Should Every Embryo be Screened or Frozen? What does the evidence say?

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Chloe Stafford
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Scott, Jr, MD, HCLD Clinical and Scientific Director, Reproductive Medicine Associates

1 Should Every Embryo be Screened or Frozen? What does the evidence say? acgh (Lab 1) 45,XY,-8 qpcr (Lab 2) SNP array (Lab 3) 46,XY Richard T. Scott, Jr, MD, HCLD Clinical and Scientific Director, Reproductive Medicine Associates of New Jersey Professor and Director, Reproductive Endocrinology Robert Wood Johnson Medical School, Rutgers University

2 Percent of Embryos Which are Aneuploid Contemporary Understanding of Maternal Age and Human Embryonic Aneuploidy N=15, Age (yrs) Franasiak et al Fertil Steril 2014

3 Copy Number Is transferring an aneuploid embryo clinically useful? Gain of X Chromosome #

4 What are the Burdens of CCS Thus the real questions are: 1. Safely attaining embryonic DNA 2. Predictive values of the techniques 3. Proportion of euploid embryos that will fail 4. Cost effectiveness

5 Some Disagree with PGS

Some Disagree with PGS All embryo selection techniques are detrimental Inappropriate to use Implantation Rates as an endpoint it can be questioned whether all patients will ever be able to understand

without impairing, and maybe even improving, the cumulative pregnancy rate of that IVF cycle Embryo selection should therefore not be used to select out embryos, but only to determine the order in

6 Some Disagree with PGS All embryo selection techniques are detrimental Inappropriate to use Implantation Rates as an endpoint it can be questioned whether all patients will ever be able to understand all of the complexities concerning PGS cost-effectiveness is being forgotten evidence is now accumulating that all embryos in an IVF cycle can be cryopreserved and transferred in subsequent cycles without impairing, and maybe even improving, the cumulative pregnancy rate of that IVF cycle Embryo selection should therefore not be used to select out embryos, but only to determine the order in which the embryos will be transferred, as the time to pregnancy can be improved by embryo selection, if embryos with the highest implantation potential are transferred first. Culturing to the blastocyst may be harmful

7 Does Embryo Biopsy Impact the Developmental Potential of the Oocyte Routine IVF Care through Retrieval Transfer the embryos Identify mature oocytes ICSI, culture, and select 2 best embryos for transfer Implantation, Maternal serum sampling for free fetal DNA and Fingerprinting Cell submitted for eventual aneuploidy screening and fingerprinting One embryo randomized to undergo biopsy N=113 pairs; 226 embryos

8 Overall implantation rates 39% reduction insignificant In our opinion, day 3 biopsy will soon be of historic interest only 27% (mean maternal age 32) reported by Gutierrez-Mateo, C., et al. Fertility and sterility 92, (2009)

9 Predictive Value (%) Predictive Value (%) Is knowing the predictive value of a normal result sufficient? Normal Result CIN III or Malignancy If they were the same it would likely be a rare coincidence Abnormal Result CIN III or Malignancy Sherman et al 95: J Natl Cancer Inst (2003)

100 90 80 70 % 60 50 40 With greater experience, actual negative predictive value is ~98.

10 % With greater experience, actual negative predictive value is ~98.8% < Age (yrs) Scott et al Fertil Steril 2012; 97:870-5

11 To have the opportunity for meaningful improvement, when you select for one criteria you most commonly deselect for another. Transfer Based on Embryo Morphology Abnl Abnl Nl Abnl Nl Nl Transfer Based on Aneuploidy Screening and Embryo Morphology CCS changes the embryo selected 40% of the time Forman et al ASRM 2012

12 acgh enhances delivery rates an RCT RCT Age All < 35 Mean age of 31 Sample Size 55 acgh 48 control Significant improvement in outcomes Monosomy:Trisomy Ratio of 2 Answers one of the four critical validation questions

13 Scott et al Fertility and Sterility 2013; 100:

14 No-Euploid Blasts Rate (%) The No Transfer Rate with CCS N=15, > 45 Age (yrs) Franasiak et al Fertil Steril 2014

15 Proportion of Cases with this number of blastocysts available for Biopsy (%) Cumulative Proportion of Cases with this number of blastocysts available for Biopsy (%) How Many Embryos Do Patient Undergoing CCS Have? % of cases had 3 or fewer evaluable embryos N=15, Franasiak et al Fertil Steril 2014 Number of Blastocyts

16 Trisomy:Monosomy Ratio Trisomy:Monosomy Ratio by Age N=15,169 Ratios consistent across nine programs < Age Group (yrs) Franasiak et al Fertil Steril 2014 Key Indicator for QA of your assay

17 Clinical Experience Misdiagnoses 4974 embryos 2976 gestations (62.1%) 10 errors 1 tetraploid 2 monosomies 7 trisomies Clinical Error Rate Per embryo 0.2% Per transfer 0.3% Per ongoing pregnancy 0.1% 3168 transfers 2354 ongoing / delivered (72.1%) Mean age 38.4 years 10 errors 7 found in losses 3 found in ongoing preg. Mosaicism evaluated in 4 samples 100% mosaic

18 Clinical Loss Rate (%) Consolidated Pregnancy Outcomes Proportion of All Pregnancies N=4,754 pregnancies CCS - Delivery No Screening - Delivery CCS - Clinical Loss No Screening - Clinical Loss CCS - Chemical Los No Screening - Chemical Loss 10 0 < Maternal Age (yrs) Scott KL et al RMA

19 Sustained Implantation Rate (%) PGS Improves but Does Not Normalize Implantation and Delivery Rates in Older Women N=28, < Maternal Age (yrs)

20 Kulkarni D et al, New Engl J Med, PMID:

21 Kulkarni D et al, New Engl J Med, PMID:

22 Singleton Term Delivery: The Ideal IVF Outcome IVF twin pregnancies are at an increased risk of: Preeclampsia (2-fold risk increase) 1 Extreme prematurity (7.4-fold increase delivery <32 wks) 2 NICU admission (3.8-fold increased risk) 2 Perinatal Death (2-fold increase) 2 Two IVF singleton deliveries have better obstetrical outcomes than one IVF twin delivery 3 1. ASRM Practice Committee, Fertil Steril, PMID: Pinborg A, et al., Acta Obstet Gynecol Scand, PMID: Sazonova A,et al., Fertil Steril, PMID:

23 Provided by a patient

24 With >2 blastocysts, even patients at high aneuploidy risk are very likely to have a euploid blastocyst Probability of at least 1 Euploid Blastocyst 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Blastocyst Aneuploidy Rate by Age Group 21% 34% 55% 64% < Forman EJ et al., O % 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% Aneuploidy Rate 2 Blastocyst 3 Blastocyst 4 Blastocyst

25 FRESH SET RESULTS IN LOWER DELIVERY RATES THAN DOUBLE EMBRYO TRANSFER (DET) 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Livebirth Rate - SET vs. DET 13.2% 0.5% Twins Singletons 30% 26% SET DET Cochrane Review of 6 randomized trials from (N = 1,257) Young, good prognosis patients with top quality embryos available Slightly more singletons after DET Pandian Z et al., Cochrane Database Syst Rev, PMID:

Percent Dropout The Dropout Rate from IVF is Significant 70% 60% 50% 40% 30% 20% 10% Dropout/cycle Cumm Actual PR 0% 1 2 3 4 5 6 7 Cycle Number

26 Percent Dropout The Dropout Rate from IVF is Significant 70% 60% 50% 40% 30% 20% 10% Dropout/cycle Cumm Actual PR 0% Cycle Number Source: Schroder AK: Cumulative pregnancy rates and drop out rates of a German IVF programme: 4, 102 cycles in 2,130 patients. RBM Online (2004) 8:

27 Can 1 2?

28 CCS Results in Higher Implantation Rates 80% 70% 66.3% P= % 50% 40% 51.2% N=83 N=170 30% 20% 10% 0% Euploid SET Traditional DET Implantation = cardiac activity at time of discharge to obstetrical care (~9 weeks)

29 80% 70% 60% 50% 40% 30% 20% 10% 0% Same Delivery Rate: Randomized Controlled Trial Delivery Rate Per Patient (n=175) Single euploid blastocyst transfer (N=89) Untested 2-blastocyst transfer (N=86) 61% P=0.5 65% Forman EJ et al. Fertil Steril 2013

30 Eliminates Multiples 100% Singletons Multiples P<0.001 P< % 48% 0% Single euploid blastocyst transfer Untested 2-blastocyst transfer Forman EJ et al. Fertil Steril 2013

31 Birthweight (Grams) Better Obstetrical Outcomes are Attained CCS/eSET than Conventional Two Embryo Transfer Mean Birthweight: 3408 ± 562g Single euploid 2745 ± 743g 2-Blastocyst (P<0.001) Low birthweight (<2,500g): 4.4% (2/45) Single Euploid 31.9% (22/69) 2-Blastocyst (P<0.001) Single euploid blastocyst transfer euploid Grams blastocyst transfer 2- Untested blastocyst transfer Grams 2-blastocyst transfer Very low birthweight (<1,500g): 0% (0/45) Single Euploid 7.2% (5/69) 2-Blastocyst (P=0.06)

32 Ongoing Pregnancy Rates Fresh vs. Frozen Transfers Fresh ET 57% 54% Frozen ET 37% 43% 50% of transfers 66% of transfers Control SET CCS SET P = 0.4 P = 0.7

33 Obstetrical Costs for 100 Patients Current Standard Of Care Costs per Delivery* Singleton $21,458 Twins $104,831 Triplets $407,199 Does not include: Pediatric costs after 28 days of age Disability costs during bed rest Loss of productivity in the work place Lemos et al Am J Obstet Gynecol 2013; 209:586

34 Thousands Overall Cost to Provide Care CCS with SET versus Conventional Treatment Use actual cost data Inclusive of all IVF costs including IVF cycle costs CCS costs Medication costs $80 $70 $60 $50 $40 $30 $20 Costs per Delivery* Delivery costs and subsequent hospital stay through 28 days of life $10 $0 CCS / SET National Avg Regional Avg

35 Do we ever recommend two embryo transfers? Yes but with caution

36 Follow Up on Prospective Trials

37 Time Lapse Observations in the Embryology Laboratory And others..

% Euploid % Euploid % Euploid 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 ICSI to start of 1 st cytokinesis (p=0.

38 % Euploid % Euploid % Euploid ICSI to start of 1 st cytokinesis (p=0.61) 1st 2nd 3rd 4th Quartile Duration of the 2 cell stage (p=0.88) 1st 2nd 3rd 4th Quartile Time Lapse and Aneuploidy Traditional Markers Duration of the 3 cell stage (p=0.12) 1st 2nd 3rd 4th Quartile Hong KH et al in review

Rate of euploid embryos (%) Rate of euploid embryos (%) 100 90 80 70 60 50 40 30 20 10 0 Time from start of 1 st cytokinesis to start of cavitation (p=0.

39 Rate of euploid embryos (%) Rate of euploid embryos (%) Time from start of 1 st cytokinesis to start of cavitation (p=0.01) 1st 2nd 3rd 4th Quartile Time from start of 5 cell stage to start of cavitation (p=0.0076) st 2nd 3rd 4th Quartile Hong KH et al in review

40 syn_rm: time from syngamy to 1st cytokinesis Can Time Lapse Help Distinguish Which Euploid Blasts will Deliver from those Destined to Fail? 5 Temporal data evaluated: conventional endpoints through cleavage stage Failed Transfer Outcome Succesful Additional temporal endpoints from extended culture: First compaction Morula formation First cavitation Blastocyst Expansion First contraction NO: None of the 5 traditional parameters or 5 additional blast related parameters prognosticate outcome

41 Follow Up on Prospective Trials

42 Multiple Reads (depth) Next Generation Sequencing Aligned Results Reference sequence from human genome database

43 The Economics of NextGen A Major Factor for Accuracy NextGen Sequencing Chip $$$$$$$

44 NextGen Molecular Barcoding Reduced Costs Embryo 1 Embryo 2 combine samples for a single sequencing chip Barcode 1 Barcode 2 CTAAGGTAAC TAAGGAGAAC

45 The Economics of NextGen A Major Factor for Accuracy NextGen Sequencing Chip $$$$$$$/2

46 The Economics of NextGen A Major Factor for Accuracy NextGen Sequencing Chip $$$$$$$/4

47 The Economics of NextGen A Major Factor for Accuracy NextGen Sequencing Chip $$$$$$$/48

48 The Economics of NextGen A Major Factor for Accuracy NextGen Sequencing Chip 96 or more $$$$$$$/96

49 WGS (16 per chip) known trisomy copy number known monosomy unpublished data chromosome

50 WGS (48 per chip) copy number unpublished data chromosome

51 Targeted NGS (96 per chip) copy number unpublished data chromosome

52 Embryo calibration results copy number unpublished data chromosome

53 Chromosome specific cutoffs 4 NGS based copy number on chr chr16 specific cutoffs 1 0 unpublished data

54 Embryonic Endometrial Synchrony It take two..

% of Treatment Cycles Embryonic-Endometrial Asynchrony Increases with Maternal Age 80 70 60 50 40 30 20 10 0 P<0.

55 % of Treatment Cycles Embryonic-Endometrial Asynchrony Increases with Maternal Age P<0.01 Elev P Day 6 Blast Overall Asynch < (419) (436) (486) Shapiro BS et al Fertil Steril :S287 Retrospective 1,341 IVF cycles Thresholds for Asynchrony (either) P >1.5 mg/ml on day of hcg No blastulation prior to day 6 Risk for asynchrony increases with maternal age Live birth predicted Day 5 blastulation (P<0.0001) P < 1.5 ng/ml (P=0.0002) Is it asynchrony or an intrinsic diminution in quality?

56 Late follicular rise in progesterone Retrospective study 4032 patients P 4 1.5ng/mL associated with lower ongoing pregnancy rates Bosch E, et al. Hum Reprod Aug;25(8):

57 Progesterone and the Endometrial Transcriptome Leuprolide acetate 1 mg/d td sc Estradiol 0.2 mg/d td 40 mg/d IM 10 mg/d IM 5 mg/d IM 2.5 mg/d IM Adapted from S. Young, MD, PhD

58 Progesterone Pharmacokinetics Adapted from S. Young, MD, PhD

59 Progesterone and the Endometrial Transcriptome Adapted from S. Young, MD, PhD

60 Sustained Implantation Rate (%) Progesterone and Impaired Implantation: A Pilot Study of Euploid Embryos < >12 Hours Relative to Closure of the Window All patients had normal P levels prior to the administration of hcg

61 Beware of Interference in your P Assay Patients receiving DHEA have elevated DHEA-SO 4 levels These levels may falsely elevate P levels Assay dependent Forman - RMANJ

62 Natural Cycle Ovulation hcg administration Embryonic Window of Implantation Progesterone Rise Endometrial Window of Implantation time Franasiak et al ASRM 2013

63 embryo and endometrium synchrony - revisited Ovulation hcg administration Embryonic Window of Implantation Progesterone Rise 24h Endometrial Window of Implantation time Franasiak et al ASRM 2013

64 Fresh day 5 embryo transfer 70% p < % p < % 56% 50% 40% 44% 30% 20% 18% 10% 0% Franasiak et al ASRM 2013 <35 35 D5 M-B1 D5 B2-B6

65 Fresh day 6 embryo transfer 70% 60% 50% 52% p <.05 63% p < % 40% 30% 32% 20% 10% 0% <35 35 D5 M-B1 D5 B2-B6 Franasiak et al ASRM 2013

66 Frozen synchronous cycle Progesterone Start Endometrial Window of Implantation time

67 Older patients are more likely to have slow embryos 70% 60% Proportion of "Slow" Blastocysts P< % 40% 30% 31% 46% 20% 10% 0% Forman et al ASRM 2013 <35 years old 35 years old

68 Frozen day 6 embryo transfer 70% p =0.5 60% 57% 60% p =0.3 50% 40% 30% 20% 10% 0% Franasiak et al ASRM % <35 35 D5 M-B1 D5 B2-B6 42%

69 Obstetrical Outcomes Following Fresh versus Cryopreserved Embryo Transfer Fresh embryos at increased risk for Preterm birth Low birth weight Small for gestational age Wennerholm et al Hum Reprod :

70 The supraphysiologic milieu which accompanies superovulation impact low birth weight risk % Fresh ET Cryo ET Retrospective review of SART data ,792 neonates 5 0 Low Birth Wt Term LBW Preterm LBW Fresh embryo transfer at increased risk for LBW

The RMA New Jersey Team Clinical Embryology Kathleen Upham Xinying Li Rosanna Pangasnan Tian Zhao Michael

Desiree Greene Serhan Ozensoy Erin Dubell Susan Ng Maria Morel Jessica Wall Clinical Research Christine Reda

Scott Physicians Paul Bergh Michael Bohrer Maria Costantini Michael Drews Eric Forman Rita Gulati Doreen

Shastri FAEEC Rebekah Zimmerman Brynn Levy Lindsey McBain Heather Garnsey Andrew Behrens Sylvia Kloskowski

Gartmond Margaret Lebiedzinski Oksana Bendarsky Mariya Rozov Anna Czyrsznic Kay Green, MD Meir Olcha, MD

71 The RMA New Jersey Team Clinical Embryology Kathleen Upham Xinying Li Rosanna Pangasnan Tian Zhao Michael Cheng Hokyung Lee Ayesha Winslow Angela Romaniello Stephanie Milne Sarah Dunn Lauren Rary Kristen Pauley Desiree Greene Serhan Ozensoy Erin Dubell Susan Ng Maria Morel Jessica Wall Clinical Research Christine Reda Talia Metzgar Jennifer Tyler Support Andrew Ruiz Nancy Niemaseck RMANJ Nurses Scientific Director Richard T. Scott Physicians Paul Bergh Michael Bohrer Maria Costantini Michael Drews Eric Forman Rita Gulati Doreen Hock Kathleen Hong Thomas Kim Marcy Maguire Thomas Molinaro Jamie Morris Eli Rybak Wendy Schillings Shefali Shastri FAEEC Rebekah Zimmerman Brynn Levy Lindsey McBain Heather Garnsey Andrew Behrens Sylvia Kloskowski Erica Vuu The Treff Laboratory Nathan Treff Xin Tao Agnes Lonczak David Gabriele Chelsea Bohrer Tori Gartmond Margaret Lebiedzinski Oksana Bendarsky Mariya Rozov Anna Czyrsznic Kay Green, MD Meir Olcha, MD David Goodrich Bioinformatics Deanne Taylor Jessica Landis Yuanchao Zhang Fellows Marie Werner Jason Franasiak Caroline Juneau

Progesterone and clinical outcomes

Progesterone and clinical outcomes Synchronization of Slowly Developing Embryos Restores Implantation Success Richard T. Scott, Jr, MD, HCLD Clinical and Scientific Director, Reproductive Medicine Associates of New Jersey Professor and