P–278 The embryo score provided by the KIDScoreD5 is correlated with implantation rate and clinical outcomes in fresh transfer

Study question Can the algorithm used by EmbryoScopePlus software predict implantation and clinical pregnancy in women of different age groups on fresh transfer? Summary answer The embryo score generated by KIDScoreD5 is highly related to the rates of implantation and clinical pregnancy in fresh transfers in women of different age. What is known already Artificial Intelligence algorithms use statistics to find patterns in large amounts of data and describe a non-biased approach to multiparameter analysis. Several algorithms have been described, but none has been adopted for universal use. KIDScoreD5 is the algorithm included in the EmbryoScopePlus system and classifies embryos according to the cleavage times and morphology of the blastocyst. Version 3, more current, includes the annotations of the number of pronuclei, the time of division for 2, 3, 4 and 5 cells, time to start of blastulation, and morphology of the Internal Cell Mass and trophectoderm. Study design, size, duration Retrospective study evaluated 86 embryos from January to December 2019 at the Reproferty clinic, grown at EmbryoScopePlus and transferred fresh on the fifth day of embryo development. The morphological and morphokinetic parameters were automatically evaluated by the software and in case of any mistake, they were manually corrected. The embryos were evaluated by KIDScoreD5 v3 in different scores from 0.0 to 9.9 and divided into 4 groups (0.0–2.5; 2.6–5.0; 5.1–7.5; 7.6 –9.9). Participants/materials, setting, methods The inclusion criterion was transfer of a single embryo with 1 gestational sac and positive FHB and transfer of two embryos with 2 gestational sac and positive FHB. Patients with progesterone on the trigger day ≥ 1.5ng/mL and/or with endometrium ≤7mm were excluded. The implantation and clinical pregnancy rates were calculated according to age group, G1: ≤35 years; G2: between 36 and 39 years old; G3: ≥40 years, within the embryo classification. Main results and the role of chance For patients in group 1 (n = 31 embryos), 33.4% of the embryos were classified between 2.6–5.0; 69.20% of embryos with scores between 5.1–7.5 and 57.10% of embryos with scores between 7.6–9.9, with 100% of embryos that implanted, regardless of classification, resulting in clinical pregnancy . For group 2 (n = 35 embryos), they only showed an implantation rate for embryos where the scores were 5.1–7.5 (33.4%) and 7.6 - 9.9 (71.4%) , with 100% being the clinical pregnancy rate in these groups. For patients in group 3 (n = 24 embryos), we also observed implantation only in groups of embryos with a score of 5.1–7.5 (37.5%) and 7.6–9.9 (18.5%) , but the clinical pregnancy rate was lower when compared to the other age groups of the patients, with 33.5% for embryos having a score between 5.1–7.5 and 50% for the group 7.6–9.9. Regarding the average score given by the classification of KIDScore Day 5 v. 3 for embryos that implanted, for patients aged 35 years or less, the average was 6.92; for patients between 36 and 39 years old, the average was 8.06 and for patients aged 40 years or older, the average was 7.32. Limitations, reasons for caution This project is limited because it is a retrospective study and evaluated embryos from a single breeding center. Multicenter and prospective studies are necessary to validate the universal use of the KIDScoreD5 v3 algorithm in time-lapse incubators. Wider implications of the findings: The study showed the ability of KIDScoreD5 v3 to assist the embryologist in deciding which embryo to transfer fresh, according to the patient’s age, in addition to the software being effective in automatic annotation of morphological and morphokinetic parameters. Validating an algorithm universally will improve embryonic selection. Trial registration number Not applicable

P–668 We aim for one baby, not one embryo: a personalized ET strategy based on embryo score and woman age maximizes LB and minimizes twins

Study question Is it possible to define a personalized ET model to maximize the chance of live birth (LB) while minimizing the risk of twin pregnancy? Summary answer A model including age and embryo morphological score can inform a personalized ET strategy to maximize LB while minimizing the risk of twin pregnancy. What is known already The morphological score of the transferred embryos affects pregnancy (PR) and LB rates in IVF cycles. Although SET is mainly recommended to avoid multiple pregnancies, DET is still being performed extensively, especially in patients with poor prognosis, with the aim to improve PR per transfer and shorten time to pregnancy. While twin pregnancies are associated with an increased risk of maternal and fetal complications, very low PR may increase patient drop-off, extend time to pregnancy, and increase the cost per successful transfer. A personalized transfer strategy balancing high LB per transfer with low twin pregnancy rates should be defined. Study design, size, duration Retrospective study including 2,470 fresh and frozen embryo transfers (ET) of either one or two embryos at D3 from January 2016 to August 2019 in a single IVF clinic. Biochemical, clinical, multiple pregnancy and live birth rates after SET and DET were analyzed according to the morphological score of the embryos transferred. ETs were divided into 9 groups according to the combinations of their embryo morphological scores. Participants/materials, setting, methods Embryos were assessed on D3 following a national recommended morphological scale. Morphology was categorized as High (H) if A or B+, medium (M) if B or C+, and Low (L) if C or D. The likelihood of biochemical, clinical pregnancy and live birth, and the risk of multiple pregnancy, after SET and DET of embryos of different scores was analyzed. A logistic regression analysis adjusted by age of the woman was ran for each outcome. Main results and the role of chance The distribution of ETs among the 9 groups for SET was: 510 H, 715 M, 346 L; for DET: 142 HH, 148 HM, 29 HL, 268 MM, 164 ML, 148 LL. Mean woman age was similar among groups: 38.7±4.01. Live birth and twin rates increased with embryo score. Considering a SET of category M as reference, the OR of live birth in DET were: 2.76 [1.82, 4.19 95%CI] for HH, and 2.32 [1.51, 3.55 95%CI] for HM, and 1.69 [1.19, 2.40 95%CI] for MM, and in SET: 1.52 [1.12, 2.04 95%CI] for H. Considering a DET of category MM as reference, the OR of twin birth in DET were: 2.8 [1.14, 6.99 95%CI] for HH, 2.5 [0.98, 6.46 95%CI] for HM, and 0.92 [0.11, 7.84 95%CI] for HL. According to this model, a 38y.o. woman with a SET of category M would have a 16% chance of live birth, and no twins. The addition of an M (DET: MM) increases her chance of live birth to 24% with a 2.9% risk of twins. The addition of a H (DET:MH) would increase further her chance of live birth to 30.8%, however, the increase would be due almost exclusively to twins (7%). Limitations, reasons for caution The limitations of this study are its retrospective nature and the small size of some categories. Embryos were classified using a national morphological scale; other morphological classifications could influence the results. The development and validation of site-specific models, using local patients’ data, is recommended before their use in clinical practice. Wider implications of the findings: A personalized assessment of embryo quality and woman age, at a minimum, are necessary to identify the best ET strategy for each patient; this strategy allows to maximize live birth rates while keeping the risk of twin birth as low as possibl. Trial registration number Not applicable

The Graduated Embryo Score of Embryos from Infertile Women with and without Peritoneal Endometriosis

Objective To determine embryo quality (mean graduated embryo score [GES]) in infertile patients with endometriosis undergoing in vitro fertilization with embryo transfer (IVF-ET) compared with infertile patients without endometriosis. Methods A case-control study was performed comparing 706 embryos (162 patients) divided into 2 groups: 472 embryos derived from patients without endometriosis (n = 109, infertile patients with tubal infertility) and 234 embryos from patients in the study group (n = 53, infertile patients with peritoneal endometriosis). All patients were subjected to IVF using an oestradiol-antagonist-recombinant follicle-stimulating hormone (FSH) protocol for ovarian stimulation. The mean GES was performed to evaluate all embryos at 3 points in time: 16 to 18 hours, 25 to 27 hours, and 64 to 67 hours. Embryo evaluation was performed according to the following parameters: fragmentation, nucleolar alignment, polar body apposition, blastomere number/morphology, and symmetry. The primary outcome measure was the mean GES score. We also compared fertilization, implantation, and pregnancy rates. Results Although the number of embryos transferred was greater in patients with endometriosis than in the control group (2.38 ± 0.66 versus 2.15 ± 0.54; p = 0.001), the mean GES was similar in both groups (71 ± 19.8 versus 71.9 ± 23.5; p = 0.881). Likewise, the fertilization rate was similar in all groups, being 61% in patients with endometriosis and 59% in the control group (p = 0.511). No significant differences were observed in the implantation (21% versus 22%; [p = 0.989]) and pregnancy rates (26.4% versus 28.4%; p = 0.989). Conclusion Embryo quality measured by the mean GES was not influenced by peritoneal endometriosis. Likewise, the evaluated reproductive outcomes were similar between infertile patients with and without endometriosis.

Efficacy of dual progesterone administration (intramuscular and vaginal) for luteal support in fresh day 3 or day 4 embryo transfer cycles

Objective: The aim of this study was to compare in vitro fertilization outcomes between fresh day 3 or day 4 embryo transfer cycles with dual progesterone (P) administration (intramuscular and vaginal) and cycles with single intramuscular P administration for luteal support.Methods: We selected 124 cycles from 100 women (under age 40 years) who underwent oocyte pick-up (number of trials ≤ 3, 4–14 oocytes obtained) and transfer of two or three day 3 or day 4 embryos at two infertility centers from January 2014 to June 2019. Dual P (intramuscular P [50 mg] daily+vaginal P) was used in 52 cycles and a single intramuscular administration of P (50 mg daily) was used in 72 cycles.Results: Women’s age, infertility factors, number of oocytes retrieved, number of transferred embryos, and mean embryo score were similar between the dual P group and the single P group. Although the number of trial cycles was significantly higher (1.9 vs. 1.5), and the mean endometrial thickness on the trigger day (10.0 mm vs. 11.0 mm) was significantly lower in the dual P group, the implantation rate, clinical pregnancy rate, ongoing pregnancy rate, and miscarriage rate for both day 3 and day 4 transfers were similar between the two groups.Conclusion: In fresh day 3 or day 4 embryo transfer cycles, dual P administration did not demonstrate any clinical advantages. Intramuscular P alone appears to be sufficient for luteal support.

Associations of post-warming embryo or blastocyst development with clinical pregnancy in vitrified embryo or blastocyst transfer cycles

Objective: To investigate whether the degree of post-warming embryo or blastocyst development is associated with clinical pregnancy in vitrified embryo or blastocyst transfer cycles.Methods: Ninety-six vitrified cleavage-stage embryos and 58 vitrified blastocyst transfer cycles were selected. All transfer cycles were performed from February 2011 to March 2019, and all vitrified embryos or blastocysts were warmed from 4 PM to 6 PM and then transferred the next morning from 9 AM to 10 AM. The scores of the cleavage-stage embryos and blastocysts were assessed at warming and at transfer using the modified Steer method and the Gardner method, respectively. The mean embryo or blastocyst score, score of the single top-quality embryo or blastocyst, and the difference in the score between warming and transfer were compared between nonpregnant and pregnant women.Results: In the cleavage-stage embryo transfer cycles, both the top-quality embryo score at transfer and the difference in the score between warming and transfer were significantly associated with clinical pregnancy. A top-quality embryo score at transfer of ≥60.0 (area under the curve [AUC], 0.673; 95% confidence interval [CI], 0.531–0.815) and a difference in the score between warming and transfer of ≥23.0 (AUC, 0.675; 95% CI, 0.514–0.835) were significant predictors of clinical pregnancy. In blastocyst transfer cycles, the top-quality blastocyst score at transfer was the only significant factor associated with clinical pregnancy. A top-quality blastocyst score at transfer of ≥38.3 was a significant predictor of clinical pregnancy (AUC, 0.666; 95% CI, 0.525–0.807).Conclusion: The top-quality embryo score at transfer and the degree of post-warming embryo development were associated with clinical pregnancy in vitrified cleavage-stage embryo transfer cycles. In vitrified blastocyst transfer cycles, the top-quality blastocyst score at transfer was the only significant factor affecting clinical pregnancy.

Alteration in the intrafollicular thiol–redox system in infertile women with endometriosis

The aim of this study was to compare intrafollicular biomarkers of thiol–redox system and chronic inflammation in infertile patients with and without endometriosis, and examine correlations between biomarkers and IVF outcomes. The study included 65 patients receiving IVF: 31 patients with endometriosis vs 34 patients without endometriosis. Follicular fluid (FF) was obtained from a single-dominant follicle during oocyte retrieval and stored at −70 °C. Malondialdehyde, superoxide dismutase, glutathione (GSH), glutathione peroxidase 3 (GPX3), thioredoxin (TRX), TRX-binding protein 2 (TBP2), and peroxiredoxin-4 levels were measured in the FF samples by ELISAs as biomarkers of oxidative stress. The inflammatory cytokines interleukin 1 beta (IL1β), IL6, IL8, and tumor-necrosis factor alpha (TNFα) were also measured by ELISAs. GSH levels were significantly lower in the endometriosis group compared with the controls. TBP2 levels were significantly higher in the endometriosis group. IL6, IL8, and TNFα levels were significantly higher in the endometriosis group. The levels of all of the inflammatory cytokines positively correlated with the levels of TRX. GSH levels positively correlated with the number of high-quality embryos. GPX3 and TRX levels negatively correlated with the percentage of mature oocytes. TNFα levels negatively correlated with the cumulative embryo score per embryo. Logistic regression analysis revealed that the number of high-quality embryos was an independent factor predicting clinical pregnancy. In conclusion, there may be an imbalance in the thiol–redox system and increased levels of inflammatory cytokines in the intrafollicular microenvironment of infertile patients with endometriosis, which may affect the qualities of the oocyte and embryo.