title: Inter-observer and intra-observer agreement between embryologists during selection of a single Day 5 embryo for transfer: a multicenter study.
abstract: What is the inter-observer and intra-observer agreement between embryologists when selecting a single Day 5 embryo for transfer?
  
  
  
  The inter-observer and intra-observer agreement between embryologists when selecting a single Day 5 embryo for transfer was generally good, although not optimal, even among experienced embryologists.
  
  
  
  Previous research on the morphological assessment of early stage (two pronuclei to Day 3) embryos has shown varying levels of inter-observer and intra-observer agreement. However, single blastocyst transfer is now becoming increasingly popular and there are no published data that assess inter-observer and intra-observer agreement when selecting a single embryo for Day 5 transfer.
  
  
  
  This was a prospective study involving 10 embryologists working at five different IVF clinics within a single organization between July 2013 and November 2015.
  
  
  
  The top 10 embryologists were selected based on their yearly Quality Assurance Program scores for blastocyst grading and were asked to morphologically grade all Day 5 embryos and choose a single embryo for transfer in a survey of 100 cases using 2D images. A total of 1000 decisions were therefore assessed. For each case, Day 5 images were shown, followed by a Day 3 and Day 5 image of the same embryo. Subgroup analyses were also performed based on the following characteristics of embryologists: the level of clinical embryology experience in the laboratory; amount of research experience; number of days per week spent grading embryos. The agreement between these embryologists and the one that scored the embryos on the actual day of transfer was also evaluated. Inter-observer and intra-observer variability was assessed using the kappa coefficient to evaluate the extent of agreement.
  
  
  
  This study showed that all 10 embryologists agreed on the embryo chosen for transfer in 50 out of 100 cases. In 93 out of 100 cases, at least 6 out of the 10 embryologists agreed. The inter-observer and intra-observer agreement among embryologists when selecting a single Day 5 embryo for transfer was generally good as assessed by the kappa scores (kappa = 0.734, 95% CI: 0.665-0.791 and 0.759, 95% CI: 0.622-0.833, respectively). The subgroup analyses did not substantially alter the inter-observer and intra-observer agreement among embryologists. The agreement when Day 3 images were included alongside Day 5 images of the same embryos resulted in a change of mind at least three times by each embryologist (on average for <10% of cases) and resulted in a small decrease in inter-observer and intra-observer agreement between embryologists (kappa = 0.676, 95% CI: 0.617-0.724 and 0.752, 95% CI: 0.656-808, respectively).The assessment of the inter-observer agreement with regard to morphological grading of Day 5 embryos showed only a fair-to-moderate agreement, which was observed across all subgroup analyses. The highest overall kappa coefficient was seen for the grading of the developmental stage of an embryo (0.513; 95% CI: 0.492-0.538). The findings were similar when the individual embryologists were compared with the embryologist who made the morphological assessments of the available embryos on the actual day of transfer.
  
  
  
  All embryologists had already completed their training and were working under one organization with similar policies between the five clinics. Therefore, the inter-observer agreement might not be as high between embryologists working in clinics with different policies or with different levels of training.
  
  
  
  The generally good, although not optimal uniformity between participating embryologists when selecting a Day 5 embryo for transfer, as well as, the surprisingly low agreement when morphologically grading Day 5 embryos could be improved, potentially resulting in increased pregnancy rates. Future studies need to be directed toward technologies that can help achieve this.
  
  
  
  None declared.
  
  
  
  Not applicable.
authors.affiliation: IVFAustralia, Sydney, NSW, Australia ashleigh.storr@outlook.com.|School of Women's and Children's Health, UNSW Medicine, UNSW, NSW, Australia.
authors.forename: Ashleigh
authors.initials: A
authors.lastname: Storr
authors.affiliation: IVFAustralia, Sydney, NSW, Australia.|School of Women's and Children's Health, UNSW Medicine, UNSW, NSW, Australia.
authors.forename: Christos A
authors.initials: CA
authors.lastname: Venetis
authors.affiliation: IVFAustralia, Sydney, NSW, Australia.|School of Women's and Children's Health, UNSW Medicine, UNSW, NSW, Australia.
authors.forename: Simon
authors.initials: S
authors.lastname: Cooke
authors.affiliation: IVFAustralia, Sydney, NSW, Australia.|School of Women's and Children's Health, UNSW Medicine, UNSW, NSW, Australia.
authors.forename: Suha
authors.initials: S
authors.lastname: Kilani
authors.affiliation: IVFAustralia, Sydney, NSW, Australia.|School of Women's and Children's Health, UNSW Medicine, UNSW, NSW, Australia.
authors.forename: William
authors.initials: W
authors.lastname: Ledger
mesh_terms: D000328:Adult; D010064:Embryo Implantation; D005260:Female; D005307:Fertilization in Vitro / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D015588:Observer Variation; D011247:Pregnancy; D018873:Pregnancy Rate; D011446:Prospective Studies; D056826:Single Embryo Transfer / Q000379:methods*; D016896:Treatment Outcome
keywords: agreement; embryo; inter-observer variability; intra-observer variability; morphology