ArticleJournal of assisted reproduction and genetics2026
Developmental trajectories from day 2 to day 3 refine ranking and selection of cleavage-stage embryos.
Article in Journal of assisted reproduction and genetics, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
purposeTo determine whether day 2 to day 3 developmental trajectories improve day 3 embryo ranking and selection compared with day 3 cell number alone, thereby offering better prognostic information for cleavage-stage embryos, including fast-cleaving embryos whose developmental potential remains uncertain.
designThis retrospective multicenter study (2016-2024) developed a ranking framework using 27,002 embryos from one center and validated it in 1691 fresh day 3 single embryo transfers across three centers (maternal age ≤ 38 years; embryos derived from two pronuclei, with fragmentation ≤ 10%, symmetric, and no multinucleation for confounder control). Developmental trajectories combined day 2 and day 3 cell numbers. Mixed-effects logistic models assessed trajectory-blastulation associations; post hoc comparisons consolidated trajectories into four ranking categories. Validation used trend tests between ranking levels and pregnancy rates, multivariable mixed-effects logistic model to estimate adjusted odds ratios (aORs) between ranking levels, and AUC for pregnancy prediction.
resultsTrajectory analysis reversed the advantage of day 3 8-cell over 9-16-cell embryos (30.7% vs. 24.2% high-quality blastulation; P < 0.001), with Normal_Fast (4 → 9-16) achieving the highest rate (40.7%), significantly higher than Normal_Normal (4 → 8; 35.1%; P < 0.001). Trajectories were consolidated into a four-category ranking: (1) Normal_Fast (4 → 9-16); (2) Normal_Normal (4 → 8); (3) Normal_Slow (4 → 6-7), Slow_Normal (< 4 → 8), Fast_Normal and Fast_Fast (> 4 → 8-16); and (4) all others. Ranking 1 had a higher likelihood of clinical pregnancy than ranking 2 (aOR = 2.06 [1.05-6.82]), although this validation was limited by sample size (n = 24). Trajectory outperformed day 3 cell number in predicting high-quality blastocyst (AUC 0.776 vs. 0.729; P < 0.001) and clinical pregnancy (AUC original 0.619 vs. 0.596, P = 0.02; down-sampled 0.682 vs. 0.618, P = 0.016).
conclusionsFor women ≤ 38 years undergoing fresh day 3 single embryo transfer, developmental trajectories from day 2 to day 3 improve embryo ranking and selection with other morphological features controlled (two pronuclei, fragmentation ≤ 10%, symmetry, no multinucleation). The 4 → 9-16 pathway emerges as potentially optimal, though requiring further validation. This dual-day framework treats both cell numbers as interdependent markers, where day 2 status redefines the priority of day 3 cell number, rather than serving only as a secondary criterion.
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