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How to optimize
success rates in ART?
Dr Sharda Jain
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GOOD , BETTER ,BEST
NEVER LET IT REST …
UNTIL YOUR GOOD IS BETTER
AND
YOUR BETTER IS BEST
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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
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कार्य में आनंद
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Evolution of
In-vitro Fertilization (IVF)
Factors influencing IVF success
Dr Sharda Jain Dr. Jyoti Agarwal
PART - 1
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*Evolution of
In-vitro Fertilization (IVF)
*Factors influencing IVF success
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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..
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•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.
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Factors influencing IVF success
• 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
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Factors influencing IVF success
• Age
• Ovarian reserve
• Sperm quality
• Embryo quality
• Implantation
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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
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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.
Proprietary and confidential — do not distribute
Factors influencing IVF success
• Age
• Ovarian reserve
• Sperm quality
• Embryo quality
• Implantation
Proprietary and confidential — do not distribute
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:
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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
Proprietary and confidential — do not distribute
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.
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Factors influencing IVF success
• Age
• Ovarian reserve
• Sperm quality
• Embryo quality
• Implantation
Proprietary and confidential — do not distribute
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.
Proprietary and confidential — do not distribute
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
Proprietary and confidential — do not distribute
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
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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.
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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
Proprietary and confidential — do not distribute
Factors influencing IVF success
• Age
• Ovarian reserve
• Sperm quality
• Embryo quality
• Implantation
Proprietary and confidential — do not distribute
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.
Proprietary and confidential — do not distribute
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,
Proprietary and confidential — do not distribute
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
Proprietary and confidential — do not distribute
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.
Proprietary and confidential — do not distribute
Factors influencing IVF success
• Age
• Ovarian reserve
• Sperm quality
• Embryo quality
• Implantation
Proprietary and confidential — do not distribute
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.
Proprietary and confidential — do not distribute
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).
Proprietary and confidential — do not distribute
• 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
Proprietary and confidential — do not distribute
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

  • 1. Proprietary and confidential — do not distribute How to optimize success rates in ART? Dr Sharda Jain
  • 2. Proprietary and confidential — do not distribute GOOD , BETTER ,BEST NEVER LET IT REST … UNTIL YOUR GOOD IS BETTER AND YOUR BETTER IS BEST
  • 3. Proprietary and confidential — do not distribute 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
  • 4. Proprietary and confidential — do not distribute कार्य में आनंद
  • 5. Proprietary and confidential — do not distribute Evolution of In-vitro Fertilization (IVF) Factors influencing IVF success Dr Sharda Jain Dr. Jyoti Agarwal PART - 1
  • 6. Proprietary and confidential — do not distribute *Evolution of In-vitro Fertilization (IVF) *Factors influencing IVF success
  • 7. Proprietary and confidential — do not distribute 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..
  • 8. Proprietary and confidential — do not distribute •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.
  • 9. Proprietary and confidential — do not distribute Factors influencing IVF success • 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
  • 10. Proprietary and confidential — do not distribute Factors influencing IVF success • Age • Ovarian reserve • Sperm quality • Embryo quality • Implantation
  • 11. Proprietary and confidential — do not distribute 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
  • 12. Proprietary and confidential — do not distribute 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.
  • 13. Proprietary and confidential — do not distribute Factors influencing IVF success • Age • Ovarian reserve • Sperm quality • Embryo quality • Implantation
  • 14. Proprietary and confidential — do not distribute 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:
  • 15. Proprietary and confidential — do not distribute 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
  • 16. Proprietary and confidential — do not distribute 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.
  • 17. Proprietary and confidential — do not distribute Factors influencing IVF success • Age • Ovarian reserve • Sperm quality • Embryo quality • Implantation
  • 18. Proprietary and confidential — do not distribute 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.
  • 19. Proprietary and confidential — do not distribute 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
  • 20. Proprietary and confidential — do not distribute 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
  • 21. Proprietary and confidential — do not distribute 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.
  • 22. Proprietary and confidential — do not distribute 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
  • 23. Proprietary and confidential — do not distribute Factors influencing IVF success • Age • Ovarian reserve • Sperm quality • Embryo quality • Implantation
  • 24. Proprietary and confidential — do not distribute 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.
  • 25. Proprietary and confidential — do not distribute 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,
  • 26. Proprietary and confidential — do not distribute 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
  • 27. Proprietary and confidential — do not distribute 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.
  • 28. Proprietary and confidential — do not distribute Factors influencing IVF success • Age • Ovarian reserve • Sperm quality • Embryo quality • Implantation
  • 29. Proprietary and confidential — do not distribute 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.
  • 30. Proprietary and confidential — do not distribute 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).
  • 31. Proprietary and confidential — do not distribute • 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
  • 32. Proprietary and confidential — do not distribute 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
  • 33. Proprietary and confidential — do not distribute 23-Mar-24 Enter title via "insert>header and footer>footer" | | 33

Editor's Notes

  1. The primary reason for diminished ovarian reserve is age. Aging has inverse correlation with ovarian reserve and fertility.1–3 References 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. Kaur M, Arora M. Diminished Ovarian Reserve, Causes, Assessment and Management. Int J Infertil Fetal Med. 2013; 4. 45–55. Data on file (1). Last accessed on 18 January 2021.
  2. Poor ovarian response (POR) is identified by a reduction in follicular response to maximal ovarian stimulation during the in vitro fertilization (IVF) procedure, resulting in a reduced number of retrieved oocytes. Using the Bologna criteria, the European Society of Human Reproduction and Embryology (ESHRE) consensus defines ‘poor response’ to ovarian stimulation as the presence of at least two of the following three features: 1. Advanced maternal age >40 yrs. or any other risk factors for POR. 2. Previous POR (≤3 oocytes with conventional stimulation of >149 international unit follicle-stimulating hormone daily). 3. An abnormal ovarian reserve test (antral follicle count <5–7 or anti-Mullerian hormone <0.5–1.1 ng/mL). Reference Rasool S, Shah D. Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel's back. Fertil Res Pract. 2017;3:15.
  3. The main causes of diminished ovarian reserve are populated in this slide.1,2 Advanced reproductive age (older than 40 years),3 family history of early menopause, conditions that can cause ovarian injury (e.g. endometriosis and pelvic infection), lifestyle and environmental factors, genetic abnormalities (e.g. Turner syndrome and Fragile X syndrome), previous ovarian surgery (e.g. for endometriomas).1,2exposure to chemotherapy especially gonadotoxic therapy, exposure to radiotherapy especially pelvic irradiation, history of mumps oophoritis, autoimmune disorders (e.g. Addison’s disease), smoking, and galactosemia.1,2 The other chief causes of poor ovarian responsiveness are a prior poor ovarian responsiveness incident, a reduced ovarian reserve test parameter or indices ( e.g. Anti-Mullerian hormone.), and antral follicle count.3 References Committee opinion no. 618: Ovarian reserve testing. Obstet Gynecol. 2015 Jan;125(1):268–273.  Kaur M, Arora M. Diminished Ovarian Reserve, Causes, Assessment and Management. Int J Infertil Fetal Med. 2013: 4. 45–55. Hagras A, Hagras MM, Elzayat M. Different Etiological Aspects of Diminished Ovarian Reserve Impact on Clinical Outcomes of ICSI Cycles. J Gynecol Women’s Health. 2019: 16(5): 555947.
  4. The various available ovarian reserve tests have been shown on the screen. Reference Kaur M, Arora M. Diminished Ovarian Reserve, Causes, Assessment and Management. Int J Infertil Fetal Med. 2013: 4. 45–55.
  5. Let us first understand the embryo factors for optimal in vitro fertilization treatment. Compared to fresh embryo transfer (ET), pregnancies resulting from frozen embryo transfer (FET) are associated with lower birth weight, preterm delivery, small for gestational age babies, and placenta previa, and placental abruption.1,2 In women with polycystic ovary syndrome (PCOS), FET resulted in a higher frequency of live birth compared to fresh transfer (49.3% vs. 42.0%).3 In patients undergoing pre-implantation genetic testing for aneuploidies (PGT-A), ongoing pregnancy rate (80% vs. 61%) and live birth rate (77% vs. 59%) were significantly higher in the frozen group.4 High responders had a higher clinical pregnancy rate and live birth rate in the FET cycles compared with the fresh ET cycles (61.5% vs. 57.4%; 52.0% vs. 48.9%).5 References Maheshwari A, Pandey S, Amalraj Raja E, et al. Is frozen embryo transfer better for mothers and babies? Can cumulative meta-analysis provide a definitive answer?. Hum Reprod Update. 2018;24(1):35–58. Sha T, Yin X, Cheng W, et al. Pregnancy-related complications and perinatal outcomes resulting from transfer of cryopreserved versus fresh embryos in vitro fertilization: a meta-analysis. Fertil Steril. 2018;109(2):330–342. Chen ZJ, Shi Y, Sun Y, et al. Fresh versus Frozen Embryos for Infertility in the Polycystic Ovary Syndrome. N Engl J Med. 2016;375(6):523–533. Coates A, Kung A, Mounts E, et al. Optimal euploid embryo transfer strategy, fresh versus frozen, after preimplantation genetic screening with next generation sequencing: a randomized controlled trial. Fertil Steril. 2017;107(3):723–730. Acharya KS, Acharya CR, Bishop K, et al. Freezing of all embryos in in vitro fertilization is beneficial in high responders, but not intermediate and low responders: an analysis of 82,935 cycles from the Society for Assisted Reproductive Technology registry. Fertil Steril. 2018;110(5):880–887.
  6. Successful implantation depends on embryo quality, endometrial receptivity, and the microenvironment for embryo-maternal signaling. Reference Evans J, Hannan NJ, Edgell TA, et al. Fresh versus frozen embryo transfer: backing clinical decisions with scientific and clinical evidence. Hum Reprod Update. 2014;20(6):808–821.
  7. This retrospective, observational study with 105 women with regular menstrual cycles undergoing first natural cycle-in vitro fertilization (NC-IVF) cycle were analyzed. Clinical pregnancy (not hatched) and live birth rates (hatched) were measured as a function of endometrial thickness. The 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). A tendency to lower pregnancy rates was observed in women with thin endometrium (around <8 mm) as well as with particularly thick endometrium (around >11 mm). The study suggested that thin endometrium should also be considered as an independent negative prognostic factor for achieving pregnancy in women. Reference Von Wolff M, Fäh M, Roumet M, et al. Thin Endometrium Is Also Associated With Lower Clinical Pregnancy Rate in Unstimulated Menstrual Cycles: A Study Based on Natural Cycle IVF. Front Endocrinol (Lausanne). 2018;9:776.