{"paper_id":"ab3e4ab0-e4fc-4162-8d0c-5f01da0bde28","body_text":"Association between Number of Formed Embryos,\nEmbryo Morphology and Clinical Pregnancy Rate\nafter Intracytoplasmic Sperm Injection\nAssociação entre número de embriões formados,\nmorfologia embrionária e taxa de gravidez clínica após\ninjeção intracitoplasmática de espermatozoides\nCaroline Mantovani da Luz 1 Vanessa Silvestre Innocenti Giorgi 1 Marcela Alencar Coelho Neto 1\nWellington de Paula Martins 1 Rui Alberto Ferriani 1 Paula Andrea Navarro 1\n1 Obstetrics and Gynecology Department, Ribeirão Preto Medicine\nSchool, Universidade de São Paulo (DGO-FMRP-USP), Ribeirão Preto,\nSão Paulo, Brazil\nRev Bras Ginecol Obstet 2016;38:465 –470.\nAddress for correspondence Caroline Mantovani da Luz, BSc,\nObstetrics and Gynecology Department, Ribeirão Preto Medicine\nSchool, Universidade de São Paulo, Avenida Bandeirantes 3.900,\n8° andar – 14048-900, Ribeirão Preto, São Paulo, Brazil\n(e-mail: carollinemantovani@gmail.com).\nKeywords\n► number of embryos\n► morphological\nevaluation\n► embryo quality\n► clinical pregnancy\n► ICSI\nAbstract Introduction Infertility has a high prevalence in the general population, affecting /C24 5\nto 15% of couples in reproductive age. The assisted reproduction techniques (ART)\ninclude in vitro manipulation of gametes and embryos and are an important treatment\nindicated to these couples. It is well accepted that the implantation rate is positively\ninfluenced by the morphology of transferred embryos. However, we question if, apart\nfrom the assessment of embryo morphology, the number of produced embryos per\ncycle is also related to pregnancy rates in the first fresh transfer cycle.\nPurpose To evaluate the clinical pregnancy rate according to the number of formed\nembryos and the transfer of top quality embryos (TQEs).\nMethods In a retrospective cohort study, between January 2011 and December 2012,\nwe evaluated women who underwent intracytoplasmic sperm injection (ICSI), aged < 40\nyears, and with at least 1 formed embryo fresh transferred in cleavage stage. These women\nwere stratified into 3 groups according to the number of formed embryos (1 embryo, 2–3\nand /C21 4 embryos). Each group was divided into 2 subgroups according to the presence or\nnot of at least 1 transferred TQE (1 with TQE; 1 without TQE; 2 –3 with TQE, 2 –3 without\nTQE; /C21 4 with TQE; /C21 4 without TQE). The clinical pregnancy rates were compared in each\nsubgroup based on the presence or absence of at least one transferred TQE.\nResults During the study period, 636 women had at least one embryo to be transferred in\nthe first fresh cycle (17.8% had 1 formed embryo [32.7% with TQE versus 67.3% without TQE],\n42.1% of women had 2–3 formed embryos [55.6% with TQE versus 44.4% without TQE], and\n40.1% of patients had/C21 4 formed embryos [73.7% with TQE versus 26.3% without TQE]). The\nclinical pregnancy rate was significantly higher in the subgroup with /C21 4 formed embryos\nwith at least 1 transfered TQE (45.2%) compared with the subgroup without TQE (28.4%).\nreceived\nMay 25, 2016\naccepted\nJuly 25, 2016\npublished online\nSeptember 21, 2016\nDOI http://dx.doi.org/\n10.1055/s-0036-1592338.\nISSN 0100-7203.\nCopyright © 2016 by Thieme Publicações\nLtda, Rio de Janeiro, Brazil\nTHIEME\nOriginal Article 465\n\n\nIntroduction\nInfertility, defined as the absence of conception after a year of\nunprotected sexual activity, has a high prevalence in the\ngeneral population, affecting /C24 5 to 15% of couples in repro-\nductive age.\n1,2 The assisted reproduction techniques (ART) are\nprocedures that include in vitro manipulation of gametes (eggs\nand sperm) and embryos for the purpose of establishing a\npregnancy.\n3,4 In developed countries, /C24 5% of all births are\nresultant of ART, which is an important treatment indicated to\ninfertile couples.\n5,6 For ART, women are submitted to con-\ntrolled ovarian stimulation (COS) with artificial hormones.7–9\nThis strategy aims to obtain a greater number of oocytes and\nembryos, enabling an increase of cumulative pregnancy rate\nper cycle.10,11 However, we question whether the total number\nof formed embryos has an in fluence in the pregnancy rate in\nthe first fresh transfer cycle.\nThe conventional morphological evaluation is used as an\nindirect method for checking the quality and the potential of\nembryonic development; however, the analyzed parameters\nstill diverge.12,13 To homogenize the conventional morpho-\nlogical evaluation, experts in the issue created the Istanbul\nConsensus.13 Based on this consensus, a top quality embryo\n(TQE) on the second day of development (D2) has 4 cells Grade\n1 (symmetrical blastomeres, with less than 10% of fragmen-\ntation and without multinucleation), and on the third day of\ndevelopment (D3), has 8 cells Grade 1.\n13 Some studies suggest\nthat the implantation rate is positively in fluenced by the\nmorphology of transferred embryos: the TQEs, for example,\npresent greater potential for implantation and to generate live\nbirths compared with embryos with worse morphology.\n12–14\nThus, we question if, apart from the assessment of embryo\nmorphology, the number of produced embryos per cycle is\nalso related to pregnancy rates in thefirst fresh transfer cycle.\nElucidating the impact of the number of formed embryos\ntogether with embryonic morphology can help determine\nthe gestational outcomes, adjusting the expectations of\npatients and physicians. Therefore, the aim of this study\nConclusions Having at least two available emb ryos and at least one TQE for embryo\ntransfer are predictors of the pregnancy rates.\nResumo Introdução A infertilidade tem uma alta prevalência na população geral, afetando /C24 5\na 15% dos casais em idade reprodutiva. As técnicas de reprodução assistida (TRA)\nincluem a manipulação in vitro de gametas e embriões e são um importante tratamento\nindicado para esses casais. Sabe-se que a taxa de implantação é positivamente\ninfluenciada pela morfologia dos embriões transferidos. No entanto, questiona-se,\nse além da avaliação da morfologia do embrião, o número de embriões produzidos por\nciclo também está relacionado com as taxas de gravidez do primeiro ciclo de trans-\nferência fresco.\nObjetivo Avaliar a taxa de gravidez clínica de acordo com o número de embriões\nformados e a transferência de embrião com ótima morfologia (EOM).\nMétodos Em um estudo de coorte retrospectivo, entre janeiro de 2011 e dezembro\nde 2012, avaliamos mulheres submetidas a ICSI com idade < 40 anos e com pelo\nmenos um embrião formado e transferido a fresco em estágio de clivagem. Estas\nmulheres foram estrati ficadas em 3 grupos de acordo com o número de embriões\nformados (1 embrião, 2 –3e /C21 4 embriões). Cada grupo foi subdividido em 2\nsubgrupos de acordo com a presença ou não de EOM transferido (1 com EOM; 1\nsem EOM; 2 –3 com EOM; 2 –3s e mE O M ;/C21 4c o mE O M ;/C21 4 sem EOM). As taxas de\ngravidez clínica foram comparadas em ca da subgrupo segundo a presença ou não de\npelo menos um EOM transferido.\nResultados Durante o período do estudo, 636 mulheres tiveram pelo menos 1\nembrião para ser transferido no primeiro ciclo a fresco (17,8% possuíram 1 embrião\nformado [32,7% com EOM versus 67,3% sem EOM], 42,1% das mulheres apresentaram\n2–3 embriões formados [55,6% com EOM versus 44,4% sem EOM], e 40,1% das\npacientes formaram /C21 4 embriões [73,7% com EOM versus 26,3% sem EOM]). A\ntaxa de gravidez clínica foi signi ficativamente maior no subgrupo com /C21 4e m b r i õ e s\nformados com transferência de pelo menos 1 EOM (45,2%) comparando-se ao\nsubgrupo sem EOM (28,4%).\nConclusões Ter pelo menos dois embriões e pelo menos um EOM para transferência\nsão fatores preditivos da taxa de gravidez.\nPalavras-chave\n► número de\nembriões\n► avaliação\nmorfológica\n► qualidade\nembrionária\n► gravidez clínica\n► ICSI\nRev Bras Ginecol Obstet Vol. 38 No. 9/2016\nAssociation between Number of Formed Embryos, Embryo Morphology and Clinical Pregnancy Rate after ICSI Luz et al.466\n\n\nwas to compare the clinical pregnancy rate in the first fresh\ntransfer cycle of women who formed and transferred at least\n1 embryo, divided into 6 groups according to the number of\nformed embryos (1, 2 –3a n d /C21 4) and transfer or not of at\nleast 1 TQE in D2 or D3.\nMethods\nThis retrospective cohort study evaluated all women who\nunderwent COS for intracytoplasmic sperm injection (ICSI)\nat the fertility clinic of the Hospital das Clínicas da Faculdade\nde Medicina de Ribeirão Preto, Universidade de São Paulo,\nBrazil, between January 2011 and December 2012. All data\nwere obtained from medical records by one author (MACN).\nThe study protocol was approved by the Institutional Review\nBoard (# 9682/2012), which waived the requirement for\nadditional informed consent due to the retrospective nature\nof the study.\nWomen younger than 40 years submitted to COS for ICSI\nwho had at least 1 embryo formed and transferred in\ncleavage stage in the first fresh cycle were considered eligi-\nble. If the patient had been subjected to more than one COS\ncycle during this period, only data from the first cycle were\nincluded in the analysis. All women were followed-up until a\nnegative pregnancy test or until the first ultrasound per-\nformed two to three weeks after the positive pregnancy test.\nPatients were strati fied into 3 groups according to the\nnumber of formed embryos in cleavage stage (1 embryo; 2 –3\nembryos and /C21 4 embryos). Each group was subdivided into\ntwo subgroups (with or without TQE), transferred in the first\nfresh cycle (1 with TQE; 1 without TQE; 2 –3w i t hT Q E ,2–3\nwithout TQE; /C21 4w i t hT Q E ;/C21 4 without TQE). Patients who\nhad formed two or more embryos transferred only two\nembryos in the fresh cycle.\nAll included patients had menstruation programmed with\noral combined contraceptives, starting during the previous\nmenstrual cycle. The COS was started five days after the\ndiscontinuation of oral contraceptives. The transvaginal ul-\ntrasound was performed on the first day of the COS to assess\nthe endometrial pattern and rule out the presence of ovarian\ncysts. These may interfere in the response to exogenous\ngonadotropins or in the monitoring of follicle growth by\nultrasound.\n15\nThree COS protocols could be used: in the standard long\nprotocol, the use of gonadotropin-releasing hormone\n(GnRH) agonists (leuprolide acetate 0.5 mg/day) was initiat-\ned during the luteal phase of the previous cycle, followed by\ngonadotropin (150 –300 UI/day) during the first days of COS.\nSubsequently, the daily dose of gonadotropin was adjusted\naccording to follicular growth.\nIn the flexible antagonist protocol, gonadotropin (150 –\n300 IU/day) was administrated during the first 6 days of COS,\nwith a daily dose adjusted according to follicular growth.\nGonadotropin-releasing hormone antagonists (cetrorelix or\nganirelix 0.25 mg/day) were administered on the day that the\naverage diameter of the largest follicle was /C21 14 mm.\nThe minimal stimulation protocol (clomiphene citrate [CC]\nplus gonadotropins and GnRH antagonist) was offered to some\nwomen with low antral follicle count (AFC; AFC/C20 6).\n15 The CC\n(100 mg/day) was administered during thefirst 5 days of COS,\nand gonadotropins (150 UI/day) were administered on days 2\nand 4, and daily from day 6 on. The GnRH antagonist (cetrorelix\nor ganirelix 0.25 mg/day) was administered on the day that the\naverage diameter of the largest follicle was/C21 14 mm.\nThe recombinant human chorionic gonadotrophin (hCG\n[250 mcg, Ovidrel®, Serono, Brazil]), or urinary hCG (10,000\nIU Choriomon®, Meizler, Brazil) was administered when at\nleast 1 follicle with a mean diameter of 18 mm was present.\nOocytes were obtained 34 –36 hours after administration of\nthe recombinant hCG, and the luteal phase was maintained\nby administration of micronized progesterone (600 mg/day).\nThe mature oocytes were subjected to ICSI and cultured\nindividually. Fertilization was defined as the presence of two\npronuclei and two polar bodies. Embryo quality was evalu-\nated /C24 43 and 45 hours after ICSI (second day of embryonic\ndevelopment), based on the number and symmetry of blas-\ntomeres’ percentage of fragmentation and presence or ab-\nsence of multinucleation. If the embryo transfer was not\nperformed in D2, embryo quality was analyzed /C24 67 to 69\nhours after ICSI (D3).\n13\nThe D2 embryos with 4 symmetrical blastomeres, normal\nsized, with < 10% fragmentation, and without multinuclea-\ntion were considered top quality.13 Embryos on the third day\nof development and with 8 symmetrical blastomeres, normal\nsized, with < 10% of fragmentation, and without multinu-\ncleation were also considered top quality.\n13\nThe clinical pregnancy rate per cycle was de fined as the\nnumber of patients that presented an ultrasound (4 to\n5 weeks after transfer) with embryo heartbeat divided by\nthe number of cycles /C2 100.\nThe primary endpoint of this study was the rate of clinical\npregnancy. The following parameters were assessed: age,\nweight, height, body mass index (BMI), duration and etiology\nof infertility, antral follicle count (AFC), protocol used for\nCOS, number of retrieved oocytes, number of captured\nmetaphase II (MII) oocytes, number of formed embryos, of\ntransferred embryos and of TQEs. All data were obtained\nfrom medical records.\nStatistical Analyses\nThe study size was de fined as the total number of eligible\npatients (women younger than 40 years submitted to COS for\nICSI who had at least 1 embryo formed and transferred in\ncleavage stage in thefirst fresh cycle) during the study period.\nFirst, women were stratified into 3 groups according to the\nnumber of cleavage stage formed embryos (1 embryo; 2 –3\nembryos and /C21 4 embryos). Then, each group was divided into\ntwo subgroups according to the presence or absence of at least\none transferred TQE; clinical pregnancy rates and other var-\niables were compared in each group as described below.\nThe normal distribution of continuous variables was\nanalyzed using the Kolmogorov-Smirnov test. Continuous\nvariables with normal distribution were presented as mean\n/C6 standard deviation (SD) and compared between the\ngroups with and without TQE by unpaired t-test. Continuous\nvariables without normal distribution were presented as\nRev Bras Ginecol Obstet Vol. 38 No. 9/2016\nAssociation between Number of Formed Embryos, Embryo Morphology and Clinical Pregnancy Rate after ICSI Luz et al. 467\n\n\nmedian (interquartile range), and comparisons were made\nby Mann-Whitney test. Binary data were presented as a ratio\n(%) and compared using Fisher ’s exact test. The level of\nsignificance was de fined as p < 0.05. All statistical analyzes\nwere performed using the SPSS software (version 18.0, SPSS\nInc., Chicago, IL, US). For the additional analysis, we deter-\nmined the power of the study to detect a difference of 10% in\nclinical pregnancy rates among women with one embryo;\n2–3e m b r y o sa n d/C21 4e m b r y o s .\nResults\nWithin the study period, 792 women were subjected to ICSI.\nAmong these women, 130 patients had no available embryos\nafter oocyte retrieval, 19 did not transfer fresh embryos, 1\npatient had the embryo culture extended to blastocyst, and 6\nhad no full records of morphological evaluation in the\nmedical records. The 636 remaining patients (who had at\nleast one embryo to be transferred in the same cycle) were\nfollowed until a negative pregnancy test or until the trans-\nvaginal ultrasound (TVU), four to five weeks after transfer.\nOf the 636 patients included in the study, 17.8% had 1\navailable embryo (32.7% with TQE versus 67.3% without\nTQE), 42.1% of women had 2 –3 available embryos (55.6%\nwith TQE versus 44.4% without TQE), and 1% of patients\nhad /C21 4 available embryos (73.7% with TQE versus 26.3%\nwithout TQE).\nWithin each group (1, 2 –3a n d /C21 4), there were no\nstatistically signi ficant differences in the patients ’ age,\nweight, height, BMI, cause of infertility, duration of infertili-\nty, AFC, COS protocols (\n►Table 1 ), number of retrieved\noocytes and MII oocytes compared with women who had\ntransferred or not at least 1 TQE. However, the number of\nembryos was signi ficantly higher in patients in groups 2 –3\nand /C21 4 embryos with TQE compared with the groups\nwithout TQE (\n►Table 2 ).\nAmong women who had and transferred only 1 embryo,\nthere was no difference in the pregnancy rate compared with\nwomen with TQE (16.2%) and without TQE (9.2%). Among\nthose who had 2 –3 available embryos, 33.5% of women with\nTQE and 30.2% of women without TQE became pregnant, also\nshowing no signi ficant difference between groups. Of the\npatients who had 4 or more available embryos, 45.2% of\nwomen with TQE and 28.3% of women without TQE became\npregnant. The clinical pregnancy rate was signi ficantly\nhigher in the subgroup with /C21 4 available embryos with at\nleast 1 transferred TQE ( /C21 4 with TQE) compared to the\nsubgroup without TQE ( /C21 4 without TQE) (\n►Table 2 ).\nThe present study presented a test power of /C24 70% to\ndetect a difference of 20% in clinical pregnancy rates between\nTable 1 Characteristics of the included participants depending on the number of available embryos and on the presence of\nembryo(s) considered as having top morphologic criteria\nGroups 1 embryo 2 –3e m b r y o s /C21 4e m b r y o s\nSubgroups Without TQE With TQE p Without TQE With TQE p Without TQE With TQE p\nN 76 37 119 149 67 188\nParameter\nAge 35.7 /C6 4.4 34.7 /C6 4.7 0.27 34.6 /C6 4.1 34.0 /C6 4.5 0.26 33.4 /C6 3.7 33.4 /C6 4.1 0.91\nWeight 69.1 /C6 11.8 70.7 /C6 15.7 0.60 64.8 /C6 12.1 67.1 /C6 12.8 0.15 65.2 /C6 12.0 65.2 /C6 10.7 0.98\nHeight 1.65 /C6 0.06 1.65 /C6 0.06 0.70 1.63 /C6 0.07 1.64 /C6 0.06 0.42 1.64 /C6 0.06 1.63 /C6 0.06 0.16\nBMI 25.5 /C6 4.3 25.4 /C6 5.2 0.73 24.4 /C6 4.1 25.1 /C6 4.4 0.23 24.3 /C6 4.1 24.6 /C6 3.7 0.53\nAFC 6 [4 –11] 7 [4 –14] 0.49 11 [7 –15] 9 [6 –16] 0.54 16 [11 –25] 16 [11 –21] 0.31\nDuration of infertility 70 [43 –105] 58 [41 –87] 0.33 58 [36 –88] 54 [28 –77] 0.23 62 [37 –91] 51 [32 –77] 0.14\nC a u s e o f i n f e r t i l i t y 0 . 1 50 . 6 80 . 6 8\nOvulatory 4 (5%) 1 (3%) 8 (7%) 11 (7%) 1 (1%) 7 (4%)\nEndometriosis 13 (17%) 5 (14%) 13 (11%) 24 (16%) 9 (13%) 21 (11%)\nMale 21 (28%) 4 (11%) 34 (29%) 39 (26%) 15 (22%) 58 (31%)\nTubal 5 (7%) 2 (5%) 15 (13%) 14 (9%) 5 (7%) 14 (7%)\nCombined 25 (33%) 22 (59%) 39 (33%) 53 (36%) 27 (40%) 69 (37%)\nUnexplained 8 (11%) 3 (8%) 10 (8%) 8 (5%) 10 (15%) 20 (11%)\nOvarian\nstimulation\nprotocol\n0.96 0.79 0.10\nFSH þ Ant 45 (59%) 22 (59%) 79 (66%) 101 (68%) 51 (76%) 149 (79%)\nFSH þ Ago 12 (16%) 5 (14%) 30 (25%) 33 (22%) 13 (19%) 38 (20%)\nCC þ FSH þ Ant 19 (25%) 10 (27%) 10 (8%) 15 (10%) 3 (4%) 1 (1%)\nAbbreviations: AFC, antral follicle count; BMI, body mass index; CC, clomiphene citrate; FSH þAgo, agonist protocol with follicle -stimulating\nhormone; FSH þAnt, antagonist protocol with follicle -stimulating hormone ; N, number of women analyzed; TQE, top quality embryo.\nNote: Data presented as mean /C6 SD, median [interquartile range], or number (proportion).\nRev Bras Ginecol Obstet Vol. 38 No. 9/2016\nAssociation between Number of Formed Embryos, Embryo Morphology and Clinical Pregnancy Rate after ICSI Luz et al.468\n\n\npatients with and without transferred TQE and only 1\navailable embryo; 40% for the subgroups that had 2 –3\navailable embryos; and 30% for the subgroups that had /C21 4\navailable embryos.\nDiscussion\nOur study evidenced that, during ART, the embryonic mor-\nphological evaluation, in the second or third day of develop-\nment, is an important factor involved in the prognosis of\nclinical pregnancy, especially in women who had four or\nmore embryos. In the group with/C21 4 available embryos, there\nwas an increase of /C24 17% in clinical pregnancy rates in the\nsubgroup of patients that transferred at least 1 TQE in thefirst\nfresh transfer cycle (45%) compared with those women who\nhad no TQE (28%) transferred. Among the many plausible\nconditions to influence pregnancy rates after ART, the number\nof retrieved oocytes, the number of available embryos and the\nnumber of transferred TQEs seem to be the most important\nfactors of reproductive prognosis.\n16–20 However, there are few\nstudies evaluating the relationship between pregnancy rate\nand live birth rate and the number and morphological quality\nof the embryos concomitantly. In women over 40 years, Opsahl\net al\n21 found that patients who had less than 4 embryos\npresented lower chances of pregnancy than those who formed\n/C21 4; however; this study did not take into account the\nmorphology of the embryos.\n21 Corroborating our findings,\nVan Loendersloot et al 22 suggested that the number of avail-\nable embryos and their morphological quality in the third day\nof culture should be important factors in the development of a\nmodel to predict the probability of pregnancy after in vitro\nfertilization (IVF).\n22\nIn the group with 1 embryo, the difference in the clinical\npregnancy rates among the subgroups with TQE (16.2%) and\nwithout TQE (9.2%) was 7%. And in the group with 2 –3\navailable embryos, the difference in the clinical pregnancy\nrates among subgroups with TQE (33.5%) and without TQE\n(30.2%) was 3.3%. Despite the fact that these differences were\nnot statistically signi ficant, this study did not have the\nadequate test power to con firm the findings, and studies\nwith larger sample sizes are necessary to evaluate whether\npatients who present less than 4 embryos have their preg-\nnancy rates in fluenced or not by the morphology of trans-\nferred embryos.\nAmong several analyzed secondary outcomes, in groups\nwith the formation of 2 –3 embryos and /C21 4e m b r y o s ,t h e\nnumber of embryos differed between groups with and\nwithout TQEs. In the group with /C21 4e m b r y o s ,7 3 . 7 %o f\nwomen had TQEs, and just 26.3% did not. These findings\nsuggest that women who generate a greater number of\nembryos have a greater potential to form TQEs.\n23 The other\nevaluated secondary endpoints showed no statistically sig-\nnificant difference between the subgroups, further reinforc -\ning the findings of the study, excluding the interference of\nthese parameters on the primary endpoint (clinical pregnan-\ncy rate).\nPrevious researches showed that the quality and size of the\nembryo cohort allow the selection of TQEs for transfer in the\nfresh cycle and, subsequently, in frozen cycles, thus influencing\nthe cumulative pregnancy rate. 21,24 However, both factors,\nnumber and quality of embryos together, can be a valuable tool\nin predicting the probability of pregnancy after ICSI, adjusting\nthe expectations of patients and physicians.\nSince this is a retrospective study, the information was\nobtained exclusively from medical records. Another impor-\ntant point is the relatively small sample size in each sub-\ngroup, so that larger studies are important to con firm our\nfindings and investigate the in fluence of embryo morpholo-\ngy on the embryos ’ cleavage stage in women that had fewer\nthan 4 embryos per cycle of IVF/ICSI. Since in our analysis we\nincluded only data from the first cycle of each patient, it is not\npossible to extrapolate whether the cumulative clinical\npregnancy rate, per cycle or time, is different in women\nwith or without TQEs.\nThis study allows to more accurately establish the chances\nof clinical pregnancy per cycle for patients under 40 years\nwho have at least 1 embryo in the first fresh transfer cycle.\nThis information is useful when counseling couples in order\nto determine the gestational outcomes, adjusting the expect-\nations of doctors and patients.\nTable 2 Main outcomes depending on the number of available embryos and on the presence of embryo(s) considered as having\ntop morphologic criteria\nGroups 1 embryo 2 –3e m b r y o s /C21 4e m b r y o s\nSubgroups Without\nTQE\nWith TQE p Without TQE With TQE p Without TQE With TQE p\nN 76 37 119 149 67 188\nParameter\nRetrieved oocytes 2 [1 –3] 2 [1 –4] 0.86 5 [4 –7] 5 [4 –7] 0.68 10 [7 –12] 10 [8 –14] 0.25\nMII retrieved 2 [1 –3] 1 [1 –3] 0.45 4 [3 –6] 4 [3 –5] 0.42 7 [6 –10] 9 [6 –11] 0.07\nFormed embryos 1 [1 –1] 1 [1 –1] 1.00 2 [2 –2] 2 [2 –3] < 0.01/C3 4[ 4 –6] 5 [4 –7] < 0.01/C3\nTransferred embryos 1 [1 –1] 1 [1 –1] 1.00 2 [2 –2] 2 [2 –2] 0.94 2 [2 –2] 2 [2 –2] 0.64\nClinical pregnancy 7 (9.2%) 6 (16.2%) 0.35 36 (30.2%) 50 (33.5%) 0.60 19 (28.3%) 85 (45.2%) 0.02 /C3\nAbbreviations: MII, metaphase II; N, number of women analyzed; p, p-value ;T Q E ,t o pq u a l i t ye m b r y o ./C3 p statistically signi ficant.\nNote: Data presented as median [interquartile range], or number (proportion).\nRev Bras Ginecol Obstet Vol. 38 No. 9/2016\nAssociation between Number of Formed Embryos, Embryo Morphology and Clinical Pregnancy Rate after ICSI Luz et al. 469\n\n\nIn conclusion, among women undergoing COS for ICSI,\nwomen that had four or more embryos and transferred at\nleast one TQE in the first fresh transfer cycle have higher rates\nof clinical pregnancy compared with those of women with-\nout TQEs. Thus, we found that the number of embryos per\ncycle and the quality of embryos transferred are important\nprognostic factors in ART.\nAcknowledgments\nThe authors are grateful to Universidade de São Paulo\n(USP), the Fundação de Apoio ao Ensino, Pesquisa e\nAssistência do Hospital das Clínicas da Faculdade de\nMedicina de Ribeirão Preto (Foundation for Support in\nTeaching, Research and Assistance - FAEPA), and the\nConselho Nacional de Desenvolvimento Cientí fico e Tec -\nnológico (Brazilian National Council for Research and\nDevelopment (- CNPq) for their financial support.\nReferences\n1 Gnoth C, Godehardt E, Frank-Herrmann P, Friol K, Tigges J, Freundl\nG. De finition and prevalence of subfertility and infertility. Hum\nReprod 2005;20(5):1144 –1147\n2 Boivin J, Bunting L, Collins JA, Nygren KG. International estimates\nof infertility prevalence and treatment-seeking: potential need\nand demand for infertility medical care. 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