Podcast & Blog

FERTILIPOD BY IVIRMA

IVIRMA at the 2020 ASRMCongress – Part 2

with ANTONIO PELLICER, MARCOS MESEGUER, NICOLAS GARRIDO, BRENT HANSON

IVIRMA at ASRM 2020 part 2

Listen in for highlights of IVIRMA's research presented at the 76th ASRM Scientific Congress and Expo. Join us as Dr. Antonio Pellicer, Dr. Marcos Meseguer, Dr. Nicolas Garrido, and Dr. Brent Hanson comment on their presentations on non-invasive preimplantational genetic testing (PGT), assisted hatching, sperm DNA fragmentation and issues with sperm measures, and mitochondrial DNA content in the embryo.
Share on facebook
Share on linkedin
Share on twitter

Dr. Andres Reig:

The information shared in this podcast does not necessarily represent IVI-RMA’s stance. These podcasts are not a substitute for consultation with a physician.

Hi, welcome to Fertilipod, a podcast by IVI-RMA. Hello, I’m Dr. Andres Reig. Welcome back to Fertilipod, the podcast where we discuss current topics and the latest research in the field of reproduction with some of the world’s leading experts. Let’s get started.

Today’s episode is a continuation of our two-part ASRM special. In part one IVI-RMAs physicians told us about their fertility research. Today, we have Dr. Brent Hanson, Dr. Marcos Meseguer, Dr. Nicolas Garrido, and Dr. Antonio Pellicer to share some of their most recent work presented at ASRM, and highlight other areas of the conference they particularly enjoyed.

Dr. Andres Reig:

Let’s start with Dr. Brent Hanson. Dr. Hanson is currently a third-year fellow at the Thomas Jefferson University Reproductive Medicine Associates of New Jersey REI fellowship program. Thank you so much for joining us.

Dr. Brent Hanson:

Thank you for having me.

Dr. Andres Reig:

Dr. Hanson, you had an oral presentation during ASRM that was part of the price paper session. Congratulations on that by the way.

Dr. Brent Hanson:

Thank you.

Dr. Andres Reig:

Can you tell us a little bit about this study?

Dr. Brent Hanson:

Sure. So very briefly, this study was looking at a technique called noninvasive pre-implantation genetic testing or NIPGT. The thought here is that in order to avoid some of the theoretical concerns regarding the trophectoderm biopsy, that’s associated with traditional PGT. Non-invasive PGT samples, the culture media that’s around an embryo while it’s developing in the lab, and that hopefully, or potentially, an analysis of the culture media could lead to a genetic assessment, thus, accurate representation of the embryo. So that was the study. We took embryos that were in the lab and underwent both trophectoderm biopsy and non-invasive PGT and compared the accuracy and correlation between the non-invasive results and the trophectoderm and biopsy results.

Dr. Brent Hanson:

So ideally, we wanted to see the correlation and wanted to see those results being similar to each other. Unfortunately, what we found was that with the non-invasive testing platform that we were utilizing, there were high rates of DNA amplification failure, meaning that about 37% of the time, we didn’t get any results that were interpretable from non-invasive PGT. Whereas for our trophectoderm biopsy samples, we were able to get a result every time. We also then looked at factors that could potentially affect how often we were getting a result with non-invasive PGT. And we found both the day of the blastocyst biopsy as well as the euploid status of the embryo based on trophectoderm biopsy were factors that impacted how often we got results with non-invasive.

Dr. Brent Hanson:

In short, the longer an embryo was in culture, the higher the likelihood that we were to get a result with non-invasive PGT. We had about 82% of embryos failing to get a result if they were biopsied on day five of culture, whereas, that number dropped to about 32%, if there were biopsied on day six. And all of our embryos that were biopsied on day seven of culture had a result with non-invasive PGT.

Dr. Brent Hanson:

In terms of the euploid status, if an embryo was euploid based on its trophectoderm biopsy, the DNA amplification failure rates with non-invasive PGT were 45%, whereas, they were lower about 21% if that embryo was viewed at any point.

Dr. Andres Reig:

So interesting. Why do you think longer culture improved the… or actually decreased the amount of amplification failure?

Dr. Brent Hanson:

So I think when we look at what this technique involves, non-invasive PGT is sampling DNA from the media. So in order to get an adequate amount of DNA or an adequate representation, an embryo just seems to require a longer time and culture. And one of the questions that were brought up during ASRM was other publications previous to this have said that non-invasive PGT-A has much higher amplification rates than what we found in our study. But most of those studies that have been done by the commercial entities or by the proponents of non-invasive PGT-A, have involved embryos that have already undergone invasive procedures, like a biopsy, or they’ve already reached the mature stage and then were kept in culture longer. So ultimately, it seems like in the clinical setting where you have an embryo that has not been biopsied yet, has not reached the blastocyst stage yet, that’s going to be your most accurate representation of what the clinical utility of what non-invasive would be. And in our setting, we found that there were high failure rates and also inconsistencies between the results found with trophectoderm biopsy and non-invasive when that was done.

Dr. Andres Reig:

And you found as well, you were saying a big difference between how reliable this was when the result was actually euploid versus aneuploid. What do you think that’s due to? What do you think that changes the results so much?

Dr. Brent Hanson:

Well, I think, in terms of just getting a result, what we found was that the euploid embryo is based on trophectoderm biopsy were much less likely to give us a result on non-invasive testing. And I think that is due to the fact that those embryos are undergoing less cellulolysis, less apoptosis, they’re potentially not releasing as much DNA into the surrounding environment.

Dr. Brent Hanson:

When we looked at the results for the embryos that had a result for both noninvasive and trophectoderm biopsy, what we found was that across the board, there were just inconsistencies. 40% of the time, we had discrepant results between our trophectoderm biopsy result and the non-invasive result. And those were all kinds of discrepancies where sometimes both were aneuploid, but different aneuploidies, sometimes non-invasive showed genetic abnormality that we did not see on trophectoderm biopsy and vice versa. So really just all different types of discrepancies.

Dr. Andres Reig:

Very, very interesting and so important to present on negative findings as well, right? And to know when things are not yet ready for prime time quite yet.

Dr. Brent Hanson:

Sure.

Dr. Andres Reig:

Can you tell us about something else you found interesting at the conference, something that you’d like to highlight?

Dr. Brent Hanson:

Yeah, I think one of the things that I saw during the ASRM lectures was related to this topic that I presented, and it was looking at non-invasive methods to evaluate the genetic status of an embryo. Specifically, the lecture that I want to refer to is by Sarah Cabedo Canyedo. She is a bioinformatics specialist with Richer Life. She’s based out of Madrid. And the reason that I wanted to bring up her research was that it dealt with a sampling of culture media, but rather than looking at DNA, what they were looking at was the different metabolic profile of the culture media for embryos that have been undergoing development.

Dr. Brent Hanson:

So really, they sampled 80 ultra media samples and looked at the metabolic profile or all these different substances that are in the culture media, not DNA, but other substances. And they had 40 of their samples undergoing the teaching phase of their profile, while the other 40 were the test phase. And they were able to identify over 2,700 individual substances with mass spectrometry that were present in the media. And about 60 of those seem to be predictive of either a euploid or aneuploid status of the embryo.

Dr. Brent Hanson:

Once they categorize these substances as predictive, they then underwent the same sort of testing using the other half of the samples to see how accurate it was. And about 97% of the time, they were able to accurately predict the genetic status of the embryo. Again, this was in a laboratory setting. The embryos that they were using already had a known PGT-A diagnosis of aneuploid or euploid based on the biopsy.

Dr. Brent Hanson:

But it is interesting to say that DNA may not be the only thing that we should be looking at in the culture media in order to determine what’s predictive of an embryo status.

Dr. Andres Reig:

Right. I actually saw that presentation too. I found it very interesting. It’s interesting that it probably will end up not being the one answer, but rather some sort of algorithm that puts a bunch of things together to tell us with a higher degree of prediction probably.

Dr. Brent Hanson:

And I did like the fact that they were really looking at all of these different substances and determining which ones are predictive. So all of these 2,700, obviously over 2,600 of them were not found to be as important or predictive. But you’re right, there’s got to be some combination or some algorithm that’s able to put this together if we view non-invasive PGT as something that we want to consider and continue pursuing.

Dr. Andres Reig:

Absolutely. Very, very interesting. Thank you so much for giving us the time to talk to you.

Dr. Brent Hanson:

I appreciate being here. Thanks for having me.

Dr. Andres Reig:

Next, we have Dr. Marcos Meseguer. Dr. Meseguer is a world-renowned embryologist and currently serves as a scientific supervisor and senior embryologist at IVI Valencia. Thank you so much for being here. Can you tell us a little bit about what you presented at ASRM?

Dr. Marcos Meseguer:

Thank you, Andres. We have been very political this year in ASRM, and we have… as far as I remember, eight representations in the meeting. And most of them related to embryo assessment. And also, we have to spend some of our research is focused mainly on fertility. We have a main interest in artificial intelligence, and also in the diagnostic technology non-invasive assessment. Between the ones that we have been presented this year, that has been again… has been a very good year in relation to the number of factors accepted. I have a couple of factors that I would like to underline that I think may be more interesting than the others. But in general, I believe that the year has been very prolific, I would say.

Dr. Andres Reig:

Sure, go ahead.

Dr. Marcos Meseguer:

From those two, there is one which I’ve been just reviewing, how has been the number of views for each one of the aspects. And the one with more views has been presented by one of the embryologists of IVI Valencia. His name is Alberto Tajera. The work is fascinating, and I really love it because it’s about assisted hatching You may find in the literature about a lot of works, even in meta-analysis about the ET of assisted hatching. Most of them, we end up that actually there is not enough clear evidence about the utility of this intervention that we do in the embryo, in the blastocyst. Not talking about the PD of course, but in the standard cycles, when we do also freeze-thawing embryos vitrification program, or in those cases that we believe that the embryo is bad quality and we think we need to help it.

Dr. Marcos Meseguer:

So it’s difficult to find a clear indication. And maybe this is the main reason. During the last four or five years, we have been studying a lot of events of embryo development that potentially are related to the outcome. And one of those that has been very unique has been the blastocyst collapse.

Dr. Marcos Meseguer:

We have been describing the blastocyst collapse as a behavior of the blastocyst which is happening around 20% of them. We have seen that those blastocysts that are presenting collapse can be wonderful morphology or not, but we have seen that the image with blastocyst collapse is presenting lower implantation potential, even 10% less implantation potential.

Dr. Marcos Meseguer:

So we have just focused on the application of assisted hatching to those blastocysts that are presenting blastocyst collapse because we know that has reduced implantation. So Alberto has been working in the last couple of years taking a look at those blastocysts with blastocyst collapse. But recently, we just recall 10 laps, and those embryos were frozen. In the moment of thawing, we just identify them and we do the assisted hatching to those blastocysts.

Dr. Marcos Meseguer:

And we have realized that when we perform assisted hatching to those blastocysts were more or less reaching this level of implantation potential than those without collapse. So for me, it’s like a first time maybe that we have found a clear indication of assisted hatching. We know that there are others, for example, the zona pellucida thickness. But again, even in that particular case, we are not sure about which is a good cut of value to that, and also may be related to the quality of the embryo. But we’re very happy because we have found a clear indication, which is happening in 20% of our blastocyst, and also that we know that apparently, there’s not another solution, and it is easy to do. We just can’t find an option.

Dr. Marcos Meseguer:

That’s one of the assets I would like to underline. The other for me has been one in which we have to validate or evaluate one of the first commercially available algorithms or kits for embryo selection. We have been done the biggest study of this automatic discovery in the literature. And this is a particularly interesting thing because the first time that the thing lasts together with discovery is doing a totally automatic selection of the embryo without human intervention. All the parameters are recorded by the computer, and the computer automatically is bringing our blastocyst at the ratio of 1:5.

Dr. Marcos Meseguer:

So we’re have been trained to link these categorizations within validation potential, which has been successful. We have seen a clear relationship between implantation potential on this categorization, and also trying to see if there was a link between these categories and chromosomal content or blastocyst diploidy. In the second case, we have been unable to find these relationships.

Dr. Marcos Meseguer:

It’s true that the highest is the value of this selection criteria, the marches also in the BDA program to have a blastocyst viable for biopsy. So in summary, I believe that is, first of all, the first time that we are able to validate software, which was developed to automatically select blastocyst and also I think is a reference of the introduction of a totally automatic system for embryo grading, in this case, blastocyst. We know that this thing is the beginning of this technology, but we clearly see the potential of these let’s say the first time that we can automate one of the processes in the lab which is the selection of the embryos.

Dr. Andres Reig:

That’s awesome. For the first abstract you were mentioning, not only is it able to… not only did we find an indication for something that is good that we can use now for something, but it also provides a good solution to a problem, to begin with, right?

Dr. Marcos Meseguer:

Exactly.

Dr. Andres Reig:

Which is that these embryos now increase their potential.

Dr. Marcos Meseguer:

Exactly. This is why we are so happy with this study, actually, because when we first time discovered the phenomena, we were, “Okay, what could be the solution?” Because also in that particular study, we just take an overview, of course with the limitations of the study by itself, because we only keep the image on day five in the dial-up system. We did not find any link between the proportion of blastocyst that started hatching and the incidents of collapse.

Dr. Marcos Meseguer:

We have the same proportion of blastocysts that started doing hatching in those that are presenting collapse and those that are not. So at that particular time, we thought the assisted hatching will not be useful like a solution, but in the end, we also need to try. If you take a look, not to the literature only, if you just have the chance to visit labs around the world, in my expertise maybe I’ve been lucky, I’ve visited maybe more than 200 labs everywhere on the world.

Dr. Marcos Meseguer:

I have seen many embryologists that just by regular standards, they perform assisted hatching to all the blastocysts. In the first cycle, some of them all in the frozen, and some of them do it just from time to time, depending on the criteria of the embryology, which is very subjective. So I’ve been unable to find everywhere just clinically, at least practically, any clear criteria of where to perform assisted hatching.

Dr. Marcos Meseguer:

Some of the embryologists were performing only to frozen and recycled some of them to all, some of them to no one, no embryos at all. So a lot of that identity in the literature and also in the experience with embryologists. So this is why I believe that always finding an indication or a solution to a lower implantation potential is always a good thing for the embryology field. And also we are providing solutions. I like basic research, but the thing is this is more relational. We’re just putting a solution to all the clicks to improve the outcome.

Dr. Andres Reig:

I wanted to ask you. It sounds like from these two abstracts specifically, but in general, it sounds like a lot of the research we’re doing in the last few years, especially from an embryology perspective is trying to almost cut out the embryologist from the embryology job, right?

Dr. Marcos Meseguer:

Yes, it is.

Dr. Andres Reig:

Basically in a way, we acknowledge that there is a problem with the subjectivity and the interrupt server variability, and we’re basically trying to apply a little more strict or more perhaps algorithmic criteria. What other areas are you finding interesting in this field in the idea of automating the process of making things a little more objective?

Dr. Marcos Meseguer:

I would say that from the perspective of automation, still I haven’t seen too many things in the Congress. Not only in ASRM, even in ESHRE. So what we have seen is very limited. Maybe we start to see something later with microfluidics and stem preparation. The intention to try to validate the data by using microfluidics, but nothing else. Still, we have a lot of promising things in some venture capitals, but nothing real. So it’s true that the first approach to automation is the introduction of this time of technology. I’ve seen also some communications about the non-invasive embryo assessment, which in part are including the observation of the embryo by monitoring with their labs, or artificial intelligence. But also, I am very, very interested in what’s going on with non-invasive embryo assessment, and also related to the secretions of the embryos, and also about the chromosome content. We know, and also there are publications coming from our own group, which are describing that actually looks that this non-invasive chromosome assessment is not reliable at all at this point. And I totally agree.

Dr. Andres Reig:

There was a presentation two days ago about that.

Dr. Marcos Meseguer:

Yes, yes. I totally agree about that basically, because still, what they are offering to us is against embryology… we need to keep our blastocyst longer than expected in the incubator just to be able to analyze the chromosome content in the media which is against the embryo. We are going to transfer the embryo at the wrong time, or we are artificially extending the culture without any need. So there is a-

Dr. Andres Reig:

We’re increasing our diagnostic capability, but only at the expense of the embryo, and that will disappoint.

Dr. Marcos Meseguer:

Exactly. So we’re creating a conflict between embryology and diagnostic, which is not good. So I think that this line is very promising and maybe will be an increase which is wondering why we’re finding DNA in the media. We should not find DNA in the media if there’s also in the embryo. So if there is DNA in the media is because the embryo is loose… the embryos are losing cells or cells that are dying and are releasing the DNA. That’s also about saying, you were able to find all this content in the DNA, something is wrong in the embryo development.

Dr. Marcos Meseguer:

So even that this line is very promising and I love it, I think that all the amazing information that we are getting from the images of the embryos from five days, and how the software that is doing image analysis are going to be able to extract information, that is impossible to get from our own view or eyes, something that we’re able to get extra that is going to be probably very informative. And also, if you’ll be culturing that, very cheap, because software or just computer, doing computer analysis is not proceeded. You were mentioning also that all these things that we’re performing, even though automation is going against the embryologist. And in some other cases, it’s all our fault because we have been unable in the last-

Dr. Andres Reig:

I didn’t mean it literally.

Dr. Marcos Meseguer:

But we have been unable to be consistent in our way to do embryo assessment, even internally. Unfortunately, is the human being, we are very subjective, so it’s our own fault. But I have admitted at least in Valencia, all this research is giving a lot of work to many embryologists. Actually, I feel very lucky I have a team of seven embryologists working exclusively in research around non-invasive embryo assessment with artificial intelligence. Also, we are including in our field also bringing field engineers, bioinformatics, which are amazing. So I think it’s a very exciting moment for biologists. Really, in the next year, if all this field is going to end up with maybe a loss of some of the positions of the embryologist. From my perspective, what we need to do the embryologist is to just move forward and study more, start to learn about also other topics, not only embryology. And then we will keep for sure working and we’ll have a very promising future. But these are in our hands, I would say.

Dr. Andres Reig:

Absolutely. Thank you so much for your insight.

Dr. Marcos Meseguer:

You’re welcome. You’re welcome.

Dr. Andres Reig:

We are now joined by Dr. Nicolas Garrido. Dr. Garrido is the Director of Research and Innovation at IVI, as well as the IVI Foundation Director. We are so happy to have you on.

Dr. Nicolas Garrido:

It’s a pleasure. Thank you, Dr. Reig.

Dr. Andres Reig:

So go ahead. Tell us a little bit about the research you presented at ASRM.

Dr. Nicolas Garrido:

Well, one of the papers that we published in the current meeting is entitled Accurate Measurement of Sperm DNA Fragmentation Effect on Reproductive Outcomes by Cumulative Live Birth Rates for Embryo Transfer and O-Sites Utilized. So the basic idea is that sperm DNA fragmentation is a widely spread test, which is frequently unclear on its indications, its use, and some centers ask for it routinely while others are not providing these kinds of service.

Dr. Nicolas Garrido:

So there’s a lot of scientific information available out there with very controversial messages. And while DNA fermentation in sperm seems to be related to infertility, the effect size from the reproductive outcomes is somehow unclear. Classically, when you try to link some sperm features with reproductive outcomes, several measurements have been utilized, including pregnancy rates, ongoing pregnancy rates, miscarriages, and live birth rates. But for us, the most important thing is when you consider an outcome, which is the denominator, which frequently is established as the first embryo transfer.

Dr. Nicolas Garrido:

Given that within the standard procedures on the IVF lab lead to the selection of the best embryo to transfer, this might be biasing to the negative, any effect of sperm on the final reproductive outcomes when comparing any risk factors such as DNA fragmentation. So one possible alternative is measuring cumulative live birth rates or pain after having considered successive embryo transfers until a child is achieved or the patient’s abandon treatment.

Dr. Nicolas Garrido:

But moreover, this approach is not penalizing the embryo blockage during the development. So this may also lead to a false interpretation about the effect of DNA fragmentation on reproductive outcomes.

Dr. Nicolas Garrido:

So we propose a new approach, and this is I think the main interest of our board. In order to evaluate, which is the effect of having high or low DNA fragmentation in sperm, by computing the cumulative live birth rates but also employ until our first live birth is achieved. Then this is a new way to measure sperm quality referred to the number of four sites at that level in order to achieve the patient’s aim, which is a first live birth.

Dr. Nicolas Garrido:

So from our results in a retrospective study with more than 1000 cycles, in unselected males where DNA fragmentation analysis was done, we were unable to compare among the different levels of DNA fragmentation, its influence below the mentioned indicators. There were very small to no differences found, indicating the lack of any influence or predictive value of such test for unselected males.

Dr. Nicolas Garrido:

So now we are trying to better address this issue by controlling by some potential biasing variables, and also reanalyzing our data in some more specific patients population in order to better address the potential use of sperm DNA fragmentation analysis.

Dr. Andres Reig:

What other studies did you see that you thought were interesting or worth mentioning, something that really caught your eye during the conference?

Dr. Nicolas Garrido:

It was a very interesting meeting. But to me, there was a specialist on male factor or more interested on the male factor part. There was a very nice interactive session concerning antioxidants and male fertility trying to answer the question about, “Should men take supplements or not?” And this was lead by Dr. Anne Steiner and Dr. Jorge Chavarro from Duke University and Harvard University respectively. So Dr. Steiner as the first author of the famous MOXIe trial, and Dr. Chavarro as a specialist, mainly on life habits and nutrition relationship with male infertility. They both provided a very interesting and balanced overview about the topic.

Dr. Nicolas Garrido:

So basically, Dr. Steiner shows that from the resource of her MOXIe trial, there’s no clear benefit shown by using an antioxidant combination. Although some discomfort and secondary effects mainly related to gastrointestinal issues might harass some men taking this supplement.

Dr. Nicolas Garrido:

So these results are reinforced by some other important trial and recent trial conducted by Dr. Schusterman, the past trial, where there is not evidence enough about the beneficial aspects of the use of these antioxidants to fight against male infertility. The presentation also included a nice overview and a deep analysis of the most recent corporate review. This topic by Smits in 2019, where the whole literature has been scrutinized and the info updated from the first day cocaine reviews, some years ago. And this include significant number of trials using different antioxidants doses combinations. It ended in a probably not or no position in light of the available evidence. So there are a number of problems on the trials already available that probably may be causing this confusing situation, including a large number of cases, recruiting males with no demonstrated stress that express situations not controlling for other potential biasing factors. For instance, related to life habits, performing trials with compounds that have more basic science supporting or indicating the potential benefits.

Dr. Nicolas Garrido:

Also, the quality of the trials in many of the cases was low or very low. And interestingly, trials with significant findings tend to be of lower quality compared with those that were not able to demonstrate any difference. Additionally, many of them are focused on secondary endpoints, such as sperm DNA fragmentation and the spread of culture for three or six months, which do not perfectly correlate with male fertility itself.

Dr. Nicolas Garrido:

So it seems there’s no one-fits-all solution and the question is too big, and probably needs to be less wide, and be able to address one by one or case by case all these kinds of antioxidants. For each trial, the conclusion is important to be only related to the specific intervention evaluated regarding the dose, the time, the product. For the specific population, what it was tested, and also considering for which effect size the trial was prepared for. In this case, we are frequently unfair to conclude that the results of a single trial can be extended to other populations or interventions, or other Lauer effect sizes.

Dr. Nicolas Garrido:

So in conclusion, it seems that prescribing antioxidant therapies do not provide a benefit and further study might help to ascertain the effects on particular agent. That’s why I found this a very interesting and exhaustive session about this topic.

Dr. Andres Reig:

It definitely was very interesting. And it’s also interesting what you’re saying that we kind of generalize our results a little too much.

Dr. Nicolas Garrido:

Exactly. Exactly.

Dr. Andres Reig:

Going back to your abstract that you presented, I found it very interesting what you were saying in the beginning. And I think it’s mentioned in the introduction to the abstract how the fact that we use the number of embryos transferred as the denominator is a problem. Can you elaborate a little more and explain why that’s a problem?

Dr. Nicolas Garrido:

I have training in Statistics and I think this provides with that different perspective. So numbers are frequently tricky, so it depends on how you see things, or how you measure things you may take out from this one message or some other message. So when I think about the effect of measuring something within sperm, trying to relate to reproductive outcome, there are many different measurements of the reproductive outcome. We are mainly used to measure things by embryo transfer.

Dr. Nicolas Garrido:

In some other cases, some interventions are measured… its effect is measured, cumulative life birth rates per embryo transfer. But I think we are missing a piece of nice information, which is, what happens with these cases where you finally are not able to conduct an embryo transfer because the embryos are blocked during the development? Or I think there’s an interesting defect, which is the embryo selection conditioning the reproductive outcome.

Dr. Nicolas Garrido:

So if you have patient A and patient B. And the sperm from patient A is providing with 10 embryos, and you are then transferring the best one. And patient B is providing with two embryos and you are finally transferring the best one. So you are just comparing the best against the best, you are not comparing the total effect conditioned by the sperm characteristics, the intervention on the sperm, and so on.

Dr. Nicolas Garrido:

So I think the best and the most precise way to evaluate any effect from sperm on the reproductive outcomes is for instance, by considering how many O sites you needed with this semen sample in order to get the first live birth, which is the main objective for the couple that we are attending. So this is a little bit the explanation of all this approach.

Dr. Andres Reig:

That’s very interesting. In many things in the fertility world, we focus on the female aspect a lot more. And I think it’s clear that we have obviously a good denominator when we’re looking at O-sites, for example. And we’re saying out of these many O sites, we’ve made these many blastocysts or things like that. But of course, we don’t count sperm individually, and that definitely poses a big challenge in order to assess the denominator. I see what you’re saying. It’s true. Definitely.

Dr. Nicolas Garrido:

Mm-hmm (affirmative)

Dr. Andres Reig:

Thank you so much.

Dr. Nicolas Garrido:

You’re very welcome. It was a pleasure. Thank you.

Dr. Andres Reig:

Our final guest for today hardly needs any introduction at all. Dr. Antonio Pellicer is a professor of OB-GYN at the university of Olympia, and is also the co-president of IVI-RMA. Thank you so much for making time for us.

Dr. Antonio Pellicer:

Thank you, Andres. Nice to hear from you.

Dr. Andres Reig:

Somebody from your team presented an interesting abstract during ASRM regarding mitochondrial DNA content. Can you tell us a little bit about this?

Dr. Antonio Pellicer:

Yes. A few years ago, we developed the IVI Foundation, a test that was introduced as Mitoscore, which intended to measure the mitochondrial DNA content of a trophectoderm, taking profit of the biopsies done for brain plantation genetic screening.

Dr. Antonio Pellicer:

So we wanted to actually realize whether this test was useful or not. And just comparing the mitochondrial content of the trophectoderm cells with the total content of the embryo, because we all know that is the inner cell mass that… the one that becomes, let’s say an embryo’s fetus, and it’s important for the baby less than the trophectoderm themselves. So we ask the permission to do research with discarded embryos. These were aneuploid blastocysts that were frozen in our labs. And we analyzed a total of 51 and compare the Mitoscore test, the data that the Mitoscore provided with the total mitochondrial content as ascertained by a confocal microscopy.

Dr. Antonio Pellicer:

And the bottom line of the study was that unfortunately, there was no correlation between the mitochondrial DNA content either with a number of mitochondria per cell, or the number of active mitochondria per cell using a different microscopic analysis.

Dr. Antonio Pellicer:

So the conclusion is that, although it’s important to find new markets of embryo viability because we know that around 65% of the diploid embryos implant. So there is something more to learn about embryo viability. The mitochondrial DNA contents of the trophectoderms doesn’t seem to be the way to go.

Dr. Andres Reig:

Very interesting. So essentially, you’re saying the mitochondrial content in terms of the mitochondrial DNA, it doesn’t really correlate with how many mitochondria there are, and therefore it may not be a good surrogate marker.

Dr. Antonio Pellicer:

Exactly. That’s the point. In IVF or in ART when we transfer an embryo, and especially when we transfer an opioid embryo, we expect that the woman gets pregnant, but the pregnancy rates are between 65 and 70%. No more than that. And many people look at the endometrium and the uterus. But in reality, unless there is something evident, like, it could be, for example, adenomyosis, or a uterus which is full of fibroids, et cetera, et cetera. So unless you see something morphologically relevant, the uterus is not that important. And this has been shown by our groupers, especially by a paper that was presented last year by Dr. Peter, Paul Peter. He showed that when the couples had three euploid embryos and the uterus was apparently normal, the take-home baby rate was about 93%.

Dr. Antonio Pellicer:

So the bottom line or the message from there is that if you have normal embryos, usually the women get pregnant, and they have children. Now, in order to do it better, we need other markers, and mitochondrial DNA content could be one of them, or there are different morphokinetic markers that people look at… use in time-lapse machines and registration with the time-lapse incubators. And some others will come in the future, right? But this mitochondrial DNA specifically in our hands is not useful.

Dr. Andres Reig:

Understood. Well, it’s an important study and it’s also good to know when things don’t work.

Dr. Antonio Pellicer:

Absolutely. Absolutely.

Dr. Andres Reig:

Tell us a little bit about some other abstract that you found particularly interesting during this year’s ASRM.

Dr. Antonio Pellicer:

I’m following for some years, the work that the Nuno Costa Borgers and Gloria Calderon are doing in Barcelona together with a group from Athens, the Institute of Life in Athens. And it is actually a very interesting work because the concept was to be able to increase the quality of the O-sites of women who have undergone many repeated cycles of IVF and all failed.

Dr. Antonio Pellicer:

So in a study that they did first because of the controversy about the spindle transfer. So taking the spindle of a patient and introducing it in a donor cytoplasm, which has been previously emptied of its own spindle. This concept, the great controversy is all about the possibility of carry-over mitochondrial DNA, and the new fetus and the newborn may carry genetic material from three different individuals, the father, the mother, and the O side donor, right? And this is why the technique is specifically forbidden in many countries.

Dr. Antonio Pellicer:

So they did a series of studies in animals that were nicely presented and published a couple of years ago, in which they showed that the actual carry-over percentage was very low. But they never intended before in humans. So they got permission in Greece. So the study was done in Greece, but they got all the permissions from their National Authority of the system, reproduction, the hospital trial B. So they got all the approval. So this is a clear, registered, and the well done pilot study in which they had a total of 25 patients who had a mean of 5.7 IVF attempt before. The mean age of the patient was 37. So they were quite young, but they produced very low quality, poor quality embryos.

Dr. Antonio Pellicer:

So they did spindle transfer using the specific technique that they have, again, described in animals. And in the end, the story ended in a total of 16 patients out of the 25 having aneuploid blastocyst. And after that, they did single embryo transfer in nine out of these 16 patients so far, and six became pregnant. So the pregnancy rate was really high, it was almost 70% in women, again, with a very poor prognosis with more than five cycles in the past.

Dr. Antonio Pellicer:

And the two children have been born, three ongoing pregnancies. And the discussion about mitochondrial DNA carry-over is answered by the fact that they showed that the carry-over was less than 1% of the mitochondrial DNA from the donor. So they collected also after birth, blood, urine, salivacal blood, placenta confirming that the parentage of the children and the origin of the donated mitochondrial DNA.

Dr. Antonio Pellicer:

So they did a complete study, and they confirm not only that they increase the quality of those embryos in these patients, but also that they have healthy children without the mitochondrial DNA carry-over. So I think this is a very promising technique and is especially promising when you think about aged women. Now, most of our patients have abnormal embryos, and they are forced somehow to undergo oocyte donation. And perhaps this technique with important technical modifications from the very beginning, because you have to work maybe within mature O sites. But still, this technique can be a new window of opportunity to help our patients in the future.

Dr. Andres Reig:

Truly cutting edge, maybe a way, like you said, in the somewhat near future, that we can help these patients achieve babies with their own genetic material, of course.

Dr. Antonio Pellicer:

Yes. The technique is controversial. The technique is very controversial because as I tell you, this is specifically forbidden and regulated against doing it in many countries. And I think included the United States and Spain. But again, these data are encouraging, and perhaps one day… and I know this is one of the goals of the authors is to present it to the European authorities and say, “Listen, here we have something that works. So let’s think about it again, and try perhaps to authorize it in some centers. So under special circumstances, but definitely something to be considered.”

Dr. Andres Reig:

Definitely. Very, very interesting. Thank you so much for joining us today, Dr. Pellicer.

Dr. Antonio Pellicer:

Thanks to you, Andres.

Dr. Andres Reig:

That is all we have time for today, unfortunately. Join us next week for a topic review on elective egg freezing. See you soon.