Baris Ata

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@juanjo_fraire @NoemiSalme30386 In these studies, the answer is not in the final cumulative live birth rate achieved. It is in the difference between increments with each subsequent transfer. If there is a uterine factor, you are supposed to observe a gradual decline with each transfer, which is not visible.

@NoemiSalme30386 According to the work by Pirtea and Gill, If only euploid embryos are transferred after 3 ETs you reach 92% CLBR and after 5 you reach 98% 😅 in a normal uterus for sure! #ESHREjc

Q4: Moving into the “ideal” setting of IVF. ✨LBR after multiple ET reach 60–70% in women <35 years…. 🔎to what extent can the remaining failure be explained by uterine factors? could this account for the entire 30–40%? Or are we missing something else? #ESHREjc

@zoyaalii_ @MicahJHillDO @PirteaP @Genera_pma @GLiperis @juanjo_fraire @LaurCraciunas @ESHRE @PaolaVigano3 @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco An ambiguous term such as RIF wouldn’t help the patient’s well being. They already feel lost as they did “even IVF”, the most sophisticated treatment, and it failed several times. Assuring them that each new embryo still has a descent chance would help. #ESHREjc

@MicahJHillDO @drbarisata @PirteaP @Genera_pma @GLiperis @juanjo_fraire @LaurCraciunas @ESHRE @PaolaVigano3 @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco This brings up a really good point of how terminology can impact emotional well-being as well. Do you have any insights on this? #ESHREjc

Q1. Gill et al, defined their unit of analysis 🔍as euploid blastocysts transferred (instead of the transfer of an euploid blastocyst). How are DETs affecting the calculation 🧮 of CLBR? Should the CLBR calculation in general be based only on euploid blastocysts? #ESHREjc @ESHRE

@LaurCraciunas @GLiperis @PaolaVigano3 @PirteaP @MicahJHillDO @juanjo_fraire @SCobanMune @kashish__ Agree. Euploidy is not everything. Even though current PGT-A is capable of detecting subchromosomal anomalies still the resolution is not 100%. There are more than 20.000 genes and PGT-A is only about copy numbers. Genetics is much more than that. #ESHREjc

@GLiperis @PaolaVigano3 @PirteaP @MicahJHillDO @juanjo_fraire @SCobanMune @kashish__ The number 1 misconception about PGT-A normal embryos is that they are genetically normal. There are many more genetic abnormalities that would not be reflected in the PGT-A (normal) result, with lethal single gene mutations coming first to mind. #ESHREjc

Q2: Not all euploid embryos implant, suggesting that embryo quality goes beyond ploidy. What embryological reasons could explain why euploid embryos do not implant? Can current and emerging technologies aid in identifying embryos that could lead to success? #ESHREjc #ESHRE

@Genera_pma @juanjo_fraire @GLiperis @LaurCraciunas @SCobanMune @MicahJHillDO @PaolaVigano3 Managing patient expectations and preventing dropouts is also very relevant even for one child as you always highlight. Counseling about possible need for multiple cycles is crucial for poor prognosis patients. This may be the next frontier. #ESHREjc

@drbarisata @juanjo_fraire @GLiperis @LaurCraciunas @SCobanMune @MicahJHillDO @PaolaVigano3 #eshrejc Agree 100% we shall start talking about family planning and not a single child. Even because the replacement rate is 2.1 babies per couple.

Q4: Based on the results in this article📰, how should we counsel patients who have experienced 2-3 failed euploid blastocyst transfers and have 2-3 remaining blastocysts of low morphological grade❓🤔#Eshrejc @MicahJHillDO @drbarisata @PaolaVigano3 @Genera_pma @LaurCraciunas

@juanjo_fraire @Genera_pma @GLiperis @LaurCraciunas @SCobanMune @MicahJHillDO @PaolaVigano3 The study does not suggest everyone will need 5 euploids for a live birth. It shows live birth rate remains stable across up to 5 transfers when obvious uterine pathology is ruled out. Majority will deliver earlier. #ESHREjc

@Genera_pma @GLiperis @LaurCraciunas @SCobanMune @MicahJHillDO @drbarisata @PaolaVigano3 How about planning in advance for 2-3 stimulations to store embryos until you reach at least 5 euploid blastocysts? Is this discouraged? #ESHREjc I guess this would be the least cost-effective, right?

@PirteaP @Genera_pma @GLiperis @juanjo_fraire @LaurCraciunas @ESHRE @PaolaVigano3 @MicahJHillDO @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco Yes, absolutely. Every transfer requires proper assessment in advance, we don’t need a number of failures to cover relevant bases. On the other hand, we shouldn’t panic and delve into controversial practices after a failure. #ESHREjc

@Genera_pma @drbarisata @GLiperis @juanjo_fraire @LaurCraciunas @ESHRE @PaolaVigano3 @MicahJHillDO @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco The lugano consensus has made a big effort to define exactly that. pubmed.ncbi.nlm.nih.gov/36822566/

@LaurCraciunas @SCobanMune @MicahJHillDO @PaolaVigano3 @Genera_pma While we did not address the morphologic quality issue, it is associated with live birth. It is a subjective choice since euploid low grade embryos also have a descent chance of live birth E.g., day 5 5AA 62.5% vs D5 5CC 24% based on our data from UAE #ESHREjc

@SCobanMune @MicahJHillDO @drbarisata @PaolaVigano3 @Genera_pma One would question the rationale for freezing low grade embryos. I suppose the policy varies from clinic to clinic, but in ours we do not freeze embryos that do not stand a chance at thawing survival and subsequent implantation. #ESHREjc

@juanjo_fraire @ESHRE @LaurCraciunas @PirteaP @NMacklon @Genera_pma @maclaudiaa @PaolaVigano3 Unlikely as we or others did not observe an increasing probability of live birth with consecutive euploid or untested transfers. What we have shown is that each euploid transfer had similar chance of live birth when obvious uterine anomaly was excluded. #ESHREjc

Q3. #ESHREjc @ESHRE

@GLiperis @juanjo_fraire @LaurCraciunas @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco Another important point we are trying to make is that all relevant investigations should be complete before any transfer, the “RIF” concept has little relevance. We tried to explain this here pubmed.ncbi.nlm.nih.gov/34332750/ #ESHREjc

@juanjo_fraire @LaurCraciunas @drbarisata @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco I think it all starts with what is considered as the necessary investigations to exclude RIF. Should all investigations take place prior to initiating treatment to avoid futile attempts? #ESHREjc

@juanjo_fraire @LaurCraciunas @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco We have recently published on the role of PGT-A in management of RPL. It is a different discussion but here is the link pubmed.ncbi.nlm.nih.gov/39151684/ It is important to do proper evaluation in advance and maybe genetic analysis of products of conception may help too. #ESHREjc

@LaurCraciunas @drbarisata @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco So it’s important to understand the definitions/distinctions btw etiologies! And at least Gill et al have shown the prevalence of RIF is low! How could we address recurrent miscarriage now in your opinion? @PirteaP @MicahJHillDO @JuanchoGVelasco @Genera_pma @drbarisata #ESHREjc

@LaurCraciunas @juanjo_fraire @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco @Genera_pma can answer this in more detail. With euploid transfers even number of previous pregnancy losses may not be that relevant #ESHREjc

@drbarisata @juanjo_fraire @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco Agree. The study results are extremely important and position failed implantation at the opposite corner from recurrent miscarriage where the chance of a successful pregnancy reduces progressively with the number of previous miscarriages. But not for failed transfers! #ESHREjc

@juanjo_fraire Thanks for reposting @juanjo_fraire I seem to forget adding #eshrejc 🙈

@Genera_pma @SCobanMune @GLiperis @juanjo_fraire @ESHRE @PirteaP @PaolaVigano3 @LaurCraciunas @MicahJHillDO @kashish__ @NMacklon I have been doing SET for everyone for over 10 yrs now. I think risk of multiple gestation is even more relevant for patients with poor prognosis. They may not have a second chance😬

@SCobanMune @GLiperis @juanjo_fraire @ESHRE @PirteaP @PaolaVigano3 @LaurCraciunas @MicahJHillDO @drbarisata @kashish__ @NMacklon #ESHRE jc We tend to discourage it Especially in view of GILL’s data the chance is not lower if they failed previously Perhaps a different discussion might be done in case of embryos lower than BB or day7 euploid, but still I see the risks of multiple pregnancy much worse

@juanjo_fraire @LaurCraciunas @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco so even if one assumes that embryos could have impacted each others chances of implantation, which is controversial, this does not seem to affect the conclusions of the study

@drbarisata @LaurCraciunas @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco Exactly! So not so many DETs and when only considering SETs, similar results! 💪🏼 #ESHREjc

@juanjo_fraire @LaurCraciunas @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco BTW only 16 of the 305 transfer cycles that led to the failure of three euploid blasts to qualify for inclusion in the study were DETs

@juanjo_fraire @LaurCraciunas @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon @JuanchoGVelasco Right. Sensitivity analysis limited to patients who exclusively underwent single euploid transfers included 92 patients and yielded similar results with the overall analysis, i.e., the 4th and 5th euploid blastocysts had similar live birth rate 40% vs 50% RR 1.24 (0.81-1.91).

@LaurCraciunas @ESHRE @PirteaP @PaolaVigano3 @MicahJHillDO @drbarisata @Genera_pma @GLiperis @kashish__ @SCobanMune @NMacklon Yes! So it will be detrimental to achieve a higher CLBR! In the case of Gill et al, the number of DETs seemed not so high thoug! Right? @Genera_pma @drbarisata @JuanchoGVelasco #ESHREjc

Now your turn to ask questions! Join the discussion on September 27 at 17:00 CET! You’ll have 24 hours to ask and interact with authors @drbarisata @JuanchoGVelasco @fubaldi @Genera_pma and experts @PirteaP @PaolaVigano3 @LaurCraciunas @MicahJHillDO and the #ESHREjc team! @ESHRE