Should Every Embryo be Screened or Frozen? Should we cryo...FRESH SET RESULTS IN LOWER DELIVERY...
Transcript of Should Every Embryo be Screened or Frozen? Should we cryo...FRESH SET RESULTS IN LOWER DELIVERY...
Should Every Embryo be Screened or Frozen?
What does the evidence say?
Richard T. Scott, Jr, MD, HCLDClinical and Scientific Director,
Reproductive Medicine Associates of New JerseyProfessor and Director, Reproductive Endocrinology
Robert Wood Johnson Medical School, Rutgers University
aCGH (Lab 1)
SNP array (Lab 3)
qPCR (Lab 2)
46,XY
45,XY,-8
Contemporary Understanding of Maternal Age and Human Embryonic Aneuploidy
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Per
cen
t o
f Em
bry
os
Wh
ich
are
An
eup
loid
Age (yrs)
Franasiak et al – Fertil Steril 2014
N=15,169
Is transferring an aneuploid embryo clinically useful?
Gain of 21
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Chromosome #
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py
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mb
er
What are the “Burdens” of CCS
Thus the real questions are:
1. Safely attaining embryonic DNA
2. Predictive values of the techniques
3. Proportion of euploid embryos that will fail
4. Cost effectiveness
Some Disagree with PGS
Some Disagree with PGS
• All embryo selection techniques are detrimental
• Inappropriate to use “Implantation Rates” as an endpoint
• “it can be questioned whether all patients will ever be able to understand all of the complexities concerning PGS”
• “cost-effectiveness is being forgotten”
• “evidence is now accumulating that all embryos in an IVF cycle can be cryopreserved and transferred in subsequent cycles without impairing, and maybe even improving, the cumulative pregnancy rate of that IVF cycle”
• Embryo selection should therefore not be used to select out embryos, but only to determine the order in which the embryos will be transferred, as the time to pregnancy can be improved by embryo selection, if embryos with the highest implantation potential are transferred first.
• Culturing to the blastocyst may be harmful
Does Embryo Biopsy Impact the Developmental Potential of the Oocyte
Routine IVF Care through Retrieval
Identify mature oocytes ICSI, culture, and select 2 best embryos for transfer
One embryo randomized to undergo biopsy
Transfer the embryos
Implantation, Maternal serum sampling for free fetal DNA and Fingerprinting
Cell submitted for eventual aneuploidy screening and fingerprinting
N=113 pairs; 226 embryos
Overall implantation rates
39% reduction insignificant
27% (mean maternal age 32) reported by Gutierrez-Mateo, C., et al. Fertility and sterility 92, 1544-1556 (2009)
In our opinion, day 3 biopsy will soon be of historic interest only
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Is knowing the predictive value of a normal result sufficient?
Sherman et al 95:429-36 J Natl Cancer Inst (2003)
If they were the same it would likely be a rare coincidence…
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< 32 33-35 36-38 39-40 41-42
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Age (yrs)
With greater experience, actual negative
predictive value is ~98.8%
Scott et al Fertil Steril 2012; 97:870-5
To have the opportunity for meaningful improvement, when you select for one criteria you most commonly deselect for another….
Transfer Based on Embryo Morphology
Abnl Abnl Nl Abnl Nl Nl
Transfer Based on Aneuploidy Screening and
Embryo Morphology
CCS changes the embryo selected 40% of the timeForman et al ASRM 2012
aCGH enhances delivery rates – an RCT
• RCT
• Age– All < 35– Mean age of 31
• Sample Size– 55 aCGH– 48 control
• Significant improvement in outcomes
• Answers one of the four critical validation questionsMonosomy:Trisomy Ratio of 2
Scott et al Fertility and Sterility 2013; 100:697-703
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No
-Eu
plo
id B
last
s R
ate
(%
)
Age (yrs)
The No Transfer Rate with CCS
Franasiak et al – Fertil Steril 2014
N=15,169
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%)
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his
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er o
f b
last
ocy
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avai
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le f
or
Bio
psy
(%
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Number of Blastocyts
52% of cases had 3 or fewer evaluable embryos
How Many Embryos Do Patient Undergoing CCS Have?
Franasiak et al – Fertil Steril 2014
N=15,169
Trisomy:Monosomy Ratio by Age
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<35 35-37 38-40 41-42 43+
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om
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oso
my
Rat
io
Age Group (yrs)
Franasiak et al – Fertil Steril 2014Key Indicator for QA of your assay
N=15,169 Ratios consistent across nine programs
Clinical ExperienceMisdiagnoses
• 4974 embryos
• 2976 gestations (62.1%)
• 10 errors– 1 tetraploid
– 2 monosomies
– 7 trisomies
• 3168 transfers
• 2354 ongoing / delivered (72.1%)
• Mean age 38.4 years
• 10 errors– 7 found in losses
– 3 found in ongoing preg.
Mosaicism evaluated in 4 samples – 100% mosaic
Clinical Error RatePer embryo 0.2%Per transfer 0.3%Per ongoing pregnancy 0.1%
Consolidated Pregnancy OutcomesProportion of All Pregnancies
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Clin
ical
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ss R
ate
(%)
Maternal Age (yrs)
CCS - Delivery
No Screening - Delivery
CCS - Clinical Loss
No Screening - Clinical Loss
CCS - Chemical Los
No Screening - Chemical Loss
N=4,754 pregnancies
Scott KL et al – RMA
PGS Improves but Does Not Normalize Implantation and Delivery Rates in Older Women
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tati
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Rat
e (
%)
Maternal Age (yrs)
N=28,567
Kulkarni D et al, New Engl J Med, 2014. PMID: 24304051
Kulkarni D et al, New Engl J Med, 2014. PMID: 24304051
Singleton Term Delivery: The Ideal IVF Outcome
• IVF twin pregnancies are at an increased risk of:
–Preeclampsia (2-fold risk increase)1
– Extreme prematurity (7.4-fold increase delivery <32 wks) 2
–NICU admission (3.8-fold increased risk)2
–Perinatal Death (2-fold increase)2
• Two IVF singleton deliveries have better obstetrical outcomes than one IVF twin delivery3
1. ASRM Practice Committee, Fertil Steril, 2012. PMID: 221923522. Pinborg A, et al., Acta Obstet Gynecol Scand, 2004. PMID: 154881253. Sazonova A ,et al., Fertil Steril, 2013. PMID: 23219009
Provided by a patient…
With >2 blastocysts, even patients at high aneuploidy risk are very likely to have a euploid blastocyst
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Pro
bab
ility
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at le
ast
1 E
up
loid
Bla
sto
cyst
Aneuploidy Rate
2 Blastocyst
3 Blastocyst
4 Blastocyst
21%34%
55%64%
<35 35-37 38-40 41-42
Blastocyst Aneuploidy Rate by Age Group
Forman EJ et al., O-161
FRESH SET RESULTS IN LOWER DELIVERY RATES THAN DOUBLE EMBRYO TRANSFER (DET)
• Cochrane Review of 6 randomized trials from
1999-2006 (N = 1,257)
• Young, good prognosis patients with “top quality” embryos available
• Slightly more singletons after DET
Pandian Z et al., Cochrane Database Syst Rev, 2009. PMID: 19370588
26%30%
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SET DET
Livebirth Rate - SET vs. DET
Twins
Singletons
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The Dropout Rate from IVF is Significant
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Cycle Number
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rce
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po
ut
Source: Schroder AK: Cumulative pregnancy rates and drop out rates of a German IVF programme: 4, 102 cycles in 2,130 patients. RBM Online (2004) 8:600-606
Can1 ≥ 2?
CCS Results in Higher Implantation Rates
Implantation = cardiac activity at time of discharge to obstetrical care (~9 weeks)
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Euploid SET Traditional DET
P=0.02
N=83 N=170
Same Delivery Rate:Randomized Controlled Trial
Forman EJ et al. Fertil Steril 2013
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Delivery Rate Per Patient (n=175)
Single euploid blastocyst transfer (N=89)Untested 2-blastocyst transfer (N=86)
P=0.5
P<0.001
Eliminates Multiples
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Single euploid blastocyst transfer Untested 2-blastocyst transfer
Singletons Multiples
P<0.001
Forman EJ et al. Fertil Steril 2013
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Single euploidblastocyst
transfer Grams
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transfer Grams
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ht
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ms)
Better Obstetrical Outcomes are Attained CCS/eSET than Conventional Two Embryo Transfer
•Mean Birthweight:3408 ± 562g – Single euploid2745 ± 743g – 2-Blastocyst
(P<0.001)
•Low birthweight (<2,500g):4.4% (2/45) – Single Euploid31.9% (22/69) – 2-Blastocyst
(P<0.001)
•Very low birthweight (<1,500g):0% (0/45) – Single Euploid7.2% (5/69) – 2-Blastocyst (P=0.06)
Single euploid
blastocyst transfer
Untested 2-blastocyst
transfer
Ongoing Pregnancy Rates Fresh vs. Frozen Transfers
37%
57%
43%
54%
ControlSET CCSSET
FreshET
FrozenET
66%oftransfers
50%oftransfers
P = 0.4 P = 0.7
Obstetrical Costs for 100 PatientsCurrent Standard Of Care
Costs per Delivery*
Singleton $21,458
Twins $104,831
Triplets $407,199
Does not include:Pediatric costs after 28 days of age
Disability costs during bed rest
Loss of productivity in the work place
Lemos et al Am J Obstet Gynecol 2013; 209:586
Overall Cost to Provide CareCCS with SET versus Conventional Treatment
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Costs per Delivery*• Use actual cost data
• Inclusive of all IVF costs including
– IVF cycle costs
– CCS costs
– Medication costs
• Delivery costs and subsequent hospital stay through 28 days of life
Do we ever recommend two embryo transfers?
Yes – but with caution…
Follow Up on Prospective Trials
Time Lapse Observations in the Embryology Laboratory
And others…..
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ICSI to start of 1st cytokinesis (p=0.61)
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Duration of the 2 cell stage (p=0.88)
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Time Lapse and AneuploidyTraditional Markers
Hong KH et al – in review
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Can Time Lapse Help Distinguish Which Euploid Blasts will Deliver from those Destined to Fail?
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Transfer Outcome
NO: None of the 5 traditional parameters or 5 additional blast
related parameters prognosticate outcome
Temporal data evaluated:
• 5 conventional endpoints through cleavage stage
• Additional temporal endpoints from extended culture:• First compaction• Morula formation• First cavitation• Blastocyst Expansion• First contraction
Follow Up on Prospective Trials
Next Generation SequencingAligned Results
Reference sequence from
human genome database
Mu
ltip
le R
ea
ds (
de
pth
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The Economics of NextGenA Major Factor for Accuracy
$$$$$$$
NextGen Sequencing Chip
NextGen Molecular Barcoding Reduced Costs
Embryo 1 Embryo 2
Barcode 1
Barcode 2
CTAAGGTAAC
TAAGGAGAAC
combine samples for a single sequencing chip
The Economics of NextGenA Major Factor for Accuracy
$$$$$$$/2
NextGen Sequencing Chip
The Economics of NextGenA Major Factor for Accuracy
$$$$$$$/4
NextGen Sequencing Chip
The Economics of NextGenA Major Factor for Accuracy
$$$$$$$/48
NextGen Sequencing Chip
The Economics of NextGenA Major Factor for Accuracy
$$$$$$$/96
NextGen Sequencing Chip
96 or more…
WGS(16 per chip)
chromosome
copy number
known trisomy
known monosomy
unpublished data
WGS(48 per chip)
chromosome
copy number
unpublished data
Targeted NGS (96 per chip)
chromosome
copy number
unpublished data
Embryo calibration results
chromosome
copy number
unpublished data
Chromosome specific cutoffs
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NGS based copy number
on chr16
chr16 specific cutoffs
unpublished data
Embryonic Endometrial Synchrony
It take two…..
Embryonic-Endometrial Asynchrony Increases with Maternal Age
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• Retrospective
• 1,341 IVF cycles
• Thresholds for Asynchrony (either)– P >1.5 mg/mL on day of hCG – No blastulation prior to day 6
• Risk for asynchrony increases with maternal age
• Live birth predicted – Day 5 blastulation (P<0.0001)– P < 1.5 ng/mL (P=0.0002)
Shapiro BS et al Fertil Steril 2013 100:S287
P<0.01
(419) (436) (486)
Is it asynchrony or an intrinsic diminution in quality?
Late follicular rise in progesterone
• Retrospective study
• 4032 patients
• P4 ≥1.5ng/mL associated with lower ongoing pregnancy rates
Bosch E, et al. Hum Reprod. 2010 Aug;25(8):2092-100.
Progesterone and the Endometrial Transcriptome
Adapted from S. Young, MD, PhD
2.5 mg/d IM
Leuprolide acetate 1 mg/d td sc
40 mg/d IM
5 mg/d IM
Estradiol 0.2 mg/d td
10 mg/d IM
Progesterone Pharmacokinetics
Adapted from S. Young, MD, PhD
Progesterone and the Endometrial Transcriptome
Adapted from S. Young, MD, PhD
Progesterone and Impaired Implantation:A Pilot Study of Euploid Embryos
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Hours Relative to “Closure” of the Window
All patients had normal P levels prior to the administration of hCG
Beware of Interference in your P Assay
• Patients receiving DHEA have elevated DHEA-SO4 levels
• These levels may falsely elevate P levels
• Assay dependent
Forman - RMANJ
Natural Cycle
hCG
administration
Progesterone
Rise
Ovulation
Embryonic
Window of
Implantation
Endometrial
Window of
Implantation
time
Franasiak et al ASRM 2013
hCG
administration
timeEndometrial
Window of
Implantation
Embryonic
Window of
Implantation
embryo and endometrium synchrony -revisited
Progesterone
Rise
24h
Ovulation
Franasiak et al ASRM 2013
Fresh day 5 embryo transfer
44%
18%
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<35 ≥35
D5 M-B1 D5 B2-B6
p <.001p <.001
Franasiak et al ASRM 2013
Fresh day 6 embryo transfer
p <.05
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32%
63%
48%
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<35 ≥35
D5 M-B1 D5 B2-B6
p <.005
Franasiak et al ASRM 2013
timeEndometrial
Window of
Implantation
Frozen synchronous cycle
Progesterone
Start
Older patients are more likely to have “slow” embryos
31%
46%
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70%
<35 years old ≥35 years old
Proportion of "Slow" Blastocysts
P<0.0001
Forman et al ASRM 2013
Frozen day 6 embryo transfer
p =0.5
57%
37%
60%
42%
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40%
50%
60%
70%
<35 ≥35
D5 M-B1 D5 B2-B6
p =0.3
Franasiak et al ASRM 2013
Obstetrical Outcomes Following Fresh versus Cryopreserved Embryo Transfer
• Fresh embryos at increased risk for• Preterm birth• Low birth weight• Small for gestational age
Wennerholm et al Hum Reprod 2013 28:2545-53
The supraphysiologic milieu which accompanies superovulation impact low birth weight risk
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Fresh ET
Cryo ET
• Retrospective review of SART data
• 2004-2006
• 56,792 neonates
• Fresh embryo transfer at increased risk for LBW
%
The RMA New Jersey TeamScientific Director
Richard T. Scott
PhysiciansPaul Bergh
Michael BohrerMaria CostantiniMichael Drews
Eric FormanRita Gulati
Doreen HockKathleen Hong
Thomas KimMarcy Maguire
Thomas MolinaroJamie Morris
Eli RybakWendy Schillings
Shefali Shastri
FellowsMarie Werner
Jason FranasiakCaroline Juneau
The Treff LaboratoryNathan Treff
Xin TaoAgnes LonczakDavid GabrieleChelsea BohrerTori Gartmond
Margaret LebiedzinskiOksana Bendarsky
Mariya RozovAnna CzyrsznicKay Green, MDMeir Olcha, MDDavid Goodrich
BioinformaticsDeanne TaylorJessica Landis
Yuanchao Zhang
Clinical EmbryologyKathleen Upham
Xinying LiRosanna Pangasnan
Tian ZhaoMichael ChengHokyung Lee
Ayesha WinslowAngela Romaniello
Stephanie MilneSarah DunnLauren Rary
Kristen PauleyDesiree GreeneSerhan Ozensoy
Erin DubellSusan Ng
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FAEECRebekah
ZimmermanBrynn Levy
Lindsey McBainHeather Garnsey Andrew Behrens Sylvia Kloskowski
Erica Vuu
Clinical ResearchChristine RedaTalia MetzgarJennifer Tyler
SupportAndrew Ruiz
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