PGT-A Versus Blastocyst Morphology Selection

NCT ID: NCT03095053

Last Updated: 2019-06-17

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 302 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2017-03-23
• Study Completion Date: 2018-02-21

Brief Summary

Introduction Embryo aneuploidy is likely the leading cause of implantation failure in IVF cycles. Since the inception of IVF, non-invasive morphology based scoring has been the most widely used embryo selection method, resulting in relatively low embryo implantation rates. Our understanding of the optimal conditions required for in vitro embryo culture in IVF has advanced significantly over the past two decades. The implementation of improved in vitro embryo culture technologies (i.e., culture media and incubators) has resulted in an increase in the number of good quality embryos and consequently in increased numbers of blastocysts. While blastocyst transfers have seemingly improved the reproductive outcomes of IVF, they still remain suboptimal. The main objective of this randomized controlled trial (RCT) will be to investigate whether preimplantation genetic testing (i.e., PGT with comprehensive chromosome screening (CCS)) for aneuploidy is a superior embryo selection method, with the live birth outcomes of euploid blastocyst frozen embryo transfers (FET) compared with the LB outcomes of unknown-ploidy blastocyst FET, with blastocysts selected on (standard) morphological score.

Methods This RCT will be conducted at a single private IVF centre performing routine segmented-IVF, with intracytoplasmic sperm injection (ICSI), blastocyst freeze-all, and artificial frozen embryo transfer (art-FET). Normo-ovulatory infertile patients, with maternal age ≤35 years and at least two blastocysts with a morphology score of 2BB cryopreserved, will be randomized by computer-generated randomized allocation to either the PGT or morphology arm of the trial. All transfers will be single embryo transfers (SET), with only the first FET cycles following freeze-all to be analyzed.

Consent and Ethics Akdeniz University Medical Faculty Clinical Research Ethics Committee has approved the trial (reference number: 2015/399), with anonymized results to be released in ClinicalTrials.gov. All patients will provide informed consent, which included an agreement for the use of anonymised data for research and SET.

Detailed Description

Introduction Embryo aneuploidy is likely the leading cause of implantation failure in IVF cycles. Since the inception of IVF, non-invasive morphology based scoring has been the most widely used embryo selection method, resulting in relatively low embryo implantation rates. Embryo morphology assessment methods have significant limitations (i.e., the assessments are subjective and the method uses fixed time-point assessments to define dynamic embryo development) and shortcomings (i.e., exposes embryos to sub-optimal conditions during assessment). Notwithstanding the limitations and shortcomings of this method its use worldwide has continued, because it is a relatively simple and non-invasive method and its scores have been shown to be (moderately) positively correlated to embryo euploidy, ongoing pregnancy, and live birth (Van Royen et al., 1999, Ahlstrom et al., 2011, Forman et al., 2013, Capalbo et al., 2014, Oron et al., 2014, Rhenman et al., 2015).

However multiple gestations still represents one of the most significant complications in IVF, which are mainly the result of multiple-embryo embryo transfers, with multiple-embryo transfers used to overcome the relatively low embryo implantation rates in IVF. Our understanding of the optimal conditions required for in vitro embryo culture in IVF has advanced significantly in the past two decades. The implementation of improved in vitro embryo culture technologies (i.e., culture media and incubators) has resulted in an increase in the number of good quality embryos and consequently in the numbers of blastocysts. While blastocyst transfers have seemingly improved the reproductive outcomes in IVF, the use of SET and PGT technologies have revealed embryo implantation still to be sub-optimal (Schoolcraft et al., 2013). New CCS platforms are a major breakthrough in PGT, allowing 24-chromosome screening to be performed with high degree of accuracy from single cells (Harper and Harton, 2010). The evidence that morphology scores were only moderately associated with euploidy and that the transfer of PGT predicted euploid embryos resulted in higher implantation rates (Dahdouh et al., 2015), has seen the continued use of morphology-based scoring methods increasingly being challenged.

In addition to all the other advances in IVF, significant improvements have also been made in cryopreservation technologies. These improvements have resulted in significant improvements in frozen-thawed embryo survival (i.e. minimizing of risks), post-thaw developmental competence (Cobo et al., 2012; Balaban et al., 2008), and in the reproductive outcomes of FET (Evans et al., 2014; Ozgur et al., 2015). The benefits of FET include; the transfer of embryos to a more physiologic endometrium (i.e., early luteal phase), the ability to time transfers more accurately, and the ability to use patient-specific endometrial preparations (Casper and Yanushpolsky, 2016, Franasiak et al., 2016; Groenewoud et al., 2013, Yarali et al., 2016).

Moreover, the hypotheses of PGT requires to be confirmed in further robust RCT before its implementation in routine IVF.

Objectives The primary objective of this RCT will be to investigate whether PGT for aneuploidy as a blastocyst selection method is superior to standard morphology scoring blastocyst selection, comparing the reproductive outcomes in FET cycles. The decision to transfer all blastocysts in FET will eliminate any potential impact of ovarian stimulation confounding on endometrial receptivity and to use freeze-all cycles will allow the use of the primary blastocysts of blastocyst cohorts. The primary outcome measure of this trial will be LB, with a LB defined as a pregnancy cycle delivering at >20 weeks of gestation.

Secondary objectives The secondary objective of the RCT will be to investigate whether euploid blastocyst transfer results in reduced miscarriage, with a miscarriage defined as a clinical pregnancy lost at <20 weeks of gestation.

Keywords: blastocyst; comprehensive chromosome screening; euploidy; frozen embryo transfer

Conditions

Pregnancy

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

PGT-A group

Next Generation sequencing preimplantation genetic testing for aneuploidy

Group Type: ACTIVE_COMPARATOR

comprehensive chromosome screening

Intervention Type: PROCEDURE

Biopsy Blastocysts with morphological grades of ≥2BB will be biopsied on day 5 of in vitro embryo culture. Biopsies will be performed using a Hamilton Thorne Zilos laser (Hamilton Thorne, MA, USA), with 3-10 trophectoderm cells removed from the blastocysts.

Comprehensive chromosome screening All trophectoderm biopsies will be processed for analysis by Next-Generation Sequencing (NGS, Illumina, California, USA).

Morphology group

morphological assessment of blastocyst by light microscope

Group Type: NO_INTERVENTION

No interventions assigned to this group

Interventions

comprehensive chromosome screening

Biopsy Blastocysts with morphological grades of ≥2BB will be biopsied on day 5 of in vitro embryo culture. Biopsies will be performed using a Hamilton Thorne Zilos laser (Hamilton Thorne, MA, USA), with 3-10 trophectoderm cells removed from the blastocysts.

Comprehensive chromosome screening All trophectoderm biopsies will be processed for analysis by Next-Generation Sequencing (NGS, Illumina, California, USA).

Intervention Type: PROCEDURE

Eligibility Criteria

Inclusion Criteria

Patient-couples eligible for inclusion in the trial must satisfy the following criteria; female age of ≤35 years, female body mass index (BMI) of ≥18 or ≤35 kg/m2, antral follicle count (AFC) of ≥10, normo-ovulatory, intend to use autologous oocytes, and have ≥2 blastocysts with a morphological score of 2BB on day 5 of embryo development

Exclusion Criteria

Patient couples will be excluded from the trial for the following reasons, patients with drug contraindications, patients with pathophysiology unrelated to reproduction, patients with intrauterine pathophysiologies, patients with no blastocysts, patients with <2 blastocysts with a morphological score of 2BB.

• Minimum Eligible Age: 18 Years
• Maximum Eligible Age: 35 Years
• Eligible Sex: FEMALE
• Accepts Healthy Volunteers: No

Sponsors

Antalya IVF

OTHER

Sponsor Role: lead

Responsible Party

Kevin Coetzee

Scientific advisor

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Kevin Coetzee, PhD

Role: PRINCIPAL_INVESTIGATOR

Antalya IVF

Locations

Antalya IVF

Antalya, , Turkey (Türkiye)

Countries

Turkey (Türkiye)

References

Ahlstrom A, Westin C, Reismer E, Wikland M, Hardarson T. Trophectoderm morphology: an important parameter for predicting live birth after single blastocyst transfer. Hum Reprod. 2011 Dec;26(12):3289-96. doi: 10.1093/humrep/der325. Epub 2011 Oct 3.

Reference Type: RESULT

PMID: 21972253 (View on PubMed)

Balaban B, Urman B, Ata B, Isiklar A, Larman MG, Hamilton R, Gardner DK. A randomized controlled study of human Day 3 embryo cryopreservation by slow freezing or vitrification: vitrification is associated with higher survival, metabolism and blastocyst formation. Hum Reprod. 2008 Sep;23(9):1976-82. doi: 10.1093/humrep/den222. Epub 2008 Jun 10.

Reference Type: RESULT

PMID: 18544577 (View on PubMed)

Capalbo A, Rienzi L, Cimadomo D, Maggiulli R, Elliott T, Wright G, Nagy ZP, Ubaldi FM. Correlation between standard blastocyst morphology, euploidy and implantation: an observational study in two centers involving 956 screened blastocysts. Hum Reprod. 2014 Jun;29(6):1173-81. doi: 10.1093/humrep/deu033. Epub 2014 Feb 26.

Reference Type: RESULT

PMID: 24578475 (View on PubMed)

Casper RF, Yanushpolsky EH. Optimal endometrial preparation for frozen embryo transfer cycles: window of implantation and progesterone support. Fertil Steril. 2016 Apr;105(4):867-72. doi: 10.1016/j.fertnstert.2016.01.006. Epub 2016 Jan 25.

Reference Type: RESULT

PMID: 26820769 (View on PubMed)

Cobo A, de los Santos MJ, Castello D, Gamiz P, Campos P, Remohi J. Outcomes of vitrified early cleavage-stage and blastocyst-stage embryos in a cryopreservation program: evaluation of 3,150 warming cycles. Fertil Steril. 2012 Nov;98(5):1138-46.e1. doi: 10.1016/j.fertnstert.2012.07.1107. Epub 2012 Aug 3.

Reference Type: RESULT

PMID: 22862909 (View on PubMed)

Dahdouh EM, Balayla J, Garcia-Velasco JA. Comprehensive chromosome screening improves embryo selection: a meta-analysis. Fertil Steril. 2015 Dec;104(6):1503-12. doi: 10.1016/j.fertnstert.2015.08.038. Epub 2015 Sep 16.

Reference Type: RESULT

PMID: 26385405 (View on PubMed)

Evans J, Hannan NJ, Edgell TA, Vollenhoven BJ, Lutjen PJ, Osianlis T, Salamonsen LA, Rombauts LJ. Fresh versus frozen embryo transfer: backing clinical decisions with scientific and clinical evidence. Hum Reprod Update. 2014 Nov-Dec;20(6):808-21. doi: 10.1093/humupd/dmu027. Epub 2014 Jun 10.

Reference Type: RESULT

PMID: 24916455 (View on PubMed)

Forman EJ, Upham KM, Cheng M, Zhao T, Hong KH, Treff NR, Scott RT Jr. Comprehensive chromosome screening alters traditional morphology-based embryo selection: a prospective study of 100 consecutive cycles of planned fresh euploid blastocyst transfer. Fertil Steril. 2013 Sep;100(3):718-24. doi: 10.1016/j.fertnstert.2013.04.043. Epub 2013 May 30.

Reference Type: RESULT

PMID: 23725804 (View on PubMed)

Franasiak JM, Ruiz-Alonso M, Scott RT, Simon C. Both slowly developing embryos and a variable pace of luteal endometrial progression may conspire to prevent normal birth in spite of a capable embryo. Fertil Steril. 2016 Apr;105(4):861-6. doi: 10.1016/j.fertnstert.2016.02.030.

Reference Type: RESULT

PMID: 26940791 (View on PubMed)

Groenewoud ER, Cantineau AE, Kollen BJ, Macklon NS, Cohlen BJ. What is the optimal means of preparing the endometrium in frozen-thawed embryo transfer cycles? A systematic review and meta-analysis. Hum Reprod Update. 2013 Sep-Oct;19(5):458-70. doi: 10.1093/humupd/dmt030. Epub 2013 Jul 2.

Reference Type: RESULT

PMID: 23820515 (View on PubMed)

Harper JC, Harton G. The use of arrays in preimplantation genetic diagnosis and screening. Fertil Steril. 2010 Sep;94(4):1173-1177. doi: 10.1016/j.fertnstert.2010.04.064. Epub 2010 Jun 25.

Reference Type: RESULT

PMID: 20579641 (View on PubMed)

Oron G, Son WY, Buckett W, Tulandi T, Holzer H. The association between embryo quality and perinatal outcome of singletons born after single embryo transfers: a pilot study. Hum Reprod. 2014 Jul;29(7):1444-51. doi: 10.1093/humrep/deu079. Epub 2014 May 8.

Reference Type: RESULT

PMID: 24812313 (View on PubMed)

Ozgur K, Berkkanoglu M, Bulut H, Isikli A, Coetzee K. Higher clinical pregnancy rates from frozen-thawed blastocyst transfers compared to fresh blastocyst transfers: a retrospective matched-cohort study. J Assist Reprod Genet. 2015 Oct;32(10):1483-90. doi: 10.1007/s10815-015-0576-1. Epub 2015 Sep 23.

Reference Type: RESULT

PMID: 26400506 (View on PubMed)

Rhenman A, Berglund L, Brodin T, Olovsson M, Milton K, Hadziosmanovic N, Holte J. Which set of embryo variables is most predictive for live birth? A prospective study in 6252 single embryo transfers to construct an embryo score for the ranking and selection of embryos. Hum Reprod. 2015 Jan;30(1):28-36. doi: 10.1093/humrep/deu295. Epub 2014 Nov 5.

Reference Type: RESULT

PMID: 25376459 (View on PubMed)

Schoolcraft WB, Katz-Jaffe MG. Comprehensive chromosome screening of trophectoderm with vitrification facilitates elective single-embryo transfer for infertile women with advanced maternal age. Fertil Steril. 2013 Sep;100(3):615-9. doi: 10.1016/j.fertnstert.2013.07.1972.

Reference Type: RESULT

PMID: 23993664 (View on PubMed)

Van Royen E, Mangelschots K, De Neubourg D, Valkenburg M, Van de Meerssche M, Ryckaert G, Eestermans W, Gerris J. Characterization of a top quality embryo, a step towards single-embryo transfer. Hum Reprod. 1999 Sep;14(9):2345-9. doi: 10.1093/humrep/14.9.2345.

Reference Type: RESULT

PMID: 10469708 (View on PubMed)

Yarali H, Polat M, Mumusoglu S, Yarali I, Bozdag G. Preparation of endometrium for frozen embryo replacement cycles: a systematic review and meta-analysis. J Assist Reprod Genet. 2016 Oct;33(10):1287-1304. doi: 10.1007/s10815-016-0787-0. Epub 2016 Aug 22.

Reference Type: RESULT

PMID: 27549760 (View on PubMed)

Ozgur K, Berkkanoglu M, Bulut H, Yoruk GDA, Candurmaz NN, Coetzee K. Single best euploid versus single best unknown-ploidy blastocyst frozen embryo transfers: a randomized controlled trial. J Assist Reprod Genet. 2019 Apr;36(4):629-636. doi: 10.1007/s10815-018-01399-1. Epub 2019 Jan 7.

Reference Type: DERIVED

PMID: 30617927 (View on PubMed)

Provided Documents

Document Type: Study Protocol and Statistical Analysis Plan

View Document

Other Identifiers

Optimizing implantation in FET

Identifier Type: OTHER

Identifier Source: secondary_id

euploid versus morphology

Identifier Type: -

Identifier Source: org_study_id