Comparisons of Human Embryonic Development Using Single Medium With and Without the Addition of Antioxidants
Condition: Culture Media; Blastocyst; Antioxidants; Embryo; Human
Study type: Interventional

Summary: 
      Aim: To investigate the impact of antioxidants (acetyl-L-carnitine, N-acetyl-L-cysteine and
      a-lipoic acid) on embryo development and subsequently the clinical outcome. Including clinics
      using low oxygen and ambient air during embryo culture. Analysed with time-lapse system.

      Study media: G-TL with antioxidants. Control media: Same media without antioxidants. Type of
      study: Study comparing blastocyst development on the same cohort of oocytes using two
      different media, G-TL versus G-TL supplemented with antioxidants. Statistics based on an
      absolute increase in Good Quality Blastocysts on day 5 of 7%.

      Design: Multicentre prospective randomized sibling trial. Single blastocyst transfer.
      Superiority study Primary Endpoint: Good Quality Blastocysts on day 5 per allocated normally
      fertilized oocyte.

      Patients: Comparative embryo sibling study with 128 patients included.
    

Detailed description: 
      Study objective: Study comparing blastocyst development on the same cohort of oocytes using
      two different media, G-TL versus G-TL supplemented with antioxidants.

      Primary endpoint: Percentage of good quality blastocysts (GQB) per fertilized oocyte on day
      5.

      Secondary endpoints

        -  Embryo development day 3, 5 and 6

        -  Embryo quality day 3, 5 and 6

        -  Total blastocyst formation (day 5 and day 6)

        -  Utilization rate (embryos available for transfer and cryopreservation)

        -  Implantation rate

        -  Clinical pregnancy rate

      Setup: Prospective embryo sibling, superiority study

      MATERIALS AND METHODS Intervention New type of embryo culture media used for in vitro culture
      of human IVF embryos.

      Power analysis The planning and the power analysis was made together with a statistician,
      Nils-Gunnar Pehrsson.

      From retrospective data using simulation, the intra individual SD for the difference in % GQB
      between the two media strategies was estimated to 32%. In order to find a difference in 8% in
      GQB between the two media with power 80% with paired T-test 128 couples will be needed.

      Randomization Couples will be enrolled in the study after fertilization check (day 1). A
      minimum of 6 zygotes is required for participation.

      Stratified randomization of the zygotes by couple will be performed. For each couple the
      zygotes will be numbered.

      These zygotes for each couple will then be block (by two) randomized to the two media types;
      A (Traditional culture media = Control) and B (Antioxidant media = intervention). In both
      groups traditional culture will be performed. Allocation will be performed in a 1:1 ratio
      according to a unique randomization list for each couple.

      Blinding To minimize possible bias for the primary outcome (GQE D5) the embryologist
      performing the morphological evaluation on day 5/6 will not know which group the embryos
      belong to.

      Both the physician and the couple will be blinded to which group they have been allocated.

      IVF treatment procedure A traditional IVF treatment will be performed including ovarian
      stimulation and oocyte pick-up using the standard methods at the clinics.

      Embryo assessment and timing of assessment according to Alpha/ESHRE consensus criteria.

      Morphological scoring Blastocyst morphology will be scored according to Consensus Scoring
      system for blastocysts (Istanbul Consensus workshop on embryo assessment) and the morphology
      will be documented with individual photos of each blastocyst. Blastocyst scoring will be
      performed under an inverted microscope on day 5 and day 6. A good quality blastocyst is
      defined as at least Grade 2:2:2 according to Istanbul Consensus grading system. (Balaban et
      al., 2011).

      DOCUMENTATION All patients participating in the study will be documented on a computerized
      CRF. This document will be related to patients' records with all relevant clinical and
      laboratory data from the specific IVF cycle. Through the journal system (WinIVF) used at
      Fertilitetscentrum, it will be possible to generate a complete list of all the variables
      included in the study.

      Patients who have been asked to participate in the study but did not fulfill the criteria for
      randomization will also be registered.

      STATISTICAL ANALYSIS Both an Intention-to-Treat (ITT) population and a Per Protocol (PP)
      population will be defined. Primary efficacy variable in this superiority study will be
      difference in %GQB between the two media types for each couple. Primary statistical analysis
      will be two-sided paired T-test regarding the mean of difference in %GQB between Standard
      culture media and Antioxidant media on the ITT population. A two sided 95% confidence
      interval for the mean difference in %GOB between the two media will be calculated. All
      significance tests will be two-sided and conducted at the 5% significance level.
    

Intervention name(s): Acetyl-L-carnitine (ALC), N-acetyl-L-cysteine (NAC) and α-lipoic acid (ALA)
Intervention type(s): Biological
Intervention description(s): Human embryos will be cultured in media that contains 3 antioxidants (Acetyl-L-carnitine (ALC), N-acetyl-L-cysteine (NAC) and α-lipoic acid (ALA)) that can be found in the in vivo Environment.
Intervention MeSH terms: Thioctic Acid; Acetylcarnitine; Acetylcysteine; N-monoacetylcystine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Treatment