Evidence-based medicine in ART

Sir, The treatment of infertility through assisted reproduction technology (ART) is currently helping hundreds of thousands of people each year to achieve parenthood. This branch of medicine is also undergoing substan tial technological development. While the technology is implemented quickly, solid clinical data become available slowly, resulting in a growing gap between current ART practices and evidence-based standards

High reliability of morphokinetic annotations among embryologists

Are morphokinetic measurements of time lapse-videos of human embryos comparable among operators? There is little variation among morphokinetic measurements taken by different operators when analyzing the same time lapse-videos of human embryos. Morphokinetic analysis of preimplantation embryo development is a complementary method of embryo assessment increasingly used in IVF laboratories. Time-lapse videos of embryo development are normally viewed by trained embryologists and annotated with the times when specific developmental events occur. Such annotations form the basis of embryo selection algorithms, used to rank the embryos for transfer. It is unknown whether the reliability of morphokinetic annotations is related to the morphological characteristics of the analyzed embryo or to the ability of the embryologists performing the annotation. One study so far reported the reliability of morphokinetic annotations among three embryologists using the time-lapse system (TLS), but larger studies with different setups are needed to address this issue further. A prospective study was carried out between October 2015 and June 2016. Six embryologists with various degrees of experience in static, morphology-based evaluation, individually annotated the same 93 videos of preimplantation development, corresponding to 18 IVF/ICSI cycles, recorded with a TLS. Times of second polar body extrusion, appearance and disappearance of pronuclei, and embryo cleavages (times from 2-cell to 5-cell stage: t2, t3, t4, t5) were annotated. Each embryologist was blinded to the annotations of the others. Intra- and inter-observer agreement was evaluated by computing intra-class correlation coefficients (ICCs). In the inter-observer analysis, most ICCs obtained were higher than 0.80, indicating a high level of agreement: t2: 0.93; t3: 0.80; t4: 0.89; t5: 0.89; disappearance of two pronuclei: 0.98. However, the ICCs obtained for second polar body extrusion and the appearance of two pronuclei annotations was lower: 0.51 and 0.63, respectively, indicating an average level of agreement. The ICCs obtained from the intra-observer analysis were also higher than 0.80 (t2: 0.96; t3: 0.89; t4: 0.88; t5: 0.86; disappearance of two pronuclei: 0.96). The ICCs obtained from second polar body extrusion and the appearance of two pronuclei annotations were 0.77 and 0.66, respectively. These results indicate that developmental timings, annotated in time-lapse videos, are highly reliable both within and among observers. The events at the developmental stages from 6-cells to blastocyst were not evaluated; since some morphokinetic algorithms use times past the 6-cell stage in their calculations, further studies should be carried out to understand the variations among observers in these cases. Time-lapse measurement should be as objective as possible, especially for the first embryo cleavages, because they are often measured to define algorithms to assess the embryonic implantation potential. Our results show that measurements using this particular TLS are consistent and reliable both within and among operators

Reproductive outcomes in lesbian couples undergoing reception of oocytes from partner versus autologous in vitro fertilization/intracytoplasmic sperm injection

Introduction: The utilization of assisted reproductive technology (ART) by the lesbian, gay, bisexual, transgender, inter sex, and queer community, and specifically lesbian couples, has substantially increased over the past decade.1,2 Depend ing on their reproductive history, age, and preference, same sex female couples may elect to undergo donor intrauterine insemination (IUI) or in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) using autologous oocytes and donor sperm. Couples may also opt for co-in vitro fertiliza tion (co-IVF), also known as reciprocal IVF or Reception of Oocytes from Partner (ROPA). This is a reproductive in tervention in which one woman in the couple contributes her oocytes, which are fertilized with donor sperm to generate embryos that are transferred to the uterus of the second woman, who will carry the pregnancy and deliver the child. Lesbian couples in Spain have had legal access to treatment with donor sperm since 1977, after the establish ment of the first sperm bank, whereas ART in Spain was first regulated in 1988.3 However, at that time, the partner of the woman undergoing the treatment had no legal rights toward the child. Some years later, the legalization of same-sex marriage in Spain (Law 13/2005)4 and legislation allowing the utilization of embryos generated by ART by a woman or by her partner (Law 14/2006),5 ultimately made it possible for both women in a lesbian couple to participate in the pregnancy plan

Two decades of embryonic stem cells : a historical overview

STUDY QUESTION How did the field of stem cell research develop in the years following the derivation of the first human embryonic stem cell (hESC) line? SUMMARY ANSWER Supported by the increasing number of clinical trials to date, significant technological advances in the past two decades have brought us ever closer to clinical therapies derived from pluripotent cells. WHAT IS KNOWN ALREADY Since their discovery 20 years ago, the use of human pluripotent stem cells has progressed tremendously from bench to bedside. Here, we provide a concise review of the main keystones of this journey and focus on ongoing clinical trials, while indicating the most relevant future research directions. STUDY DESIGN, SIZE, DURATION This is a historical narrative, including relevant publications in the field of pluripotent stem cells (PSC) derivation and differentiation, recounted both through scholarly research of published evidence and interviews of six pioneers who participated in some of the most relevant discoveries in the field. PARTICIPANTS/MATERIALS, SETTING, METHODS The authors all contributed by researching the literature and agreed upon body of works. Portions of the interviews of the field pioneers have been integrated into the review and have also been included in full for advanced reader interest. MAIN RESULTS AND THE ROLE OF CHANCE The stem cell field is ever expanding. We find that in the 20 years since the derivation of the first hESC lines, several relevant developments have shaped the pluripotent cell field, from the discovery of different states of pluripotency, the derivation of induced PSC, the refinement of differentiation protocols with several clinical trials underway, as well as the recent development of organoids. The challenge for the years to come will be to validate and refine PSCs for clinical use, from the production of highly defined cell populations in clinical grade conditions to the possibility of creating replacement organoids for functional, if not anatomical, function restoration. LIMITATIONS, REASONS FOR CAUTION This is a non-systematic review of current literature. Some references may have escaped the experts’ analysis due to the exceedingly diverse nature of the field. As the field of regenerative medicine is rapidly advancing, some of the most recent developments may have not been captured entirely. WIDER IMPLICATIONS OF THE FINDINGS The multi-disciplinary nature and tremendous potential of the stem cell field has important implications for basic as well as translational research. Recounting these activities will serve to provide an in-depth overview of the field, fostering a further understanding of human stem cell and developmental biology. The comprehensive overview of clinical trials and expert opinions included in this narrative may serve as a valuable scientific resource, supporting future efforts in translational approaches. STUDY FUNDING/COMPETING INTEREST(S) ESHRE provided funding for the authors’ on-site meeting and discussion during the preparation of this manuscript. S.M.C.S.L. is funded by the European Research Council Consolidator (ERC-CoG-725722-OVOGROWTH). M.P. is supported by the Special Research Fund, Bijzonder Onderzoeksfonds (BOF01D08114). M.G. is supported by the Methusalem grant of Vrije Universiteit Brussel, in the name of Prof. Karen Sermon and by Innovation by Science and Technology in Flanders (IWT, Project Number: 150042). A.V. and B.A. are supported by the Plataforma de Proteomica, Genotipado y Líneas Celulares (PT1770019/0015) (PRB3), Instituto de Salud Carlos III. Research grant to B.H. by the Research Foundation—Flanders (FWO) (FWO.KAN.2016.0005.01 and FWO.Project G051516N). There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER Not applicable. ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE

Generation of induced pluripotent stem cells from human cord blood using OCT4 and SOX2

Mouse and human fibroblasts were the first cell types successfully reprog- rammed by ectopic expression of OCT4, SOX2, KLF4, and c-MYC (OSKM) (Lowry et al., 2008; Maherali et al., 2007; Park et al., 2008; Takahashi et al., 2007; Taka- hashi and Yamanaka, 2006; Yu et al., 2007). Further studies have shown that the age, origin, and cell type used have a deep impact on the reprogramming effi- ciency, eventually requiring the expres- sion of fewer factors and/or reducing the timing of the whole process. In general, stem cells are rare and difficult to access and isolate in large numbers (neural stem cells, for instance [Kim et al., 2008, 2009c]) and, therefore, represent a com- plicated target for reprogramming. How- ever, Cord Blood (CB) could represent an alternative and readily accessible source of stem cells. Here, we describe reprog- ramming of CB cells to pluripotency by retroviral transduction of four (OSKM), three (OSK), and as few as two (OS) tran- scription factors, without the need for additional chemical compounds

The ethics of preconception expanded carrier screening in patients seeking assisted reproduction.

Expanded carrier screening (ECS) entails a screening offer for carrier status for multiple recessive disorders simultaneously and allows testing of couples or individuals regardless of ancestry or geographic origin. Although universal ECS-referring to a screening offer for the general population-has generated considerable ethical debate, little attention has been given to the ethics of preconception ECS for patients applying for assisted reproduction using their own gametes. There are several reasons why it is time for a systematic reflection on this practice. Firstly, various European fertility clinics already offer preconception ECS on a routine basis, and others are considering such a screening offer. Professionals involved in assisted reproduction have indicated a need for ethical guidance for ECS. Secondly, it is expected that patients seeking assisted reproduction will be particularly interested in preconception ECS, as they are already undertaking the physical, emotional and economic burdens of such reproduction. Thirdly, an offer of preconception ECS to patients seeking assisted reproduction raises particular ethical questions that do not arise in the context of universal ECS: the professional's involvement in the conception implies that both parental and professional responsibilities should be taken into account. This paper reflects on and provides ethical guidance for a responsible implementation of preconception ECS to patients seeking assisted reproduction using their own gametes by assessing the proportionality of such a screening offer: do the possible benefits clearly outweigh the possible harms and disadvantages? If so, for what kinds of disorders and under what conditions

Tailored support may be required to reduce the impact of the infertility journey on mental health, relationships and daily lives of infertile patients and partners to infertile patients

Research question What is the psychological impact of infertility on infertile patients and partners of infertile patients? Design This online, international, quantitative survey assessed the impact of infertility on mental health, relationships and daily activities for 1944 respondents. Respondents were male or female infertile patients (n = 1037) or partners to infertile patients (n = 907; not necessarily partners of the patient sample) and were recruited at different stages of the treatment journey. Results The most common emotions were ‘sadness’ at infertility diagnosis and ‘anxiety’ during treatment. Emotions differed in nature and intensity throughout the journey. Envy of others who achieved pregnancy was frequently reported by women. More than half of respondents (60.4%; n = 1174) perceived the infertility journey to have impacted their mental health, and 44.1% (n = 857) of respondents sought mental health support. More patients reported mental health impacts (70.1%, n = 727) than partners (49.3%, n = 447). One in three respondents indicated that their relationship had suffered due to the infertility diagnosis. Of these respondents, 55.0% (n = 409) strongly agreed that infertility caused an emotional strain. Patients more often than partners reported a detrimental impact on daily activities. Respondents most commonly agreed with statements regarding an ‘effect on work–life balance’. Conclusion Treatment journey stages are defined by their impact profile, which differs between infertile patients and partners of infertile patients. Negative impacts are diverse (mental health, relational, daily activities). There was disparity between the number of respondents reporting mental health issues and the number seeking mental health support. This indicates the need for support services tailored to different treatment stages

Trophoblast attachment to the endometrial epithelium elicits compartment-specific transcriptional waves in an in-vitro model

Implantation is a major bottleneck in human reproduction (Polanski et al., 2014). The average implantation rate for an embryo ranges from 30% to 40% (Coughlan et al., 2014). Recurrent implantation failure (RIF) is estimated to occur in approximately 4% of IVF cycles (Koot et al., 2012), although estimates vary because there are several somewhat different definitions of RIF in the literature. Implantation of the blastocyst in the receptive endometrium is a sequential process involving apposition, attachment and invasion that precedes the establishment of pregnancy (Wang and Dey, 2006). Successful implantation requires embryo competence and endometrial receptivity, both of which are dynamic and highly regulated states (Wang and Dey, 2006). In addition to genetic disorders (which are a major cause of implantation failure and miscarriage), embryo competence, quality and ultimately developmental potential depend on the embryo achieving the correct regulatory, signalling and metabolic states (Fu et al., 2009; Hourvitz et al., 2006; Lundin et al., 2001; Simon and Laufer, 2012; Sjoblom et al., 2006). A key determinant of these embryonic states is their underlying transcriptional dynamics; for instance, waves of embryonic transcriptional activation direct early development and the symmetry breaking needed for cell fate specification (Shi et al., 2015; Vassena et al., 2011).info:eu-repo/semantics/publishedVersio

Developmental competence of bovine oocytes: follicular status and ultrasound image characteristics

This thesis investigates the relationship between the physiological phase of follicles in cattle, their echotexture attributes and the developmental competence of the oocytes that they contain. This study also investigates the local influence of ovarian structures (CL and dominant follicle) on developmental competence of oocytes and follicular echotexture. The drive behind this work was to improve the understanding of ovarian function in this species for the purpose of refining the techniques of follicle manipulation, and to determine ultrasound image characteristics useful to the development of diagnostic and prognostic tools for use in cattle and other species, including humans. After stimulating the emergence of a new ovarian follicular wave in cows, images of dominant and subordinate follicles were digitalized at Days 2, 3, 5 and 7 of the follicular wave. Cumulus oocyte complexes from the same ovaries were collected from subordinate follicles &#8805;3 mm and underwent in vitro embryo production to the blastocyst stage. Image analysis revealed differences in echotexture between dominant and subordinate follicles among Days 2 to 7 of the follicular wave. Follicles at Day 7 of the wave displayed consistently lower (P < 0.05) values of image attributes in peripheral antrum, follicular wall and perifollicular stroma. Oocytes collected on this day displayed low developmental competence. The proportion of oocytes that developed to the blastocyst stage was higher (

Transcriptomics analysis and human preimplantation development

International audienceThe study of oocyte and preimplantation embryo biology has been regarded with great curiosity throughout scientific history, but it is not until the development of robust methods for in vitro observation and manipulation of animal gametes that developmental biology has flourished as a discipline. By far the biggest technical challenge in studying transcription in oocytes and early embryo has been the necessity of developing techniques that retain a high level of accuracy when starting from small amount of material. The objective of this narrative review is to summarize the knowledge gained about the embryonic preimplantation period in the human species from tran-scriptomics experiments, and to discuss technical limitations and solutions to the study of transcriptomics in these samples.Significance: In this review we identify key critical issues in performing transcriptomics experiments during the human preimplantation period, and identifying possible ways to overcome them. This, combined with a description of clinical perspectives and the definition of future avenues for research will provide useful for future research