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      We appreciate Drs Y. Guo, S. Guo, and Zhang for their interest in our work. After studying the role of blastocyst morphology in selecting among euploid embryos, we have demonstrated that morphological grading and specifically inner cell mass and trophectoderm grade influence the ongoing pregnancy rates of euploid embryos, while the degree of blastocoel expansion does not correlate with outcomes.
      • Irani M.
      • Reichman D.
      • Robles A.
      • et al.
      Morphologic grading of euploid blastocysts influences implantation and ongoing pregnancy rates.
      Most importantly, after controlling for confounding factors, the inner cell mass grade was the best predictor of euploid blastocyst viability.
      • Irani M.
      • Reichman D.
      • Robles A.
      • et al.
      Morphologic grading of euploid blastocysts influences implantation and ongoing pregnancy rates.
      We have also shown that the rate of blastocyst development affects the implantation potential of similarly graded euploid blastocysts.
      • Irani M.
      • O'Neill C.
      • Palermo G.D.
      • et al.
      Blastocyst development rate influences implantation and live birth rates of similarly graded euploid blastocysts.
      Given these findings, it would be ideal to separate AB and BA embryos into 2 different groups and not include them with AA or BB groups. However, we do not believe that AB and AA embryos should be included in the same group because AB embryos were associated with a significantly lower live birth rate (LBR) compared with the AA group (61.7% vs 78.8%, P = .03).
      In addition, the current study showed that excellent-quality blastocysts are associated with a significantly higher LBR and a trend toward a higher implantation rate compared with good-quality blastocysts (Table 2). Furthermore, there were only 11 cycles in which BA embryos were transferred, leading to an implantation rate of 90.9% and an LBR of 81.8%. Therefore, the current embryo grouping certainly did not affect the primary outcome of the study or the difference in LBRs between groups of different blastocyst grades. Of note, we did not have embryos of grades AC, CA, or 1-2AA within the study cohort.
      The aim of the current paper
      • Irani M.
      • Zaninovic N.
      • Rosenwaks Z.
      • Xu K.
      Does maternal age at retrieval influence the implantation potential of euploid blastocysts?.
      was to determine whether maternal age at retrieval influences the LBRs of euploid embryos. While we agree that we included only cycles with at least 1 euploid embryo that survived the biopsy/freeze/thaw process, the survival rate of these embryos is >98% in our laboratory, regardless of a woman’s age.
      We have also shown in Table 1 that the number of euploid embryos decreases with age, and we adjusted for this factor when we compared the outcomes between the 5 age groups. Embryo survival should be taken into account in centers where there is a significant difference in embryo biopsy/freeze/thaw survival rates between women in different age groups.
      The findings of this study are reassuring and confirm that maternal age at retrieval does not affect the LBR of a euploid embryo.
      • Irani M.
      • Zaninovic N.
      • Rosenwaks Z.
      • Xu K.
      Does maternal age at retrieval influence the implantation potential of euploid blastocysts?.
      However, we concur that further studies are required to investigate whether a woman’s age at retrieval influences perinatal outcomes.
      In conclusion, blastocyst grading and development rate, but not maternal age at retrieval, influence the viability of euploid embryos.
      • Irani M.
      • Reichman D.
      • Robles A.
      • et al.
      Morphologic grading of euploid blastocysts influences implantation and ongoing pregnancy rates.
      • Irani M.
      • O'Neill C.
      • Palermo G.D.
      • et al.
      Blastocyst development rate influences implantation and live birth rates of similarly graded euploid blastocysts.
      • Irani M.
      • Zaninovic N.
      • Rosenwaks Z.
      • Xu K.
      Does maternal age at retrieval influence the implantation potential of euploid blastocysts?.

      References

        • Irani M.
        • Reichman D.
        • Robles A.
        • et al.
        Morphologic grading of euploid blastocysts influences implantation and ongoing pregnancy rates.
        Fertil Steril. 2017; 107: 664-670
        • Irani M.
        • O'Neill C.
        • Palermo G.D.
        • et al.
        Blastocyst development rate influences implantation and live birth rates of similarly graded euploid blastocysts.
        Fertil Steril. 2018; 110: 95-102.e1
        • Irani M.
        • Zaninovic N.
        • Rosenwaks Z.
        • Xu K.
        Does maternal age at retrieval influence the implantation potential of euploid blastocysts?.
        Am J Obstet Gynecol. 2019; 220: 379.e1-379.e7

      Linked Article

      • In women with transplantable euploid blastocysts, age does not affect transplant potential
        American Journal of Obstetrics & GynecologyVol. 221Issue 4
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          The published study by Irani et al1 entitled “Does maternal age at retrieval influence the implantation potential of euploid blastocysts?” was well designed. However, the grouping of morphological ratings may have some of the following issues: 2BC, 2CB, and 2CC were inconsistent in the Methods and abstract and lack the grouping of morphological ratings, such as AC, CA, and 1-2AA. More importantly, placing AB and BA in the same group may be controversial.
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