如何進行發育第3天胚胎品質評估與分級？

 

胚葉細胞數量

取卵後 48 小時，胚胎應有 2~ 4 個細胞，

在 72 小時內約 7~10 個細胞。

 

胚胎內碎片化程度

碎片(Fragment)，是胚胎細胞的一部分並與細胞的有核部分分離的過程。優選具有很少的碎片或沒有碎片。

碎片百分比。破碎率太高的胚胎植入潛力較低。

A級: 無碎片:  著床率優

B級: <10%碎片:  著床率優，等同A級

C級: 10%~50%碎片:  著床率較低

D級: >50%碎片:  著床率極低

 

胚葉細胞多核心的存在

• 如果在第 2 天或第 3 天在任何胚葉細胞中可以看到多個細胞核，則胚胎是多核的。絕大多數多核胚胎已被證明有染色體異常。
• 有時多核胚胎會植入並導致健康懷孕和正常嬰兒的出生。通常只有在沒其他選擇的情況下才會被移植到子宮。

 

其他因素

• 胚葉細胞大小相似是最好的。胚葉細胞大小差距太大懷孕率不高
• 胚葉細胞對稱性，最好是立體排列
• 胚葉細胞是否有部分融合現象。若有懷孕率更高
• 胚葉細胞細胞質顆粒度，細胞質過黑懷孕率較差
• 胚胎畸形(橢圓形)，懷孕率較差
• 胚胎過大或過小，懷孕率較差
• 透明帶厚度太厚，懷孕率較差

 不孕症或懷孕前後安眠藥物之使用概念

安眠藥分類

BZD類	FDA等級
Alprazolam (Xanax)	D
Diazepam (valium)	D
Lorazepam (Ativan)	D
Z系列
Zaleplon (Sonaplon)	C
Zolpidem (史蒂諾斯)	C
Zopiclone (Imovane)	C
抗組織胺
Diphenhydramine	B
Doxylamine	A
Hydroxyzine	C

 

Zolpidem對懷孕胚胎或嬰兒之影響

l          在zolpidem最高劑量的5-10倍劑量下，沒有對於老鼠或兔子寶寶胚胎的藥物毒性，致畸胎性在每一種劑量下都沒有出現。

l          但在zolpidem超高劑量組(相當人類建議最高劑量的10-20倍的劑量下)，有受精卵著床失敗增加。

l          懷孕過程中服用zolpidem超過90天，與寶寶出生體重較輕、早產、剖腹產有關。不過在生下畸胎兒的比率上，並沒有顯著的差異。

l          沒有證據顯示服用Stillnox會降低男性或女性的生育能力。

l          Zolpidem在美國FDA懷孕分級中被歸類為C級，動物試驗發現zolpidem可能致畸胎或對胚胎產生損害，是否會對人類有同樣的影響還無法得知。 故目前此藥對於孕婦非絕對禁忌，應權衡利害謹慎使用。 

l          不建議懷孕期間使用Stillnox，因為對其對嬰兒的影響知之甚少。

 

Ativan對懷孕胚胎或嬰兒之影響

l        兔子的研究上發現異常與Ativan的劑量無關。在高於40mg/公斤的劑量時，在兔子寶寶上造成死胎的情況增加，在低劑量沒有出現這個情況。建議不要在懷孕的前三個月服用Ativan。在頭三個月使用Ativan可能會增加先天畸形。

l          BZD類藥物可能與早產，寶寶體重較低有關，

l        少數研究認為Ativan與唇裂有關‧

l          Ativan使用於胚胎植入期間對於懷孕率活產率無明顯影響

l          胚胎移植期間使用Ativan並未顯示出對包括活產率在內的生殖結果的明顯影響，顯示其在影響IVF成功率方面的效果有限。

  

總結

l          每天睡眠時間不到6個小時的女性，容易會造成賀爾蒙失調，卵巢功能干擾‧

l          所有安眠藥會透過胎盤，讓寶寶也接觸到。要注意出生之後的戒斷症狀。寶寶出生後可能需要住院幾天進行額外監測。

l          孕媽咪及哺乳期服用安眠藥恐透過血液或是泌乳對於胎兒造成不良影響。

l          懷孕前後失眠建議先選用抗組織胺(FDA分級A或B)，比較安全。

l          失眠太嚴重，需要使用安眠藥物，考慮使用Z系列安眠藥如使蒂諾斯(FDA分級C級藥物)。

l          不建議使用屬於BZD類安眠藥(FDA分級D級藥物) 。

l          懷孕前後服用安眠藥應諮詢您的醫生決定是否更換更適合藥物。

l          提供病患舒適、放鬆的環境，透過親朋好友，嘗試各種方式來支持媽咪好孕。

 

 

 

 

植入前非整倍體基因檢測（PGT-A）的使用一直在穩定增加。用於 24 染色體分析的基礎技術繼續快速發展。 

PGT-A 作為所有接受體外受精患者的常規篩檢測試的價值尚未得到證實。

儘管一些早期的單中心研究報告稱，預後良好的患者在PGT-A 後的活產率較高，

但最近對具有可用囊胚的女性進行的多中心隨機對照試驗得出結論，

透過冷凍胚胎移植的整體妊娠結局在PGT-A 之間是相似的。

PGT-A 降低臨床流產風險的價值尚不清楚。 

結論:  美國不孕權威期刊仍不建議常規使用PGT於所有試管病患，

The use of preimplantation genetic testing for aneuploidy: a committee opinion

The use of preimplantation genetic testing for aneuploidy (PGT-A) in the United States has been increasing steadily. Moreover, the underlying technology used for 24-chromosome analysis continues to evolve rapidly. The value of PGT-A as a routine screening test for all patients undergoing in vitro fertilization has not been demonstrated. Although some earlier single-center studies reported higher live-birth rates after PGT-A in favorable-prognosis patients, recent multicenter, randomized control trials in women with available blastocysts concluded that the overall pregnancy outcomes via frozen embryo transfer were similar between PGT-A and conventional in vitro fertilization. The value of PGT-A to lower the risk of clinical miscarriage is also unclear, although these studies have important limitations. This document replaces the document of the same name, last published in 2018.

PGT之使用並無法明顯提升一般病患之累積懷孕率

Live Birth with or without Preimplantation Genetic Testing for Aneuploidy

Published November 24, 2021

N Engl J Med 2021;385:2047-2058

Embryo selection with preimplantation genetic testing for aneuploidy (PGT-A) may improve pregnancy outcomes after initial embryo transfer. However, it remains uncertain whether PGT-A improves the cumulative live-birth rate as compared with conventional in vitro fertilization (IVF).

METHODS

In this multicenter, randomized, controlled trial, we randomly assigned subfertile women with three or more good-quality blastocysts to undergo either PGT-A or conventional IVF; all the women were between 20 and 37 years of age. Three blastocysts were screened by next-generation sequencing in the PGT-A group or were chosen by morphologic criteria in the conventional-IVF group and then were successively transferred one by one. The primary outcome was the cumulative live-birth rate after up to three embryo-transfer procedures within 1 year after randomization. We hypothesized that the use of PGT-A would result in a cumulative live-birth rate that was no more than 7 percentage points higher than the rate after conventional IVF, which would constitute the noninferiority margin for conventional IVF as compared with PGT-A.

Download a PDF of the Research Summary.

RESULTS

A total of 1212 patients underwent randomization, and 606 were assigned to each trial group. Live births occurred in 468 women (77.2%) in the PGT-A group and in 496 (81.8%) in the conventional-IVF group (absolute difference, −4.6 percentage points; 95% confidence interval [CI], −9.2 to −0.0; P<0.001). The cumulative frequency of clinical pregnancy loss was 8.7% and 12.6%, respectively (absolute difference, −3.9 percentage points; 95% CI, −7.5 to −0.2). The incidences of obstetrical or neonatal complications and other adverse events were similar in the two groups.

CONCLUSIONS

Among women with three or more good-quality blastocysts, conventional IVF resulted in a cumulative live-birth rate that was noninferior to the rate with PGT-A. (Funded by the National Natural Science Foundation of China and others; ClinicalTrials.gov number, NCT03118141.)

. 2021 Nov 25;385(22):2047-2058.

 Diazepam 安眠藥使用於胚胎植入期間對於懷孕率活產律無明顯影響

. 2024 Sep;41(9):2379-2383.

 

The efficacy of diazepam administration during embryo transfer: a retrospective multicenter cohort study on reproductive outcomes

Purpose: This retrospective multicenter cohort study aimed to investigate the impact of diazepam administration during embryo transfer on reproductive outcomes, focusing primarily on the live birth rate. Secondary outcomes included the positive beta-hCG rate, clinical pregnancy rate, miscarriage rate, ectopic pregnancy rate, and preterm birth rate.

Methods: Data from 5607 embryo transfers, encompassing 465 cases with diazepam administration, were retrospectively analyzed. The study included single blastocyst transfers from 12 clinics in Portugal and Spain between January 2015 and December 2022.

Results: Comparison of reproductive outcomes between patients receiving diazepam and those who did not showed no statistically significant differences. Positive beta-hCG rates (60.8% non-diazepam vs. 60.4% diazepam, p = 0.92, adjusted p = 0.32) and clinical pregnancy rates (45.6% non-diazepam vs. 46.2% diazepam, p = 0.81, adjusted p = 0.11) were comparable. Miscarriage rates (11.0% diazepam vs. 9.3% non-diazepam, p = 0.25, adjusted p = 0.26) and ectopic pregnancy rates (0.9% diazepam vs. 0.1% non-diazepam, p = 0.1, adjusted p = 0.20) were similar. Live birth rates (36.3% non-diazepam vs. 35.3% diazepam, p = 0.69, adjusted p = 0.82) and prematurity rates (0.3% non-diazepam vs. 0% diazepam, p > 0.99, adjusted p = 0.99) also exhibited no statistically significant differences.

Conclusions: Based on the results, diazepam administration during embryo transfer did not show a discernible impact on reproductive outcomes, including live birth rates, suggesting its limited effectiveness in enhancing success.

•  本研究評估了低嵌合體水平（< 50%）胚胎的潛在活力。
• 研究表明嵌合胚胎可以發育成具有不同水平或類型嵌合體的整倍體健康嬰兒。
• 整倍體和嵌合囊胚移植的嬰兒之間沒有觀察到顯著差異。
• 如果患者沒有整倍體胚胎，則可以移植嵌合胚胎，它們有可能植入並發育成整倍體健康嬰兒。
• 這項研究對於諮詢單一嵌合胚胎移植後的臨床結果非常有價值。

. 2020 Sep;37(9):2305-2313.

 doi: 10.1007/s10815-020-01876-6. Epub 2020 Jul 4.Healthy live births from transfer of low-mosaicism embryos after preimplantation genetic testing for aneuploidy

• This study evaluated the potential viability of embryos with low mosaicism level (< 50%) by comparing the clinical outcomes of single mosaic versus euploid blastocyst transfer.  
• Our study indicated that mosaic embryos can develop into euploid healthy infants with various levels or types of mosaicism. 
• No significant difference was observed between infants from euploid and mosaic blastocyst transfers.
• If patients have no euploid embryos, mosaic embryos can be transferred as they have potential for implantation and development into euploid healthy infants. 
• This study is invaluable for counseling clinical results after single mosaic embryo transfers.

 對於 42 歲以上且僅存非整倍體胚胎的患者，鑲嵌染色體胚胎移植是比另外再施行IVF- PGT-A 週期更好的替代方案。

對於年齡小於 42 歲、無法進行額外施行IVF的患者，也應考慮鑲嵌染色體胚胎移植。 

. 2024 Mar;41(3):635-641.

 doi: 10.1007/s10815-024-03027-7. Epub 2024 Jan 17. Mosaic embryo transfer versus additional IVF with PGT-A Cycle: a decision model comparing live birth rate and cost

Mosaic embryo transfers are a superior alternative to an additional cycle of IVF with PGT-A for patients older than 42 whose only remaining embryos are non-euploid. Mosaic embryo transfers also should be considered for patients younger than 42 who are unable to pursue additional autologous IVF cycles

Ficoll-400 密度梯度可用於精蟲分離&產生了更高百分比的活的、成熟的、形態正常的精子。

分層方式: 5% (v/v) density top layer and 90% (v/v) Ficoll-400 density lower layer. 

密度比較: Ficoll density 1.2 g/ml

-----normal spermatozoa (1.17 g/ml)

-----immotile immature sperm cells having lower density of 1.02 g/ml,

----------------------------------------------------------------------------------------------------------------

Ficoll-400 density gradient method as an effective sperm preparation technique for assisted reproductive techniques J Hum Reprod Sci. 2016 Jul-Sep; 9(3): 194–199.

Ficoll-400 density gradient yielded higher percentage of live, mature, morphologically normal spermatozoa in an isolated fraction as compared to other three techniques.

 使用密度梯度 density gradient centrifugation來分離狗精子性別的技術並不有效。

. 2018 Dec:199:84-92.  

Sperm sexing with density gradient centrifugation in dogs

•  Sperms were separated using gradients of Percoll® or Ficoll. 
• The percentage of sperm containing X and Y chromosomes was evaluated by qPCR. 
• The use of the Ficoll gradient resulted in the greatest sperm quality after centrifugation. 
• No sperm enhancement containing X or Y chromosome occurred with use of any of the methods 

1. Percoll® 54.8 ± 1.9 compared with 45.2 ± 1.9; 
2. Percoll® associated with Nycodenz® 53.2 ± 2.0 compared with 46.8 ± 2.0; 
3. Ficoll 55.0 ± 1.5 compared with 45.0 ± 1.5 
4. for the percentages of cells containing the X and Y chromosomes, respectively

• The technique of sexing dog sperm using density gradients was not effective for commercial application.