Freeze-all policy: fresh vs.

frozen-thawed embryo transfer

~es, B.S.,a Marcos Sampaio, M.D., Ph.D.,b
Matheus Roque, M.D.,a Marcello Valle, M.D.,a Fernando Guimara
and Selmo Geber, M.D., Ph.D.b,c
a
ORIGEN, Center for Reproductive Medicine, Rio de Janeiro; b ORIGEN, Center for Reproductive Medicine, Belo Horizonte;
and c Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

Objective: To compare in vitro fertilization (IVF) outcomes between fresh embryo transfer (ET) and frozen-thawed ET (the ‘‘freeze-all’’
policy), with fresh ET performed only in cases without progesterone (P) elevation.
Design: Prospective, observational, cohort study.
Setting: Private IVF center.
Patient(s): A total of 530 patients submitted to controlled ovarian stimulation (COS) with a gonadotropin-releasing hormone–
antagonist protocol, and cleavage-stage, day-3 ET.
Intervention(s): None.
Main Outcome Measure(s): Ongoing pregnancy rates.
Result(s): A total of 530 cycles were included in the analysis: 351 in the fresh ET group (when P levels were %1.5 ng/mL on the trigger
day); and 179 cycles in the freeze-all group (ET performed after endometrial priming with estradiol valerate, at 6 mg/d, taken orally). For
the fresh ET group vs. the freeze-all group, respectively, the implantation rate was 19.9% and 26.5%; clinical pregnancy rate was 35.9%
and 46.4%; and ongoing pregnancy rate was 31.1% and 39.7%.
Conclusion(s): The IVF outcomes were significantly better in the group using the freeze-all policy, compared with the group using fresh
ET. These results suggest that even in a select group of patients that underwent fresh ET (P levels %1.5 ng/mL), endometrial receptivity
may have been impaired by COS, and outcomes may be improved by using the freeze-all policy.
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I
mplantation is one of the most as the COS may have adverse effects to better pregnancy rates and decrease
important steps to ensure in vitro on ER (6), and embryo cryopreservation maternal and perinatal morbidity (11).
fertilization (IVF) cycle success (1); has become a routine procedure in IVF However, controversies remain
its effectiveness depends on embryo labs (7), the ‘‘freeze-all’’ policy has regarding patient selection and the
quality, the embryo-endometrium emerged as an alternative to fresh ET threshold at which a cycle becomes
interaction, and endometrial recep- to improve IVF outcomes (8–10). supraphysiologic (11).
tivity (ER) (2). Growing evidence in With the freeze-all policy, the To date, no effective noninvasive
the literature shows that controlled entire cohort of embryos is cryopre- clinical tools are available to evaluate
ovarian stimulation (COS), with its served, and the ET is performed later ER that can be used during a fresh cycle
supraphysiologic hormonal levels, in a natural cycle, or in a cycle with as well. The best way to select patients
may decrease ER (3, 4). Moreover, hormonal replacement for endometrial for the freeze-all policy seems to be
endometrial development can be priming. The potential advantage of by assessing progesterone (P) levels on
controlled more precisely during its this method is that it provides a more the day of final oocyte maturation, as
priming for frozen-thawed embryo physiologic environment in which ET P-level elevation is related to decreased
transfer (ET) vs. for COS (5). Therefore, can occur; this advantage could lead pregnancy rates in fresh cycles (12–14).
To our knowledge, no published studies
Received November 20, 2014; revised January 27, 2015; accepted January 30, 2015; published online
March 4, 2015.
have used this method to select patients
M.R. has nothing to disclose. M.V. has nothing to disclose. F.G. has nothing to disclose. M.S. has for fresh or frozen ET. Therefore, we
nothing to disclose. S.G. has nothing to disclose. performed this study to compare IVF
Reprint requests: Matheus Roque, M.D., ORIGEN, Center for Reproductive Medicine, Avenida Rodolfo
de Amoedo, 140, Barra da Tijuca, Rio de Janeiro, Brazil (E-mail: [email protected]). outcomes for patients using fresh ET,
performed when P levels were
Fertility and Sterility® Vol. 103, No. 5, May 2015 0015-0282/$36.00
Copyright ©2015 American Society for Reproductive Medicine, Published by Elsevier Inc.
<1.5 ng/dL on the trigger day, vs.
http://dx.doi.org/10.1016/j.fertnstert.2015.01.045 patients using the freeze-all policy.

1190 VOL. 103 NO. 5 / MAY 2015

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MATERIALS AND METHODS the 2nd day of each patient's menstrual cycle, when E2
A prospective, observational, cohort study was conducted be- valerate was orally administered at a dose of 6 mg/d. After
tween January 2012 and December 2013, in a private IVF cen- at least 12 days of E2 replacement, an ultrasound scan and
ter in Brazil. An institutional review board approved this hormone-level measurements were performed. If the endo-
study, and informed consent was obtained from all patients. metrium was R7 mm, and the P level was %1.5 ng/mL,
the frozen-thawed ET was scheduled. The P replacement
with vaginal micronized P in gel (Crinone 8%; Merck Se-
Patient Selection rono) for a single daily administration started 3 days before
The following inclusion criteria were established: [1] ET. Estradiol valerate and P were continued until the 9th
gonadotropin-releasing hormone (GnRH) antagonist cycles week of pregnancy. If the endometrium was <7 mm and/
with day-3 ETs; [2] women aged 20–45 years; [3] fresh and or the P level was >1.5 ng/mL after endometrial priming,
frozen-thawed ET performed with good-quality embryos the ET was canceled.
only, i.e., 6–10 cells with %20% fragmentation, and equal
blastomere size. Exclusion criteria included: [1] patients Hormone Analysis
with a history of recurrent pregnancy loss; [2] implantation
failure (R3 previous ETs without pregnancy); [3] antral folli- Blood samples were collected on the day of the ovulation
cle count %5; [4] severe male factor infertility (oligospermia trigger, and serum P levels were measured using a chemilumi-
<1 million/mL, and azoospermia); [5] uterine pathology; [6] nescent immunoassay for quantitative determination of the
patients with a risk of ovarian hyperstimulation syndrome, hormone (Diagnostics Biochem Canada Inc), with a sensitivity
defined by estradiol (E2) >3,000 pg/mL, and/or >15 follicles of 0.1 ng/mL.
on the trigger day. Pregnant patients were followed for
%12 weeks of pregnancy, via an ultrasound scan to confirm Outcomes
ongoing pregnancy. Fresh ET was performed only if P was Pregnancy was determined by hCG levels measured 11 days
%1.5 ng/mL on the trigger day. The freeze-all strategy was after ET. Clinical pregnancy was defined by the observation
implemented in cases in which P was >1.5 ng/mL on the of intrauterine embryo heart motion by 7 weeks of gestation.
trigger day. Ongoing pregnancy was defined as pregnancy proceeding
beyond the 12th week of gestation. The implantation rate
Study Protocol was calculated as the ratio of the number of observed embryo
Patients underwent COS with recombinant follicle- heart beats to the number of transferred embryos. The main
stimulating hormone (FSH) (Gonal-f; Merck Serono) starting outcome measure was ongoing pregnancy rate, which was
on day 2 or 3 of menses, with doses ranging from 150 to shown to be comparable to that for live births, as a measure
450 international units per day, according to the patient's of efficacy (18). Implantation, pregnancy, and clinical preg-
age, in a step-down protocol. A GnRH antagonist (cetrorelix; nancy rates were the secondary outcome measures.
Cetrotide, Merck Serono) was used for pituitary suppression
when a leading follicle achieved 14 mm. Final oocyte matura- Statistical Analysis
tion was induced with a ‘‘dual trigger’’: 250 mcg of recombi- The data are presented as the mean
standard deviation (SD),
nant human chorionic gonadotropin (hCG) (Ovidrel, Merck or as a percentage. A comparison of the quantitative variables
Serono) and 0.2 mg of triptorelin (Gonapeptyl Daily; Ferring was performed using Student's t-test for independent sam-
Pharmaceuticals) when R2 follicles reached a diameter of ples. For a comparison of the categoric data, c2 analysis
18 mm (15). The patients underwent transvaginal was performed. Differences were considered significant if
ultrasound-guided oocyte retrieval 35 hours after the trigger, P< .05.
followed by intracytoplasmic sperm injection (16). On the A logistic regression analysis was performed to determine
third day after oocyte retrieval, embryo quality was evalu- the variables that could be independently associated with
ated, and 1–4 good-quality embryos (6–10 cells with %20% ongoing pregnancy, and could affect outcomes. Age, basal
fragmentation, and equal blastomere size) were transferred FSH level, antral follicle count, number of retrieved oocytes
(fresh cycles). and mature eggs, number that were bipronuclear (2 PN), num-
In the freeze-all group, the entire cohort of good-quality ber of transferred embryos, and cycle type (freeze-all vs. fresh)
embryos was cryopreserved on day 3. Luteal phase support were included in the analysis. Statistical analysis was done
started on the day of oocyte retrieval. All patients received with SPSS version 19.0 for Windows (SPSS, Inc).
vaginal micronized P in gel form (Crinone 8%, Merck Serono)
in a single daily administration. Progesterone was used for RESULTS
R13 days, when a pregnancy test was performed, and until
During the study period, 1,357 oocyte retrievals were per-
9 weeks if pregnancy was confirmed (17).
formed, and 530 patients fulfilled the inclusion criteria and
agreed to participate in the study. The women's characteristics
Frozen-Thawed Cycles are shown in Table 1.
All embryos were cryopreserved on day 3, by vitrification A logistic regression analysis was performed, and the var-
using an open system. The endometrial priming started on iables that were found to be independently associated with

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ORIGINAL ARTICLE: ASSISTED REPRODUCTION

TABLE 1

Clinical characteristics of the patients who were using freeze-all cycles vs. fresh embryo transfer cycles.
Characteristic Freeze-all cycles (n [ 179) Fresh cycles (n [ 351) P value
Patient age (y) 35.59
3.46 35.83
4.88 .398
FSH levels (day 2 or 3) (mIU/mL) 7.96
2.17 8.44
2.56 .023
Antral follicle count (n) 11.46
4.18 9.23
3.88 .001
Days of stimulation (n) 10.89
1.09 10.94
1.18 .614
E2 trigger (pg/mL) 1,636.28
571.85 1,567.88
649.63 .215
P4 trigger (ng/mL) 1.66
0.14 0.70
0.27 .001
Retrieved oocytes (n) 8.87
4.14 7.38
3.94 .001
Mature eggs (n) 6.28
3.22 5.39
3.10 .002
Fertilization rate (%) 76.78
17.10 80.12
16.97 .042
Post-thaw survival rate (%) 94.9
9.42
Note: Values are mean
SD. E2 ¼ estradiol; FSH ¼ follicle-stimulating hormone; P4 ¼ progesterone.
Roque. Freeze-all policy. Fertil Steril 2015.

ongoing pregnancy were age, number of embryos transferred, freeze-all policy has advantages. We observed an increase
and cycle type. All other variables were not independently of 33% and 28% in implantation and ongoing pregnancy
associated with IVF outcomes. The odds ratio (OR) for age rates, respectively.
was 0.90, with a 95% confidence interval (CI) of 0.858– Embryo cryopreservation is a routine procedure in most
0.943 (P¼ .001); the OR for number of embryos transferred IVF centers, and it is associated with good outcomes when
was 1.78, with a 95% CI of 1.35–2.35 (P¼ .0001); and the frozen-thawed ET is performed (7, 19). Therefore, the freeze-
OR for cycle type was 1.73 with a 95% CI of 1.16–2.58 all policy can be implemented as an alternative, to avoid
(P¼ .008), favoring the freeze-all group. All measured IVF the deleterious effects of COS on embryo-endometrium syn-
outcomes (implantation, clinical pregnancy rate, and ongoing chrony (8, 9). With this strategy, the best embryos can be
pregnancy rate) were higher in the freeze-all group (Table 2). cryopreserved and transferred into a more receptive
endometrium, compared with a fresh cycle, as COS may
jeopardize ER (20). Our results showed good post-thaw sur-
DISCUSSION vival rates (>90%), which are in accordance with those found
To our knowledge, this is the first study comparing the freeze- in previous studies (7, 21). Although we used vitrification for
all policy to fresh ET when fresh ET is performed only if all patients, and given that cryopreservation was performed
P%1.5 ng/mL on the trigger day. The results suggest that on day 3, a point that remains unclear is which
the freeze-all policy was advantageous in IVF outcomes, developmental embryo stage yielded better results (22, 23).
compared with fresh ET. The ovarian response differed in the 2 groups; however,
Implantation failure remains an unsolved problem in this difference fell within a range observed in previous
assisted reproductive technology cycles, and 1 factor respon- studies. In this range, for 1 ET, IVF outcomes did not differ.
sible for this problem could be poorer ER resulting from COS In these studies, patients that obtained either between 6 and
(2). In the past few years, much effort has been focused on em- 15 oocytes (24) or 6 and 13 oocytes (25) had the same preg-
bryo quality and selection. On the other hand, no effective nancy rates. Furthermore, we performed logistic regression
noninvasive clinical tools are available to evaluate ER, to analyses, which showed that the number of oocytes retrieved,
select patients for fresh or frozen ET. To date, using the P the number of mature eggs, and the number of fertilized eggs,
levels on the day of final oocyte maturation has seemed to were not independently associated with outcomes.
be the best strategy for selecting patients. However, our re- In conclusion, IVF outcomes can be improved using the
sults suggest that, even among patients who had fresh ET per- freeze-all policy. Even in a group of patients that was selected
formed only if P was %1.5 ng/mL on the trigger day, the for fresh ET (P%1.5 ng/mL), ER may be impaired by COS, and

TABLE 2

In vitro fertilization outcomes for freeze-all cycles and fresh ET cycles.

Outcome Freeze-all cycles (n [ 179) Fresh ET cycles (n [ 351) P value Relative risk (95% CI)
Embryos transferred, mean
SD 2.07
0.65 2.27
0.79 .003
Implantation rate 98/370 (26.5) 159/797 (19.9) .011 1.33 (1.07–1.65)
Pregnancy rate
Pregnancy 90 (50.3) 144 (41) .038 1.23 (1.01–1.49)
Clinical pregnancy 83 (46.4) 126 (35.9) .017 1.29 (1.05–1.59)
Ongoing pregnancy 71 (39.7) 109 (31.1) .044 1.28 (1.01–1.62)
Note: Values are n (%), unless otherwise indicated.
Roque. Freeze-all policy. Fertil Steril 2015.

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