How to optimize success rates in ART? : Dr Sharda Jain

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How to optimize
success rates in ART?
Dr Sharda Jain

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HOW TO IMPROVE SUCCESS RATES IN ART?
THE BIG DEBATE कार्य में आनंद
• Evolution of In-vitro Fertilization (IVF)
• Factors Influencing IVF Success Ist Part
• Strategies for Improving Success Rates in ART Second Part
• Innovations & Breakthroughs in IVF Part Three
• OPEN DEBATE

कार्य में आनंद

Evolution of
In-vitro Fertilization (IVF)
Factors influencing IVF success
Dr Sharda Jain Dr. Jyoti Agarwal
PART - 1

*Evolution of
In-vitro Fertilization (IVF)
*Factors influencing IVF success

Lesley Brown
and John, from
Bristol, UK had
failed to
conceive
naturally after 9
years of
marriage
In 1976, she was
referred to Dr.
Patrick
Christopher
Steptoe, a
gynecologist in
the Oldham
hospital,
Manchester, UK
Mr. Robert
Geoffrey
Edwards, a
British
physiologist,
used John’s
sperm to
fertilize the
retrieved oocyte
in his lab
Upon his advice,
Lesley
underwent a
laparoscopic
oocyte retrieval
during a natural
non- stimulated
ovulatory cycle
An 8-cell stage
embryo was
placed inside
Lesley’s uterine
cavity.
On July 25th
1978, Lesley
delivered a
healthy 5
pounds and 12
ounces baby
named Louise.
was an inspiring event.
First “Test-tube” baby
Kamel RM. Assisted reproductive technology after the birth of louise brown. J Reprod Infertil. 2013 Jul;14(3):96-109..

•1983 – First birth from IVF using cryopreserved embryos
•1984 – Introduction of the GIFT procedure
•1987 – Transvaginal US guided oocyte retrieval
•1990 – Introduction of PGD for sex-linked disease
• 1991 – First birth from IVF with ICSI
1993 – First birth from IVF using testicular sperm extraction
1997 – First birth from cryopreserved oocytes
Evolution of In-Vitro fertilization since 1978
Major milestones in ART
Wang, J.G., & Sauer, M.V. (2006). In vitro fertilization (IVF): a review of 3 decades of clinical innovation and technological
advancement. Therapeutics and Clinical Risk Management, 2, 355 - 364.

• Age
• Ovarian reserve
• Sperm quality
• Embryo quality
• Implantation
IVF Success
1. Amini P, Factors Associated with In Vitro Fertilization Live Birth Outcome: A Comparison of Different Classification Methods. Int
J Fertil Steril. 2021 Apr;15(2):128-134. 2. https://www.asianinfertility.com/blog/factors-affecting-ivf-success-rate

• Age
• Ovarian reserve
• Sperm quality
• Embryo quality
• Implantation

Age correlates inversely with ovarian reserve and fertility1–3
Optimal
fertility
60
50
40
20
10
0
102
103
104
Number
of
follicles 105
106
107
30
Age (years)
Declining
fertility
End of
fertility
Menopause
Irregular
cycles
Chronological Age vs Biological Age
1.Practice Committee of the American Society for Reproductive Medicine. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril.
2012;98(6):1407–15. 2.. Kaur M, et al. Int J Infertil Fetal Med. 2013; 4. 45–55. 3. Data on file (1). Last accessed on 18 January 2021.
Female Age & Fertility

How female age affects IVF success rate?
With increasing age, fertility in women declines1,2
1. Tan TY. Female ageing and reproductive outcome in assisted reproduction cycles. Singapore Med J. 2014 Jun;55(6):305-9. 2.
Francis, Int J Gynecol Obstet. 2023;161:283–288
The reason postulated which leads to poor IVF success rate with age –
• poor ovarian reserve,
• poor oocyte quality,
• lower embryo implantation rates,
• altered hormonal environment resulting in ovulatory dysfunction, and
• uterine problems.
There is a higher propensity for acquired conditions such as-
• endometriosis,
• fibroids and
• pelvic infections in older women.
Lifestyle factors such as –
• Obesity and
• Lower frequency of intercourse, are also potential risk factors.

Ovarian Reserve
AFC: Antral follicle count; AMH: Anti-Mullerian hormone; ESHRE: European Society of Human Reproduction and Embryology; FSH: Follicle-stimulating hormone;
IU: International unit; IVF: In vitro fertilization; ng/mL: Nanogram per milliliter; POR: Poor ovarian response.
Rasool S, et al. Fertil Res Pract. 2017;3:15.
Advanced maternal age
> 40 years or any other
risk factors for poor
ovarian response
Previous POR (≤3 oocytes with
conventional stimulation
of >149 IU FSH daily)
An abnormal ovarian
reserve test (AFC <5–7, or
AMH <0.5–1.1 ng/mL)
Poor ovarian response is identified by a reduction in follicular response to maximal stimulation
during the IVF procedure.
The European Society of Human Reproduction and Embryology (ESHRE) consensus defines poor ovarian response
(POR) to ovarian stimulation as, “when at least two of the following three characteristics are present:

Possible Causes of Diminished Ovarian Response
1. Committee opinion no. 618: Ovarian reserve testing. Obstet Gynecol. 2015 Jan;125(1):268–27
2. 3. 2. Kaur M, et al. Int J Infertil Fetal Med. 2013: 4. 45–55. 3. Hagras A, et al. J Gynecol Women’s Health. 2019: 16(5):
AMH: Anti-Mullerian hormone.
Advanced
reproductive
age
(>40 years) 3
family history
of early
menopause
Conditions that
can cause
ovarian injury
Lifestyle and
Environmental
factors
Genetic
abnormalities
Exposure to
chemotherapy,
radiotherapy
Autoimmune
disorders
Smoking and
Galactosemia
Mumps
oophoritis
Other causes: A prior poor ovarian responsiveness incident, a reduced ovarian reserve test
parameter (e.g. AMH), and antral follicle count.3

Ovarian Reserve Tests: Clinical Assessment
What should be done if
ORT results are positive?
• Age
• Menstrual
cycle
characteristics
• AFC
• Ovarian volume
• Ovarian blood flow
• Basal FSH
• Basal E2
• AMH
• Inhibin B
• CCCT
• EFFORT
• GAST
AFC: Antral follicle count; AMH: Anti-Mullerian hormone; CCCT: Clomiphene citrate challenge test; E2: Estradiol; EFFORT: Exogenous FSH ovarian response test; FSH: Follicle-stimulating hormone; GAST: Gonadotropin agonist stimulation test.
Kaur M, et al. Int J Infertil Fetal Med. 2013: 4. 45–55.

Quality of sperm
Male gametes contribute to 50% of the embryo genome 1
Sperm Motility Sperm Morphology
Sperm Count
1. Chapuis, A., Gala, A., Ferrières-Hoa, A. et al. Sperm quality and paternal age: effect on blastocyst formation and pregnancy rates. Basic Clin. Androl. 27 2. WHO.WHO
Laboratory Manual for the Examination and Processing ofHumanSemen.5thed.WorldHealthOrganization;2010.

WHO reference values for semen characteristics
Parameter Values
Semen volume 1.5 mL (1.4-1.7)
Sperm concentration Spermatozoa - 15×106/mL
Total sperm number per ejaculate (106/ejaculate) Spermatozoa- 39×10
Progressive motility (% ) 32 (31-34) of sperm moving forward
Total motility (% ) 40 (38-42) of all sperm moving
Vitality (% ) 58 (55-63) of spermatozoa live
Sperm morphology (% ) 4 (3-4) of forms normal
Peroxidase positive leukocytes <1.0×106/mL
Semen pH ≥7.2
Cooper TG et al . World Health Organization reference values for human semen characteristics. Hum Reprod Update
2010;16:231-45.19934213
WHO reference values for semen characteristics

A recent study, concluded that infertile patients with a normal sperm morphology rate
< 4% are more likely to have a poor normal fertilization status in IVF. Sperm
morphology analysis is one of the most common tests used for providing informative
evaluation of male fertility.
The ideal sperm morphology criteria is as followed:
1) There’s a well-defined acrosomal region comprising 40% to 70% of the head area.
The acrosomal region contained no large vacuoles.
2) The midpart of the sperm was slender, regular, and approximately the same length
as the sperm head.
3) The principal part of the sperm is a uniform caliber along its length, & is thinner
than the midpart, and is approximately 45 mm long.
Zhu DL, Zhang HG, Wang RX, Jiang YT, Liu RZ. Re-evaluation of the value of sperm morphology in classical in vitro fertilization in a
Northeastern Chinese population. J Int Med Res. 2019 Sep;47(9):4134-4142
Sperm morphology

At least 10 x 10(6) spermatozoa/ml, of which at least 30% are motile and 15% have
progressive motility, are required for IVF or insemination therapy, despite the fact that
pregnancies can be achieved with lower parameters. As a minimum, 20% of spermatozoa
should be of normal morphology 1.
Sperm motility
Spermiogram quality Below average Average Above average
Total sperm count (sperm density in
millions)
<33 33-46 >46
Sperm concentration (millions/ml) <12 12-16 >16
Sperm motility (A+B in %) <38 38-42 >42
1. Michelmann HW. Minimal criteria of sperm quality for insemination and IVF therapy. Int J Androl. 1995 Dec;18 Suppl 2:81-7. PMID:
8719866. 2. Classifcation of the spermiogram - WHO criteria
Classifcation of the spermiogram - WHO criteria2.

Oligospermia, is a major cause of male infertility. Sperm count is considered
low if it dips below 15 million sperm per milliliter (mL) of semen, main
causes can be categorized in to medical, environmental, and lifestyle.
Low sperm count if caused by— a hormone imbalance, chromosomal abnormality,
testicular issue, or blockage — person may experience symptoms like:
• low sex drive
• erectile dysfunction
• swelling or pain in or around the testicles
Low sperm count
Medically reviewed by Kevin O. Hwang, MD, MPH — By Ashley Marcin on February 27, 2020

Previous studies have reported good
embryo quality was strongly associated
with increasing implantation rate, clinical
pregnancy rate, and live birth rate.
A study done by Oron et al. found that clinical
pregnancy and live birth rates per transfer
were nearly 2-fold higher with the transfer
of a single good quality embryo than with the
transfer of a poor-quality embryo.
The Gardner embryo grading system
quantifies three characteristics of embryo
morphology: expansion; trophectoderm
quality; and inner cell mass (ICM) quality.
Expansion status is described on a
numerical scale from 1 to 6. Qualities of
the trophectoderm and ICM are described
using letter grades A-B-C.
Embryo Quality
1. Dobson SJA, Effect of Transfer of a Poor Quality Embryo Along With a Top Quality Embryo on the Outcome During Fresh and Frozen In
Vitro Fertilization Cycles. Fertil Steril (2018) 110(4):655–60. 2. Pierson, Hannah E et al. “A novel system for rapid conversion of Gardner
embryo grades to linear scale numeric variables.” Reproductive biomedicine online vol. 46,5 (2023): 808-818.
For example, an embryo with a grade of 4AA is fully expanded
with good-quality and well-organized ICM and T cells.

Day 5 vs Day 6
Cochrane 2022 - Significant difference in live birth rates from fresh cycles in favour of blastocyst stage
transfer compared to cleavage-stage transfer cycles (low-quality evidence)
Papanikolaou 2008 - Systematic review, which reported that cycles where equal numbers of embryos were
transferred had higher live birth rates in blastocyst-stage transfers than in cleavage-stage
transfers.
Wang 2014 - Shows similar results with respect to live birth rates, but reported lower miscarriage rates
in the blastocyst group,
Further new studies of blastocyst cycles must report live birth, cumulative live birth rates (especially when vitrification is used),
and miscarriage rates to enable consumers and service providers to make well-informed decisions
Embryo factors: Stage of Embryo Transfer
Cleavage vs Blastocyst stage
Rao 2021 - No significant differences in the biochemical pregnancy rate, clinical pregnancy or ongoing
pregnancy rate between the day 3 cleavage stage embryo and day 5 single blastocyst transfer
(SBT) groups,
Significantly higher pregnancy rates compared with those in the day 6 SBT group
1. Rao, Jinpeng et al. The Journal of international medical research vol. 49,12 (2021)
2. Glujovsky, Demián et al.” The Cochrane database of systematic reviews vol. 5,5 CD002118. 19 May. 2022,

1. Maheshwari A, et al. Hum Reprod Update. 2018;24(1):35–58. 2. Sha T, et al. Fertil Steril. 2018;109(2):330–342. 3. Cheng ZJ, et al. N Engl J Med.
2016;375(6):523–533. 4. Coates A, et al. Fertil Steril. 2017;107(3):723–730. 5. Acharya KS, et al. Fertil Steril. 2018;110(5):880–887.
CPR: Clinical pregnancy rate; ET: Embryo transfer; FET: Frozen embryo transfer; IVF: In vitro fertilization; LBR: Live birth rate; PCOS: Polycystic ovary
syndrome; PGT-A :Pre-implantation genetic testing for aneuploidies; PR: Pregnancy rate.
Embryo factors: Fresh vs. frozen embryo transfer
Compared to fresh ET, pregnancies resulting from
FET are associated with:
Lower risk of:1,2
FET vs.
fresh cycle
Low birth weight
Preterm delivery
Small for
gestational age
Placenta previa,
placental abruption
FET in specific IVF populations:
Women with PCOS:
FET resulted in a higher frequency of live birth compared to
fresh transfer (49.3% vs. 42.0%)3
Patients Undergoing PGT-A:
Ongoing PR (80% vs. 61%) and LBR (77% vs. 59%) were significantly
higher in the frozen group4
High Responders
High responders had a higher CPR and LBR in the FET cycles
compared with the fresh ET cycles (61.5% vs. 57.4%; 52.0% vs.
48.9%)5
In recent years, IVF segmentation, i.e. the ‘freeze-all’ strategy, has been proposed to increase cycle outcomes by
• avoiding the transfer of embryos in the same ovarian stimulation cycle
• reducing the risk of ovarian hyperstimulation
• improving endometrial receptivity

Does double embryo transfer increase success rate?
A study done by Wintner et al in
2017, has been shown that double
embryo transfers [DET] are
associated with higher clinical
pregnancy and live birth rates,
compared to single embryo
transfers.
Roberts et al. reported that SETs
have a one-third lower live birth rate
then DETs in fresh cycles
Wintner, E.M., Hershko-Klement, A., Tzadikevitch, K. et al. Does the transfer of a poor quality embryo together with a good quality embryo affect the In Vitro
Fertilization (IVF) outcome?. J Ovarian Res 10, 2 (2017)
Double embryo transfers should be limited to patients with repeated implantation
failure or repeated pregnancy loss. Yet, when two embryos are transferred, women can
be reassured that the quality of the second embryo does not seem to affect the pregnancy
rate or the risk of twin pregnancy.

Evans J, et al. Hum Reprod Update. 2014;20(6):808–821.
BV: Blood vessels; M: Macrophages; NK: Natural killer.
Implantation—A critical step for reproduction
• Endometrial receptivity
• Embryo quality
• Microenvironment for embryo-maternal
signaling
Successful implantation depends on
Adaptation of uterus:
To enable implantation, the uterus goes
through changes in order to be able to receive
the embryo.
Preparation of Endometrium:
The endometrium increases thickness,
becomes more vascularized and its glands
grow to be tortuous and boosted in their
secretions. These changes reach their
maximum about 7 days after ovulation.

Von Wolff M, et al. Front Endocrinol (Lausanne). 2018;9:776.
NC-IVF: Natural cycle-in vitro fertilization.
Endometrial thickness
Clinical pregnancy (not hatched) and live birth
(hatched) rates as a function of endometrial
thickness
Retrospective, observational study with 105
women with regular menstrual cycles undergoing
first NC-IVF cycle were analyzed
Pregnancy rate in women with endometrial
thickness ≤7 mm was 7.4% and 30.8% in women
with endometrial thickness >7 mm (p=0.03).

• The limited period of optimal endometrial receptivity in which the endometrium is
ready to receive an embryo, paired with an embryo's readiness to the implant, is
commonly referred to as the "window of implantation (WOI)" and is generally
detected between days 20 and 24 of a normal 28-day menstrual cycle 1.
• Many molecular pathways involve hormones, adhesion molecules, cytokines, and
growth factors acting in concert to create a synchronous window of implantation.
• Progesterone prepares the endometrium, both morphologically and
functionally, for implantation by bring secretory transformation of the
endometrium.
• Few adhesions widely used are – Albumin (present in female reproductive tract),
Hyaluronan (HA) supplementation, (glycosaminoglycan) and EmbryoGlue is a human E 2.
Uterine Receptivity
1. Miranda F, Endometrial receptivity, National Center for Biotechnology Information, June 23, 2007. 2. Singh N, Gupta M, Kriplani A, Vanamail P. Role
of Embryo Glue as a transfer medium in the outcome of fresh non-donor in-vitro fertilization cycles. J Hum Reprod Sci. 2015 Oct-Dec;8(4):214-7

Summary
• IVF Success rates have improved significantly over past decades.
• IVF is a multifactorial procedure that is reliant on proper timing & accuracy.
• Age, ovarian reserve, sperm quality, embryo quality, endometrial receptivity, timing of embryo transfer
influence the success rates of IVF cycles.
• The Implantation window is the time when the endometrium is functionally competent to receive the
embryo. Any displacement in the Window of Implantation can be determined by Endometrial receptivity Array
(ERA).
• Progesterone prepares the endometrium for implantation by bring secretory transformation of the
endometrium.
• Newer practices such as tailored ovarian stimulation protocols, mild stimulation, elective single embryo
transfer, frozen embryo transfer, blastocyst culture have increased the pregnancy rates.
https://www.youtube.com/@DGFInfertility-IVF

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How to optimize success rates in ART? : Dr Sharda Jain

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