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Purpose: To determine which blastocyst assessment variables predict clinical implantations in single blastocyst frozen embryo transfers (FET) of freeze-only-IVF cycles, following improved vitrified-warmed blastocyst survival and developmental competence preservation., Method: In this retrospective cohort study performed at a single private IVF center, the pregnancy outcomes of 1795 single blastocyst FET cycles were analyzed, from freeze-only-IVF retrievals performed between January 2017 and January 2020. Stepwise forward logistic regressions with clinical implantation (i.e., normal gestational sac and cardiac activity) as dependent variable were performed to identify the significant predictors. All blastocysts were vitrified using Cryotop technology, with before transfer (post-warming) blastocyst morphology scores used in all analyses., Result(s): The 1795 blastocysts transferred were vitrifıed on embryo days 4 (1057), 5 (716), and 6 (22). The overall clinical implantation rate was 50.9%; however, using blastocyst age and blastocyst morphological score the clinical implantation rates increased from 49.0% (day-4 1 and 2) and 25.2% (day-5 1 and 2) to 71.2% (day-4 4AA) and 64.3% (day-5 4AA), respectively. Whereas full (≥3) blastocysts with scores of AA and BA had similar clinical implantation rates (66.2 vs. 66.7%), the rate of full blastocysts with scores of AB was lower (58.9%). In stepwise forward logistic regressions, female age, blastocyst age, blastocyst expansion score, blastocyst trophectoderm score, and number of blastocysts vitrified were significant predictors of clinical implantation., Conclusion(s): Using blastocyst age and before transfer blastocyst expansion and trophectoderm morphology scores to select blastocysts, clinical implantation rates greater than 70% could be achieved for top-scoring blastocysts.

Purpose: To construct a new embryonic quality scoring system to compare groups of embryos at different developmental stages., Methods: Based on a hypothesis that the implantation potential of any embryo in an ovum pickup (OPU) cycle remains the same at any stage of development, be it day 2, 3, or 5, a new embryo quality scoring (EQS) system was designed. It was based on the analysis of the clinical results of 1610 single embryo transfers. We validated this scoring system in the comparison of embryonic quality between groups by evaluating the mean scores calculated at day 2, day 3, and day 5 for 957 embryos (150 cycles) from 3 different groups. We then compared EQSs of patients with pregnancy favorable factors (group A) such as young age and high AMH levels, with the patients with contra features (group B)., Results: We confirmed that each mean EQS assessed at different stages of embryonic development within the same group was similar. The mean EQSs on day 3 and day 5 in group A were significantly higher than the mean EQSs on days 2, 3, and 5 in group B., Conclusion: The novel EQS system proposed by us enables embryonic quality comparison between groups of embryos at different developmental stages.

Purpose: To characterize national oocyte donation practice patterns from the perspective of individual donors rather than of recipients., Methods: Retrospective cohort including all donor oocyte retrievals and transfers reported to SARTCORS in 2016 and 2017 in the USA. Primary outcomes include characteristics of oocyte donors and of donor oocyte cycles. Secondary outcomes include overall pregnancy rates, elective single embryo transfer (eSET) rates, and perinatal outcomes among donor oocyte recipient transfers., Results: During the study period, 49,193 donor oocyte retrievals were performed, of which the largest proportion were in the Western US. For all reported retrievals, there were 17,099 unique donors, each of whom underwent an average of 2.4 retrievals (range 1-22). Average donor age was 26.3 years (range 18-48). On average, 24.6 oocytes (SD 12.4) were retrieved each cycle, ranging from 0 to 102. Among 37,657 donor oocyte recipient transfers, 20,159 (53.5%) involved eSET, and 17,725 (47.1%) resulted in live birth. Miscarriage rates were 17.5%, and good perinatal outcome (GPO), defined as full-term normal birthweight delivery, was more likely among singleton (75.7%) than multiple (23.8%) pregnancies., Conclusion: The average number of retrievals that donors underwent and oocyte yield mirrored national guidelines; however outliers, exist that may unnecessarily increase donor risk. Additionally, among resultant donor transfers, 46.5% transferred more than one embryo despite national recommendations for eSET. The significantly higher likelihood of GPO among singleton pregnancies points to the need to further increase donor recipient eSET rates.

The success of a pregnancy and the birth of a heathy baby following embryo transfer are conditioned by many factors, including embryo quality and the uterine environment. While we keep looking for more indicators of embryo quality, it also is critical to understand what constitutes a favorable uterine environment leading to a successful pregnancy and birth. This issue of JARG offers new insights on both components-so called by some "the seed and the soil"-and also highlights the critical interactions between the two. Collectively, these publications are contributing to a better understanding of basic embryology and reproductive biology. They could lead to multiple applications to mitigate infertility issues; however, our knowledge base remains rudimentary when it comes to sorting out the 'soil or seed' dilemma. The call from all authors for more research in their respective areas resonates within the ART community. Recognizing the practical and ethical limitations of studies in human patients also reemphasizes the need for solid research in multiple animal models to better understand what constitutes the best recipe for successful embryo transfer outcomes.

Purpose: In the era of personalized medicine and the increased use of frozen embryo transfer (FET), assay of the endometrium's receptivity prior to transfer has gained popularity, especially among patients. However, the optimal timing for single thawed euploid embryo transfers (STEET) in a programmed FET has yet to be determined Mackens et al. (Hum Reprod. 32(11):2234-42, 2017). We sought to examine the outcomes of euploid FETs by length of progesterone (P4) exposure., Methods: Prospective cohort study of programmed FETs of single euploid embryos between June 1, 2018, and December, 18, 2018, at our center. Subjects reported the exact start time for initiating progesterone. The transfer time was noted to calculate the primary independent variable, duration of progesterone exposure. Statistical analysis included ANOVA and Spearman's rho correlation, with p < 0.05 considered significant., Results: Inclusion criteria were met for 253 programmed STEET cycles in the analysis. There was no significant difference in P4 duration when comparing outcome groups (112.8 ± 3.1 ongoing pregnancy (OP), 112.4 ± 4.4 spontaneous abortion (SAB), 111.6 ± 1.7 biochemical pregnancy (BP), 113.9 ± 5.7 no pregnancy (NP), F 1.76, df 3, p = 0.16). An ROC curve assessing the ability of P4 duration to predict ongoing pregnancy (OP) had an area under the curve of 0.467 (p = 0.38)., Conclusion: Duration of P4 was not associated with outcome. Of the cycles, 65.6% resulted in ongoing pregnancy with our center's instructions resulting in an average progesterone exposure of 112.8 h, with a range of 98.3-123.7 h. With growing popularity for individualized testing, these results provide evidence for patient counseling of the high likelihood of ongoing pregnancy without personalized testing.

Multiple pregnancies following fertility treatments typically occur in 30% of women in whom more than one embryo is transferred. Worldwide, fewer than 20 countries have fully funded public fertility treatments, and many women utilizing assisted reproduction technologies are transferring more than one embryo for financial reasons because they consider it will be cheaper to have two embryos transferred in the one procedure. Yet, there is a large body of evidence for the poorer health, economic, and social outcomes for mother and baby from multiple pregnancies. Some countries have reduced the multiple pregnancy rate to less than 5% by linking the funding of ART to policies where the large majority of transfers are single embryos., (Copyright © 2020. Published by Elsevier Inc.)

In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

The health of children born through assisted reproductive technologies (ART) is particularly vulnerable to policy decisions and market forces that play out before they are even conceived. ART treatment is costly, and public and third-party funding varies significantly between and within countries, leading to considerable variation in consumer affordability globally. These relative cost differences affect not only who can afford to access ART treatment, but also how ART is practiced in terms of embryo transfer practices, with less affordable treatment creating a financial incentive to transfer more than one embryo to maximize the pregnancy rates in fewer cycles. One mechanism for reducing the burden of excessive multiple pregnancies is to link insurance coverage to the number of embryos that can be transferred; another is to combine supportive funding with patient and clinician education and public reporting that emphasizes a "complete" ART cycle (all embryo transfers associated with an egg retrieval) and penalizes multiple embryo transfers. Improving funding for fertility services in a way that respects clinician and patient autonomy and allows patients to undertake a sufficient number of cycles to minimize moral hazard improves outcomes for mothers and babies while reducing the long-term economic burden associated with fertility treatments., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Question: Have ART live birth rates improved in Australia over the last 12 years?, Summary Answer: There were striking improvements in per-cycle live birth rates observed for frozen/thaw embryo transfers, blastocyst transfer and single embryo transfer (SET), while live birth rates following ICSI were lower than IVF for non-male factor infertility in most years., What Is Already Known: ART and associated techniques have become the predominant treatment of infertility over the past 30 years in most developed countries. However, there are differences in ART laboratory and clinical practices, and success rates worldwide. Australia has one of the highest ART utilization rates and lowest multiple birth rates in the world, thus providing a unique setting to investigate the contribution of common ART strategies in an unrestricted population of patients to ART success rates., Study Design, Size, Duration: A retrospective cohort study of 585 065 ART treatment cycles performed in Australia between 2002 and 2013 using the Australian and New Zealand Assisted Reproduction Database (ANZARD)., Participants Materials, Setting, Method: An unrestricted population of all women who underwent autologous ART treatment between 2002 and 2013. Visual descriptive analysis was used to assess the trends in ART procedures by the calendar years. Adjusted odds ratios (aORs) of a live birth for four common ART techniques were calculated after controlling for important confounders including female age, infertility diagnosis, stage of the embryo (blastocyst versus cleavage stage), type of embryo (fresh versus thawed), fertilization method (IVF versus ICSI) and number of embryos transferred (SET versus multiple embryos)., Main Results and the Role of Chance: The overall live birth rate per embryo transfer increased from 19.2% in 2002 to 23.3% in 2013 (21.9-24.3% for fresh embryo transfers and 14.6-23.3% for frozen/thaw embryo transfers). This occurred concurrently with an increase in SET from 29.7% to 78.9%, and an increase in the average age of women undergoing treatment from 35.0 to 35.9 years. Individuals who had a frozen/thaw embryo transfer cycle in 2002 had 43% (aOR: 0.57, 95% CI: 0.53-0.61) reduced odds of a live birth compared with a fresh embryo transfer cycle. This contrasted with 16% (aOR: 0.84, 95% CI: 0.80-0.98) reduced odds of a live birth from frozen/thaw embryo transfer cycles in 2013. In 2013, the odds of blastocyst transfer resulting in a live birth were more than twice as great as for cleavage stage transfer (aOR 2.01, 95% CI: 1.92-2.11). The adjusted odds of live birth per SET compared with multiple embryo transfer increased significantly over the last 12 years, from a 38% reduced odds of a live birth follow SET in 2002 (aOR: 062, 95% CI: 0.57-0.67) compared to an 8% reduced odds in 2013 (aOR: 0.92, 95% CI: 0.87-0.98). The aOR of a live birth using ICSI compared to IVF in non-male factor patients was lower in most years bringing into question its widespread use., Limitation, Reasons for Caution: This is a retrospective cohort analysis and cannot confirm causality. High-level evidence on the effectiveness of particular ART techniques, particularly ICSI and blastocyst culture, requires prospective randomized controlled trials or detailed statistical analysis using large-scale data that counts for fertilization failure, embryo loss, prognostic factors and cycle characteristics., Wider Implication of the Findings: The most striking improvements in ART success rates in Australia have been observed for frozen/thaw embryo transfers, blastocyst transfer and SET. Further studies of the role of ICSI in non-male factor infertility and blastocyst transfer success rates that take into account embryo loss are needed., Study Funding/competing Interests: No funding was received to undertake this study. The authors declare that they do not have competing interests with this study., Trial Registration Number: NA., (© The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Characteristics routinely used to evaluate embryo quality after thawing include number of blastomeres survived and presence of mitosis resumption after overnight culture. It is unknown to which extent symmetry and fragmentation affect implantation after warming and whether application of stricter criteria either before vitrification or after warming would improve implantation rate (IR) of vitrified/warmed embryos. This study aimed to find new parameters to improve selection criteria for vitrification and for transfer after warming., Methods: Firstly, we evaluated standard morphological characteristics (intact survival, mitosis resumption, number of blastomeres, symmetry and fragmentation) of 986 warmed day 3 embryos and, from a subset of 654, we evaluated morphometric characteristics (fragmentation, symmetry and volume change). Secondly, we tested the hypothesis that IR of day 3 vitrified/warmed embryos is influenced by morphometric characteristics. IR per embryo transferred was calculated using embryos that were transferred in a single embryo transfer (SET) or a double embryo transfer (DET) with either 0 or 100 % implantation (830/986). We investigated the significant differences in IR between the different categories of a specific characteristic. These categories were based on our standard embryo evaluation system. The statistical tests Chi-square, Fisher's exact or Cochrane-Armitage were used according to the type and/or categories of the variable., Results: The 986 embryos were transferred in 671 FET cycles with 16.9 % (167/986) IR. After exclusion of DET with 1 embryo implanted, IR per embryo transferred was 12.4 % (103/830). Embryo symmetry, fragmentation and volume change in vitrified/warmed day 3 embryos were not associated with IR. However, when mitosis resumption was present after overnight culture, intact embryos reached significantly higher IR than non-intact embryos and only when the embryo compacted after overnight culture the number of cells damaged after warming had no effect on IR. Concretely, embryos with 8 cells after warming or >9 cells after overnight culture-including compacted embryos-reached the highest IR (>15 %) while embryos with <6 cells after warming or with ≤6 cells after overnight culture had extremely low IR (<1 %)., Conclusions: IR of vitrified embryos is determined by the number of cells lost, by the occurrence of mitosis resumption, and by the specific number of blastomeres present but not by fragmentation, blastomere symmetry or volume change. Unselecting embryos for cryopreservation because of fragmentation >10 % and/or symmetry < 75 % only leads to unwanted loss of embryos with acceptable implantation potential., Trial Registration: Retrospectively registered NCT02639715 .

Objective: To evaluate factors associated with elective single-embryo transfer (eSET) utilization and its effect on assisted reproductive technology outcomes in the United States., Design: Historical cohort., Setting: Not applicable., Patient(s): Fresh IVF cycles of women aged 18-37 years using autologous oocytes with either one (SET) or two (double-embryo transfer [DET]) embryos transferred and reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System between 2004 and 2012. Cycles were categorized into four groups with ([+]) or without ([-]) supernumerary embryos cryopreserved. The SET group with embryos cryopreserved was designated as eSET., Intervention(s): None., Main Outcomes Measure(s): The likelihood of eSET utilization, live birth, and singleton non-low birth weight term live birth, modeled using logistic regression. Presented as adjusted odds ratios (aORs) and 95% confidence intervals (CIs)., Result(s): The study included 263,375 cycles (21,917 SET[-]cryopreservation, 20,996 SET[+]cryopreservation, 103,371 DET[-]cryopreservation, and 117,091 DET[+]cryopreservation). The utilization of eSET (SET[+]cryopreservation) increased from 1.8% in 2004 to 14.9% in 2012 (aOR 7.66, 95% CI 6.87-8.53) and was more likely with assisted reproductive technology insurance coverage (aOR 1.60, 95% CI 1.54-1.66), Asian race (aOR 1.26, 95% CI 1.20-1.33), uterine factor diagnosis (aOR 1.48, 95% CI 1.37-1.59), retrieval of ≥16 oocytes (aOR 2.85, 95% CI 2.55-3.19), and the transfer of day 5-6 embryos (aOR 4.23, 95% CI 4.06-4.40); eSET was less likely in women aged 35-37 years (aOR 0.76, 95% CI 0.73-0.80). Compared with DET cycles, the likelihood of the ideal outcome, term non-low birth weight singleton live birth, was increased 45%-52% with eSET., Conclusion(s): Expanding insurance coverage for IVF would facilitate the broader use of eSET and may reduce the morbidity and healthcare costs associated with multiple pregnancies., (Copyright © 2016 American Society for Reproductive Medicine. All rights reserved.)

Objective: To evaluate the independent effects of the degree of blastocoele expansion and re-expansion and the inner cell mass (ICM) and trophectoderm (TE) grades on predicting live birth after fresh and vitrified/warmed single blastocyst transfer., Design: Retrospective study., Setting: Reproductive medical center., Patient(s): Women undergoing 844 fresh and 370 vitrified/warmed single blastocyst transfer cycles., Intervention(s): None., Main Outcome Measure(s): Live-birth rate correlated with blastocyst morphology parameters by logistic regression analysis and Spearman correlations analysis., Result(s): The degree of blastocoele expansion and re-expansion was the only blastocyst morphology parameter that exhibited a significant ability to predict live birth in both fresh and vitrified/warmed single blastocyst transfer cycles respectively by multivariate logistic regression and Spearman correlations analysis. Although the ICM grade was significantly related to live birth in fresh cycles according to the univariate model, its effect was not maintained in the multivariate logistic analysis. In vitrified/warmed cycles, neither ICM nor TE grade was correlated with live birth by logistic regression analysis., Conclusion(s): This study is the first to confirm that the degree of blastocoele expansion and re-expansion is a better predictor of live birth after both fresh and vitrified/warmed single blastocyst transfer cycles than ICM or TE grade., (Copyright © 2016. Published by Elsevier Inc.)

Objective: To evaluate the effect of semen quality on human sex ratio in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)., Design: Retrospective cohort study., Setting: Not applicable., Patient(s): A total of 27,158 singleton infants born between 2007 and 2012 after fresh single-embryo transfer., Intervention(s): None., Main Outcome Measure(s): Proportion of male infants among liveborn infants., Result(s): There were 14,996 infants born after IVF, 12,164 infants born after ICSI with ejaculated sperm, and 646 infants born after ICSI with nonejaculated sperm. The sex ratio of IVF was 53.1% (95% confidence interval [CI], 52.3-53.9); the sex ratio of ICSI with ejaculated and nonejaculated sperm demonstrated as statistically significant reduction (48.2%; 95% CI, 47.3-49.1 and 47.7%; 95% CI, 43.8-51.6, respectively). In IVF, lower sperm motility, including asthenozoospermia (sperm motility <40%), was associated with a statistically significantly lower sex ratio compared with normal sperm (51.0%; 95% CI, 48.6-53.3 vs. 53.4%; 95% CI, 52.5-54.3). In ICSI with ejaculated sperm, there was no association between sperm motility and sex ratio. Sperm concentration was not associated with sex ratio in both IVF and ICSI., Conclusion(s): In IVF, lower sperm motility was associated with a statistically significant reduction in sex ratio; ICSI with either ejaculated or nonejaculated sperm was associated with a statistically significant reduction in sex ratio regardless of semen quality., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare pregnancy and neonatal outcomes after fresh and vitrified-warmed single-blastocyst transfers., Design: Retrospective study., Setting: Private in vitro fertilization (IVF) clinic., Patient(s): 1,209 infertile patients who underwent a total of 1,157 fresh and 645 vitrified-warmed embryo transfers., Intervention(s): Day-5 single-blastocyst transfers using fresh or vitrified-warmed (Cryotop method) grade I and grade II embryos., Main Outcome Measure(s): Fetal heart pregnancy rate, live-birth rate, gestational age, and live-birth weight., Result(s): The overall blastocyst thaw survival rate was 94.4% and was not significantly different between blastocyst grades or developmental stages. Similar clinical outcomes were achieved for fresh and vitrified-warmed blastocyst transfers; for example, grade I blastocysts had a live-birth rate of 52.8% versus 55.3%, respectively, and grade II blastocysts had a rate of 34.9% versus 30.4%, respectively. Significantly improved neonatal outcomes were evident for vitrified-warmed blastocyst transfers for gestational age, being on average 0.3 weeks longer, and for live-birth weight with babies born on average 145 g heavier (3,296 g versus 3,441 g for fresh and vitrified-warmed groups, respectively), as compared with fresh transfers., Conclusion(s): Embryo transfer of vitrified-warmed blastocysts yields equivalent live-birth rates and improved neonatal outcomes compared with fresh transfers., (Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess trends in elective single ET and identify factors associated with a good perinatal outcome., Design: Retrospective cohort study., Setting: Clinic-based data., Patient(s): A total of 886,686 fresh, nondonor cycles reported to the National Assisted Reproductive Technology Surveillance System during 1999-2010, of which 17,166 met criteria for elective single ET., Intervention(s): None., Main Outcome Measure(s): Rates of elective single ET and good perinatal outcome (term, singleton infant with normal birth weight)., Result(s): In 2010, elective single ET comprised 5.6% of all fresh transfers, representing an eightfold increase since publication of first guidelines in 2004 recommending elective single ET. Compared with other ETs, elective single ETs were nearly twice as likely to result in a good perinatal outcome (37.1% vs. 18.9%, respectively). Among women using elective single ET, those aged <35 and 35-37 years had a good perinatal outcome (40.2% and 32.5%, respectively). In multivariable, log-binomial analyses, factors positively associated with a good perinatal outcome included male factor infertility, day 5 ET, and having ≥3 supernumerary embryos for cryopreservation., Conclusion(s): Between 1999 and 2010, national rates of elective single ET increased. Given the frequency of good perinatal outcomes among women aged 35-37 years, guidelines for elective single ET could be expanded to include patients in this age group with favorable prognoses., (Copyright © 2013 American Society for Reproductive Medicine. All rights reserved.)

Study Question: Given similar socio-demographic profiles and costs of healthcare, why has Australia been significantly more successful than the UK in reducing the assisted reproductive technology (ART) multiple birth rate?, Summary Answer: The Australian model of supportive public ART funding, permissive clinical guidelines and an absence of published clinic league tables has enabled Australian fertility specialists to act collectively to achieve rapid and widespread adoption of single embryo transfer (SET)., What Is Known Already: There are striking differences in ART utilization and clinical practice between Australia and the UK. The ART multiple birth rate in Australia is <8% compared with slightly <20% in the UK. The role played by public funding, clinical guidelines, league tables and educational campaigns deserves further evaluation., Study Design, Size, Duration: Parallel time-series analysis was performed on ART treatment and outcome data sourced from the Human Fertilisation and Embryology Authority (HFEA) ART Registry and the Australian and New Zealand Assisted Reproduction Database (ANZARD). Funding arrangements, clinical practice guidelines and key professional and public education campaigns were mapped to trends in clinical practice and ART treatment outcomes between 2001 and 2010., Participants/materials, Setting, Methods: A total of 425 360 and 422 003 autologous treatment cycles undertaken between 2001 and 2010 in the UK and Australia were analysed., Main Results and the Role of Chance: From 2001 to 2010, the most striking difference in clinical practice was the increase in SET cycles in Australia from 21 to 70% of cycles, compared with an increase from 8.4 to 31% in the UK. In 2004-2005, both countries introduced clinical guidelines encouraging safe embryo practices, however, Australia has a history of supportive funding for ART, while the National Health Service has a more restrictive and fragmented approach. While clinical guidelines and education campaigns have an important role to play, funding remains a key element in the promotion of SET., Limitations, Reasons for Caution: This is a descriptive population study and therefore quantifying the independent effect of differential levels of public funding was not possible., Wider Implications of the Findings: With demand for ART continuing to increase worldwide, it is imperative that we remove barriers that impede safe embryo transfer practices. This analysis highlights the importance of supportive public funding in achieving this goal.

Public financing of IVF aims at increasing access to treatment while decreasing the expenses associated with multiple pregnancies. Critics argue that it is associated with lower pregnancy rates. This study compared cycles performed during 2009 (before implementation of Quebec's public IVF programme; period I) to those performed in the year following implementation (period II) in a single IVF centre. First fresh cycles in period I (499 women) and first fresh cycles (815 women) along with their corresponding first vitrified-warmed transfer (271 women) in period II were evaluated. From period I to period II, single-embryo transfer increased from 17.3% to 85.0% (P<0.001), multiple ongoing pregnancy rate decreased from 25.8% to 1.6% (P<0.001) and ongoing pregnancy rate decreased from 31.9% to 23.3% (P=0.001). During period II, the ongoing pregnancy rate per vitrified-warmed embryo transfer was 19.2%, leading to a cumulative ongoing pregnancy rate per initiated cycle of 29.7%, which was not different to the pregnancy rate per fresh cycle during period I (31.9%). To conclude, Quebec's public IVF programme decreased multiple pregnancy rates while maintaining an acceptable cumulative ongoing pregnancy rate, a more precise outcome to evaluate the impact of public IVF programmes., (Copyright © 2013 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To estimate whether live birth in single-blastocyst transfers is correlated with the number of sibling supernumerary vitrified blastocysts (embryos not transferred) generated from that same cycle., Design: Retrospective cohort study., Setting: A large academic assisted reproduction clinic., Patient(s): All single-blastocyst transfers in 2010 graded as "good" embryos by Society for Assisted Reproductive Technologies (SART) criteria., Intervention(s): None., Main Outcome Measure(s): Implantation and live birth., Result(s): Of the 655 single-blastocyst transfers that met inclusion criteria, implantation occurred in 65% and live birth in 54% of cycles. In chi-square analysis, patients with supernumerary vitrified blastocysts had a statistically higher implantation rate (65% versus 50%) and live-birth rate (56% versus 41%) when compared with patients without supernumerary blastocysts. Univariate logistic regression demonstrated an increase in implantation (OR 1.09; 95% CI, 1.03-1.15) and live birth (OR 1.06; 95% CI, 1.02-1.09) with increasing number of supernumerary blastocysts. Multivariate logistic regression analysis demonstrated that patient age and the number of supernumerary blastocysts were statistically significantly associated with implantation and live birth., Conclusion(s): The number of supernumerary vitrified blastocysts correlated positively with the odds of implantation and live birth in good quality single-blastocyst transfers. Patients with supernumerary blastocysts are good candidates for single-embryo transfer., (Published by Elsevier Inc.)

Objective: To evaluate delivery rate and multiple pregnancy rates in ART (assisted reproductive techniques) following introduction of an elective single embryo tranfer (eSET) policy. This strategy was started in 2002 including transfer of one embryo for women less than 35 years with a least two good quality embryo during their first or second attempts., Patients and Methods: Retrospective study including all IVF cycles performed in the IVF centre of Clermont-Ferrand University Hospital from 01/01/2001 to 31/12/2010. Main outcome measures were number of embryos transferred, cumulative delivery and multiple pregnancy rates (including fresh and frozen embryo transfers). A subgroup analysis including patients' age was done., Results: Cumulative delivery rate reached 27,3% in 2010 with a significant drop in multiple pregnancy rate: from 30% in 2001 to 7,9% in 2010. The average number of transferred embryo decreased from 2.29 to 1.55 in the same period. In our centre, eSET was performed in 85% of first IVF attempt and in 34,4% of second attempts for women less than 35 years., Conclusion: The implementation of an eSET policy does not change the delivery rate but significantly decrease the number of multiple pregnancies compared to double embryo transfer. eSET should be carried out during the 1st and 2nd attempts in patients under 35 years when at least two good quality embryos were obtained., (Copyright © 2012. Published by Elsevier SAS.)

Objectives: To calculate cost savings to the Australian federal and state governments from the reduction in twin and triplet birth rates for infants conceived by assisted reproductive technology (ART) since 2002, and to determine the number of ART treatment programs theoretically funded by means of these savings., Design and Setting: Costing model using data from the Australia and New Zealand Assisted Reproduction Database, the National Perinatal Data Collection and Medicare Australia on ART treatment cycles undertaken in Australia between 2002 and 2008., Main Outcome Measures: Annual savings in maternal and infant inpatient birth-admission costs resulting from the reduction in ART multiple birth rate; theoretical number of ART treatment programs funded and infants born by means of these savings., Results: The reduction in the ART multiple birth rate from 18.8% in 2002 to 8.6% in 2008 resulted in estimated savings to government of $47.6 million in birth-admission costs alone. Theoretically, these savings funded 7042 ART treatment programs comprising one fresh plus one frozen embryo transfer cycle, equating to the birth of 2841 babies. Fifty-five per cent of the increased use of ART services since 2002 has been theoretically funded by the reduction in multiple birth infants., Conclusions: Against a backdrop of supportive public funding of ART in Australia, a voluntary shift to single embryo transfer by fertility clinicians and ART patients has resulted in substantial savings in hospital costs. Much of the growth in ART use has been theoretically cross-subsidised by the move to safer embryo transfer practices.

Objective: To identify the cumulus cell gene expression associated with oocyte developmental competence, specifically live birth, after single ET (SET) assisted reproductive technology., Design: Retrospective gene expression analysis in human cumulus cells from oocytes that established a pregnancy resulting in live birth versus no pregnancy after SET., Setting: Independent IVF clinic and research institute., Patient(s): Women undergoing IVF/intracytoplasmic sperm injection with SET., Intervention(s): Quantitative reverse-transcriptase-polymerase chain reaction analysis was performed on cumulus masses collected before insemination. Oocytes and embryos were cultured and transferred independently in 38 patients undergoing elective SET. Paired cumulus samples from oocytes that developed into high- versus low-grade embryos also were compared., Main Outcome Measure(s): Gene expression profiles of metabolic (ALDOA, LDHA, PFKP, PKM2), signaling (AHR, GREM1, PTGS2, STS), extracellular matrix (HAS2, PTX3, TNFAIP6, VCAN), and loading control GAPDH in individual cumulus masses., Result(s): VCAN and PTGS2 mRNA expression was significantly higher in cumulus cells from oocytes yielding a pregnancy resulting in a live birth, while PTX3 mRNA expression trended toward higher expression in pregnant samples. Cumulus cell levels of VCAN, GREM1, and PFKP correlated with birth weight in patients at 38 weeks of gestation. No genes correlated with clinical embryo morphology scores., Conclusion(s): Cumulus cell VCAN, PTGS2, GREM1, and PFKP expression may identify oocytes with high developmental potential, leading to enhanced implantation rates and greater developmental capacity throughout gestation., (Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.)