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Abstract In vitro fertilization is typically associated with high failure rates per transfer, leading to an acute need for the identification of embryos with high developmental potential. Current methods are tailored to specific times after fertilization, often require expert inspection, and have low predictive power. Automatic methods are challenged by ambiguous labels, clinical heterogeneity, and the inability to utilize multiple developmental points. In this work, we propose a novel method that trains a classifier conditioned on the time since fertilization. This classifier is then integrated over time and its output is used to assign soft labels to pairs of samples. The classifier obtained by training on these soft labels presents a significant improvement in accuracy, even as early as 30 h post-fertilization. By integrating the classification scores, the predictive power is further improved. Our results are superior to previously reported methods, including the commercial KIDScore-D3 system, and a group of eight senior professionals, in classifying multiple groups of favorable embryos into groups defined as less favorable based on implantation outcomes, expert decisions based on developmental trajectories, and/or genetic tests.

BACKGROUND The condensed state of the human sperms chromatin is essential for the compact structure of the spermatozoon head, which is important for the fertilization process. The enzymes DNA topoisomerases (topo I and topo II) are responsible for the topological structure of the chromatin in somatic cells. The activities and the characterization of topoisomerases in mature human sperm cells have not been previously investigated. METHODS Sperm cells were purified from the semen of healthy donors by standard procedures and assays measuring the activities, protein size and sensitivity to inhibitors of topoisomerases were performed. RESULTS Topo I and topo II DNA relaxation activities are present in nuclear extracts derived from human sperm. The sperm topo I activity is inhibited by camptothecin, similarly to the somatic enzyme. An 85 kDa sperm protein, compared with the 100 kDa somatic topo IB enzyme, reacted with anti-human topo I antibody. Sperm topo II lacks the DNA decatenation activity of the somatic enzyme and a 97 kDa protein, compared with the 170 kDa somatic topo IIα enzyme, was detected with anti-human topo II antibody. Sperm nuclear extracts contained inhibitors of somatic topo II decatenation activity. CONCLUSIONS Topoisomerase I and II activities as well as topo I and topo II proteins are present in mature human sperm cells. These enzymes possess unique properties compared with their somatic counterparts. [ABSTRACT FROM AUTHOR]

Background: Sperm quality has decreased over the last decades worldwide. It is affected, among others, by season and heat. This study aimed to address the association between ambient temperature and sperm quality by assessing its shape using flexible multivariate models and identifying distinct time-dynamic patterns of temperature change based on unsupervised analysis., Material and Methods: A retrospective population-based study has been conducted, including all samples of males attending the Fertility and In-Vitro-Fertilization unit at a single medical center during 2016-2022. Flexible generalized models were fitted to characterize the relations between sperm quality and temperature while accounting for patients characteristics, and to identify temperature levels that correspond with the optimal sperm quality. This information was then used to estimate adjusted slope coefficients at specified time-windows., Results: In total, 4555 sperm samples were provided by 3229 individuals. Sperm concentration, motility and progressive motility were higher by 8 %, 11 % and 16 %, respectively, during the spring versus the fall season. Furthermore, their quality during early spermatogenesis improved with temperature, until a certain optimum around 23 °C-24 °C. Increasing temperature at later developmental stages was associated with lower sperm concentration and higher motility. Sperm concentration and motility were highest following a period of moderate gradual warming. Motility was higher and sperm concentration was lower, following a period with heatwaves or summer., Conclusions: This study assessed temperature role in sperm production quality by considering both average and time-dynamic temperatures. It identified several temperature change patterns over time and stratified the analysis by them. The differences in the relations across stages of spermatogenesis were addressed. Several mechanisms may explain the associations found, including heat-induced apoptosis of the sperm cells, and destruction of sperm cells DNA integrity by over-production of reactive oxygen species. The gradual global warming necessitates exploration of individual response to outdoor temperature in relations to genetic predisposition, lifestyle, and other health characteristics., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

To investigate whether morphokinetic parameters differ between male and female embryos in IVF embryos resulting in live births, a retrospective cohort study was undertaken. Files of all live births resulting from a single embryo transfer (SET) cultured in time-lapse incubators between 2013 and 2019 in two tertiary care centres were reviewed. The study group consisted of 187 SETs resulted in 187 live births, of which 100 were females (53.5%) and 87 were males (46.5%). Embryo selection for transfer was based on the known implantation data (KID) score provided by the Embryoscope and morphological assessment by experienced embryologists. Neonatal sex was confirmed through live birth documentation. Morphokinetic parameters and day 3 and day 5 KID scores of male and female embryos were compared. Maternal baseline and treatment characteristics were similar between groups. Morphokinetic time-lapse parameters of male and female embryos including: pronuclei fading; cleavage timings (t2-t9); second and third cell cycle durations; synchrony of the second and third cleavages; late morphokinetic parameters and KID scores did not differ between groups. In conclusion, time-lapse morphokinetic parameters and embryo selection methods do not seem to differ between male and female embryos, and their utilization does not bias towards any neonatal sex.

Blastocyst selection is primarily based on morphological scoring systems and morphokinetic data. These methods involve subjective grading and time-consuming techniques. Artificial intelligence allows for objective and quick blastocyst selection. In this study, 608 blastocysts were selected for transfer using morphokinetics and Gardner criteria. Retrospectively, morphometric parameters of blastocyst size, inner cell mass (ICM) size, ICM-to-blastocyst size ratio, and ICM shape were automatically measured by a semantic segmentation neural network model. The model was trained on 1506 videos with 102 videos for validation with no overlap between the ICM and trophectoderm models. Univariable logistic analysis found blastocyst size and ICM-to-blastocyst size ratio to be significantly associated with implantation potential. Multivariable regression analysis, adjusted for woman age, found blastocyst size to be significantly associated with implantation potential. The odds of implantation increased by 1.74 for embryos with a blastocyst size greater than the mean (147 ± 19.1 μm). The performance of the algorithm was represented by an area under the curve of 0.70 (p < 0.01). In conclusion, this study supports the association of a large blastocyst size with higher implantation potential and suggests that automatically measured blastocyst morphometrics can be used as a precise, consistent, and time-saving tool for improving blastocyst selection., (© 2023. Springer Nature Limited.)

Purpose: Our objective was to design an automated deep learning model that extracts the morphokinetic events of embryos that were recorded by time-lapse incubators. Using automated annotation, we set out to characterize the temporal heterogeneity of preimplantation development across a large number of embryos., Methods: To perform a retrospective study, we used a dataset of video files of 67,707 embryos from four IVF clinics. A convolutional neural network (CNN) model was trained to assess the developmental states that appear in single frames from 20,253 manually-annotated embryos. Probability-weighted superposition of multiple predicted states was permitted, thus accounting for visual uncertainties. Superimposed embryo states were collapsed onto discrete series of morphokinetic events via monotonic regression of whole-embryo profiles. Unsupervised K-means clustering was applied to define subpopulations of embryos of distinctive morphokinetic profiles., Results: We perform automated assessment of single-frame embryo states with 97% accuracy and demonstrate whole-embryo morphokinetic annotation with R-square 0.994. High quality embryos that had been valid candidates for transfer were clustered into nine subpopulations, as characterized by distinctive developmental dynamics. Retrospective comparative analysis of transfer versus implantation rates reveals differences between embryo clusters as marked by poor synchronization of the third mitotic cell-cleavage cycle., Conclusions: By demonstrating fully automated, accurate, and standardized morphokinetic annotation of time-lapse embryo recordings from IVF clinics, we provide practical means to overcome current limitations that hinder the implementation of morphokinetic decision-support tools within clinical IVF settings due to inter-observer and intra-observer manual annotation variations and workload constrains. Furthermore, our work provides a platform to address embryo heterogeneity using dimensionality-reduced morphokinetic descriptions of preimplantation development., (© 2023. The Author(s).)

Purpose: First trimester miscarriage is a major concern in IVF-ET treatments, accounting for one out of nine clinical pregnancies and for up to one out of three recognized pregnancies. To develop a machine learning classifier for predicting the risk of cleavage-stage embryos to undergo first trimester miscarriage based on time-lapse images of preimplantation development., Methods: Retrospective study of a 4-year multi-center cohort of 391 women undergoing intra-cytoplasmatic sperm injection (ICSI) and fresh single or double embryo transfers. The study included embryos with positive indication of clinical implantation based on gestational sac visualization either with first trimester miscarriage or live-birth outcome. Miscarriage was determined based on negative fetal heartbeat indication during the first trimester. Data were recorded and obtained in hospital setting and research was performed in university setting., Results: A minimal subset of six non-redundant morphodynamic features were screened that maintained high prediction capacity. Features that account for the distribution of the nucleolus precursor bodies within the small pronucleus and pronuclei dynamics were highly predictive of miscarriage outcome as evaluated using the SHapley Additive exPlanations (SHAP) methodology. Using this feature subset, XGBoost and random forest models were trained following a 100-fold Monte-Carlo cross validation scheme. Miscarriage was predicted with AUC 0.68 to 0.69., Conclusion: We report the development of a decision-support tool for identifying the embryos with high risk of miscarriage. Prioritizing embryos for transfer based on their predicted risk of miscarriage in combination with their predicted implantation potential is expected to improve live-birth rates and shorten time-to-pregnancy., (© 2022. The Author(s).)

Purpose: To assess the impact of post-thawing embryo culture on frozen embryo transfer (FET) outcomes., Methods: A retrospective cohort study including 678 consecutive FET cycles performed between the years 2004 and 2017 was conducted. Patients older than 45 years old were excluded. FET cycles were stratified as follows: (1) two-day (2d) embryos thawed and cultured to three-day (3d) versus 3d embryos thawed and transferred; (2) 2d or 3d embryos thawed and cultured to blastocysts versus blastocysts thawed and transferred. A p -value <.05 was considered statistically significant., Results: Maternal age, BMI, smoking, and basal FSH of the 2d and 3d cultured embryo group ( n  = 110) and the 3d non-cultured embryo group ( n  = 189) were comparable. Endometrium preparation protocols and the achieved endometrial thickness did not differ between groups. Pregnancy rate, implantation rate, clinical pregnancy, live birth rate, abortions, multiple pregnancies, perinatal outcomes, and birth weight were comparable.The 2d and 3d embryos cultured to blastocyst ( n  = 41) compared to non-cultured blastocyst ( n  = 338) showed that the non-cultured blastocyst patients had higher smoking rates and longer follicular phase. Endometrial thickness was comparable. The 2d and 3d embryos cultured to blastocyst stage had higher multiple pregnancies rate compared to the blastocyst non-cultured group, whereas pregnancy rate, implantation rate, live birth rate, miscarriages, perinatal outcomes, and birth weight were comparable., Conclusion: We could not demonstrate that the post-thaw culture had a significant impact on the outcome of FET cycles.

Study Question: What are the factors associated with human blastocyst spontaneous collapse and the consequences of this event?, Summary Answer: Approximately 50% of blastocysts collapsed, especially when non-viable, morphologically poor and/or aneuploid., What Is Known Already: Time-lapse microscopy (TLM) is a powerful tool to observe preimplantation development dynamics. Lately, artificial intelligence (AI) has been harnessed to automate and standardize such observations. Here, we adopted AI to comprehensively portray blastocyst spontaneous collapse, namely the phenomenon of reduction in size of the embryo accompanied by efflux of blastocoel fluid and the detachment of the trophectoderm (TE) from the zona pellucida (ZP). Although the underlying causes are unknown, blastocyst spontaneous collapse deserves attention as a possible marker of reduced competence., Study Design, Size, Duration: An observational study was carried out, including 2348 TLM videos recorded during preimplantation genetic testing for aneuploidies (PGT-A, n = 720) cycles performed between January 2013 and December 2020. All embryos in the analysis at least reached the time of starting blastulation (tSB), 1943 of them reached full expansion, and were biopsied and then vitrified., Participants/materials, Setting, Methods: ICSI, blastocyst culture, TE biopsy without Day 3 ZP drilling, comprehensive chromosome testing and vitrification were performed. The AI software automatically registered tSB and time of expanding blastocyst (tEB), start and end time of each collapse, time between consecutive collapses, embryo proper area, percentage of shrinkage, embryo:ZP ratio at embryo collapse, time of biopsy (t-biopsy) and related area of the fully (re-)expanded blastocyst before biopsy, time between the last collapse and biopsy. Blastocyst morphological quality was defined according to both Gardner's criteria and an AI-generated implantation score. Euploidy rate per biopsied blastocyst and live birth rate (LBR) per euploid single embryo transfer (SET) were the main outcomes. All significant associations were confirmed through regression analyses. All couple, cycle and embryo main features were also investigated for possible associations with blastocyst spontaneous collapse., Main Results and the Role of Chance: At least one collapsing embryo (either viable or subsequently undergoing degeneration) was recorded in 559 cycles (77.6%) and in 498 cycles (69.2%) if considering only viable blastocysts. The prevalence of blastocyst spontaneous collapse after the tSB, but before the achievement of full expansion, was 50% (N = 1168/2348), irrespective of cycle and/or couple characteristics. Blastocyst degeneration was 13% among non-collapsing embryos, while it was 18%, 20%, 26% and 39% among embryos collapsing once, twice, three times or ≥4 times, respectively. The results showed that 47.3% (N = 918/1943) of the viable blastocysts experienced at least one spontaneous collapse (ranging from 1 up to 9). Although starting from similar tSB, the number of spontaneous collapses was associated with a delay in both tEB and time of biopsy. Of note, the worse the quality of a blastocyst, the more and the longer its spontaneous collapses. Blastocyst spontaneous collapse was significantly associated with lower euploidy rates (47% in non-collapsing and 38%, 32%, 31% and 20% in blastocysts collapsing once, twice, three times or ≥4 times, respectively; multivariate odds ratio 0.78, 95%CI 0.62-0.98, adjusted P = 0.03). The difference in the LBR after euploid vitrified-warmed SET was not significant (46% and 39% in non-collapsing and collapsing blastocysts, respectively)., Limitations, Reasons for Caution: An association between chromosomal mosaicism and blastocyst collapse cannot be reliably assessed on a single TE biopsy. Gestational and perinatal outcomes were not evaluated. Other culture strategies and media should be tested for their association with blastocyst spontaneous collapse. Future studies with a larger sample size are needed to investigate putative impacts on clinical outcomes after euploid transfers., Wider Implications of the Findings: These results demonstrate the synergistic power of TLM and AI to increase the throughput of embryo preimplantation development observation. They also highlight the transition from compaction to full blastocyst as a delicate morphogenetic process. Blastocyst spontaneous collapse is common and associates with inherently lower competence, but additional data are required to deepen our knowledge on its causes and consequences., Study Funding/competing Interest(s): There is no external funding to report. I.E., A.B.-M., I.H.-V. and B.K. are Fairtility employees. I.E. and B.K. also have stock or stock options of Fairtility., Trial Registration Number: N/A., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

A time-lapse monitoring system provides a complete picture of the dynamic embryonic development process and simultaneously supplies extensive morphokinetic data. The objective of this study was to investigate whether the use of the morphokinetic parameter of time of starting blastulation (tSB) can improve the implantation rate of day-5 transferred blastocyst selected based on morphological parameters. In this retrospective study we analyzed the morphokinetics of 196 day-5 transferred blastocysts, selected solely based on morphological parameters. The interval time from intracytoplasmic sperm injection (ICSI) to time of starting blastocyst formation (tSB) was calculated for each embryo. The overall implantation rate of transferred blastocyst, selected based only on morphological parameters, was 49.2%. Implantation rate, determined retrospectively, was significantly higher (58.8% versus 42.6%, P = 0.02) for embryos with a short interval time to tSB (78-95.9 h) compared with embryos with a longer timeframe (96-114 h). Time of expanded blastocyst (tEB) post-ICSI was also significantly associated with implantation; however, this parameter was not available for all the embryos at time of transfer. When we tested only high ranked KIDScore day-3 sub-group embryos, the implantation rate was significantly higher in short interval time embryos compared with longer interval time embryos (62.2% vs. 45.5%, respectively, P = 0.02).These observations emphasize the importance of the timing of starting blastulation over blastocyst morphological parameters and may provide a preferable criterion for good morphology day-5 blastocyst selection.

Study Question: What is the clinical value of Day 7 blastocysts?, Summary Answer: Ending embryo culture at 144 hours post-insemination (h.p.i.; i.e. 6 days) would involve 7.3% and 4.4% relative reductions in the number of patients obtaining euploid blastocysts and live birth(s) (LBs), respectively., What Is Known Already: Many studies showed that Day 7 blastocysts are clinically valuable, although less euploid and less competent than faster-growing embryos. Nevertheless, a large variability exists in: (i) the definition of 'Day 7'; (ii) the criteria to culture embryos to Day 7; (iii) the clinical setting; (iv) the local regulation; and/or (v) the culture strategies and incubators. Here, we aimed to iron out these differences and portray Day 7 blastocysts with the lowest possible risk of bias. To this end, we have also adopted an artificial intelligence (AI)-powered software to automatize developmental timings annotations and standardize embryo morphological assessment., Study Design, Size and Duration: Observational study including 1966 blastocysts obtained from 681 patients cultured in a time-lapse incubator between January 2013 and December 2020 at a private Italian IVF center., Participants/materials, Setting, Methods: According to Italian Law 40/2004, embryos were not selected based on their morphology and culture to ≥168 h.p.i. is standard care at our center. ICSI, continuous culture with Day 5 media refresh, trophectoderm biopsy without assisted hatching and comprehensive chromosome testing (CCT) to diagnose full-chromosome non-mosaic aneuploidies, were all performed. Blastocysts were clustered in six groups based on the time of biopsy in h.p.i. at 12 hr intervals starting from <120 h.p.i. (set as control) up to >168 h.p.i. Blastocyst quality was assessed using Gardner's scheme and confirmed with AI-powered software. AI was also used to automatically annotate the time of expanding blastocyst (tEB) and the hours elapsing between this moment and the achievement of full expansion when blastocysts were biopsied and vitrified. Also, blastocyst area at tEB and at the time of biopsy was automatically assessed, as well as the hour of the working day when the procedure was performed. The main outcomes were the euploidy rate and the LB rate (LBR) per vitrified-warmed euploid single blastocyst transfer. The results were adjusted for confounders through multivariate logistic regressions. To increase their generalizability, the main outcomes were reported also based on a 144-h.p.i. cutoff (i.e. 6 exact days from ICSI). Based on this cutoff, all the main patient outcomes (i.e. number of patients obtaining blastocysts, euploid blastocysts, LBs, with supernumerary blastocysts without a LB and with surplus blastocysts after an LB) were also reported versus the standard care (>168 h.p.i.). All hypothetical relative reductions were calculated., Main Results and the Role of Chance: A total of 14.6% of the blastocysts reached full expansion beyond 144 h.p.i. (5.9% in the range 144-156 h.p.i., 7.9% in the range 156-168 h.p.i. and 0.8% beyond 168 h.p.i.). Slower blastocysts were of a worse quality based on the evaluation of both embryologists and AI. Both later tEB and longer time between tEB and full blastocyst expansion concurred to Day 7 development, quite independently of blastocyst quality. Slower growing blastocysts were slightly larger than faster-growing ones at the time of biopsy, but no difference was reported in the risk of hatching, mainly because two dedicated slots have been set along the working day for these procedures. The lower euploidy rate among Day 7 blastocysts is due to their worse morphology and more advanced oocyte age, rather than to a slower development per se. Conversely, the lower LBR was significant even after adjusting for confounders, with a first relevant decrease for blastocysts biopsied in the range 132-144 h.p.i. (N = 76/208, 36.5% versus N = 114/215, 53.0% in the control, multivariate odds ratio 0.61, 95% CI 0.40-0.92, adjusted-P = 0.02), and a second step for blastocysts biopsied in the range 156-168 h.p.i. (N = 3/21, 14.3%, multivariate odds ratio: 0.24, 95% CI 0.07-0.88, adjusted-P = 0.03). Nevertheless, when the cutoff was set at 144 h.p.i., no significant difference was reported. In this patient population, ending embryo culture at 144 h.p.i. would have caused 10.6%, 7.3%, 4.4%, 13.7% and 5.2% relative reductions in the number of patients obtaining blastocysts, euploid blastocysts, LBs, supernumerary blastocysts without an LB and surplus blastocysts after an LB, respectively., Limitations, Reasons for Caution: Gestational and perinatal outcomes were not assessed, and a cost-effectiveness analysis is missing. Moreover, we encourage other groups to investigate this topic with different culture and biopsy protocols, as well as in different clinical settings and regulatory contexts., Wider Implications of the Findings: In view of the increasing personalization and patient-centeredness of IVF, whenever allowed from the local regulations, the choice to culture embryos to Day 7 should be grounded on the careful evaluation of couples' reproductive history. Patients should be aware that Day 7 blastocysts are less competent than faster-growing ones; still, poor prognosis couples, couples less compliant toward other attempts in case of a failure and couples wishing for more than one child, may benefit from them. AI tools can help improving the generalizability of the evidence worldwide., Study Funding/competing Interest(s): This study did not receive any funding. I.E., A.B.M. and I.H.-V. are employees of Fairtility Ltd., Trial Registration Number: N/A., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

In vitro fertilization is typically associated with high failure rates per transfer, leading to an acute need for the identification of embryos with high developmental potential. Current methods are tailored to specific times after fertilization, often require expert inspection, and have low predictive power. Automatic methods are challenged by ambiguous labels, clinical heterogeneity, and the inability to utilize multiple developmental points. In this work, we propose a novel method that trains a classifier conditioned on the time since fertilization. This classifier is then integrated over time and its output is used to assign soft labels to pairs of samples. The classifier obtained by training on these soft labels presents a significant improvement in accuracy, even as early as 30 h post-fertilization. By integrating the classification scores, the predictive power is further improved. Our results are superior to previously reported methods, including the commercial KIDScore-D3 system, and a group of eight senior professionals, in classifying multiple groups of favorable embryos into groups defined as less favorable based on implantation outcomes, expert decisions based on developmental trajectories, and/or genetic tests., (© 2022. The Author(s).)

Objective: To compare pregnancy outcomes between pregnancies following day 2, day 3, and days 5/6 fresh embryo transfer (ET)., Methods: A retrospective cohort study including all pregnancies following fresh IVF/intracytoplasmic sperm injection (ICSI) ET cycles performed between January 2014 and December 2015 at Fertility and In Vitro Fertilization (IVF) Unit of the tertiary Soroka University Medical Center. The study groups consisted of 48, 72, 120, and 144 hours embryos. Pregnancies were confirmed by a serum beta-human chorionic gonadotropin measurement. Data regarding patients' medical history, infertility workup, fertility treatment characteristics, and outcome, as well as obstetrical outcome, were collected from patients' medical records and IVF Laboratory database. Multiple regression models were constructed to control for confounders. Patients who underwent fertility preservation treatment, cycles of oocyte donation or in vitro maturation oocytes, and cases of preimplantation genetic testing were excluded., Results: A total of 534 pregnancies following fresh IVF/ICSI ET on day 2 ( n  = 189, 35.4%), day 3 ( n  = 200, 37.5%), and days 5 or 6 ( n  = 145, 27.2%) were included. Live birth rate demonstrated a linear association to the developmental stage at ET with the highest rates in blastocysts and gradually lower in day 3 and day 2 ET (79.2, 65.8, and 60.6%, respectively, p  = .001). A positive linear association was also observed between ET age and clinical pregnancy rate (77.3, 87.5, and 90.3% for days 2, 3, and 5/6, respectively, p  = .002), as well as with combined pregnancy complication rate (29, 37.3, and 43.3%, p  = .026). However, using multivariate logistic regression model controlling for ET age, maternal age, smoking, obesity, initial HCG level and peak E2 level, live birth rate was comparable between the study groups regardless of ET age. Pregnancy complications were comparable between the groups; however, a composite pregnancy complications variable was higher in the blastocyst pregnancies compared to cleavage embryos pregnancies., Conclusions: The common approach of blastocyst transfer, as high quality of the embryo, has not proven beneficial in terms of live birth rate. Moreover, cleavage stage embryos were not associated with adverse perinatal outcomes. The current data suggest maternal age has an independent effect on live birth.

Purpose: To assess the effect of high ovarian response on oocyte quality and ovarian stimulation cycle outcomes., Methods: A retrospective cohort study conducted at three IVF units. The high ovarian response (HOR) and polycystic ovary syndrome (PCOS) with HOR (PCOS HOR) groups included 151 and 13 women who underwent controlled ovarian stimulation (COS) resulting in more than 15 retrieved oocytes, for a total of 1863 and 116 cultured embryos, respectively. The normal ovarian response (NOR) group comprised 741 women with 6-15 retrieved oocytes, resulting in 4907 cultured embryos. Data collected included fresh cycle data and pregnancy rates, in addition to annotation of morphokinetic events from time of pronuclei fading to time of initiation of blastocyst formation of embryos cultured in a time lapse incubator, including occurrence of direct unequal cleavage at first cleavage (DUC-1) (less than 5 h from two to three blastomeres). Comparison was made between morphokinetic parameters between the 3 groups. Cycle outcomes were compared in the high vs. normal ovarian response groups., Results: Oocyte maturation rate was significantly lower in the HOR vs. NOR groups (56.5% vs. 90.0%, p < 0.001), while the fertilization rates were similar (60.2% vs. 58.1%, p = 0.397). The prevalence of DUC-1 embryos was higher in the PCOS HOR and the HOR groups as compared to the NOR group (22.7% vs. 16.2% and 12.0%, respectively, p < 0.001). After exclusion of DUC-1 embryos, remaining embryos from the NOR and HOR groups reached the morphokinetic milestones at similar rates, with comparable implantation and clinical pregnancy rates, while the PCOS HOR showed shorter time to 5 blastomeres compared to the NOR and HOR groups., Conclusions: High ovarian response might be associated with decreased oocyte quality, manifested as a higher proportion of immature oocytes and higher rate of direct uneven cleavage embryos, while embryos exhibiting normal first cleavage have similar temporal milestones and implantation potential., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Methylphenidate (MPH) is the most widely prescribed therapy for attention deficit hyperactivity disorder. Animal studies have shown a potential adverse effect of MPH exposure on male fertility. We examined the impact of MPH on human male sperm parameters., Design: Sperm parameters of 9769 samples from patients 18 years of age or older, collected as part of the basic evaluation of couples referred to the Infertility Clinic were analyzed retrospectively. We divided the study population into three groups according to MPH purchasing information: MPH purchased ≤ 90 days prior to sperm analysis-current users (n = 83), MPH purchased > 90 days prior to sperm analysis-past users (n = 293), and MPH-naïve patients (n = 9393)., Methods: All sperm samples were analyzed by the same laboratory technician team for the following routine parameters: semen volume, sperm concentration, percentage of motile sperm, and percentage of normal morphology according to World Health Organization. The analysis of the samples was completed by evaluation of total sperm count, total sperm motility, and percentage of fast and slow motile cells. Sperm morphology was evaluated by a laboratory technician using methodological examination according to the strict Kruger-Tygerberg criteria., Results: Methylphenidate exposure did not affect sperm morphology but was associated with increased sperm concentration as well as increased total sperm count and total sperm motility among current and past users compared with MPH-naïve patients. In particular, progressive motility and total motile sperm count were significantly increased following MPH use. A multivariate analysis adjusting for age and current smoking was conducted, further supporting a positive correlation between current MPH use and increased values of total sperm count and total sperm motility., Limitations: Our study has several inherent weaknesses, foremost of which is its retrospective nature. Another notable weakness is that medication purchasing data may not accurately reflect MPH exposure in the study population. Patients may be purchasing MPH and not taking it as prescribed., Conclusions: In the present study, we could not demonstrate a negative impact of methylphenidate treatment on sperm parameters in adults with ADHD. Hence, we may assume that methylphenidate does not negatively affect male fertility., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Objective: To study the association among fertility treatments, treatment protocol, and offspring neoplasm risk up to the age of 18 years., Design: A population-based retrospective cohort., Setting: Soroka University Medical Center (SUMC), the single tertiary medical center and in vitro fertilization (IVF) unit in southern Israel., Patient(s): All offspring born at the SUMC between the years 1995 and 2018 after IVF treatment (the exposed group) and offspring conceived spontaneously (the unexposed group)., Intervention(s): The study was performed at the SUMC, the single tertiary medical center and IVF unit in southern Israel. The exposed and unexposed were matched with a ratio of 1:4, based on maternal age and calendar month of delivery. Data collection included a summary of the couple's medical records, delivery data, and offspring neoplasm diagnoses., Main Outcome Measure(s): Offspring neoplasm of any kind and time to diagnosis in each of the groups., Result(s): A total of 1,583 exposed and 5,874 offspring were included in the study. The incidences of offspring benign neoplasm were 14 (0.9%) versus 21 (0.4%), and the incidences of malignancies were 17 (1.1%) versus 29 (0.5%) among offspring of the IVF and spontaneous groups, respectively. The association between mode of conception and offspring neoplasm risk remained significant after adjusting for confounders, including mode of delivery and pregnancy complications such as hypertensive disorder, gestational diabetes mellitus, and preterm delivery compared with spontaneously conceived offspring. Among the IVF group, the increased risk for neoplasm was found among offspring who were transferred as fresh embryos, at an earlier stage of development (cleavage stage), or after three or more aspirated oocytes., Conclusion(s): IVF treatment is associated with offspring neoplasm risk; specifically, the risk was greater among offspring who were returned as fresh embryos, at an earlier embryotic stage (cleavage stage), or after three or more aspirated oocytes., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess oocyte quality in young patients with decreased ovarian response to controlled ovarian stimulation using time-lapse analysis., Methods: A retrospective cohort study conducted at five medical centers between 2013 and 2017. The "decreased ovarian response" (DOR) group consisted of 241 women who underwent controlled ovarian stimulation with ≤ 5 retrieved oocytes and 519 cultured embryos. The "normal response" (NOR) group consisted of 667 women with ≥ 6 retrieved oocytes resulting in 3633 embryos. Data included annotation of morphokinetic events of embryos cultured in a time-lapse incubator from time of pronuclei appearance to time of starting blastocyst formation (tSB). Comparison was made between morphokinetic parameters of DOR and NOR patients with additional subgroup analysis according to the implantation status., Results: Implantation and clinical pregnancy rates were significantly higher in the NOR group compared with the DOR group (44.5% vs. 31.6% and 51.5% vs. 37.7%, respectively; p < 0.05). Embryos from the DOR group reached the morphokinetic milestones later than embryos obtained from NOR patients. In the DOR group, implanted embryos reached starting blastocyst formation (tSB) faster than embryos which failed to be implanted, however, manifested a protracted course compared with implanted embryos from the NOR group. In a multivariate analysis-decreased ovarian response, nulliparity, number of transferred embryos, and t4, and were predictive for implantation., Conclusions: The quantitative decrease in ovarian response is associated with reduced oocyte quality, reflected by a slower developmental rate and lower implantation and pregnancy rates.

Background: Mutation in S-phase cyclin A-associated protein rin the endoplasmic reticulum ( SCAPER ) have been found across ethnicities and have been shown to cause variable penetrance of an array of pathological traits, including intellectual disability, retinitis pigmentosa and ciliopathies., Methods: Human clinical phenotyping, surgical testicular sperm extraction and testicular tissue staining. Generation and analysis of short spindle 3 ( ssp3 ) ( SCAPER orthologue) Drosophila CAS9-knockout lines. In vitro microtubule (MT) binding assayed by total internal reflection fluorescence microscopy., Results: We show that patients homozygous for a SCAPER mutation lack SCAPER expression in spermatogonia (SPG) and are azoospermic due to early defects in spermatogenesis, leading to the complete absence of meiotic cells . Interestingly, Drosophil a null mutants for the ubiquitously expressed ssp3 gene are viable and female fertile but male sterile. We further show that male sterility in ssp3 null mutants is due to failure in both chromosome segregation and cytokinesis. In cells undergoing male meiosis, the MTs emanating from the centrosomes do not appear to interact properly with the chromosomes, which remain dispersed within dividing spermatocytes (SPCs). In addition, mutant SPCs are unable to assemble a normal central spindle and undergo cytokinesis. Consistent with these results, an in vitro assay demonstrated that both SCAPER and Ssp3 directly bind MTs., Conclusions: Our results show that SCAPER null mutations block the entry into meiosis of SPG, causing azoospermia. Null mutations in ssp3 specifically disrupt MT dynamics during male meiosis, leading to sterility. Moreover, both SCAPER and Ssp3 bind MTs in vitro. These results raise the intriguing possibility of a common feature between human and Drosophila meiosis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: It is unclear whether sperm origin, either ejaculated or testicular, in couples diagnosed with male factor infertility, affects the timing of the embryo's developmental events evaluated by time-lapse monitoring and implantation rates., Objective: To examine the effect of sperm origin on embryo morphokinetics in couples diagnosed with male factor infertility., Materials and Methods: This study included a retrospective analysis of morphokinetic parameters performed by time-lapse monitoring between 2013 and 2017. The developmental processes and morphokinetic parameters of 419 embryos obtained from couples with male factor infertility attributed to oligo-astheno-teratozoospermia, 158 embryos derived from surgically extracted testicular spermatozoa from couples diagnosed with non-obstructive azoospermia, and 190 embryos from couples with normal ejaculated spermatozoa and female mechanical factor-related infertility, were evaluated. A comparison of morphokinetic parameters, implantation, and clinical pregnancy rates was performed between the groups with additional analysis in accordance with implantation status., Results: Embryos from the normal ejaculated spermatozoa and oligo-astheno-teratozoospermia patients reached the later morphokinetic milestones-synchronous division (S3) and time to morula (tM)-faster than embryos obtained from testicular spermatozoa. Implantation rate was similar in the normal ejaculated spermatozoa and oligo-astheno-teratozoospermia groups (41.9% vs. 45.8%, NS), with higher implantation rate in the oligo-astheno-teratozoospermia group compared to the testicular spermatozoa group (45.8% vs. 33.6%, p = 0.02). Comparison of Known Implantation Data (KID) positive (KIDp) and KID negative (KIDn) embryos in each group revealed more rapid development in KIDp embryos in the normal ejaculated spermatozoa and the oligo-astheno-teratozoospermia groups, while in the testicular spermatozoa group implanted embryos reached the late morphokinetic milestones (time to 8 cell stage-t8, ECC3, S3, and tM) significantly faster than embryos that failed to implant. In a multivariate logistic regression analysis of the male factor infertility population, (oligo-astheno-teratospermia) (OR = 2.54, p = 0.003) and t8 (OR = 0.95, p = 0.027) were predictive of successful implantation. Male factor infertility embryos that reached the t8 milestone within 48-56 h had favorable implantation rates (p < 0.001)., Discussion: The study results may highlight another pathophysiology by means of which sperm origin affects embryo developmental kinetics. Selecting embryos demonstrating a faster developmental rate at t8 and specifically the 48- to 56 h interval following time of pronuclei fading (tPNf) may improve implantation rates in cases of male factor infertility., Conclusion: This study showed that ejaculated spermatozoa is associated with faster late cell divisions, more rapid compaction, and higher implantation rates compared to testicular spermatozoa. Additionally, t8 is an important predictor for implantation in the male factor infertility population., (© 2020 American Society of Andrology and European Academy of Andrology.)

Research Question: Are obstetric and perinatal complications associated with morphokinetic parameters of embryo development?, Design: This proof-of-concept pilot study included a retrospective analysis of embryo morphokinetic parameters of 85 live births following day 5 single blastocyst transfer. Kinetic variables included time interval (hours) from time of pronuclei fading (tPNf) to: time of 2 cells (tPNf-t2), 9 cells (tPNf-t9), morula (tPNf-tM), start of blastulation (tPNf-tSB), full blastocyst (tPNf-tB) and expanded blastocyst (tPNf-tEB). Multivariable logistic models were used to calculate the risk of perinatal complications after adjustment for confounders., Results: The mean interval of tPNf-tSB was significantly longer for newborns with congenital anomalies compared with healthy newborns (79.49 ± 5.78 versus 71.7 ± 6.3, respectively, P = 0.01) and for embryos of women who had gestational diabetes mellitus compared with normoglycemic women (76.56 ± 7.55 versus 71.5 ± 6.13, respectively, P = 0.015). The mean interval of tPNf-t9 was significantly longer for low-birthweight newborns compared with normal weight (49.25 ± 5.54 versus 45.47 ± 4.77, respectively, P = 0.01). Preterm delivery was associated with several longer intervals of cell divisions compared with delivery at term (tPNf-t5: 28.76 ± 3.13 versus 26.64 ± 2.40, respectively, P = 0.01; tPNf-t6: 30.10 ± 3.05 versus 27.68 ± 2.30, respectively, P < 0.001; tPNf-t7: 32.08 ± 4.11 versus 28.70 ± 2.67, respectively, P < 0.001; tPNf-t8: 34.75 ± 4.95 versus 30.70 ± 4.10, respectively, P < 0.001; tPNf-t9: 50.23 ± 5.87 versus 45.44 ± 4.67, respectively, P < 0.001). For each of the outcomes, the association remained significant after adjusting for confounders., Conclusion: This study indicates that there may be a possible association between adverse perinatal outcomes and morphokinetic parameters. Larger studies are needed to establish this association., (Copyright © 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

The present study investigated the association between oocyte zona pellucida shear modulus (ZPSM) and implantation rate (IR). Ninety-three oocytes collected from 38 in-vitro fertilization patients who underwent intracytoplasmic sperm injection were included in this case-control study. The ZP was modeled as an isotropic compressible hyperelastic material with parameter [Formula: see text], which represents the ZPSM. Computational methodology was used to calculate the mechanical parameters that govern ZP deformation. Fifty-one developed embryos were transferred and divided into two groups-implanted and not implanted. Multivariate logistic regression analysis was performed to identify the association between ZPSM and IR while controlling for confounders. Maternal age and number of embryos per transfer were significantly associated with implantation. The IR of embryos characterized by [Formula: see text] values in the range of 0.20-0.40 kPa was 66.75%, while outside this range it was 6.70%. This range was significantly associated with implantation (p < 0.001). Geometric properties were not associated with implantation. Multivariate logistic regression analysis that controlled for relevant confounders indicated that this range was independently associated with implantation (adjusted OR 38.03, 95% confidence interval 4.67-309.36, p = 0.001). The present study suggests that ZPSM may improve the classic embryo selection process with the aim of increasing IR.

Background: Ubiquitin-Specific Peptidase 26 (USP26), located on the X chromosome, encodes a deubiquitinating enzyme expressed mainly in testis, where it regulates protein turnover during spermatogenesis and modulates the ubiquitination levels of the Androgen Receptor (AR), and as a consequence, affects AR signaling., Methods: The patient was thoroughly characterized clinically. He was genetically tested by chromosome analysis and whole exome sequencing (WES)., Results: The patient was diagnosed with Sertoli cell-only syndrome pattern (SCOS). The WES analysis revealed only the variation in USP26: causing p.P469S in a highly evolutionary conserved amino acid as the possible cause for SCOS. The literature search identified 34 single variations and 14 clusters of variations in USP26 that were associated with male infertility. Only one of the 22 variations and of one cluster of three mutations tested for ubiquitination activity was found as damaging. Only one out of six variations tested for effect on AR function was found as damaging. Thus, the association of USP26 with male fertility was questioned., Conclusions: The finding in our patient and the discussion on the reviewed literature support a possible role for USP26 in male fertility., (© 2020 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals LLC.)

Study Question: Can a machine-learning-based model trained in clinical and biological variables support the prediction of the presence or absence of sperm in testicular biopsy in non-obstructive azoospermia (NOA) patients?, Summary Answer: Our machine-learning model was able to accurately predict (AUC of 0.8) the presence or absence of spermatozoa in patients with NOA., What Is Known Already: Patients with NOA can conceive with their own biological gametes using ICSI in combination with successful testicular sperm extraction (TESE). Testicular sperm retrieval is successful in up to 50% of men with NOA. However, to the best of our knowledge, there is no existing model that can accurately predict the success of sperm retrieval in TESE. Moreover, machine-learning has never been used for this purpose., Study Design, Size, Duration: A retrospective cohort study of 119 patients who underwent TESE in a single IVF unit between 1995 and 2017 was conducted. All patients with NOA who underwent TESE during their fertility treatments were included. The development of gradient-boosted trees (GBTs) aimed to predict the presence or absence of spermatozoa in patients with NOA. The accuracy of these GBTs was then compared to a similar multivariate logistic regression model (MvLRM)., Participants/materials, Setting, Methods: We employed univariate and multivariate binary logistic regression models to predict the probability of successful TESE using a dataset from a retrospective cohort. In addition, we examined various ensemble machine-learning models (GBT and random forest) and evaluated their predictive performance using the leave-one-out cross-validation procedure. A cutoff value for successful/unsuccessful TESE was calculated with receiver operating characteristic (ROC) curve analysis., Main Results and the Role of Chance: ROC analysis resulted in an AUC of 0.807 ± 0.032 (95% CI 0.743-0.871) for the proposed GBTs and 0.75 ± 0.052 (95% CI 0.65-0.85) for the MvLRM for the prediction of presence or absence of spermatozoa in patients with NOA. The GBT approach and the MvLRM yielded a sensitivity of 91% vs. 97%, respectively, but the GBT approach has a specificity of 51% compared with 25% for the MvLRM. A total of 78 (65.3%) men with NOA experienced successful TESE. FSH, LH, testosterone, semen volume, age, BMI, ethnicity and testicular size on clinical evaluation were included in these models., Limitations, Reasons for Caution: This study is a retrospective cohort study, with all the associated inherent biases of such studies. This model was used only for TESE, since micro-TESE is not performed at our center., Wider Implications of the Findings: Machine-learning models may lay the foundation for a decision support system for clinicians together with their NOA patients concerning TESE. The findings of this study should be confirmed with further larger and prospective studies., Study Funding/competing Interest(s): The study was funded by the Division of Obstetrics and Gynecology, Soroka University Medical Center, there are no potential conflicts of interest for all authors., (© The Author(s) 2020. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Oligoteratoasthenozoospermia (OTA) combines deteriorated quantity, morphology and motility of the sperm, resulting in male factor infertility., Methods: We used whole genome genotyping and exome sequencing to identify the mutation causing OTA in four men in a consanguineous Bedouin family. We expressed the normal and mutated proteins tagged with c-Myc at the carboxy termini by transfection with pCDNA3.1 plasmid constructs to evaluate the effects on protein stability in HEK293 cells and on the kinetics of actin repolymerisation in retinal pigment epithelium cells. Patients' sperm samples were visualised by transmission electron microscopy to determine axoneme structures and were stained with fluorescent phalloidin to visualise the fibrillar (F)-actin., Results: A homozygous missense mutation in Ciliogenesis Associated TTC17 Interacting Protein ( CATIP ): c. T103A, p. Phe35Ile, a gene encoding a protein important in actin organisation and ciliogenesis, was identified as the causative mutation with a LOD score of 3.25. The mutation reduces the protein stability compared with the normal protein. Furthermore, overexpression of the normal protein, but not the mutated protein, inhibits repolymerisation of actin after disruption with cytochalasin D. A high percentage of spermatozoa axonemes from patients have abnormalities, as well as disturbances in the distribution of F-actin., Conclusion: This is the first report of a recessive mutation in CATIP in humans. The identified mutation may contribute to asthenozoospermia by its involvement in actin polymerisation and on the actin cytoskeleton. A mouse knockout homozygote for CATIP was reported to demonstrate male infertility as the sole phenotype., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Telomerase, a ribonucleoprotein responsible for telomere re-elongation, is important for male and female fertility. Several factors, including the steroid hormone estrogen, regulate the expression of Telomerase Reverse Transcriptase (TERT), which one of its non-canonical functions is gene expression regulation. The steroidogenesis process is regulated principally by transcription of genes encoding steroidogenic enzymes, but it is not clear if TERT non-canonical functions affect the expression of steroidogenic genes. Here we investigated this new notion by increasing TERT expression and activity in granulosa cells (GCs) derived from rat and from women that underwent in vitro fertilization (IVF) procedures and in vivo in mouse ovary. We show that gonadotropin enhanced the expression of TERT in rat GCs. Overexpression of human- TERT enhanced the expression of steroidogenesis genes in gonadotropin-stimulated rat GCs. Moreover, treatment with TERT increasing compounds (AGS) alone enhanced the expression of the steroidogenic genes in both rat and human GCs and in vivo in mouse ovary, while telomerase inhibitor reduced their expression. Treatment with AGS compounds, together with gonadotropin stimulation, additively increased steroidogenic gene expression. Enhancing TERT expression and activity increased the level of progesterone in mouse blood and in the medium of rat GCs and estrogen in women derived pre-ovulatory luteinized GCs. These data suggest that increasing TERT in GCs by pharmaceutical compounds enhanced steroidogenesis and the production of steroid hormones that are essential processes in human and animal reproduction. These data also suggest a novel possible strategy for the enhancement of the production of steroid hormones., Competing Interests: Declaration of Competing Interest E.P filed a patent on the AGS compounds. A.M, M.W, M.A, D.B.M, I.H, and E.L declare that they have no conflicts of interest with the contents of this article., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: Endometrial scratching (ES) using a biopsy catheter prior to the IVF cycle in the repeated implantation failure (RIF) population has been suggested, but no convincing evidence of its benefit has been presented until now., Methods: A retrospective mono-center study among 300 consecutive IVF-RIF cycles following evaluation of the ovarian reserve, hysterosalpingography or hysteroscopy, pelvic ultrasound, thrombophilia evaluation, karyotyping and assessment of male sperm parametrs. The findings within normal limits. All the patients offered ES, 78 consented and underwent ES prior to their next IVF cycle., Results: A comparison of treatment outcomes between the post-ES cycles (n = 78) and the non-ES cycles (222) demonstrated the following: 34 (43.5%) versus 14 (6.3%) conceptions, respectively (p = 0.001) and 30 (38.4%) versus 2 (0.9%) clinical pregnancies, respectively (p < 0.001%), emphasizing an extremely high biochemical pregnancy rate among the non-ES cycles. Implantation rate was 19.7% versus 0.4%, respectively (p < 0.001) and live birth rate was 33.33% (26 newborns) versus 0.45% (1 newborn), respectively (p < 0.001). Since there were more embryos available for transfer and more top-quality embryos in the post-ES-IVF conception cycles, the role of ES became questionable. A multivariate analysis that included ES and the percentage of top-quality embryos demonstrated that ES was an independent factor highly correlated with conception in this particular RIF population., Conclusions: ES proved to be an efficient tool in a particular subgroup of RIF patients with fertility investigation results within normal limits, an optimal ovarian response to gonadotropins, and a high percentage of top-quality embryos. Nevertheless, the results should not be overestimated, since the study has limitations related to its retrospective model.

Research Question: To assess the perinatal and obstetric outcomes of twin pregnancies resulting from IVF frozen embryo transfer (FET) in comparison with fresh embryo transfer., Design: A retrospective cohort study of 773 twin pregnancies conceived via IVF treatment. Data were collected from the records of two outpatient fertility IVF clinics of cycles conducted between 2006 and 2016., Results: A total of 773 pregnancies were evaluated: 614 (79.4%) following FET and 159 (20.6%) following fresh embryo transfer. The FET group had a significantly higher mean birthweight (P = 0.002), and lower rates of small for gestational age (P = 0.003), low (P = 0.003) and very low birthweight (P = 0.006) infants. Also, a significantly lower rate of spontaneous second trimester miscarriage compared with the fresh embryo transfer group was observed (P = 0.001). No significant difference was found between groups regarding gestational age at delivery, term birth (after 37 weeks of gestation), twin discordancy rate, fetal major malformation rate, and hospitalization duration., Conclusion: In twin pregnancies, FET might have better perinatal outcomes compared with fresh embryo transfer in regards to birthweight and spontaneous second trimester miscarriages. Further research is needed to evaluate these results., (Copyright © 2018 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare perinatal outcomes between spontaneous conception and assisted reproductive technologies (ART) among patients of advanced maternal age., Methods: The present retrospective study included data from singleton pregnancies of women aged at least 40 years who delivered between January 1, 1991, and December 31, 2013, at Soroka University Medical Center, Beer Sheva, Israel. Demographic, obstetric, and perinatal data were compared between pregnancies conceived with ART (in vitro fertilization [IVF] or ovulation induction) and those conceived spontaneously. Multiple regression models were used to define independent predictors of adverse outcomes., Results: A total of 8244 singleton pregnancies were included; 229 (2.8%) following IVF, 86 (1.0%) following ovulation induction, and 7929 (96.2%) were spontaneous. Preterm delivery (P<0.001), fetal growth restriction (FGR) (P<0.001), and cesarean delivery (P<0.001) demonstrated linear associations with the conception mode; the highest rates for each were observed for IVF, with decreased rates for ovulation induction and spontaneous conception. The incidence of gestational diabetes and hypertensive disorders were highest among pregnancies following ART. No association was observed between conception mode and perinatal mortality. Multivariate logistic regression demonstrated that IVF was independently associated with increased odds of preterm delivery (P<0.001) and FGR (P=0.027) compared with spontaneous conception., Conclusions: Among patients of advanced maternal age, ART were independently associated with increased FGR and preterm delivery rates compared with spontaneous pregnancies; perinatal mortality was comparable., (© 2017 International Federation of Gynecology and Obstetrics.)

Background: Azoospermia is diagnosed when sperm cells are completely absent in the ejaculate even after centrifugation. It is identified in approximately 1% of all men and in 10%-20% of infertile males. Non-obstructive azoospermia (NOA) is characterised by the absence of sperm due to either a Sertoli cell-only pattern, maturation arrest, hypospermatogenesis or mixed patterns. NOA is a severe form of male infertility, with limited treatment options and low fertility success rates. In the majority of patients, the cause for NOA is not known and mutations in only a few genes were shown to be causative., Aim: We investigated the cause of maturation arrest in five azoospermic infertile men of a large consanguineous Bedouin family., Methods and Results: Using whole genome genotyping and exome sequencing we identified a 4 bp deletion frameshift mutation in TDRD9 as the causative mutation with a Lod Score of 3.42. We demonstrate that the mutation results in a frameshift as well as exon skipping. Immunofluorescent staining with anti-TDRD9 antibody directed towards the N terminus demonstrated the presence of the protein in testicular biopsies of patients with an intracellular distribution comparable to a control biopsy. The mutation does not cause female infertility., Conclusion: This is the first report of a recessive deleterious mutation in TDRD9 in humans. The clinical phenotype recapitulates that observed in the Tdrd9 knockout mice where this gene was demonstrated to participate in long interspersed element-1 retrotransposon silencing. If this function is preserved in human, our data underscore the importance of maintaining DNA stability in the human male germ line., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To compare intracytoplasmic sperm injection (ICSI) outcomes with the use of fresh or frozen-thawed ejaculated or testicular sperm in patients with cryptozoospermia or nonobstructive azoospermia., Design: Retrospective cohort study., Setting: Tertiary medical center IVF unit., Patient(s): A total of 274 patients evaluated from 1999 to 2011., Intervention(s): A total of 103 patients underwent testicular sperm extraction (TESE) because of nonobstructive azoospermia, and 171 patients were diagnosed with cryptozoospermia., Main Outcome Measure(s): ICSI outcomes during the first cycle in each technique performed according to the sperm origin (testicular vs. ejaculated) and processing (frozen vs. fresh)., Result(s): Forty-eight cycles with the use of frozen testicular sperm, 22 cycles with fresh testicular sperm, 66 cycles with frozen ejaculated sperm, and 138 cycles with fresh ejaculated sperm were examined. Significantly more motile sperm were found in the fresh ejaculate group compared with the frozen-thawed ejaculate group (96% vs. 88%, respectively). Furthermore, fresh ejaculated sperm were found to have better fertilization rates than frozen ejaculated sperm (64% vs. 56%, respectively). No significant difference was found between fresh and frozen-thawed testicular sperm, either in motile sperm available for ICSI or in fertilization rate (64% vs. 62% and 52% vs. 49%, respectively)., Conclusion(s): In cases of cryptozoospermia, frozen-thawed ejaculated sperm is inferior to fresh ejaculated sperm in fertilization rates. However, in nonobstructive azoospermia, no major differences were found between fresh and frozen-thawed testicular sperm. Therefore, uncoupled TESE/oocyte pick-up (OPU) should be considered in NOA cases to prevent possible unnecessary ovarian stimulation and OPU when no sperm cells are detected., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the characteristics of patients and IVF cycles with recurrent implantation failure who eventually succeeded to conceive compared to those who failed to do so., Methods: In a retrospective study, we explored our database for patients younger than 35 years old who underwent at least three unsuccessful fresh IVF cycles. The following parameters were analyzed: cause of infertility, FSH level, stimulation cycle characteristics, fertilization rate, the type of luteal support, and cycle outcome. Uterine cavity assessment was also included. The relationship between endometrial scratching and the outcome of the following IVF cycle was assessed for the subsequent pregnancy rate., Results: The study included 184 patients who underwent 854 IVF cycles. There were no statistically significant differences between patients who eventually conceived and those who did not in terms of ovarian reserve and response to gonadotropin treatment. IVF cycles that eventually ended with conception were characterized by shorter stimulation (10.87 ± 2.17 versus 11.34 ± 2.33 days, p < 0.05), higher estrogen level on the day of hCG administration (1661 ± 667 versus 1472 ± 633 pg/ml, p = 0.009), more fertilized oocytes via ICSI (5.04 ± 4.29 versus 3.85 ± 3.45, p = 0.002), and more embryos available for transfer (5.98 ± 3.89 versus 5.12 ± 3.31, p = 0.002). Combined estrogen and progesterone luteal support combined with endometrial scratching prior to the subsequent IVF cycle has been positively related to increased pregnancy rates., Conclusions: Young patients with RIF having a normal ovarian reserve and satisfactory ovarian response to superovulation should be encouraged to pursue IVF, even though the probability to conceive is relatively low compared to the general IVF population.

Introduction: Fertility preservation consideration prior to gonadotoxic aggressive treatment is now mandatory. Nevertheless, while cryopreservation of mature sperm cells is a well-established technique, preserving fertitity from testicular tissue of pre-pubertal male children in whom only spermatogonial stem cells are avaitable is still under investigation. In rodents, our group was able to demonstrate in-vitro maturation of spermatogonial stem cells to a mature sperm cell which undergoes acrosome reaction., Aim: To culture, expand and preserve spermatogonial stem cells in-vitro in order to allow future fertility to pre-pubertal male children undergoing aggressive gondotoxic treatment., Methods: Pre-pubertal male children scheduled for aggressive gonadotoxic treatment were referred to the Soroka University Medical Center. Testicular biopsy was performed from one testicle. Most of the tissue was cryopreserved for future fertility. A minor part of the tissue was transferred to the research laboratory for culturing and further growth and differentiation. Testicular cells were isolated by enzymatic digestion., Results: This is a first published account in humans of cells from testicular tissue that were cultured for more than two months. In this culture, isolated and groups of cells were observed. Some of the cells expressed pre-meiotic markers, while meiotic markers were expressed by other cells after culture., Conclusion: Preliminary results indicate a possible culturing technique from human testicular tissue in-vitro. Furthermore, meiotic activity may indicate the beginning of differentiation. Further studies are required to develop growth and differentiation techniques and for examining the cell for possible genetic and epigenetic changes before injecting them to mature oocytes for the purpose of fertilization and embryo development.

Oxidative stress is induced by reactive oxygen substances (ROS) that are known to affect male fertility. The aims of this study were to prospectively investigate and characterize total antioxidant and specifically polyphenols concentrations and their relations to sperm quality and fertility treatment success. During their infertility treatment, sixty-seven males were prospectively recruited to this study. After separation of the sperm from the semen sample, the semen fluid samples antioxidants and polyphenols concentrations were determined. Antioxidant concentration was significantly associated with sperm concentration and total motile count. Antioxidants concentration in the group of male with sperm concentration ≥ 15 × 10(6) was significantly higher than in the group of male with antioxidants concentration < 15 × 10(6) (830.3 ± 350 μM and 268.3 ± 220 μM, resp., p < 0.001). Polyphenols concentration did not differ between the groups of sperm concentration above and below 15 × 10(6) (178.7 ± 121 μM and 161.7 ± 61 μM, resp., p-NS). No difference was found between fertilization rates and antioxidants or polyphenols concentrations. This is the first study that reports on polyphenols concentration within semen fluid. More studies are needed in order to investigate polyphenols role in male fertility.

Purpose: The current research is aimed at finding potential non-invasive bio-markers that will help us learn more about the mechanisms at play in failed assisted reproduction treatment. This exploratory pilot study examined the relationship between cell-free DNA (CFD) in plasma and telomere length in lymphocytes among women undergoing in vitro fertilization (IVF) and compared telomere length and CFD levels to a healthy control group., Methods: Blood of 20 women undergoing IVF was collected at three time points during the IVF cycle. We assessed the relationship between CFD and telomere length as well as controlling for morning cortisol levels. We also collected blood of 10 healthy controls at two time points (luteal and follicular phases of the menstrual cycle) and compared mean telomere length, CFD, and cortisol levels between the IVF patients and healthy controls., Results: The results revealed an inverse relationship between CFD levels and telomere lengths at several time points that remained significant even after controlling for cortisol levels. Women undergoing IVF had statistically significant higher levels of CFD and shorter telomeres compared to healthy controls., Conclusions: The relationship between telomere length and CFD should be further explored in larger studies in order to uncover potential mechanisms that cause both shortened telomere length and elevated CFD in women undergoing IVF.

This pilot study examined differences in plasma cell free DNA (CFD) levels based on practice of stress reduction techniques among 14 women undergoing in vitro fertilization (IVF) and embryo transfer (ET) treatment who had higher than normal levels of plasma CFD before beginning IVF treatment. Wilcoxon nonparametric tests were used to examine the significance of the rate of decline in CFD levels between the time points in each of the groups. A paired sample t-test examined the changes in CFD levels among each participant in each of the groups separately. We found that women who engaged in these techniques had reduced plasma CFD, below what is considered elevated in comparison to those who did not practice. High plasma CFD levels have been associated with IVF failure. Stress reduction techniques may facilitate physiological changes that lead to the reduction of plasma CFD levels.

Topoisomerase I (topo I) is an essential nuclear enzyme involved in virtually all aspects of gene expression, and is the target of the anti-cancer drugs- camptothecin (CPT) and its derivatives. Improvement of the survival rates of young women with cancer has led to the consideration of the effects of long-term chemotherapy on their fertility. The effect of anticancer drugs on ovarian function was previously investigated; however, no reports are available concerning their effect on the endometrium, whose integrity is an important factor in embryo implantation. Here we used a rat animal model to investigate the expression and activity of topo I in the various physiologic phases of the endometrium and the influence of CPT on its integrity and receptivity. The results show, for the first time, that the endometrial topo I level and activity are influenced by the physiologic phases of the endometrium (estrous cycle) and correlate with the estrogen blood concentration. Treatment with the anti-cancer drug CPT caused histological disruption of the endometrium and deleterious effect on its cyclicity. Moreover, CPT treatment significantly reduced the implantation rate of embryos, suggesting alteration in the receptivity of the endometrium. These results suggest that topo I is important for maintaining the normal physiologic cyclicity and functionality of the endometrium in rats. Anti-cancer agents that target topo I severely impair estrous cycle progression and endometrial integrity and receptivity, emphasizing the importance of addressing the effect of chemotherapy on the endometrial functionality.