P–360 Blastocyst biopsy day does have an impact on clinical pregnancies in different frozen embryo transfer (FET) regimens: natural cycle (NC) versus hormone replacement therapy (HRT)
Authors: Abdala A , Munck N D , ElKhatib I , Bayram A , Arnanz A , El-Damen A , Melado L , Lawrenz B , Fatemi H M 
Published: August 2021

Abstract

Study question
Do euploid blastocysts biopsied on day (D) 5 or D6 differ in clinical pregnancy rates when single FET are performed in NC or HRT cycles?

Summary answer
In single FET cycles, euploid D5 blastocysts have higher clinical pregnancy rates than D6 in NC, while outcomes are comparable in HRT cycles. What is known already: The synchronization between the endometrium and the embryo development is fundamental for a successful implantation. When performing FET with euploid blastocysts biopsied on D5 or D6, higher clinical pregnancy rates have been reported with D5 blastocysts, however contradictory findings were described due to the study design heterogeneity and endometrial preparation (EP) protocol variabilities. In FET cycles, no consensus has been defined of the superiority of NC over HRT cycles when euploid blastocysts are transferred. Consequently, the question remains unanswered if the clinical pregnancy rates of single euploid FET with D5 or D6 blastocysts differ when the EP protocol remains constant.

Study design, size, duration
A single center observational study was performed between June 2017 and November 2020, including 1027 single euploid FET with blastocysts biopsied on D5 or D6. All patients with primary or secondary infertility who underwent a FET in a NC or HRT EP protocol, with blastocysts graded ≥ BL3CC (Gardner scoring system) prior to biopsy were included. Vitrified-warmed blastocysts that did not re-expand within 1-hour post-warming were excluded from the analysis.

Participants/materials, setting, methods
In NCs, vaginal progesterone (P4) (Endometrin®) was administrated (3x100mg) after endocrinological confirmation of ovulation until pregnancy test. For HRT cycles, oral estradiol administration was started on day 2 (4 mg) and increased to 6mg on D5 of the cycle. When endometrial thickness was ≥6 mm, P4 was given (3x100mg) until pregnancy test. All FET were performed on D5 after start of P4 administration. Clinical pregnancy was recorded as the presence of an intrauterine gestational sac.

Main results and the role of chance
Women’s mean age was 33.8 ± 5.5 years. A total of 651 FETs were performed with D5 euploid blastocysts (37.6% in NC and 62.4% in HRT) and 376 with D6 (43.1% in NC and 56.9% in HRT). Clinical pregnancy rate in NC was higher with D5 blastocysts compared to D6 (66.9% vs 50.0%; OR = 0.494, 95% CI = 0.322–0.758; p &lt; 0.001), while no significant differences were found when vitrified-warmed blastocysts were transferred in HRT cycles (64.3% vs 58.4%; OR = 0.781, 95% CI = 0.548–1.112; p = 0.164). Additionally, clinical miscarriage was significantly higher with D5 euploid blastocysts transferred in NC (D5=10.9% vs D6=3.7%, OR = 0.239, 95% CI = 0.044–0.837; p = 0.019). In HRT, miscarriage outcomes were similar between D5 and D6 euploid blastocysts (D5=18.7% vs D6=20.8%, OR = 0.781, 95% CI = 0.548–1.112; p = 0.164), but significantly higher (p &lt; 0.001) than in NC. From a multinomial logistic regression model including age, blastocyst quality and day of biopsy as confounding factors, the clinical pregnancy rate was significantly affected by D6 blastocyst biopsy (OR = 0.571, 95% CI = 0.360–0.906, p = 0.017) and inner cell mass (ICM) grade A (OR = 3.941, 95% CI = 1.149–10.402; p = 0.006) or B (OR = 2.601, 95% CI = 1.146–5.907, p = 0.022) in NC. In HRT cycles, exclusively ICM was statistically significant (OR = 2.555, 95% CI = 1.214–5.381, p = 0.015 and OR = 2.397, 95% CI = 1.286–4.470, p &lt; 0.001 for grade A and B, respectively).

Limitations, reasons for caution
The current results are based on an observational retrospective study. Live birth and perinatal outcomes should be considered in a further analysis to evaluate the performance of the NC vs HRT protocols when D5 or D6 euploid blastocysts are transferred in FET cycles.
Wider implications of the findings: While the clinical pregnancies of D5 and D6 euploid blastocysts are comparable in HRT protocols only, the miscarriage rates seem to be significantly increased as compared to NC. Further studies are required to personalize EP protocols based on the day of blastocyst biopsy in order to improve clinical outcomes.

Trial registration number
No