review the evidence (RCT & meta-analyses) concerning the best practices in contemporary Recurrent Pregnancy Loss and Thrombophilia depending on Eshre guideline 2017 and other EBM sources.
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
review the evidence (RCT & meta-analyses) concerning the best practices in contemporary Recurrent Pregnancy Loss and Thrombophilia depending on Eshre guideline 2017 and other EBM sources.
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
Multiple births—the delivery of twins, triplets, or more—is common with fertility treatments. During the use of assisted reproductive technology (ART)—such as in vitro fertilization (IVF)—multiple births primarily result from transfer of more than one embryo during the procedure
Koh Takeuchi, Ryo Nishida, Hisashi Kashima, Masaki Onishi. "Grab the Reins of Crowds: Estimating the Effects of Crowd Movement Guidance Using Causal Inference", AAMAS, 2021.
のスライド
Multiple births—the delivery of twins, triplets, or more—is common with fertility treatments. During the use of assisted reproductive technology (ART)—such as in vitro fertilization (IVF)—multiple births primarily result from transfer of more than one embryo during the procedure
Koh Takeuchi, Ryo Nishida, Hisashi Kashima, Masaki Onishi. "Grab the Reins of Crowds: Estimating the Effects of Crowd Movement Guidance Using Causal Inference", AAMAS, 2021.
のスライド
60. 高雄榮總生殖醫學中心
Hyporesponse to Gonadotropin Stimulation
Follicle Output RaTe (FORT)
FORT (%) =
Trigger day 16-22mm
Baseline 3-8mm
Follicle-to-Oocte Index (FOI)
FOI (%) = Oocyte Number / Antral Follicle Count
• Discrepancy between AFC and the number of pre-ovulatory follicles
at the end of stimulation (e.g., FORT<50% ) or the number of
retrieved oocytes (e.g., FOI <50% ) is suggestive of hyporesponse
to gonadotropin stimulation.
Hum Reprod. 2012 Apr;27(4):1066-72.
Front Endocrinol (Lausanne). 2018 Oct 17;9:589.
Front Endocrinol (Lausanne). 2019 Feb 28;10:99.
69. 高雄榮總生殖醫學中心
Fertil Steril. 2021 Jan;115(1):45-53.
A retrospective cohort study
4,429 women (35.4 y) with PGT-A (qPCR or NGS)
3 consecutive single euploid FET
Live birth
ETx3: 92.6%
Cumulative
live birth
1st ET: 64.8%
2nd ET: 54.4%
3rd ET: 54.1%
70. Transfer fully aneuploid embryos
is not recommended
Aneuploid
transfers
Implanted Miscarried To term
Baby
karyotype
Rubino et al., 2016* 13 1 0 1 1 Normal
Munne et al., 2017* 10 1 0 1 1 Abnormal
Tiegs et al., 2020** 102 24 24 0 0
Gleicher 2020*** 17 8 8 0 0
TOTAL 132 34 (26%) 32 (94%) 2 (1.5%) 1 Normal
*Only monosomies, **non-selection study, *** Any trisomy but 12, 18, 21 PPV: 99.2% (1/132)
aeuploidy囊胚期胚胎品質活產率極低
高雄榮總生殖醫學中心
71. 高雄榮總生殖醫學中心
J Assist Reprod Genet. 2021 Aug;38(8):1939-1957.
6 RCTs (n=1,334)
PGT-A with CCS
Live birth per transfer
<35 y/o PGT-A = Ctrl
>35 y/o PGT-A > Ctrl
72. 高雄榮總生殖醫學中心
外強乾……
implantation failures (IFs), biochemical pregnancy losses (BPLs), and early (EMs) and late miscarriages (LMs)
A retrospective cohort study (n=792)
PGT-A after multiple pregnancy failures
J Assist Reprod Genet. 2020 Mar;37(3):579-588.
aneuploidy rate
RIF or RPL
73. 高雄榮總生殖醫學中心
外強乾……
A multi-centre prospective study
PGT-A with aCGH, single FBT
92 RIF and 79 RPL
RIF
Live birth
per transfer
PGT-A > Non PGT-A
(62.5% vs. 31.7%) Hum Reprod.
2020 Jan 1;35(1):255.
74. 高雄榮總生殖醫學中心
外強乾…… Hum Reprod.
2020 Jan 1;35(1):255.
A multi-centre prospective study
PGT-A with aCGH, single FBT
92 RIF and 79 RPL
RPL (embryonic aneuploidy)
Live birth
per transfer
PGT-A > Non PGT-A
(52.4% vs. 21.6%)
RPL
75. 高雄榮總生殖醫學中心
外強乾……
A retrospective cohort study
RPL patients
660 euploid FET cycles
Blastocyst grade Live birth
F S Rep. 2020 Sep;1(2):113-118.
染色體正常的囊胚
期胚胎品質越差
活產率越低
85. • 回溯性研究，single euploid FBT cycles，和No KS5級胚胎
相較，合併KS5懷孕率顯著較高。
A retrospective study
184 single euploid FBT
KIDscoreTM D5 algorithm (KS5)
JBRA Assist Reprod. 2020 Jan 30;24(1):55-60.
高雄榮總生殖醫學中心
86. 高雄榮總生殖醫學中心
JBRA Assist Reprod. 2020 Jan 30;24(1):55-60.
A retrospective study
134 single euploid FBT PGT-A + KS5 (n=48) vs. PGT-A only (n=86)
Pregnancy
PGT-A + KS5 > PGT-A only
(66.7% vs. 48.8%)
Embryoscope® time-lapse incubator with KIDscoreTM D5 algorithm (KS5)
87. 高雄榮總生殖醫學中心
外強乾……
A retrospective cohort study
PGT-A using NGS
KIDScore D5 was evaluated after single euploid FBT cycles (n=107)
Pregnancy
Grade A = Grade B > Grade C
(68.3%/62.5% vs. 10.0%)
96. 高雄榮總生殖醫學中心
自動化、大數據及人工智慧
Automation, Big Data and Artificial Intelligence
• Decision making will be precise, faster and more efficient.
Intuitive medicine
Based on Symptoms
(基於症狀的直覺醫學)
Based Evidence medicine
Based on patterns
(基於模式的循證醫學)
Precision medicine & Embryology
Based on algorithms
(基於算法的精密醫學與胚胎學)
101. 高雄榮總生殖醫學中心
PGT-ai2.0: reduces false mosaic results
CNV+SNPs: Provides a second assessment of aneuploidy
by investigating.
allelic contributions: quantitative (CNV) + quatitative (SNPs)
Paired-end sequencing: Alows for reading a
DNA fragment from both ends, increasing the amount
and quality of data and improving sequence alignment.
Artificial intelligence: trained on >1000 ongoing
preignancies, 10,000 embryos.
PGT-ai2.0: NGS + SNP + AI
ESHRE 2021 www.eshre.eu
102. 高雄榮總生殖醫學中心
Significant OPR improvement with PGT-ai2.0
PGT-ai2.0 > NGS
PGT-ai2.0 < NGS
Live birth
Miscarriage
Significant decrease in
biochemical loss
Significant increase in
OP/LBR
* p < 0.05 * p < 0.05
ESHRE 2021 www.eshre.eu
103. 高雄榮總生殖醫學中心
胚胎游離DNA → 染色體套數檢查
Embryonic cell-free DNA→ Preimplantation Genetic Testing for Aneuploidy
Ni-PGT-A
(非侵入性植入前染色體檢測)
Just like NiPT
(非侵入性胎兒染色體檢測)
↓
Non-invasive
Spent blastocyst medium (SBM)
NiPGT-A
