY ON IMPLANTATION RATE AMONG PREVIOUSLY FAILED IVF-ICSI CYCLES. N. Singh,a M. Bhat,b D. Ghosh.c aDepartment of Obstetrics & Gynaecology & IVF, All India Institute Of Medical Sciences, Delhi, India; bSenior Research Fellow, Department of Physiology, All India Institute Of Medical Sciences, Delhi, India; cDepartment of Physiology, All India Institute Of Medical Sciences, Delhi, India. OBJECTIVE: To assess the impact of transcriptomic basis of local endometrial injury on implantation rate among the women with previously failed attempt of IVF-ICSI cycles. DESIGN: Prospective non randomized intervention study was performed in IVF Center, Department of Obstetrics and Gynaecology, and Molecular Biology Laboratory, Department of Physiology of a tertiary care hospital. MATERIALS AND METHODS: A total of 20 women with previously failed attempts of IVF were recruited in the ethically approved study during the period January 2014-December 2015. Endometrial samples were obtained by gentle scratching of the endometrium using karmen’’s cannula no.4 at cycle day 14-18 and endometrial tissue was subjected to mRNA extraction using standard protocol (Khan et al 2012). IVF-ET was done in subsequent cycles. Based on pregnancy outcome, the subjects were classified into groups; those who became pregnant and those who did not become pregnant. High quality (RIN>8.0) RNA were employed for microarray-based expression analysis using 4X44K human whole genome chips and agilent microarray platform. Exploratory and differentials display analysis of gene expression data were performed using Gene Spring software.(Khan et al 2012).

Vol. 106, No. 3, Supplement, September 2016