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Disclosure
Marcos MeseguerValencian Infertility Institute (IVI)Valencia, Spain
Declared no potential conflict of interest.
How we can use recent technology in the IVF cycles to improve IVF
Marcos Meseguer
Spain
✓ What makes a difference? technologies?
Excellence in IVF?
IVF Lab
Vitrification
GeneticScreening
IMSI
Macs
PolarizedMicroscopy
Time-Lapse
Meseguer M. Fertil Steril. 2016;105:295-6.
Time-lapse the remaining questions
Time-lapse set-up; IVI Valencia
Less disturbancebetter development
Time-lapse set-up; IVI Valencia
Less disturbancebetter development
Time-lapse set-up; IVI Valencia
More observations better selection
Time-lapse set-up; IVI Valencia
Less disturbancebetter development
INDIVIDUAL CHAMBERS & BENCHTOP
Fast Tº & CO2 recovery
Small volume
Undisturbed culture
Continuous monitoring
Time lapse incubator: Exploring Biomimetics Concepts
D5+D6 D5
Blastocyst Rate
20%
30%
40%
50%
60%
70%
80%69,00%
64,70%
75,00%69,60%
Dry Conditions
Humid Conditions
Albert C and Meseguer M Alpha 2018
Improved Cultured conditions Dry vs Humid conditions
**
10%
20%
30%
40%
50%
60%
70%
80%
90%
Abortion Pregnancy
Blastocyst Rate
26,50%
66,70%
16,00%
83,30%
Dry Conditions
Humid Conditions
n=1366 EmbryosN=84 patients
Time lapse incubator: Exploring Biomimetics Concepts
Albert C and Meseguer M Alpha 2018
Improved Cultured conditions Dry vs Humid conditions
n=1366 EmbryosN=84 patients
0
20
40
60
80
100
120
Dry Conditions
Humid Conditions
Time lapse incubator: Exploring Biomimetics Concepts
Albert C and Meseguer M Alpha 2018
Improved Cultured conditions Dry vs Humid conditionsn=1366 Embryos
N=84 patients
40,0
50,0
60,0
70,0
80,0
90,0
100,0
110,0
120,0
130,0
H1sm H2sm H3sm Ratiosm AVEHsm
Co
un
ts P
er
Seco
nd
Embryo Spent Culture Media Oxidation-ThermoChemoluminiscence (TCL)
Humid
Dry
Time lapse incubator : Exploring Biomimetics Concepts
The evolution of TL incubators
ESD+; Precision Embryology
HIGHEST RESOLUTION VIDEOS
ESD+; Precision Embryology
Accurate Annotations
Accurate Annotations
Accurate Annotations
CLINICAL RESULTS JANUARY 2016–JUNE 2017
All blastocysts 90% SET
Standard incubator (no evaluation on cleavage stage) vs time-lapse
More observations Better selection
Less disturbanceBetter development
41.1%58.9%
Number of cyclestime-lapse vs conventional
incubator
CI TIME-LAPSE
Conventional incubators vs time-lapse incubators(n = 5574)
CONVENTIONALINCUBATOR
Ongoing pregnancy
*
*p < 0.05
More observations Better selection
Less disturbanceBetter development
PGS, preimplantation genetic screening. Meseguer M, personal data.
Fresh or deferred first-transfer time-lapse - NO PGS
Age
% O
ngo
ing
pre
gnan
cy
*
Ongoing pregnancy
Meseguer M, personal data.
PGS first-transfer trophoectoderm biopsy time-lapse vs standard incubator
More observations Better selection
Less disturbanceBetter development
Age
% O
ngo
ing
pre
gnan
cy
*
56,2
0,8 0,7
41,3
1
55
1,5 0,3
42,4
0,8
52,8
0 0
47,2
00
10
20
30
40
50
60
ABNORMAL ABNORMAL/DESEQ AMPLIFICATION FAILURE NORMAL NORMAL/EQUIL
CI
ESD
GERI
*
*p = 0.022
n = 163
n = 1,832
n = 3,307
Meseguer M, personal data.
Less disturbanceBetter development
% ploidy of the results in each incubatorN = 5,311 blastocysts
*
CONVENTIONAL INCUBATOR
ESD
% p
loid
yOUTCOME FROM DIFFERENT TIME-LAPSE SYSTEMS
GERI
n = 4,573
n = 3,614n = 366
0
5
10
15
20
25
30
35
40
CI EEVA ESD GERI
Less disturbanceBetter development
Meseguer M, personal data.
% of good-quality blastocysts (A/B) on Day 5 in each incubator
**
CONVENTIONAL INCUBATOR
% o
f go
od
-qu
alit
y b
last
ocy
sts
(A/B
)
OUTCOME FROM DIFFERENT TIME-LAPSE SYSTEMS
Evolution of the data; exponential growth
1653 2120 363011699
44800
78000
124000
189000
243000
288000
0
50000
100000
150000
200000
250000
300000
350000
YEAR 2009 2010 2011 2012 2013 2014 2015 2016 2017
EMBRYOS RECORDED
Manual annotations
Database registration
Exponential growth of time required for data acquisition/annotation…
Next evolutionary steps of automated software analysis for CEM
27
The evolution of the analysis in DANA: V2.0. Machine vs Embryologists
Del Gallego ASRM 201828
Phase 4
Prospective Automatic
DANA vs Embryologist
320 embryos
Event detection
V.2% Total %V.1%
Precision embryology
92%97%
90%86%
91%
9%13%
87%
The evolution of the analysis: Software vs embryologist
Del Gallego, ASRM 201829
Phase 4
Prospective Automatic
DANA vs Embryologist
320 embryos
Accuracy
Detected events % of Events in Range
Precision embryology
Meseguer and Hickman, Eshre 2018
The evolution of the a analysis; artificial Intelligence vs embryologist
Grade of
Expansion
Cat. 1
2
Cat. 2
3
Cat. 3
4
Kappa
Average
Kappa 0.751
(0.620-0.883)
0.652
(0.521-0.783)
0.790
(0.659-0.921)
0.729
(0.632-0.826)
P-value < 0.001 < 0.001 < 0.001 < 0.001
Inner Cell MassCat. 1
1
Cat. 2
2
Cat. 3
3
Kappa
Average
Kappa da
categoria
0.779
(0.363-0.446)
0.688
(0.137-0.220)
0.681
(0.551-0.811)
0.705
(0.606-0.804)
P-value < 0.001 < 0.001 < 0.001 < 0.001
TrophoectodermCat. 1
1
Cat. 2
2
Cat. 3
3
Kappa 0.382
(0.256-0.507)
0.402
(0.273-0.531)
0.501
(0.370-0.631)
0.438
(0.332-0.544)
P-value < 0.001 < 0.001 < 0.001 < 0.001
Meseguer, Hickman Rocha. Eshre 2018
The evolution of the a analysis; artificial Intelligence vs embryologist
Grade of
Expansion
Cat. 1
2
Cat. 2
3
Cat. 3
4
Cat. 4
5
Kappa
Average
Kappa 0.422
(0.464-0.381)
0.222
(0.181-0.264)
0.508
(0.466-0.549)
0.114
(0.072-0.155)
0.371
(0.342-0.400)
P-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Inner Cell MassCat. 1
1
Cat. 2
2
Cat. 3
3-
Kappa
Average
Kappa da
categoria
0.404
(0.363-0.446)
0.178
(0.137-0.220)
0.285
(0.243-0.326)-
0.267
(0.236-0.298)
P-value < 0.001 < 0.001 < 0.001 - < 0.001
TrophoectodermCat. 1
1
Cat. 2
2
Cat. 3
3
Kappa 0.353
(0.312-0.395)
0.209
(0.167-0.250)
0.376
(0.334-0.417)-
0.299
(0.268-0.331)
P-value < 0.001 < 0.001 < 0.001 - < 0.001
Embryologist vs artificial Intelligence
Meseguer M, personal data.
Machine Learning Embryo selection Software
360 videos and corresponding metadata (morphokinetics and clinical data); LiveBirth Prediction
1. Image Processing
2. Learning Embeddings of Images
3. Training Prediction Model using Image
4. Creating features from embryo meta-data
5. Training Prediction Model using embryo meta-data
6. Combining two prediction models (image + meta-data) to produce final prediction for the embryo
RCT, randomized controlled trial. Pribenszky C, et al. Reprod Biomed Online. 2017;35:511-20.
The last metanalysis reported More observations Better selection
Less disturbanceBetter development
Outcomes
Assumed risk(conventional
incubation, median-risk population)
Corresponding risk(time-lapse,Median-riskpopulation)
Relativeeffect
(95% CI)
No. of participants
(studies)
Quality ofevidence (GRADE)
Ongoing pregnancy 410/1,000517/1,000(457–577)
OR 1.542 (1.211–1.965)
1,637 (5 RCTs) Moderate 1.5
Early pregnancy loss 196/1,000139/1,000(103–186)
OR 0.662 (0.469–0.935)
904 (5 RCTs) Moderate 2.5
Live birth 321/1,000441/1,000(349–537)
OR 1.668(1.134–2.455)
481 (3 RCTs) Moderate 3.5
Stillbirth 29/1,00069/1,000(23–188)
OR 2.483(0.794–7.759)
481 (3 RCTs) Low 4.5
GRADE Working Group grades of evidence• High quality: further research is very unlikely to change our confidence in the estimate of effect• Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may
change the estimate• Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is
likely to change the estimate• Very low quality: we are very uncertain about the estimate
Vitrification in IVF
Vitrification as an adjunct tool to PGT programs
1 hour
Vitrification
NGS
Euploid
blastocysts
Embryo transfer
0,00%
20,00%
40,00%
60,00%
80,00%
100,00%
SV IR CPR OPR
93,60%
56,20% 60,90%53,90%
N=3552 embryos
6% Euploid Embryos do not Survive
and ~40% do not implant
Overall outcomes in PGT cycles: TE biopsy + blastocyst vitrification
What are the reasons for the failure
Implantation failure of Euploid Embryos
✓Synchrony embryo-endometrium✓Age: Older patients are more likely
to have “slow” embryos✓Immunology and uterine receptivity
✓ Harmful effect of vitrification?✓ Embryo quality?
Survival Failure of Euploid Embryos
Implantation rate according to embryo quality
Own oocytes Ovum donation
IVI data 2016-2017 (Unpublished)
The biopsied blastocysts…o SV and IRo TE scoreo Expansion
Evaluation of Survival. Post-warming observations
2. Clearly Dead
T0 post-warmingPost-biopsy 6h post-warming 6h post warming
1. Clearly Alive
T0 post-warming
PGT Day 5-6 blastocyst. Embryo quality according to ASEBIR
22,40%
56,90%
19,90%
0,60%
A
B
C
D
N=3974 embryos
Embryo quality and PGT outcomes.
*= P<0.05N=3974 embryos
97,8
63,7 63,357,1
92,9
56,7 59,751,8
92
45,4 44,936,7
0
20
40
60
80
100
120
SV rate (%) IR (%) CPR (%) OPR (%)
ASEBIR PGS D5+D6
A B C
*
*
* ** *
*
Survival and Clinical outcomes for PGT embryos according to embryo quality (ASEBIR)
PGT. SV and IR according to embryo quality and day of biopsy/vitrification
94,8%95,7%
92,6%91,9%
87,3%85,7%
80,0%
82,0%
84,0%
86,0%
88,0%
90,0%
92,0%
94,0%
96,0%
98,0%
A B C
Survival according to ASEBIR
SV D5 SV D6
* *
Nº warmed D5 embryos
A
B
C
Number of warmed D6 embryos A
B
62,9%58,1%
51,1%
58,4%52,8%
41,0%
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
A B C
IR according to ASEBIR
IR D5 IR D6
**
* P<0.05
25,8%
61,3%
12,9%
16,8%
51,6%
31,5%
Day5 Day6
Nº warmed embryos 2159 1815
* P<0.05
PGT. SV and IR according to Blastocyst expansion and day of biopsy/vitrification
NS
98,9% 99,6%
92,9%
98,6% 99,6%
88,5%
80,0%
85,0%
90,0%
95,0%
100,0%
105,0%
BE BHi BH
Survival rate Day 5/6
SV D5 SV D6
73,7%
53,6%
43,7%
75,0%
43,0%37,7%
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
80,0%
BE BHi BH
Implantation rate Day 5/6
IR D5 IR D6
*
Nº embryos D5
BHi
83,8%
11%5,2%
Nº embryos D6
BHi
65,7%
30,8%3,5%
o Both survival and IR are closely related toembryo quality.
o Type A embryos: comparable resultsbetween day-5 and day 6 (IR).
o Type B and C embryos: higher outcomesfor day 5 vs. day 6 (SV and IR).
o Hatched Blastocysts yield the lowestoutcomes.
The hatched blastocyst.
Can we do better?
Evaluation of survival of biopsied blastocysts can be sometimes difficult, especially with hatched blastocysts….
t0
4.5h post warming
1.
**
t0
2h post warming
4.
**
2.
*
t0
3.
*
t0
T0 post-warming 2h post-warming
5.
TimingProgramming of biopsies and vitrification procedures in order to perform the biopsy at the HiB stage. RESCHEDULE.
If not sure of the quality of the blastocyst once biopsied: Do the tubbing and wait at least 2 hours before going on with the vitrification procedure.
Timing after warming: Make sure about survival: re-expansion.
Re-expansion of the he warmed biopsied blastocyst
ZP-Included: 3.2h ZP-Included: 4.3h Hatched Blastocysts: 5.3h
Initiation of re-expansion
Coello, A., et al. (2017) Fertil Steril 108(4): 659-666 e654.
Time-lapse evaluation of re-expansion of warmed blastocysts (No PGT)
Timing for cryotransfer after warming
64,80% 63,60%
50,00%
35,30%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
up to 4 hours 4-5 hours 5-6 hours >6 hours
Included within the ZPCPR
60,90%68,20%
81,80%
50,00%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
80,00%
90,00%
up to 4hours
4-5 hours 5-6 hours >6 hours
Hatching and Hatched Blastocysts
CPR
The Operator
Capalbo et al. (2016). Hum Reprod 31(1): 199-208.
Operator experience and outcome
This technology is the combination of:
- A single dish were the embryos remain meanwhile the media
are exchanged automatically.
- Automatic sealing “reduce cross contamination risk”
- Very thin dish walls to allow quick vitrification and warming
Fungible of individual use; Gavi Dish, Cassette, Gavi Cartridge
with media, Gavi Cartridge with pipette and seal.
4 steps
Automated Vitrification Instrument
Source: Web search
AUTOMATION IN THE IVF LAB
Acknowledgements:
Lucia Alegre (DANA)Raquel del Gallego (DANA)
Lorena Bori (ESD+)Ernesto Bosch (Data Analysis)
Belen Aparicio-Ruiz (Eeva)Carmela Albert (Geri)
Sonia Perez-Albala (Eeva)
Thank you