Page 9 - Focus on REPRODUCTION SEP 2015

duration, Joop Laven from the Erasmus Medical Centre in Rotterdam confirmed that survival rates from these cancers are increasing ‘dramatically’, but with it an increasing likelihood of ovarian dysfunction and infertility. He described combination therapy of alkylating agents with abdominal or pelvic radiotherapy as ‘especially gonadotoxic’, with premature ovarian insufficiency a high risk, adding that an assessment of ovarian function in pre- and post- pubertal girls and young adult cancers is ‘mandatory’. He recommended that fertility preservation should depend on a fixed protocol of risk assessment (such as the Edinburgh criteria) which recognised health status, ovarian reserve, treatment, and informed consent.
WITH MORE than 10,000 registered
participants, ESHRE 2015 was yet another record-breaking congress, just surpassing the attendance of London in 2013. But record
attendance means big crowds and, on day one especially, there were several sessions packed
out well before the starting gun, with proceedings only visible on screens outside.
One such hot session was on ‘endometrial receptivity’, but interest lay unequivocally in the contentious practice of endometrial scratch and its effect on implantation and IVF outcome. A systematic review performed by Carol Coughlan and colleagues from Dublin and Sheffield, UK, included RCTs published up to September 2014 and suggested that endometrial injury in the cycle immediately preceding embryo transfer cycle does indeed improve clinical pregnancy rates in those with at least one previous unsuccessful embryo transfer. This conclusion, derived from an analysis of seven applicable RCTs, was not far away from an earlier Cochrane review which, based on ‘moderate quality evidence’, also found endometrial injury performed between day 7 of the previous cycle and day 7 of the transfer cycle associated with improved outcome in women with one or two previous transfers. However, with reference to her own study, Coughlan was ‘not clear’ on how many scratches might have a beneficial effect, nor precisely when they
Record attendance meant some packed sessions were only watchable on TV screen outside the lecture hall. One of this year’s highpoints was the invited lecture by Mary Herbert on the prevention of mitochondrial disease by pronuclear transfer.
A study on cumulative live birth rate in IVF women over 38 presented by Marta Devesa proved exceptionally popular with the press. Ernesto Bosch in a study on freeze-all embryos found no benefit in normo- responder patients.
might be performed. Aim for once in the luteal phase, she suggested.
Such lack of clarity paved the way for another presentation in the same session on the 'pitfalls' of judging endometrial injury by meta-analysis. One, raised by Jose Franco from Sao Paulo, Brazil, was a lack of biological plausibility, with no support in basic research for any increase in endometrial receptivity in the cycle following injury. And epidemiologically, the results of meta-analysis are no better than those of the trials included, and so far, said Franco, with so much heterogeneity and absence of credibility in those trials, endometrial injury has no support in reliable evidence-based ART.
Another hot topic causing controversy is a freeze-all policy in IVF to delay transfer until a subsequent ‘natural’ cycle. However, an observational study of 882 first- or second-cycle patients at IVI Valencia found little encouragement for the policy in routine cases comparing 364 patients (41%) having embryo transfer in the initial fresh cycle, and 518 (59%)
having all embryos frozen for later transfer. When the outcomes were compared, no differences were observed between ongoing pregnancy rate and live birth rate (36.2% freeze-all vs 33.8% fresh). All patients in the study were considered normal responders and were thus, said Ernesto Bosch, representative of a routine IVF population. ‘These findings,’ he said, ‘do not support a change in IVF practice moving to a freeze-all strategy in normo- responders in IVF.’
However, a detailed review by Matheus Roque from Brazil, wich covered efficacy and obstetric outcomes in frozen embryo transfers, found the prevalence of risk (such as OHSS, ectopic pregnacy, placental disruption and preterm birth) greater in fresh cycles - and thus favouring frozen transfers.
The question of reproductive ageing continues to be of interest, especially in the lay press, and one study included in the press programme made the front pages of several newspapers. The study quantified the age- related decline in fertility evident in all ART programmes by analysing cumulative birth rate at the
SEPTEMBER 2015 // Focus on Reproduction 9