Improved clinical outcomes after non-invasive oocyte selection and Day 3 eSET in ICSI patients

Inge Van Vaerenbergh, Tom Adriaenssens, Wim Coucke, Lisbet Van Landuyt, Greta Verheyen, Michaël De Brucker, Michel Camus, Peter Platteau, Michel De Vos, Elien Van Hecke, André Rosenthal, Johan Smitz, Inge Van Vaerenbergh, Tom Adriaenssens, Wim Coucke, Lisbet Van Landuyt, Greta Verheyen, Michaël De Brucker, Michel Camus, Peter Platteau, Michel De Vos, Elien Van Hecke, André Rosenthal, Johan Smitz

Abstract

Background: Non-invasive oocyte quality scoring, based on cumulus gene expression analysis, in combination with morphology scoring, can increase the clinical pregnancy (CPR) and live birth rates (LBR) in Day 3 eSET (elective single embryo transfer) ICSI patients. This was first investigated in a pilot study and is now confirmed in a large patient cohort of 633 patients. It was investigated whether CPR, LBR and time-to-pregnancy could be improved by analyzing the gene expression profile of three predictive genes in the cumulus cells, compared to patients with morphology-based embryo selection only.

Methods: A large interventional, non-randomized, assessor-blinded cohort study with 633 ICSI patients was conducted in a tertiary fertility center. Non-PCOS patients, 22-39 years old, with good ovarian reserve, were stimulated with HP-hMG using a GnRH antagonist protocol and planned for fresh Day 3 eSET. The cumulus cells from individually denuded oocytes were ranked by a lab-developed cumulus cell test: qRT-PCR for three predictive genes (CAMK1D, EFNB2 and SASH1) and two control genes (UBC, B2M). The embryo selected for transfer was highest ranked from the pool of morphologically transferable Day 3 embryos. Patients in the control (n = 520) and experimental arm (n = 113) were compared for clinical pregnancy and live birth, using a weighted generalized linear model, and time-to-pregnancy using Kaplan-Meier curves.

Results: The CPR was 61% in the experimental arm (n = 113) vs 29% in the control arm (n = 520, p < 0.0001). The LBR in the experimental arm (50%) was significantly higher than in the control arm (27%,p < 0.0001). Time-to-pregnancy was significantly shortened by 3 transfer cycles independent of the number of embryos available on Day 3 (Kaplan-Meier, p < 0.0001). Cumulus cell tested patients < 35 years (n = 65) or ≥ 35 years (n = 48) had a CPR of 62 and 60% respectively (ns). For cumulus cell tested patients with 2, 3-4, or > 4 transferable embryos, the CPR was 66, 52, and 67% (ns) respectively, and thus independent of the number of transferable embryos on Day 3.

Conclusions: This study provides further evidence of the clinical usefulness of the non-invasive cumulus cell test over time in a larger patient cohort.

Trial registration: Clinicaltrials.gov, NCT03659786 / NCT02962466 (Registered 6Sep2018/11Nov2016, retrospectively registered.

Keywords: Clinical pregnancy; Cumulus cells; Gene expression; Live birth; Non-invasive; Single embryo transfer.

Conflict of interest statement

IVV and TA conducted all work related to the study while employees at Universitair Ziekenhuis Brussel. IVV reported employment by Fertiga NV since November 2019, TA reported employment by Fertiga NV since February 2020. JS was professor at Universitair Ziekenhuis Brussel until September 2019 and is currently Chief Medical Officer at Fertiga NV. EVH is Chief Commercial Officer and AR is Chief Executive Officer at Fertiga NV. EVH, AR and JS report board membership of Fertiga NV, hold stock in Fertiga NV, and receive service fees from Fertiga NV.

MDV reports honoraria for lectures in the last 2 years from MSD and Ferring, outside the submitted work, as well as grant support from MSD. Other authors declared no conflicts of interest.

Figures

Fig. 1
Fig. 1
Patient flow. *Patients eligible for the cumulus cell test study: Not recruited for any other study, stimulated with HP-hMG in a GnRH antagonist protocol from Day 6, fresh eSET, scheduled for ICSI, up to 39 years old, with at least 2 transferable embryos on Day 3, with follow up data (up to clinical pregnancy) Excluded: PGD/PGS, TESE, FNA, PCOS, known poor ovarian response. **: A weighted generalized linear model was used with weighted averages to stratify the populations for age and number of transferable embryos on Day 3. *** to prevent potential confounding factors 113 exact matched controls nearest in time to the experimental case were retained for the Kaplan-Meier analysis
Fig. 2
Fig. 2
Three-dimensional histogram of the experimental arm (n = 113, left side) and control arm (n = 520, right side) depicting age vs the number of COC at oocyte pick-up (number of cases per data point are depicted with different colours)
Fig. 3
Fig. 3
Histograms of total stimulation dose (IU), maturation rate (%), fertilization rate (%), number of transferable embryos (n) at Day 3 and transferable embryo rate (number of transferable embryos at Day 3 divided by the number of fertilized embryos, %) for the experimental arm (n = 113) and the control arm (n = 520). Distributions are shown as relative frequency distributions (%)
Fig. 4
Fig. 4
CPR and LBR after fresh Day 3 eSET in a prospective study with 113 patients in the experimental arm (with cumulus cell test) and 520 patients (520 patients for CPR and 509 patients for LBR) in the control arm (without the cumulus cell test) at Universitair Ziekenhuis Brussel. In the experimental arm Day 3 transfer is based on embryo morphology and the cumulus cell test (right side), and in the control arm on morphology only (left side). CPR is shown in blue bars and LBR in orange. Numbers in the bars are the % clinical pregnancies or live birth, respectively
Fig. 5
Fig. 5
CPR and LBR after fresh Day 3 transfer in a prospective study with 113 patients in the experimental arm. CPR and LBR in the experimental arm (with cumulus cell test) are shown only in relation to the number of embryos of transferable quality (left side) and age groups (right side). CPR is shown in blue bars and LBR in orange. Numbers in the bars are the % clinical pregnancies or live birth respectively. Comparisons were performed using the Chi square analysis between the different subgroups and revealed no statistical difference
Fig. 6
Fig. 6
Kaplan-Meier curves for patients with > 2 transferable embryos on Day 3. Graph was generated on the data of 113 patients for each arm with 113 fresh transfers for each arm, plus 137 and 88 frozen embryo transfers for the control and the cumulus cell test arm respectively (451 single embryo transfers in total). 1 = fresh embryo transfer, 2–7 = frozen embryo transfers

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