Abstract
Study question
Is delayed blastocyst development, assessed by the day of trophectoderm (TE) biopsy, associated with higher rates of aneuploidy?
Summary answer
Our findings show an association between delayed blastocyst development and poorer prognosis, in terms of euploidy rates, in patients of advanced maternal age.
What is known already
Extended culture of embryos past day 5 of development has become routine practice in all freeze-all cycles, including those applying preimplantation genetic testing for aneuploidies (PGT-A). As healthy live births have been obtained from day 6 and day 7 blastocysts, increasing the pool of embryos available for PGT-A is beneficial, particularly for patients of advanced maternal age who face higher cancellation rates. Nevertheless, the association between delayed blastocyst development and aneuploidy rates remains unclear. As current studies have reported opposing findings, detailed analysis of the chromosomal constitution of slowly developing embryos remains paramount.
Study design, size, duration
Retrospective, international, multicentre cohort study of 4211 patients undergoing preimplantation genetic testing for aneuploidy (PGT-A) from January 2016 to July 2020. We evaluated the chromosomal status of 14757 blastocysts tested using TE biopsy and next generation sequencing (NGS). Both autologous and donation cycles were included in the analysis. Cycles were excluded if they utilised preimplantation genetic testing for monogenic disorders (PGT-M) or preimplantation genetic testing for structural rearrangements (PGT-SR).
Participants/materials, setting, methods
We evaluated euploidy, aneuploidy and mosaicism rates reported in day 5 (n = 9560), day 6 (n = 4753) and day 7 (n = 262) blastocysts, stratified by SART-defined maternal age categories (<35, 35–37, 38–40, 41–42, >42). We further assessed the type and frequency of abnormalities reported in all blastocysts classified as clinically unsuitable, according to the day of biopsy. Finally, we examined the specific chromosomes affected in embryos diagnosed with a single uniform (n = 3882) or single mosaic (n = 518) abnormality.
Main results and the role of chance
The mean maternal age within our patient cohort was 39.9±3.7. Overall, slowly developing blastocysts were significantly more likely to be classified as clinically unsuitable (60.6%) compared to day 5 embryos (55.2%; p < 0.0001). This correlation was also observed when stratified by age, with the exception of the <35 age group (p = 0.25). Markedly, the risk of aneuploidy in slowly developing blastocysts became progressively higher with advancing maternal age (p < 0.0001). We did not observe any significant differences in the types of abnormalities diagnosed in slowly developing embryos compared to day 5 blastocysts. Nevertheless, abnormalities affecting all chromosomes were present at the blastocyst stage. Single trisomies and monosomies were the most frequent across all age groups, and were equally prevalent in day 5, 6 and 7 blastocysts. These most commonly affected chromosomes 16, 22, 21 and 15. We observed no significant differences in the incidence of segmental aneuploidies in relation to the day of biopsy, across all age groups. When considered separately, day 7 blastocysts presented with higher rates of structural aberrations, however low numbers limited statistical power. Finally, delayed blastocyst development was not associated with higher mosaicism rates (p = 0.79). Interestingly, single mosaic trisomies and monosomies were most frequently associated with chromosome 19.
Limitations, reasons for caution
Due to the retrospective nature of the study, full elucidation of all potential confounders may not be possible in all instances. The low number of day 7 blastocysts limited statistical power. As such, the results from day 6 and day 7 embryos were evaluated together.
Wider implications of the findings: Our findings offer an important clinical resource for counselling patients of advanced maternal age. Maternal aging may be associated with a higher incidence of aneuploidy in slowly developing blastocysts. Nevertheless, extended culture increases the pool of biopsiable blastocysts, ultimately improving the chance of having a euploid embryo for transfer.
Trial registration number
NA
Elevated BMI in patients of advanced maternal age does not affect blastocyst development or chromosomal complement, but has negative consequences for embryo metabolism and implantation
