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The analysis of warmed blastocysts by time-lapse imaging may provide objective quantitative markers for the blastocyst implantation potential. We propose a hierarchical model to classify vitrified/warmed blastocysts according to their implantation probability. The observed correlations and the proposed algorithm should be validated in a prospective trial to evaluate its efficacy.

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Objective: To develop a noninvasive embryo selection algorithm consisting of time-lapse morphokinetics and the oxidative status of the spent embryo culture medium determined using the Thermochemiluminescence (TCL) Analyzer. Design: Retrospective cohort. Setting: Not applicable. Patient(s): From women participating in the oocyte donation program, data from 505 samples of spent embryo culture media samples from 292 intracytoplasmic sperm injection cycles. Intervention(s): None. Main Outcome Measure(s): Morphokinetic parameters assessed during incubation in the time-lapse system Embryoscope. Oxidative parameters (H1 sm , H2 sm , and H3 sm ) from the spent culture medium on day 5 of incubation measured using the TCL assay; and a combined assessment algorithm, including morphology, morphokinetics, and the embryo's culture medium oxidative status, developed as a tool for embryo selection, based on implantation success and confirmed ongoing pregnancy. Result(s): The levels of the oxidative parameters H1 sm , H2 sm , and H3 sm on day 5 of incubation were statistically significantly higher in transferred and vitrified embryos compared with discarded embryos and in successfully implanted embryos compared with those that did not result in pregnancy. The assessment algorithm resulted in a hierarchical classification with six embryo quality categories (A to F), associated with implantation rates of between 76.5% and 29.2%. Conclusion(s):An assessment algorithm combining morphology, morphokinetics and the embryo's culture medium oxidative status may help to improve current embryo selection methods criteria and in vitro fertilization success. (Fertil Steril Ò 2019;111:918-27. Ó2019 by American Society for Reproductive Medicine.) El resumen está disponible en Español al final del artículo.

STUDY QUESTION Does the embryo cleavage pattern and rate of blastocyst formation differ between normal weight and obese women undergoing IVF? SUMMARY ANSWER Embryo morphokinetic development, final blastocyst formation rate and blastocyst morphology do not differ between obese and normal weight women. WHAT IS KNOWN ALREADY Female obesity has been related to impaired IVF outcomes. Although the mechanisms responsible for this detrimental effect are thought to include impaired oocyte and embryo quality and reduced endometrial receptivity, they are yet to be confirmed. Embryo quality has been commonly assessed using static morphological criteria. Only three studies have analysed the progress of embryos up to the blastocyst stage in women with elevated BMI, but they have used small samples of patients or have obtained contradictory results. STUDY DESIGN, SIZE, DURATION This retrospective, cohort study, was performed from January 2016 to May 2020. A total of 3316 ICSI cycles from 2822 women were included, of which 1251 cycles were part of a preimplantation genetic testing programme. In total, 17 848 embryos were analysed. PARTICIPANTS/MATERIALS, SETTING, METHODS This study reports on the IVF cycles of infertile women, with a known BMI, who underwent ICSI and whose embryos were grown until the fifth/sixth day of development in a time-lapse system. Patients were grouped as follows. Underweight was defined as a BMI <18.5 kg/m2; normal weight was a BMI of 18.5–24.9 kg/m2; overweight was a BMI of 25–29.9 kg/m2; and obesity was a BMI of ≥30 kg/m2. Embryo development was assessed on an external computer with analysis software. MAIN RESULTS AND THE ROLE OF CHANCE Despite an initial slower pattern of embryo development, the blastocyst formation rate on day 5 or on day 5 plus day 6 did not differ in obese women with respect to the other three BMI groups. Moreover, based on the evaluation of inner cell mass and the trophectoderm on both days of blastocyst development, embryo quality was similar across the BMI groups, as were the pattern of development and arrest up to blastocyst formation and the distribution of the categories of full, expanded and hatching blastocysts. LIMITATIONS, REASONS FOR CAUTION Limitations include the retrospective analysis of data, the use of BMI as the only parameter to define normal/abnormal female body weight, and the lack of complete information about clinical outcomes. WIDER IMPLICATIONS OF THE FINDINGS Blastocyst formation and embryo morphokinetics are not affected by female obesity, and the poorer IVF outcomes described for such women are probably due to deficient endometrial receptivity. The role of endometrial progesterone exposure on the day of embryo transfer should be analysed in future studies as a possible determining factor. STUDY FUNDING/COMPETING INTEREST(S) No external funding was used and there are no competing interests. TRIAL REGISTRATION NUMBER N/A.

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