Human embryos frequently harbor large-scale complex chromosomal errors that impede normal development. Affected embryos may fail to implant although many first breach the endometrial epithelium and embed in the decidualizing stroma before being rejected via mechanisms that are poorly understood. Here we show that developmentally impaired human embryos elicit an endoplasmic stress response in human decidual cells. A stress response was also evident upon in vivo exposure of mouse uteri to culture medium conditioned by low-quality human embryos. By contrast, signals emanating from developmentally competent embryos activated a focused gene network enriched in metabolic enzymes and implantation factors. We further show that trypsin, a serine protease released by pre-implantation embryos, elicits Ca2+ signaling in endometrial epithelial cells. Competent human embryos triggered short-lived oscillatory Ca2+ fluxes whereas low-quality embryos caused a heightened and prolonged Ca2+ response. Thus, distinct positive and negative mechanisms contribute to active selection of human embryos at implantation.
STUDY QUESTION Does conventional blastocyst morphological evaluation correlate with euploidy (as assessed by comprehensive chromosome screening (CCS) of trophectoderm (TE) biopsies) and implantation potential? SUMMARY ANSWER A moderate relation between blastocyst morphology and CCS data was observed but the ability to implant seems to be mainly determined by the chromosomal complement of preimplantation embryos rather than developmental and morphological parameters conventionally used for blastocyst evaluation. WHAT IS KNOWN ALREADY Combined with improving methods for cryopreservation and blastocyst culture, TE biopsy and CCS is considered to be a promising approach to select euploid embryos for transfer. Understanding the role of morphology in blastocyst stage preimplantation genetic screening (PGS) cycles may help in further optimizing the cycle management and clinical outcomes. STUDY DESIGN, SIZE, DURATION This is a multicenter retrospective observational study performed between January 2009 and August 2013. The study includes the data analysis of 956 blastocysts with conclusive CCS results obtained from 213 patients following 223 PGS cycles. Single frozen embryo transfer (FET) cycles of 215 euploid blastocysts were performed where it was possible to track the implantation outcome of each embryo transferred. PARTICIPANTS/MATERIALS, SETTING, METHODS PGS was offered to infertile patients of advanced maternal age (>35 years) and/or with a history of unsuccessful IVF treatments (more than two failed IVF cycles) and/or previous spontaneous abortion (more than two spontaneous miscarriages). Prior to TE biopsy for CCS, blastocyst morphology was assessed and categorized in four groups (excellent, good, average and poor quality). The developmental rate of each embryo reaching the expanded blastocyst stage was defined according to the day of biopsy post-fertilization. Day 5 and Day 6 biopsied blastocysts were defined as faster and slower growing embryos, respectively. A novel blastocyst biopsy method, not requiring the opening of the zona pellucida at the cleavage stage of embryo development, was used. Linear regression models were used to test the relationship between blastocyst morphology and developmental rate CCS data and FET cycle outcomes of euploid blastocysts. MAIN RESULTS AND THE ROLE OF CHANCE Among the embryological variables assessed (morphology and developmental rate), only blastocyst morphology was predictive of the CCS data. The euploidy rate was 56.4, 39.1, 42.8 and 25.5% in the excellent, good, average and poor blastocyst morphology groups, respectively. A diagnosis of complex aneuploidy was also associated with blastocyst morphology (P < 0.01) with 6.8, 15.2, 17.4 and 27.5% of excellent, good, average and poor quality embryos, respectively, showing multiple chromosome errors. Faster and slower growing embryos showed a similar aneuploidy rate. Regression logistic analysis showed that none of the parameters used for conventional blastocyst evaluation (morphology and developmental rate) was predictive of the implantation potential of euploid embryos. The implantation potential of euploid embryos was the same, despite different morphologies and developmental rates. LIMITATIONS, REASONS FOR CAUTION The study is limited by its retrospective nature. A higher sample size or a prospective randomized design could be used in future studies to corroborate the current findings. WIDER IMPLICATIONS OF THE FINDINGS This study provides knowledge for a better laboratory and clinical management of blastocyst stage PGS cycles suggesting that the commonly used parameters of blastocyst evaluation are not good enough indicators to improve the selection among euploid embryos. Accordingly, all poor morphology and slower growing expanded blastocysts should be biopsied and similarly considered for FET cycles. This knowledge will be of critical importance to achieve similar cumulative live birth rates in PGS programs compared with conventional IVF, avoiding the potential for exclusion of low quality but viable embryos from the biopsy and transfer procedures. Future research to identify non-invasive biomarkers of reproductive potential may further enhance selection among euploid blastocysts. STUDY FUNDING/COMPETING INTEREST(S) No funding was obtained for the study. All authors have no conflicts to declare. TRIAL REGISTRATION NUMBER None.
Objective To compare the clinical outcome of fresh versus vitrified-warmed blastocyst transfer (BT) cycles. Design Retrospective study. Setting Medical university affiliated hospital. Patient(s) Women aged less than 40 years undergoing BT cycles. Intervention(s) Vitrification and warming of blastocyst with the Cryotop system. Main Outcome Measure(s) Clinical pregnancy rate (CPR), implantation rate (IR), and multiple pregnancy rate (MPR). Result(s) In 110 fresh BT cycles versus 136 vitrified-warmed BT cycles performed from January 2007 to March 2010, the IR and CPR of vitrified-warmed BT cycles were 37.0% and 55.1%, respectively, which were statistically significantly higher than the corresponding values of 25.2% and 36.4% obtained for fresh BT cycles. Additionally, the MPR was not statistically significantly different between vitrified-warmed and fresh BT cycles when a similar number of blastocysts was transferred to patients. Conclusion(s) Vitrified-warmed BT cycles resulted in statistically significantly higher CPR and IR compared with fresh BT cycles. A new embryo transfer strategy is therefore proposed whereby fresh BT would be avoided in the initial ovarian stimulation cycle. Instead, all the patient’s available blastocysts would be vitrified-warmed and transferred in subsequent cycles.
The molecular changes that support implantation in eutherian mammals are necessary to establish pregnancy. In marsupials, pregnancy is relatively short, and although a placenta does form, it is present for only a few days before parturition. However, morphological changes in the uterus of marsupials at term mimic those that occur during implantation in humans and mice. We investigated themolecular similarity between term pregnancy in the marsupials and implantation in eutherian mammals using the gray short-tailed opossum (Monodelphis domestica) as a model. Transcriptomic analysis shows that term pregnancy in the opossum is characterized by an inflammatory response consistent with implantation in humans and mice. This immune response is temporally correlated with the loss of the eggshell, and we used immunohistochemistry to report that this reaction occurs at the materno-fetal interface. We demonstrate that key markers of implantation, including Heparin binding EGF-like growth factor and Mucin 1, exhibit expression and localization profiles consistent with the pattern observed during implantation in eutherian mammals. Finally, we show that there are transcriptome-wide similarities between the opossum attachment reaction and implantation in rabbits and humans. Our data suggest that the implantation reaction that occurs in eutherians is derived froman attachment reaction in the ancestral therianmammal which, in the opossum, leads directly to parturition. Finally, we argue that the ability to shift from an inflammatory attachment reaction to a noninflammatory period of pregnancy was a key innovation in eutherian mammals that allowed an extended period of intimate placentation.
Abstract STUDY QUESTION Can a generally applicable morphokinetic algorithm suitable for Day 3 transfers of time-lapse monitored embryos originating from different culture conditions and fertilization methods be developed for the purpose of supporting the embryologist's decision on which embryo to transfer back to the patient in assisted reproduction? SUMMARY ANSWER The algorithm presented here can be used independently of culture conditions and fertilization method and provides predictive power not surpassed by other published algorithms for ranking embryos according to their blastocyst formation potential. WHAT IS KNOWN ALREADY Generally applicable algorithms have so far been developed only for predicting blastocyst formation. A number of clinics have reported validated implantation prediction algorithms, which have been developed based on clinic-specific culture conditions and clinical environment. However, a generally applicable embryo evaluation algorithm based on actual implantation outcome has not yet been reported. STUDY DESIGN, SIZE, DURATION Retrospective evaluation of data extracted from a database of known implantation data (KID) originating from 3275 embryos transferred on Day 3 conducted in 24 clinics between 2009 and 2014. The data represented different culture conditions (reduced and ambient oxygen with various culture medium strategies) and fertilization methods (IVF, ICSI). The capability to predict blastocyst formation was evaluated on an independent set of morphokinetic data from 11 218 embryos which had been cultured to Day 5. PARTICIPANTS/MATERIALS, SETTING, METHODS The algorithm was developed by applying automated recursive partitioning to a large number of annotation types and derived equations, progressing to a five-fold cross-validation test of the complete data set and a validation test of different incubation conditions and fertilization methods. The results were expressed as receiver operating characteristics curves using the area under the curve (AUC) to establish the predictive strength of the algorithm. MAIN RESULTS AND THE ROLE OF CHANCE By applying the here developed algorithm (KIDScore), which was based on six annotations (the number of pronuclei equals 2 at the 1-cell stage, time from insemination to pronuclei fading at the 1-cell stage, time from insemination to the 2-cell stage, time from insemination to the 3-cell stage, time from insemination to the 5-cell stage and time from insemination to the 8-cell stage) and ranking the embryos in five groups, the implantation potential of the embryos was predicted with an AUC of 0.650. On Day 3 the KIDScore algorithm was capable of predicting blastocyst development with an AUC of 0.745 and blastocyst quality with an AUC of 0.679. In a comparison of blastocyst prediction including six other published algorithms and KIDScore, only KIDScore and one more algorithm surpassed an algorithm constructed on conventional Alpha/ESHRE consensus timings in terms of predictive power. LIMITATIONS, REASONS FOR CAUTION Some morphological assessments were not available and consequently three of the algorithms in the comparison were not used in full and may therefore have been put at a disadvantage. Algorithms based on implantation data from Day 3 embryo transfers require adjustments to be capable of predicting the implantation potential of Day 5 embryo transfers. The current study is restricted by its retrospective nature and absence of live birth information. Prospective Randomized Controlled Trials should be used in future studies to establish the value of time-lapse technology and morphokinetic evaluation. WIDER IMPLICATIONS OF THE FINDINGS Algorithms applicable to different culture conditions can be developed if based on large data sets of heterogeneous origin. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by Vitrolife A/S, Denmark and Vitrolife AB, Sweden. B.M.P.’s company BMP Analytics is performing consultancy for Vitrolife A/S. M.B. is employed at Vitrolife A/S. M.M.’s company ilabcomm GmbH received honorarium for consultancy from Vitrolife AB. D.K.G. received research support from Vitrolife AB.
Objective To determine if cleavage- or blastocyst-stage embryo biopsy affects reproductive competence. Design Paired randomized clinical trial. Setting Academic-assisted reproduction program. Patient(s) Attempting conception through IVF. Intervention(s) After selecting two embryos for transfer, one was randomized to biopsy and the other to control. Both were transferred within shortly thereafter. The biopsy was submitted for microarray analysis and single-nucleotide polymorphism (SNP) profiling. Buccal DNA obtained from the neonate after delivery had microarray analysis and SNP profile compared with that of the embryonic DNA. A match confirmed that the biopsied embryo implanted and developed to term, whereas a nonmatch indicated that the control embryo had led to the delivery. Main Outcome Measure(s) Paired analysis of the delivery rates of the transferred embryos. Either twin delivery or failure to deliver represents equivalent outcomes for the biopsied and control embryos. In contrast, singletons were determined to be from the biopsied or the control embryo. Result(s) Blastomere biopsy on day 3 of development resulted in a significant reduction in sustained implantation. Only 30% of biopsied embryos had sustained implantation and ultimately developed into live-born infants versus 50% of unbiopsied controls, a relative reduction of 39%. In contrast, sustained implantation rates were equivalent (51% vs. 54%) for biopsied and control blastocysts. Conclusion(s) Cleavage-stage biopsy markedly reduced embryonic reproductive potential. In contrast, trophectoderm biopsy had no measurable impact and may be used safely when embryo biopsy is indicated. Clinical Trial Registration Number NCT01219504.
Every successful pregnancy requires proper embryo implantation. Low implantation rate is a major problem during infertility treatments using assisted reproductive technologies. Here we report a newly discovered molecular influence on implantation through the lysophosphatidic acid (LPA) receptor LPA3 (refs 2-4). Targeted deletion of LPA3 in mice resulted in significantly reduced litter size, which could be attributed to delayed implantation and altered embryo spacing. These two events led to delayed embryonic development, hypertrophic placentas shared by multiple embryos and embryonic death. An enzyme demonstrated to influence implantation, cyclooxygenase 2 (COX2) (ref. 5), was downregulated in LPA3-deficient uteri during pre-implantation. Downregulation of COX2 led to reduced levels of prostaglandins E2 and I2 (PGE2 and PGI2), which are critical for implantation. Exogenous administration of PGE2 or carbaprostacyclin (a stable analogue of PGI2) into LPA3-deficient female mice rescued delayed implantation but did not rescue defects in embryo spacing. These data identify LPA3 receptor-mediated signalling as having an influence on implantation, and further indicate linkage between LPA signalling and prostaglandin biosynthesis.
Embryo implantation into receptive endometrium requires synergistic endometrial-blastocyst interactions within the uterine cavity and is essential for establishing pregnancy. We demonstrate that exosomes (40-150 nm nanovesicles) released from endometrial epithelial cells are an important component of these interactions. We defined the proteome of purified endometrial epithelial-derived exosomes (Exos) influenced by menstrual cycle hormones estrogen (E; proliferative phase) and estrogen plus progesterone (EP; receptive phase) and examined their potential to modify trophoblast function. E-/EP-Exos were uniquely enriched with 254 and 126 proteins, respectively, with 35% newly identified proteins not previously reported in exosome databases. Importantly, EP-Exos protein cargo was related to fundamental changes in implantation: adhesion, migration, invasion, and extracellular matrix remodeling. These findings from hormonally treated ECC1 endometrial cancer cells were validated in human primary uterine epithelial cell-derived exosomes. Functionally, exosomes were internalized by human trophoblast cells and enhanced their adhesive capacity, a response mediated partially through active focal adhesion kinase (FAK) signaling. Thus, exosomes contribute to the endometrialembryo interactions within the human uterine microenvironment essential for successful implantation.
During implantation, uterine luminal epithelial (LE) cells first interact with the blastocyst trophectoderm. Within 30hr after the initiation of attachment, LE cells surrounding the blastocyst in the implantation chamber (crypt) disappear, allowing trophoblast cells to make direct physical contact with the underneath stroma for successful implantation. The mechanism for the extraction of LE cells was thought to be mediated by apoptosis. Here, we show that LE cells in direct contact with the blastocyst are endocytosed by trophoblast cells by adopting the nonapoptotic cell-in-cell invasion process (entosis) in the absence of caspase 3 activation. Our invivo observations were reinforced by the results of co-culture experiments with primary uterine epithelial cells with trophoblast stem cells or blastocysts showing internalization of epithelial cells by trophoblasts. We have identified entosis as a mechanism to remove LE cells by trophoblast cells in implantation, conferring a role for entosis in an important physiological process.
Objective To use a rodent model of male diet-induced obesity (DIO) to examine resultant preimplantation embryo development and implantation rate, as well as fetal and placental growth. Design Experimental animal study. Setting University research facilities. Animal(s) C57BL/6 male and CBAxC57BL/6 female mice. Intervention(s) Male mice were fed a standard rodent chow (lean) or a high-fat diet (obese) for up to 13 weeks. After mating, zygotes were collected and cultured to the blastocyst stage, then assessed or transferred into recipient females. Main Outcome Measure(s) Embryo morphology and cell number were assessed and pregnancy outcomes determined at postmortem day 18. Result(s) Embryos from obese males had reduced cleavage and decreased development to blastocyst stage during culture relative to control males. Blastocysts from obese males implanted at a reduced rate, and the proportion of fetuses that developed was significantly decreased, although fetal and placental weight did not differ between groups. Conclusion(s) This study demonstrates that paternal obesity impairs preimplantation embryo development and implantation but does not influence gross fetal or placental morphology. It highlights the important contribution that paternal health and lifestyle choices have for achieving a viable pregnancy.