Intra- and interobserver analysis in the morphological assessment of early stage embryos during an IVF procedure: a multicentre study

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Intra- and inter-observer analysis in the morphological assessment of early-stage embryos

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to determine the intra- and inter-observer variability in the evaluation of embryo quality. Multilevel images of embryos on day 1, day 2 and day 3, were analysed using different morphological parameters.</p> <p>Methods</p> <p>Multilevel images of embryos on day 1, day 2 and day 3, were analysed using a standard scoring system. The kappa coefficient was calculated to measure intra- and inter-observer variability before and after training sessions.</p> <p>Results</p> <p>Good to excellent intra-observer agreement was present for most parameters exceptions being scoring the position of pronuclei and the presence of a cytoplasmic halo on day 1, multinucleation on day 2 and the size of fragments on day 3. Inter-observer agreement was only good to excellent for the number of blastomeres on day 2 and day 3 and the orientation of the cleavage axes on day 2. Training sessions had a positive impact on inter-observer agreement.</p> <p>Conclusion</p> <p>In conclusion, assessment of morphological characteristics of early stage embryos using multilevel images was marked by a high intra-observer and a moderate inter-observer agreement. Training sessions were useful to increase inter-observer agreement.</p

Selecting the embryo with the highest implantation potential using non-invasive methods

Scientific summaryWorldwide, the incidence of multiple pregnancies has increased. These multiple pregnancies are leading to a higher incidence of pregnancy complications, higher long-term morbidity and are having a 13-fold increased risk of handicap following preterm birth meaning that there is a higher need of special education and hospitalization. Health-economics studies revealed that medical costs of an IVF treatment until the end of neonatal period per twin pregnancy is five times higher compared to the costs per singleton pregnancy. Performing more single embryo transfers (SET) is the most effective way to reduce the incidence of multiple pregnancies and more important to avoid high long-term costs. These data were the basis for the introduction of a new Belgian law in July 2003. This law proscribes the refunding of six IVF/ICSI cycles per patient with, in return, a restriction to transfer only one embryo in the first and second IVF/ICSI cycle if certain criteria are fulfilled. These criteria are based on the number of cycles, maternal age and embryo quality.Transferring a single embryo makes the embryo selection process very important. Therefore the first part of this PhD project focused on the selection of embryos using non-invasive methods. In the second part, culture conditions were investigated in order to increase the number of good quality embryos.Currently, embryo selection is based on the morphology of the embryo which has the advantage that the embryo can be evaluated in a non-invasive and fast way without compromising the development. In the first part of this project, some intra- and inter-observer variability was found in the evaluation of early stage embryos when a standard scoring system was used (mono- and multi-centre study). In order to decrease this variability, we focused on a computer-assisted scoring system. We concluded that the intra- and inter-observer variability was lower compared to the evaluation with the standard scoring system. In addition, it was found that the computer-assisted scoring system was superior to the standard scoring system in predicting life birth.New morphological characteristics (contact surface, total volume and orientation of cleavage axes) were evaluated of which the total volume on day 3 and the orientation of the cleavage axes on day 2 were promising characteristics. In addition, the peptide content in follicular fluid was found to be promising in the evaluation of embryo quality. The second part of the project revealed that the use of a single medium results in the highest utilization rate. In addition, we concluded that batch to batch variation in culture medium and mineral oil has an important impact on the embryo quality. In conclusion, the current standard scoring system can be expanded with new characteristics that need extra validation in future studies. Nevertheless, new non-invasive methods, such as peptidomics and time-lapse analysis, will be needed to substantially improve the embryo selection.TABLE OF CONTENTS List of Abbreviations ....................................................................................................................1 Introduction ...............................................................................................................................3 Objectives of the PHD project ..................................................................................................... 29 Part I. Evaluation of embryo quality ....................................................................................... 31 Chapter 1. Intra- and inter-observer analysis in the morphological assessment of early-stage embryos ......... 33 Chapter 2. Intra- and inter-observer analysis in the morphological assessment of early-stage embryos during an IVF procedure: a multicentre study ............................................................................................. 41 Chapter 3. A computer-assisted scoring system improves the intra- and inter-observer agreement ............... 47 Chapter 4. Computer-assisted embryo selection: a benefit in the evaluation of embryo quality? ................... 59 Chapter 5. Morphometric analysis of human embryos and the impact of the total embryo volume on pregnancy rate ................................................................................................................................ 69 Chapter 6. Is there a link between blastomere contact surfaces of day 3 embryos and live birth? .................. 87 Chapter 7. The orientation of cleavage planes of 4-cell stage embryos and IVF outcome .............................. 103 Chapter 8. Peptide patterns in follicular fluid and embryo quality of day 3 embryos: a pilot study ............... 117 Part II. Optimization of culture conditions ............................................................................. 135 Chapter 9. Early embryo development in a sequential versus single medium: a randomized study .............. 137 Chapter 10. The impact of opening the incubator on the embryo quality: a randomized study ...................... 145 Chapter 11. Batch to batch variation in culture medium and oil influences IVF outcome ................................ 159 Discussion ............................................................................................................................... 175 Summary ................................................................................................................................ 183 List of publications ................................................................................................................... 193 Curriculum Vitae ...................................................................................................................... 196 References ............................................................................................................................... 199nrpages: 219status: publishe

Triple touch sperm immobilization vs. single touch sperm immobilization in ICSI - a randomised trial

Abstract Background Although different techniques for sperm immobilization have been described, their value has not been assessed in an adequately powered randomized study. The aim of this study was to compare two types of sperm immobilization methods prior to ICSI and to test the hypothesis that triple touch immobilization (TTIm) would lead to a higher (5% -65% up to 70%) fertilization rate (FR) than single touch immobilization (STIm). Methods A total of 3056 metaphase II (MII) oocytes, from 290 patients, were randomly assigned to the STIm group (n = 1528 oocytes; 145 cycles) or to the TTIm group (n = 1528 oocytes; 138 cycles). A total of 1478 oocytes (STIm group) and 1476 oocytes (TTIm group) were used in the statistical analysis. The primary outcome variable was FR. Secondary outcome variables included: number of good quality embryos (GQE) on day 2 and day 3, implantation rate (IR) and implantation with foetal heart beat rate (FHB). Statistical analysis was done using the Fisher Exact test with a significance level of 0.05. Results The results showed no differences in FR between both groups. The proportion of good quality embryos on day 3, was significantly higher in the STIm group (37.5%) compared to the TTIm group (31.8%; p = 0.02). Conclusions In this RCT, the hypothesis that the post-ICSI FR would be higher after TTIm than after STIm was not confirmed and the number of good quality embryos on day 3 was significantly lower in the TTIm group than in the STIm group. These data suggest that more ‘aggressive’ TTIm technique has no advantages compared to the STIm technique.</p

Is there a link between blastomere contact surfaces of day 3 embryos and live birth rate?

Abstract Background Cell-cell communication and adhesion are essential for the compaction process of early stage embryos. The aim of this study was to develop a non-invasive objective calculation system of embryo compaction in order to test the hypothesis that embryos with a larger mean contact surface result in a higher live birth rate compared to embryos with a lower mean contact surface. Methods Multilevel images of 474 embryos transferred on day 3 were evaluated by the Cellify software. This software calculates the contact surfaces between the blastomeres. The primary outcome of this study was live birth. An ideal range of contact surface was determined and the positive and negative predictive value, the sensitivity, the specificity and the area under the curve for this new characteristic were calculated. Results In total, 115 (24%) transferred embryos resulted in a live birth. Selection of an embryo for transfer on its mean contact surface could predict live birth with a high sensitivity (80%) and high negative predicting value (83%) but with a low positive predictive value (27%), a low specificity (31%) and low area under the ROC curve (0.56). The mean contact surface of embryos cultured in a single medium was significantly higher compared to the mean contact surface of embryos cultured in a sequential medium (p = 0.0003). Conclusions Neither the mean contact surface nor the number of contact surfaces of a day 3 embryo had an additional value in the prediction of live birth. The type of culture medium, however, had an impact on the contact surface of an embryo. Embryos cultured in a single medium had a significant larger contact surface compared to embryos cultured in the sequential medium.</p

Biocompatibility of a new PD solution for Japan, Reguneal™, measured as in vitro proliferation of fibroblasts

BACKGROUND: The aim of this study was to investigate in vitro biocompatibility of Reguneal™, a new bicarbonate containing peritoneal dialysis fluid (PDF) for Japan, and compare it with other PDFs available in that country. METHODS: We assessed basal cytotoxicity using in vitro proliferation of cultured fibroblasts, L-929, determining the quantity of living cells by the uptake of Neutral Red. Levels of ten glucose degradation products (GDPs) were measured by a validated ultrahigh-performance liquid chromatography method in combination with an ultraviolet detector. We compared inhibition of fibroblast cell growth between brands of PDF, adjusting for dextrose and GDP concentrations using random-effects mixed models. RESULTS: The results demonstrate that cytotoxicity of Reguneal™ is comparable to a sterile-filtered control and is less cytotoxic than most of the other PDFs, most of which significantly inhibited cell growth. As a class effect , increasing dextrose and GDP concentrations were non-significantly but positively associated with cytotoxicity. As a brand effect , these relationships varied widely between brands, and some PDFs had significant residual effects on basal cytotoxicity through mechanisms that were unassociated with either dextrose or GDP concentration. CONCLUSION: Our study suggests that Reguneal™ is a biocompatible PDF. The results of our study also highlight that dextrose and GDPs are important for biocompatibility, but alone are not a complete surrogate. The results of our study need to be confirmed in other tissue culture models, and should lead to further research on determinants of biocompatibility and the effect of such PDFs on clinical outcomes