Horizons in Endometriosis: Proceedings of the Montreux Reproductive Summit, 14-15 July 2023

Endometriosis is a complex and chronic gynaecological disorder that affects millions of women worldwide, leading to significant morbidity and impacting reproductive health. This condition affects up to 10% of women of reproductive age and is characterised by the presence of endometrial-like tissue outside the uterus, potentially leading to symptoms such as chronic pelvic pain, dysmenorrhoea, dyspareunia, and infertility. The Montreux summit brought a number of experts in this field together to provide a platform for discussion and exchange of ideas. These proceedings summarise the six main topics that were discussed at this summit to shed light on future directions of endometriosis classification, diagnosis, and therapeutical management. The first question addressed the possibility of preventing endometriosis in the future by identifying risk factors, genetic predispositions, and further understanding of the pathophysiology of the condition to develop targeted interventions. The clinical presentation of endometriosis is varied, and the correlation between symptoms severity and disease extent is unclear. While there is currently no universally accepted optimal classification system for endometriosis, several attempts striving towards its optimisation - each with its own advantages and limitations - were discussed. The ideal classification should be able to reconcile disease status based on the various diagnostic tools, and prognosis to guide proper patient tailored management. Regarding diagnosis, we focused on future tools and critically discussed emerging approaches aimed at reducing diagnostic delay. Preserving fertility in endometriosis patients was another debatable aspect of management that was reviewed. Moreover, besides current treatment modalities, potential novel medical therapies that can target underlying mechanisms, provide effective symptom relief, and minimise side effects in endometriotic patients were considered, including hormonal therapies, immunomodulation, and regenerative medicine. Finally, the question of hormonal substitution therapy after radical treatment for endometriosis was debated, weighing the benefits of hormone replacement.

Declining global fertility rates and the implications for family planning and family building: an IFFS consensus document based on a narrative review of the literature

BACKGROUND

Family-planning policies have focused on contraceptive approaches to avoid unintended pregnancies, postpone, or terminate pregnancies and mitigate population growth. These policies have contributed to significantly slowing world population growth. Presently, half the countries worldwide exhibit a fertility rate below replacement level. Not including the effects of migration, many countries are predicted to have a population decline of >50% from 2017 to 2100, causing demographic changes with profound societal implications. Policies that optimize chances to have a child when desired increase fertility rates and are gaining interest as a family-building method. Increasingly, countries have implemented child-friendly policies (mainly financial incentives in addition to public funding of fertility treatment in a limited number of countries) to mitigate decreasing national populations. However, the extent of public spending on child benefits varies greatly from country to country. To our knowledge, this International Federation of Fertility Societies (IFFS) consensus document represents the first attempt to describe major disparities in access to fertility care in the context of the global trend of decreasing growth in the world population, based on a narrative review of the existing literature.

OBJECTIVE AND RATIONALE

The concept of family building, the process by which individuals or couples create or expand their families, has been largely ignored in family-planning paradigms. Family building encompasses various methods and options for individuals or couples who wish to have children. It can involve biological means, such as natural conception, as well as ART, surrogacy, adoption, and foster care. Family-building acknowledges the diverse ways in which individuals or couples can create their desired family and reflects the understanding that there is no one-size-fits-all approach to building a family. Developing education programs for young adults to increase family-building awareness and prevent infertility is urgently needed. Recommendations are provided and important knowledge gaps identified to provide professionals, the public, and policymakers with a comprehensive understanding of the role of child-friendly policies.

SEARCH METHODS

A narrative review of the existing literature was performed by invited global leaders who themselves significantly contributed to this research field. Each section of the review was prepared by two to three experts, each of whom searched the published literature (PubMed) for peer reviewed full papers and reviews. Sections were discussed monthly by all authors and quarterly by the review board. The final document was prepared following discussions among all team members during a hybrid invitational meeting where full consensus was reached.

OUTCOMES

Major advances in fertility care have dramatically improved family-building opportunities since the 1990s. Although up to 10% of all children are born as a result of fertility care in some wealthy countries, there is great variation in access to care. The high cost to patients of infertility treatment renders it unaffordable for most. Preliminary studies point to the increasing contribution of fertility care to the global population and the associated economic benefits for society.

WIDER IMPLICATIONS

Fertility care has rarely been discussed in the context of a rapid decrease in world population growth. Soon, most countries will have an average number of children per woman far below the replacement level. While this may have a beneficial impact on the environment, underpopulation is of great concern in many countries. Although governments have implemented child-friendly policies, distinct discrepancies in access to fertility care remain.

O-174 The association of chromosomal abnormalities with embryo ultrastructure, spindle anomalies and metabolic profiling

Study question

Can metabolic profiling predict embryos at risk of chromosomal abnormalities and how are these reflected in the ultrustructure and cytoskeleton?

Summary answer

Different metabolic profiles are observed between normal and aneuploid/chaotic embryos which are linked to altered mitochondrial and other organelles’ structure/function and spindle and nuclear abnormalities.

What is known already

One of the greatest challenges in IVF is the selection of the best ‘fit’ embryo for implantation in a non-invasive way. Down’s syndrome embryos and Monosomy 21 embryos have previously been shown to have differential expression of metabolites compared to normal embryos, but limited studies, have investigated in detail the metabolic profiling of embryos with other abnormalities in comparison to chromosomally normal embryos or their reflection in the ultrustructure and the cytoskeleton.

Study design, size, duration

Culture media collected on day 3 from 200 embryos which underwent PGT-A, were analysed by hydrophilic interaction liquid chromatography tandem mass spectrometry (HILIC-MS/MS). The chromosomally normal embryos were transferred to the uterus (1–2 embryos/ET) or still remain vitrified for clinical use and 120 of the embryos that were diagnosed with chromosomal abnormalities were either processed for spindle/chromosome configurations analysis (n = 60) by confocal laser scanning microscopy(CLSM) or for ultrastructural analysis (n = 60) by Transmission Electron Microscopy(TEM).

Participants/materials, setting, methods

Metabolic profiling was conducted in a Forensic Toxicology Laboratory by HILIC-MS/MS (100 metabolites). Spindle Chromosome Configuration analysis was conducted in an academic hospital after methanol fixation and immunostaining with α-tubulin, γ-tubulin, acetylated-tubulin antibodies and DAPI or/ PI to visualise DNA. Ultrastructure analysis by TEM was carried out in a Histology/Embryology Laboratory following embryo fixation in 3% glutaraldehyde, 1% osmium tetroxide, washes in  PBS and staining with 1% aqueous uranyl acetate.

Main results and the role of chance

This  study provides screening  for >100 primary metabolites using HILIC-MS/MS in a single run of 40 minutes. Characteristic patient specific metabolic profiles were observed which differed between normal embryos that had resulted in a viable pregnancy and aneuploid and chaotic embryos. Logistic regression analysis revealed a number of metabolites that had a high predictive value including Isoleucine,  lysine and glucose and models were created in combination with embryo score which in the future could serve as non-invasive markers for the detection of chromosomal abnormalities before embryo transfer. TEM analysis revealed differences in the quality of cells and organelle activity which were reflected in the embryo metabolic profiles. Chaotic poor quality embryos showed a lower number of mitochondria, often with no cisternae, increased number of vacuoles, and frequently problems in junctions between cells. Aneuploid but well developed hatching blastocysts had mainly cells with good mitochondrial morphology/ activity, nice Golgi apparatus and well developed rough and smooth endoplasmic reticulum but depending on the aneuploidy involved, inner cell mass cells with limited organelles and occasionally lipofuscin droplets in the trophectoderm were evident. Nuclear and chromosomal abnormalities were interrelated through abnormalities in cytokinesis and spindle formation and reflected in the embryo metabolic profiles.

Limitations, reasons for caution

Although metabolic profiles were compared between normal and chromosomally abnormal embryos identified by PGT-A, all the  normal embryos were transferred to the uterus or remain vitrified for clinical purposes and therefore the ultrastructure analysis and the spindle chromosome configuration analysis are based only on chromosomally abnormal embryos.

Wider implications of the findings

This study identified distinct differences in the metabolic profiles of normal and chromosomally abnormal embryos and provides unique metabolites which in the future could serve as non-invasive biomarkers for the detection of chromosomal abnormalities before embryo transfer.

Trial registration number

not applicable

European board and college of obstetrics and gynaecology position statement to mark "World Patient safety day - Safe maternal and newborn care" on 17th September 2021

Maternal morbidity and mortality remain stubborn highly in many parts of the world. Similarly Neonatal morbidity, mortality and five years survival in most of the under-resourced countries has not declined significantly over the past decades. Furthermore sexual reproductive health services provision has not met the needs of the women and there remains a huge unmet need for reliable contraception globally. This is the time for a global action plan and for all agencies to work together to achieve meaningful outcomes to improve health of women and their babies. Covid 19 pandemic has led to increase in gender based violence as well which is deplorable. European Board and College of Obstetrics and Gynaecology welcome this initiative and commits to work with all the stakeholders to improve safety and quality of care for women and the newborn.

P–400 Endometrial changes in estrogen and progesterone receptor expression during implantation in an oocyte donation program

Study question

Which are the endometrial changes during implantation in assisted reproduction techniques?

Summary answer

Synchronization between blastocyst development and the acquisition of endometrial receptivity is a prerequisite for the success of in vitro fertilisation (IVF).

What is known already

Implantation is the final and most important stage of embryogenesis and is of paramount importance in achieving a successful pregnancy. Progesterone and estrogen are steroid hormones responsible for the regulation of the implantation window and the current study hypothesised that their receptors may be implicated in women undergoing oocyte donation. Implantation is directly dependent on the synchronization of the fertilized egg’s progression into a blastocyst and the specific differentiation of the endometrium through molecular and cellular changes regulated by agents with an endocrine, paracrine or autocrine activity.

Study design, size, duration

The study was conducted at the 1st Dept. of OB-GYN, Centre for Human Reproduction of the Aristotle University of Thessaloniki, ‘Papageorgiou’ General Hospital and the ‘Biogenesis’ Assisted Reproduction Centre, (both in Thessaloniki, Greece).

Participants/materials, setting, methods

The participants recruited for this prospective study included 15 oocyte donors (age range, 25–32 years; mean age, 28.9±2.89) undergoing IVF treatment. The inclusion criteria were white race, no uterine-ovarian pathology, age <35 years and no prior known medical pathology. All donors had undergone extensive preoperative work-up, which included common blood tests, karyotyping, specific test for cystic fibrosis and pap smear. All donors were non-smokers and had given their informed consent.

Main results and the role of chance

Both ERα and PR-B were expressed abundantly on both days (0 and 5; Fig. 1B). The ERα nodal staining percentage on day 0 was age-related, with patients aged <30 years showing 100% staining and those aged >30 years showing 90% staining (Mann-Whitney U test; P = 0.014; Fig. 2A)Both steroid hormone receptors showed significant variation between days 0 and 5, both in the nodal and stromal preparations. According to Wilcoxon signed-rank test; for ER (nodes% and stromal%) Day 0/5, P = 0.0001; for PR (nodes% and stromal%) Day 0/5, P = 0.0001 and P = 0.035, respectively; for ER (Grade nodes and stromal) Day 0/5, P = 0.0001; and for PR (Grade nodes and stromal) Day 0/5, P = 0.0001 and P = 0.016, respectively (Fig. 2B and ​andC;C; Table I).

Limitations, reasons for caution

Immunohistochemistry is less quantitative than western blotting. Alternatively, ELISA or a gene expression assessment of both receptors using RT-qPCR could have been conducted. However, due to ethical restrictions, sufficient tissue for protein extraction could not be obtained in order to pursue this further.

Wider implications of the findings: It was shown herein that both ER-a and PR-B were expressed abundantly on days 0 and 5, showing significant variation in the nodal and stromal preparations. Age appeared to be a critical factor, since ER-a nodal staining showed higher values in the age group of oocyte donors <30 years old.

Trial registration number

15

P–261 The human embryo following biopsy on day5 vs day3: Implantation, cytoskeleton, ultrastructure and effects of endometrial damage/inflammation on receptivity as revealed by scanning electron microscopy

Study question

Are there any differences in implantation, cytoskeleton and ultrastructure of embryos biopsied on day5 vs day3 and how endometrial damage/inflammation may affect receptivity and implantation?

Summary answer

No differences are observed in implantation rates but vitrification following day5 biopsy led to more cytoskeletal/ultrastructural anomalies. Infections and epithelial damage severely affected endometrial receptivity.

What is known already

Successful implantation is dependent on the correct synchronization of the window of implantantation with the transfer of chromosomally/genetically normal embryos, in a well prepared receptive endometrium. This is the first study to examine the effects of day5 vs day3 embryo biopsy by comparing implantation/pregnancy rates and by analysing cytoskeleton using Confocal Laser Scanning Microscopy (CLSM), and ultrastructure by Transmission Electron Microscopy (TEM). In addition, Scanning Electron Microscopy (SEM) was used on endometrial biopsies to assess possible uterine pathologies/inflammation that may be responsible for the failed implantation after PGT-A/M and if subsequent treatment can increase implantation/pregnancy rates in succeeding PGT-A/M cycles.

Study design, size, duration

470 embryos were biopsied on day5 for PGT-A (n = 152–37 cycles) or on day3 for PGT-A (n = 162–29 cycles) and PGT-M (n = 156–22 cycles). Following transfer of normal embryos, spare embryos, rejected for transfer following day5 or day3 biopsy were processed for Cytoskeletal analysis (n = 30 fresh day3 biopsied, n = 30 day5 biopsied/vitrified) or TEM (n = 20 fresh day3 biopsied, n = 20 day5 biopsied/vitrified). Also, patients with a –ve hCG test, underwent endometrial biopsy to detect infection/inflammation and assess receptivity.

Participants/materials, setting, methods

Cytoskeletal analysis was performed by embryo immunostaining with α-tubulin, γ-tubulin, acetylated-tubulin antibodies and DAPI or/ PI to visualise DNA. TEM analysis was carried out following embryo fixation in gluteraldehyde, incubation in osmium, aqueous uranyl acetate, dehydration through ethanol series, and immersion in Epon. Endometrial biopsies were fixed in gluteraldehyde solution and processed for SEM using standard methods. The study was conducted in an academic hospital with an IVF/PGD laboratory and 3 private IVF Units.

Main results and the role of chance

162 embryos were biopsied on day 3 for PGT-A (29 cycles), 10 cycles had no normal embryos for transfer, 30 normal embryos were transferred in 19 cycles leading to 12/19 (63.2%) +vehCG/ET and 11/19 (57.9%) Ongoing pregnancy rate/ET. 156 embryos were biopsied on day 3 for PGT-M (22 cycles), 2 cycles had no normal embryos for transfer, 34 normal or carrier embryos were transferred in 20 cycles leading to 15/20 (75.0%) +vehCG/ET and 13/20 Ongoing pregnancy rate/ET (65.0%). 152 embryos were biopsied on day 5 for PGT-A (37 cycles), 8 cycles had no normal embryos for transfer, 34 normal embryos were transferred in 29 cycles leading to 18/29 (62.1%) +vehCG/ET and 16/29 (55.2%) Ongoing pregnancy rate /ET. Analysis of endometrial biopsies with SEM revealed bacterial infections, inflammation and epithelial damage. So far, 33.3% of patients who received intracavitary infusions-antibiotic treatment per os achieved a +vehCG/ET in their next PGT-A/M cycle. Cytoskeletal analysis showed that the majority of spindles examined in both day3 and day5 biopsied embryos were normal (85/114(74.6%) and 87/137(63.5). However vitrification following day5 biopsy led to more cytoskeletal/ultrastructural anomalies which included multipolar/abnormally shaped spindles, chromosome-bridging, chromosome-lagging and more vacuoles, lipofuscins. and distension of mitochondria.

Limitations, reasons for caution

Patients undergoing PGT-A have various aetiologies (heterogeneous group). The embryos used for cytoskeletal and ultrastructural analysis in this study were all diagnosed with either chromosomal abnormalities or single gene defects following PGT-A or PGT-M.

Wider implications of the findings: This is the first study to compare implantation/pregnancy rates, cytoskeleton and ultrastructure of day5 vs day3 biopsied embryos. The similarities observed in implantation/pregnancy rates, and the limited ultrastuctural and cytoskeletal anomalies identified confirm the procedures’ safety and indicate in certain cases endometrial factors/inflammation responsible for failed implantation following PGT-A/M.

Trial registration number

Not applicable

Influence of conception and delivery mode on stress response marker Oct4B1 and imprinted gene expression related to embryo development: A cohort study

Background

Recent scientific data support that the mode of conception and delivery may influence epigenetic regulation and therefore embryo development. Octamer-binding transcription factor 4-B1 (OCT4B1), a novel variant of OCT4 with yet unknown biological function, is suggested to have a potential role in mediating cellular stress response. Furthermore, Insulinlike Growth Factor 2(IGF2), Mesoderm-specific Transcript(MEST) and paternally expressed gene 10(PEG10) are genes known as imprinted and are regulated via means of epigenetic regulation. The influence of delivery mode and conception on epigenetic regulation is an active research field.

Objective

Our aim was to correlate the expression level of Oct4B1 and the expression and methylation level of IGF2, MEST, and PEG10 imprinted genes with the mode of delivery and conception in the umbilical cord blood of newborns.

Materials and Methods

Samples of umbilical cord blood from infants born after vaginal delivery, caesarean section (CS) with the infant in cephalic position and CS due to breech position were examined. Furthermore, the investigation included infants conceived through means of assisted reproductive technology.

Results

No statistically significant differences were found in mRNA expression levels between different modes of conception and delivery (p = 0.96). Oct4B1, IGF2, MEST, and PEG10 expression levels do not seem to be significantly affected by different modes of conception and delivery.

Conclusion

These results indicate that the expression and methylation patterns of Oct4B1, IGF2, MEST and PEG10 in umbilical cord blood are not affected by the conception and delivery mode.

Endometrial changes in estrogen and progesterone receptor expression during implantation in an oocyte donation program

Implantation is the final and most important stage of embryogenesis and is of paramount importance in achieving a successful pregnancy. Progesterone and estrogen are steroid hormones responsible for the regulation of the implantation window and the current study hypothesised that their receptors may be implicated in women undergoing oocyte donation. A total of 15 women aged 25-32 years old (mean ± SD, 28.9±2.89) undergoing oocyte donation were recruited into the present study. Participants underwent ovarian stimulation with gonadotrophin-releasing hormone antagonist and recombinant follicle-stimulating hormone. Endometrial aspiration biopsy was performed on the day of oocyte retrieval and after 5 days (on days 0 and 5, respectively). Endometrial histology and evaluation of estrogen receptor (ER)α and progesterone receptor (PR)-B were performed on days 0 and 5. The ER nodal staining percentage on day 0 was age-associated, with patients aged <30 years demonstrating 100% staining and those aged >30 years exhibiting 90% staining. Pathological staining revealed statistically significant differences between days 0 and 5 following all staining procedures. Wilcoxon signed-rank test resulted in the following P-values, for ER (nodes % and stromal %) day 0/5, P=0.0001; for PR (nodes % and stromal %) day 0/5, P=0.0001 and P=0.035, respectively; for ER (grade nodes and stromal %) day 0/5, P=0.0001; and PR (grade nodes and stromal %) day 0/5 P=0.0001 and P=0.016, respectively. Synchronization between blastocyst development and the acquisition of endometrial receptivity is a prerequisite for the success of in vitro fertilisation (IVF). Aside from the recent discovery of molecules that are considered crucial for successful embryo implantation, assessing the functional characteristics of the endometrium may offer unique insights into this process, thus improving IVF results.

Pathogenic BRCA1 mutations may be necessary but not sufficient for tissue genomic heterogeneity: Deep sequencing data from ovarian cancer patients

BACKGROUND

Tissue genomic heterogeneity (t-HET) in patients with epithelial ovarian cancer (OVCA) is related to tissue plasticity, i.e., flexibility to adapt to adverse molecular environments. Here, we interrogated the presence and clinical relevance of OVCA t-HET.

METHODS

We applied high-depth (>2000×) sequencing on 297 paraffin tissue samples (fallopian tubes, ovaries, intra-abdominal metastases) from 71 treatment-naïve patients who subsequently received first-line platinum-based chemotherapy. Based on tissue mutation patterns, we distinguished tissue genotypes into: no mutation (33/297 samples; 11.1%), stable (173; 58.2%) and unstable (91; 30.7%). We profiled genotypes per patient and assessed t-HET in 69 patients. Predicted pathogenic mutations refer to germline and/or tissues.

RESULTS

Among all 71 patients, 46 (64.8%) had pathogenic BRCA1 mutations and 15 (21.7%) had BRCA1/2 disruption (i.e., pathogenic mutations with position-LOH). We classified 29 patients with t-HET (42%), all with pathogenic BRCA1; t-HET was observed in 64% with such mutations (p < 0.001). As opposed to non-t-HET, matched tissues in t-HET shared pathogenic BRCA1 (p < 0.001) but not BRCA2 and TP53. Germline BRCA1 mutations in tissues exhibited position-LOH; heterozygous status; or, partial loss of the inherited allele accompanied by additional clonal mutations. Patients with t-HET had worse outcome (log-rank p = 0.048 [progression-free]; p = 0.037 [overall survival]), including 12/15 patients with disrupted BRCA1/2 and 3 BRCA1 carriers with partial germline loss in tissues.

CONCLUSIONS

Pathogenic BRCA1 mutations appear necessary but may not be sufficient for the establishment of t-HET. t-HET may be associated with worse outcome, including in patients with disrupted BRCA1/2, which is usually considered as a favourable marker. OVCA t-HET may need to be addressed for treatment decisions.

Recurrent complete hydatidiform mole: where we are, is there a safe gestational horizon? Opinion and mini-review

Benign hydatidiform mole, complete or partial, is the most common type of gestational trophoblastic disease (GTD) characterised by excessive trophoblastic proliferation and abnormal embryonic development. Although most complete hydatidiform moles (CHMs) are diploid androgenetic, a few cases of CHMs are biparental, characterised by recurrence and familial clustering. In these rare cases, mutations in NLRP7 or KHDC3L genes, associated with maternal imprinting defects, have been implicated. Current data regarding future pregnancy options in hydatidiform moles are discussed and our opinion is presented based on an incidence that took place in our hospital with a woman with consecutive molar pregnancies. In recurrent hydatidiform moles, DNA testing should be performed and when NLRP7 or KHDC3L mutation are detected, oocyte donation should be proposed as an option to maximise woman's chances of having a normal pregnancy.

The impact of paclitaxel and carboplatin chemotherapy on the autonomous nervous system of patients with ovarian cancer

Background

Paclitaxel-based regimens are frequently associated with the development of peripheral neuropathy. The autonomous nervous system (ANS) effects, however, of this chemotherapeutic agent remain unexplored.

Methods

We investigated a group of 31 female patients with ovarian cancer receiving treatment with paclitaxel and carboplatin, as well as a group of 16 healthy age- and gender-matched healthy volunteers. All study participants completed a questionnaire and were assessed neurophysiologically at three time points (baseline, 3–4 months and 6–8 months following the onset of chemotherapy). The evaluation of the ANS included assessment of the adrenergic cardiovascular function (orthostatic hypotension-OH), parasympathetic heart innervation (30/15 ratio) and sympathetic skin response (SSR).

Results

At the 3–4 months ANS assessment, 19.2 % of the patients had systolic OH and the same percentage had diastolic OH, but at the 6–8 months evaluation no patient had systolic OH and only 13.8 % had diastolic OH. The values of the 30/15 ratio were significantly reduced at both time points, whereas the SSR was not affected.

Conclusions

Combined paclitaxel and carboplatin chemotherapy is associated with significant effects on the parasympathetic heart innervation and occasionally with effects on the adrenergic cardiovascular reaction. The SSR remained unaffected. Physicians should be alert to the possibility of these treatment-emergent side effects, so as to monitor ANS parameters and introduce treatment modifications accordingly. Our findings however, should be validated in larger cohorts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0710-4) contains supplementary material, which is available to authorized users.

Ethico-legal issues related to ovarian tissue transplantation

Ovarian tissue transplantation (OTT) is a promising experimental method which may soon become well-established. In cases of minor oncology, where patients' fertility is seriously threatened by treatment, it may be applied as a unique fertility preservation option. OTT has a dual nature ('organ' and 'gamete'). Many stakeholders are involved, including donor, recipient, child, health-care providers and society at large. There is considerable uncertainty about the long-term consequences of the application of OTT and OT cryopreservation (OTC). Thus, application of OTT gives rise to a number of very different ethico-legal issues and dilemmas which are hard to solve coherently through a principlism-based bioethical approach. This study focuses on such dilemmas and attempts to review them. The role of virtue ethics, which may be combined with principlism, is essential to solve such dilemmas coherently and reasonably. Dealing with conflicts of ethical principles equivalent between them, or moral dilemmas without available answers and mind-sharing in a difficult interpersonal process of decision making, requires a virtue-based ethical approach. Besides, ethico-legal issues related to OTC/OTT are complex issues requiring a multidisciplinary approach (ethical considerations, medical, psychological and social evaluations etc.). We stress the crucial role of multidisciplinary Ethics Committee which is considered indispensable for each reproductive health-care unit practicing OTC/OTT.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies

STUDY QUESTION

What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system?

SUMMARY ANSWER

The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented.

WHAT IS KNOWN ALREADY

Accurate diagnosis of congenital anomalies still remains a clinical challenge because of the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes.

STUDY DESIGN, SIZE, DURATION

The ESHRE/ESGE CONgenital UTerine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The consensus is developed based on: (i) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy by performing a systematic review of evidence and (ii) consensus for the definition of where and how to measure uterine wall thickness and the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method.

MAIN RESULTS AND THE ROLE OF CHANCE

Uterine wall thickness is defined as the distance between the interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional (3D) US is recommended for the diagnosis of female genital anomalies in 'symptomatic' patients belonging to high risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine evaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the subgroup of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopically.

LIMITATIONS, REASONS FOR CAUTION

The various diagnostic methods should always be used in the proper way and evaluated by experts to avoid mis-, over- and underdiagnosis.

WIDER IMPLICATIONS OF THE FINDINGS

The role of a combined US examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity.

STUDY FUNDING/COMPETING INTERESTS

None.

Is the time interval between HCG administration and oocyte retrieval associated with oocyte retrieval rate?

The aim of this study was to evaluate whether prolongation of the time interval between HCG administration and oocyte retrieval, from 36 h to 38 h, affects oocyte retrieval rate in women undergoing ovarian stimulation with gonadotrophins and GnRH antagonists for IVF. One hundred and fifty-six normo-ovulatory women were randomized to have oocyte retrieval performed 36 h (n = 78) or 38 h (n = 78) following HCG administration. Oocyte retrieval rate was defined as number of cumulus-oocyte-complex (COC) retrieved/follicle ≥ 11 mm present on day of HCG administration. No significant differences were observed between the groups regarding baseline characteristics. Moreover, no significant difference was observed between the groups regarding oocyte retrieval rate (difference: + 1.2%, 95% CI for difference between medians: -4.5 to +12.1). The median (95% CI for the median) was not significantly different between the groups regarding number of cumulus-oocyte-complexes (COCs) retrieved: 5.5 (5.0-7.0) versus 6.0 (5.0-6.2), respectively, and fertilization rates: 57.7% (50.0-66.7) versus 50.0% (44.8-65.5), respectively. Live birth rates were similar between the groups (20.5% versus 16.7%, RD: + 3.8%, 95% CI: -8.5 to +16.1, respectively). Prolongation of time interval between HCG administration and oocyte retrieval from 36 h to 38 h does not affect oocyte retrieval rate.

ISGE statement on oral emergency contraception

Unintended pregnancy is an important public health problem worldwide. Unwanted pregnancies may end in induced abortion (legal or illegal, safe or unsafe) or in childbirth. In many parts of the world both can be life threatening. Even where both are safe, abortion is distressing for all concerned while unwanted births often lead to poor health and social outcomes for both the mother and her child.

ESHRE Task Force on Ethics and Law 23: medically assisted reproduction in singles, lesbian and gay couples, and transsexual people†

This Task Force document discusses ethical issues arising with requests for medically assisted reproduction from people in what may be called 'non-standard' situations and relationships. The document stresses that categorically denying access to any of these groups cannot be reconciled with a human rights perspective. If there are concerns about the implications of assisted reproduction on the wellbeing of any of the persons involved, including the future child, a surrogate mother or the applicants themselves, these concerns have to be considered in the light of the available scientific evidence. When doing so it is important to avoid the use of double standards. More research is needed into the psychosocial implications of raising children in non-standard situations, especially with regard to single women, male homosexual couples and transsexual people.

ESHRE task force on ethics and Law22: preimplantation genetic diagnosis

This Task Force document discusses some relatively unexplored ethical issues involved in preimplantation genetic diagnosis (PGD). The document starts from the wide consensus that PGD is ethically acceptable if aimed at helping at-risk couples to avoid having a child with a serious disorder. However, if understood as a limit to acceptable indications for PGD, this 'medical model' may turn out too restrictive. The document discusses a range of possible requests for PGD that for different reasons fall outwith the accepted model and argues that instead of rejecting those requests out of hand, they need to be independently assessed in the light of ethical criteria. Whereas, for instance, there is no good reason for rejecting PGD in order to avoid health problems in a third generation (where the second generation would be healthy but faced with burdensome reproductive choices if wanting to have children), using PGD to make sure that one's child will have the same disorder or handicap as its parents, is ethically unacceptable.

Recombinant human follicle-stimulating hormone (r-hFSH) plus recombinant luteinizing hormone versus r-hFSH alone for ovarian stimulation during assisted reproductive technology: systematic review and meta-analysis

BACKGROUND

The potential benefit of adding recombinant human luteinizing hormone (r-hLH) to recombinant human follicle-stimulating hormone (r-hFSH) during ovarian stimulation is a subject of debate, although there is evidence that it may benefit certain subpopulations, e.g. poor responders.

METHODS

A systematic review and a meta-analysis were performed. Three databases (MEDLINE, Embase and CENTRAL) were searched (from 1990 to 2011). Prospective, parallel-, comparative-group randomized controlled trials (RCTs) in women aged 18-45 years undergoing in vitro fertilization, intracytoplasmic sperm injection or both, treated with gonadotrophin-releasing hormone analogues and r-hFSH plus r-hLH or r-hFSH alone were included. The co-primary endpoints were number of oocytes retrieved and clinical pregnancy rate. Analyses were conducted for the overall population and for prospectively identified patient subgroups, including patients with poor ovarian response (POR).

RESULTS

In total, 40 RCTs (6443 patients) were included in the analysis. Data on the number of oocytes retrieved were reported in 41 studies and imputed in two studies. Therefore, data were available from 43 studies (r-hFSH plus r-hLH, n=3113; r-hFSH, n=3228) in the intention-to-treat (ITT) population (all randomly allocated patients, including imputed data). Overall, no significant difference in the number of oocytes retrieved was found between the r-hFSH plus r-hLH and r-hFSH groups (weighted mean difference -0.03; 95% confidence interval [CI] -0.41 to 0.34). However, in poor responders, significantly more oocytes were retrieved with r-hFSH plus r-hLH versus r-hFSH alone (n=1077; weighted mean difference +0.75 oocytes; 95% CI 0.14-1.36). Significantly higher clinical pregnancy rates were observed with r-hFSH plus r-hLH versus r-hFSH alone in the overall population analysed in this review (risk ratio [RR] 1.09; 95% CI 1.01-1.18) and in poor responders (n=1179; RR 1.30; 95% CI 1.01-1.67; ITT population); the observed difference was more pronounced in poor responders.

CONCLUSIONS

These data suggest that there is a relative increase in the clinical pregnancy rates of 9% in the overall population and 30% in poor responders. In conclusion, this meta-analysis suggests that the addition of r-hLH to r-hFSH may be beneficial for women with POR.

Comparison of hCG triggering versus hCG in combination with a GnRH agonist: a prospective randomized controlled trial

A prospective randomized controlled trial comparing two groups of ICSI (intra-cytoplasmatic sperm injection) patients with a different form of triggering the final oocyte maturation has been performed. All patients received an ovarian stimulation for in vitro fertilisation (IVF) using an antagonist protocol using recombinant-FSH -(rec-FSH) and Ganirelix. 120 Patients were randomized into two groups with similar clinical parameters. The first group had triggering with hCG, whereas the second group received a combination of hCG + GnRH agonist (Gonadotropin Releasing Hormone). As the primary endpoint, the number of metaphase II oocytes were analysed, the secondary endpoints were the number of cumulus oocyte complexes (COC), the number of fertilized oocytes, embryo morphology, pregnancy rate and the number of cryopreserved embryos. The mean number of MII oocytes in the hCG triggered group was 9.2 compared with 10.3 in the hCG-GnRH agonist group. There was no statistically significant difference in the number of COCs or pregnancy rates. However, the number of patients who received at least one embryo of excellent quality was significantly higher (p = 0.001) in the group with the combined triggering (45 out of 61 patients or 73.8%) versus the group with hCG triggering alone (28 out of 59 patients or 47.5%). The number of cryopreserved embryos was also higher in this group.

ESHRE Task Force on ethics and Law 20: sex selection for non-medical reasons

This Task Force document revisits the debate about the ethics of sex selection for non-medical reasons in the light of relevant new technological developments. First, as a result of improvement of the Microsort® flow cytometry method, there is now a proven technique for preconception sex selection that can be combined both with IVF and IUI. Secondly, the scenario where new approaches that are currently being developed for preimplantation genetic screening (PGS) may lead to such screening becoming a routine part of all IVF treatment. In that scenario professionals will more often be confronted with parental requests for transfer of an embryo of a specific sex. Thirdly, the recent development of non-invasive prenatal testing based on cell-free fetal DNA in maternal plasma allows for easy and safe sex determination in the early stages of pregnancy. While stressing the new urgency that these developments give to the debate, the Task Force did not come to a unanimous position with regard to the acceptability of sex selection for non-medical reasons in the context of assisted reproduction. Whereas some think maintaining the current ban is the best approach, others are in favour of allowing sex selection for non-medical reasons under conditions that take account of societal concerns about the possible impact of the practice. By presenting these positions, the document reflects the different views about this issue that also exist in the field. Specific recommendations include the need for a wider delineation of accepted 'medical reasons' than in terms of avoiding a serious sex-linked disorder, and for a clarification of the legal position with regard to answering parental requests for 'additional sex selection' in the context of medically indicated preimplantation genetic diagnosis, or routine PGS.

Pregnancy management and outcome in women with chronic kidney disease

An increasing number of pregnancies occur in the presence of chronic kidney diseases (CKD), mainly including chronic glomerulonephritis (GN), diabetic nephropathy (DN), and lupus nephritis (LN). The most important factor affecting fetal and maternal prognosis is the degree of renal function at conception. In the majority of patients with mild renal function impairment, and well-controlled blood pressure, pregnancy is usually successful and does not alter the natural course of maternal renal disease. Conversely, fetal outcome and long-term maternal renal function might be seriously threatened by pregnancy in women with moderate or severe renal function impairment. The last few years, advances in our knowledge about the interaction of pregnancy and renal function resulted in the improvement of fetal outcome in patients with chronic renal failure and also in the management of pregnant women with end-stage renal disease (ESRD) maintained on dialysis. However, women with impaired renal function and those on dialysis should be carefully counseled about the risks of pregnancy.

Operative treatment of gynaecologic diseases in puberty: seven years of experience

PURPOSE OF INVESTIGATION

The aim of this study is to present the incidence and surgical management of gynaecologic pathology in adolescence in the 1st Obstetrics and Gynecology Department of Aristotle University of Thessaloniki.

METHODS

After a retrospective review of the medical records of over a seven year period (2004-2011), 32 adolescent patients with reported surgical gynaecologic procedures were identified and analysed.

RESULTS

Fourteen out of the 16 adolescents with ovarian masses (eight neoplastic and eight non-neoplastic) were treated by laparoscopy. Congenital anomalies were diagnosed in seven patients and only one of them was treated by laparotomy. The rest were surgically treated for uterine leiomyoma (1), ectopic pregnancy (2), pelvic abscess (1), mesosalpingeal cysts (2), mesenterian cyst (1) and investigation of chronic pelvic pain.

DISCUSSION

Although benign ovarian cysts and congenital anomalies represent the major indication for operative treatment of gynaecologic diseases in puberty, laparoscopy and/or hysteroscopy should be the gold standard procedure after careful preoperative investigation.

Obstetric outcome in adolescence: a single centre experience over seven years

PURPOSE OF INVESTIGATION

The aim of this study was to compare the obstetric outcome of adolescent pregnant women (aged < or = 18) with the outcome of adult pregnant women who delivered in a tertiary university hospital.

MATERIALS AND METHODS

Delivery files from 2004 to 2011 were reviewed concerning age of the pregnant women, parity, gestational age, mode of delivery and birth weight of the neonates.

RESULTS

During the study period 119 (0.94%) out of 10,483 deliveries were performed in adolescent women. Caesarean section was the mode of delivery in 41 adolescent patients (34.45%), while the corresponding rate was 53.6% (5,556 cases) in adult pregnant women. The preterm labour rate in the adolescent group was 13.44% (16 cases) while in the adult group it was 21% (2,201 cases). The most frequent indication of caesarean section in the adults was previous caesarean section (21%).

DISCUSSION

In adolescent pregnancies the caesarean section rate was lower than in adult pregnancies. As far as the prevalent cause of caesarean section is concerned, it was repeat caesarean section for adults while in adolescents it was failure of labour to progress.

Economic evaluation of alternative assisted reproduction techniques in management of infertility in Greece

BACKGROUND

The purpose of this study was to compare Gonal-F(®), a recombinant follicle-stimulating hormone, with Menopur(®), a highly purified human menopausal gonadotrophin (hpHMG) in assisted reproduction in Greece.

METHODS

A decision tree in combination with a Markov model was used to assess the clinical and economical impact of comparators for up to three consecutive cycles. Transition probabilities were derived from the literature and validated by clinical experts. Cost components were derived from the electronic databases of selected private and public clinics. A probabilistic sensitivity analysis was performed to deal with uncertainty and to construct a cost-effectiveness acceptability curve.

RESULTS

There was a statistically significant difference in favor of the recombinant follicle-stimulating hormone arm compared with hpHMG, which was associated with 52 more births (95% uncertainty interval 26-78, P = 0.001) per 1000 patients. The cost per birth was estimated at €16,906 and €17,286 in the recombinant follicle-stimulating hormone and hpHMG arms, respectively. The cost per in vitro fertilization was estimated at €4365 in the recombinant follicle-stimulating hormone arm and €3815 in the hpHMG arm, indicating a difference of €550. The incremental cost per birth for recombinant follicle-stimulating hormone versus hpHMG was estimated at €14,540, while the incremental cost per life-year was estimated at €175.41.

CONCLUSION

Recombinant follicle-stimulating hormone may represent a cost-effective choice compared with hpHMG when used for ovarian stimulation for a pharmacoeconomic point of view in the Greek public health care setting. However, it must be noted that in clinical practice both agents may be used together to increase the number of follicles, oocytes, embryos, and/or pregnancies in treated patients, an approach which has not been evaluated in Greece or reported in the literature due to obvious limitations.

Laparoscopic management of unexpected borderline ovarian tumors in women of reproductive age

PURPOSE OF INVESTIGATION

The aim of this study was to review the clinical features of women with unexpected borderline ovarian tumours.

METHODS

Between October 1992 and December 2010, 1332 out of 4016 laparoscopies were performed for adnexal masses in women of reproductive age and 1838 cysts were removed. When ultrasonographic findings did not meet the criteria for low risk malignancy, tumour markers, colour Doppler and MRI/CT were applied. At laparoscopy any solid component or papilla was sent for rapid frozen section.

RESULTS

Borderline ovarian tumours were found in eight (0.6%) out of 1332 patients, two of which were bilateral. The mean age was 28.75 +/- 9.27 years and the mean diameter of the cysts was 5.1 +/- 1.7 cm. In two cases unexpected malignancy was discovered during the diagnostic and in six cases during the operative phase of the intervention.

CONCLUSION(S)

Risk of failure to diagnose cancer could be minimised with careful patient selection preoperatively. Adequate training on laparoscopic oncology is the necessary prerequisite for a safe laparoscopic approach.

New algorithm for OHSS prevention

Ovarian hyperstimulation syndrome (OHSS) still remains a life-threatening complication of in vitro fertilization treatment (IVF), keeping patients and especially those, who previously experienced OHSS, from attempting infertility treatment and childbearing. The recent implementation of four new modalities: the GnRH antagonist protocol, GnRH agonist (GnRHa) triggering of ovulation, blastocyst transfer and embryo/oocyte vitrification, renders feasible the elimination of OHSS in connection with ovarian hyperstimulation for IVF treatment. The proposed current algorithm is based on the number of follicles developed after ovarian stimulation, setting a cut-off level at the development of 18 or more follicles. Further, fulfilling this criterion, the algorithm is based on four decision-making points: the final day of patient work-up, the day of triggering final oocyte maturation, day-1 post oocyte pick-up (OPU) and day-5 post OPU. If the physician decides to administer hCG for final oocyte maturation regardless the type of analogue used, he has the option on day-1 to either freeze all embryos or to proceed to day-5. On this day, based on the clinical condition of the patient, a decision should be made to either transfer a single blastocyst or to vitrify all blastocysts available. However, this strategy will not guarantee an OHSS free luteal phase especially if a pregnancy occurs. If the physician decides to trigger ovulation with GnRHa, feasible only with the antagonist protocol, embryos can be cultured until day-5. On this day a transfer can be performed with no risk of OHSS and spare blastocysts may be vitrified. Alternatively, on day-1 or day-2 post OPU, all embryos could be frozen. Hopefully, in a near future, GnRHa triggering and vitrification of oocytes will become everyday practice. Only the combined use of a GnRH antagonist protocol with GnRHa triggering and subsequent single blastocyst transfer or embryo/oocyte freezing will completely abolish the risk of OHSS after ovarian hyperstimulation.

Aromatase inhibitors in stimulated IVF cycles

Aromatase inhibitors have been introduced as a new treatment modality that could challenge clomiphene citrate as an ovulation induction regiment in patients with PCOS. Although several randomized trials have been conducted regarding their use as ovulation induction agents, only few trials are available regarding their efficacy in IVF stimulated cycles. Current available evidence support that letrozole may have a promising role in stimulated IVF cycles, either when administered during the follicular phase for ovarian stimulation. Especially for women with poor ovarian response, letrozole appears to have the potential to increase clinical pregnancy rates when combined with gonadotropins, whereas at the same time reduces the total gonadotropin dose required for ovarian stimulation. However, given that in all of the trials letrozole has been administered in GnRH antagonist cycles, it is intriguing to test in the future how it may perform when used in GnRH agonist cycles. Finally administration of letrozole during luteal phase in IVF cycles offers another treatment modality for patients at high risk for OHSS taking into account that it drastically reduces estradiol levels.

Aromatase inhibitors in post-menopausal endometriosis

Postmenopausal endometriosis is a rare clinical condition. The diagnosis and treatment of an endometriotic lesion in postmenopausal women is complicated. First line treatment choice should be surgical, given that there is a potential risk of malignancy. Medical treatment may be considered as second line or as an alternate first line treatment whenever surgery is contradicted and aims to alter the hormonal pathway leading to endometriosis progress. Different hormonal regimens have been administered to these patients, with conflicting however results. Aromatase inhibitors (AIs) represent one of the most recently used drugs for postmenopausal endometriosis. Clinical data for the use of (AIs) in postmenopausal patients is scarce. Up to date only 5 case reports are available regarding the use of these agents in postmenopausal women. Although definite conclusions may be premature, AIs appear to considerably improve patients' symptoms and reduce endometriotic lesions size. Nonetheless the subsequent induced reduction in estrogen production, leads to certain short-term and long-term adverse effects. Despite the limited available data, AIs appear to represent a new promising method which may improve symptoms and treat these patients, either as first line treatment, when surgery is contraindicated or as a second line for recurrences following surgical treatment. However, careful monitoring of patients' risk profile and further research regarding long-term effects and side-effects of these agents is essential prior implementing them in everyday clinical practice.