Prospective Observational and Validation Study Using Time-lapse Morphometry MIRI Imaging Incubator (TiMMI Study)
Phase: NA
Conditions: Fertility
Sponsor: Ovation Fertility

TiMMI Study 
2016-TiMMI-001 
Clinical Investigation Protocol 
Prospective Observational, Comparative 
and Validation Study using TimeLapse 
Morphometry MIRI Imaging Incubator 
(TiMMI Study) 
Device: 
ESCO MIRI-TL         
Protocol #: 
2016-TiMMI-001        
Version: 
A 
Sponsor: 
ESCO Medical 
21 Changi South Street 1 
Singapore 486 777 
CONFIDENTIALITY STATEMENT 
The information in this document is privileged and confidential and may not be disclosed unless federal or 
state law requires such disclosure. The information in this document may be disclosed only to those persons 
involved in the conduct of the study. These restrictions on disclosure will apply as well to all future 
information supplied under this Protocol.  The confidentiality of this material is further protected by the 
terms of the Nondisclosure Agreement entered into by the Parties. 
Date:                    June 15, 2016

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Table of Contents 
1. Introduction .................................................................................................................................. 4 
2.   Background ................................................................................................................................. 4 
3.    Study Objectives ......................................................................................................................... 5 
3.1 Primary Objective ................................................................................................................... 5 
3.2 Secondary Objectives ............................................................................................................. 5 
4. Description of Device .................................................................................................................... 6 
4.1 CultureCoin ........................................................................................................................... 11 
5. Number of Centers and Study Duration ..................................................................................... 12 
6. Study Design ................................................................................................................................ 12 
7. Statistical Methods and Analyses ............................................................................................... 12 
8.0 Patient Randomization ......................................................................................................... 13 
8.1 Egg Retrieval and Fertilization‐Day 0 ................................................................................... 13 
8.2   Day 3 Embryo Assessment .................................................................................................. 14 
8.6 Outcome: Pregnancy Test .................................................................................................... 14 
8.7 Outcome: Pregnancy Confirmation Ultrasound ................................................................... 15 
8.8 Outcome: Ongoing Pregnancy Ultrasound ........................................................................... 15 
8.9 Frozen Embryo Transfer (FET) Cycles – if applicable ............................................................ 15 
8.10 Protocol Deviations ............................................................................................................ 16 
8.11 Device Incidents ................................................................................................................. 16 
8.12 Adverse Events ................................................................................................................... 16 
8.13 Study Exit ............................................................................................................................ 17 
8.14 Subject Confidentiality ....................................................................................................... 18 
9. Potential Benefits ....................................................................................................................... 18 
10. 
References ..................................................................................................................... 19 
 

 
 
Study Title 
Prospective Observational, Comparative and Validation Study 
Using TimeLapse Morphometry MIRI-TL Imaging Incubator   
(TiMMI Study) 
Protocol # 2016-TiMMI-001 
Sponsor 
ESCO Medical 
21 Changi South Street 1 
Singapore 486 777 
Study Device 
MIRI-TL , including: 
• MIRI-TL incubator 
• MIRI-TL Viewer 
• Uninterruptible Power Supply 
• Accessories 
CultureCoin dish 
Indications for 
Use/Intended Use 
The MIRI-TL is a purpose built embryo culture incubator using a 
built-in microscope and camera designed specifically for the 
continuous assessment of embryo development in-vitro. As images 
are digitally obtained and stored, a video can be generated to 
enable more objective and reliable grading criteria. This 
technology, in conjunction with the MIRI-TL Viewer allows for non-
invasive viability evaluation and assessment allowing for better 
prediction of embryo developmental potential and implantation 
success.  The MIRI-TL is CE marked for clinical use. 
The CultureCoin is intended to be used to hold human oocytes 
and embryos during handling and culture. 
Study Purpose 
The purpose of this study is to demonstrate and validate 
the non-inferior or superior safety and efficacy of the MIRI-
TL compared to standard big-box incubators used for 
embryo culture. 
Study Design 
Prospective, observational, randomized, double-arm 

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Safety Measures 
Adverse events and device malfunctions will be reported and 
summarized from the start of embryo culture through study 
exit. 

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Number of Subjects Up to 500 patients 
Subject 
Population 
Patients undergoing in vitro fertilization treatment who fulfill all 
eligibility criteria. 
Eligibility Criteria 
Inclusion Criteria: 
• At least 18 years of age 
• Women undergoing in vitro fertilization treatment 
using their own or frozen oocytes 
• Fresh or Frozen Embryo Transfer 
• Fertilization by ICSI 
• At least 4 diploid (2PN) embryos at fertilization check 
• Willing to have all inseminated oocytes imaged by Miri 
• Willing to comply with study protocol and procedures 
• Willing to provide written informed consent 
Exclusion Criteria: 
• Fertilization using surgically removed sperm 
• History of cancer 
Number of Sites 
1 
Study Duration 
Expected study duration is 18 months including enrollment and 
follow‐up. Subjects will be followed until pregnancy outcome has 
been determined (i.e. date of negative hCG test, 8‐12 week clinical 
pregnancy ultrasound, or date of live birth, if pregnant). 
Summary of 
Data Collection 
• Enrollment:  Demographics, IVF and pregnancy history 
• IVF Lab:  Embryo morphology 
• Time‐Lapse Imaging Data 
• Pregnancy test and Live Birth Outcome 
• Preimplantation Genetic Screening (PGS) Data, if applicable 
• Frozen Embryo Transfer (FET) Data, if applicable 
Study Start 
April 2016 

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1.  Introduction 
The purpose of this clinical study protocol is to gather information regarding the 
performance and safety of a novel time lapse incubator compared to standard 
incubator systems.  The MIRI-TL and the Culture Coin are CE Marked and have 
therefore fulfilled EU safety and performance criteria. In the US, 510(k) 
submission for both products is planned for Q2/Q3 2016. 
As the sponsor of this clinical study, ESCO Medical has the overall responsibility 
for the conduct of the study, including assurance that the study will be 
performed according to the clinical investigation plan, applicable US Food and 
Drug Administration (FDA) and local regulation. 
2.   Background 
The optimal goal of IVF should be the delivery of a healthy singleton baby and 
healthcare providers may be compelled via legal, financial, and moral 
obligations to reduce multiple pregnancies.1‐4  The clinical dilemma is how to 
restrict the number of embryos for transfer to prevent multiple births while at 
the same time maintaining or improving IVF success rates. The ability to 
selecting the highest quality embryo that is most likely to result in implantation 
becomes the key solution, however, this has proven to be challenging.  
In the late 1990s, improved culture media enabled blastocyst culture, allowing 
embryos to develop in a petri dish for 2 to 3 additional days. Generally, about 
40% of the embryos will form a blastocyst while others arrest in the culture dish 
during this extended period of incubation. It was broadly reported that 
blastocyst formation was a key embryo selection criterion for predicting 
successful implantation. Papanikolaou et al demonstrated in prospective 
randomized studies that embryo implantation rates and live birth rates were 
significantly improved with Day 5 transfer, as compared to Day 3 transfer.5‐6 
Because of improved implantation and live birth rates, blastocyst culture was 
widely  adopted  in  clinics,  in  particular  those  which  utilized  single embryo 
transfer. 
 
Embryos selection based on traditional morphology scores developed in the 
early 1980s. The morphological criteria are based on multiple 'static' 
observations of embryos under regular light microscopes. This involved removing 
the culture dish, which contained the embryos, from the incubator on a daily 
basis and assessing the embryos based on their morphology and growth.   A 
number of studies have reported observations relating embryo morphology and 
implantation, including 2‐pronuclear score, early cleavage observation, Day 2 or 

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Day 3 cleaved embryo assessments, and Day 5 or Day 6 blastocyst grading.7‐24 
 
However, despite exhaustive efforts by clinical embryologists using a regular 
light microscope to assess embryo quality, it is clear that traditional morphology 
grading, which only captures static images at a few time points, is of limited 
predictive value.  
Several studies have indicated that using information obtained from time‐lapse 
imaging, which provides a continuous 'movie' of embryo development,  may 
improve embryo selection and ultimately improve clinical pregnancy or 
implantation.25‐27 This is partly due to the non-invasive and controlled micro 
environment most purpose built time-lapse incubators provide. The literature 
has been encouraging as it appears that using time‐lapse in the IVF laboratory 
may have a significant positive impact by providing embryologists with an 
additional tool to assess and predict which embryo is more likely to lead to a 
successful pregnancy.  
 
3.    Study Objectives 
The purpose of this clinical study is to demonstrate and validate the safety and 
efficacy of the purpose built MIRI-TL incubator and correlate morphokinetic data 
to improved success rates.   
 
3.1 Primary Objective 
• To collect safety and imaging data on the MIRI-TL and CultureCoin. 
 
3.2 Secondary Objectives 
• To collect enrollment data: demographics, IVF and pregnancy history 
• To collect Day 3, Day 5 and Day 6 embryo morphology data 
• To collect pregnancy test and live birth outcome data 
• To collect pre‐implantation genetic screening (PGS) data (if applicable) 
• To collect Frozen Embryo Transfer (FET) data (if applicable) 

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4. Description of Device 
The Miri- TL, manufactured by the study sponsor Esco Medical is a closed-system 
incubator device with built-in visual monitoring system.   This closed system 
incubation system eliminates any environmental disruption and contamination risk by 
daily handling.  The built-in camera has the ability to record cell division kinetics and 
morphology of developing embryos which can provide more reliable indicators of 
embryo quality.  This novel time-lapse incubator captures images at five (5) minute 
intervals and its six (6) separate incubation chambers maximizes temperature and gas 
stability, providing a safe and secure environment for human embryos.   
 
 
Figure 1:  MIRI-TL  
 
 

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4.1 CultureCoin 
The 16‐well CultureCoin (Figure 2) is a standard size (60mm) embryo culture dish 
with individual micro‐ wells aligned in a row in the center of the dish. Each micro‐
well is designed to accommodate a single patient’s oocytes or developing 
embryos through the blastocyst stage and are culture individually. The 16‐well 
CultureCoin is designed to fit in only one (1) position in one (1) of the individual 
six (6) incubator chambers, and each micro‐well is identified to facilitate embryo 
tracking (for example, micro‐well 
 
Figure 2:  CultureCoin 
 
 
 
 
 
 
 
 
 

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5. Number of Centers and Study Duration 
The TiMMI study will include only one investigational site. This site will conduct 
the study under a single clinical investigation plan. 
Expected study duration is 18 months including enrollment and follow‐up. 
Subjects will be followed until pregnancy outcome has been determined (i.e. 
date of negative hCG test or 8‐12 week clinical pregnancy ultrasound, if 
pregnant). 
 
6. Study Design 
This is a prospective, non-blinded, observational, randomized, double‐arm study. 
 
7. Statistical Methods and Analyses 
Up to 500 subjects’ embryos will be collected in this ongoing data collection 
protocol. We aim to recruit 200 patients in the standard culture group, and 300 
patients in the MIRI-TL group. 
Assuming that 25% of all inseminated oocytes would develop into blastocysts 
(based on published clinical data), at least 1300 inseminated oocytes (~163 
patients) would be needed in each group to detect an increase in blastocyst 
proportion of 20% with 80% power and a significance level of 0.05 (two-tailed 
tests).  
Assuming that time from insemination to start of blastulation (tSB) follows a 
normal distribution, and is 96h with a variance of 49h in euploid embryos, and 
98h (variance 49h) in aneuploid embryos, ~405 blastocysts (1620 inseminated 
oocytes = 203 patients) in the MIRI-TL group will need to be biopsied to detect 
a significant difference in tSB (80% power, 0.95 confidence level, 2-tailed test). 
Since ~80% of all patients receive PGS at our clinical site, we will need ~255 
patients in our MIRI-TL group. 
To account for patient dropout and lower than expected oocyte retrieval per 
patient, we propose to recruit up to 500 subjects in this ongoing data collection 
protocol: 200 patients in the standard culture (SC) group and 300 patients in 
the MIRI-TL (MIRI) group. 
Embryos with incomplete annotations will be excluded from analysis. All 
variables will be tested for normality using Shapiro–Wilks test. Continuous data 
following a normal distribution will be analyzed with Students t-test. 

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Continuous data not fulfilling the assumption of normality will be analyzed with 
non-parametric tests such as the Wilcoxon rank-sum test. For categorical data 
Chi-squared or Fisher’s exact test will be used. Two-tailed p-values < 0.05 will 
be considered significant. 
 
8. Study Protocol 
8.0 Patient Randomization 
Patients will be randomized to the MIRI-TL group (MIRI) or the Standard culture 
group (SC) by randomization number generator through www.randomizer.org, 
using a number set from 1 to 500. Numbers 1-300 will be assigned to the study 
(MIRI-TL) group while numbers 301-500 will be assigned to the control (Standard 
Incubator). 
 
 
 
 
 
 
8.1 Egg Retrieval and Fertilization‐Day 0 
Egg retrieval and fertilization follow the standard protocol in place at the clinical 
site. Insemination, by intracytoplasmic sperm injection (ICSI) will take place on 
Day 0 (egg retrieval day) following standard protocol currently in place at the 
clinical site. The fertilized eggs should be free of cumulus cells as much as 
possible. If the cumulus cells remain in place, they may interfere with the quality 
of the imaging. Immediately after micro insemination, eggs will be placed in 
individual wells within a CultureCoin (MIRI group), or a standard culture dish (SC 
group), and incubated in the MIRI-TL or standard incubator respectively. All eggs 
will be cultured in the standard fertilization media currently in place at the 
clinical site. At 20hr after insemination, the MIRI-TL imaging software will be 
Paused, and all embryos will be examined by the embryologist for successful 
fertilization (2PN). All normally fertilized eggs will be placed into a new 
CultureCoin (MIRI group) or standard culture dish (SC group) containing the 
standard embryo culture media, and incubated in the MIRI-TL or standard 
incubator respectively. 
Once an embryo is assigned a micro‐well location, it must remain in the same 
location throughout the study imaging period. Embryos assigned to the MIRI 
group will be imaged in the CultureCoin from Day 0 to Day 7. Images of the 
developing embryos will automatically be captured with the MIRI-TL Microscope. 
Data collected will include the following: 
• Number of eggs inseminated 

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• Fertilization method 
• Total number of fertilized eggs (2PN) 
 
8.2   Day 3 Embryo Assessment 
At Day 3, the MIRI-TL imaging software will be Paused and the embryologist will 
evaluate embryos from both groups per standard procedure. The development 
stage of the embryos and grading based on traditional morphology criteria will 
be recorded. It is recommended that the Day 3 morphology assessment is done 
within 48 hours after the fertilization (2PN) check. Per protocol, Assisted 
Hatching (AH) is allowed if patients have opted for embryo biopsy and PGS. 
After embryo assessment the embryos may be placed back into the MIRI-TL or 
standard incubator as per their respective groups, and imaging will be resumed 
for the MIRI group.  
8.3 Day 5, 6 and 7 Embryo Assessment 
The embryologist will evaluate the embryos using traditional morphological 
grading. It is recommended that the Day 5 morphology assessment is done 
within 48 hours after the Day 3 morphology assessment.  
 
8.4 Embryo Biopsy and Preimplantation Genetic Screening Data ‐ if applicable 
Pre‐implantation Genetic Screening (PGS) is not required in this study. If the 
physician and the patient have previously decided to perform PGS in the IVF 
cycle, the outcome data will be collected. Embryo biopsy and PGS will be 
performed per standard procedure. Transfer procedures and disposition of 
embryos not selected for transfer will be determined as per the standard 
protocol in place at the time of the study.  
8.5 Embryo Transfer 
Embryo(s) will be selected for transfer based on the current standard protocol in 
place at the clinical site. Data pertaining to the embryo transfer procedure will 
include the following: 
• Day and date of transfer 
• Total number of embryos transferred 
• Luteal phase support 
 
8.6 Outcome: Pregnancy Test 
After embryo transfer, each subject will be followed to determine if a chemical 
pregnancy has been achieved by undergoing the clinical sites’ standard serum 
pregnancy testing procedure.  Data will be recorded and include the following: 

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• Date of the serum pregnancy test 
• Quantitative hCG level 
 
Each subject with a positive serum pregnancy test result will continue to be 
followed. If the result of the pregnancy test is negative, the subject will have 
completed the study and be exited at that time. 
8.7 Outcome: Pregnancy Confirmation Ultrasound 
A clinical pregnancy is typically verified by the detection of a fetal heartbeat via 
vaginal ultrasound. The clinical site verifies clinical pregnancy at approximately 5‐ 
8 weeks gestation. The results of the test will be recorded and include the 
following: 
• Date of ultrasound 
• Result of initial pregnancy ultrasound 
o Number of intrauterine gestational sacs 
o Number of fetal heart beats 
 
If the result of the ultrasound is negative, that is, if no fetal heartbeat is 
detected, then the subject will have completed the study and be exited at that 
time. 
8.8 Outcome: Ongoing Pregnancy Ultrasound 
The clinical site verifies the viability of the pregnancy (ongoing pregnancy) at 
approximately 8‐12 weeks gestational age via vaginal ultrasound. Data will be 
recorded and include the following: 
• Date of ultrasound 
• Result of ultrasound 
o Number of gestational sacs 
o Number of fetal heartbeats 
• Pregnancy outcome 
 
If the result of the ultrasound is negative, that is, if an ongoing pregnancy is not 
confirmed, then the subject will have completed the study and be exited at that 
time. 
8.9 Frozen Embryo Transfer (FET) Cycles – if applicable 
If the patient does not get pregnant from the fresh embryo transfer, data from 
blastocysts previously frozen in the fresh cycle may be thawed for a FET for the 
duration of the study. Endometrial preparation for FET cycles will be performed 
per the clinical sites standard protocol. Data pertaining to the stimulation 
protocol, pregnancy, and outcome data will be collected. 

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8.10 Protocol Deviations 
A protocol deviation occurs when a clinical investigator and/or study site 
personnel does not conduct the study according to the clinical investigation plan. 
All deviations are recorded on the Protocol Deviation case report form. Data 
collected will include the following: 
• Date of deviation 
• Type of deviation 
• Description of deviation 
• Corrective action 
 
The Investigator must maintain accurate, complete, and current records relating 
to the clinical study. This includes source documents showing the dates and 
reasons for each deviation from the clinical investigation plan. 
 
 
 
 
 
 
8.11 Device Incidents 
Any feedback in regards to the Miri- TL should be reported to Esco Global as 
soon as possible. Feedback may consist of any alleged deficiency related to the 
physical 
characteristics, 
identity, 
quality, 
durability, 
reliability, 
safety, 
effectiveness, or performance of the MIRI-TL and/or CultureCoin. Engineering 
and Quality will investigate device deficiencies and perform an evaluation to 
determine and document the root cause of any device deficiency. Reports will be 
filed in the MIRI-TL Study project file and/or in document control.   The following 
data will be collected: 
 
• Date and time incident first observed 
• Associated Device(s) 
• Description of incident 
• Troubleshooting 
• Outcome 
 
8.12 Adverse Events 
While the overall IVF procedure may involve several visits and procedures, the 
first time the subject or user has any encounter with the MIRI-TL and CultureCoin 
is when the embryos are first loaded onto the MIRI-TL for imaging. Adverse 

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events for the subject or user will be reported from the point of embryos being 
placed in the MIRI-TL through study completion for each subject. An adverse 
event will be followed until resolved or stabilized at a level acceptable to the 
investigator. 
Events well documented to be associated with ART/IVF procedures (as outlined 
in each clinic’s consent for IVF procedures) will not be collected as adverse 
events under this protocol. Other common non‐study or non‐device related, 
minor health complaints will not be collected as adverse events (for example: 
colds, sprains, headaches). 
The investigator should follow the reporting requirements of the reviewing 
IRB/REB for all adverse events (including serious and unanticipated adverse 
device effects). Documentation of any IRB and Esco Global notifications should 
be maintained in the site’s clinical study files. It is recommended that 
acknowledgement of receipt from the IRB be maintained in the study file as well. 
Adverse events will be reported to Esco Global and data collected will include 
the following: 
• Date of adverse event 
• Type of event and description 
• Action/treatment taken 
• Severity of event 
• Seriousness of event 
• Investigator’s assessment as to the relationship of the AE to the MIRI-
TL 
• Investigator’s assessment as to the relationship of the AE to IVF/ART 
procedures 
Investigator’s assessment if the event is a potential Unanticipated 
Adverse Device Effect (UADE) 
 
Source documentation for adverse events must be collected and filed with the 
subject’s medical chart. Refer to Section 10 – Adverse Event Definitions and 
Reporting for additional information. Because study procedures are limited to 
the noninvasive collection of clinical data, no Data Safety Monitoring Board will 
be established for this study. 
8.13 Study Exit 
Study Exit data should be collected at the time a subject is exited from the study. 
A subject will be considered to have exited from the study for any of the 
following reasons including, but not limited to: 

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• Subject completed follow‐ups required by the clinical protocol 
• IVF cycle not completed or cancelled 
• Subject requested to be withdrawn 
• Subject terminated IVF treatment for personal reasons 
• No availability of culture slots in the MIRI-TL  
• Investigator requested that subject be withdrawn to protect the 
welfare of the subject 
• Subject was lost to follow‐up 
• Subject was not compliant 
• Other (specify) 
 
A subject may elect to withdraw from the study at any time. The subject should 
notify the investigator if she wishes to withdraw from the study.  The 
investigator and research staff should encourage all subjects to return for 
required follow‐up visits. The investigator is free to withdraw a subject at any 
time if, in the investigator’s opinion, it is in the best medical interest of the 
subject. A subject so withdrawn will be treated according to standard of medical 
care. The sponsor reserves the right to terminate this study at any time. Subject 
data will be included in the analyses up to the time that consent was withdrawn 
or up to the time that the study was terminated. 
8.14 Subject Confidentiality 
Subject confidentiality will be maintained throughout the study to the extent 
permitted by law. That is, every attempt will be made to remove subject 
identifiers from study documents. For this purpose, a unique subject 
identification code (subject number) will be assigned and used to allow 
identification of all data reported for each subject. A log of subject initials and 
the corresponding subject ID will be maintained to ensure that the information 
can be tracked back to the source data. All subject study records and files shall 
be kept in a secure location with limited access. Access shall be granted only to 
those individuals who are recorded as authorized study staff members. 
Study data may be made available to third parties, e.g., in the case of an audit 
performed by regulatory authorities. The identity of a subject will never be 
disclosed in the event that study data are published. 
 
9. Potential Benefits 
In this study, there is no direct benefit to subjects who participate. However, the 
data collected in this study may lead to more effective methods of visualizing, 
monitoring, and selecting the most viable IVF embryos by a physician or 
embryologist, to maximize the chances of implantation and successful pregnancy 

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outcome for future patients. 
Subjects who successfully complete all study procedures will receive a video of the 
embryo which was transferred or embryo(s) which were cryopreserved.  No other 
reimbursement will be provided for the IVF cycle.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Gardner DK, Lane M, Stevens J. Blastocyst score affects implantation and 

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