Presentation on D3 versus D5 Embryo Transfer.pptx

The day 3 embryo versus day 5 embryo transfer is a debate that has always persisted and here we attempt to present relevant data to assist in making a decision #day3embryo #day5embryo #ivf #icsi #embryotransfer #bestembryo #ivfsuccess #pgt #pgd #preimplantationgenetictesting #embryo #day3versusday5embryo

1. D3 VERSUS D5 EMBRYO TRANSFER Dr. Shivani Sachdev Gour M.D. DNB, M.R.C.O.G. (UK) SCI Healthcare Pvt. Ltd. New Delhi Noida Gurugram

2. INTRODUCTION ET is a critical step in an assisted reproduction cycle. Over the past decade there has been an increasing trend to extending culture from cleavage-stage to blastocyst transfer Direct comparisons between the two stages of embryo development appear to support the use of blastocyst transfers in clinical practice.

3. CAUSES OF SHIFT FROM DAY 3 TO DAY 5 The advent of sequential culture media, better lab culture media and lab conditions. Successful sustained embryo culture Physiological synchronization- better embryo– endometrium synchrony, and therefore higher chances of implantation as it mimics more closely the sequence of events in natural conception Intrinsic embryo selection-Allows identification of embryos that have managed to activate their embryonic genome Improved live birth rates Strategy of PGT chromosome screening after day 5 biopsy improves implantation and pregnancy rates E ncourage single embryo transfer.

4. OPPOSING DEBATE- FAVOURING D3 Synchrony similar- supraphysiological levels of oestrogen and progesterone, which enhances the endometrial development, i.e. the endometrial milieu at day 3 after egg collection (in a stimulated environment) could be similar to the endometrial milieu on day 5 (after ovulation) in a natural cycle owing to the effect of ovarian stimulation. Selection of best embryo not stage based- Studies have shown that chromosomally abnormal embryos can become blastocysts Minimizing embryo wastage- in-vitro culture could lead to the possibility of more pregnancies and therefore higher cumulative live birth rate even in those with good prognosis. Higher incidence of cycle cancellation and lower rates of embryo cryopreservation PGT - PGT tested embryos also fail to implant

5. CLEAVAGE VS BLAST-HOW DO WE DECIDE? Best embryo selection with maximum implantation and LBR High cumulative PR, no cycle cancellation Maximum feto maternal safety Minimum cost and minimum time to pregnancy

6. EVIDENCE- COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022 Women who undergo fresh blastocyst transfers achieve higher clinical pregnancy rate (moderate q evidence) and live-birth rates (low q evidence) compared with those who receive fresh cleavage-stage transfers. If 31% of women achieve live births after fresh cleavage-stage transfer, 32–42% will do so after fresh blastocyst transfer Results were not conclusive when the transfers of frozen embryos were considered Cleavage‐stage versus blastocyst‐stage embryo transfer in assisted reproductive technology 2022. Demián Glujovsky

7. EMBRYO FREEZING RATES AND FAILURE TO TRANSFER ANY EMBRYOS( A reduced embryo freezing rate (14 RCTs; 2,292 women) and an increased failure to transfer any embryos (17 RCTs; 2,459 women) day 2 to 3: 3.6% day 5 to 6: 8.5% were observed with blastocyst-stage transfers

8. CUMULATIVE PR RATE No difference was found in the cumulative pregnancy rates between cleavage-stage and blastocyst transfer day 2 to 3: 48.9% day 5 to 6: 52.0% Cumulative rates are affected not only by the success rates of fresh transfers (which have improved for blastocyst transfers in the last few years) but also by the technique of embryo freezing (vitrification versus slow freezing). Single blast transfer compared to multiple cleavage transfer reduce wastage

9. 2023 ANNUAL MEETING eshre-tof (3 or 5 Study) A multicentre RCT, A total of 1202 women from 21 Dutch centers were randomly assigned to blastocyst-stage transfers (N ¼ 599) or cleavage stage transfers (N ¼ 603) between 2018 and 2021. The results revealed no difference in Cumulative LBR(CLBR) for the day-5 group and day-3 group (58.9% vs 58.4%), but a different picture emerged when CLBR was analysed by age group. Cornelisse said there was a clear effect in favour of day-5 embryos among women aged 36 and over (52.1% vs 43.1%) which became even more marked from the age of 37 onwards. The CLBR for women aged 36 years and under was 62.6% for day-3 and 67.1% for day-5. Conclusion: live births just as likely from cleavage stage embryos as from blastocysts, but older women do better with day-5 transfers

10. Transferring cleavage-stage embryos and freezing the remainder for later transfer obviously provides couples more opportunities to transfer and more ETs, but this does not necessarily result in improved cumulative pregnancy rates The additional transfers may result in increased burden for patients by increasing cost and time to pregnancy

11. All the studies and meta analysis focused mainly on IVF success outcome in terms of Live birth and Clinical pregnancy rates Decision Focus has shifted from live birth as the sole measure of treatment success to outcomes which reflect feto – maternal safety , especially when evidence is emerging that birth outcomes can be predictive of diseases in later life Early studies suggested adverse perinatal outcome with blastocyst transfer compared to cleavage embryo. Studies in this regard presented with conflicting data

12. Increased multiple pregnancies increased incidence of biochemical pregnancies, miscarriages Higher risk of preterm <37 weeks and very preterm <32 weeks delivery Increased risk of placenta previa increased chance of monozygotic twins large for gestation offspring the odds of congenital anomalies significantly higher altered sex ratio with a male–female ratio of 1.29 D5 D3

13. Suggested Reasons for adverse perinatal outcomes after extended culture Extended culture may trigger genetic and epigenetic changes in trophodermal cells that can lead to abnormal placentation and implantation, and hence increased risk of preterm delivery. ( Rizos et al., 2002). Alteration in zona pellucida induced by extended culture increases monozyg twining Male embryos develop faster(animal studies) , and embryologists tend to select preferentially more developmentally advanced blastocysts for transfer

14. DRAWBACK OF THESE STUDIES Studies compiled older data Blastocyst culture is relatively new technique Has only been applied in human IVF routinely from the years after the millennium. During the initial years of the study, it was still at the starting period of application worldwide, with inappropriate media, gas composition and embryo-handling issues All clinics have their own variations Potential inconsistencies were caused by diverse and changing blastocyst culture techniques Older blastocyst culture methods do not achieve the same clinical outcomes as observed in more recent studies. Better survival rates and better pregnancy outcome All these issues may play a considerable effect on the long-term consequences of blastocyst culture

15. Result: Of 127,632 singleton live births, 54,688 occurred after blastocyst transfer while 72,944 resulted from cleavage-stage transfer Outcomes following blastocyst and cleavage-stage transfer were comparable in terms of low birth weight (7.2% vs. 7.5%) very low birth weight (1.7% vs. 1.8%) high birth weight (6.4% vs. 7.3%) very high birth weight (1.2% vs. 1.4%) very preterm birth (1.7% vs. 1.7%) and congenital anomalies (0.6% vs. 2.5%) The chance to deliver a healthy singleton was similar across both groups MORE RECENT STUDY

16. Current very-low certainty of evidence shows that there may be little-to-no difference in the risk for congenital anomaly or adverse perinatal outcome of pregnancy following blastocyst- vs cleavage-stage embryo transfer, although there was a slightly increased probability of a male neonate following blastocyst transfer.

17. When to Transfer if There ARE ONLY FEW EMBRYOS? Conflicting DATA Some authors maintain that as in vitro survival of embryos does not relate to in vivo survival, transferring embryos at the blastocyst stage could lead to a loss of viable embryos as a result of them not surviving the prolonged culture (Maheshwari et al., 2016). Xiao et al. (2019) confirmed this hypothesis in women with only one embryo available on D3, in whom pregnancy rates were higher when the embryo was transferred on D3 than on D5/6 Three retrospective studies have demonstrated that extended culture of embryos does not alter implantation potential when fewer than three embryos are available

18. In a retrospective study ,A total of 1116 women whose embryo transfers were planned were included. Cleavage-stage (D3) and blastocyst-stage (D5) transfer outcomes were analyzed per number of zygotes.  Result:Blastocyst transfers were found non inferior to cleavage-stage embryo transfers among patients with few zygotes(<5) and were preferable for patients with several zygotes. Analysis for clinical pregnancy did not show significant differences between the blastocyst and cleavage-stage transfers in patients with ≤ 5 zygotes Enver Kerem Dirican Arch Gynecol Obstetric 2022 Mar

19. What is the optimal timing of embryo transfer when there are only one or two embryos at cleavage stage? Jigal Haas . ? Gynecol Endocrinol 2019 A retrospective study of 102 patients with one or two cleavage stage embryos that had their embryos transferred on day 3 and 429 patients had their embryos cultured to day 5 for transfer. The number of mature oocytes (4.0 vs 4.6) and number of cleavage stage embryos on day 3 was similar in the two groups (1.3 vs. 1.5). The clinical pregnancy rate per retrieval (22% vs. 24.6%) and the ongoing pregnancy rate per retrieval (20% vs. 20.2%) was comparable between the groups . Fifty seven (13.2%) of the patients had cleavage embryo arrest and did not have an embryo to transfer on day 5. Conclusion : that the cumulative pregnancy rate is the same for patients with 1–2 cleavage stage embryos regardless of whether the embryo is transferred on day 3 or day 5.

20. In this study in poor prognosis patients (four or fewer zygotes) shows a similar Cumulative LBR per Oocyte collection cycle, and LBR per fresh transfer, regardless of the day of fresh transfer, when combined with blastocyst vitrification on Day 5

21. PRECISE TRIAL ONGOING- comparing blastocyst to cleavage stage embryo transfer in poorer prognosis patients with ≤5 zygotes on day 1 Multicenter , non-inferiority, randomized controlled The hypothesis of the PRECiSE ( PooR Embryo Yield Cleavage Stage Versus blaStocyst Embryo Transfer ) trial is that blastocyst ET is not inferior to cleavage stage ET with regard to live birth rates per retrieval in poorer prognosis patients. The adoption of routine blastocyst culture for all patients would result in higher rates of single embryo transfers (SET), reduced incidence of multiple pregnancies and simplified laboratory protocols, thereby reducing costs. The estimated completion date is 28 February 2024

22. As Per the UK National Institute of Health guidelines (NICE Guidelines), cleavage transfers are recommended to avoid transfer cancellations when few embryos are available. The American Society for Reproductive Medicine also recommends avoiding transfer cancellations. Cleavage-stage transfer is a good option for younger patients who are at risk of having no blastocyst-stage embryos to transfer based on poor embryo progression or failure to make it to the blastocyst stage in a previous cycle. Not having any embryos to transfer after culture to the blastocyst stage can be devastating. Cleavage-stage transfer may help patients feel that they have tried everything they can to conceive. Some patients may want to try a transfer with autologous oocytes before moving on to using donor oocytes To date, it remains unclear whether these patients benefit from cleavage transfer

23. In good-prognosis patients , blastocyst transfer results in increased live-birth rates compared with transfer of equal numbers of cleavage-stage embryos. Given the high implantation rate with blastocysts , eSET should be routinely utilized to minimize multiple gestation. Extended culture yields fewer surplus embryos for cryopreservation compared with cleavage-stage cryopreservation. Reliable criteria to identify embryos destined to develop to viable blastocysts in vitro remain to be established. Although the data are conflicting, blastocyst culture and transfer may be associated with a small increased risk of monozygotic twinning and sex imbalance when compared with cleavage stage transfer. Embryologists must be sure to have appropriate equipment, protocols, and personnel to routinely offer blastocyst transfer.

24. DEBATE IS STILL ON-CAN WE HAVE BEST OF BOTH We should do our best to improve and standardise our blastocyst culture system by eliminating systematically factors that cause complications Investment should be made on evaluating new technology such as time lapse, AI to select the best embryo on day 3 to give maximum number of pregnancies per treatment and reducing perinatal risks and reducing number of embryo transferred. More follow-up studies on long-term health of children born by embryo transfer at both cleavage and blastocyst stages are needed throughout the world to determine the final recommendations for clinical practice

25. CONCLUSIONS Evidence supports blastocyst transfer in good-prognosis patients. Elective single-embryo transfer should be routinely utilized to minimize the high risk of multiples in good-prognosis patients. Future studies are needed about selection of embryos destined to blastulate to avoid no-transfer scenarios. Till that time a flexible and individualized approach can be undertaken concerning embryo transfer in poor prognosis patients Individual lab performance rates should also be taken into account Recent Data suggest relative safety of blastocyst culture on obstetric and perinatal risks

26. Thank You.…