HIGHLIGHTS OF THE ANNUAL MEETING OF THE

EUROPEAN SOCIETY OF HUMAN REPRODUCTION AND EMBRYOLOGY

2020

Virtual Congress,5th-8th July 2020

The purpose of this report is to capture highlights from the ESHRE 2020 congress. The REPROFACTS faculty has selected the studies presented in this report; putting study findings in perspective and extracting the practice points. The faculty members were independent in their choice of studies and their evaluation and this report is based on the REPROFACTS 2020 Post-ESHRE meeting. The development of this congress report has been financially supported by MERCK KGaA, however MERCK KGaA had no influence on the content and scientific opinions presented in the congress report do not necessarily represent the position of MERCK KGaA. MERCK KGaA is not responsible for the content of the report. Consequently, MERCK KGaA does not give any warranty, express or implied, regarding the scientific use of this report, or regarding any other particular use for any purpose, and MERCK KGaA therefore is not liable for any direct, indirect, incidental, or consequential damages related to the use of the information contained herein.

Sponsored byGL-NONF-00570 August 2020

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Foreword

The year 2020 marks a new era in many fields of life and profession, and this is also true for reproductive medicine. For the first time since the inaugural meeting in Bonn in 1985, ESHREs annual get-to-together went exclusively virtual, providing a totally new experience for everyone involved, from presenter to audience to industry. While online lectures on-demand and ease of access to the presentations were convenient (and will likely stay), the inspiration gained from personal contact and the focus to the conference without distraction from routine business at home was certainly missed by many of the 12,520 online participants.

The COVID-19 crisis did, however, not impact the quantity or quality of the main scientific program, with 200+ peer-reviewed oral communications and more than 60 invited lectures. The wealth and breadth of information was as challenging as ever, so our REPROFACTs expert team once again shared the subspecialties among each other, sorted out ‘the wheat from the chaff’, and presented the essence of the ESHRE lectures in a one-day meeting in Mainz, Germany, on July 17, 2020.

This years REPROFACTS meeting marked the 10th anniversary of an initiative which started as a small ‘POST-ESHRE’ discussion forum and which grew, with Merck as a strong partner, into one of the largest reproductive medicine conferences within the German speaking countries. The COVID crisis also left its mark on the format of REPROFACTS, which was for the first time held as a hybrid-meeting, with online live streaming of the real event.

This report contains some of the key highlights from the REPROFACTS meeting 2020. Selection of topics was done by the REPROFACTS faculty, independently and neutrally, with a focus on clinically relevant novelties.

Watch Prof. Griesinger discuss the virtual ESHRE 2020 congress.

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Prof. Dr. med. Heribert KentenichBerlin. Subspecialities: safety and quality, law and ethics, psychology

Prof. Dr. med. Michael von WolffBern. Subspecialities: fertility preservation, ovarian reserve, surgery

Dr. med. Maren GoeckenjanDresden. Subspecialities: endometrium, endometriosis, early pregnancy

Dr. rer. nat. Jens HirchenhainDüsseldorf. Subspeciality: clinical embryology

Priv.-Doz. Dr. rer. nat. Verena NordhoffMünster. Subspecialities: basic science and reproductive genetics

Prof. Dr. med. Michael ZitzmannMünster. Subspeciality: andrology

Prof. Dr. med. habil. Jürgen M. WeissLucerne. Subspecialities: female infertility and ovarian stimulation

Prof. med. Ludwig WildtInnsbruck. Subspeciality: endocrinology

Faculty members

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Early pregnancyPre-treatment with mifepristone to misoprostol in early pregnancy failure 13

Conception after early IVF pregnancy loss - should we wait? 15

Updated terminology for early pregnancy assessment 17

Andrology Low male testosterone 5

Negative impact of elevated DFI and HPV presence in sperm 7

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Efficacy and safety of linzagolix on HMB due to uterine fibroids 8

Reproductive endocrinology

Use of testosterone gel treatment in poor ovarian reserve in IVF-ICSI cycles 11

Relugolix for heavy menstrual bleeding due to uterine fibroids 10

Fertility preservation and reproductive surgery

LH preserves the meiotic potential of oocytes exposed to chemotherapy 21

Live birth rate and utilization rate of eggs and embryos following FP 19

Septum resection versus expectant management in women with a septate uterus 22

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Clinical embryology

Complex mosaic embryos after preimplantation genetic testing 26

New evidence on mosaic developmental potential 24

Novel technologies for single-sperm vitrification 27

Intracytoplasmic sperm injection vs conventional IVF in couples with non-male factor infertility 29

Embryos excluding multinucleated cells during blastocyst formation increase their reproductive potential 31

Ovarian stimulation

Comparing different progestin regimens for pituitary suppression 34

Optimal GnRH antagonist protocol during ovarian stimulation 33

MPA as a pituitary suppressor instead of a GnRH antagonist during ovarian stimulation 36

Pituitary suppression is not necessary for blocking LH surge during luteal-phase stimulation 37

Natural cycle frozen-thawed embryo transfer 38

Safety & OutcomesNordic sibling study 39

Imprinting disorders in children born after ART 41

Major congenital malformations risk in children conceived after ICSI 43

Artificially prepared frozen cycles and increased risk of preeclampsia 44

Additional Video Highlights 46

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Background

Sperm production is regulated via a complex and dynamic process that requires interaction of multiple hormones and testicular cell types. Testosterone is indispensable for sperm production; however, testosterone exerts it spermatogenetic action only within a network of endocrine and paracrine signals and tightly coordinated gene and protein expression programs within the testis. Little attention has so far been paid on the potential association of testosterone synthesis with fertility in case of normal sperm parameters. The necessity of routinely evaluating serum testosterone levels in male partner of couples trying to conceive is also under dispute.

Study

In a retrospective analysis (time period 2011 to 2018), conducted at the University of Brussels Reproductive Medicine Center, 1,026 couples undergoing a first IVF cycle for non-male factor subfertility were identified. Treatment course and outcome of 136 couples (13.3%) with a male partner with a total serum testosterone of <264ng/dl (<9.2 nmol/L) were compared with couples with male partners above this threshold. This threshold represents the recommended lower limit of the normal total testosterone (TT) in healthy non-obese young men1. In a recent post-hoc analysis of the AMIGOS RCT2, a decreased odds of live birth was observed in couples with unexplained infertility undergoing ovarian stimulation with letrozole, clomifen or FSH for timed intercourse or IUI, whose male partner was below 264ng/dl total testosterone (adjusted OR, 0.65; 95% CI, 0.38, 1.12). Only morning testosterone samples and men with no exogenous testosterone or other relevant medication were included in the Brussels study.

Low male testosterone results in a substantial decrease of fresh live birth rates in couples with non-male factor infertility undergoing IVF, O-016

P. Drakopoulos et al.

No relevant difference in sperm parameters were found in patients with low vs. normal testosterone levels. However, the live birth rate was significantly reduced in the low testosterone group (13%; 95% CI, 8, 20) vs. normal testosterone group (23%; 95% CI, 21, 26). This finding remained after adjusting for male and female age, male smoking, female BMI, number of oocytes and embryos, cause of infertility and SHBG levels (adjusted OR, 0.35; 95% CI, 0.15, 0.79). Accordingly, both total and free testosterone in serum were positively associated with live birth likelihood.

Watch Prof. Michael Zitzmann discuss the potential role of testosterone as a functional marker for reduced fertility potential.

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Univariate-analysis:live birth rate by male partner testosterone serum

Normal Testosterone(≥264 ng/dl)

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Comment

This study aimed at validating the post-hoc observation from the AMIGOS trial2 in the setting of IVF. In both studies, male factor (defined by sperm analysis) was excluded. Thus, the findings hint at a qualitative association of the endocrine and reproductive function of the testis.

Low male testosterone results in a substantial decrease of fresh live birth rates in couples with non-male factor infertility undergoing IVF, O-016

P. Drakopoulos et al.

Testosterone administration is contra-indicated in the context of fertility treatment. Selective estrogen receptor modulators, gonadotropins and aromatase inhibitors can restore serum testosterone levels, however, the consequences of these pharmacological interventions for natural fertility or ART have not yet been fully clarified.

Practice point

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Background

Human Papillomavirus (HPV) are sexually transmitted DNA viruses with high prevalence. The association of HPV infection and fertility in the male1 and female2 have remained inconclusive so far. The head of spermatozoa carry syndecan-I, a transmembrane protein also used by the HI-virus (HIV) to enter cells. HPV virions can bind to syndecan I, potentially inducing DNA damage in the sperm and infecting the oocyte leading to embryonic arrest after fertilization with an infected spermatozoon.

Study Summary

In a prospective, multi-center study, 161 men undergoing 209 IUI cycles were examined. HPV DNA of 18 different subspecies was analyzed by PCR and the amount of DNA damage was quantified by the sperm chromatin structure assay (DNA fragmentation index, DFI).

15% of the sperm samples used for IUI were positive for one of the HPV subtypes tested, in 10% of sperm samples a high-risk HPV subtype was detected. The DFI was higher in infected vs. non-infected samples (29% vs. 20%, p=0.01). A cut-off of 26% DFI was identified as a strong predictor of pregnancy, e.g. all pregnancies in this cohort originated from sperm samples below this threshold. No pregnancy was achieved in the 31 IUIs with sperm tested positive for HPV.

Comment

This study corroborates the hypothesis further that HPV infection does play a role in human fertility. However, infected men may infect their partners and the impairment of fertility may differ between males and females. Furthermore, socio-economic status and immune status may play a role in acquiring and resolving a HPV infection. Such interactions impose significant difficulties when deciphering the impact of HPV on fertility.

Negative impact of elevated DNA fragmentation index (DFI) and human Papillomavirus (HPV) presence in sperm on the outcome of intra-uterine insemination (IUI), O-017

C. Depuydt et al.

Routine fertility work-up of the male still does not require testing for HPV.

Practice point

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Watch Prof. Michael Zitzmann discuss available data and the impact of HPV infections on the impairment of fertility.

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Placebo Linzagolix100mg

Linzagolix200mg

Linzagolix100mg + ABT

Linzagolix200mg + ABT

Background

Sex steroid withdrawal via GnRH-analogue administration mitigates heavy menstrual bleeding. While full suppression of sex steroids induced by GnRH-analogues is highly effective, bone mineral density and overall quality of life are negatively affected. Therefore, hormone add-back therapy is necessary. Linzagolix is a novel, non-peptide, orally active gonadotropin-releasing hormone antagonist that reduces circulating serum sex steroid levels in a dose-dependent manner. A dose-dependent, only partial suppression of estradiol could make the need for add-back redundant, while still achieving good bleeding control. Recently, the use of Linzagolix within a phase IIb trial for the treatment of endometriosis-associated pain was reported1. In this trial, no hormone add-back was given. Both pain and bone mineral density were reduced in a dose-dependent fashion within 24 weeks of treatment.

Study

In a phase III, double-blind, placebo-controlled, multicenter RCT (PRIMROSE2 study), women with uterine fibroids and >80ml menstrual blood loss per cycle received 100mg or 200mg daily linzagolix with or without hormonal add-back (estradiol 1mg/NETA 0.5mg) for 52 weeks. Menstrual blood loss was significantly reduced in all linzagolix treated patients, as was uterine volume and pain. Median estradiol levels were below 20pg/ml in the 200mg without add-back therapy, but were 20-60pg/ml in all other groups. Bone mineral density loss was most pronounced in the 200mg group without add-back therapy.

Efficacy and safety of linzagolix on heavy menstrual bleeding (HMB) due to uterine fibroids (UF): Results from a placebo-controlled, randomized, Phase 3 trial, O-027

H. Taylor et al.

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Figure 1: Proportion of women achieving amenorrhoea at the end of linzagolix vs. placebo treatment (p<0.0125) (ABT = add-back therapy)

ESHRE 2020-Clinical science award for oral presentation

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Comment

This study identified two linzagolix doses for the treatment of uterine fibroids: 100mg without add-back therapy for potential longer-term usage and the highly effective 200mg dose necessitating add-back, a regimen which is still most likely better suitable for shorter treatment courses.

Efficacy and safety of linzagolix on heavy menstrual bleeding (HMB) due to uterine fibroids (UF): Results from a placebo-controlled, randomized, Phase 3 trial, O-027

H. Taylor et al.

Currently available oral GnRH-antagonists in Gynecology are Relugolix2 and Elagolix3,4, licensed for the treatment of fibroids in Japan (Relumina©, Takeda) and endometriosis in the U.S. (Orilissa©, AbbVie). ASP17075 is another oral GnRH-antagonist that is still under development for endometriosis, but not yet clinically available.

Practice point

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Figure 2: Mean percentage change in lumbar spine bone mineral density under linzagolix vs. placebo treatment.

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Relugolix(n=254)

Background

Relugolix is an orally active non-peptide GnRH-antagonist recently licensed for use in women with symptomatic fibroids. Two phase III trials have recently been conducted (LIBERTY 11 and LIBERTY 22) in a total of 770 women with heavy menstrual bleeding and fibroids. Both trials were randomized, double-blind, placebo-controlled RCTs, and in both trials, 24 weeks of oral daily relugolix 40 mg co-administered with 1mg E2 and 0.5mg NETA vs. 12 weeks of daily oral relugolix 40 mg alone followed by 12 weeks of daily oral relugolix 40 mg co-administered with the same add-back vs 24 weeks of placebo was compared.

Study

A pooled analysis of LIBERTY 1 and LIBERTY 2 was conducted. The results of an analysis of a subset of women with fibroids and heavy menstrual bleeding and with hemoglobin ≤ 10.5 g/dL at baseline were reported. The outcome of primary interest was the proportion of patients who had a (clinically meaningful) increase of ≥2 g/dL hemoglobin from baseline. This increase in hemoglobin levels was observed more often in the Relugolix arms (55.7%) compared with the placebo arms (11.7%; p< 0.0001). Similarly, the mean percentage increase in hemoglobin concentration was greater in the pooled Relugolix-CT arms (23.0%) compared with the placebo arms (6.4%; p <0.0001).

Comment

This study shows that the reduction in menstrual blood loss, one of the key outcome parameters of the phase III trial program, also translates into a meaningful increase in serum hemoglobin levels in women with low levels at screening. Another sub-analyses of LIBERTY trial program data presented at ESHRE 20203 reported significantly reduced patient-reported distress from common uterine fibroid symptoms and improved physical and social activities vs placebo.

Relugolix combination therapy improves hemoglobin levels in anemic women with heavy menstrual bleeding due to uterine fibroids: results from the LIBERTY Phase 3 program, O-023

Venturella et al.

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Figure 1: Percentage change in hemoglobin concentration from baseline to week 24 in the pooled data from LIBERTY 1 and 2.

Relugolix is currently licensed for the treatment of fibroids only in Japan (Relumina©,Takeda).

Practice point

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2506±278 3108±346 < 0.0001

4.5±0.4 5.6±1.4 0.0003

5.0±1.4 3.1±1.7 < 0.0001

3.12±1.14 1.27±1.03 < 0.0001

2.3±1.08 0.39±0.48 < 0.0001

15% (4/26) 4% (1/26) 0.0096

Number of mature follicles onday of hCG

Number of mature oocytes

Grade I and II embryos

Clinical pregnancy rate

Antagonist (days)

FSH dose (IU)

Parameter Testosterone pre-treatment Placebo pre-treatment P value

Background

Testosterone treatment has been investigated for women with diminished ovarian reserve undergoing ART. Proposed mechanisms of action include the facilitation of the transition of follicles from the quiescent to the growing pool, thereby increasing the number of pre-antral and antral follicles and an augmentation of the expression of FSH receptors in granulosa cells, potentially enhancing the ovarian responsiveness to ovarian stimulation. A number of RCTs (included in a number of systematic reviews are available1,2) investigated the effect of testosterone pre-treatment before ovarian stimulation in poor responder women. However, the evidence is overall inconclusive, all single RCTs are too small to allow conclusions on the pregnancy or live birth rate and the risk of bias in most studies is high3.

Study

Fifty-two patients fulfilling the “Bologna criteria” of poor ovarian response (age ≥40 years and/or AFC <5-7 or AMH <0.5 ng/ml and/or a previous IVF cycle with low response) were randomly treated with either placebo (lubricant) or with 12.5mg trans-dermal testosterone gel once daily. Previous ovarian surgery, BMI ≥30kg/m2 and endometriosis grade III-IV were key exclusion criteria. All patients received pre-treatment for 28 days with estradiol valerate 2mg and norethindrone 5mg for 21 days. On the 6th day of pre-treatment, patients in the verum group applied once daily 12.5mg testogel on the inner thigh and continued for 21 days. All patients underwent ovarian stimulation with rFSH 225 IU in a GnRH-antagonist protocol. Key findings were that the mean number of mature oocytes and the mean number of good quality embryos was higher in the testosterone pre-treated patients.

A prospective study of testosterone gel treatment in poor ovarian reserve in IVF-ICSI cycles, O-198

Singh & Singh

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Figure 1: Key findings of the testosterone pre-treatment trial.

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A prospective study of testosterone gel treatment in poor ovarian reserve in IVF-ICSI cycles, O-198

Singh & Singh

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Comment

The ESHRE guideline on ovarian stimulation (2020) states that the use of testosterone before ovarian stimulation is probably not recommended for poor responders3 since there is currently inconsistent evidence that adjuvant testosterone pre-treatment before ovarian stimulation improves ovarian response in terms of number of oocytes retrieved and clinical outcomes. The study of Singh et al. is unlikely to change this conclusion, as the study received criticism at the ESHRE meeting as being too small in sample size, lacking the measurement of actual serum testosterone levels in the patients, not being prospectively registered and several methodological aspects remaining unclear. Another randomized clinical trial4 presented at the ESHRE meeting found no impact of either ~60 days or ~14 days of 12.5mg transdermal testosterone pre-treatment on oocyte numbers in poor response patients.

The results from the “T-Transport Trial”5, started in 2015, in which 400 poor ovarian response patients undergoing IVF will be randomized to 0.55g transdermal testosterone per day or placebo for 65 days will hopefully clarify the place of androgen pre-treatment for poor responders.

Practice point

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Background

Early pregnancy failure is common, often necessitating pharmacological or surgical intervention. While D&C is highly effective, it is invasive, requires anesthesia and is associated with significant risks, most importantly the risk of injury to the uterine lining. A randomized trial published in NEJM in 20181 on 300 women with pregnancy failure reported that pharmacological treatment with mifepristone followed by misoprostol resulted in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone. A Cochrane systematic review, however, concluded in 20192 that Mifepristone did not appear to further hasten miscarriage when added to a misoprostol regimen and that a single small study (46 women) reported that mifepristone alone was more effective than placebo.

Study

A multi-center, prospective, two-armed, randomized, double-blinded and placebo-controlled study included women with confirmed early pregnancy failure (6–14 weeks), managed expectantly for at least 1 week, and then randomized to pre-treatment with oral mifepristone (600 mg) or oral placebo. In both arms, mifepristone treatment was followed by oral misoprostol, started 36–48 h later consisting of two doses 400 μg (4 hours apart), repeated after 24 hours if no tissue was lost. The primary outcome was complete evacuation six weeks after treatment. The Data Safety Board stopped the trial after 50% recruitment (344 subjects) according to a pre-defined rule, since successful treatment, need for uterine aspiration and risk profile were strongly in favor of mifepristone. Serious adverse events occurred in 24 vs. 55 subjects in the mifepristone vs. placebo group (p=0.0005). It was also found that mifepristone treatment was more cost-effective.

Results of a highly significant, prematurely halted Dutch multicenter randomized double-blinded placebo-controlled study of pretreatment with mifepristone to misoprostol in early pregnancy failure (triple m), O-300

C. Hamel et al.

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Results of a highly significant, prematurely halted Dutch multicenter randomized double-blinded placebo-controlled study of pretreatment with mifepristone to misoprostol in early pregnancy failure (triple m), O-300

C. Hamel et al.

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Comment

This trial corroborates the NEJM trial1 findings from 2018 and provides good evidence for the effectiveness and safety of mifepristone for managing early pregnancy failure. A slightly higher incidence of patient reported adverse events occurred in the mifepristone group (mostly nausea, dizziness and diarrhea), which must be taken into account when counseling patients.

Use of Mifepristone may not be available for managing early pregnancy failure in some countries.

Practice point

Figure 1: Main outcomes of the >triple m< trial on mifegyne followed by misoprostol vs. misoprostol alone for managing early pregnancy failure.

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Background

The effect of the inter-pregnancy interval (IPI) on the course and outcome of a subsequent pregnancy has received considerable attention in obstetrical literature. A short IPI (<6 months) appears to be associated with increased risks for preterm birth, small-for-gestational age and infant death1,2. However, a recent systematic review indicated that a short interpregnancy interval after a miscarriage was found to be associated with a reduced miscarriage risk (RR 0.82, 95% CI 0.78, 0.86) and reduced preterm delivery risk (RR 0.79 95% CI 0.75, 0.83).3

Conception after early IVF pregnancy loss - should we wait? O-256

M. Sharon-Weiner et al.

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Study

A retrospective cohort study included 289 women who experienced first trimester IVF pregnancy loss who reinitiated IVF treatment. The type of miscarriage (spontaneous, medical, surgical), the interval between miscarriage and subsequent treatment and the outcome of the subsequent IVF cycle were analyzed by multi-variable modelling. It was found that the interval did not impact the chance of clinical pregnancy, while the type of miscarriage did: compared to biochemical pregnancy, the odds ratio in a multi-variable analysis for achieving pregnancy after a spontaneous miscarriage was 0.7 (P=0.5), 0.3 (P=0.002) for a pregnancy after a medical termination, and OR=0.3 (P=0.001) for a pregnancy following surgical termination.

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Conception after early IVF pregnancy loss- Should we wait? O-256

M. Sharon-Weiner et al.

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Comment

Previous studies have already shown that an IPI of less than 6 months following miscarriage is not associated with adverse outcomes in the next pregnancy. This present study added further to this knowledge by investigating the IPI specifically in the setting of IVF. In an ideal world, patients would be randomized to different IPIs following pregnancy failure, but such a study will be difficult to be performed, therefore we can only resort to observational data.

Figure 1: Clinical pregnancy rate by type of pregnancy failure in the previous IVF cycle.

Women who desire to continue IVF treatment after early pregnancy failure can be encouraged to do so. This is especially relevant for advanced age women, where time may play a crucial role.

Practice point

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Background

Sonography in early pregnancy is performed to confirm the location of the pregnancy (eutopic vs. ectopic), to establish the viability of the conceptus and to assess the risk to maternal health posed by ectopic pregnancy. The Special Interest Group “Implantation and early pregnancy (SIG-IEP)” of the ESHRE underwent a formal 9-step procedure for creating a new recommendation document on the criteria for the diagnosis of pregnancy location and differentiation between normally and abnormally sited pregnancies.

Draft document

Ectopic pregnancies have traditionally been labelled as tubal or non-tubal, which is no longer considered appropriate as pregnancies can potentially implant anywhere along the passage from the ovary to the cervical canal with some pregnancies being partially implanted within and partially outside the uterine cavity.

Selected key recommendations of the draft document are as follows:

• A pregnancy which is located within the uterine cavity, should be described as normally-sited (eutopic) pregnancy, a pregnancy which is located within the uterine cavity, with embryonic/foetal heart pulsations should be described as a live normally-sited (eutopic) pregnancy.

• The term miscarriage should be used to describe a normally-sited (eutopic) pregnancy with abnormal development. The term miscarriage should not be used for an ectopic pregnancy.

• An ectopic pregnancy which contained an embryo/foetus with evidence of heart pulsations should be described as a live ectopic pregnancy.

• Ectopic pregnancies should be classified as uterine or extrauterine. Previous classification of ectopic pregnancies as tubal and non-tubal should be abandoned.

• All uterine ectopics (cervical, Caesarean scar and intramural) should be described as partial or complete.

• The term intramural pregnancy should be used to describe a pregnancy which is located within the uterus, but it breaches the endometrial/myometrial junction and invades myometrium of the uterine corpus above the internal os.

• Tubal ectopic pregnancies should be described as either interstitial, isthmic or ampullary.

Updated terminology for early pregnancy assessment, O-046

D. Jurkovic

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Ectopic pregnancies are not necessarily extrauterine pregnancies, but all extra-uterine pregnancies are ectopic pregnancies.

Practice point

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Residual EctopicPregnancy

Morphology of theEctopic Pregnancy

Gestational Sac

+/- Yolk Sac +/- Fetal Pole hCG +ve hCG -ve

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Location of theEctopic Pregnancy

EarlyLiveMiscarriage

CervicalCaesarean scarIntramural

Pregnancy ofunknown location(PUL)

Normally Sited Not identified

Cornual UterineExtra-uterine

Ectopic

EarlyPregnancy

Tubal Interstitial Isthmic AmpullaryOvarianAbdominal

Updated terminology for early pregnancy assessment, O-046

D. Jurkovic

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Figure 2: Flow diagram illustrating how to evaluate the morphology of an ectopic pregnancy.

Figure 1: Flow diagram illustrating how to classify an early pregnancy.

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Background

Fertility preservation for medical reasons is widely available in industrialized countries. With increasing numbers of cryobanked cases, utilization rate and outcomes are now receiving more and more attention. A recent systematic review reported a rate of use of cryopreserved semen of 8%1 in cancer patients. The utilization rate of cryopreserved oocytes has previously been estimated as ~ 6%2,3, the rate of use of cryopreserved ovarian tissue as ~3%4,5.

Live birth rate and utilization rate of eggs and embryos following fertility preservation (FP) in 879 female cancer patients over 19 years, O-036

Khalife et al.FER

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Study

In a retrospective evaluation of single center data, 879 women who underwent fertility preservation counselling in a hospital in London because of a cancer diagnosis were identified within the time frame 2000 to 2019. 373 (43.4%) of women eventually underwent a fertility preservation procedure, the majority for breast cancer (63%), the vast majority (99%) underwent cryopreservation of oocytes or/and embryos.

Eventually, 61 of 373 cases (16.4%) used their cryopreserved material, 44/61 (72.1%) achieved a live birth per utilization, equaling a 11.8% live birth incidence in 373 cases with cryopreservation. These rates were similar in the total population and the subpopulation of women with breast cancer.

Breast cancer63%

Lymphoma18%

Brain cancer2%

Ovarian cancer2% Other

15%

Oocytescryopreserved

54%

Embryoscryopreserved

40%

Oocytes and embryoscryopreserved

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Ovarian cortexcryopreserved

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Figures 1 and 2: Distribution of diagnoses and type of fertility preservation performed.

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Live birth rate and utilization rate of eggs and embryos following fertility preservation (FP) in 879 female cancer patients over 19 years, O-036

Khalife et al. FER

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Comment

This rather large study with a comparatively long follow-up detects utilization rates higher than previously reported. Of note, the majority of patients were breast cancer patients (with a rather good overall survival prognosis) and the vast majority had oocytes or embryos banked. Utilization and success rates are likely to be lower in ovarian tissue cryopreservation programs. A weakness of the study is the incomplete follow-up with lack of information on survival and spontaneous pregnancy.

Fertility preservation programs should have a high utilization rate to be efficacious and thus women with good prognosis and high risk of ovarian failure should be prioritized.

Practice point

Figure 3: Rates in the total population and the subpopulation of women with breast cancer.

Watch Prof. Michael von Wolff discuss what we know about utilization of cryopreserved material and longer-term clinical outcomes.

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Background

Chemotherapy drugs, particularly those in the alkylating category, are detrimental to the ovaries. The damage is thought to be inflicted mostly by DNA alterations leading to apoptosis and follicular depletion in the ovary. Apart from freezing ovarian tissue or oocytes, only GnRH agonist downregulation is effective in protecting the ovaries during chemotherapy, in terms of maintenance and resumption of menstruation, preventing treatment-related premature ovarian failure and resumption of ovulation1,2. Recently, a protective effect of luteinizing hormone (LH) on the primordial follicle pool of prepubertal mice ovaries against cisplatin induced apoptosis has been suggested.3

Study

In an experimental animal study, 24 seven-week old female mice (n=8/group) were treated as follows: Control; chemotherapy (ChT) (intraperitoneally injection of 12mg/Kg-busulfan and 120mg/kg-cyclo-phosphamide); or ChT+LH (1 IU LH 24hrs before ChT and 1IU together with ChT). Ovaries from 6 animals/group were collected at 12 and 24 hours, while the remaining mice were maintained for 30 days.

Key findings were:

• LH treatment increased the expression of the DNA repair gene Rad51

• LH treatment enhanced cell survival via an activation of a DNA repair signaling pathway (increase in Bcl2/cleaved caspase-3 protein ratio)

• In the LH treated mice, apoptosis and DNA damage were reduced in oocytes and granulosa cells

Comment

LH treatment could be a new therapeutic option for ovarian protection from ChT induced damage. However, pre-clinical studies on human tissue followed by clinical studies in the human must be undertaken before routine use.

LH prevents follicular damage and preserves the meiotic potential of oocytes exposed to chemotherapy at the primordial stage, O-260

Castillo et al.

To date, the only clinically accepted method of ovarian protection in young women facing gonadotoxic chemo- and/or radiotherapy is the use of gonadotropin-releasing hormone agonists for downregulation of the hypothalamus-pituitary- ovarian axis.

Practice point

• LH treatment appeared to be also associated with less spindle damage in the oocytes

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Watch Prof. Michael Von Wolff discuss whether LH can be used as a protective substance against chemotherapy induced ovarian damage.

22

Background

A septate uterus is a common anomaly in the human. Definitions of septate uterus vary and accordingly so do estimated incidences1. While it is acknowledged that septate uterus are associated with a higher risk of infertility, miscarriage and pre-term birth2, little robust evidence is available on which to build consensus regarding the optimal management strategies.

Study

In a multi-national, randomized clinical trial led by researchers from Amsterdam, 80 women with a (predominantly partial) septate uterus and a history of subfertility, pregnancy loss or preterm birth were randomized to hysteroscopic septum resection (n=40) or expectant management (n=40). The primary outcome was live birth within 12 months after randomization. No benefit of the septum resection for any of the reproductive outcomes was found, including fetal presentation and mode of delivery. One uterine perforation occurred in the resection group.

Comment

This RCT adds high-quality evidence to a recently published, large retrospective analysis also led by the group from Amsterdam3. In this multi-centric evaluation of a large sample size (n=257 women, 81% with a partial septum), live birth occurred in 80/151 women following septum resection (53.0%) compared to 76/106 women following expectant management (71.7%) (HR 0.71 95% CI 0.49-1.02). ASRM, NICE and ESHRE guidelines have so far been inconsistent in their management recommendations. Foreseeably, expectant management will soon receive an upgrade on the recommendation list of professional organizations on how to manage septate uterus.

Septum resection versus expectant management in women with a septate uterus: a randomised controlled trial (NTR 1676), O-057

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Table 1: Reproductive outcomes after septum resection vs. expectant management.

22 (56%)

11 (28%)Miscarriage rate, n (%)

Clinical pregnancy rate, n (%)

Septum resection(n=39)

19 (48%)

5 (13%)

Expectant management(n=40)

1.2 (0.77-1.9)

1.8 (0.83-3.8)

12 (31%)Live birth rate, n (%) 14 (35%) 0.91 (0.58-1.41)

Relative Risk and 95%confidence interval

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Septum resection versus expectant management in women with a septate uterus: a randomised controlled trial (NTR 1676), O-057

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Watch Prof. Michael von Wolff discuss the potential use of uterine septum resection in fertility management.

Routine resection of a partial uterine septum in subfertile women or women with previous miscarriage should be discouraged. Data regarding a full septum are still too limited to draw a conclusion.

Practice point

24

Background

Mosaicism, a phenomenon where within one embryo two or more cytogenetically distinct cell lines exist, occurs frequently in human preimplantation embryos with estimated incidences of 15-90% in cleavage stage embryos1 and up to 30% in blastocysts2. The origin of mosaicism is mitotic, and therefore mosaicism occurs independently of maternal age3. It is already known that mosaic blastocysts have a lower chance of implantation and a higher risk of miscarriage. Nevertheless, it is also acknowledged that mosaic embryos can establish a viable and healthy pregnancy, though the extent of mosaicism and the type of chromosomal abnormality involved may play a role4.

Study

2,685 PGT-A cycles with 12,187 blastocysts analyzed by next-generation sequencing were included in a multi-centric, prospective study (March 2016 to January 2020). Trophectoderm biopsies were classified as mosaic if they had 20%-80% abnormal cells. In total, 2,282 (18.7%) mosaic embryos were detected, of which approximately 50% had numerical and 50% segmental aneuploidies. 1,000 mosaic embryos were eventually transferred to 923 women (467 of which had no euploid embryo available for transfer). A comparison group consisted of 5,561 transferred euploid embryos. Overall, outcome was better in the euploid embryo transfer group.

New evidence on mosaic developmental potential: multicentric study of 822 mosaic embryos diagnosed by preimplantation genetic testing with trophectoderm biopsy, O-081

F. Spinella et al.

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Figure 1: Ongoing pregnancy and miscarriage rate in mosaic embryos versus euploid embryos.

Watch Prof. Verena Nordhoff discuss the latest insights on the management and relevance of mosaic findings.

Miscarriage rateOngoingpregnancy rate

52.3

37.0

20.4

8.6

mosaic embryos (all)euploid embryos

0.0

20.0

40.0%

60.0

80.0

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No difference in ongoing pregnancy rate was seen for whole-chromosome mosaics with monosomy vs. trisomy. Segmental mosaic embryos had a higher chance of a positive outcome as compared to embryos with two or more whole chromosome aneuploidies, as well as complex mosaics.

A statistically insignificant negative association of the extent of mosaicism and pregnancy rate was found for whole-chromosome mosaics, but not for segmental mosaics.

Comment

This study adds that mosaic embryos with low or high level of segmental anomalies have a better chance of viability than any other mosaic embryo group. Furthermore, the study corroborated that mosaic monosomies implant and establish a viable pregnancy with a similar incidence as do mosaic trisomies.

New evidence on mosaic developmental potential: multicentric study of 822 mosaic embryos diagnosed by preimplantation genetic testing with trophectoderm biopsy, O-081

F. Spinella et al.

Embryos with different patterns of chromosomal mosaicism have different likelihoods of positive outcomes. A recently published scoring system for prioritizing mosaic aneuploid embryos for transfer5 may help in genetic counselling and clinical decision making.

Practice point

Figure 2: Ongoing pregnancy rate in whole chromosome versus segmental mosaic.

0.0

15.0

19.3

36.1

43.9 41.5

30.0%

60.0

45.0

Segmental mosaicWhole chromosome mosaic

<0.05 n.s.

≥50% <50%<50% ≥50%

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Background

Embryonic mosaicism is frequently encountered in the context of PGD-Aneuploidy Screening when performed with methods of high sensitivity such as high-resolution next-generation sequencing. Non-complex, low level mosaic embryos can be considered for transfer, especially if there is no euploid embryo available1. A complex mosaicism is defined as three or more affected chromosomes or chromosome segments. Clinicians are currently cautioned against transfer of complex, high level mosaic embryos1.

Study

Within a large PGD-Aneuploidy Screening program in a Chinese IVF center, the overall incidence of mosaic embryos was 2.4% (per total embryo number n= 13,451), with similar incidences in different age groups. No association was found between blastocyst morphology and the occurrence of complex mosaicism. 85 patients with at least one complex mosaic embryo frozen chose to undergo embryo warming, re-biopsy, re-analysis by NGS and re-vitrification for a potential later transfer. Re-biopsy and re-analysis were successful in 86/89 cases (97%).

Key findings were:

• Approximately 60% of the re-biopsied samples were classified as euploid.

• Of the 38% (33/86) cases that were found not to be euploid in re-analysis, only 33% of the second diagnosis were concordant with the first diagnosis.

• 100% of 18 euploid blastocysts (by second diagnosis) that were warmed, survived double vitrification and double biopsy.

• Pregnancy rate was 39% (7/18), four healthy babies born to date.

Comment

A significant false-positive rate of PGD-A is a serious concern, as is the potential harm of biopsy and vitrification to the embryo and the financial cost of PGD-AS.2 It is reassuring, that the incidence of complex mosaicism was confirmed to be low in the present study. However, the diagnosis could not be re-iterated in more than 70% of cases with re-biopsy hinting at inherent methodological shortcomings of PGD-AS.

Complex mosaic embryos after preimplantation genetic testing: go for a second biopsy? O-281

Z. Shuang et al.

In case of a complex mosaic embryo, re-biopsy and re-diagnosis is a clinical option.

Practice point

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Background

Open system oocyte vitrification using, for example, the “CryoTop” carrier system (Kitazato Biopharma, Japan) is now widely performed. Single spermatozoa in case of cryptozoospermia or TESE have also been vitrified with this system, however, samples are in direct contact with the liquid nitrogen and therefore specific devices (such as “Cell Sleeper”, “Cryo Piece” or “Sperm VD”), which are closed types of cell-cryopreservation container, have been developed1.

Study

In a retrospective study (January 2010 to December 2018), 12/1825 (0.7%) of patients with severe male factor infertility required single sperm cryopreservation. 475 spermatozoa were cryopreserved in 55 “CryoTops” and 171 sperm in 18 “Cell Sleeper” devices (approx. 8-9 sperm per container). A higher rate of recovery of sperm was observed with the “cell sleeper” container system, however, a better fertilization rate was observed with “CryoTop” system. Pregnancy rate was similar in the two groups. In total, four babies were born.

Novel Technologies for Single-Sperm Vitrification with Cryotop and Cell Sleeper: A Follow-Up Study, O-226

Endo et al.

Table 1: Recovery rates of single sperm in two different vitrification systems.

n

148

Warmedspermatozoa

n

135 (91%)

n

16Cell Sleeper

Warmedstraws

30Cryotop 264 218 (83%)

Total

Collected spermatozoa

n

20 (15%)

75 (34%)

Motile

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Table 2: Outcome of ICSI (AOA = artificial oocyte activation).

n

74

ICSI AOA

n

24 (32%)

n

14Cell Sleeper

Cycles

16Cryotop 87 42 (48%)

2PN fertilisation

n

23 (96%)

37 (88%)

Cleavage

Novel Technologies for Single-Sperm Vitrification with Cryotop and Cell Sleeper: A Follow-Up Study, O-226

Endo et al.

Comment

Single sperm cryopreservation and use for later ICSI is at the outermost boundary of treating severe male factor infertility. Single sperm vitrification may save time on the day of oocyte retrieval for searching for sperm in depleted ejaculate or tissue samples. This study, together with further evidence2,3, demonstrates the feasibility of this approach. However, the optimal procedure and carrier still need to be determined.

Single sperm cryopreservation can be an option for cases of cryptozoospermia or TESE.

Practice point

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Background

On a global scale, ICSI instead of IVF is increasingly being used to inseminate oocytes, even in cases of non-male factor infertility. One of the reasons for the increasing preferential use of ICSI is that ICSI putatively provides a better chance of fertilization, which would be especially pertinent in the case of low ovarian response (e.g. only few oocytes available). A Cochrane review1 identified a single RCT2 comparing IVF vs. ICSI for the treatment of non-male factor infertility showing no benefit of ICSI in the case of normal sperm parameters. Recently, retrospective studies reported no advantage of ICSI over IVF in non-male factor infertility, either in terms of blastulation rate3 or in terms of clinical outcome stratified by ovarian response4.

Study

In a bi-centric, open-label RCT conducted in Vietnam, 1064 couples were randomized 1:1 to ICSI or IVF if the male partner had normal sperm count and motility (by WHO 2010 definition) and had under-gone ≤2 previous IVF/ICSI attempts. Key exclusion criteria were frozen semen, poor fertilization rate in a previous cycle, or in-vitro maturation of oocytes. The study was designed as a superiority trial (e.g. an increase of 10% live birth rate with ICSI above a control arm estimated live birth rate of 31.5% was hypothesized5). Patients underwent day 3 embryo transfer with ≤2 embryos, approximately 55-60 had ‘freeze-all’ and the primary outcome was live birth rate after first ET.

Intracytoplasmic sperm injection versus conventional in vitro fertilisation in couples with non-male factor infertility: a randomised controlled trial, O-167

Dang et al.

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Table 1: Key findings from the ICSI vs. IVF trial

5.7 (2.5 - 9.0)

2.9 (-0.1 - 5.8)Fertilisation rate per oocyte retrieved

Fertilisation failure, n (%) -0.9 (-4.0 - 2.1)

Difference or RR(95% CI)

-2.4 (-4.6 - -0.3)

0.04 (-0.4 - 0.5)GQ day 3 embryos

Clinical pregnancy rate RR 1.07 (0.93-1.24)

RR 1.09 (0.92-1.29)

RR 1.11 (0.93-1.32)Live birth rate per first ET

Cumulative ongoing pregnancy 12 monthsafter randomization

64.4 %

52.7 %

IVFn= 532

70.1 %

55.6 %

ICSIn= 532

29 (5.5) 34 (6.4)

23 (3.9)

4.4 ± 3.9

8 (1.5)

4.5 ± 3.4

42.7 % 39.8 %

32.7 %

31.2 %

35.7 %

34.6 %

44.0% 42.9% RR 1.03 (0.89 -1.28)

0.001

0.06

0.60

0.02

0.87

0.38

0.33

0.27

0.75

P-value

Fertilisation rate per oocyte inseminated

No embryo available on day3, n (%)

Ongoing pregnancy rate

30

Comment

This is by far the strongest evidence to date that routine ICSI use in case of normal sperm count and motility does not bring relevant benefit. However, it is also re-assuring that the invasiveness of ICSI is not associated with a negative effect on live birth rate, as reported at the ESHRE meeting in 20196 and reported by a systematic review of mostly retrospective cohort studies this year7. The reasons for the global increase in ICSI utilization over the years is multi-fold and factors are “erring on the safe side”, the extension of embryo biopsy in the context of PGT-AS, the availability of the technology on a global scale and financial aspects.

Intracytoplasmic sperm injection versus conventional in vitro fertilisation in couples with non-male factor infertility: a randomised controlled trial, O-167

Dang et al.

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Key findings were:

• The fertilization rate was not significantly increased in ICSI cases per mature oocyte retrieved

• Approx. 2.5% more patients had at least one embryo available for transfer on day 3 in the ICSI group

• The live birth rate per ITT per first ET was statistically not significantly increased in the ICSI group (absolute difference: 3.4% [95% CI: 0.93-1.32], p=0.24)

• Maternal and fetal safety parameters were highly similar

Use of ICSI in the case of non-male factor infertility is associated with only small and insignificant benefits, and therefore IVF should be routinely used for non-male factor infertility.

Practice point

31

Background

Fragmentation, blastomere asymmetry, reverse cleavage, direct cleavage, blastocyst collapse and multinucleation are considered prognostically negative morphometric criteria of the developing preimplantation embryo. A blastomere containing more than a single interphase nucleus is defined as being multinucleated. The presence of multinucleation is considered abnormal, the incidence of multinucleation in human embryos has been estimated as 15-70%, the chance of implantation appears to be decreased with an increasing proportion of multinucleated cells within the embryo1-3. However, the underlying mechanism leading to multinucleation are not fully understood and live births from transfer of multinucleated embryos have been reported suggesting that correction mechanisms may exist4.

Study

A retrospective study from Brazil included time-lapse observational data of 20,779 embryos from 5,621 cycles performed between 2014 and 2019. Embryos with at least one multi-nucleated blastomere (n=3,879) were compared with embryos without multinucleation (n=16,897). The blastulation rate was significantly lower in multinucleated embryos.

Embryos excluding multinucleated cells during blastocyst formation increase their reproductive potential, O-231

Munuera Puigvert

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Table 1: Development of embryos with and without at least one multinucleated blastomere. (* p <0.05)

Embryos transferred belonging to MNC Group (n=307) were subdivided according to the multinucleated cell location after blastulation:

• MNC-1 (N=142), no cells excluded

• MNC-2 (N=73), mononucleated cells excluded

• MNC-3 (n=46), multinucleated cells excluded

No difference in blastocyst formation rate and quality was detected between the groups. Embryos from group MNC-3, e.g. embryos that were able to exclude multi-nucleated cells, had a higher chance of live birth than embryo from groups MNC-1 and -2.

n

9,793 (57.9%)

Blastulation rate

n

4210

n

16,897Embryos without multinucleation

Day 2/3 Embryos

3,879 (18.7%)Embryos with at least onemultinucleated blastomere 776 (20.0%)* 307 (261 analysed)

Blastocysts transferred

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Comment

This study corroborates previous findings that have suggested auto-correction mechanisms take place in cleaving embryos. It has also been shown, that a large percentage (approx. 60%) of 2-cell multinucleated embryos develop into good-quality blastocysts and that half of those embryos were euploid4.

Embryos excluding multinucleated cells during blastocyst formation increase their reproductive potential, O-231

Munuera Puigvert

Embryos with multinucleated blastomeres that can exclude these cells during development up to the blastocyst stage have the same reproductive potential as embryos without multinucleation.

Practice point

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Figure 1: Blastocyst quality by type of multinucleation process.

Figure 2: Clinical outcome by type of multinucleation process and control blastocysts.

MNC-2MNC-1 MNC-3

%

control MNC-2MNC-1 MNC-3 control MNC-2MNC-1 MNC-3 control

Miscarriage rateClinical pregnancy rate Live birth rate

56.5

41.5

32.9

50.6

16.2

9.66.5

11.3

24.822.2

50

34.4

MNC-2

71.2%

MNC-1

Blasotcyst ≥3CBBlasotcyst <3CB

MNC-3

87%88%

0

25

50

100

75

%

33

Background

GnRH-antagonists are commonly used for ovarian stimulation and GnRH-antagonist protocols are recommended for predicted normal and high responder patients undergoing IVF1. A number of modifications to the so-called fixed start, multiple-dose GnRH-antagonist protocol have been published and there is wide variety of protocols used in secular practice.

Study

A systematic literature review identified 72 RCTS comparing different GnRH-antagonist protocols with one another (direct data) and 69 RCTs comparing GnRH-antagonist protocols with GnRH-agonist protocols (indirect data). The following protocol aspects were evaluated: the type of GnRH antagonist (cetrorelix or ganirelix), the type of protocol (fixed day 5/6 or flexible protocol) and the type of pre-treatment (no pre-treatment or pre-treatment with OCPs, estrogens, progestins).

Key findings of the direct comparison meta-analysis were:

These findings were, in essence, corroborated by the network meta-analysis.

• A lower ongoing pregnancy rate (OPR) was observed after a flexible protocol compared with the fixed day 5/6 protocol (RR: 0.74, 95% CI: 0.58 to 0.96, I2=0%; 5 RCTs; 703 participants; moderate quality evidence)

• A lower OPR was observed after oral contraceptive pill pre-treatment compared with no pre-treatment (RR: 0.79, 95% CI: 0.64 to 0.97; I2=0%; 4 RCTs, n=1,244 participants; moderate quality evidence)

• There was no difference in clinical pregnancy rates when comparing cetrorelix with ganirelix (RR: 0.99, 95% CI: 0.74 to 1.33; I2=0%; 2 RCTs; 258 participants; low-quality evidence)

What is the optimal gonadotropin releasing hormone (GnRH) antagonist protocol during ovarian stimulation for assisted reproductive technologies (ART)? A pairwise and network meta-analysis, O-119

C. Venetis

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Comment

A network meta-analysis combines direct (within trial) and indirect (between trial) comparisons of interventions based on a common comparator. This systematic review thus comprehensively collates all the currently available evidence on the efficacy of commonly used GnRH-antagonist protocols, however, data were too limited to arrive at conclusions on some protocol modifications such as pre-treatment with progesterone or estrogen. The main findings of the meta-analysis corroborate an expert recommendation from 20092. However, the flexible protocols used in the included studies have been very heterogeneous and it is not clear to which extend standardization of flexible protocols might improve outcomes.

In normo-ovulatory patients, pretreatment with a combined oral contraceptive pill is not recommended. A fixed GnRH antagonist protocol appears to result in better outcomes than a flexible GnRH-antagonist protocol, possibly related to lack of standardization and heterogeneity of flexible protocols. No outcome differences between cetrorelix and ganirelix have been demonstrated.

Practice point

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Background

Oral progestins are effective in blocking the LH surge and may serve as an alternative to GnRH-antagonists for prevention of premature LH rises during ovarian stimulation. Medroxyprogesterone-acetate (MPA), dydrogesterone (DYD) and bioidentical progesterone (P), administered concomitantly with gonadotropins, have been used for this purpose. The term “progestin primed ovarian stimulation (PPOS)” has been established for this procedure.

Study

A systematic literature review identified five randomized clinical trials and cohort studies (n= 2,404 women) in which two different progestins or two different doses of the same progestin were compared. The most often used dosages of the progestins were daily 10mg for MPA, daily 20mg for DYD and daily 100-200 mg for P.

Outcomes of interest were live birth rate and pregnancy rate (including ectopic and multiple pregnancy rate), as well as stimulation characteristics (duration of stimulation, gonadotropins consumed, number of oocytes and number of MII oocytes).

Comparison of different progestin regimens for pituitary suppression during ovarian stimulation for assisted reproductive technology, a systematic review, O-121

B. Ata

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Table 1: Studies included in the systematic review on progestin primed ovarian stimulation (RC = retrospective cohort; PC = prospective cohort).

MPA 10 mg n=315

MPA 10 mg n=256

DYG 20 mg n=125

Intervention

MPA 10 mg n=1002

MP 100 mg n=75

MPA 10 mg n=150

RC

RCT

Design

Huang 2019

Yu 2018

Author

Zhu 2017(a) RCT

RC

PC

Guo 2019

Zhu 2017(b)

Donh 2017 RCT

DYG 20 mg N=105

DYG 20 mg N=260

MP 100 mg n=125

MP 200 mg n=186

MP 200 mg n=75

MPA 4 mg n=150

Comparator

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Comparison of different progestin regimens for pituitary suppression during ovarian stimulation for assisted reproductive technology, a systematic review, O-121

B. Ata

Comment

The sample sizes in subgroups are insufficient to reliably detect clinically relevant outcome differences and the methodological quality of some of the evidence is not sufficiently high for definitive answers. For testing the true efficacy of progestins for preventing LH surges, a placebo-controlled trial would be warranted.

Until contrary evidence arises, MPA 10mg, DYD 20mg or P 100-200mg appear equally suitable for preventing premature LH surges during ovarian stimulation in ‘freeze-all’ cycles.

Practice point

Key findings were:

No (statistically significant) differences were found for any of the outcomes when comparing:

• MPA 10mg vs. DYD 20mg

• DYD 20mg vs. 100mg P

• MPA 10mg vs. 200mg P

A RCT on 300 women1 confirmed similar pregnancy outcomes in progestin primed ovarian stimulation with a daily dose of 4 or 10 mg MPA.

In the studies measuring endocrine levels, all progestins were associated with a similar extent of endogenous LH suppression.

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Background

A daily dose of oral MPA 10mg has been suggested to be as effective as oral dydrogesterone 20mg in blocking LH surges in women undergoing ovarian stimulation1. MPA has been suggested as an alternative to GnRH-antagonists for ovarian stimulation of oocytes donors.

Study

A RCT conducted in a university-affiliated infertility clinic in Spain included 318 oocyte donors, 161 of which received 10 mg daily administered oral MPA and 156 received daily 0.25mg GnRH-antagonist (started once the leading follicle reached 13 mm). Primary outcome was the number of oocytes retrieved.

No differences were identified for:

• Number of oocytes retrieved (21.4±11.7 vs. 21.3±9.3 in the two groups)

• Total dose of rFSH

• Duration of stimulation

• Endocrine profile in follicular fluid

• Pregnancy rate & pregnancy loss rate

Oral MPA was found to be superior in terms of:

• Total number of injections per ovarian stimulation cycle

• Ease of administration

Can Medroxiprogesterone acetate (MPA) serve as a pituitary suppressor instead of GnRH antagonist during ovarian stimulation (OS) in oocyte donation (OD) cycles trigger with GnRH agonist? O-010

Giles et al.

Comment

This RCT adds further evidence to the existing clinical studies (reported herein by Ata et al., O-121) on the feasibility of progestin administration during ovarian stimulation for oocyte donors and freeze-all cycle. Another retrospective analysis presented at the ESHRE meeting2 reported the outcome of 1090 oocyte donor cycles, in which 200mg bioidentical progesterone were orally administered to prevent LH surges. When compared to a matched cohort receiving GnRH-antagonists, the number of oocytes and MII oocytes were highly similar, as were other stimulation characteristics and clinical outcomes.

For oocyte donors or freeze-all patients (for example in the context of PGD-M), oral progestins used in the follicular phase to prevent LH-surge appear to be comparable to GnRH antagonists with respect to number of oocytes, duration of stimulation and reproductive outcomes. GnRH-agonist triggering of final oocyte maturation is possible in progestin primed cycles3. An overall health economic and patient experience comparison of oral progestins with GnRH-antagonists, using validated state of the art methodologies, is needed taking into account all cycle-specific costs, as some studies have indicated a higher consumption of gonadotropins when oral progestins are used.

Practice point

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Background

Ovarian stimulation initiated in the luteal phase results in a similar number of oocytes of similar development competence as compared to oocytes originating from ovarian stimulation initiated in the early follicular phase1,2. Furthermore, after conventional ovarian stimulation started in the follicular phase, triggering of final oocyte maturation and oocyte pick-up, ovarian stimulation may be re-initiated in the ensuing luteal phase for a second oocyte pick, a concept termed “DuoStim”3.

Study

In a prospective randomized trial, oocytes donors underwent follicular phase ovarian stimulation with 225 IU daily rFSH, 10mg MPA and GnRH-agonist trigger and, after oocyte pick-up, reinitiated ovarian stimulation with 225 rFSH with (n=10) or without (n=10) MPA as a LH suppressant. The endocrine profile was similar as was the oocyte number in patients with and without MPA suppression of endogenous LH in the luteal phase.

Comment

The authors conclude from their study that LH suppression is not necessary in ovarian stimulation cycles initiated in the luteal due to the LH suppression from the endogenous progesterone from multiple follicles.

Pituitary supression is not necessary for blocking LH surge during luteal-phase stimulation, O-156

Palomino et al.

Further studies on larger samples are needed to corroborate these findings. If replicated, DuoStim could be further simplified.

Practice point

Table 1: Main findings from the DuoStim study with and without LH suppression by MPA in the luteal phase ovarian stimulation.

12.1

1.7±0.6 IULH basal

LH on trigger day 1.5±0.6 IU

Luteal phase Stimulation- MPA

0.4±0.1 ng/ml

12.8±2.1COCs

MII 10.4±2.3

13

1.6±1.3 IU

Luteal phase Stimulation+MPA

11

6.11±1.6 IU

Follicular phase Stimulation+MPA

3.1±1.8 IU 0.5±0.4 IU

0.6±0.1 ng/ml

14.5±1.6

1.4±0.3 ng/ml

16.7±3.0

14.2±3.5 11.7±1.0

0.31

0.335

0.300

0.398

0.575

0.609

P-value comparing Luteal phase stimulation ±MPA

Stim. duration

P4 on trigger day

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Background

The optimal time for transferring a blastocyst in a natural cycle after occurrence of the endogenous LH surge has not been properly studied as of yet.

Study

In a private IVF center in the UK, the protocol for transferring frozen-thawed blastocysts was changed in May 2018. Before that time-point, blastocyst transfers were performed on day seven after urinary LH surge (LH+7), after May 2018, transfers were done on day six after urinary LH surge (LH+6). In a retrospective analysis, the clinical outcomes of 378 treatment cycles “LH+7“ were compared against 180 treatment cycles “LH+6”. Only vitrified, unbiopsied blastocyst transfers were analyzed. As an internal control, artificial hormone replacement cycles from the same time period were evaluated. It was found that the (adjusted) likelihood of live birth was approximately 2-fold higher in “LH+6” patients. In the artificial cycles, ongoing pregnancy rate was approximately 39-42%.

Natural cycle frozen-thawed embryo transfer (FET): A comparison of outcomes following blastocyst transfer on day six versus day seven after urinary luteinising hormone (LH) surge, O-168

M. Noble

Comment

This is an interesting study suggesting an impressive effect of transferring a blastocyst into a “younger” endometrium. However, because of the retrospective nature of the analysis, risk of bias is high.

The optimal protocol in terms of pregnancy rate for transferring frozen-thawed embryos has not been determined. For now, the choice of protocol will vary between settings based on individual efficacy beliefs, financial aspects and the practicability of a protocol within a center working routine.

Practice point

Table 1: Main findings from the natural cycle blastocyst transfer study.

aOR: 2.06 95% CI: 1.42-3.01

p< 0.0001

aOR 2.3095% CI 1.58 – 3.33

p<0.0001

Clinicalpregnancyrate

Miscarriagerate

aOR 0.79 95% CI 0.45- 1.36

p=0.317

29.1%

32.8%

LH+7(N=378)

45.0%

52.2%

LH+6(n=180)

27.0% 30.8%

Ongoingpregnancyrate

OV

AR

IAN

STI

MU

LATI

ON

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Background

Outcome differences of children conceived by natural conception or by IVF with frozen or fresh embryo transfers have been well documented. The contribution of parental vs. treatment factors to phenomena such as altered fetal growth or pre-term birth are not yet fully elucidated1. In a sibling study design (same mother), maternal factors can be controlled. Comparing siblings after different types of conception therefore allows distinguishing the contribution of treatment factors from maternal factors to perinatal outcomes.

Study

In a large registry cohort study (CoNARTaS project) combining data from Denmark (1994-2014), Norway (1988-2015) and Sweden (1988-2015), birthweight and the incidences of SGA, LGA, preterm birth (<37 weeks) and very preterm birth (VPTB, <32 weeks) were compared at the population levels and in nine sibling pair groups from 27,041 maternal sibling with at least two different conception modes from a total population of 2.6 million babies.

The main study findings from the sibling comparisons were that:• Babies after frozen-thawed ET had higher birthweights and increased risk of LGA when compared

to spontaneously conceived babies• Babies after fresh ET had lower birthweights and increased risk of SGA as compared to spontaneously conceived babies

• Preterm birth risk was modestly increased with a similar effect size for fresh ET and frozen ET

These results were similar in the sibling comparisons and the population level.

Maternal and treatment contributions to perinatal outcomes after transfer of fresh and cryopreserved embryos in assisted reproduction: A Nordic sibling study, O-029

Westvik-Johari et al.

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Table 1: Sequence of births in women with two singleton babies resulting in nine different comparison groups in the sibling study (abbr.: NC = natural conception; Fresh = birth after IVF with fresh embryo transfer; Frozen = birth after IVF with frozen-thawed embryo transfer).

2

3

5

6

1,353,526

7,080

n

1,712

16,674

3,066

8,010

Siblinggroups

1

4

NC

Fresh

Frozen

Second babyborn after

NC

NC

Fresh

NC

NC

First baby bornafter

NC

Fresh

Frozen

Fresh only ART

7

9

5,354

1,256

1,302

Frozen

Fresh

Frozen

Fresh

Frozen

Frozen

only ART

only ART

only ART

8

40

Table 2: Main findings from the Nordic Sibling study.

Comment

This study is the largest and most robust comparison of ART offspring outcome differences measured on observational data to date. The Sibling Study showed that fetal growth is more strongly influenced by treatment, whereas risk of preterm birth is more strongly influenced by maternal factors.

Maternal and treatment contributions to perinatal outcomes after transfer of fresh and cryopreserved embryos in assisted reproduction: A Nordic sibling study, O-029

Westvik-Johari et al.

The ART treatment itself is likely to impact on fetal growth. As a principal rule, the treatment chosen should be effect but with the least possible alteration of natural conditions.

Practice point

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Birth weight (grams)

(-90 to -81)(47 to 64)

(-63 to -48)(58 to 87)

95% CI

-85+56

-56+72

3,5283,4013,578

3,5403,424 3,623

Mean Adjusted meandifference*

Sibling Comparison

NCFresh-ETFrozen-ET

NCFresh-ETFrozen-ET

Population level

* adjusted for age, parity, country, year of birth, smoking, height, BMI

Preterm birth (< 37 gestational weeks)

(1.59 to 1.73)(1.32 to 1.57)

(1.13 to 1.41)(1.02 to 1.46)

95% CI

1.661.44

1.271.22

4.67.66.3

4.76.75.2

Prevalence Adjusted oddsratio

NCFresh-ETFrozen-ET

NCFresh-ETFrozen-ET

Population level

Sibling Comparison

Watch Prof. Heribert Kentenich discuss the key learnings from the Nordic sibling study.

41

Background

Genomic imprinting is an epigenetic phenomenon that causes genes to be expressed in a parent-of-origin-specific manner, e.g. the expression of genes of one of the two alleles inherited from mother and father is silenced. During gametogenesis, the principal imprinting of genes determined by the parental origin takes place, while modifications of the established imprinting patterns occur in early embryogenesis, mostly likely induced by environmental factors. An increased risk of imprinting defects and somatic epigenetic changes in ART conceived children has been reported1, but the data are not consistent as yet.

Study

In a bi-national registry study (Denmark and Finland), 74,637 children after ART were compared with the background population of babies born during the same time period (1990-2014), follow-up period of the children was 9-12 years. The imprinting disorders of interest were Prader-Willi-Syndrome, Silver-Russel-Syndrome, Beckwith-Wiedemann-Syndrome and Angelman-Syndrome.

Imprinting disorders in children born after assisted reproductive technology (ART): a Nordic study from the CoNARTaS group, O-139

O. Lidegaard et al.

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Figure 1: Incidence rates of four imprinting disorders per 10,000 babies in the CoNARTaS registry.

0.0 0.5 1.51 2.52

ART

Natural conception

Incident of impriming disorders per 10,000 babies

In the total population of 2.7 million naturally conceived babies, 371 imprinting disorders were found. In the ART population, 16 imprinting disorders in 74,631 babies were found.

42

Overall, the risk increase for any imprinting disorder was not statistically significant (OR 1.35, 95%CI: 0.80-2.29). Eight ART children, however, were diagnosed with Beckwith-Wiedemann syndrome, implying a significant risk increase (adj. OR 2.84, 95%CI 1.34-6.01). No risk increase was detected for Prader-Willi-Syndrome, Silver-Russel-Syndrome and Angelman-Syndrome.

Comment

To date, the studies have not been consistent on the magnitude of risk increase of distinct imprinting disorders in children after ART. This study, by now fully published in Human Reproduction2, shows that the risk of imprinting disorders in ART children is overall very small and maybe restricted to Beckwith-Wiedemann Syndrome.

Imprinting disorders in children born after assisted reproductive technology (ART): a Nordic study from the CoNARTaS group, O-139

O. Lidegaard et al.

Patients may be reassured that the absolute risk of having a baby with an imprinting disorder is small and that the relative risk increase observed in ART babies is likewise very small.

Practice point

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Background

The use of ICSI is more prevalent than IVF in most western countries, and ICSI is increasingly often used for non-male factor infertility1. The (unadjusted) prevalence of any birth defect has previously been estimated as 7.1%, 9.9%, and 5.7% after IVF, ICSI, and natural conception, respectively2. However, the specific risk increases with ICSI as compared to IVF are still under debate.

Study

Within the CoNARTaS registry project covering Denmark, Norway and Sweden, singletons born after ICSI (n=39,684), IVF (n=58,342) and natural conception (n=4,804,844) between 1992 and 2015 were identified. Birth after fresh or frozen-thawed embryo transfers were

No risk increase with the use of ICSI vs. IVF was found and only a small risk increase was detected when comparing ICSI with natural conception. Likewise, no risk increase with ICSI was observed in sub-analyses by organ system (ICSI vs. IVF).

The risk of major congenital malformations in children conceived after ICSI: a Nordic cohort study, O-141

A.K. Henningsen et al.

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Table 1: Main findings from the CoNARTaS registry study on malformation risk in IVF and ICSI offspring (NC = natural conception; aOR = adjusted odds ratio; CI = confidence interval).

Comment

ICSI was initially developed and used for severe male factor infertility and safety concerns alluded to use of such impaired sperm but also to the invasiveness of the technique itself. With the expansion of ICSI and the more liberal use in non-severe male factor infertility, it appears as if registry data now allow ruling out a relevant risk of the ICSI technique itself.

ICSI does not pose an independent risk for major malformations in ART offspring based on 39,684 Nordic ICSI children analyzed in the CoNARTaS registry project.

Practice point

included. Only major malformations (according to EUROCAT) were analyzed. A multivariable analysis accounting for maternal age, parity, year of birth, child’s sex, body mass index, smoking and country was conducted to estimate the risk of birth defects.

ICSI vs. NC

ICSI fresh vs. ICSI frozen

aOR 1.06; 95% CI: 0.99-1.13

aOR 1.30; 95% CI 1.24-1.36

Risk

aOR 1.11; 95% CI: 0.98-1.26

aOR 1.04; 95% CI: 0.9-1.21

Comparison

ICSI vs. IVF

ICSI frozen vs. IVF frozen

n.s.

p<0.0001

p-value

n.s.

n.s.

44

Background

Multiple studies have shown that pregnancies after ART have an increased risk for developing hypertensive diseases, e.g. gestational hypertension and preeclampsia1. In a large RCT comparing a deferred frozen embryo transfer with a fresh transfer policy, it was found that frozen single blastocyst transfer was associated with a higher risk of pre-eclampsia (RR 3·13, 95% CI 1·06-9·30, p=0·029)2. Furthermore, it has been suggested that the risk increase in frozen-thawed cycles may originate from ‘artificial’ hormone replacement cycles (HRT) in which the corpus luteum is suppressed, which then perturbs the maternal circulation in early pregnancy and thereby increases the incidence of preeclampsia3.

Study

In a retrospective, single-center cohort study, 536 patients were identified who delivered after an autologous frozen-thawed embryo transfer: 325 patients after embryo transfer in a natural cycle (e.g. with a corpus luteum) and 211 patients in an artificial hormone replacement cycle (e.g. with the corpus luteum absent). The primary outcome was the development of hypertension after 20 weeks of gestation associated with one or more new-onset conditions: proteinuria, maternal or uteroplacental dysfunctions. Multivariable regression analysis was performed to account for confounding factors knowing to affect the occurrence of PE, including: NC versus HRT, body mass index, ethnicity, previous history of hypertension during pregnancy and mean arterial pressure at the first prenatal consultation.

O-242: Artificially prepared frozen embryo transfer cycles are associated with an increased risk of preeclampsia

C. Roelens et al. (Brussels)

Figure: Incidences of adverse events in pregnancies of patients undergoing a natural cycle or hormone replacement cycle FET.

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0

5

11.8

3.72.8

11.4

10%

15

20

Gestational hypertension(p<0.001)

Early haemorhage(p=0.048)

Pre-eclampsia(p<0.001)

9.5

15.2

NC HRT

45

O-242: Artificially prepared frozen embryo transfer cycles are associated with an increased risk of preeclampsia

C. Roelens et al. (Brussels)

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Comment

This study adds to the growing concern that HRT cycles for a frozen-thawed embryo transfer cycle may be associated with increased maternal and fetal risks4 . However, both efficacy and safety of the two protocols should be precisely determined via a large sized RCT given the wide-spread use of FET cycles and the multiple ramifications of the protocol choice not only efficacy and safety but also convenience, cost, reliability and treatment calculability.

Several RCTs are currently being planned or already ongoing that will soon allow a better judgement on outcome and safety differences between natural and HRT cycle FETs.

Practice point

The multi-variable analysis showed an increased risk for pre-eclampsia (adjusted OR 2.9; 95% CI: 1.4-6.0; p=0.005) in HRT patients. The mean arterial pressure at the first prenatal consultation was higher by approximately 5mm meanHg in the HRT group.

Watch Prof. Heribert Kentenich discuss the rise of frozen-thawed embryos.

46

Watch Prof. Verena Nordhoff discuss modelling blastocyst formation from stem cells.

Watch Prof. Heribert Kentenich discuss the current status of elective single embryo transfer in Germany and how this differs from the rest of the world.

Additional Video Highlights

47

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Low male testosterone

Andrology

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2. Yuan S, Qiu Y, Xu Y and Wang H. Human papillomavirus infection and female infertility: a systematic review and meta-analysis. Reprod Biomed Online. 2020;40(2):229-237

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2. https://clinicaltrials.gov/ct2/show/NCT03103087

3. Stewart et al. Relugolix combination therapy reduced patient-reported distress from bleeding and pelvic symptoms and improved daily activities in patients with uterine fibroids in the LIBERTY program, ESHRE 2020, O-024

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1. Nagels HE, Rishworth JR, Siristatidis CS, Kroon B. Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction. Cochrane Database Syst Rev. 2015;(11):CD009749

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3. Ovarian Stimulation TEGGO, Bosch E, Broer S, et al. ESHRE guideline: ovarian stimulation for IVF/ICSI†. Hum Reprod Open. 2020;2020(2):hoaa009

4. Subira et al., Testosterone priming (short or long course) before IVF does not improve the number of oocytes retrieved in poor ovarian responders: a randomized controlled trial, O-014

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2. Regan AK, Arnaout A, Marinovich L, et al. Interpregnancy interval and risk of perinatal death: a systematic review and meta-analysis [published online ahead of print, 2020 May 7]. BJOG. 2020;10.1111/1471-0528.16303

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1. Jurkovic D. Updated Terminology for early pregnancy assessment, ESHRE 2020, O-046

Conception after early IVF pregnancy loss - should we wait?

Updated Terminology for early pregnancy assessment

Early pregnancy

1. Schreiber CA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ, Barnhart KT. Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss. N Engl J Med. 2018;378(23):2161-2170

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3. Cobo A, García-Velasco JA, Coello A, Domingo J, Pellicer A, Remohí J. Oocyte vitrification as an efficient option for elective fertility preservation. Fertil Steril. 2016;105(3):755-764.e8

4. Van der Ven H, Liebenthron J, Beckmann M, et al. Ninety-five orthotopic transplantations in 74 women of ovarian tissue after cytotoxic treatment in a fertility preservation network: tissue activity, pregnancy and delivery rates. Hum Reprod. 2016;31(9):2031-2041

5. Jadoul P, Guilmain A, Squifflet J, et al. Efficacy of ovarian tissue cryopreservation for fertility preservation: lessons learned from 545 cases. Hum Reprod. 2017;32(5):1046-1054

Live birth rate and utilization rate of eggs and embryos following FP

1. Ludwin A, Ludwin I, Coelho Neto MA, et al. Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare systems. Ultrasound Obstet Gynecol. 2019;54(6):800-814

2. Chan YY, Jayaprakasan K, Zamora J, Thornton JG, Raine-Fenning N, Coomarasamy A. The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review. Hum Reprod Update. 2011;17(6):761-771

3. Rikken JFW, Verhorstert KWJ, Emanuel MH, et al. Septum resection in women with a septate uterus: a cohort study. Hum Reprod. 2020;35(7):1578-1588

Septum resection versus expectant management in women with a septate uterus

1. Blumenfeld Z. Fertility Preservation Using GnRH Agonists: Rationale, Possible Mechanisms, and Explanation of Controversy. Clin Med Insights Reprod Health. 2019;13:1179558119870163

2. Chen H, Xiao L, Li J, Cui L, Huang W. Adjuvant gonadotropin-releasing hormone analogues for the prevention of chemotherapy-induced premature ovarian failure in premenopausal women. Cochrane Database Syst Rev. 2019;3(3):CD008018. Published 2019 Mar 3. doi:10.1002/14651858

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LH prevents preserves the meiotic potential of oocytes exposed to chemotherapy

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2. Fragouli E, Alfarawati S, Daphnis DD, et al. Cytogenetic analysis of human blastocysts with the use of FISH, CGH and aCGH: scientific data and technical evaluation. Hum Reprod. 2011;26(2):480-490

3. Munné S, Wells D. Detection of mosaicism at blastocyst stage with the use of high-resolution next-generation sequencing. Fertil Steril. 2017;107(5):1085-1091

4. Spinella F, Fiorentino F, Biricik A, et al. Extent of chromosomal mosaicism influences the clinical outcome of in vitro fertilization treatments. Fertil Steril. 2018;109(1):77-83

5. Grati FR, Gallazzi G, Branca L, Maggi F, Simoni G, Yaron Y. An evidence-based scoring system for prioritizing mosaic aneuploid embryos following preimplantation genetic screening. Reprod Biomed Online. 2018;36(4):442-449

New evidence on mosaic developmental potential

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2. Berkovitz A, Miller N, Silberman M, Belenky M, Itsykson P. A novel solution for freezing small numbers of spermatozoa using a sperm vitrification device. Hum Reprod. 2018;33(11):1975-1983

3. Liu, S., Li, F. Cryopreservation of single-sperm: where are we today? Reprod Biol Endocrinol 18, 41 (2020). https://doi.org/10.1186/s12958-020-00607-x

Novel Technologies for Single-Sperm Vitrification

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2. Gleicher N, Albertini DF, Barad DH, et al. The 2019 PGDIS position statement on transfer of mosaic embryos within a context of new information on PGT-A. Reprod Biol Endocrinol. 2020;18(1):57

Complex mosaic embryos after preimplantation genetic testing

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impact on pregnancy outcome. Fertil Steril. 2014;102(4):1029-1033.e1

2. Fauque P, Audureau E, Leandri R, et al. Is the nuclear status of an embryo an independent factor to predict its ability to develop to term? Fertil Steril. 2013;99(5):1299-1304.e3

3. Alpha Scientists in Reproductive Medicine and ESHRE Special Interest Group of Embryology. The Istanbul consensus workshop on embryo assessment: proceedings of an expert meeting. Hum Reprod. 2011;26(6):1270-1283

4. Balakier H, Sojecki A, Motamedi G, Librach C. Impact of multinucleated blastomeres on embryo developmental competence, morphokinetics, and aneuploidy. Fertil Steril. 2016;106(3):608-614.e2

5. Balakier H, Sojecki A, Motamedi G, Librach C. Impact of multinucleated blastomeres on embryo developmental competence, morphokinetics, and aneuploidy. Fertil Steril. 2016;106(3):608-614.e2

1. Van Rumste MM, Evers JL, Farquhar CM. ICSI versus conventional techniques for oocyte insemination during IVF in patients with non-male factor subfertility: a Cochrane review. Hum Reprod. 2004 Feb;19(2):223-7

2. Bhattacharya S, Hamilton MP, Shaaban M, Khalaf Y, Seddler M, Ghobara T, Braude P, Kennedy R, Rutherford A, Hartshorne G, Templeton A. Conventional in-vitro fertilisation versus intracytoplasmic sperm injection for the treatment of non-male-factor infertility: a randomised controlled trial. Lancet. 2001 Jun 30;357(9274):2075-9

3. Sauerbrun-Cutler MT, Huber WJ 3rd, Has P, et al. Is intracytoplasmic sperm (ICSI) better than traditional in vitro fertilization (IVF): confirmation of higher blastocyst rates per oocyte using a split insemination design. J Assist Reprod Genet. 2020;37(7):1661-1667

4. Drakopoulos P, Garcia-Velasco J, Bosch E, et al. ICSI does not offer any benefit over conventional IVF across different ovarian response categories in non-male factor infertility: a European multicenter analysis [published correction appears in J Assist Reprod Genet. 2019 Oct 14. J Assist Reprod Genet. 2019;36(10):2067-2076

5. Dang VQ, Vuong LN, Ho TM, et al. The effectiveness of ICSI versus conventional IVF in couples with non-male factor infertility: study protocol for a randomised controlled trial. Hum Reprod Open. 2019;2019(2):hoz006

6. IVF vs ICSI in non-male factor infertility: time to change course?” (O-232), K. Lattes Altamirano et al., ESHRE, 26.06.2019, Vienna, Austria. https://doi.org/10.1093/humrep/34.Supplement_1.1

7. Intracytoplasmic sperm injection (ICSI) is not superior to conventional in vitro fertilisation (IVF) in non-male factor infertility: a systematic review and meta-analysis, Finet et al., P-115, ESHRE 2020

Intracytoplasmic sperm injection vs conventional IVF in couples with non-male factor infertility

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Ovarian Stimulation

1. Ovarian Stimulation TEGGO, Bosch E, Broer S, et al. ESHRE guideline: ovarian stimulation for IVF/ICSI†. Hum Reprod Open. 2020;2020(2):hoaa009

2. Devroey P, Aboulghar M, Garcia-Velasco J, et al. Improving the patient’s experience of IVF/ICSI: a proposal for an ovarian stimulation protocol with GnRH antagonist co-treatment. Hum Reprod. 2009;24(4):764-774

Optimal GnRH antagonist protocol during ovarian stimulation

1. Yu S, Long H, Chang HY, et al. New application of dydrogesterone as a part of a progestin-primed ovarian stimulation protocol for IVF: a randomized controlled trial including 516 first IVF/ICSI cycles. Hum Reprod. 2018;33(2):229-237.

2. J.C. Castillo et al., Natural micronized progesterone versus a GnRH antagonist in egg-donation cycles. An extended experience. ESHRE 2020, O-124

3. La Marca A, Capuzzo M. Use of progestins to inhibit spontaneous ovulation during ovarian stimulation: the beginning of a new era?. Reprod Biomed Online. 2019;39(2):321-331

MPA as a pituitary suppressor instead of a GnRH antagonist during ovarian stimulation

1. Dong J, Wang Y, Chai WR, et al. The pregnancy outcome of progestin-primed ovarian stimulation using 4 versus 10 mg of medroxyprogesterone acetate per day in infertile women undergoing in vitro fertilisation: a randomised controlled trial. BJOG. 2017;124(7):1048-1055

Comparing different progestin regimens for pituitary suppression

1. Kuang Y, Hong Q, Chen Q, et al. Luteal-phase ovarian stimulation is feasible for producing competent oocytes in women undergoing in vitro fertilization/intracytoplasmic sperm injection treatment, with optimal pregnancy outcomes in frozen-thawed embryo transfer cycles. Fertil Steril. 2014;101(1):105-111

2. Qin N, Chen Q, Hong Q, et al. Flexibility in starting ovarian stimulation at different phases of the menstrual cycle for treatment of infertile women with the use of in vitro fertilization or intracytoplasmic sperm injection. Fertil Steril. 2016;106(2):334-341.e1

3. Vaiarelli A, Cimadomo D, Petriglia C, et al. DuoStim - a reproducible strategy to obtain more oocytes and competent embryos in a short time-frame aimed at fertility preservation and IVF purposes. A systematic review. Ups J Med Sci. 2020;125(2):121-130

1. Noble M. Natural cycle frozen-thawed embryo transfer (FET): A comparison of outcomes following blastocyst transfer on day six versus day seven after urinary luteinising hormone (LH) surge. ESHRE 2020. 0-168

Pituitary suppression is not necessary for blocking LH surge during luteal-phase stimulation

Natural cycle frozen-thawed embryo transfer

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Safety & outcome

1. Berntsen, S., Söderström-Anttila, V., Wennerholm, U. B., Laivuori, H., Loft, A., Oldereid, N. B., Romundstad, L. B., Bergh, C., & Pinborg, A. (2019). The health of children conceived by ART: ‘the chicken or the egg?’. Human reproduction update, 25(2), 137–158

Nordic sibling study

1. Boulet SL, Mehta A, Kissin DM, Warner L, Kawwass JF, Jamieson DJ. Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection. JAMA. 2015;313(3):255-263

2. Davies, M. J., Rumbold, A. R., Marino, J. L., Willson, K., Giles, L. C., Whitrow, M. J., Scheil, W., Moran, L. J., Thompson, J. G., Lane, M., & Moore, V. M. (2017). Maternal factors and the risk of birth defects after IVF and ICSI: a whole of population cohort study. BJOG : an international journal of obstetrics and gynaecology, 124(10), 1537–1544

Major congenital malformations risk in children conceived after ICSI

1. Lazaraviciute G, Kauser M, Bhattacharya S, Haggarty P, . A systematic review and meta-analysis of DNA methylation levels and imprinting disorders in children conceived by IVF/ICSI compared with children conceived spontaneously. Hum Reprod Update. 2014;20(6):840-852

2. Henningsen AA, Gissler M, Rasmussen S, et al. Imprinting disorders in children born after ART: a Nordic study from the CoNARTaS group. Hum Reprod. 2020;35(5):1178-1184

Imprinting disorders in children born after ART

1. Bartsch E, Medcalf KE, Park AL, Ray JG. Clinical risk factors for pre-eclampsia determined in early pregnancy: Systematic review and meta-analysis of large cohort studies. BMJ. 2016;353:i1753

2. Wei D, Liu JY, Sun Y, et al. Frozen versus fresh single blastocyst transfer in ovulatory women: a multicentre, randomised controlled trial. Lancet. 2019;393(10178):1310-1318

3. Von Versen-Höynck F, Schaub AM, Chi YY, et al. Increased Preeclampsia Risk and Reduced Aortic Compliance With In Vitro Fertilization Cycles in the Absence of a Corpus Luteum. Hypertension. 2019;73(3):640-649

4. Lawrenz B, Coughlan C, Melado L, Fatemi HM. The ART of frozen embryo transfer: back to nature!. Gynecol Endocrinol. 2020;36(6):479-483

Artificially prepared frozen cycles and increased risk of preeclampsia

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