Page 20 - Focus on REPRODUCTION SEP 2015

was possible to inseminate every oocyte and to analyse the polar bodies. In Italy we couldn't generate more than three embryos, and all had to be transferred. At least in Lugano we could bypass that restriction.
And what’s the situation in Italy today?
We are just about back to where we were before Law 40, although we are still struggling with some points - for example, no compensation or reimbursement whatsoever can be given to gamete donors. And research on embryos is still forbidden. Considering how many embryos are declared ‘abandoned’, it seems strange that our polticians and legislators care so much about embryos when the legitimate owners - the couple - seem to care less once their purpose in one way or another has been fulfilled. If properly used, they could represent an unbelievable source of scientific information.
You were one of the first groups to work on PGS. Do you believe there’s been much genuine progress in the past 20 years, or just a lot of work and not much progress? A lot of people have been disappointed in PGS - do you share that disappointment?
I think there has been a lot of progress and this has provided much knowledge on meiotic and mitotic processes. Even when we began, the techniques were difficult. We studied a lot, tried to gain experience. But it wasn’t even easy to do the chromosome and genetic analysis. I think the problems began to occur when everything became available off the shelf. Using a laser for the biopsy was very easy, but it was also easy to cause damage. And I think this is one reason why results in PGS have not
been as good as expected. Of course, the technical
developments have been huge - we can now analyse all the chromosomes, for example.
So no problems in PGS?
The biggest limitation I see is the difficulty of arranging properly done studies. This is for several reasons. One is the cost of procedures, another the difficulty of recruiting patients. The more we advance our techniques, the less people want to be randomised.
Yes, it's an interesting paradox - that the more we need to test these new developments, the less patients want to be in a control group. Do you think we will ever have randomised trials big enough to provide a strong answer?
From what I see it’s going to be really difficult. We have problems recruiting patients for the ESTEEM trial of polar body analysis, so that’s not a promising example.
So those recent PGS studies we’ve seen in the USA, do you think they’re as good as we’re going to get?
Those studies are not perfect, because they’re in young good prognosis patients. But even in these patients, if there is a difference then there is a difference. So I don’t think this is a real drawback. Studies with a limited number of cycles are a problem, and I know that from the randomisation perspective we can be critical here. But all of these studies, however small, do provide valuable information. Could we do them better? Yes, we could, but even the best planned study will have some weak points.
So basically, Cristina, you’re still a believer? You believe in the concept of PGS, even if we haven’t yet perfected the technology? Yes, I do believe - biologically speaking and
from what we know about meiosis, mitosis and so on. I think there is very big rational
support for embryo screening. Maybe screening is not the right word when we’re talking about embryo selection -
testing would be more suitable. Perhaps PGT instead of PGS?
So it's reasonable for clinics to offer PGS to their patients on the
assumption that it may well improve birth rates or provide a better opportunity of single embryo transfer?
Yes, if presented with honesty I think it is fair enough. We know what evidence is available, but unfortunately we also know there are some groups who tend
to over-emphasise the advantages. Money is involved, of course, and this disturbs me a lot. I work in a private centre and I don’t like to hear that we are over-treating patients. PGS in our centre doesn’t even cover its costs. The fact is that not every technique is good for everybody, not every approach suits every patient, so we need to customise a bit more and a bit better.
Now, your new role with ESHRE. You’re about to take on responsibility for ESHRE’s Special Interest Groups and Task Forces. Yes, I find it very exciting - although my own excitement with ESHRE began when I got involved with the SIG Embryology in the late 1990s, when the SIG had been revitalised by Luca Gianaroli. Looking back, I’m not sure if I liked the idea of a special group for embryologists being run by a clinician, but that was the situation and I have to say that he is a very special ‘clinician’. Now, I am very proud to say that, because, as I tried to help Luca with his responsibilities, so I learned a lot from him and actually became more and more interested - and I ended up as Co- ordinator in 2009. It was very exciting for me when the SIG Embryology became ESHRE’s largest specialty group. I couldn’t avoid thinking of the legacy of Bob Edwards and how strongly he had fought to have the word ‘embryology’ included in the name of the Society.
So why do you think embryology became so important in ESHRE?
Many reasons, but recently the certification programme has had a big impact. It is unbelievable that such an important profession does not have an official recognition in the great majority of states. But the Atlas and good practice guidelines have also been very important. The good laboratory practice guidelines were the first guidelines ever produced by ESHRE.
But hasn’t there also been a big shift of interest to the lab because of the demands of single embryo transfer? Embryo selection has become more and more important.
Yes, without doubt. There have been so many advances in the past few years - much more in the lab than in the clinic. Every time I leave an ESHRE annual meeting I think of how exciting it has been. We don’t have big stories every year - ICSI, vitrification, blastocysts - but we have so many advances, exchanges of opinion, new data.
Do you think the mix of precongress courses, Campus events, training for
20 Focus on Reproduction // SEPTEMBER 2015