Human Reproduction, Vol.26, No.5 pp.

964–966, 2011
Advanced Access publication on March 3, 2011 doi:10.1093/humrep/der050

DEBATES Embryology

Embryo selection in IVF

Sebastiaan Mastenbroek 1,*, Fulco van der Veen 1, Abbas Aflatoonian 2,
Bruce Shapiro 3, Patrick Bossuyt 4, and Sjoerd Repping 1
1
Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands 2Research and
Clinical Center for Infertility, Department of Obstetrics and Gynecology, Shahid Sadoughi University of Medical Science, Yazd, Iran 3Fertility
Center of Las Vegas, University of Nevada School of Medicine, Las Vegas, NV, USA 4Department of Clinical Epidemiology and Biostatistics,

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Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

*Correspondence address. Tel: +31-20-5663090; E-mail: s.mastenbroek@amc.uva.nl

Submitted on February 11, 2010; resubmitted on January 23, 2011; accepted on February 4, 2011

abstract: To optimize success rates of IVF, selection of the most viable embryo(s) for transfer has always been essential, as embryos
that are cryopreserved are thought to have a reduced chance of implanting after thawing. Recent developments challenge this concept. Evi-
dence is accumulating that all embryos can now be cryopreserved and transferred in subsequent cycles without impairing pregnancy rates or
maybe even with an improvement in pregnancy rates. In such a scenario no selection method will ever lead to improved live birth rates, as,
by definition, the live birth rate per stimulated IVF cycle can never be improved when all embryos are serially transferred. In fact, selection
could then only lower the live birth rate after IVF. The only parameter that could possibly be improved by embryo selection would be time to
pregnancy, if embryos with the highest implantation potential are transferred first.
Key words: assisted reproduction / embryo transfer / embryo quality / IVF / ICSI outcome

In the majority of human IVF cycles multiple embryos are created after
ovarian hyperstimulation. The viability of these embryos, and as a con-
sequence the chance for an embryo to successfully implant, is subject
to biological variation. To achieve the best possible live birth rates
after IVF while minimizing the risk for multiple pregnancy, one or two
embryos that are considered to have the best chance of implanting
are selected for transfer. Subsequently, supernumerary embryos with
a good chance of implanting are selected for cryopreservation and poss-
ible transfer in the future while remaining embryos are discarded.
The best available method for embryo selection is morphological
evaluation. On the basis of multiple morphological characteristics at
one or several stages of preimplantation development, embryos are
selected for transfer (Ebner et al., 2003; Gerris, 2005). However,
with embryo selection based on morphological evaluation implan-
tation rates in general do not exceed 35%, although varying results
have been reported (Centers for Disease Control and Prevention
et al., 2010). This has resulted in a strong drive for finding alternative
selection methods.
The best studied alternative selection method is preimplantation
genetic screening (PGS). The classical form of PGS involves the
biopsy at Day 3 of embryo development of a single cell of each of
the embryos available in an IVF cycle and analysis of this cell by fluor-
escence in-situ hybridization (FISH) for aneuploidies, for a limited
number of chromosomes. Only embryos for which the analyzed blas-
tomere is euploid for the chromosomes tested are transferred
(Wilton, 2002). Although this method of PGS has been increasingly
used in the last decade, recent trials show that it actually decreases
ongoing pregnancy rates compared with standard IVF with morpho-
logical selection of embryos (Mastenbroek et al., 2008).
In an effort to overcome some of the drawbacks of PGS using clea-
vage stage biopsy and FISH, new methods to determine the ploidy
status of a single cell are developed, such as comparative genomic
hybridization arrays or single nucleotide polymorphism arrays (Wells
et al., 2008). Furthermore, in an attempt to avoid the confounding
effects of chromosomal mosaicism, embryos are now biopsied at
either the zygote or blastocyst stage (Geraedts et al., 2009). In
addition, increasing time and money are invested in the development
of high-tech, non-invasive methods to select the best embryo for
transfer in IVF. This includes metabolomic profiling, amino acid profil-
ing, respiration-rate measurement and birefringence imaging (Nagy,
2008). In metabolomic profiling, spectrophotometric tests are used
to measure metabolomic changes in the culture medium of
embryos; in proteomic profiling, proteins produced by the embryo
and released into the culture medium are identified; in amino acid pro-
filing, amino acid depletion and production by the embryo is assessed
using the culture medium; in respiration-rate measurement, the respir-
ation rate of embryos is assessed; and in birefringence imaging, polar-
ization light microscopy is used to assess the meiotic spindle or the
zona pellucida (see for review Nagy, 2008).
All this research on alternative selection methods is driven by the
concept that embryo selection is essential to optimize the success
rates of IVF, since embryos that are cryopreserved have a reduced

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Embryo selection or other methods to improve IVF
chance of implanting after thawing. Better selection methods should
thus result in higher live birth rates without an increase in multiple
pregnancies.
Recent developments challenge this concept. Endometrial receptiv-
ity and synchronization between embryo and endometrial develop-
ment have been suggested to be suboptimal in cycles with ovarian
hyperstimulation (Paulson et al., 1990; Check et al., 1999; Shapiro
et al., 2008). Therefore, cryopreservation of embryos and transfer
later in a non-hyperstimulated cycle would not necessarily have to
result in a lower chance of pregnancy, as the better endometrial
receptivity could very well counterbalance the negative effect of cryo-
preservation on embryo viability. Reports on cycles where embryo
transfer was disengaged from the cycle with ovarian hyperstimulation
in case of embryo donation or in women at risk of ovarian hyperstimu-
lation syndrome, indeed suggested comparable or even increased
pregnancy rates (Check et al., 1995; Shaker et al., 1996; Ferraretti
et al., 1999; Zhou et al., 2009).
The results described above were all obtained using slow freeze
embryo cryopreservation protocols. With the use of vitrification
even better results are to be expected (Zhang et al., 2010), since post-
thaw survival rates and in vitro development after vitrification seem
better than after slow freezing (Loutradi et al., 2008), and, more
importantly, a recent meta-analysis showed a significantly improved
ongoing pregnancy rate after vitrification in comparison with slow
freezing (OR 1.82, 95% CI 1.04 –3.20; Abdelhafez et al., 2010).
Indeed, a recent well-designed and robust randomized controlled
trial in women with a high response to ovarian hyperstimulation has
shown that vitrification of all embryos followed by a transfer in a sub-
sequent non-hyperstimulated cycle results in significantly improved
ongoing pregnancy rates compared with a fresh transfer in a cycle
with ovarian hyperstimulation (Aflatoonian et al., 2010).
If more well-designed and powered studies corroborate these find-
ings, also for other groups of women, then the concept of embryo
selection in IVF needs to be re-evaluated. In a scenario where all avail-
able embryos can be cryopreserved and transferred in subsequent
cycles without impairment of pregnancy rates, or maybe even with
improvement of pregnancy rates, no selection method will ever lead
to improved live birth rates, as, by definition, the live birth rate per
stimulated IVF cycle can never be improved when all embryos are seri-
ally transferred.
Embryo selection techniques will not only be unable to improve live
birth rates but also they could even lower the success rate of IVF. In
comparison to a situation where all embryos are transferred, the live
birth rate per stimulated cycle will be lowered by any embryo selection
method that identifies and discards non-viable embryos with an accu-
racy of ,100%. Unfortunately, this holds for all selection methods
currently available and a selection method that is able to identify non-
viable embryos with 100% accuracy is not to be expected in the near
future. The only parameter that can possibly be improved by embryo
selection after optimal cryopreservation is time to pregnancy, if
embryos with the highest implantation potential are transferred first.
In our opinion, the path of embryo selection is turning into a
dead-end in the quest for optimal IVF success rates. Other routes
should therefore be embarked upon, including optimization, evalu-
ation and broad implementation of the best cryopreservation proto-
cols. Decision models need to be developed to determine the most
cost-effective transfer policies for cryopreserved embryos.
965
Such transfer policies could perhaps involve the transfer of multiple
low-quality embryos at once after cryopreservation to obtain optimal
pregnancy rates without increasing the multiple pregnancy risk,
especially in aging women, as the time necessary to transfer all cryo-
preserved embryos in subsequent cycles might have an impact on
the overall success rates. Cost-effectiveness analysis needs to
confirm that the costs of extra transfer cycles after cryopreservation
are counterbalanced by the savings related to the fewer hyperstimula-
tion cycles, the avoidance of multiple pregnancies and the avoidance of
selection methodologies.
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Authors’ roles
S.M., F.V., S.R.: conceptualization of manuscript. S.M.: drafting the
article. A.A., B.S., P.B.: refinement of the proposed concept. All
authors: critical revision of manuscript and approval of final
manuscript.
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