Building robust time-lapse models. Kirstine Kirkegaard The Fertility Clinic Aarhus University Hospital

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1 Building robust time-lapse models Kirstine Kirkegaard The Fertility Clinic Aarhus University Hospital

2 Time-lapse as a diagnostic test

3 Morphology Limited information Dependent on timing Subjective Validated Time-lapse Detailed information Flexible Precise *) Validated? *Sundvall et al 2013

4 Time-lapse incubation Improved culture? Improved selection? Improved treatment?

5 Improved pregnancy rates Assumptions: 1. Culture conditions Un-interrupted culture Incubator 2. Selection

6 Culture conditions

7 Embryo selection Assupmtion: Timing of development can distinguish viable from non-viable embryos Accuracy and precision Viable? What is normal? Sensitivity and specificity

8 Precision and accuracy ACCURACY: Dependent on time between image recordings

9 What is viable?

10 Blastocyst development STUDY ENDPOINT PARAMETERS Wong 2010 Blastocyst development (n=100) 1st cytokinesis, duration 2- and 3-cell stage Hashimoto 2012 Blastocyst score (n=80) T(7/8), 3rd cell cycle, duration 3-cell stage Cruz 2012 Blastocyst score (n=834) T(4), duration 3-cell stage, morula, direct cleavage 1-3, uneveness 2-cell stage Dal Canto 2012 Expanded blastocyst (n=459) T(3)-t(8), duration of all cleavage stages Hlinka 2012 Blastocyst development (n=180) Cleavage cycles and interphases. Conaghan 2013 Blastocyst quality (n=1233) Duration 2- and 3-cell stage Kirkegaard 2013 High quality blastocysts (n=571) 1st cytokinesis, duration 3-cell stage, direct cleavage 1-3

11 Prediction of blastocyst formation vs. pregnancy AUC: 0.69 Kirkegaard et al, 2013

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13 What is normal? Viable Nonviable

14 Diagnostic sensitivity and specificity Depends on the reference intervals/cut off levels! In practice there is rarely a sharp demarcation between normal/abnormal

15 t5:48 56; s2(t4-t3): 0.75; cc2(t3-t2): 5-12

16 T3 : 31/34 40 h; cc h; t5: 45-55

17 P2 (duration 2 cell stage) hours P3 (duration 3 cell stage) hours specificity of 84.7% sensitivity of 38.0%, PPV of 54.7%, NPV of 73.7%

18 Test usable Test nonusable usable nonusable TP FP PPV 54.7% FN TN NPV 73.7% Sensitivitet 38.0% Specificitet 84.7%

19 Implanted Not implanted Usable* n=131 n=445 22,7 % Non-usable # n=134 n= % Entire cohort n=265 n= % *P2 : hours and P3: hours. #P2 outside hours and P3> hours. Implantationrate AUC 0.57 Kirkegaard et al, 2014

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21 What is normal? Viable Nonviable

22 What is normal? Laboratory/culture conditions IVF/ICSI Oxygen Culture media Treatment? Patients (Age, diagnosis, BMI, hormones)? Cell cycle check points

23 hrs after fert IVF vs. ICSI 59,1 57,4 59,4 62,5 60, ,1 54,5 53,7 56, , , ,3 38,2 IVF ICSI ,5 27,2 26,7 n IVF =622 n ICSI =581 Cruz et al 2013

24 hrs after PNF IVF vs ICSI (t0=pnf) ,5 33, ,4 31, , ,8 16,8 16,5 14,1 IVF ICSI ,1 3,1 n IVF =622 n ICSI =581 Cruz et al 2013

25 IVF vs. ICSI *p<0.001 *p<0.001 *p=0.02 *p=0.001 *p=0.01 *p=0.01 *Students t-test. Blastocyst only n IVF =262 n ICSI =375, unpublished data

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27 hrs after hcg 5% vs 20 % O 2 110,0 100,0 90,0 80,0 70,0 60,0 50,0 40,0 30,0 20,0 10,0 0,0 2-cell 3-cell 4-cell 5-cell 6-cell 7-cell 8-cell EB FB hatching 5% 31,4 51,0 51,9 62,4 63,0 63,4 63,8 89,1 95,8 102,5 20% 31,9 51,7 52,7 65,5 66,1 66,6 67,0 92,6 98,9 105,0 Culture under 20% oxygen results in cummulative delayed development and increased developmental arrest at all stages Wale and Gardner 2010

28 Oxygen- Human embryos 20% O 2 5%+20% O 2 5% O 2

29 Kirkegaard et al 2013

30 hrs after fert (ICSI) single vs sequential media * 39,5 * 41,5 40,1 * 52,2 48, * 25,9 25,1 * 29,1 27,4 37,8 single sequential 10 PNF t2 t3 t4 t5 0 Ciray et al 2012 n single =231 (2 PN=170), n seq =215 (2 PN=149) 71 cycles

31 hrs after fert Sage vs Global 51,1 51,2 40, ,8 40,2 38, ,6 23,4 26,7 27,3 Sage Global 10 8,2 8,4 0 2PN Basile et al 2012 PNF t2 t3 t4 t5

32 hrs after fertilisation 60 stimulation protocol 50 50,7 49,8 53,4 52, ,2 37,1 40,3 39,5 agonist+hcg ,8 26,9 antagonist n=2101 n= Munoz et al t2 t3 t4 t5 t6 +FSH dose

33 What is normal? Laboratory/culture conditions IVF/ICSI Oxygen Culture media Treatment? Patients (Age, diagnosis, BMI, hormones)? Cell cycle check points

34 hrs after fert 60 weight/infertile/fertile group age Obese infertile 34.7 (SD 3.4) obese infertile normoweight infertile donors Normo weight infertile 33.3 (SD 2.9) Donors 27.1 (SD 4.2) 10 0 t2 t3 t4 t5 Bellver et al 2013

35 hrs after fert 60 PCOS controls normoandrogenic PCOS hyperandrogenic PCOS 10 0 PNF t2 t3 t4 t5 Wissing et al 2013

36 Confounding Age pregnancy timing aneuploidy

37 Age, aneuploidy and tsb Model effect Estimate Significance of additional effect Age 0.16 (0.04) tsb 0.05 (0.02) Logistic regression analysis of the effect of age and tsb on aneuplodi. Campbell et al 2014

38 AGE AND BLASTOCYST TIMING Regression coefficient (95% CI) P-value Early blast 0.44 (0.16; 0.71) Full blast 0,42 (0.10;0.74) Coefficient of determination (R 2 ) Clustered linear regression, n=653, npt=149

39 Prediction of blastocyst formation vs. pregnancy AUC: 0.69 Kirkegaard et al, 2013

40 A few words about RCT s - Equal distribution of known and unknown confounders - Elimination of selection bias Age pregnancy timing aneuploidy

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42 What is normal? Laboratory/culture conditions IVF/ICSI Oxygen Culture media Treatment? Patients (Age, diagnosis, BMI, hormones)? Cell cycle check points

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44 Sensitivity/specificity Ranking Confounders Validation