My wife, Mandy Rodrigues and I had the pleasure of attending the ESHRE congress held recently in Lisbon. ESHRE is the European Society of Human Reproduction and Embryology, and its main aim is to promote interest in, and understanding of, reproductive biology and medicine.
This is a summary of some of the papers presented at the conference to allow infertility patients insight in to the latest thought processes.
It was really fantastic to see that the keynote address was related to stress as a cause of infertility. Medfem Fertility Clinic has studied stress and its role in infertility for the last 17 years. This study emphasises the need to manage stress as an added tool to improving fertility. I have included the full paper of this address.
Dr. Tony Rodrigues
Preconception stress increases the risk of infertility: results from a couple-based prospective cohort study, the LIFE study
Study question: Are women’s stress levels prospectively associated with fecundity and infertility?
Summary answer: Higher levels of stress as measured by salivary alpha-amylase are associated with a longer time-to-pregnancy (TTP) and an increased risk of infertility.
What is known already: Data suggest that stress and reproduction are interrelated; however, the directionality of that association is unclear.
Study design, size, duration: In 2005-2009, we enrolled 501 couples preconceptually in a prospective cohort study in Michigan and Texas, USA. Couples were followed for up to 12 months and through pregnancy if it occurred. A total of 401 (80%) couples completed the study and 373 (93%) had complete data available for this analysis.
Participants/materials, setting, methods: Enrolled women collected saliva the morning following enrolment and then the morning following their first observed study menses for the measurement of cortisol and alpha-amylase, which are biomarkers of stress. TTP was measured in cycles. Covariate data were captured on both a baseline questionnaire and daily journals.
Main results and the role of chance: Among the 401 (80%) women who completed the protocol, 347 (87%) became pregnant and 54 (13%) did not. After adjustment for female age, race, income, and use of alcohol, caffeine, and cigarettes while trying to conceive, women in the highest tertile of alpha-amylase exhibited a 29% reduction in fecundity (longer TTP) compared with women in the lowest tertile [fecundability odds ratio =0.71; 95% confidence interval (CI)=(0.51, 1.00); p<0.05]. This reduction in fecundity translated into a more than two-fold increased risk of infertility among women these women [Relative Risk=2.07; 95% CI=(1.04, 4.11)]. In contrast, we found no association between salivary cortisol and fecundability.
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Embryo quality scoring: A correlation between trophectoderm development and aneuploidy rate in developing blastocysts.
J. Blazek, M. Large, V. Pham, M. Hughes, T. Gordon. Genesis Genetics, R&D/PGS, Houston TX, U.S.A..
Study question: Blastocysts cultured for IVF are graded based on stage of hatching and organization of the inner cell mass and trophectoderm. Common practice is to implant embryos based on quality score in cases where preimplantation genetic screening (PGS) is not used. Is blastocyst embryo quality score correlated with chromosomal ploidy?
Summary answer: PGS is critical to improving success rates in implantation and live birth during IVF. In cases where PGS is not used prior to implantation, embryo quality score can be used to determine the likelihood of embryo aneuploidy based on strong correlations between embryo aneuploidy and in vitro trophectoderm development.
TAKE HOME MESSAGE: The outside layer of the embryo is called the trophectoderm. The analysis of this layer is the best predictor of the potential normality of embryos
Endometrial biopsy prior to assisted reproductive techniques (ART) does not improve treatment outcome in unselected patients
L. Polanski, M. Baumgarten, A. Richardson, K. Sewell, J. Brosens, S. Quenby, B. Campbell4, N. Raine-Fenning. University of Nottingham, School of Medicine, Nottingham, United Kingdom.
Does a timed mid-luteal phase endometrial biopsy (EB) affect the chances of a clinical pregnancy in an unselected population of women undergoing ART in the next menstrual cycle?
Summary answer: EB performed in the mid-luteal phase of the menstrual cycle does not increase clinical pregnancy rates in an unselected group of women undergoing ART.
TAKE HOME MESSAGE: Endometrial scratching does not increase pregnancy rates if you perform it on every patient. There may be a place in women with recurrent failed IVF cycles.
Study question: Can laser-assisted hatching of the zona pellucida (ZP) positively effect pregnancy outcome of frozen-thawed cleavage stage embryos?
Summary answer: Performing assisted hatching (AH) on frozen-thawed cleavage stage embryos prior to ET in women above 35 years was shown to reduce clinical pregnancy rate, to increase chemical pregnancy and missed abortion rates. No significant effect of AH was shown regarding those parameters in women below 35 years.
TAKE HOME MESSAGE: Assisted hatching of thawed frozen embryo’s in women older than 35 had a negative effect on the overall outcome.
Perinatal outcomes following stimulated versus natural cycle IVF: analysis of 90,980 singleton live births following stimulated and unstimulated IVF
S. Sunkara, P. Seed, Y. Khalaf. Aberdeen Fertility Clinic, Aberdeen Maternity Hospital University of Aberseen, Aberdeen, United Kingdom.
Study question: Does ovarian stimulation affect perinatal outcomes such as preterm birth (PTB) and low birth weight (LBW) following IVF treatment.
Summary answer: There was no increase in the risk of adverse perinatal outcomes of PTB, early PTB, LBW and very LBW following acceptable limits of ovarian stimulation (≤ 20 oocytes retrieved) compared to unstimulated IVF treatment.
TAKE HOME MESSAGE: Pregnancies resulting from assisted reproductive treatments (ART) are associated with a higher risk of pregnancy complications compared to spontaneously conceived pregnancies. This study shows that these risks are not related to the medication used. It may be that whatever causes the fertility problems, may in fact also cause pregnancy complications.
Efficacy of Dehydroepiandrosterone (DHEA) to overcome the effect of ovarian ageing (DITTO): A double blinded Randomized placebo Controlled Trial
K. Jayaprakasa1, A. Narkwichean, W. Maalouf, M. Baumgartean, L. Polanski, N. Raine-Fenning, L. Zujovic, J. Thornton, B. Campbell. NURTURE University of Nottingham & Royal Derby Hospital, Reproductive Medicine, Nottingham & Derby, United Kingdom.
Study question: To evaluate the effect of pre-treatment DHEA supplementation on the outcome of In-Vitro Fertilisation (IVF) treatment in women predicted to have poor Ovarian Reserve (OR).
Summary answer: Pre-treatment DHEA supplementation doesn’t seem to improve the ovarian response as measured by the number of oocytes retrieved or clinical pregnancy rates during IVF treatment in women predicted to have poor OR.
TAKE HOME MESSAGE: DHEA does not increase pregnancy rates in patients who are older and who are poor responders
Study question: Does AMH predict the chances of natural conception and time to conception in women with unknown fertility status?
Summary answer: AMH does not predict the chances of conception in women <40 years and the time to conception independently from the age of women. AMH predicts the chances of conception in women aged 40 years or older.
TAKE HOME MESSAGE: AMH levels in women <40 years does not have a predictive value to achieving a pregnancy.
Study question: Is the periconceptional thyroid stimulating hormone (TSH) level in women undergoing in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) correlated with pregnancy outcome in terms of implantation, biochemical pregnancy, clinical pregnancy, miscarriage, live birth and pregnancy complications?
Summary answer: In women with a normal body mass index (BMI) who underwent IVF/ICSI, a periconceptional TSH level of ≥2.5 mU/L is correlated with a 3.8-fold increase in risk of miscarriage.
TAKE HOME MESSAGE: its important to treat pre-clinical thyroid disease to optimize fertility outcome.
Study question: Does obesity affects male fertility potentials?
Summary answer: BMI was proved, in thisstudy, to have a significant effect on sperm concentration.
TAKE HOME MESSAGE: The lifestyle of men including their eating habits influence sperm concentrations and sperm quality.
Study question: Is there an association between ovarian response in IVF treatment and the risk of a trisomic pregnancy resulting from that treatment?
Summary answer: Subfertile women with a poor response in IVF treatment are not at a higher risk of a trisomic pregnancy resulting from this IVF treatment.
TAKE HOME MESSAGE: Women with low amh levels or are older and have a poor response to stimulation are not at a higher risk for having babies with abnormal chromosomes.
Study question: The aim of the present study was to evaluate the effect of Myo-inositol (INOFOLIC)on ovarian function in poor responders patients undergoing ovulation induction for ICSI cycle.
Summary answer: The results suggest that myo-inositol may improve ovarian response to stimulation in poor responder patients
TAKE HOME MESSAGE: Inofolic use for 3 months before IVF in poor responder patients may improve ovarian response.