Member Societies and readers are invited to send all comments, reports or articles to
Middle East Fertility Society ,
Achrafieh, P.O.Box :167220, Beirut, Lebanon, Phone: + 961-1-610400, Fax: + 961-1-612400, email@example.com
Important to know in 2017
1-Starting menstrual periods at a young age and childlessness increase risk of premature and early menopause
January 24, 2017, Oxford University Press (OUP)
“Women who had their first menstrual period when they were aged 11 or younger have an increased risk of an early or premature menopause and if they remain childless the risk is increased even more, according to results from the first large scale, multi-national study to investigate the links between age at puberty and menopause and whether or not a woman has had children.”
2-Researchers improve technology to save sperm stem cells
Method key to preserving fertility of boys with cancer
April 6, 2017, Washington State University
“Researchers have found a promising way to preserve sperm stem cells so boys could undergo cancer treatment without risking their fertility. Stem cell can produce 5,000 sperm with each heartbeat, mature, fertile men produce some 1,300 sperm cells. They come from a pool of self-renewing spermatogonial stem cells that are present at birth. As each stem cell differentiates, it can produce some 5,000 sperm. Glycolysis is important for the stem cell. Trials were done to change the culture environment to favor glycolysis. By lowering the oxygen in the culture -- adding nitrogen to cut it by more than half -- the researchers found they could dramatically improve the percentage of stem cells capable of making normal sperm when put back into the testes. Where before only 5 percent of the cells remained viable after six months, now 40 percent were viable.”
3-100-year-old fertility technique reduces need for IVF
May 18, 2017, University of Adelaide
Infertile couples have a major opportunity to achieve a successful pregnancy without the need for IVF, thanks to new research into a 100-year-old medical technique. This was hystero-salpingography. Almost 40% of infertile women in the oil group and 29% of infertile women in the water group achieved successful pregnancies within six months of the technique being performed.
4-Technique for 'three-parent baby' revealed
April 3, 2017, Elsevier
“Details of a pioneering IVF technique using mitochondrial replacement therapy (MRT) have been published, giving hope to those families with inheritable mitochondrial disorders that they may be able to have healthy children in the future.”
5-Artificial mouse embryo developed in vitro
March 2017, Science
A structure whose composition and architecture very closely resemble a mouse embryo has been developed in vitro by scientists at the University of Cambridge, in UK
6-Stem cell therapy in the restoration of endometrial function
‘Autologous cell therapy with CD133+ bone marrow-derived stem cells for refractory Asherman’s syndrome and endometrial atrophy: a pilot cohort study’ by Santamaria and colleagues in Hum Reprod Journal 2016
7-Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial.
Lancet, June, 2016
Multicentre, randomized controlled trial in seven university hospitals and 15 large general hospitals in the Netherlands, 750 women were randomized to receive either hysteroscopy (n=373) or immediate IVF (n=377). 209 (57%) of 369 women in the hysteroscopy group and 200 (54%) in the immediate IVF group had a livebirth. The conclusion was that routine hysteroscopy does not improve livebirth rates in infertile women with a normal transvaginal ultrasound of the uterine cavity scheduled for a first IVF treatment. Women with a normal transvaginal ultrasound should not be offered routine hysteroscopy.
Important to learn in 2017
BEST OF ESHRE & ASRM 2017: an emphasis on transatlantic ‘debate’
1-The barriers to treatment faced by those living on these two transatlantic continents
There is markedly limited public or insurance-funded options in the US. Culturally, politically and legally the US has taken a ‘hands-off ’ approach to infertility, what Adashi described as a ‘quintessentially American’ libertarian response. 15 state mandates for infertility insurance, many of which will not provide full IVF coverage.
‘non-economic’ barriers to full care here seem much greater than in the US. Boivin emphasized low levels of education, the female partner in full employment, ‘reproductive choice’ (‘decisional avoidance’, voluntary childlessness), limited access and of course legal constraints.
2- PGS in recurrent pregnancy loss
The greatest debate was on the role of PGD and PGS in the diagnosis and prevention of recurrent pregnancy loss (RPL).
Mariette Goddijn from the Amsterdam Medical Center: reported pregnancy rates after PGS are no higher than after natural conception; that pregnancy rates anyway after natural conception are ‘relatively good’, and that ICSI following PGS is associated with complications and high cost. Goddijn emphasised that the case for expectant management in RPL - or at least the case against PGS - was recently made in a Human Reproduction report in which a retrospective cohort study of 300 RPL patients found similar live birth and miscarriage rates in both the expectant management and PGS groups.
William Kutteh criticized the HR study (retrospective, selection bias, different patient group ages). He claimed that PGS in RPL lay largely in the growing incidence of aneuploidy with female age and the possibility that comprehensive chromosome screening following blastocyst biopsy in good prognosis patients improves embryo selection and implantation rates. This needs centres ‘with significant experience’ in biopsy and testing. Kutteh underscored that the overall value of PGS in unselected patients is still ‘unclear’, its potential value might be (‘promising’) in RPL
3- Value of CCS
Richard Scott from Reproductive Medicine Associates of New Jersey (whose association with IVI of Valencia was announced just before this meeting) was defending the CCS. Scott recognised ‘real questions’ regarding comprehensive chromosome screening: the safety of taking the embryonic sample; predictive value; mosaicism; and cost. He emphasized that ‘day 3 biopsy will soon be of historic interest only’ and that blastocyst biopsy will increase implantation rate (while cleavage stage biopsy will not). On predictive value, a prospective study performed by Scott’s own group showed that CCS is indeed ‘highly predictive’ of reproductive potential - which in this study was around 98% for negative predictive value at all ages from 32 to 42. His arguments in cases of mosaicism (lower predictive value) and on cost were less persuasive. Scott also presented data reflecting the precision with which PGS can identify subchromosomal defects (duplications and defects) and the impact they are likely to have on outcome if not identified.
Scott was taking part in a debate on whether aneuploid embryos should ever be transferred; his answer was never, provided they are truly aneuploid, which of course requires PGS to verify.
Siobhan Quenby from the University of Warwick, UK, entertainingly proposed that 'diversity' in the gene pool provided the spice of life - and anyway, she added, the maternal decidua can make embryo selection far better than any laboratory test.
4-Embryo selectivity and the function of the endometrium in early embryo development
This was presented from one side, which was Nick Macklon from the University of Southampton, UK, on this emerging concept. Macklon’s theme, based on his own work with colleagues at the University of Warwick, was that the endometrium is more than merely ‘receptive’ - that it allows implantation of the healthy embryo but also prevents implantation of the unhealthy embryo and goes on to nourish and incubate the preimplantation embryo. The decidualised stromal cells of the endometrium recognise the incompetent embryo, such that those stromal cells do not migrate to poor quality embryos. This support the concept of the 'choosy' endometrium. This might occur by the endometrium's transcriptional response to developmentally competent and incompetent embryos. In recurrent implantation losses, he suggested, the less choosy ‘superfertile' mothers will experience more miscarriages. 'New concepts are required,' he said, which recognise the active - and not passive - role of the endometrium. The expression of endometrial genes, said Macklon, might yet provide the basis of a new - and finally accurate - test of uterine receptivity.
5- Sperm DNA fragmentation tests
Herman Tournaye from the VUB Brussels was only lukewarm. He emphasized that DNA fragmentation occurs normally during spermatogenesis.He suggested that, reproductive consequences are just associations, not causations. It is unclear who might benefit, even though the tests seem recommended in couples with repeated ART failure or miscarriage. Tournaye also emphasised that the range of present tests all offer a ‘proxy' result in that the tested sperm cells are thereafter unsuitable for clinical use. Moreover, despite the hype of antioxidants, there are no proven therapies to remedy subfertility associated with high levels of DNA fragmentation in sperm.
6- Luteal phase support after agonist triggering
This was presented by Human Fatemi from IVI Abu Dhabi. He underscored ‘segmentation’ principle for the prevention of OHSS in IVF. Yet, as Fatemi noted, OHSS cases do - albeit rarely - occur with agonist triggering and the likely explanation is severe luteolysis. Luteal support with hCG following the agonist trigger results in good pregnancy rates and low risk of OHSS.
7- Primary Ovarian insufficiency
Aaron Hsueh from Stanford University recalled how genomic and genetic studies implicating hippo signalling genes in POI, PCOS and ovarian reserve had led to the possibility of in vitro activation (IVA) and childbirth in women previously diagnosed with POI. Hsueh and his Japanese colleagues’ work on ovarian physiology and signalling pathways had identified ‘residual follicles’ which could be activated and grown into embryos for implantation and pregnancy. Hsueh found that blocking a protein known as PTEN (in mouse and human ovaries) stirred dormant follicles into life. ‘Our treatment was able to activate or awaken some of the remaining primordial follicles and cause them to release eggs,’ said Hsueh. He reported that three babies had been born in women previously diagnosed with POI. The genome editing technique of CRISPR Cas9 is a long way from clinical use, but it was described by Robin Lovell-Badge of the Francis Crick Institute in London as 'a revolution over the past five years'. He devoted his presentation to the report of the US National Academies of Science, Engineering, and Medicine, whose conclusions reflect a degree of scientific and clinical consensus evident throughout most of this ESHRE/ASRM meeting. Lovell-Badge, a member of the report’s writing group, said progress should not go ahead without guidelines, nor beyond the treatment of disease. ‘Caution is needed,’ he said, ‘but that does not mean prohibition.’
Graduation of the first batch fellows after a three-year fellowship program in the field of Reproductive Endocrine and Infertility under the umbrella of the Saudi Commission for Health Specialties
Thursday, the 21st of December 2017 was a special day for the reproductive endocrinology field in Saudi Arabia.
The first batch of reproductive endocrine and infertility (REI) fellows have graduated after an extensive 3- year training program under the umbrella of the Saudi Commission of Health Specialties (SCHS).
This is in alignment with the vision and mission of SCHS which is to “improve healthcare professional performance in the Kingdom to meet international standards and develop healthcare standards through designing and organizing health training programs, ensure the effectiveness of health practitioners’ registration and classification, promote medical research and education, and achieve sustained professional development in the Kingdom through coordination and partnerships with local and international institutions”.
The training REI fellowship program is a three year program.
The first year the fellows are involved in the in vitro fertilization service. This includes participation in both the clinical and laboratory components of this program with responsibility for protocol assignment and cycle monitoring, and an in-depth experience at performance of the technical aspects of in vitro fertilization including egg retrieval and embryo transfer. During the first year the fellow chooses a research mentor and begins to develop a protocol for their research project which is a requirement for completion of their training.
The second year of the fellowship focuses on completing the required research along with their clinical responsibilities. All the fellows rotate in different hospitals with recognized reproductive medicine services such as the Prince Sultan Military Medical City, King Abdulaziz for Health Sciences, King Fahad Medical City and King Faisal Specialist Hospital & Research Centre.
Participation in a serious research program is important in developing special competence in reproductive endocrinology and infertility and in training future leaders in the field. The third year of training includes reproductive surgeries which includes, but are not limited to, extensive laparoscopy with operative treatment for endometriosis, fertility sparing surgery, myomectomies, operative and diagnostic hysteroscopy and more. During their third year in training, the fellows are expected to complete their research in addition to their clinical practice.
Throughout all three years, the fellow participates in a variety of didactic sessions within the Division of Reproductive Endocrinology and Infertility and the Department of Obstetrics and Gynecology. The program is supervised by the program directors of the different hospitals Dr. Hisham Ayoub from Prince Sultan Military Medical City, (Chairman of the Scientific Committee of REI Fellowship Program), Dr. Samar Hassan from King Abdulaziz for Health Sciences, Dr. Dania Al-Jaroudi from King Fahad Medical City and Dr. Khalid Awartani from King Faisal Specialist Hospital & Research Centre, (Chairman of the Exam committee in REI Fellowship Program) .
On Thursday, all the fellows have presented their research projects at King Faisal Specialist Hospital & Research Centre in the presence of all renowned REI consultants from all over Riyadh, both in the governmental and private sector.
The graduate fellows are Dr. Asmaa Kaseb AlBadran, Dr. Gamar Ahmed Salim, Dr. Dr. Hanan Alanazi, Dr. Jawharah Ali AlZebidi, Dr. Maryam Salim AlShabibi, Dr. Nayla Bushaqer, Dr. Wadha Marei Mohawesh.We wish all the fellows the best of luck in their new journey, and we hope that the effect of training and credentialing will continue to improve women's health.
Dania Al-Jaroudi, MD, MHA
Hisham Ayoub, MD
Khalid Awartani, MD
Samar Hassan, MD