Published online: 2020-08-14 GebFra Science | Original Article Impact of Transferring a Poor Quality Embryo Along with a Good Quality Embryo on Pregnancy Outcomes in IVF/ICSI Cycles: a Retrospective Study Auswirkungen des Transfers eines Embryos von schlechter Qualität zusammen mit einem Embryo von guter Qualität auf das Schwangerschafts-Outcome: eine retrospektive Studie Authors Oya Aldemir 1, Runa Ozelci 1,EmreBaser2, Iskender Kaplanoglu 1,SerdarDilbaz1, Berna Dilbaz 1, Ozlem Moraloglu Tekin 1 Affiliations ity embryo on the transfer day, double-embryo transfer (DET) 1 Department of Assisted Reproductive Technology, can be performed with these embryos, but generally, differ- Ankara Etlik Zubeyde HanımWomenʼs Health Training ent quality embryos are present in the available transfer co- and Research Hospital, Ankara, Turkey hort. We aimed to investigate the effect of transferring a poor 2 Department of Obstetrics and Gynaecology, quality embryo along with a good quality embryo on IVF out- Bozok University Medical Faculty, Yozgat, Turkey comes. Methods In this study, 2298 fresh IVF/intracytoplasmic Key words sperm injection (ICSI) cycles with two good quality embryos double embryo transfer, embryo quality, cleavage stage, (group A), one good and one poor quality embryo (group B), blastocyst stage, live birth rate, multiple pregnancy and single good quality embryo (group C) transfers were ex- amined. All groups were divided into two subgroups accord- Schlüsselwörter ing to the transfer day as cleavage or blastocyst stage. Clinical Doppelembryonentransfer, Embryoqualität, Teilungsstadium, pregnancy and live birth rates were the primary outcomes. Blastozystenstadium, Lebendgeburtenrate, Mehrlings- Results In the cleavage stage transfer subgroups, the clinical schwangerschaft pregnancy rates were lower in the single-embryo transfer (SET) subgroup compared with DET subgroups, but the differ- received 28.3.2020 ence was not statistically significant compared with DET with accepted after revision 7.7.2020 mixed quality embryos. The live birth rates were comparable between the three groups. In the blastocyst transfer sub- Bibliography groups, the clinical pregnancy and live birth rates were signif- DOI https://doi.org/10.1055/a-1213-9164 icantly higher in DET with two good quality embryos than DET Geburtsh Frauenheilk 2020; 80: 844–850 © Georg Thieme with mixed quality embryos and SET groups. Multiple preg- Verlag KG Stuttgart · New York | ISSN 0016‑5751 nancy rates were higher in both DET groups in terms of trans- fer day (p = 0.001). Correspondence Conclusion DET with mixed quality embryos results with Oya Aldemir lower clinical pregnancy and live birth rates compared with Department of Assisted Reproductive Technology, DET with two good quality embryos at the blastocyst stage. Ankara Etlik Zubeyde HanımWomenʼs Health Training At cleavage stage transfer, there is no difference in live birth and Research Hospital rates between the two groups. Varlik Mahallesi, Etlik Caddesi, No: 55, Kecioren, Ankara, Turkey ZUSAMMENFASSUNG [email protected] Hintergrund Anzahl und Qualität von transferierten Embry- os sind wichtige Prädiktoren für den Erfolg bei In-vitro-Fertili- ABSTRACT sations-(IVF-)Zyklen. Wenn mehr als ein Embryo von guter Background The number and the quality of embryos trans- Qualität am Transfertag vorhanden ist, kann ein Doppel- ferred are important predictors of success in in vitro fertiliza- embryonentransfer (DET) mit diesen Embyros vorgenommen tion (IVF) cycles. In the presence of more than one good qual- werden. Generell sind aber die verfügbaren Embryos von sehr 844 Aldemir O et al. Impact of Transferring … Geburtsh Frauenheilk 2020; 80: 844–850 unterschiedlicher Qualität. Ziel dieser Studie war es, die Aus- verglichen mit den DET-Untergruppen, aber der Unterschied wirkung eines Transfers von einem Embryo schlechter Quali- zu den DET-Untergruppen mit Embyros gemischter Qualität tät zusammen mit einem Embryo guter Qualität auf das IVF- war nicht statistisch signifikant. Die Lebendgeburtenraten Outcome zu untersuchen. waren bei allen 3 Gruppen vergleichbar. Bei den Blastozysten- Methoden In dieser Studie wurden 2298 frische IVF/intra- transfer-Untergruppen waren die klinischen Schwanger- zytoplasmatische Spermieninjektions-(ICSI-)Zyklen, bei de- schaftsraten und Lebendgeburtenraten signifikant höher in nen entweder 2 Embryos von guter Qualität (Gruppe A), ein der DET-Untergruppe mit 2 Embyros guter Qualität vergli- Embryo von guter Qualität und ein Embryo von schlechter chen mit der DET-Untergruppe mit Embryos gemischer Qua- Qualität (Gruppe B), oder ein einziges Embryo von guter Qua- lität und den SET-Untergruppen. Die Mehrlingsschwanger- lität (Gruppe C) transferiert wurden, verglichen. Alle diese schaftsraten waren in beiden DET-Gruppen höher (p = 0,001). Gruppen wurden je nach Transfertag (im Teilungsstadium Schlussfolgerung DET mit Embryos von gemischter Qualität bzw. Blastozystenstadium) nochmals in 2 Untergruppen un- geht einher mit niedrigeren klinischen Schwangerschafts- terteilt. Die primären Endpunkte waren klinische Schwanger- raten und Lebendgeburtenraten als DET mit 2 Embryos von schaftsrate und Lebendgeburtenrate. guter Qualität im Blastozystenstadium. Werden die Embryos Ergebnisse In den Teilungsstadiumtransfer-Untergruppen im Teilungsstadium transferiert, gibt es hinsichtlich der Le- waren die klinischen Schwangerschaftsraten niedriger in der bendgeburtenraten keinen Unterschied zwischen den Untergruppe mit einem einzigen transferierten Embryo (SET) 2Gruppen. Introduction Materials and Methods The number and quality of embryos transferred are important in determining the success of assisted reproductive technology Study design (ART) treatment cycles. Good quality embryo transfers result in The presented retrospective clinical study was conducted at the higher clinical pregnancy and live birth rates [1], and poor quality ART clinic of Health Sciences University Etlik Zubeyde Hanım embryo transfers result in higher miscarriage and lower ongoing Womenʼs Health Teaching and Research Hospital, Ankara, Turkey. pregnancy rates [2]. This is probably the result of different endo- The patient files between January 2007 and February 2018 were metrial responses to the quality of the embryo; decidualized en- reviewed using a computer-based database. The IVF cycle was ac- dometrial stromal cells have been shown to act as biomarkers for cepted as the process that started with controlled ovarian stimu- arrested embryos, thus preventing implantation [3]. Clinical preg- lation (COH) and resulted with embryo transfer. We analyzed nancy and live birth rates are lower with single poor quality em- 2298 fresh cycles of women aged ≤ 40 years who had their first, bryo transfers; however, when clinical pregnancy is achieved, mis- second or third cycles with SET or DET. The patients were divided carriage rates, obstetric, and perinatal outcomes are similar to into three groups: group A included two good quality embryo good quality embryo transfer cycles [1]. Therefore, a poor quality transfer cycles, group B included one good and one poor quality embryo may also have the chance of a live birth. embryo transfer cycle, and group C included a single good quality There is increasing preference for elective single-embryo trans- embryo tranfer cycle. All groups were divided into two subgroups fers (SET) in in vitro fertilization (IVF) cycles because cumulative according to the stage of the embryo transferred as cleavage live birth rates are high after fresh cycles followed by frozen and stage (day 3) or blastocyst (day 5) transfer subgroups. Patients thawed cycles with SET [4]. However, double-embryo transfers with endometrial, uterine pathologies, endometriosis or hydrosal- (DET) are still preferred in many IVF clinics because the clinical pinx were excluded. The study was approved by the institutional pregnancy and live birth rates are higher than with SET cycles [5, ethics committee (12/11/2018–19). Formal consent was not re- 6]. Nevertheless, it is also known that multiple pregnancy rates quired because it was a retrospective study. are higher in DET, resulting in higher maternal and perinatal mor- tality and morbidity rates [5,6]. When there is more than one Ovarian stimulation, intracytoplasmic sperm injection good quality embryo on the transfer day, many clinics prefer (ICSI), and embryo transfer procedures DET, but generally, there are embryos of different qualities in the Patients were stimulated with standard-antagonist or long-ago- available transfer cohort. It is difficult to decide whether to trans- nist protocols after evaluation of the ovarian reserve. The dose of fer the mixed quality embryos together or to transfer a single gonadotropins was individualized according to the patientʼsage, good quality embryo, because a good quality embryo has been basal serum follicle-stimulating hormone (FSH) level, antral follicle shown to have a higher implantation rate than DET with mixed count (AFC), and body mass index (BMI), and was adjusted de- quality embryos [7]. pending on the ovarian response. Cycle monitorization with serial The aim of this study was to investigate whether a poor quality transvaginal ultrasonography and measurement of serum estra- embryo transfer along with a good quality embryo had a negative diol (E2), luteinizing hormone (LH), and progesterone levels were effect on IVF outcomes compared with DET with two good quality continued until human chorionic gonadotropin (hCG) administra- embryos. tion for final