The objective of the study was to investigate the relationship between advanced paternal age and sperm DNA fragmentation (SDF) levels, specifically identifying the age at which a significant increase in SDF occurs. This is a retrospective cohort study involving 4250 consecutive semen samples from patients presenting for infertility evaluation. Patients were stratified into seven age groups: < 26 (n = 36; 0.8 %), 26-30 (n = 500; 11.8 %), 31-35 (n = 1269; 29.9 %), 36-40 (n = 1268; 29.8 %), 41-45 (n = 732; 17.2 %), 46-50 (n = 304; 7.2 %), > 50 (n = 141; 3.3 %). The main outcome measures included comparing mean SDF levels throughout different age groups and assessing the prevalence of normal, intermediate, and high SDF among the age groups. A positive correlation was observed between paternal age and SDF (r = 0.17, p < 0.001). SDF remained relatively constant until the age of 35 but increased significantly beyond age 35. Mean SDF levels in the older age groups (36-40, 41-45, 46-50, and >50 years) were significantly higher than in the younger age groups (<26, 26-30, and 31-35 years) (p < 0.001). The prevalence of normal SDF was highest among the younger age groups, whereas the prevalence of high SDF was highest among the older age groups. Interestingly, the prevalence of intermediate SDF was relatively constant throughout the age groups (ranging between 29.8 % to 37.2 %). The increase in SDF after the age of 35 highlights the importance of considering male age in infertility evaluations. Assessing SDF in men over the age of 35 is crucial in couples seeking to conceive.

Abstract Study question Which patients are eligible to skip ovulation monitoring before day 10 in In Vitro Fertilization (IVF) and what are the financial implications? Summary answer Thanks to our innovative gonadotropin prescription algorithm, patients with low ovarian reserve and maximum ovarian stimulation may not require monitoring until day 10 of IVF. What is known already In most fertility clinics, the standard procedure for IVF is early monitoring on day 6 of ovarian stimulation. Our focus is on personalizing the stimulation protocol by identifying the optimal dose of gonadotropin. With the aid of our unique algorithm, we aim to streamline monitoring. Frequent ultrasound examinations required for IVF can impose restrictions and create a burden for patients, resulting in increased costs for both patients and physicians. Study design, size, duration In a retrospective study conducted from April 2021 to August 2022 at the OVO clinic in Montreal (Canada), participants included all patients over 18 years old who underwent an IVF stimulation cycle utilizing an antagonist protocol and a customized mixed protocol prescription consisting of follitrophin delta and human menopausal gonadotropin, based on the patient's weight and anti-Mullerian hormone level. The sudy was approved by Veritas IRB, an independent ethic committee. Tracking number of study :2023-3189-13659-2 Participants/materials, setting, methods In the study, gonadotropin dosages were assigned either based on our algorithm (group 1) or at the physician's discretion (group 2). Ultrasound and hormonal analysis were performed on day 6. Following the physician's evaluation, adjustments to the gonadotropin dosage were made if necessary. The common trigger criteria was the presence of at least three follicles measuring between 16 and 22mm. Main results and the role of chance The study included 714 patients meeting the inclusion criteria. In group 1, there was a high percentage of patients stimulated with the maximum doses (80.3% compared to 22.5% in group 2). No dosage modifications or incidents of ovarian hyperstimulation syndrome were observed in group 1. Only 4.5% of patients (n = 16) triggered ovulation before day 10 (on day 9). In the non-maximal dose population, patients treated according to the algorithm (group A) experienced significantly fewer changes to the gonadotropin dosage at day 6 compared to patients treated based on the physician's discretion only (group B) (24.6% vs 46.9%, p < 0.001). The dosage of gonadotropins was notably more frequent adjusted in group B (46.9% vs 24.6%, p < 0.001). A higher risk of ovarian hyperstimulation syndrome was significantly more frequent in the non-maximal dose population compared to the maximal dose population (64.6% vs 27.5%, p < 0.01). These findings suggest that ovulation monitoring may not be necessary in the population stimulated to the maximum dose. This could result in 478 ultrasound and blood tests being avoided in the context of this study. Limitations, reasons for caution The data was obtained through a retrospective analysis. However, not monitoring before day 10 could pose a risk of delaying the cancellation of the IVF cycle, resulting in unnecessary treatment continuation. Wider implications of the findings This significant study indicates that, thanks to our algorithm, monitoring only on day 10 would be adequate for patients with low ovarian reserve who are stimulated to the maximum dose. Further validation of this strategy can be conducted through a randomized prospective study or with the use of different gonadotropins. Trial registration number non applicable

Research question: What is the efficacy and safety of individualized follitropin delta dosing for ovarian stimulation in intrauterine insemination (IUI)? Design: This single-centre, prospective, open-label, single-cohort study involving 106 patients established an original dosing regimen based on body weight and anti-Mueurollerian hormone (AMH) concentrations, with adjustments based on the ovarian response from the previous IUI cycle. Each participant was enrolled in a maximum of three IUI cycles. Results: Mean age was 34.5 +/- 4.5 years, mean weight 69.2 +/- 11.2 kg, mean AMH 15.7 +/- 8.6 pmol/l, mean FSH 6.3 +/- 2.6 IU/l and mean antral follicle count 16.4 +/- 8.2. The percentage of patients who produced more than three mature follicles was 1.9%, 0% and 1.5%, respectively, for the three IUI cycles. The percentage of patients with two or three mature follicles was 34.0%, 36.9% and 47.1% for the three IUI cycles. The clinical pregnancy rate per IUI cycle was 17.9%, 14.3% and 17.6% for the three cycles, with a cumulative clinical pregnancy rate of 40.6%. Out of 258 cycles, 43 (16.7%) resulted in clinical pregnancy, with six of those resulting in multiple pregnancies (14.0%). Two resulted in spontaneous reduction within the first trimester and four resulted in live twin births, representing only 1.6% of the total cycles. Conclusions: This study is the first to utilize follitropin delta for stimulation in IUI. It demonstrates that individualized dosing is both effective and safe, resulting in satisfactory cumulative pregnancy rates and an acceptable multiple pregnancy rate, thus achieving the primary objectives of the research.

Abstract Study question What is the impact of advanced paternal age (APA) on sperm DNA fragmentation index (DFI)? Summary answer Sperm DFI levels remain relatively stable until the age of 35 and increase progressively beyond that age. What is known already APA can have a negative impact on male fertility and the health of offspring. Previous studies have shown that APA is linked to poor conventional sperm parameters, including decreased semen volume, sperm count, motility, morphology, as well as poor sperm DNA integrity. Additionally, APA has been associated with reduced natural or assisted reproduction and perinatal outcomes and a higher risk of genetic and chromosomal abnormalities in the offspring. Study design, size, duration A retrospective cohort study of 4250 consecutive semen samples from men undergoing infertility evaluation at the OVO clinic, in Montreal, Canada, between April 2016 and December 2022. Participants were stratified into seven age groups: <26 (n = 36; 0,8%), 26-30 (n = 500; 11,8%), 31-35 (n = 1269; 29,9%), 36-40 (n = 1268; 29,8%), 41-45 (n = 732; 17,2%), 46-50 (n = 304; 7,2%), >50 years (n = 141; 3,3%). The mean age was 37.4 ± 6.4 years (range 18-71 years). Participants/materials, setting, methods The study was population-based and included male patients from all ages, ethnicities, and medical histories. Semen samples were collected after 2-3 days of abstinence. For patients who underwent more than one DFI testing, only the first sample was included, and any duplicates were excluded. DFI was evaluated by flow-cytometry based TUNEL assay using the APO-Direct Kit. Data were analyzed using one-way ANOVA and T3 Dunnett post-hoc multiple comparison test, as well as Pearson’s correlation coefficient. Main results and the role of chance The results show a significant positive correlation between %DFI and age (r = 0.19, p < 0.001). Mean %DFI levels were relatively stable in men aged <26 to 35 years (17.9%, 18.1% and 18.1% in men aged <26, 26-30 and 31-35, respectively), with %DFI increasing progressively beyond age 35 (20.7%, 22.5%, 25.7% and 27.9% in men aged 36-40, 41-45, 46-50 and >50, respectively). The mean %DFI in the 36-40 age group was significantly higher than in the 31-35 age group (p < 0,001). Our study has uncovered that %DFI follows an exponential curve starting at age 35, indicating that the %DFI accelerates significantly as men age beyond their mid-30s. Limitations, reasons for caution This retrospective analysis has inherent limitations that may introduce confounding variables. The patient clinical background, such as medical history and lifestyle factors was not assessed. Also, the studied cohort consisted of a population under investigation for infertility and may not be representative of the general male population. Wider implications of the findings The study demonstrates the age-related increase in sperm %DFI and suggests that there may be an age cut-off below which sperm %DFI is stable and beyond which sperm %DFI increases. This information may be useful to medical specialists that offer sperm DNA testing to infertile couples. Trial registration number not applicable

ABSTRACT Objective To identify the subset of the in vitro fertilization (IVF) population suitable for minimal monitoring by implementing a novel dosing regimen. Methods A retrospective study conducted between April 2021 and August 2022. Eligible participants were aged 18 or older, had undergone IVF stimulation using an antagonist protocol, and were prescribed a combination of follitropin delta and human menopausal gonadotropin. The dosage was either based on a patient-specific dosing regimen developed by the ovo clinic utilizing weight and AMH levels (Group 1, n=356) or determined through clinical evaluation by the physician (Group 2, n=358). On day 6, ultrasound and serum hormone analyses were performed, with adjustments made solely to the menotropin dosage in necessary. Results The study enrolled a total of 714 patients. In Group 1, 80,3% of patients were stimulated at maximal doses compared to 14,5% in Group 2. No cases of moderate or severe cases of ovarian hyperstimulation syndrome (OHSS) were recorded. The frequency of dose adjustments before day 10 was minimal. Patients treated with non-maximal doses according to the dosing regimen showed significantly fewer adjustments on day 6 compared to those treated according to physician’s assessment (24.6% versus 46.9%, p<0.001). Among this subgroup, OHSS risk was observed in 30.4% of cases. Conclusion Our innovative dosing regimen suggests that initial monitoring on day 10 would suffice for IVF patients with low ovarian reserve undergoing maximal stimulation.

Abstract Study question Is there a mixed ovarian stimulation antagonist protocol for IVF that obtains more good quality blastocysts with less cost? Summary answer Mixed protocol of HP-hMG and follitropin delta obtains a significantly more good quality blastocysts with significantly lower cost per embryo obtained. What is known already FSH and LH are used for controlled ovarian stimulation (COS) to increase the number of oocytes produced in IVF. Determination of a stimulation protocol and FSH dosage is generally established by the physician based on the patient’s age, body weight and ovarian reserve profile. Mixed protocols (concomitant HP-hMG and rFSH) for ovarian stimulation have been used to obtain better quality oocytes and embryos and thus, higher pregnancy rates compared to the use of rFSH alone. However, to date no data exist comparing cost-effectiveness of mixed protocols using different rFSH preparations. Study design, size, duration This is a cost-effectiveness analysis of the retrospective cohort study encompassing COS for IVF with 3 different mixed protocols performed between January 2018 and September 2019 in 2 fertility clinics. The 267 subjects evaluated were between 18 and 42 years of age and were divided into 3 groups of 89 subjects each according to the rFSH used: group A follitropin alfa; group B follitropin beta and group D follitropin delta. Participants/materials, setting, methods HP-hMG was used in all three groups while different rFSH was prescribed. All three groups used an antagonist protocol. IVF or intra-cytoplasmatic sperm injection (ICSI) was used as clinically indicated. Resulting embryos were cultured until day 5 or 6. The dose of gonadotropins used, the number of mature oocytes (MII), the number of utilizable blastocysts and the FSH/blastocyst ratio were evaluated. For cost-effectiveness analysis we used prices accepted by the provincial healthcare system in Quebec. Main results and the role of chance The mean age of subjects was 34.62 years (± 3.74) and weight 71.65 kg (± 14.61). No significant differences were observed in age or weight among groups. Since follitropin delta is administered in micrograms, the comparison between rFSH preparations was performed using dose equivalence between (10 µg follitropin delta) and (150 IU follitropin alpha and beta). Statistically significant differences were observed among groups in mean total dose of FSH (IU) (A = 4269 IU vs. B = 3947 IU vs. D = 3713 IU, p = 0.01), and number of days of stimulation (A = 11.6 vs. B = 10.6 vs. D = 11.4, p < 0.01). Group D used less gonadotropins despite a longer stimulation. No statistically significant differences were observed in the number of MII oocytes. However, the number of good quality utilizable blastocysts was significantly higher in group D (4.8) than in group A (3.9) or B (3.6). The FSH/blastocyst ratio was significantly lower in group D (370) than in the other groups (A = 541, B = 653). The total price per cycle was similar (A= $4,028 vs. B= $3,649 D= $3,740), however the price per embryo obtained was significantly lower in group D ($779) than in the other groups (A= $1,033, B= $1,014). Limitations, reasons for caution The limitation of this cost-effectiveness analysis is the retrospective nature of the study. Wider implications of the findings Our analysis demonstrates that the price per cycle was similar between the groups, however the price per embryo obtained was significantly lower in group D compared to the other groups. This gives follitropin delta an advantage in terms of cost-effectiveness. Trial registration number NA

Abstract Study question Does advancing paternal age correlate with sperm DNA fragmentation index (DFI) and is there a cut-off age beyond which sperm DFI increases significantly? Summary answer In infertile men, DFI correlate with advancing paternal age and should be routinely screened starting 35 years of age. What is known already In recent decades, birth rates have substantially increased for men older than 30 years because of advanced age of marriage, rising life expectancy at birth, modern societal norms, and accessibility to assisted reproductive technology (ART). Advanced paternal age has been associated with a decline in conventional semen parameters (volume, concentration, motility, DFI), as well as, reduced fertility, increased risk of miscarriage, structural chromosomal aberrations and complex epigenetic disorders. Several studies have recommended testing sperm DFI in infertile men with advanced age (≥40 years) as it may provide prognostic information for couple attempting natural and assisted reproduction. Study design, size, duration This is a retrospective study of 3446 semen samples from patients under investigation for infertility between April 2016 and January 2022. Semen samples were obtained after 2-3 days of sexual abstinence. Patients were stratified into seven groups based on their age: patients ≤ 29 years (n = 127; 3.7%), 30-35 years (n = 868; 25.2%), 36-39 years (n = 863; 25.0%), 40-45 years (n = 1017, 29.5%), 46-49 years (n = 321; 9.3%), 50-55 years (n = 179, 5.2%) and ≥ 56 years (n = 71, 2.1%). Participants/materials, setting, methods Conventional semen parameters were assessed according to the WHO criteria and DFI was evaluated by TUNEL assay using the APODirect Kit run on BDAccuriC6 flow cytometer. Pearson’s r was used for correlation analysis between sperm concentration, DFI and paternal age. DFI results for each stratified patient group were evaluated by one-way ANOVA, followed by Tukey pos-hoc multiple comparison test. Results are presented as the mean±standard error and a P-value of < 0.05 was considered statistically significant. Main results and the role of chance In this cohort of men with a mean age of 39.5 years ± 0.1 (range 23-76 years), sperm deoxyribonucleic acid (DNA) fragmentation (21.1% ± 0.2) was positively correlated with age (r = 0.23, p˂0.001). In contrast, the correlation between sperm concentration and age was non-significant (r = 0.03, p = 0.07). Mean DFI in patients segregated into seven age groups were: ≤29 years (15.7% ± 0.8), 30-35 years (17.7% ± 0.4), 36-39 years (19.7% ± 0.4), 40-45 years (22.6% ± 0.4), 46-49 years (26.2% ± 0.9), 50-55 years (26.7% ± 1.2) and ≥ 56 years (31.1% ± 2.0). Mean %DFI level in the 26-29 and 30-35 age groups were non-significantly different (p = 0.65). However, mean %DFI level in the 36-39 age group was significantly higher than in the 26-29 and 30-35 age groups (p = 0.02 and p = 0.03, respectively). Mean %DFI level in the older age groups (40-45, 46-49, 50-55 and ≥ 56 years) were all significantly higher than in the 26-29 or 30-35 age groups (p˂0.001). Using a %DFI threshold level of 16.9%, 46.0% of patients ˂36, 52.2% of men aged 36-39, 60.2% of men aged 40-45, 67.3% of men aged 46-49, 72.6% of men aged 50-55 and 74.7% of men aged ≥56 years had an elevated DFI. Limitations, reasons for caution This is a retrospective analysis that did not account for confounding variables (e.g., clinical diagnosis, gonadotoxin exposure, febrile illness) that may affect conventional sperm parameters and DFI. Wider implications of the findings Our results underline the relationship between paternal age and sperm DFI and demonstrate a significant decline in sperm DNA fragmentation in men over the age of 35 years. The data suggest that we may want to reconsider the age cut-off we traditionally use to define advanced paternal age. Trial registration number No trial registration

Abstract Study question Would a personalized dosing regimen of follitropin delta based on AMH and body weight allow better management of women’s IUI cycle? Summary answer A personalized regimen of follitropin delta based on AMH and body weight has increased pregnancy rate without having increased multiple pregnancies in our studied population. What is known already IUI has been widely used as a common treatment for infertile couples due to its simplicity and low cost. Some studies have shown that cumulative live birth rate (LBR) can be increased by use of controlled ovarian stimulation. A recent meta-analysis reported that a protocol based on exogenous gonadotropins increases the LBR. Hence, this technique remains a treatment option reaching a LBR ranging from 8.5 to 12.2%. Nevertheless, this increase in LBR is associated with a non-negligible rate of adverse events, including ovarian hyper-stimulation syndrome (OHSS) and multiple pregnancies (7.2% - 9% of twins and 0.4% - 0.5% of triplets). Study design, size, duration This prospective, phase 2, open-label study enrolled 110 women 18 - 42 years of age from January 2020 to January 2021. Participants had received up to 3 IUIs. The primary efficacy variable was the number of cycles where target number of 2 or 3 mature follicles (MII) were reached. The secondary objective and safety variable were the incidence of cycle cancellations, the clinical pregnancy rate and the proportion of multiple pregnancies over 3 consecutive cycles. Participants/materials, setting, methods Follitropin delta dosing algorithm is modeled to achieve 8-14 oocytes in IVF cycles. To achieve 2-3 mature follicles, the algorithmically derived dose was divided by 4. Follitropin delta adjustment for subsequent IUIs were based on number of MII at previous IUI and age. Dose modification was made when excessive or no response were observed at stimulation day 8 during ultrasound monitoring. If urine pregnancy test was positive, a viability ultrasound was prescribed at 6-8 weeks. Main results and the role of chance Descriptive statistics were used in this proof-of-concept study. The mean age of all subjects was 34.46 years (± 4.5). The mean weight was 69.2 kg (± 11.24), AMH - 3.84 ng/ml (± 13), FSH - 6.3 IU (± 2.61), antral follicular count - 15 (± 8.6). The mean number of years of infertility was 2.48 ± 3.57. The percentage of patients who obtained 2 or 3 follicles during the 3 consecutive IUI was 34%, 37% and 47% respectively. The percentage of patients who reached ≥3 follicles was 1.9%, 0% and 1.4% respectively, demonstrating the ability of the proposed dosing regimen to achieve the desired goal. The percentage of cycle cancelation was stable throughout the 3 cycles: 8.5%, 2.4% and 8.8% respectively. Only 6 multiple pregnancies over 40 clinical pregnancies (15%) were observed, showing the proposed dosing regimen’s safe approach. The cumulative clinical pregnancy rate over the 3 cycles among patients completing the study was 37.7%, and the cumulative live birth rate (calculated ad hoc, as it was not part of the study protocol) was 33%, leading to the personalized dosing regimen proposed in this study to be considered for use in clinical practice. Limitations, reasons for caution The study’s limitations are its exploratory nature, open-label design and small sample size. Wider implications of the findings PITS study is the first one using follitropin delta for stimulation in intra-uterine insemination. It confirms the initial hypothesis of a potential benefit of a personalized dosing regimen of follitropin delta. A larger, randomized controlled study will be needed to confirm these initial findings. Trial registration number NCT03830723

Many authors have studied the effects of the NMSI on the success of IUI, but a real consensus has not yet been achieved, and NMSI and female age have rarely been studied together. In addition, the upper limit of NMSI has rarely been studied while some fertility centers perform a dilution of the sperm sample to obtain a NMSI between 1 × 106 and 10 × 106. What is the impact of the number of motile spermatozoa inseminated (NMSI) on clinical pregnancy rates (CPR) in IUI with partner sperm according to female age?

Objective: To evaluate the safety profile and the number of usable blastocysts on day 5 and on day 6 after treatment with an individualized dosing regimen of a follitropin delta and highly purified human menopausal gonadotropin (HP-hMG) for controlled ovarian stimulation. Design: Multicenter, open label, exploratory study. Setting: Reproductive medicine clinics. Patient(s): A total of 110 patients (aged 18-40 years). Intervention(s): Follitropin delta coadministered with HP-hMG, with follitropin delta dose fixed according to an established algorithm and HP-hMG dose at 75 IU when the follitropin delta starting dosage was <12 mg; 150 IU when follitropin delta dosage was 12 mg and weight <100 kg, and 225 IU when follitropin delta dosage was 12 mg and weight >= 100 kg (dosage adjustments confined to HP-hMG only). Main Outcome Measure(s): Mean number of good-quality blastocysts obtained at day 5 and day 6 as well as the proportion of women with ovarian hyperstimulation syndrome (OHSS). Result(s): A cohort study was compared with the follitropin delta group from the Evidence-based Stimulation Trial with Human Recombinant Follicle-Stimulating Hormone in Europe and Rest of World 1 (ESTHER-1) study. Even when stratified by age, a statistically significantly higher mean in the number of oocytes retrieved and number of good-quality blastocysts was observed in this study compared with the ESTHER-1 trial in which follitropin delta was used alone. The rate of patients triggered with a gonadotropin-releasing hormone agonist was statistically significantly higher in our Menopur and Rekovelle Combined Study (MARCS) cohort (43%) when compared with the rates reported in the follitropin delta cohort in the ESTHER-1 study (2.3%). Incidence of any grade of OHSS was 9.3% in the present study compared to 2.6% in follitropin delta group from ESTHER-1 trial. No cases of moderate or severe OHSS were observed in our study compared with 1.4% in the follitropin delta group of ESTHER-1. Conclusion(s): Optimizing the ovarian response during in vitro fertilization employing a mixed protocol of individualized dosing of follitropin delta and HP-hMG resulted in a statistically significant number of usable blastocysts on days 5 and 6 with an increased risk of mild OHSS, which did not require medical intervention or hospitalization. ((C) 2020 by American Society for Reproductive Medicine.)

STUDY QUESTION: What is the status of fertility treatment and birth outcomes documented over the first 6 years of the Canadian Assisted Reproductive Technologies Register (CARTR) Plus registry? SUMMARY ANSWER: The CARTR Plus registry is a robust database containing comprehensive Canadian fertility treatment data to assist with providing evidence-based rationale for clinical practice change. WHAT IS KNOWN ALREADY: The rate of infertility is increasing globally and having data on fertility treatment cycles and outcomes at a population level is important for accurately documenting and effecting changes in clinical practice. STUDY DESIGN, SIZE, DURATION: This is a descriptive manuscript of 183 739 fertility treatment cycles from 36 Canadian clinics over 6 years from the CARTR Plus registry. PARTICIPANTS/MATERIALS, SETTING, METHODS: Canadian ART treatment cycles from 2013 through 2018 were included. This manuscript described trends in type of fertility treatment cycles, pregnancy rates, multiple pregnancy rates, primary transfer rates and birth outcomes. MAIN RESULTS AND THE ROLE OF CHANCE: Over the 6 years of the CARTR Plus registry, the number of treatment cycles performed ranged from less than 200 to greater than 1000 per clinic. Patient age and the underlying cause of infertility were two of the most variable characteristics across clinics. Similar clinical pregnancy rates were found among IVF and frozen embryo transfer (FET) cycles with own oocytes (38.9 and 39.7% per embryo transfer cycle, respectively). Fertility treatment cycles that used donor oocytes had a higher clinical pregnancy rate among IVF cycles compared with FET cycles (54.9 and 39.8% per embryo transfer cycle, respectively). The multiple pregnancy rate was 7.4% per ongoing clinical pregnancy in 2018, which reflected a decreasing trend across the study period. Between 2013 and 2017, there were 31 811 pregnancies that had live births from all ART treatment cycles, which corresponded to a live birth rate of 21.4% per cycle start and 89.1% of these pregnancies were singleton live births. The low multiple pregnancy rate and high singleton birth rate are associated with the increase in single embryo transfers. LIMITATIONS, REASONS FOR CAUTION: There is potential for misclassification of data, which is present in all administrative health databases. WIDER IMPLICATIONS OF THE FINDINGS: The CARTR Plus registry is a robust resource for ART data in Canada. It provides easily accessible aggregated data for Canadian fertility clinics, and it contains data that are internationally comparable.

Background: Sperm DNA damage has been associated with poor reproductive outcomes. While a number of studies have shown that antioxidants may lower sperm DNA fragmentation, little is known about the effect of oral antioxidants on sperm chromatin integrity. The goal was to evaluate the influence of an antioxidant supplement on sperm chromatin and DNA integrity in a cohort of men with idiopathic infertility. Methods: This is a retrospective study of 17 consecutive infertile men treated with an oral antioxidant supplement between May 2016 and November 2017. Sperm DNA fragmentation and chromatin integrity were examined before and 3 months after initiating treatment. Sperm DNA fragmentation was measured by a flow cytometry-based terminal deoxynucleotidyl transferase 2'-deoxyuridine 5'-triphosphate (dUTP) nick end labeling (TUNEL) assay and the results were expressed as DNA fragmentation index (%DFI). Sperm chromatin integrity was assessed by aniline blue (AB) staining and the results expressed as % chromatin damage. Results: It was observed that oral antioxidant therapy was associated with a significant decrease in mean [± standard error (SE)] %DFI (38.6%±1.7% to 26.6%±1.8%, P<0.0001), with the majority of patients (94%) experiencing a diminution in their %DFI after therapy. However, antioxidant therapy was not associated with a significant change in chromatin damage (28.8%±3.2% to 30.1%±2.8%, P=0.48). Conclusions: The data show that infertile men may experience a reduction in sperm DNA fragmentation, but not chromatin integrity after oral antioxidant therapy. This may be explained by the possible interference of antioxidants with the mild oxidative stress (OS) required for induction of sperm chromatin compaction. These data demonstrate the complex nature of sperm chromatin and the variable influence of OS on sperm chromatin targets.

Research question: Does autologous endometrial cell co-culture (AECC) improve the number of good-quality blastocysts obtained by IVF/intracytoplasmic sperm injection (ICSI), compared with conventional embryo culture medium in a broad group of patients referred to assisted reproductive technology (ART)? Design: This interventional, randomized, double-blind study took place at Clinique Ovo from March 2013 to October 2015 and included 207 healthy patients undergoing an IVF or ICSI protocol, of which 71 were excluded before randomization. On the previous cycle, all participants underwent an endometrial biopsy at D5 to D7 post-ovulation, following which the endometrial cells were prepared for AECC. Results: The data demonstrated that AECC significantly increased the incidence of good-quality blastocysts compared with culture in conventional media (42.6% vs 28.4%, P < 0.001). No significant differences were found in pregnancy and live birth rates. Conclusion: This study demonstrated the benefits of AECC on blastocyst quality compared with conventional embryo culture medium, in a broader category of patients referred to ART as opposed to other studies that concentrated on specific causes of infertility only. However, limitations of the study design should be taken into consideration; the analysis was performed using embryos rather than patients and a follow-up of children born following the treatments could not be conducted.

Over the course of the last four decades, IVF has allowed an increasing number of infertile couples the chance to conceive. Considering the extensive research and advances in ART, too many IVF attempts still do not result in a successful pregnancy [1, 2]. Embryo implantation is a crucial event in the establishment of a pregnancy. It is now clear that embryo implantation relies upon cross-talk and synchronicity between the implanting embryo and a receptive endometrium [3]. This embryo-maternal cross-talk involves an elaborate and coordinated network of communication via timely released embryonic, maternal-derived signals, and well-targeted actions [4]. If the clinical and culture conditions to obtain a “good quality” embryo are well advanced today, ER remains the last barrier in ART. When a high-quality embryo is transferred, impaired uterine receptivity is believed to be one of the major reasons behind failure of the establishment of pregnancy [5, 6]. It has been suggested in a few studies that up to two-thirds of implantation failures are due to defects in ER whereas the quality of the embryo itself is responsible for only one-third of failures [7, 8]. An endometrium is receptive to an embryo in a spatially and temporally restricted period called the window of implantation (WOI). In natural cycles, this period, occurring during the mid-secretory phase, is limited to approximately 48 h, starting around the seventh day after the LH (luteinizing hormone) surge [9, 10]. The dynamic transition from a non-receptive to a receptive endometrium is still poorly understood. Several reports have shown that ER is defined by specific changes in factors involved in adhesion, invasion, survival, growth, differentiation, decidualization and immuno-modulation. The correct spatio-temporal synthesis and balance of these various factors are thought to play an important role in human uterine preparation for implantation [4, 11]. Extensive efforts have been made to understand and characterize a receptive endometrium, from the first histological dating methods to the ‘omics’ technologies [3, 7, 12]. Several endometrial dating criteria have been commonly used in clinical practice. One or more panels of biomarkers, predictive of optimal ER, have been analyzed in blood and uterine fluid. Leukaemia inhibitor factor (LIF) is an example of a potential biomarker of the WOI [13]. However, this approach has been judged unsatisfactory by several studies because LIF measurements in serum do not reflect fertility status and similar conclusions were reported for other biomarkers [3, 14]. Cervical mucus has also been used to date ER by analyzing cytokines and growth factors produced by a receptive endometrium and their transport to the cervical mucus [15]. However, other studies have been unable to detect these growth factors in cervical secretions throughout the menstrual cycle and in these studies no correlation was observed between cytokine levels in cervico-vaginal secretions and serum and between the cytokines gene expression level in the secretory endometrium and the concentrations in serum [3, 16]. Another group evaluated ER during IVF cycles using three-dimensional power Doppler ultrasound [17]. However, Sterzik et al. concluded that ultrasonography is an inadequate method to predict ER in IVF cycles since neither the endometrial thickness nor the echogenic pattern correlate with histological findings [18]. As demonstrated, endometrial dating criteria have been questioned in various randomized studies. This has encouraged further investigation and application of new technologies to try to objectively diagnose ER. Omics technologies, such as transcriptomics, have been used to identify biomarkers of human endometrium [7, 19]. Based on the transcriptomic signature identified in these studies, only two ER diagnostic tools have been commercialized in order to personalize the frozen embryo transfer (FET): the ERA test (Endometrial Receptivity Array) [20] and the Win-Test (Window Implantation Test) [21]. In this review, we screened publications of the transcriptomic profiles of fertile and infertile women during the secretory phase of natural and stimulated cycles in order to understand lessons learned from endometrial gene profiling.

An analysis of national registry data for 5 years of in-vitro fertilization (IVF) funding in Quebec, Canada was compared with the previous complete year of non-funded IVF cycles, as well as the first complete year following the end of funding. The number of cycles, livebirth rates, age group of patients treated, use of donor gametes, multiple pregnancy rates and cycle cancellation rates were assessed. The total number of IVF cycles performed increased dramatically during the funded period, averaging over 10,000 cycles per year. There was no change in the age group distribution of patients treated, but less egg donation was performed. Interestingly, funding was also associated with an increase in the IVF cycle cancellation rate (17.0% versus 34.4%, P < 0.001), a dramatic decline in the multiple pregnancy rate (25.6% versus 4.9%, P < 0.001), and a decline in the livebirth rate per fresh embryo transfer in stimulated IVF cycles (32.3% versus 25.5%, P < 0.001). Although the livebirth rate for stimulated IVF declined, over 9000 babies were born as a result of the coverage. Lessons learned from this experience could help develop a more fiscally responsible programme that still facilitates access to IVF care.

The endometrial receptivity is a key process for the success in assisted reproductive technology. Despite careful embryo selection, two of every three in vitro fertilization (IVF) cycles fail to result in pregnancy, making reproduction in humans an inefficient process. The key to successful implantation is synchronization. The embryo must not only evolve to the blastocyst stage, but the endometrium must also achieve a specific receptive status and cross-talk between the embryo and endometrium must occur during the window of implantation (WOI). Therefore, it appears essential to identify inadequate endometrial receptivity to offer personalized care management. Molecular diagnostic tools currently available to characterize this process are very limited. In this study, we describe the development of a new personalized molecular test based on endometrial receptivity and maternal-fetal dialogue. As a result of a single site study at ovo clinic from December 2016 to March 2019, the development and clinical validation of a new test, Adhesio RT, allowed us to analyze 215 biopsies of which 50 endometrial biopsy samples and 35 autologous endometrial co-culture samples were analyzed by using microarray technology and 130 biopsies from IVF-patients with a known pregnancy outcome were used for clinical validation. Microarray data from 50 endometrial biopsies obtained during the optimal theoretical implantation window LH+7 to LH+11 in natural cycle (35 with successful clinical pregnancy 15 with implantation failure). Similarly, a total of microarray data obtained from 29 co-culture biopsies were performed on autologous- endometrial co-culture (14 endometrial cells cultured in absence of embryo, 5 in presence of good-quality embryo successfully transferred, 10 with good quality embryo but with implantation failures). Microarray data were analyzed and selected biomarkers were assessed using RT-qPCR. 10 genes have been identified for the first time by using a new approach that incorporates two specific transcriptomic signatures obtained by different bioinformatics and statistical technologies applied to microarray analyses: A first specific transcriptomic signature of 1717 genes specifically modulated associated to biopsies from patients with successful clinical pregnancy versus biopsies from patients with implantation failure. Gene ontology analyzes revealed that cell division, cellular proliferation, cell adhesion and mitotic cycle are the most over-represented biological terms in this group of genes. A second specific signature of 60 genes associated to endometrial co-culture successfully transferred was obtained using class prediction approach. Gene expression was validated by RT–qPCR. Clinical validation was performed on 130 biopsies from IVF-patients with a known pregnancy outcome. Evaluation of receptivity and embryo implantation with this new molecular signature can predict IVF success and may help in the management of endometrial preparation for embryo transfer and optimizes chances of successful pregnancy for many couples.

Birth weight (BW) is higher after frozen embryo transfer (FET) than after fresh embryo replacement. No study has compared the BW of siblings conceived using the same oocyte/embryo cohort. The aim of this study was to determine whether the freezing-thawing procedure is involved in such difference. Multicenter study at Montpellier University Hospital, Clinique Ovo, Canada and Grenoble-Alpes University Hospital. The first cohort (Fresh/FET) included in vitro fertilization (IVF) cycles where the older was born after fresh embryo transfer (n = 158) and the younger after transfer of frozen supernumerary embryos (n = 158). The second cohort (FET/FET) included IVF cycles where older and younger were born after FET of embryos from the same cohort. The mean adjusted BW of the FET group was higher than that of the fresh group (3508.9 ± 452.4 g vs 3237.7 ± 463.3 g; p < 0.01). In the FET/FET cohort, the mean adjusted BW was higher for the younger by 93.1 g but this difference is not significant (3430.2 ± 347.6 g vs 3337.1 ± 391.9 g; p = 0.3789). Our results strongly suggest that cryopreservation is directly involved in the BW variation. Comparing BW difference between Fresh/FET cohort and FET/FET one, it suggests that parity is not the only responsible, increasing the role of cryopreservation step in BW variation.