Focus on Reproduction

Transgenderism is indeed one of hottest topics of this year’s Annual Meeting – for several reasons. First, many people working in the field of fertility are coming new to the subject but are already receiving more and more referrals and appointments from transgenders. And second, the topic is attracting much interest in the press and social media.

The attention paid to transgenderism has grown over the past few years, especially since a few celebrities came out in public – and certainly with since more fertility options available to them. In the UK most of the transgender cases can have medical/psychological care, treatments to assist them in their transition and fertility preservation for free. This is not the case for other EU countries, where many treatments, such as surrogacy, remain illegal.

What are the answers which many transgender people most wish to hear – and indeed what are their tricky questions? Fertility preservation opportunities will depend on their wishes for the future. In Sweden, for example, 46% of trans-men cryopreserve eggs and 76% of trans-women preserve sperm. But why should any does sex gender definition really matter in 2017? Non-binary gender identification is more often a question in adolescents, when they do not know to which sex they belong. Moreover, are eggs and sperm the only cells dissociated from womanhood or manhood in 2017? As children  grow free from sexual identification they are more open to changes than adults who are embedded within cultural, religious and ethical constraints.

And is uterine transplantation a real option for trans-women to experience motherhood in the same way that women do? Finally, if we think that a man who becomes pregnant and gives birth is a real challenge, how do we react to stem cell-derived gametes which may even allow us to grow eggs from male cells in future? Watch this space.

Arianna D’Angelo, Co-ordinator SIG Safety and Quality in ART

No matter how many times you do it, standing up in front of a room full of people is a daunting task.  As a speaker, you will worry about whether you have rehearsed enough.  You will worry whether you are going to ‘keep to time’ or you might start to doubt your data.  These are all perfectly normal emotions (at least I suffer them), but as a speaker, when you stand up to start, you have your slides, your presentation to help.  Yes, your slides are important for the audience, but they also help you, the speaker – keeping you on track and acting as a reminder.  This morning however, I was due to stand in front of a room in a different capacity – the session Chair for the SIG Embryology.  Not only the session chair, but the chair of the opening session.  This is a very different experience, but many of the pre-talk nerves were there, although my worries were different, and I didn’t have any slides to hide behind.  First up, are the speakers here? (yes, thankfully they were).  Can I correctly pronounce their names? (Pleasingly, I knew both speakers of the session).  Who will start – my co chair (Kersti Lundin) or me – it was me.  Right, so, I had given this a few moments thought last night before I went to bed, yet my mind had gone blank.  Welcome – yes, yes, remember to welcome the audience to the PCC in… ARRGGGHHH I had forgotten the precise title of the PCC.  Like a flash, I got onto the ESHRE 2017 Webapp and my embarrassment was avoided – as the full title was there.  Frantic scrawling to write down the exact title and then…  it’s time; we’re up.

I remember that the lights were REALLY bright, but I don’t really remember what words came out of my mouth when I welcomed the delegates, but I think it was OK.  Our first speaker, Giovanni Coticchio, got going and did a super job… and soon it was time for questions.  Scan the room – who might be itching to ask a question.  Well, not many – again, it’s scary standing up in a room full of people to ask a question, and no one is standing up to the microphone.  That’s the other thing about being a chair – as well as being ready to interrupt that speaker who just keeps talking, you also need to listen actively, because, if there are no questions, then it falls to you to stimulate some discussion.  If you are scared to ask a question from the floor, imagine the feeling of asking a question AT THE FRONT of the room, with the lights on you, illuminating every spot and blemish…  Thankfully, I had plenty of questions, but not as many as my co-chair, who provided a really stimulating question, which prompted questions from the floor…

Our second speaker was also incredible – Prof Keith Jones telling us all about the spindle assembly checkpoint and so it soon came time to close the session.  Suddenly I need to think again – “what should I say?”  What to the ‘proper chairs’ say?  Thank the speakers – check.  Thank the audience – check.  Invite people to go for coffee… WHERE???  Arrrrggg again – I don’t know where coffee is – but thankfully you all found your way.  And more importantly, you all found you way back again.

Chairing is a privilege – but it is daunting – no matter how often you do it.  But introducing experts to come and give talks is a really super feeling – so if you ever get the opportunity, then take it.

Roger Sturmey, BSO SIG Embryology

So ESHRE comes round again, now in its 33rd year and still with the reliable regularity of a cuckoo clock. Back at the first edition, 500 pioneers registered; now, attendance seems to have settled at around 9000, including 2000 on Sunday for precongress courses. What will they all take home from Geneva, besides their bar of Toblerone and army knife?

1. More on IUI, especially in the treatment of unexplained infertility. A large RCT from the Netherlands (n = 369) has found that stimulation with clomiphene citrate is just as effective as FSH in terms of live birth, ongoing pregnancy and time-to-pregnancy (Session 3, Monday 10.00 am). The study would suggest that this ‘least expensive and least invasive agent’ is now the drug of choice in IUI. Next up in the same session will be another RCT – this from New Zealand – which compared three cycles of IUI (stimulated with clomiphene) with three cycles of expectant management in couples with unexplained infertility. Results showed that the IUI option was associated with a three-fold higher live birth rate than expectant management. In 2013 NICE in the UK controversially recommended that IUI should not be routinely offered for unexplained infertility, with or without ovarian stimulation. Now results from both these trials suggest that this recommendation may need a rethink.

2. A shift in thinking on ovarian response to stimulation for IVF? The Danish specialist Anders Nyboe Andersen will conclude in an invited session (Session 13, Monday 14.00) that, while stimulation dose might be individualised to maximise cumulative outcome, there still remains the need to balance oocyte yield with safety. Both the ESTHER and OPTIMIST trials cited by Andersen suggested that individualised dosing (higher for predicted low responders and vice versa) had no benefits in terms of ongoing pregnancy rates and cumulative LBR.

   However, a huge multicentre study (n = 14,469) to be presented by Nicholas Polyzos on Tuesday (Session 48, Tuesday 14.15) will show that cumulative LBRs steadily increase with the number of oocytes generated in an initial stimulation cycle, even reaching 70% when 25 or more oocytes were retrieved. Although no significant decrease was detected up 20 oocytes, a drop in fresh LBRs was identified thereafter. The landmark study of Sunkara et al based on data from the HFEA database (Sunkara SK, et al. Hum Reprod 2011; 26:1768-1774) also suggested that birth rate in IVF is directly related to the number of eggs retrieved (ie, birth rates rose according to the number of eggs retrieved, but levelled out after 20 eggs). The study reported that around 15 eggs were needed to maximise the chance of delivery.

   Similarly, an Australian study presented here as a poster (P-657, Venetis C, Is more better? A higher oocyte yield is independently associated with more day-3 euploid embryos) also found that a higher number of eggs retrieved in an IVF cycle is independently associated with more chromosomally normal embryos available for transfer.

   So where does this leave mild IVF and the intuitive emphasis on quality, not quantity. Some studies have pointed to a negative association of a higher oocyte yield and pregnancy after fresh embryo transfer, most likely because of an adverse effect on the uterus. The study from Fauser’s group in 2007 (Heijnen EM, et al, Lancet 2007; 369: 743-749) remains a landmark and found comparable cumulative outcomes between mild and conventional IVF, and reduced patient burden.

3. Cryopreserved oocytes as viable as fresh? Deborah Gook from Melbourne, one of the true pioneers of oocyte cryopreservation, will propose on Tuesday (Session 100, Tuesday 08.30) that, with evidence from large donor oocyte programmes, high survival rates can be achieved from oocyte vitrification and that the surviving oocytes can fertilise, develop and implant at rates indistinguishable from those of comparable fresh oocytes. The benefits of this are now seen not just in donor egg banks but in fertility preservation programmes too – and may well extend to other clinical contexts. Robotic automation may guarantee the standarisation of vitrification, according to embryologist Laura Rienzi (Session 28, Tuesday 09.00), whose work with Lobo et al from Spain has done much to prove the viability of vitrified oocytes.

What else from ESHRE 2017? There are new sessions from the Cochrane group and, appropriately in Geneva, the WHO. The latter’s theme is ‘unmet needs’, which must also include the provision of abstracts for the online programme book. Other high points this year – with abstracts – will include Robin Lovell-Badge on genome editing (Session 12, Monday 14.30), Jacques Cohen on mitochondrial transfer (Session 8, Monday 11.45) and Karen Sermon with the much anticipated results from the ESTEEM trial, the largest RCT to date addressing the potential benefit of aneuploidy testing by array CGH in patients of advanced maternal age (Session 39, Tuesday 12.15).

Simon Brown, Editor of Focus on Reproduction

Tomorrow, the Annual Meeting of ESHRE finally gets under way. I am sure you have scanned the programme of oral sessions and made your itinerary, but have you also looked at the posters?

Let me persuade you to at least check them out and to attend the poster discussions on Monday and Tuesday.

But first, my DOI: I am a bit biased towards poster presentations. My bias could be because of the many posters I presented during my PhD (my subject was not very hot, I believe), and the nice memories of having to stand in front of the poster over lunch, chatting and laughing, meeting new people – and even the relief when a poster was lost during transport but made  it to the conference in time..

Anyway, since I started working with ESHRE, poster presentations at the Annual Meeting have been a point of discussion, the core of the issue being how to attract a broader audience. Ideas of breakfast sessions with croissants, wine and cheese posters, paper versus electronic posters . . . . Today, however, it feels as if the posters have been accepted for what they are, or are believed to be, “the second cut”, the leftovers.

From my experience, and a little bit of help from PUBMED, I would like to raise six reasons why posters are of value to the conference, and why you should invest a little time over the next three days to check them out:

1. Posters have always been there, and are an essential part of the conference

Since the seventies, posters have been established as common practice in science and academia. Conference organisers use poster presentations to accommodate a large number of delegates within the limited time frame of a few days, thereby providing an excellent means for (young) doctors and scientist to participate actively at the conference. At the ESHRE meetings, 75% of the accepted abstracts are presented as posters. Not viewing the posters means you miss a large proportion of the science presented.

2. The poster presenters

This is your chance to acknowledge the work of over 800 authors who have invested their time and energy in proudly making a poster of their work. Some of these authors will have scanned the web for information on how to make a poster appealing, while others may only have been satisfied after the 15th version.

3. Posters are a great source of information

Or not?  In a recent study, podium presentations at the Arthroscopy Association of North America meetings were more likely to be published within three years than poster presentations (59% versus 44%, respectively). I checked the abstracts (i.e. a random sample of 250 titles) of the ESHRE Annual Meeting in Lisbon 2015 in a similar way: 32.7% of the selected oral presentations and 25.1% of the poster presentations were published two years after the conference. This is not too bad, right? Moreover, the median impact factors of the journals that published oral and poster presentations were similar, as was the time to publication.

4. Posters facilitate networking

Why do you attend a conference? Of course, to learn and be up to date, but networking is probably your second answer. Poster presentations and discussion are considered a great way for two-way conference interaction and can be a catalyst for future collaborations. If you see an interesting poster, just contact the author through the app, or via e-mail to discuss the poster and at the same time expand your network.

5. Posters can promote active learning

Unfortunately, studies have shown that passive poster presentations in itself are not very effective in promoting knowledge transfer. However, this changes when posters are accompanied by active interventions (oral presentation, physical interaction). To facilitate this, ESHRE is organising poster-discussion sessions per topic, where there is time for moderated discussions between the presenter and the audience. Check out the schedule and join the discussion.

6. You can view all posters with one finger

As you know, ESHRE switched completely from traditional paper posters to e-posters at last year’s conference in Helsinki. I am not a fan of e-posters: they do not provide an opportunity to stroll through lanes of posters, take pictures of interesting ones, chat with colleagues and interact with presenters. However, they do take away the need for printing, transportation and disposal, and as such they fit in a paper-free meeting. Furthermore, the e-poster system ESHRE is using attempts to mimic the paper-poster experience and improve it; you can stroll through posters on one screen, e-mail the poster to yourself or your colleagues (instead of a blurry picture), send a question to the authors, but you can also easily find one poster, search all posters on a certain topic, zoom in or out, and watch videos.

In the end, there is only one thing for you to do. Check out the poster area in Hall 3 and join the poster discussion sessions on Monday and Tuesday!

Nathalie Vermeulen, ESHRE’s Research Specialist

In the latest HR Editor’s highlight, Professor Hans Evers questioned the usage, or rather the overusage, of ICSI in fertility treatments. He referred to the newly published world ART figures in the ICMART World Report on Assisted Reproductice Technologies from 2008-2010. This report covers over 4.5 million started cycles, with about twice as many ICSI as IVF. 
Although a method originally developed to treat male infertiliy, today it is clearly being used for many other indications – such as advanced maternal age – and to ensure fertilisation.

The provocative statement of Evers that “ICSI on faulty indications has prevented at least 25,000 couples from getting pregnant” has stimulated much discussion in recent weeks – and of course here at this congress. 
On Tuesday Julius Hreinsson, in a discussion of individualised or standard treatment in IVF, proposed that certain treatments – including ICSI – should not be offered as a standard treatment to all patients as it will not improve our results. ICSI, said Hreinsson, should only be offered as an individualised option in cases where the access of sperm is limited.

Further support for limiting the use of ICSI was also presented in a session on IVF laboratory quality and strategies. Samer Tannus presented data from a study showing that ICSI does not improve pregnancy and LBRs in women of advanced age with non-male factor infertility.
 ICSI is an invasive technique and it seems that the need to reconsider its use is greater than ever.

Susanna Apter, Deputy Co-ordinator of SIG Embryology

Fertility Europe had a great patient session this year. Our topic was “Double Gamete Donation and Embryo Donation”, and our four speakers did a good job explaining some of the considerations related to the two in their own countries.

What struck me most during Anna Krawczak’s lecture is that forced embryo donation may become a reality in Poland. When listening to Nicoleta Cristea-Brunel’s presentation I found it very interesting that for some couples in Romania the financial aspect was the strongest factor in choosing embryo donation (less expensive, less time away from home) rather than egg donation.

Listening to Caroline Spencer describe how she held her infant son in her arms, telling him how happy she was to be his mom and how thankful she was to the doctors and nurses, and the kind man and woman who donated their gametes to create him, gave me goose bumps – even though she had shared the story with me last night. The importance of telling a child of their origin can’t be emphasised too strongly. But telling isn’t a one time thing, Caroline pointed out, it’s something that the parents will be talking about with their child now and then for a long time.

The situation in Israel is such that there are tens of thousands of embryos now being kept frozen because the couples who had them created have reached their desired family size but can’t imagine having the embryos destroyed. Ofra Balaban-Kasztelanski told us how the patient association in Israel has plans to try and have the laws changed so that embryo donation will be possible as relief for the endess storage of surplus embryos.

Even though the situations and circumstances mentioned above are all different, one thing remains the same. The patient and the desire to have a child.

Ella Einarsdottir, Chairman of Fertility Europe

Nursing sessions well attended, despite early start. Good to see so many nurses and midwives attending and presenting at the sessions here in Helsinki. Lots of high quality presentations from great speakers.

The week started well on Sunday with a precongress course on epigenetics. Eight speakers guided delegates through understanding epigenetics, the impact of diet by way of the Dutch famine, stress, lifestyle, the influence on gametes and embryos of culture medium and freezing, and ultimately the impact that all these factors have on children.

The Paramedical Board were most flattered to see Henry Leese in the audience, who told me he had learnt a lot!

Epigenetics then seemed to weave a route through most of the main meeting sessions I went to.

Invited sessions were well attended in spite of early starts. Kelly Tilleman gave a talk on fertility preservation for transgender patients prior to transition surgery, highlighting their centre’s approach and the legal requirements in different countries. Fascinating for me as I had recently met a family seeking information about future fertility for their 14-year-old contemplating gender reassignment.

The nurse’s role in improving patient satisfaction was definitely a theme in the oral abstract and invited sessions – using patient-centered assessment tools to improve pain control for patients with endometriosis or nurse support for fertility patients who achieve a pregnancy.

Changes and reorganisation of accepted custom and practice was the theme of a presentation by Jolieneke  Schoonenberg- Pomper, a former Chair of the Paramedical Board. She urged nurses to take on tasks often more associated with clinicians – for example, ultrasound scanning. The clear message was that with appropriate training and assessment of competence nurses and midwives could learn this skill. Benefits include good levels of patient satisfaction, efficient use of clinic time, cost effective and raised levels of job satisfaction.

All the sessions were well received and stimulated questions from the audience. Already looking forward to next year.

Helen Kendrew, Chair of the Paramedical Group