Midwest Fertility Specialists

Abstract Study question How does the embryo morphological grade and day of vitrification affect FET outcomes from in vitro fertilization cycles utilizing preimplantation genetic testing for aneuploidy (PGT-A)? Summary answer The morphological grade of a transferred embryo affects FET outcomes in age groups differently, and Day-5 embryos have significantly better pregnancy outcomes than Day-6 embryos. What is known already The use of PGT-A has shown to increase implantation rates, lower miscarriage rates and promote counseling for a single embryo transfer. Although euploid embryos are the priority for transfer, it is important to examine embryo characteristics that may influence these outcomes within these euploid embryos to maximize the outcome for each FET. Study design, size, duration In this retrospective study, 1,554 FETs transferring one euploid Day-5 or Day-6 embryo between January 2020 and October 2022 were evaluated, with the exclusion of donor oocyte, donor embryo, gestational carrier and Day-7 embryo transfer cycles. The inner cell mass and trophectoderm were each categorized as good (G), fair (F) or poor (P) respectively at the time of embryo cryopreservation. A total of 282 GG, 1,053 FG, and 209 FF embryos were transferred. Participants/materials, setting, methods Embryo grade categories were used to compare Day-5 versus Day-6 transfer outcomes and by age groups. Separating groups as < 34, 34-37, and ≥38 eliminated age as a significant factor. Primary outcomes included rates of positive chemical pregnancy (CP), biochemical loss (BL), clinical uterine gestation (CIG), and fetal cardiac activity (FCA). Independent t-tests compared age, and aggregate data was analyzed by proportional z-tests. A p-value <0.05 was defined as statistically significant with a 95% confidence interval. Main results and the role of chance Age and BL were not significant between transfer days or age groups. Day-5 had higher CP (GG: 84% vs 65%, p < 0.001; FG: 75% vs 59%, p = 0.006; FF: 63% vs 44%, p = 0.019), CIG (GG: 73% vs 57%, p = 0.006; FG: 64% vs 48%, p < 0.001; FF: 55% vs 34%, p = 0.007), and FCA (GG: 66% vs 52%, p = 0.022, FG: 60% vs 40%, p < 0.001, FF: 55% vs 30%, p < 0.001). For patients <34, GG had higher CP compared to FG and FF (74% vs 64%, p = 0.017; 74% vs 46%, p < 0.001), CIG (66% vs 55%s, p = 0.011; 66% vs 38%, p < 0.001) and FCA (61% vs 50%, p = 0.012; 61% vs 38%, p = 0.001). FG had higher CP (64% vs 46%, p = 0.007) and CIG (55% vs 38%, p = 0.008) compared to FF. For patients 34-37, GG and FG had higher CP (78% vs 53, p < 0.001; 70% vs 53%, p = 0.004), CIG (66% vs 42%, p = 0.002; 56% vs 42%, p = 0.029), and FCA (58% vs 35%, p = 0.002; 50% vs 35%, p = 0.011) compared to FF. When compared to FF in patients ≥38, GG and FG had increased CP (79% vs 47%, p < 0.001; 64% vs 47%, p = 0.012) and CIG (65% vs 36%, p = 0.004; 53% vs 36%, p = 0.010). Only GG had higher FCA (56% vs 36%, p = 0.049). Limitations, reasons for caution Even with the exclusion criteria, the retrospective nature of the study may be viewed as a limitation, so the significance of the results should be evaluated further. Wider implications of the findings Based on these results, this study demonstrates the need to compare the characteristics of euploid embryos before selection to maximize the chance of pregnancy. Embryos vitrified on Day-5 or categorized as GG, especially in patients <34, or FG should be prioritized over Day-6 or FF embryos. Trial registration number not applicable

This chapter includes clinical cases, background, evidence-based practical management options, preventive measures, key-point summaries of suspected ectopic pregnancy after IVF and answers to questions patients ask. The first IVF pregnancy, reported in 1976, was in fact an ectopic, and ever since then there have been numerous reports of both ectopic and heterotopic pregnancies occurring after IVF. With the use of modern technology, it is now increasingly possible to diagnose ectopic pregnancy (EP) prior to rupture. In pregnancies after assisted reproduction techniques, EP is reported to occur with a rate of 2–11%, although this has been declining in recent years. The mainstay of management is early diagnosis and treatment before rupture of the EP. This is particularly relevant and possible in pregnancies following IVF, where early follow- up is the rule. Methotrexate, a folic acid antagonist, remains the mainstay for medical treatment of EP.

Mouse Embryonic Stem Cells (mESCs) are unique in their self-renewal and pluripotency. Hypothetically, mESCs model gestational stress effects or stresses of in vitro fertilization/assisted reproductive technologies or drug/environmental exposures that endanger embryos. Testing mESCs stress responses should diminish and expedite in vivo embryo screening. Transgenic mESCs for green fluorescent protein (GFP) reporters of differentiation use the promoter for platelet-derived growth factor receptor (Pdgfr)a driving GFP expression to monitor hyperosmotic stress-forced mESC proliferation decrease (stunting), and differentiation increase that further stunts mESC population growth. In differentiating mESCs Pdgfra marks the first-lineage extraembryonic primitive endoderm (ExEndo). Hyperosmotic stress forces mESC differentiation gain (Pdgfra-GFP) in monolayer or three-dimensional embryoid bodies. Despite culture with potency-maintaining leukemia inhibitory factor (LIF), stress forces ExEndo as assayed using microplate readers and validated by coexpression of Pdgfra-GFP, Disabled 2 (Dab2), and laminin by immunofluorescence and GFP protein and Dab2 by immunoblot. In agreement with previous reports, Rex1 and Oct4 loss was inversely proportional to increased Pdgfra-GFP mESC after treatment with high hyperosmotic sorbitol despite LIF. The increase in subpopulations of Pdgfra-GFP+ cells>background at ∼23% was similar to the previously reported ∼25% increase in Rex1-red fluorescent protein (RFP)-negative subpopulation at matched high sorbitol doses. By microplate reader, there is a ∼7-11-fold increase in GFP at a high nonmorbid and a morbid dose despite LIF, compared with LIF alone. By flow cytometry (FACS), the subpopulation of Pdgfra-GFP+ cells>background increases ∼8-16-fold at these doses. Taken together, the microplate, FACS, immunoblot, and immunofluorescence data suggest that retinoic acid or hyperosmotic stress forces dose-dependent differentiation whether LIF is present or not and this is negatively correlated with and possibly compensates for stress-forced diminished ESC population expansion and potency loss.

Delayed nonspecific posterior neck pain after pharyngeal instrumentation can be associated with a syndrome of rapidly progressive neurologic embarrassment. We present this cohort to help define the syndrome and aid in early detection. We conducted a retrospective case series of 6 patients presenting from 2003 to 2012 with a history of laryngeal or hypopharyngeal squamous cell carcinoma (SCC) who underwent radiotherapy (RT) or chemoradiotherapy (CRT) followed by salvage laryngectomy. Posterior neck and upper back pain developed a mean of 27.5 days after instrumentation of the pharynx (reconstruction after laryngectomy or pharyngeal dilation). Myelopathy developed an average of 21.5 days after the onset of posterior neck pain. Five patients required urgent decompression. Three patients developed quadriplegia. The disease-specific mortality was 50%. There is a syndrome of late neurological effects after RT, salvage surgery, and pharyngeal instrumentation that is associated with high morbidity and mortality. © 2016 Wiley Periodicals, Inc. Head Neck 38:1187-1193, 2016.