Bourdon,  M.1,  Santulli,  P.  1,  Maignein,  C.1  ,  Gayet,  V.1,  Marcellin,  L.1,  Blanchet,  V.1,  Gonnot,    J.1,  Chapron,  C.  1      

1  Université  Paris  Descartes,  Sorbonne  Paris  Cité,  Faculté  de  Médecine,  Assistance  Publique  –  Hôpitaux  de  Paris  (AP-­‐  HP),  Groupe  Hospitalier  Universitaire  (GHU)  Ouest,  Centre  Hospitalier  Universitaire  (CHU)  Cochin,  Department  of  Gynecology  Obstetrics  

II  and  ReproducMve  Medicine,  75679  Paris,  France    

ART  outcomes  for  fresh  versus  deferred  frozen-­‐thawed  day-­‐2  embryo  transfer:    

a  matched  cohort  study      

Mathilde  Bourdon  

Weinerman.  R  and  Mainigi.  M,  FS.,  2014  

Gene  expression  profiles  of  simulated  and  nonsLmulated  human  endometrium  during  the  window  of  embryo  implantaLon  

Adverse  impact  of  COS  on  endometrial  recepLvity  ?  

Bourgain  C.and  Devroey  P.,  HR,  2003    

“freeze-­‐all”  strategy    

-­‐>  The  hypothesis  is  that  introducMon  of  a  frozen-­‐thawed-­‐embryo  into  a  potenMally  more  favorable  intrauterine  environment  could  avoid  possible  adverse  

impact  of  COS  on  endometrial  recepMvity.    

cryopreservaMon  of  all  viable  embryos  aXer  COS,    with  transfer  of  a  frozen-­‐thawed  embryo  in  a  subsequent  cycle  

Vitrified-warmed blastocyst transfer cycles yieldhigher pregnancy and implantation rates comparedwith fresh blastocyst transfer cycles—time for a newembryo transfer strategy?

Dandan Zhu, M.D.,a Juanjuan Zhang, M.D.,a Shanren Cao, M.Sc.,a Junqiang Zhang, M.Sc.,a

Boon Chin Heng, Ph.D.,b Meiling Huang, B.Sc.,a Xiufeng Ling, M.D., Ph.D.,a Tao Duan, M.D., Ph.D.,c

and Guo Qing Tong, M.D., Ph.D.a,c

a IVF Program, Nanjing Maternity and Child Health Hospital, Nanjing Medical University, Jiangsu, People’s Republic of China;b Nanyang Technological University, Singapore; and c IVF Program, Shanghai 1st Maternity and Infant Hospital, TongjiUniversity, Shanghai, People’s Republic of China

Objective: To compare the clinical outcome of fresh versus vitrified-warmed blastocyst transfer (BT) cycles.Design: Retrospective study.Setting: Medical university affiliated hospital.Patient(s): Women aged less than 40 years undergoing BT cycles.Intervention(s): Vitrification and warming of blastocyst with the Cryotop system.Main Outcome Measure(s): Clinical pregnancy rate (CPR), implantation rate (IR), and multiple pregnancy rate(MPR).Result(s): In 110 fresh BT cycles versus 136 vitrified-warmed BT cycles performed from January 2007 to March2010, the IR and CPR of vitrified-warmed BT cycles were 37.0% and 55.1%, respectively, which were statisticallysignificantly higher than the corresponding values of 25.2% and 36.4% obtained for fresh BT cycles. Additionally,the MPR was not statistically significantly different between vitrified-warmed and fresh BT cycles when a similarnumber of blastocysts was transferred to patients.Conclusion(s): Vitrified-warmed BT cycles resulted in statistically significantly higher CPR and IR compared withfresh BT cycles. A new embryo transfer strategy is therefore proposed whereby fresh BTwould be avoided in theinitial ovarian stimulation cycle. Instead, all the patient’s available blastocysts would be vitrified-warmed andtransferred in subsequent cycles. (Fertil Steril! 2011;95:1691–5. "2011 by American Society for ReproductiveMedicine.)

Key Words: Blastocyst transfer, clinical pregnancy, implantation, vitrification

Blastocyst transfer (BT) is effective for enhancing implantation andclinical pregnancy rates, resulting in better clinical outcomes (1, 2).However, it is not always possible to perform fresh BT cycles forevery patient with in vitro fertilization/intracytoplasmic sperminjection (IVF-ICSI) embryos that have successfully been culturedup to the blastocyst stage. Occasionally, fresh BT cycles must becanceled for patients who have exhibited poor endometrialreceptivity or ovarian hyperstimulation syndrome. Under suchcircumstances, all available fresh blastocysts would be cryopreservedfor transfer in a subsequent cycle. Additionally, if there is failure inachieving pregnancy after initial transfer of fresh blastocysts, surpluscryopreserved blastocysts would be transferred in a subsequent cycle.

Vitrification is the preferred method of cryopreservation as op-posed to slow-freezing protocols, due to lack of ice crystallizationand convenience of the procedure itself (3, 4). Generally, it is

widely believed that fresh embryo transfer cycles yield betterclinical results than either frozen-thawed or vitrified-warmed em-bryo transfer cycles. The pertinent question that remains unan-swered is whether blastocyst vitrification compromises embryonicdevelopmental potential. We compared the implantation and clinicalpregnancy rates of fresh versus vitrified-warmed BT cycles.

MATERIALS AND METHODSPatientsFrom January 2007 to March 2010, we performed 136 vitrified-warmed BTcycles, in 48 patients undergoing ICSI treatment. During the same period, weperformed 110 fresh BT cycles, in 32 patients undergoing ICSI treatment.The two data sets were comparable as there were no statistically significantdifferences between the two groups in patient parameters such as age, dura-tion of infertility, etiology of infertility, or proportion of ICSI cycles (P>.05,Table 1). All patients in the control group had surplus vitrified blastocysts forfuture transfer. Hence, the data were not in any way skewed by the inherentlyhigher success rate of patients with excess embryos to cryopreserve ascompared with patients who had only fresh embryos for transfer.

Ovarian StimulationThe standard long protocol for ovarian stimulation was used for patients inthis study (5). Briefly, 0.1 mg SC of the gonadotropin-releasing hormone(GnRH) agonist triptorelin (Decapeptyl; Ipsen-Biotech Inc., Paris, France)was administered in the midluteal phase of the previous cycle, followed by

Received October 12, 2010; revised December 8, 2010; accepted January6, 2011; published online February 11, 2011.

D.Z. has nothing to disclose. J.Z. has nothing to disclose. S.C. has nothingto disclose. J.Z. has nothing to disclose. B.C.H. has nothing to disclose.M.H. has nothing to disclose. X.L. has nothing to disclose. T.D. hasnothing to disclose. G.Q.T. has nothing to disclose.

Reprint requests: Guo Qing Tong, M.D., Ph.D., Director, Department ofAssisted Reproductive Technology, Shanghai 1st Maternity and InfantHospital of Tongji University, Changle Road 536, Shanghai, People’sRepublic of China 200040 (E-mail: tongguoqing@hotmail.com).

0015-0282/$36.00 Fertility and Sterility# Vol. 95, No. 5, April 2011 1691doi:10.1016/j.fertnstert.2011.01.022 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.

ARTICLE

Freeze-all can be a superior therapy toanother fresh cycle in patients with priorfresh blastocyst implantation failure

Bruce S. Shapiro a,b,*, Said T. Daneshmand a,b, Forest C. Garner a,b,Martha Aguirre a, Cynthia Hudson a

a Fertility Center of Las Vegas, Las Vegas, NV, USA; b Department of Obstetrics and Gynecology, School of Medicine,University of Nevada, Las Vegas, NV, USA* Corresponding author. E-mail address: bsshapiro@aol.com (BS Shapiro).

Dr Shapiro earned his MD from the University of Nevada, Reno, and his PhD from the University of Amsterdam.He completed his residency in obstetrics and gynaecology and his fellowship in reproduction endocrinology atYale-New Haven Hospital. He is chief of the Division of Reproductive Endocrinology and Infertility in the Uni-versity of Nevada School of Medicine’s Department of Obstetrics and Gynecology. He is also a high-complexitylaboratory director. He is the founder and medical director of the Fertility Center of Las Vegas. His recent re-search has included endometrial receptivity, embryo cryopreservation and alternative ovulatory triggeringtechniques.

Abstract Implantation failure has various causes, including impaired uterine receptivity following ovarian stimulation. This retro-spective cohort study compared outcomes in patients with prior implantation failure who elected to undergo another fresh cycleversus those who opted for embryo cohort cryopreservation (freeze-all) and subsequent thaw. There were 269 patients with implan-tation failure following fresh autologous blastocyst transfer opting to undergo a subsequent cycle, with 163 choosing another freshcycle and 106 electing freeze-all and subsequent thaw. Multiple logistic regression analysis indicated that cohort cryopreservationwas associated with greater chance of live birth when compared with another fresh cycle (P < 0.0001). The odds ratio for live birthwith freeze-all relative to a fresh cycle was 3.8 (95% CI 2.1–7.2). A second analysis was then performed using cumulative live birthrate as the outcome measure. Multiple logistic regression indicated freeze-all was associated with greater cumulative live birth ratethan was a fresh cycle (OR 1.9, 95% CI 1.1–3.3, P = 0.0287). These findings suggest that, following implantation failure with freshblastocysts, patients have a significantly greater chance of live birth with freeze-all and subsequent thaw than with another freshcycle.© 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

KEYWORDS: embryo cryopreservation, endometrial receptivity, implantation failure, IVF, ovarian stimulation

http://dx.doi.org/10.1016/j.rbmo.2014.04.0091472-6483/© 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Reproductive BioMedicine Online (2014) ■■, ■■–■■

ARTICLE IN PRESS

Please cite this article in press as: Bruce S. Shapiro, Said T. Daneshmand, Forest C. Garner, Martha Aguirre, Cynthia Hudson, Freeze-all is a superior therapy toanother fresh cycle in patients with prior fresh blastocyst implantation failure, Reproductive BioMedicine Online (2014), doi: 10.1016/j.rbmo.2014.04.009

www.sciencedirect .comwww.rbmonl ine.com

Freeze  all    Cleavage  stage  embryo  transfer    

Roque,et  al.  FS,  2015  

DAY-­‐2  ET  to  freeze  or  not  to  freeze?    

 

?  

fresh  day-­‐2  embryo  transfer  (ET)     deferred  frozen-­‐thawed    day-­‐2  embryo  transfer  (def-­‐ET)  

ART  outcomes    

10/2012     12/2014  

A"er  the  first  ET:    ü  Clinical  PR    ü  Ongoing  PR    ü  ImplantaMon  rate    

Fresh  Group    Deferred  Group  

     Matched  for:  ü     Age  ü Number  of  previous  IVF  cycle  

Day-­‐2  deferred  group   Day-­‐2  fresh  group  

Material  and  methods  

Controlled  observaMonal  cohort  study    

IndicaLons  Deferred  ET  

OHSS  risk    

≥  2  IVF  Failures    

Endometriosis  

Endometrial  AbnormaliLes:  Premature  progesterone  elevaMon  

Anatomical  defects  (polyps,  fibroids,  hydrosalpinx)    

Thromboembolism  Risk  Autoimmune  diseases  

Fresh  ET  

COS  

hCG  

OR   ET  

P4  

Fresh  ET    

deferred  ET  

COS  

GnRHa  triggering  or  hCG    

OR  

Blasto.  

or  

P4   Menses    Deferred  ET  5  weeks  later      

P4  E2  

Frozen  ET  CryopreservaGon  of  all  embryos  

Frozen  ET    

<  7  Zygotes     ≥7  zygotes    

All  zygotes  VitrificaMon  and  warmed      Extended  

culture  for  extra  embryos    

VitrificaMon  at  blastocyst  stage    

VitrificaMon  at  blastocyst  stage    

VitrificaMon  algorithm    

Transfer  of    2  best  cleavage  stage  embryos  

Transfer  of    1  blastocyst  

Scheduled  ART  cycles    from  10/2012  to  12/2014  

n=3116  Cancelled  cycles*  n=535  

Fresh  embryo  transfer  (ET)  n=1667  

Oocytes  retrieval  n=2581  

Deferred  frozen-­‐thawed    embryo  transfer  (def-­‐ET)    

N=594  

day  5-­‐6  FET  n=269  

Matched  for:  ü     Age  

ü  Number  of  IVF  cycle  

Day-­‐2  def-­‐ET    N=325  

 Day-­‐2  Fresh  ET  

N=1296    

Def-­‐ET  group  $  N=325  

Fresh  ET  group  $  N=325  

No  embryo  obtained  n=  247  Oocytes  vitrificaMon  n=  35  Inclusion  in  another  ART  research  protocol        n=38  

day  5-­‐6  fresh  ET  n=25  

≥7  zygotes  obtained  n=346  

Flow  chart    

<7  zygotes    

   Fresh  (n=325)  

Def-­‐ET      (n=325)   P  value  

PaLent’s  Age  at  IVF  (years)   35.96  ±  4.4   35.65  ±  4.3   NS  Number   of   previous   IVF  cycles  

2.41  ±  1.27   2.51  ±  1.33   NS  

Length  of  inferLlity  (years)   4.98  ±  2.91   5.08  ±  2.83   NS  BMI  (kg/m2)   23.88  ±  4.08   23.66  ±  4.01   NS  Smoking   29  (8.92)   30  (9.23)   NS  Cause  of  inferLlity:             NS  .  Ovula2on  disorder   31  (9.54)   35  (10.77)      

.  Male  factor   125  (38.46)    104  (32.00)      

.  Tubal  factor   37  (11.38)   35  (10.77)      

.  Endometriosis     49  (15.08)   76  (23.38)      

.  Idiopathic   57  (17.54)   52  (16.00)      

.  Diminished   ovar ian  reserve    

15  (4.62)   9  (2.77)      

.  More  than  1  e2ology     11  (3.38)   14  (4.31)      PaLent’s  ovarian  reserve:              .  Day  3  FSH  (UI/L)   7.35  ±  2.31   7.07  ±  2.07   NS  .  Day  3  LH  (UI/L)   4.85  ±  2.18   4.97  ±  2.53   NS  .  Day  3  Estradiol  (pg/mL)   46.39  ±  21.91   44.46  ±  24.84   NS  .  AFC   13.17  ±  6.72   14.44  ±  8.28   0.039  t  .  AMH  (ng/mL)   2.87  ±  2.10   3.70  ±  3.50   <0.001t  

PaLents  basal  characterisLcs    

    Fresh  (n=325)   Def-­‐ET  (n=325)   P  value  

SLmulaLon  protocol           <0.001  k        -­‐  Long  protocol     65  (20.00)   22  (6.77)            -­‐  GnRH  antagonist     196  (60.31)   273  (84.00)            -­‐  Short  protocol   64  (19.69)   30  (9.23)      Total  dose  of  injected  gonadotropin  (IU)  

2710.39  ±  1056.30   2466.00  ±  857.02   <0.001t  

DuraLon  of  sLmulaLon  (days)   9.56  ±  1.35   10.47  ±  1.53   <0.001t  

Peak  estradiol  levels  (pg/ml)  a   1627.26  ±  655.90   1881.05  ±  1052.84   <0.001t  

Peak  progesterone  levels  (ng/ml)  a     0.75  ±  0.35   0.91  ±  0.84   <0.001t  

Number  of  oocytes  retrieved     6.84  ±  3.42   7.90  ±  4.52   <0.001t  

Number  of  mature  oocytes  retrieved    

5.43  ±  2.60   6.20  ±  3.55   <0.001t  

Number  of  2PN  embryos     3.41  ±  1.58   3.56  ±  1.72   NS  

FerLlizaLon  rate   68.08±25.40   66.00±27.24   NS  

ART-­‐characterisLcs  

    Fresh  (n=325)   Def-­‐ET  (n=325)   P  value  Survival  rate       NA   92.9%   NA  Mean  number  of  embryos  transfer   1.77  ±  0.44   1.72  ±  0.47   NS  Total  number  of  embryos  transferred    

574   555    NS  

Quality  of  transferred  embryos  *  

Grade  1    

Grade  2  

Grade  3  

   

141(24.56)  

135(23.52)  

298(51.92)  

   

122(21.98)  

111(20.00)  

322(58.02)  

NS  

   

   

   ≥  1  embryo  grade  1*  transferred   114(35.08)   104(32.00)   NS  

Embryo  characterisLcs    

*  embryos  were  morphologically  assessed  according  to  Consensus  scoring  system  for  cleavage-­‐stage  embryos  (Alpha  ScienMsts  in  ReproducMve  Medicine  and  ESHRE  Special  Interest  Group  of  Embryology,  2011)    

    Fresh  (n=325)   Def-­‐ET  (n=325)   P  value  

ImplantaLon  rate   0.20  ±  0.33   0.17  ±  0.31   NS  Clinical  pregnancy  rate     98/325  (30.15)   85/325  (26.15)   NS  Miscarriage   27/98  (27.55)   25/85  (25.51)   NS  MulLple  pregnancy     11/98  (11.22)   9/85  (10.59)   NS  On  going  pregnancy  rate     71/325  (21.85)   60/325  (18.46)   NS  

ART-­‐outcomes  

30,15  

21,85  26,15  

18,46  

0  

10  

20  

30  

40  

50  

Clinical  PR   Ongoing  PR  

Fresh  ET     Def-­‐ET  

%  

%  %  

%  %  

NS  

NS  

Parameters     Odds  raLo   95%  CI   p  

PaLent’s  Age  at  IVF  (years)   0.92   0.88-­‐0.97   0.001  

BMI  (kg/m2)   0.94   0.89-­‐0.99   0.030  

Number  of  2PN  embryos   1.19   1.04-­‐1.40   0.010  

≥  1  embryo  grade  1*  transferred    

1.97   1.26-­‐3.05   0.003  

Independent  predictors  for  ongoing  pregnancy    mulLple  logisLc  regression  analysis    

Age  Number  of  previous  IVF  cycles  BMI  AMH  levels  total  dose  of  injected  gonadotropin    type  of  protocol  number  of  2PN  transfer  of  at  least  one  embryo  grade  1  

PotenMal  confounding  factors  for  ongoing  pregnancy    found  to  be  staMsMcally  significant  at  the  threshold  of  p  ≤  0.10  in  univariate  analysis  were  tested  in  a  mulMple  logisMc  regression  model.    

 •  ART  outcomes  were  not  improved  by  a  deferred  day-­‐2  ET  as  compared  to  

a  fresh  day-­‐2  ET    •  This  provided  us  an  overall  view  of  the  impact  of  day-­‐2  deferred  ET  on  

ART  outcomes  regardless  of  the  indicaLons  for  the  deferred  transfers.  

•  Further  invesMgaMons  may  be  required  to  determine  for  which  specific  subgroups  the  “freeze  -­‐  all  strategy”  may  be  most  efficient  for  ensuring  increased-­‐pregnancy  rates    

 •  Randomized  controlled  studies  seems  necessary  to  confirm  theses  results  

Conclusion    

Gynecology Surgical unit: C Chapron, B Borghese, P Santulli,

H Foulot, MC Lafay-Pillet, A Bourret, G Pierre, M Even, MC Lamau, L Marcellin, P Marzouk, Medical unit: A Gompel, G Plu-Bureau, L Maitrot

Reproductive Endocrinology unit: D de Ziegler, P Santulli, V Gayet, C Maignien, FX Aubriot

Intestinal surgery B Dousset, S Gaujoux, M Leconte

Radiology AE Millischer, L Maitrot

Laboratory: Genetic D Vaiman, F Mondon, S Barbaux

Laboratory: Imunulogy

F Batteux, S Chouzenoux C Nicco, C Chéreau, B Weill

Laboratory: Reproductive biology

JP Wolf, V Lange, K Pocate, JM Kuntzman, C Chalas

Statistical unit

F Goffinet, PY Ancel, C Prunet

D. de Ziegler, Professor and Head, Reproductive Endocrinology and Infertility unit, A. Gompel, Professor and Head, Medical Gynecological unit,

C. Chapron, Professor and Chair, Gynecology Obstetrics II and Reproductive Medicine