Highlights From March 2015 Combined European/American Reproductive Society Meeting
The American Society For Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) held a combined meeting in New York City. Leaders from around the world in the field of Reproductive Medicine met to exchange ideas and debate controversial issues pertaining to infertility, and reproductive endocrine disorders. In this blog post we provide a brief overview of some of the highlights of the symposium.
TESTICULAR BIOPSIES WITH TISSUE FREEZING FOR STERILE PRE-PUBERTAL BOYS WITH KLINEFELTER SYNDROME
Dr. Herman Tournaye from Brussels presented a talk suggesting that pre-pubertal boys born with sterility due a genetic abnormality called Klinefelter Syndrome should undergo testicular biopsy with cryopreservation of the tissue for use later in life when they are ready to have children. Their research group was able to thaw the testicular tissue and isolate sperm stem cells that could be grown to mature sperm cells in tissue culture.
ENDOMETRIOSIS TREATMENT UPDATE
Dr. Hugh S. Taylor from Yale University gave a comprehensive update on the management of endometriosis. When infertility is not the issue, Dr. Hughes recommended simple inexpensive time honored therapy such as continuous oral contraceptives or progestins as first line therapy. For unresponsive patients, he recommended a combination of a progestin or gnRH agonist in conjunction with an aromatase inhibitor (decreases estrogen levels). His recommendation was that surgery be reserved for patients with pain unresponsive to medical therapy.
When early stage endometriosis patients have infertility, Dr. Hughes suggests that therapy should be either Clomid or gonadotropins with IUI (intrauterine insemination) as initial therapy followed by IVF if this treatment fails.
PRE-IMPLANTATION GENETIC SCREENING OF ALL EMBRYOS TO IMPROVE LIVE BIRTH RATES
Discussion of whether it is time to consider selection of the best embryo for transfer through the use of pre-implantation genetic screening (PGS) was presented in a debate format with one speaker taking the “pro” position and an opponent taking the “con” position. This debate proved to be one of the most interesting and controversial of the conference. It was pointed out that only one well designed randomized controlled trial (RCT) has been published addressing whether day 5 blastocyst biopsy improves live birth rates compared with selection of the embryo based on its microscopic characteristics. In spite of the relatively sparse data available at this time some clinics are advising patients to consider this approach. The data from the one available study is encouraging, but it was pointed out that early acceptance of change before the publication of a satisfactory number of properly controlled trials has misled clinicians in the past. Both presenters seemed to agree that pregnancy occurs sooner when embryo selection with PGS is done, and that miscarriage rates are lower.
Several of the lectures at the combined 2015 ASRM/ESHRE New York City meeting centered on egg freezing whether for medical reasons or social purposes. There seemed to be general agreement that egg freezing is a viable fertility preserving option for women facing potentially toxic cancer therapy, as well as for those women who are not ready to conceive having reached the age of 33-34. The ideal age for egg freezing seems to be approximately 33-35. The point was made that egg freezing is not a guarantee of future pregnancy, but rather offers an opportunity for pregnancy at a future time. The following data from the largest published egg freezing experience in the world to date: (Cobo, A. et. al., 2012)
Survival After Thawing 90-97%
Fertilization Rate 71-79%
Implantation Rate 17-41%
Pregnancy Rate 36-61%
Pregnancy/ Single Thawed Oocyte 4.5-12%
CURRENT STATUS OF “FREEZE ALL” CONCEPT
Momentum seems to be gathering for freezing all embryos in a given fresh IVF treatment cycle, rather than the traditional approach of replacing them in the uterus in the cycle in which they were removed. The proposed benefit of this approach is that the process of embryo implantation does not take place in the highly stimulated and perhaps poorly synchronized endometrial environment. It was pointed out that this approach delays and adds expense to IVF treatment because of the expense of freezing as well as the extra costs of the frozen embryo transfer cycle. To date, there has been only one published randomized controlled study suggesting a significant benefit to this approach. The point was made that this approach can only be advantageous if an IVF center has excellent freeze/thaw survival. On a show of hands among the attendees at the conference, many indicated that their freeze/thaw survival was in the 50-75% range. Clearly, such a freeze/thaw rate would negate any benefits derived from freezing all embryos.
There seemed to be general agreement that additional large well-controlled studies are needed before widespread application of the “freeze all” approach.
LEVELS OF SCIENTIFIC EVIDENCE
One of the speakers presented the following description of the various levels of scientific evidence. The credibility of scientific evidence is listed from the most credible to the least credible. It was suggested that this information be kept in mind as we decide whether to implement new therapies.
1a. - Evidence from meta-analysis (multiple trials included) from Randomized Controlled Trials
1b. – Evidence from one Randomized Controlled Trial
2a. – Evidence from at least one well designed Non-Randomized Controlled Trial
2b. – Evidence from one well designed experimental trial
3. - Evidence from case, correlation, and comparative studies
4. – Evidence from a panel of experts