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Purpose: This study aimed to analyze whether tripronuclear (3PN) zygotes, with two normal-sized PNs and an additional smaller PN (2.1PN), can be used for embryo transfer., Methods: A retrospective embryo cohort study was conducted on 695 patients who underwent intracytoplasmic sperm injection treatment. Blastocyst formation rates were compared between 2.1PN and 2PN zygotes and PGT-A analysis was performed on 15 blastocysts derived from 2.1PN zygotes., Results: Blastocyst formation rates were comparable between 2.1PN (43.8%) and 2PN zygotes (54.8%; p  = 0.212). The rates of blastocysts with good morphology derived from 2.1 PN and 2PN zygotes were 18.8% and 25.5%, respectively. No significant differences were detected ( p  = 0.383). All of the analyzed blastocysts were diploid; however, 13 of these were found to be aneuploid, with a further two being mosaic., Conclusion: Our results suggest that 2.1PN embryos can reach blastocyst stage. These blastocysts were diploid, however, predominantly aneuploid, and therefore could not be used for embryo transfer., Competing Interests: Hiromi Takahashi, Rei Hirata, Junko Otsuki, Toshihiro Habara and Nobuyoshi Hayashi declare that they have no conflicts of interest., (© 2022 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Purpose: The purpose of the study was to invent and evaluate the novel artificial intelligence (AI) system named Fertility image Testing Through Embryo (FiTTE) for predicting blastocyst viability and visualizing the explanations via gradient-based localization., Methods: The authors retrospectively analyzed 19 342 static blastocyst images with related inspection histories from 9961 infertile patients who underwent in vitro fertilization. Among these data, 17 984 cycles of single-blastocyst transfer were used for training, and data from 1358 cycles were used for testing purposes., Results: The prediction accuracy for clinical pregnancy achieved by a control model using conventional Gardner scoring system was 59.8%, and area under the curve (AUC) was 0.62. FiTTE improved the prediction accuracy by using blastocyst images to 62.7% and AUC of 0.68. Additionally, the accuracy achieved by an ensemble model using image plus clinical data was 65.2% and AUC was 0.71, representing an improvement in prediction accuracy. The visualization algorithm showed brighter colors with blastocysts that resulted in clinical pregnancy., Conclusions: The authors invented the novel AI system, FiTTE, which could provide more precise prediction of the probability of clinical pregnancy using blastocyst images secondary to single embryo transfer than the conventional Gardner scoring assessments. FiTTE could also provide explanation of AI prediction using colored blastocyst images., Competing Interests: This study was funded in part by the Kobe Medical Industry Development Project, which is a public grant providing support in the form of research materials. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Isao Miyatsuka and Le My An are employees of NextGem Inc. The equipment and programs have been jointly provided by NextGem Inc., (© 2022 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Purpose: This study aimed to evaluate the effectiveness of intrauterine infusion of platelet-rich plasma (PRP) before embryo transfer (ET) in recurrent implantation failure (RIF) cases., Methods: The authors retrospectively analyzed 54 ET cycles involving frozen and thawed high-quality blastocysts after intrauterine PRP infusion between September 2019 and November 2020. All patients had a history of at least two times of implantation failure on ET. A total of 54 patients were categorized into two groups: thin endometrium (39 patients) and unexplained implantation failure (15 patients). In the thin-endometrium group, the endometrial thickness (EMT) was <8.0 mm at cycle days 12-14 in the prior ET cycle., Results: Among the 54 ET cycles after PRP infusion, 31 (57.4%) were positive for human chorionic gonadotropin (hCG) and 27 (50%) achieved clinical pregnancy, which was significantly better than that in prior ET cycles without PRP infusion (27.2% and 9.6%, respectively). The EMT was not increased at ET date on the PRP cycle compared with that in the prior ET cycle in both patient groups. Moreover, EMT was not different between the hCG-positive and hCG-negative groups., Conclusion: Although intrauterine PRP infusion had no superior effect on increasing the EMT than conventional therapeutic agents, it resulted in high pregnancy rates in patients experiencing RIF with or without thin endometrium., Competing Interests: Yihsien Enatsu, Noritoshi Enatsu, Junko Otsuki, Toshiro Iwasaki, Eri Okamoto, Shoji Kokeguchi, Masahide Shiotani declare that they have no conflict of interest., (© 2021 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Purpose: To evaluate the outcomes of embryo transfer (ET) and to identify the parameters influencing pregnancy outcomes., Methods: This study included 938 ET cycles involving single frozen and thawed good-quality blastocyst (Gardner grade ≥3BB) between August 2017 and January 2018. The significance of several parameters including endometrial thickness, position of the transferred air bubble, self-evaluation score by physicians, and uterus direction at ET as predictors of clinical pregnancy was evaluated using univariate and multivariate analyses., Results: Among 938 ET cycles, 462 (49.3%) resulted in a clinical pregnancy. Endometrial thickness was positively associated with clinical pregnancy in a linear trend. Between the variable position of the transferred air bubble and clinical pregnancy rate showed a curvilinear relationship. Clinical pregnancy rate was higher in cases with good self-evaluation score, whereas there was no difference between groups with different uterus directions. Univariate analysis of predictive parameters identified endometrial thickness, self-evaluation score by physicians, and position of air bubbles as significant predictors of clinical pregnancy, of which endometrial thickness and position of air bubbles appeared to be independently related to clinical pregnancy., Conclusion: Endometrial thickness and the position of transferred air bubbles influenced clinical pregnancy in ET cycles., Competing Interests: Conflict of interest: Nao Hayashi, Noritoshi Enatsu, Toshiro Iwasaki, Junko Otsuki, Yukiko Matsumoto, Shoji Kokeguchi, Masahide Shiotani declare that they have no conflict of interest. Human rights statement and informed consent: All patients were well informed, and written informed consent was obtained prior to the treatment period. The treatment investigated in this study has already been discussed in other studies that have shown positive outcomes. Animal studies: This article contains no studies with animal subjects performed by any of the authors. Approval by Ethics Committee: This study was approved by Ethical Committee of Hanabusa Women's Clinic consists of members chosen by our institute and third party medical institute (approval number; 2019‐08)., (© 2020 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Purpose: This study aimed to analyze whether the presence of refractile bodies (RFs) negatively affects fertilization, embryo development, and/or implantation rates following intracytoplasmic sperm injection (ICSI)., Methods: This retrospective embryo cohort study involved a total of 272 patients undergoing ICSI treatment of blastocyst cryopreservation., Results: In the study, no significant differences were found regarding 2PN formation rates between RF(+) (76.5%) and RF(-) oocytes (77.2%). However, the blastocyst formation rate on Day 5 in RF(+) oocytes was 45.8%, which was significantly lower than that of 52.2% in RF(-) oocytes (aOR 0.74, 95% CI 0.59-0.93, P  = .011). Implantation rates were also significantly lower in RF(+) oocytes (24.2%) as compared to RF(-) oocytes (42.2%) (aOR 0.46, 95% CI 0.26-0.78, P  = .005). Furthermore, the implantation rate of RF(+) oocytes (28.6%), when high-quality blastocysts were transferred, was significantly lower than that of RF(-) oocytes (46.1%) (aOR 0.50, 95% CI 0.25-0.96, P  = .043)., Conclusion: Our results suggest that oocytes with the presence of RFs have a lower potential for blastocyst development. Even when they develop into high-quality blastocysts, the chances of implantation are reduced., Competing Interests: Hiromi Takahashi, Junko Otsuki, Michio Yamamoto, Hiroe Saito, Rei Hirata, Toshihiro Habara, and Nobuyoshi Hayashi declare that they have no conflicts of interest., (© 2019 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Purpose: This study aimed to analyze whether a regimen of aromatase inhibitor (AI) could reduce the occurrence of smooth endoplasmic reticulum clusters (sERCs) in oocytes., Methods: The AI and the clomiphene citrate (CC) regimens were compared, regarding the sERC (+) rates and the serum estradiol and progesterone levels on the date of hCG administration, and the duration of AI, CC, and hMG administration., Results: The occurrence of sERCs in oocytes from patients treated with AI was significantly higher than that in oocytes from those treated with CC. Both the serum estradiol and progesterone levels were found to be significantly higher in sERC (+) than in sERC (-) cycles. With regard to the CC cycles, no significant differences were detected. The duration of AI and hMG administration was longer for sERC (+) than for sERC (-) cycles., Conclusion: As AI did not reduce the occurrence of sERCs, the elevation of estradiol may not be the cause of sERC occurrence but a consequence. Considering the higher levels of progesterone and longer duration of hMG in sERC (+) cycles, the negative effects of premature luteinization, which frequently occur with the AI protocol, should be investigated further., Competing Interests: Hiroe Saito, Junko Otsuki, Hiromi Takahashi, Rei Hirata, Toshihiro Habara and Nobuyoshi Hayashi declare that they have no conflicts of interest., (© 2019 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Aim: Several studies have indicated that the cause of the increased birthweight of frozen-thawed embryos was associated with assisted reproductive technology (ART) procedures, such as cryopreservation. In the present study, the mean birthweight of singletons was compared between the ovulatory and hormone replacement therapy (HRT) cycles in order to investigate the primary factor that leads to higher birthweights from frozen-thawed embryo transfer (FET)., Methods: This retrospective study was carried out from January 2011 to December 2014 on 2738 singletons who were born at 37-41 weeks' gestation, following ART in a single facility. The mean birthweight of the singletons who were born after a fresh embryo transfer (ET) was compared to the mean birthweight of the singletons who were born after a FET. In the FET cycles, the mean birthweight of the singletons was compared between the ovulatory and HRT cycles., Results: The mean birthweight of the singletons who were born after a FET was significantly higher than that of the singletons who were born after a fresh ET. In the FET cycles, the birthweight from the HRT cycles was significantly higher than that from the ovulatory cycles. Among the HRT cycles, there was no difference between the birthweight of the singleton who were born from a blastocyst transfer and those who were born from a cleavage-stage ET., Conclusion: The primary factor to affect the birthweight of singletons might be the pre/postET hormonal environment of the endometrium and not the stage of the transferred embryo nor the frozen-thawed procedure itself.

Aim: To determine whether there are differences in size between the male and female pronuclei immediately before the pronuclear membrane breakdown (PNMBD) and to evaluate whether pronuclear size differences influence normal birth rates., Methods: Time-lapse photography was used to measure the size of each pronucleus, while the outcome of 71 frozen-thawed single blastocyst transfers in patients receiving hormone therapy was analyzed retrospectively. The pronuclear measurements were made 4 hours before the PNMBD, corresponding to 16-20 hours after insemination or intracytoplasmic sperm injection, and immediately before the PNMBD. The differences in the areas between the pronuclei in the zygotes that were associated with the live births were compared with those that were associated with the failed pregnancies., Results: The average difference in the area between the pronuclei 4 hours before and immediately before the PNMBD in the patients with a live birth was significantly smaller than in the patients with a failed birth. In addition, the average area difference in the patients with a successful birth was significantly smaller when the measurements were made immediately before the PNMBD, compared with the measurements 4 hours before the PNMBD. Such differences were not detected among the patients who did not achieve a birth., Conclusion: The birth of healthy babies resulted from zygotes that contained pronuclei of similar size when the measurements were made immediately before the PNMBD. Evaluating the size of each pronucleus immediately before the PNMBD provides an effective indicator of the embryo's potential at an early stage of development.