A Pilot Analysis of Whole Transcriptome of Human Cryopreserved Sperm

Sperm cryopreservation is a procedure widely used to store gametes for later use, to preserve fertility in patients prior to gonadotoxic treatments or surgery, and for sperm donation programs. The purpose of the study was to assess the impact of cryopreservation on human sperm transcriptome. Semen samples were collected from 13 normospermic men. Each sample was divided into two aliquots. The total RNA was immediately extracted from one aliquot. The second aliquot was frozen and total RNA was extracted after a week of storage in liquid nitrogen. The RNA samples were randomized in four pools, each of six donors, and analyzed by microarrays. The paired Significance Analysis of Microarray was performed. We found 219 lower abundant transcripts and 28 higher abundant transcripts in cryopreserved sperm than fresh sperm. The gene ontology analysis disclosed that cryopreservation alters transcripts of pathways important for fertility (i.e., spermatogenesis, sperm motility, mitochondria function, fertilization, calcium homeostasis, cell differentiation, and early embryo development), although the increase of some transcripts involved in immune response can compensate for the harmful effects of freezing.

Luteal phase support in assisted reproductive technology centers: Italian survey

BACKGROUND

In assisted reproductive cycles (ART), the fine balance of controlling corpus luteum function is severely disrupted. To challenge this iatrogenic deficiency, clinicians aim to provide exogenous support. Several reviews have investigated progesterone route of administration, dosage and timing.

METHODS

A survey about luteal phase support (LPS) after ovarian stimulation was conducted among doctors in charge in Italian II-III level ART centers.

RESULTS

With regards to the general approach to LPS, 87.9% doctors declare to diversify the approach; the reasons for diversifying (69.7%) were based on the type of cycle. For all the most important administration routes (vaginal, intramuscular, subcutaneous) it appears that in frozen cycles there is a shift towards higher dosages. The 90.9% of the centers use vaginal progesterone, and when a combined approach is required, in 72.7% of cases vaginal administration is combined with injective route of administration. When Italian doctors were asked about the beginning and duration of LPS, 96% of the centers start the day of the pickup or the day after, while 80% of the centers continue LPS until week 8-12. The rate of participation of the centers confirms the low perceived importance of LPS among Italian ART centers, while may be considered quite surprising the relatively higher percentage of centers that measures P level. Tailorization to women's needs is the new objective of LPS: self-administration, good tolerability are the main aspects for Italian centers.

CONCLUSIONS

In conclusion, results of Italian survey are consistent to results of main international surveys about LPS.

Algorithm vs. clinical experience: controlled ovarian stimulations with follitropin-delta and individualised doses of follitropin-alpha/beta

In the registrational trials, follitropin delta was compared with a fixed dose of 150 UI of follitropin alpha/beta, finding higher chances to reach a target response of 8-14 oocytes compared to controls. For this reason, follitropin delta is marketed as particularly useful in expected hyper-responder patients. The main outcome of this study is to report if comparable results are reached in a real-life scenario with follitropin alpha/beta personalized doses, based on patients' characteristics. This is a retrospective study performed in two public fertility centres. All first cycles from January 2020 to June 2022 with either follitropin delta (cases) or alpha/beta (controls) in patients with antiMüllerian hormone >2.5 ng/ml were compared by an inverse probability weighting approach based on propensity score. The follitropin total dose was higher in controls (1179.06 ± 344.93 vs. 1668.67 ± 555.22 IU, p<0.001). The target response of 8-14 oocytes was reached by 40.2% of cases and 40.7% of controls (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.65-1.53, p=0.98). Fewer than 8 oocytes were collected in 24.1% of cases and 22% of controls (OR 1.10, 95% CI 0.71-1.69, p=0.67); more than 14 oocytes in 35.7% of cases and 37.3% of controls (OR 0.83, 95% CI 0.54-1.28, p=0.40). Our experience did not find worse results in term of proportion of patients who reached the target response with an algorithm-chosen dose of follitropin delta compared to a personalised starting dose of follitropin alpha/beta, with follitropin delta having the advantage of objectivity. Larger numbers are needed to confirm these results.

Collecting semen samples at home for fertility assessment: time for a new standard?

BACKGROUND

In fertility clinics the standard approach to semen collection involves a private room close to the laboratory to avoid fluctuations in temperature and to control the time between collection and processing. There are still no firm conclusions whether collecting semen at home has any influence on sperm quality and reproductive competence. The purpose of this study was to assess whether the site of semen collection affects semen parameters.

METHODS

This retrospective cohort study performed at a tertiary level public fertility center included 8634 semen samples from 5880 men undergoing fertility assessment from 2015 to 2021. The impact of sample collection site was evaluated using a generalized linear mixed model. A subgroup analysis comparing clinic to home collection within the same patient was performed on 1260 samples from 428 men by paired t-test or Wilcoxon Signed Rank Test.

RESULTS

Samples collected at home (N.=3240) had significantly higher semen volume, sperm concentration and total sperm count respect to samples collected at clinic (N.=5530) (median (range): 2.9 (0.0-13.9) mL versus 2.9 (0.0-11.5) mL, P=0.016; 24.0 (0.0-252.0) million/mL versus 18.0 (0.0-390.0), P<0.0001; 64.6 (0.0-946.0) million versus 49.3 (0.0-1045.0), P<0.0001, respectively). There was no difference in abstinence period and sperm motility. Paired comparisons of semen characteristics in 428 patients with home-collected (N.=583) and clinic-collected (N.=677) samples confirmed a no negative effect on volume and total sperm count.

CONCLUSIONS

Our data provide evidence for a not disadvantage with collection at home.

Optimizing the "Time to pregnancy" in women with multiple sclerosis: the OPTIMUS Delphi survey

Background

The debate on how to manage women affected by multiple sclerosis (MS) during reproductive age is still open, as is the issue of fertility in such patients. Main issue regard the identification of the optimal window for pregnancy and how to deal with medical therapy before and during conception. The aim of this Delphi consensus was to collect the opinions of a multidisciplinary group, involving reproductive medicine specialists and neurologists with experience in the management of multiple sclerosis women with reproductive desire.

Methods

Four experts plus scientific coordinators developed a questionnaire distributed online to 10 neurologists and later discussed the responses and amended a list of statements. The statements were then distributed via an online survey to 23 neurologists (comprising the first 10), who voted on their level of agreement/disagreement with each statement. Consensus was achieved if agreement or disagreement with a statement exceeded 66%.

Results

Twenty-one statements reached consensus after two rounds of voting, leading to the following main recommendations: (1) Fertility evaluation should be suggested to wMS, in case of the need to shorten time to pregnancy and before treatment switch in women on DMTs contraindicated in pregnancy, particularly in case of highly active disease and age > 35 years. (2) ART should not be discouraged in wMS, but the use of DMTs until pregnancy confirmation should be suggested; ART may be considered in order to reduce time to pregnancy in MS women with a reduced ovarian reserve and/or age > 35 years, but in case of an expected poor ART prognosis and the need for more than one ART cycle, a switch to a high-efficacy DMD before ART should be offered. (3) Oocyte cryopreservation may be considered in women with reduced ovarian reserve, with unpredictable time to complete diagnostic workup and achieve disease control; a risk/cost-benefit analysis must be performed in women >35 years, considering the diminished ovarian reserve.

Conclusion

This consensus will help MS neurologists to support family planning in wMS, respecting MS therapeutic needs while also taking into account the safety and impact of advancing age on fertility.

Telehealth for infertile patients during SARS-CoV-2 pandemic: far, and yet close

BACKGROUND

In Italy during the first pandemic wave of SARS-CoV-2 the activity of fertility centers was stopped, with the exception of fertility preservation in oncological patients. We adopted telehealth and we evaluated whether it could help in the management of infertile couples at a fertility center.

METHODS

A longitudinal study performed at a public fertility center. Telehealth was offered to 72 couples referred to our center for a first consultation from March 17th to May 31st, 2020. Percentage of patients who performed the first assisted reproduction technology (ART) cycle or intrauterine insemination (IUI) within 6 months from the first visit and drop-out rate were analyzed during COVID-19 pandemic and compared to historical controls (couples admitted to our center in 2017-2019).

RESULTS

Eighty-five (61/72) percent of the couples accepted telehealth. Time to first treatment after online consultation in telehealth group (4.5±1.8 months) was significantly shorter (P=0.033) respect to time to first treatment after face-to-face visit of historical controls (7.5±6.9 months). After telehealth consultation, we observed a significant reduction (P=0.002) of drop-out rate from 39% in historical controls to 17% of telehealth group. Telehealth significantly diminished the drop-out rate also during the COVID-19 pandemic respect to 73% after traditional face-to-face visits (P=0.0005), with a time to first treatment of 3.7±2.1 months in couples who refused telehealth.

CONCLUSIONS

Telehealth could be a useful tool to facilitate the path of patients in a fertility center.

Does SARS-CoV-2 Affect the Prostate? A Molecular Analysis from a Case Series of COVID-19 Patients

Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) causes COVID-19 that has been spreading worldwide since December 2019. Viral entry into cells requires expression of both angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2) on the surface of the host cell. The male reproductive system, including the prostate, was supposed to be a potential target for SARS-CoV-2 since the presence of ACE and TMPRS2 receptors. This paper investigated for the first time the presence of SARS-CoV-2 mRNA in the prostatic tissue of a patient with active infection. In addition, we searched for the virus in the prostate of five patients after their recovery from COVID-19. The SARS-CoV-2 RNA was not detected in any of the prostate tissues tested even during the acute phase of infection. As case series have limitations, causality cannot be excluded and sporadic evidence of prostatic tissue invasion by SARS-CoV-2 may be detectable.

Long-acting gonadotropin-releasing hormone agonist trigger in fertility preservation cycles before chemotherapy

BACKGROUND

Oocytes/embryo cryopreservation and ovarian function suppression with gonadotropin-releasing hormone (GnRH) agonists (GnRHas) are two established strategies for preserving fertility in patients with cancer, frequently both being offered to the same woman. As the first injection of GnRHa should be administered before chemotherapy, it is usually performed in the luteal phase of the urgent controlled ovarian stimulation (COS) cycle. The GnRHa flare-up effect on recently stimulated ovaries may cause ovarian hyperstimulation syndrome (OHSS) and this risk may discourage some oncologists to offer an ovarian function preservation method with proven efficacy. We suggest the long-acting GnRHa as an option to trigger ovulation for egg retrieval in oncological patients, whenever ovarian suppression during chemotherapy is planned.

PATIENTS AND METHODS

We retrospectively analyzed prospectively collected data from all consecutive ovarian stimulation cases in oncological patients for oocyte cryopreservation from 2016 to 2021 in a single academic referral center. The COS was performed according to good clinical practice standards. Since 2020 long-acting GnRHa trigger was offered to all patients for whom ovarian suppression after cryopreservation was planned. All other patients served as controls, stratified for the triggering method used: highly purified chorionic gonadotrophin 10 000 UI or short-acting GnRHa 0.2 mg.

RESULTS

Mature oocytes were collected, with the expected maturation rate, in all the 22 cycles triggered with GnRHa. The mean number of cryopreserved oocytes was 11.1 ± 4, with a maturation rate of 80% (57%-100%), versus 8.8 ± 5.8, 74% (33%-100%) with highly purified chorionic gonadotrophin and 14 ± 8.4, 80% (44%-100%) with short-acting GnRHa. No case of OHSS was observed after long-acting GnRHa triggering and by 5 days after egg retrieval most patients had reached luteinizing hormone levels showing suppression.

CONCLUSIONS

Our preliminary data show that long-acting GnRHa is efficacious in inducing the final oocytes' maturation, reducing OHSS risk and suppressing ovarian function by the start of chemotherapy.

Vaginal oxygen plus hyaluronic acid on genito-urinary symptoms of breast cancer survivors

OBJECTIVES

This study aimed to evaluate the efficacy of vaginal oxygen and hyaluronic acid on genito-urinary symptoms of breast cancer survivors.

METHODS

Patients were enrolled at the Menopause Outpatient Clinic of a university hospital. Breast cancer patients in a stable relationship, suffering from vaginal atrophy (VA) consequent to hypoestrogenism, were included. Natural oxygen was introduced into the vagina for 15 min, coupled in the last 5 min with a 2% solution of hyaluronic acid. Treatment was repeated five times, every 15 days.

RESULTS

Out of the 40 breast cancer patients enrolled, 65% had no sexual intercourse due to pain. During treatment, the Vaginal Health Index Score gradually improved from 9.5 ± 2.2 to 16.8 ± 2.8 (p < 0.001), the visual analog scale score for dyspareunia decreased from 8.9 ± 1.3 to 3.4 ± 2.1 (p < 0.001) and the Female Sexual Function Index increased from 8.6 ± 6.3 to 15.2 ± 8.1 (p < 0.001). At the end of treatment, only 15% women (p = 0.001 vs. pretreatment) had no intercourse due to pain. Benefits remained 30 days after last treatment.

CONCLUSION

Vaginal oxygenation coupled with hyaluronic acid every 15 days improves VA, sexuality and urinary symptoms of breast cancer patients. Beside data confirmation, additional studies are needed to determine the best interval between treatments, the optimal length of treatment and the long-term duration of the benefits.

Semen parameters and male reproductive potential are not adversely affected after three or more months of recovery from COVID-19 disease

Background

The male reproductive system may be a potential target for SARS-CoV-2 since the presence of ACE and TMPRS2 receptors. After a first report of the presence of SARS-CoV-2 in semen of COVID-19 patients, several papers reported that SARS-CoV-2 was not detected in the semen. However, some evidences indicated that COVID-19 disease could impair semen parameters. During the infection, or in a short period after, a reduction in sperm concentration and motility and an increase in DNA fragmentation were observed, even in asymptomatic patients. There is no conclusive data exploring whether this damage changes with time. We investigated whether COVID-19 disease has a negative impact on semen parameters and male reproductive potential after recovery.

Methods

In this longitudinal retrospective study, we enrolled 20 men who had COVID-19 disease. We compared sperm parameters in samples collected before COVID-19 and after infection (8.3 ± 4.8 months). We also evaluated the reproductive potential in pre- and post-COVID-19 infertility treatments of 8 self-controlled couples as well as in 40 cycles after COVID-19 infection of the male partner.

Results

For most patients, we obtained results of more than one semen analysis before and after COVID-19. After adjusting for age, days of sexual abstinence, frequency of ejaculations and presence of fever, we found no significant difference over time in any semen parameter. The interval between COVID-19 infection and subsequent infertility treatments was 10.7 ± 7.5 months. There were no differences in the embryological and clinical outcomes of infertility treatments performed before and after male infection. One couple obtained a single pregnancy in the post COVID-19 IUI. Normal fertilization (65%), cleavage (99%) and blastocyst development (40%) rates in treatments performed after male infection were within the expected range of competencies. A total of 5 singleton and 1 twin clinical pregnancies were obtained, and 6 healthy children were born. A total of 10 blastocysts have been cryopreserved.

Conclusion

Our data are reassuring that COVID-19 disease has no negative effect on semen quality and male reproductive potential when semen samples are collected three months or more after infection.

mRNA and Viral Vector COVID-19 Vaccines Do Not Affect Male Fertility: A Prospective Study

Purpose

To assess whether mRNA and viral vector coronavirus disease 2019 (COVID-19) vaccines detrimentally affected semen parameters.

Materials and Methods

In this prospective study, we enrolled 101 men vaccinated for COVID-19 (76% received mRNA vaccines, 20% viral vector vaccines, 2% a mixed formulation, and for 2 men no information about vaccine xlink:type was available) in 2021 and with a previous semen analysis. For each man we compared semen parameters before and after vaccination.

Results

Post-vaccine samples were obtained at a median of 2.3±1.5 months after the second dose. After vaccination, the median sample volume significantly decreased (from 3.0 to 2.6 mL, p=0.036), whereas the median sperm concentration, the progressive motility, and total motile sperm count increased (from 25.0 to 43.0 million/mL, p<0.0001; from 50% to 56%, p=0.022; from 34.8 to 54.6 million, p<0.0001, respectively). Thirty-four patients were oligospermic before the vaccine, and also in these patients we observed a significant increase of sperm parameters after vaccine. Finally, we confirmed the aforementioned results in men who received a mRNA or a viral vector vaccine.

Conclusions

The semen parameters following COVID-19 vaccination did not reflect any causative detrimental effect from vaccination, and for the first time we demonstrated that this applies to both mRNA and viral-vector vaccines. The known individual variation in semen and the reduced abstinence time before the post-vaccine sample collection may explain the increases in sperm parameters.

Contraception and Hormone Replacement Therapy in Healthy Carriers of Germline BRCA1/2 Genes Pathogenic Variants: Results from an Italian Survey

Several myths and misconceptions exist about hormones in women with familial predisposition to cancer, and there are few real-life data on their prescription and uptake. To better understand how they are prescribed and accepted in healthy carriers of a BRCA1/2 pathogenetic variant, an online survey was uploaded on Google Forms and shared through social media closed groups of patients' associations, aBRCAcadabra and ACTO Campania. A total of 241 questionnaires were collected. Sexual quality of life was considered of the utmost importance by most of the respondents (mean score of 7 ± 2.8/10), but they felt the counseling they received by healthcare professionals on the topic was insufficient (4.9 ± 3.2/10). Only 57 women out of 233 (24.5%) had used hormonal contraception after being diagnosed as carriers of a BRCA pathogenetic variant, and 42 out of 148 (28.4%) underwent menopause hormonal therapy. The majority of women (53.6% for contraception and 61.5% for menopause) reported being dissatisfied with the counseling received, and 58.2% were not aware of the protective effect of hormonal contraception on the risk of ovarian cancer. An educational effort is desirable to guarantee healthy BRCA carriers reliable contraception and evidence-based menopause counseling.

P-464 Long-acting GnRH agonist ovulation trigger to avoid ovarian hyperstimulation and to combine oocyte cryopreservation with ovarian suppression during chemotherapy

Study question

Is long-acting GnRH agonist (GnRHa) trigger an efficacious and safe option in oocyte cryopreservation cycles before chemotherapy, when ovarian suppression is planned?

Summary answer

The flare-up effect of long-acting GnRHa is able to induce the final oocytes’ maturation and subsequently suppress ovarian function for chemotherapy

What is known already

When both oocyte cryopreservation and gonadal suppression during chemotherapy with long-acting GnRHa are accepted by the patient for fertility preservation (FP), the first injection of GnRHa is administered few days after oocyte retrieval in order to start oncological therapies as soon as possible. Some cases of ovarian hyperstimulation (OHSS) have been described in this setting, as a consequence of the initial flare-up effect on recently stimulated ovaries. The subsequent risks (including a possible delay in the start of chemotherapy) may discourage physicians from proposing gonadal suppression in combination with oocyte cryopreservation, denying women a FP opportunity with proven efficacy.

Study design, size, duration

Prospectively collected data from 75 oncological patients who underwent ovarian stimulation for oocyte cryopreservation from 2016 to 2021 were evaluated. From 2020 all patients for whom ovarian suppression after cryopreservation was planned were offered long-acting GnRHa trigger. All other patients were enrolled as controls, stratified for triggering method used (highly purified Chorionic Gonadotrophin 10000 UI or short acting GnRHa 0.2 mg).

Participants/materials, setting, methods

All the ovarian stimulation cycles for oocyte cryopreservation in oncological patients before chemotherapy were performed in a single tertiary level public fertility centre. Cycle outcomes were evaluated accordingly to the trigger method. Maturation rate was defined as number of cryopreserved mature oocytes/total number of oocytes retrieved. Results were compared by Mann-Whitney U test or Chi-Square test, as appropriate. When the long-acting GnRHa was used for triggering, luteal phase hormones were assessed.

Main results and the role of chance

After controlled ovarian stimulation (COS) with standard or random start antagonist protocol, 13 women received the long-acting GnRHa trigger (Triptorelin 3.75 mg. Group A) 36 hours before oocyte retrieval, 37 women received highly purified Chorionic Gonadotrophin 10000 UI (Group B) and 25 women the short-acting GnRHa (Triptorelin 0.2 mg. Group C). The groups were comparable in terms of demographic and clinical parameters. Median number of mature cryopreserved oocytes in group A was 11 (range 7-18) with a maturation rate of 80% (68-100), 9 (0-24) with a maturation rate of 78% (43-100) in group B, and 12 (0-34), 79% (50-100) in group C (no statistically significative difference). There was no case of OHSS in Group A. One patient in group B and one in group C developed OHSS after administration of long-acting GnRH in the luteal phase after COS (five days after oocytes retrieval). Five days after oocyte retrieval (7 days after trigger), serum FSH median level in group A was 1.29 mUI/ml (0.48-2.50) and LH median level was 1.04 mUI/ml (0.26-2.46).

Limitations, reasons for caution

We are aware that our data should be confirmed by more robust randomized studies and higher numbers.

Wider implications of the findings

We report for the first time the efficacy of long-acting GnRHa in obtaining mature oocytes and in guaranteeing complete suppression by chemotherapy initiation. The feasibility of this strategy is an important step in reducing the risk of OHSS, giving the opportunity to combine oocyte cryopreservation and ovarian suppression during chemotherapy.

Trial registration number

not applicable

P-463 Anti-Müllerian hormone levels in breast cancer patients receiving chemotherapy with or without concurrent luteinizing hormone-releasing hormone agonist: results from the PROMISE phase III trial

Study question

How (neo)adjuvant chemotherapy and concurrent administration of luteinizing hormone-releasing hormone agonist (LHRHa) affect Anti-Mullerian hormone (AMH) and estradiol level dynamics in premenopausal breast cancer patients.

Summary answer

Breast cancer chemotherapy has a major negative impact on patients’ ovarian function and reserve. Women receiving LHRHa showed higher probability of long-term ovarian function recovery.

What is known already

The risk of developing treatment-induced premature ovarian insufficiency (POI) and infertility following chemotherapy is among the most important concern in premenopausal breast cancer patients.

AMH is a promising biomarker for assessing treatment-induced gonadotoxicity in patients receiving anticancer therapies.

Concurrent administration of LHRHa with chemotherapy is associated with a lower risk of treatment-induced ovarian failure and higher rates of menstrual function recovery. However, data on the impact of LHRHa during chemotherapy on patients’ ovarian reserve are still insufficient.

Study design, size, duration

Between 2003 and 2008, the PROMISE-GIM6 trial randomized 281 premenopausal early breast cancer women to receive chemotherapy alone (control group) or chemotherapy plus triptorelin (LHRHa group). Primary endpoints were incidence of early menopause and long-term ovarian function. For exploratory purposes in a subset of patients, AMH and estradiol levels were measured at baseline, &lt;3 months after last cycle of chemotherapy, 1 year after last cycle of chemotherapy, and at the end of adjuvant endocrine treatment.

Participants/materials, setting, methods

The main results of the trial showed that use of concurrent LHRHa significantly reduced the risk of early menopause, increased the chances of long-term ovarian function recovery and did not influence survival outcomes (JAMA 2011, JAMA 2015, JNCI 2022). The present exploratory analysis reports on dynamics of ovarian biomarkers (AMH and estradiol) at baseline and following (neo)adjuvant chemotherapy.

Main results and the role of chance

Out of 281 enrolled patients, 48 enrolled at the coordinating centers had at least one measurement of AMH and estradiol levels at baseline and after (neo)adjuvant chemotherapy. Baseline patient characteristics were similar between treatment arms, with median age being 41 and 39 years, and median AMH levels being 3.9 and 4.9 mcg/L in the control and LHRHa groups, respectively.

In the overall population, estradiol levels showed a significant decrease at the end of chemotherapy, a significant increase after one year, and a return to baseline values at the end of endocrine therapy. By contrast, AMH levels showed a constant decrease over time.

As compared to patients in the control group, those in the LHRHa group had a significant reduction in the risk of early menopause (p = 0.02) and significantly higher estradiol levels at the end of chemotherapy and 1 year after chemotherapy (p &lt; 0.001), suggesting a higher probability of ovarian function recovery. By contrast, no significant differences were observed in the AMH level dynamics between patients receiving LHRHa and those who did not.

Limitations, reasons for caution

Relatively small number of included patients (n = 48) and small number of patients with AMH and estradiol levels determined at each timepoint.

Wider implications of the findings

This biomarker analysis within a phase III randomized trial confirmed that patients receiving LHRHa had a higher probability of ovarian function recovery also supported by estradiol dynamics. However, both patients in the LHRHa and control group showed a major decline in AMH levels after chemotherapy that persisted over time.

Trial registration number

NCT00311636

P-091 Semen parameters and male reproductive potential are not negatively affected after recovery from COVID-19 disease

Study question

Does COVID-19 disease negatively impact on male fertility after adequate time of recovery?

Summary answer

COVID-19 disease did not impact on semen parameters and male reproductive potential in infertile patients, when semen was collected at least three months after recovery

What is known already

The male reproductive system may be a potential target for SARS-CoV-2 since the presence of ACE and TMPRS2 receptors. After a first report of the presence of SARS-CoV-2 in semen of COVID-19 patients, several papers reported that SARS-CoV-2 was not detected in the semen. However, some evidences indicated that COVID-19 disease could impair semen parameters. During the infection, or in a short period after, a reduction in sperm concentration (up to cases of azoospermia) and motility and an increase in DNA fragmentation were observed. There are no conclusive data exploring if these damages persist.

Study design, size, duration

In this longitudinal prospective study, performed at a tertiary level public fertility center from February 2020 to December 2021 we enrolled 20 men who had COVID-19 disease (1 severe, 15 mild/moderate, and 4 asymptomatic). We compared sperm parameters in semen samples collected before COVID-19 and at least three months after recovery (median=6 months, IQR 4-9). We also evaluated the reproductive potential of 18 men who performed ART cycles after the recovery.

Participants/materials, setting, methods

For each man we compared semen parameters before the COVID-19 disease and at least three months after recovery. Semen samples were analyzed following WHO guidelines. Medians and interquartile ranges (IQRs) were reported. The impact of COVID-19 on endpoints (semen volume, concentration, motility) was evaluated by Wilcoxon rank sum test. A subset of 18 patients performed ART cycles after COVID-19 recovery. Outcomes of these cycles were compared with reference performance indicators set at our center.

Main results and the role of chance

Comparing median semen volume and progressive motility before (2.9 ml, IQR 2.0-3.5; 38.5%, IQR 30.0-52.5) and after COVID-19 (2.5 ml, IQR 2.0-3.6; 40%, IQR 30.0-47.5) we did not find any statistical difference (p = 0.766 and p = 0.782, respectively). We observed an improvement of median sperm concentration after disease recovery (before COVID-19: 26.0 million/ml, IQR 16-37, after: 68.0 million/ml, IQR 29.5-93.5, p = 0. 003), which may be due to intra-individual variability and to patients’ management at our center (i.e., oral antioxidant treatments, other therapies, higher ejaculatory frequency). On the whole, semen parameters did not worsen although the median age of patients obviously increased (36.5 years, IQR 33.8-38 versus 37.5 years, IQR 35.9-39.6). Eighteen couples performed 29 ART cycles after recovery from COVID-19 disease of the male partners (12 IUI, 8 FIVET, 9 ICSI of which one from frozen oocytes). Fertilization, cleavage and top-quality rates were within the normal reference ranges of our center. A total of 6 clinical pregnancies were achieved (5 singletons and 1 twin). One gestation ended in a successful healthy newborn, whereas the remining 5 pregnancies are ongoing. A total of 10 blastocysts were vitrificated in 4 cycles, thus further embryo transfers will be performed.

Limitations, reasons for caution

The main limitations of the study are: small sample size, limited generalizability because no data were collected in fertile patients.

Wider implications of the findings

Our data are reassuring about the effect of COVID-19 disease on male fertility, if semen samples are collected at least three months after recovery from infection.

Trial registration number

not applicable

O-017 mRNA and viral vector COVID-19 vaccines do not affect male fertility

Study question

Do mRNA and viral vector coronavirus disease 2019 (COVID-19) vaccines detrimentally affect semen parameters?

Summary answer

The semen parameters following COVID-19 vaccination did not reflect any causative detrimental effect from vaccination.

What is known already

Based on a still debatable observation of detrimental effect of COVID-19 infection on male fertility, unfounded claims in the social media suggested a potential association between COVID-19 vaccine and male infertility. To date, only two reports on the possible effect of COVID-19 mRNA vaccines on semen quality are available. First, a study on semen samples from 75 fertile men analyzed only 1-2 months after vaccination concluded that semen parameters following vaccine were predominantly within the normal WHO reference ranges. Secondly, in 45 men comparison of semen before and after COVID-19 mRNA vaccine showed no significant decreases in any sperm parameter.

Study design, size, duration

This prospective study performed at a tertiary public fertility center included 101 men undergoing ART from January 2018 and December 2021. For each man we compared semen parameters before and after the COVID-19 vaccination: 78% of men received mRNA vaccines (78% Pfizer, 22% Moderna), 20% viral vector vaccines (70% AstraZeneca, 30% Johnson & Johnson), and 2% a mixed formulation. Post-vaccine samples were obtained at a median of 2.3 + 1.5 months after the second dose.

Participants/materials, setting, methods

Semen analysis was performed according to WHO guidelines. Medians and interquartile ranges (IQRs) were reported for all parameters. The impact of COVID-19 vaccine on endpoints (semen volume, concentration, motility) was evaluated by Wilcoxon rank sum test to perform paired comparison of pre- and post-vaccination semen parameters. We also evaluated the following covariates: age, BMI, smoke habit, days of sexual abstinence, and frequency of ejaculations. Analyses were carried out by MedCalc^® software.

Main results and the role of chance

Pre-vaccination samples were obtained after a median abstinence period of 4 days (IQR 3-5) and post-vaccination samples after a median of 3 days (IQR 3-4, p = 0.004). Pre-vaccination median sample volume, sperm concentration, progressive motility, and total motile sperm count (TMSC) were 3.0 ml (IQR 2.2-4.0), 25.0 million/ml (IQR 11.4-38.0), 50% (IQR 40-60) and 34.8 million (IQR 11.6-68.8), respectively. After the second vaccine dose, the median sample volume significantly decreased to 2.6 ml (IQR 1.9-3.5, p = 0.036), whereas the median sperm concentration, the progressive motility, and TMSC significantly increased to 43.0 million/ml (IQR 17.0-86.5, p < 0.0001), 56% (IQR 40-65, p = 0.022) and 54.6 million (IQR 18.9-105.6, p < 0.0001), respectively. Thirty-four patients were oligospermic before the vaccine (mean concentration 7.8 + 4.3 million/ml), and also in this subset of patients we observed a significant increase of the median sperm concentration, progressive motility, and TMSC (p = 0.001, p = 0.002, p = 0.001, respectively) in post-vaccine semen samples respect to the pre-vaccine ones. Finally, we analyzed separately patients who received a mRNA vaccine and those who received a viral vector vaccine, and we confirmed the aforementioned results again in these two groups.

Limitations, reasons for caution

Small sample size, short follow-up, no healthy control group, no evaluation of male reproductive potential i.e., by comparing outcomes of ART cycles before and after vaccination. Nevertheless, this work was preceded by only two other reports published on this issue, and it includes more than twice as many patients enlisted.

Wider implications of the findings

In agreement with literature, COVID-19 vaccination does not reduce sperm quality and for the first time we demonstrated that this applies to both mRNA and viral-vector vaccines. The known individual variation in semen and the reduced abstinence time before the post-vaccine sample collection may explain the increases in sperm parameters.

Trial registration number

not applicable

P-072 Collecting semen samples at home for fertility assessment has a positive effect on sperm quality

Study question

Does site of semen collection (home/clinic) affect semen parameters?

Summary answer

Semen collection is superior when performed at home as compared with at a clinic in terms of sample volume, sperm concentration, and total sperm count.

What is known already

In fertility clinics the standard approach to semen collection for diagnostic analysis and use in ART involves a private room close to the andrological/embryological laboratory. In fact, WHO recommends that semen samples should be collected at clinic to avoid fluctuations in temperature and to control the time between collection and processing. On the other hand, today - due to the COVID-19 pandemic - semen collection at home is widely advised to reduce the time of stay of patients at clinic. There are still no firm conclusions whether collecting semen at home has any influence on sperm quality and reproductive competence.

Study design, size, duration

This retrospective longitudinal cohort study performed at a tertiary level public fertility center included 8634 semen samples from 5880 men undergoing fertility assessment from 2015 to 2021: 5530 samples were collected at clinic from 3773 men, and 3104 at home from 2107 men. For a subgroup analysis comparing clinic to home collection within the same patient, we included 1260 samples from 428 men. Possible effect of seasonal variation on semen parameters was also investigated.

Participants/materials, setting, methods

The impact of sample collection site on endpoints (semen volume, concentration, motility) was evaluated using a generalized linear model for repeated measures in which the following covariates were included: age, BMI, days of sexual abstinence, smoke habit. Paired comparisons between home- and clinic-collected samples within individuals were made by paired t-test or Wilcoxon signed rank test, as appropriate. The effect of seasonality on sperm parameters was investigated plotting the time series of differences between samples.

Main results and the role of chance

Samples collected at home had significantly higher semen volume (p = 0.016), sperm concentration (p &lt; 0.0001), and total sperm count (p &lt; 0.0001) respect to samples collected at clinic. The abstinence period, known to potentially influence these parameters, was similar for all patients. There was no difference in sperm motility. Paired comparisons of semen characteristics in the 428 patients with home-collected (n = 583) and clinic-collected (n = 677) samples confirmed the aforementioned results. The semen sample collections were distributed among all months over 5 years: regarding seasonal variations in semen quality, we did not find any evidence of variations of sample parameters by month.

Limitations, reasons for caution

Some weaknesses should be considered: i) only men undergoing fertility check-up were assessed and it remains to be validated whether our conclusions are applicable to men attempting pregnancy by ART; ii) we did not measure type and degree of psychological stress that may have affected the men in our study.

Wider implications of the findings

Our observation of decrease in semen quality of clinic-collected samples may be the result of an acute psychological stress experienced by patients, as suggested by previous reports. Thus, when possible, semen collection at home should be encourage at least for men who undergo fertility assessment.

Trial registration number

not applicable

Abstract P5-18-05: Long-acting GnRH agonist ovulation trigger to avoid ovarian hyperstimulation and to combine oocyte cryopreservation with ovarian suppression during chemotherapy

Background: Oocyte cryopreservation and gonadal suppression during chemotherapy with long-acting GnRH agonists (GnRHa) are standard fertility preservation (FP) methods in women with breast cancer. When both strategies are accepted by the patient, the first injection of GnRHa is frequently administered few days after oocyte retrieval in order to start oncological therapies as soon as possible. GnRHa suppress gonadal function after an initial stimulation phase due to a gonadotropins surge. Consequently, some cases of ovarian hyperstimulation (OHSS) have been described following GnRHa administration during the luteal phase of an oocyte cryopreservation cycle, as a consequence of the initial flare-up effect on recently stimulated ovaries. OHSS is associated with specific complications, such as an increased thromboembolic risk and a possible delay in the start of chemotherapy. These risks may discourage physicians from proposing gonadal suppression in combination with oocyte cryopreservation, denying women a FP opportunity with proven efficacy. However, since the same flare up effect of short-acting GnRHa (e.g. Triptorelin 0.2 mg) is commonly used to trigger ovulation in high responding infertile patients, we propose the initiation of long-acting GnRHa administration at triggering. Our hypothesis is that by inducing ovulation with long-acting GnRHa we meet the last requirement for oocytes maturation and create suppression by the time patients start chemotherapy, without the need of a further injection in the luteal phase. Methods From 2016 to 2020, 70 consecutive ovarian stimulation cycles for oocyte cryopreservation in oncological patients before chemotherapy were performed in a single university centre. Cycle outcomes were evaluated accordingly to the trigger method. Maturation rate was defined as number of cryopreserved mature oocytes/total number of oocytes retrieved. When the long-acting GnRHa was used for triggering, luteal phase hormones were assessed. Results After controlled ovarian stimulation (COS) with standard or random start antagonist protocol, ten women received the long-acting GnRHa trigger (Decapeptyl 3.75 mg, Ipsen. Group A) 36 hours before oocyte retrieval, 37 received highly purified Chorionic Gonadotrophin (Gonasi HP 10000 UI, IBSA. Group B) and 23 the short-acting GnRHa (Decapeptyl 0.2 mg, Ipsen. Group C). The groups were comparable in terms of demographic and clinical parameters. Median number of mature cryopreserved oocytes in group A was 14 (range 8-22) with a maturation rate of 81% (68-100), versus 9 (0-24) with a maturation rate of 78% (43-100) in group B, and 9 (3-34), 78% (38-100) in group C. There was no case of OHSS in Group A. Two patients developed OHSS after administration of long-acting GnRH in the luteal phase after COS, one in Group B and one in Group C. Five days after oocyte retrieval (7 days after trigger), serum FSH median level in group A was 1.28 mUI/ml (0.48-2.50) and LH median level was 1.04 mUI/ml (0.26-2.46). Conclusion We report for the first time the efficacy of long-acting GnRHa in obtaining mature oocytes and, at the same time, in guaranteeing complete suppression by chemotherapy initiation. We are aware that our data should be confirmed by more robust studies and higher numbers. Nevertheless, the feasibility of this strategy is an important step in reducing the risk of OHSS after ovarian stimulation while giving the opportunity to combine oocyte cryopreservation and ovarian suppression during chemotherapy, with proven efficacy as options to preserve fertility and ovarian function, respectively.

Citation Format: Claudia Massarotti, Matteo Lambertini, Sara Stigliani, Fausta Sozzi, Paola Scaruffi, Paola Anserini. Long-acting GnRH agonist ovulation trigger to avoid ovarian hyperstimulation and to combine oocyte cryopreservation with ovarian suppression during chemotherapy [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-18-05.

Effect of Multiple Sclerosis and Its Treatments on Male Fertility: Cues for Future Research

Multiple sclerosis is a chronic disease that may lead to different types of symptoms and disabilities. with the better quality of life and decreased disability due to early diagnosis and the availability of disease-modifying therapies (DMTs), the treating physician is increasingly asked to counsel patients on its effects on fertility and reproduction. In particular, reproductive issues are still scarcely studied and discussed in men. Among the still open questions are the following: (a) Does multiple sclerosis cause infertility per sè? (b) Is multiple sclerosis correlated with conditions that increase the risk of infertility? (c) Do DMTs or other therapies for multiple sclerosis impact gonadal function in men? The aim of this review is to provide an overview on the available literature data about the reproductive issues unique to men with multiple sclerosis, underlining the numerous areas where evidence is lacking and, therefore, the priorities for future research.

Reproductive issues in carriers of germline pathogenic variants in the BRCA1/2 genes: an expert meeting

BACKGROUND

Healthy individuals and patients with cancer who are carriers of germline pathogenic variants in the BRCA1/2 genes face multiple reproductive challenges that require appropriate counseling and specific expertise.

MAIN BODY

On December 5th-7th, 2019, patient advocates and physicians with expertise in the field of reproductive medicine, fertility preservation, and oncology were invited to "San Giuseppe Moscati" Hospital in Avellino (Italy) for a workshop on reproductive management of women with germline pathogenic variants in the BRCA1/2 genes. From the discussion regarding the current evidence and future prospective in the field, eight main research questions were formulated and eight recommendations were developed regarding fertility, fertility preservation, preimplantation genetic testing, and pregnancy in healthy carriers and patients with cancer.

CONCLUSION

Several misconceptions about the topic persist among health care providers and patients often resulting in a discontinuous and suboptimal management. With the aim to offer patient-tailored counseling about reproductive issues, both awareness of current evidences and research should be promoted.

P–092 The more, the merrier: does ejaculatory frequency influence seminal parameters in oligospermic men?

Study question

Does ejaculatory frequency during the three months preceding semen collection influence semen parameters in oligospermic men?

Summary answer

A frequency of 2–3 ejaculations/week during the three months preceding semen collection significantly optimizes sperm motility, without any reduction in sperm concentration.

What is known already

Male gametes undergo crucial physiological and biochemical changes during epididymal transit, but a longer storage is known to have negative effects on semen quality, especially on motility. Previous studies focused on abstinence prior to semen collection, while few data are available on the effect of ejaculation frequency. On one hand, a longer storage could increase exposure to reactive oxygen species and a pro-inflammatory environment, with a reduction in vitality and motility. On the other, an increased ejaculation frequency could cause a reduction in sperm volume and concentration. The effects of ejaculatory frequency are particularly understudied in men with oligospermia.

Study design, size, duration

This is a retrospective study performed at a tertiary level public infertility center. We included all semen samples, collected both for diagnostic purposes and ART cycles between September 2019 and September 2020, with a sperm concentration of 15 million/ml or less, and an abstinence of 3- 5 days. Exclusion criteria were surgically collected or collected for fertility preservation semen samples.

Participants/materials, setting, methods

Standard demographic and clinical data were recorded, as well as semen parameters. Ejaculation frequency was considered “optimal” (at least 2–3/week) or “reduced” (&lt;1/week). The potential predictive role of ejaculation frequency, age, BMI, smoking habits, previous cryptorchidism, varicocele, days of abstinence on semen parameters was evaluated by univariate and then by multivariate analysis for all factors significant in the univariate models. P &lt; 0.05 was considered statistically significant. Main results and the role of chance: Out of 738 men, 491 reported an optimal ejaculation frequency, 247 had &lt;1 ejaculation/week, no one reported everyday ejaculations. Total sperm mobility (35.91±22.84% vs. 32.28±16.91%, p = 0.02) and sperm rapid progressive motility (5.56±6.09% vs. 4.20±6.1%, p = 0.006) were significantly higher in the group with optimal ejaculation frequency. Ejaculation frequency remained predictive of total mobility (p = 0.04) and rapid progressive mobility (p = 0.03) in a multivariate linear regression model with age and sperm concentration. Sperm volume (2.92±1.56 ml vs. 2.91±1.54 ml, p=NS) and concentration (5.74±5.05 mil/ml vs. 6.05±4.78 mil/ml, p=NS) did not significantly differ depending on the declared ejaculation frequency.

Limitations, reasons for caution

The study is retrospective and ejaculatory frequency was self-reported as an estimate of the mean of the number of ejaculations per week.

Wider implications of the findings: Optimizing ejaculatory frequency may improve ART outcomes as well as success of spontaneous conceptions. There is no reason to limit ejaculatory frequency in oligospermic men for a hypothesized benefic in sperm concentration.

Trial registration number

Not applicable

P–495 Telemedicine in ART during SARS-CoV–2 pandemic : far and yet close

Study question

Could telemedicine help in the management of the infertile couple’s path at a fertility center?

Summary answer

The introduction of telemedicine increased the number of cycles within 6 months from the first consultation and reduced the drop-out rate.

What is known already

In Italy during the complete lockdown due to the first pandemic wave of SARS-CoV–2 the activity of fertility centers were stopped, with the exception of fertility preservation procedures for oncological patients. We therefore proposed a service of telemedicine to our patients, that we called SmartPMA.

Study design, size, duration

A longitudinal study performed at a public infertility center. The SmartPMA service was offered to 93 couples referred to our center from March 9th to May 31st, 2020. Initially 72 couples was interested in SmartPMA. Our center gradually re-opened and the first oocytes retrieval was performed on June 9th .

Participants/materials, setting, methods

Sixty-one out of 72 couples (85%) performed the SmartPMA from April 7th to June 16th, 2020. After acquiring informed consent and sending two anamnestic questionnaires, we booked a video-consultation with a gynecologist and a biologist. Afterwards, we sent medical prescriptions for appropriate clinical tests. At the re-opening, we offered the chance to start the ART cycle. Time to the first treatment and drop-out rates were compared to historical controls (2017–2019) using chi-square test.

Main results and the role of chance

Eleven couples declined the SmartPMA and booked an appointment at the reopening. Only 2 of these couples (18%) actually performed an IVF treatment within six months.

Three out the 61 couples that accepted the SmartPMA did not perform IVF treatments because the age of women exceeded the legal limit to access to a public ART center. Twelve out of 58 couples (21%) did not performed any IVF treatment for the following reasons: 4 women spontaneously got pregnant, 1 couple gave up for medical reasons, 3 were referred to ovodonation, and 4 were lost to follow-up.

Thirty-eight out of 58 couples (66%) (median age of woman: 36 + 4 years, range 27–43) performed at least one ART treatment (14 IUI, 12 ICSI cycle, 12 FIVET cycle). Eight out of 58 couples (14%) needed further clinical tests and their treatments are ongoing. The mean time to first treatment in the SmartPMA couples was 4 + 1 months (range 1–6). After SmartPMA, 66% of the couples performed the first cycle within 6 months, compared to 37% of controls (333/898 couples at their first access to our center from 2017 to 2019), p < 0.00001. The drop-out was reduced from 39% to 20%, p = 0 .0038.

Limitations, reasons for caution

We cannot exclude that the couples that joined the SmartPMA service during the pandemic period were particularly motivated to perform IVF treatments. We are aware of the small sample size and that this is a monocentric study.

Wider implications of the findings: Even after the pandemic, telemedicine can be an useful tool for fertility centers to reduce the discomfort of several visits in hospital, without losing patients but rather ultimately reducing the time to treatments and drop-out.

Trial registration number

Not applicable

P–255 Hyaluronic acid-sperm selection significantly improves the clinical outcome of couples with previous ICSI cycles failure

Study question

Does hyaluronic acid (HA) sperm selection improve the intracytoplasmic sperm injection outcome of couples with previous ICSI cycles failure?

Summary answer

In couples where previous first ICSI failed, selection of HA-bound spermatozoa significantly improved clinical outcomes respect to further standard ICSI.

What is known already

HA is the major component of the matrix surrounding the human oocyte and in physiological fertilization it plays an important role in sperm selection since only mature spermatozoa express specific binding protein and are able to bind to HA. Although several studies demonstrated better outcomes of ICSI with selection of mature HA-bound spermatozoa, such a beneficial effect of HA-ICSI is still controversial and to date no firm clinical guidance for the routine use of HA can be drawn. Further studies are needed to categorize patients that really might benefit from HA sperm selection before ICSI.

Study design, size, duration

A retrospective, longitudinal cohort study performed at a tertiary level public infertility center. We selected 164 couples who performed one or more failed ICSI cycles with low fertilization rate and poor embryo quality in the period 2010–2020 (n = 164 cycles, group A), followed by other standard ICSI (n = 99, group B) and/or HA-ICSI (n = 96 group C) cycles. We included only fresh ejaculated sperm and fresh oocytes.

Participants/materials, setting, methods

Endpoints were fertilization, cleavage, top quality embryo, implantation (IR), clinical pregnancy (CPR), pregnancy loss (PLR), and live birth (LBR) rates. Comparisons among groups were performed using a generalized estimating equation model performed at patient level, to take into account the correlation between observations originating from the same woman. A p-value &lt;0.05, after correction by female age at oocyte retrieval, was considered statistically significant.

Main results and the role of chance

The three groups were similar for number of retrieved, MII and injected oocytes. As regarding embryological outcomes, there was no difference in fertilization and cleavage rates between group A and C (fertilization: 47.55 + 29.88% versus 54.10 + 28.51%, p = 0.096; cleavage: 96.19 + 12.70% versus 97.52 + 10.50%, p = 0.519), nor between group B and C (fertilization: 60.30 + 30.73% versus 53.71 + 28.61%, p = 0.112; cleavage: 92.26 + 20.540% versus 97.55 + 10.44%, p = 0.106). Selection of HA-bound spermatozoa in ICSI significantly improved the embryo quality rate (63.78 + 35.55% versus 51.42 + 34.31% p = 0.024) and the blastulation rate (43.44 + 25.55% versus 17.93 + 25.52%, p = 0.001) respect to standard ICSI. Comparisons of clinical outcomes between group B and group C highlighted significant higher IR (26.16 + 40.47% versus 7.34 + 22.16%, p = 0.0001), CPR/cycle (32.29% (31/96) versus 12.12% (12/99), p = 0.0007, chi-square test), and lower PLR (12.90% (4/31) versus 41.67% (5/12), p = 0.0398, chi-square test) in HA-ICSI respect to standard ICSI cycles. The LBR/cycle in group B was 10.10% (10/99) and in group C was 32.29% (31/96) (p = 0.0029, chi-square test). No stillbirths as well as no malformations in newborns were recorded.

Limitations, reasons for caution

We are aware of the retrospective nature of the study performed in a single ART center.

Wider implications of the findings: This study identified couples with previous ICSI cycles failure as a category of infertile patients that really may benefit from HA sperm selection before ICSI.

Trial registration number

Not applicable

Impact of the COVID-19 pandemic on voluntary terminations of pregnancy in an Italian metropolitan area

PURPOSE

The COVID-19 pandemic and national lockdown from 9 March to 4 May 2020 changed social, familial, and sexual relationships, as well as how citizens interact with the health services. How these profound changes have affected sexuality, contraception and voluntary terminations of pregnancy is still largely undescribed. The main objective of this study was therefore to find out whether the COVID-19 pandemic and ensuing lockdown affected the demand for legal abortion.

MATERIAL AND METHODS

The study period was divided into three phases: the pre-pandemic (January and February 2020); lockdown (March and April); and post-lockdown (May and June). The number and characteristics of women requesting pregnancy termination each month during that time were compared with the stats for the same months in the preceding three years (2017-2019).

RESULTS

Immediately after national lockdown, the number of voluntary abortions markedly declined (-40.45%). The effect was more evident in women below 20 years of age (-66.67%), employed versus unemployed women (-42.71% vs. -21.05), and non-Italian versus Italian citizens (-53.01 vs. -32.85). No difference was found in the mean time from request to execution of the procedure, or in the type of the procedure used.

CONCLUSION(S)

National lockdown reduced the number of unwanted pregnancies, especially in younger women. The Italian health service's response to the demand appears to have been unaffected by the pandemic. However, as the demand for abortion is still high, probably due to unplanned pregnancies among cohabitants within a stable relationship, contraception guidance should be improved among women traditionally deemed low-risk in terms of sexual behaviour.

The PREgnancy and FERtility (PREFER) Study Investigating the Need for Ovarian Function and/or Fertility Preservation Strategies in Premenopausal Women With Early Breast Cancer

Background

Offering ovarian function and/or fertility preservation strategies in premenopausal women with newly diagnosed breast cancer candidates to undergo chemotherapy is standard of care. However, few data are available on uptake and main reasons for refusing these options.

Methods

The PREFER study (NCT02895165) is an observational, prospective study enrolling premenopausal women with early breast cancer, aged between 18 and 45 years, candidates to receive (neo)adjuvant chemotherapy. Primary objective is to collect information on acceptance rates and reasons for refusal of the proposed strategies for ovarian function and/or fertility preservation available in Italy.

Results

At the study coordinating center, 223 patients were recruited between November 2012 and December 2020. Median age was 38 years (range 24 – 45 years) with 159 patients (71.3%) diagnosed at ≤40 years. Temporary ovarian suppression with gonadotropin-releasing hormone agonists (GnRHa) was accepted by 58 out of 64 (90.6%) patients aged 41-45 years and by 151 out of 159 (95.0%) of those aged ≤40 years. Among patients aged ≤40 years, 57 (35.8%) accepted to access the fertility unit to receive a complete oncofertility counseling and 29 (18.2%) accepted to undergo a cryopreservation technique. Main reasons for refusal were fear of delaying the initiation of antineoplastic treatments and contraindications to the procedure or lack of interest in future childbearing. Patients with hormone-receptor positive breast cancer had a tendency for a higher acceptance rates of ovarian function and/or fertility preservation strategies than those with hormone-receptor negative disease.

Conclusions

More than 90% of premenopausal women with early breast cancer, and particularly those with hormone receptor-positive disease, were concerned about the potential risk of chemotherapy-induced premature ovarian insufficiency and/or infertility and accepted GnRHa administration. Less than 1 out of 5 women aged ≤40 years accepted to undergo cryopreservation strategies.

Occurrence of smooth endoplasmic reticulum aggregates in metaphase II oocytes: relationship with stimulation protocols and outcome of ICSI and IVF cycles

STUDY QUESTION

Is there any association between the appearance of smooth endoplasmic reticulum aggregates (SERa) in oocytes and ovarian stimulation, embryological, clinical and neonatal outcomes of ICSI and IVF cycles?

SUMMARY ANSWER

A suboptimal prolonged ovarian stimulation is detrimental to oocytes by inducing the occurrence of SERa, which reduces the reproductive potential of oocytes.

WHAT IS KNOWN ALREADY

Controlled ovarian stimulation recruits oocytes of different qualities. Based on current evidence, it was agreed that non-homogeneous cytoplasm may represent the normal variability among oocytes rather than a dysmorphism with developmental significance. The only exception is the appearance of SERa within the ooplasm. Owing to the lack of univocal evidence in this literature about the safety of injecting oocytes with SERa and the mechanism responsible for the occurrence of SERa, this topic is still a matter of debate.

STUDY DESIGN, SIZE, DURATION

A retrospective, longitudinal cohort study performed at a tertiary level public infertility center. We included 1662 cycles (180 SERa+ and 1482 SERa-) from 1129 women (age: 20-44 years) who underwent IVF/ICSI treatments in 2012-2019. The SERa+ cycles had at least one SERa+ oocyte in the oocyte cohort. The SERa- cycles had morphologically unaffected oocytes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We collected stimulation data and embryological, clinical, neonatal outcomes of SERa- and SERa+ cycles and oocytes.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 347 out of 12 436 metaphase II oocytes (2.8%) were affected by SER. We performed only 12 transfers involving at least one SERa+ embryo. Stimulation length (P = 0.002), serum progesterone (P = 0.004) and follicle size (P = 0.046) at trigger, number of retrieved (P = 0.004) and metaphase II (P = 0.0001) oocytes were significantly higher in SERa+ than SERa- cycles. Fertilization rate was significantly (P < 0.0001) reduced in SERa+ cycles and oocytes compared to SERa- counterparts. Embryos of SERa+ cycles had a lower blastocyst formation rate compared to embryos of SERa- cycles (P = 0.059). Statistical analysis according to a generalized estimating equation model performed at patient level demonstrated that the duration of ovarian stimulation was predictive of SERa+ oocytes appearance. The clinical success of SERa+ cycles was lower than SERa- cycles, although no differences in neonatal birthweights or malformations were recorded in sibling unaffected oocytes of SERa+ cycles.

LIMITATIONS, REASONS FOR CAUTION

Given that SERa+ oocytes were discarded in our center for years and transfers of embryos originating from affected oocytes were generally avoided, clinical outcomes of SERa+ cycles are largely attributable to the transfer of embryos derived from unaffected oocytes of SERa+ cycles and we did not have data about newborns from affected oocytes, since none of the transfers involving SERa+ embryos resulted in a progressive clinical pregnancy.

WIDER IMPLICATIONS OF THE FINDINGS

For the first time, we speculate that the late-follicular phase elevated serum progesterone caused by a suboptimal prolonged ovarian stimulation may be detrimental to the oocytes by inducing the occurrence of SERa, resulting in negative effects on their reproductive potential. This raises the question of whether some stimulation regimens could be worse than others and a change in stimulation protocol would reduce the possibility of producing oocytes with suboptimal maturation. In particular, our data highlight the importance of correct timing of the trigger in order to maximize oocyte collection, not only in terms of numerosity but also their reproductive potential.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Pronuclear score improves prediction of embryo implantation success in ICSI cycles

BACKGROUND

In assisted reproduction technology embryo competence is routinely evaluated on morphological criteria but efficacy remains relatively low. Additional information could be obtained by evaluating pronuclear (PN) morphology. Up to now controversial results have been reported about the prognostic value of PN score. One of the main limitations of literature data is the use of different PN classification methods. In this regard, in 2011 the ESHRE and Alpha Scientists in Reproductive Medicine defined three PN categories to standardize zygote assessment. In this study we evaluated whether the consensus ESHRE-Alpha system for the pronuclear scoring could be an useful additional criterion to improve prediction of embryo implantation potential.

METHODS

This is a retrospective, longitudinal, observational, cohort study. We included 3004 zygotes from 555 women who underwent ICSI treatment at our Center between January 2014 and June 2019. The PN were categorized as score 1: symmetrical, 2: non-symmetrical, 3: abnormal. A subset of 110 zygotes did not cleaved. On day 2-3 1163 embryos were transferred, 232 arrested, and 9 were cryopreserved. Among the 1490 embryos cultured up to day 5-7, 516 became blastocysts: 123 were transferred on day 5 and 393 were cryopreserved. Comparisons of age, cleavage and blastocyst rate, quality of embryos, implantation success among PN score groups were evaluated by chi-square test or Kruskal-Wallis test as appropriate. Potential predictors of embryo implantation were first tested in univariable analysis using generalized estimating equations taking into account correlation between embryos originated from the same patient. Then, variables potentially associated with implantation success (P<0.05) were included in a multivariable analysis for calculating the adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS

There was no significant difference in patients'age, cleavage and blastulation rates, and embryo morphology among the three PNscore groups. The PN score 1-embryos had a greater implantation success respect to score 2-3-ones (OR 1.83; 95% CI 1.34-2.50, P=0.0001). Consistently, the pronuclear score remained predictive of implantation in top quality embryos (OR 1.68; 95%CI 1.17-2.42, P= 0.005).

CONCLUSIONS

The consensus pronuclear score may be routinely included among criteria for embryo evaluation to increase patients' chance of becoming pregnant.

Menstrual cycle resumption and female fertility after autologous hematopoietic stem cell transplantation for multiple sclerosis

Data on fertility after autologous hematopoietic stem cell transplantation (aHSCT) in women with multiple sclerosis (MS) are inconclusive. This study aims to report on post-aHSCT menstrual resumption in a multi-center MS-women cohort. Out of 43 women, 30 (70%) recovered menses after a mean time of 6.8 months. Older age (odds ratio (OR) = 0.5, p < 0.0001) and previous pulsed cyclophosphamide (OR = 0.44, p = 0.005) were independently associated with a reduced menstrual recovery probability. Conditioning regimens' intensity resulted not associated with post-procedure amenorrhea. Our results highlight younger age as significantly associated with menses recovery; proper fertility counseling for MS women candidated to aHSCT both prior- and post-transplantation is therefore warranted.

Contraception in cancer survivors: insights from oncofertility follow-up visits

OBJECTIVE

Current literature suggests that cancer survivors are less likely to receive adequate contraception counseling. However, limited data existed on barriers to contraception usage in this population and on the efficacy of dedicated consultations. This study aims to describe how contraception is perceived by cancer survivors after counseling and acceptance rates of highly effective contraceptives.

METHODS

We retrospectively analyzed clinical records from 313 consecutive cancer survivors at their first follow-up visit at the Oncofertility Unit of a tertiary hospital, from 2014 to 2019. Contraception acceptance and choice were examined stratified for the type of malignancy (hormone-sensible or not). A multivariate logistic regression model was used to evaluate possible predictors of acceptance.

RESULTS

Thity-three women were excluded from the analysis because trying to conceive or already pregnant. Out of the remaining 280, only 9 (3.2%) asked spontaneously for contraception, in all the other visits the issue was brought up by the physician. After counseling 44.3% of the women without contraindications still opted out effective methods for fear of hormones or refusal of more medications. Age < 33 years and being in a relationship were correlated with acceptance.

CONCLUSIONS

Even after a complete counseling in a dedicated service, fears of hormones and refusal of more medications remain strong issues for these patients. Family planning needs to be discussed with cancer survivors, preferably in the context of a long-term healthcare relationship. The Oncofertility Unit should become a privileged place for this type of counseling.

The PREgnancy and FERtility (PREFER) Study Investigating the Need for Ovarian Function and/or Fertility Preservation Strategies in Premenopausal Women With Early Breast Cancer

BACKGROUND

Offering ovarian function and/or fertility preservation strategies in premenopausal women with newly diagnosed breast cancer candidates to undergo chemotherapy is standard of care. However, few data are available on uptake and main reasons for refusing these options.

METHODS

The PREFER study (NCT02895165) is an observational, prospective study enrolling premenopausal women with early breast cancer, aged between 18 and 45 years, candidates to receive (neo)adjuvant chemotherapy. Primary objective is to collect information on acceptance rates and reasons for refusal of the proposed strategies for ovarian function and/or fertility preservation available in Italy.

RESULTS

At the study coordinating center, 223 patients were recruited between November 2012 and December 2020. Median age was 38 years (range 24 - 45 years) with 159 patients (71.3%) diagnosed at ≤40 years. Temporary ovarian suppression with gonadotropin-releasing hormone agonists (GnRHa) was accepted by 58 out of 64 (90.6%) patients aged 41-45 years and by 151 out of 159 (95.0%) of those aged ≤40 years. Among patients aged ≤40 years, 57 (35.8%) accepted to access the fertility unit to receive a complete oncofertility counseling and 29 (18.2%) accepted to undergo a cryopreservation technique. Main reasons for refusal were fear of delaying the initiation of antineoplastic treatments and contraindications to the procedure or lack of interest in future childbearing. Patients with hormone-receptor positive breast cancer had a tendency for a higher acceptance rates of ovarian function and/or fertility preservation strategies than those with hormone-receptor negative disease.

CONCLUSIONS

More than 90% of premenopausal women with early breast cancer, and particularly those with hormone receptor-positive disease, were concerned about the potential risk of chemotherapy-induced premature ovarian insufficiency and/or infertility and accepted GnRHa administration. Less than 1 out of 5 women aged ≤40 years accepted to undergo cryopreservation strategies.

Influence of age on response to controlled ovarian stimulation in women with low levels of serum anti-Müllerian hormone

This study aims at detecting and evaluating differences in quantitative response to controlled ovarian stimulation (COS) with high doses of gonadotropins in women with low serum anti-Müllerian hormone (AMH). About 369 first cycles in a real-life scenario in women between 21 and 43 years old and with AMH ≤0.9 ng/ml were analyzed. Older women had a significantly worse outcome with respect to young women, not only qualitatively, but also in terms of quantitative ovarian response to COS [odd ratio (OR) to obtain at least three MII oocytes with each increasing year of female age: 0.89, 95% CI: 0.85 - 0.94; p < .001]. This study endorses that age is a significant factor when counseling patients with low AMH. AMH levels per se are not a reason to exclude patients from a COS treatment, since pregnancy and live birth can be achieved, especially in younger patients. However, with an AMH equally low, the ovarian response worsens with age, making questionable the effectiveness of a stimulation with high-dose gonadotropins in the older subgroup.

Efficacy and Safety of Controlled Ovarian Stimulation With or Without Letrozole Co-administration for Fertility Preservation: A Systematic Review and Meta-Analysis

Background: The co-administration of letrozole during controlled ovarian stimulation (COS) with gonadotropins is used to limit the potentially harmful effects of a supra-physiological rise in estrogen levels on hormone-sensitive cancers. However, the efficacy and safety of adding letrozole to COS remain debated.

Methods: This is a systematic review and meta-analysis of published studies that compared the efficacy and safety of COS with co-administration of letrozole vs. COS without letrozole in all patient populations. A secondary analysis was done including only the studies in breast cancer patients. The primary efficacy endpoint was the number of retrieved mature Metaphase II (MII) oocytes. Secondary efficacy and safety endpoints were total number of oocytes, maturation rate, fertilization rate, number of cryopreserved embryos, peak estradiol levels, progesterone levels, and total gonadotropin dose. Data for each endpoint were reported and analyzed thorough mean ratio (MR) with 95% confidence interval (CI).

Results: A total of 11 records were selected including 2,121 patients (990 patients underwent COS with letrozole and 1,131 COS without letrozole). The addition of letrozole to COS did not have any negative effect on the number of mature oocytes collected (MR = 1.00, 95% CI = 0.87–1.16; P = 0.967) and the other efficacy endpoints. COS with letrozole was associated with significantly decreased peak estradiol levels (MR = 0.28, 95% CI = 0.24–0.32; P < 0.001). Similar results were observed in the secondary analysis including only breast cancer patients.

Conclusions: These findings are reassuring on the efficacy and safety of COS with gonadotropins and letrozole and are particularly important for fertility preservation in women with hormone-sensitive cancers.

Asymptomatic SARS-CoV-2 infections in pregnant patients in an Italian city during the complete lockdown

Data from both New York and London report a high prevalence of the asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection in pregnant patients admitted for delivery, raising questions on the possible correlated dangers (ie, contacts with healthcare workers; the possible creation of an intrahospital outbreak at birth; and conflicting evidence on vertical transmission). For this study, results from SARS‐CoV‐2 screening via nasopharyngeal swab from maternity wards of the four hospitals of Genoa, Italy, were collected during a month of complete lockdown from 1 April to 30 April 2020. Out of 333 tested women, only 9 were symptomatic. Only one symptomatic patient (0.3%) and six asymptomatic ones (1.8%) tested positive. Out of the six positive asymptomatic patients, five were from the most disadvantaged neighborhood of the city (assessed by postal code). In conclusion, even if Italy was badly affected by coronavirus disease 2019 in the studied month, the reported prevalence of SARS‐CoV‐2 infections in asymptomatic pregnant patients at term was lower than the ones reported in the literature.

An high prevalence of asymptomatic SARS‐CoV‐2 infections in pregnant patients admitted for delivery was reported in literature.

The maternity wards of Genoa, Italy, implemented a universal screening among women admitted for delivery.

During the month of April, 2020 only one symptomatic patient (0.3%) and 6 asymptomatic ones (1.8%) tested positive, despite an high number of new infections in the general population in the same month.

Factors that could have impacted these results are the complete national lockdown during the month and the existence of strong antenatal maternity leave policies.

Beyond fertility preservation: role of the oncofertility unit in the reproductive and gynecological follow-up of young cancer patients

STUDY QUESTION

Are there reasons that motivate young cancer survivors to ask for follow-up visits at an oncofertility unit?

SUMMARY ANSWER

Cancer survivors request oncofertility follow-up visits for the management of treatment-related side effects or ovarian reserve evaluation, even if not (or not yet) wishing for a pregnancy.

WHAT IS KNOWN ALREADY

Personalised oncofertility counselling before gonadotoxic therapies is considered standard of care for young women with newly diagnosed cancer. However, the long-term follow-up of these patients in an oncofertility unit is not described in the literature other than for the use of cryopreserved material.

STUDY DESIGN, SIZE, DURATION

We retrospectively examined rates and reasons for the first follow-up visits of 154 consecutive young female cancer patients (age range: 18-40 years) who underwent a pre-treatment consultation between January 2012 and June 2017. Demographic and clinical data were collected, as well as information about the chosen fertility preservation method, if any.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Rates and reasons for follow-up visits were collected and expressed as percentages. Different reasons were examined in the whole cohort and stratified for type of malignancy. Possible predictive factors for return to the follow-up visit (age, nulliparity, presence of a partner, neoplasm, having cryopreserved material) were investigated through logistic regression.

MAIN RESULTS AND THE ROLE OF CHANCE

Out of 154 patients, 74 returned to the oncofertility unit (48.1%) for a follow-up visit. The first visit was requested mostly at the end of anticancer therapies (51.3% versus 40.5% during therapies and 8.1% after cancer relapse). Among these patients, only 10.8% returned for the first time because they were actively desiring a pregnancy. For the others, the most common reasons for consultations were management of gynecological adverse effects of therapies (29.7%) and evaluation of ovarian reserve not linked to an immediate desire for a pregnancy (39.2%). Other patients asked for contraception (4.1%), menopause counselling (5.4%), or new fertility preservation counselling because of cancer relapse (10.8%). None of the examined factors were significantly predictive of return to the oncofertility unit.

LIMITATIONS, REASONS FOR CAUTION

These findings represent the experience of a single centre. A longer duration of follow-up would be needed to provide more precise information on this regard.

WIDER IMPLICATION OF THE FINDINGS

The role of an oncofertility unit should not be limited to proposing fertility preservation procedures. In the management of young adult cancer patients, the reproductive medical specialist should be considered a key figure not only before but also during and after anticancer treatments to explore salient aspects of gynecological and reproductive health.

STUDY FUNDING/COMPETING INTEREST(S)

This research did not receive any specific funding. M.L. served as a consultant for Teva and received honoraria from Theramex outside the submitted work. The other authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N.A.

SARS-CoV-2 in the semen: Where does it come from?

Background

The recent report of SARS‐CoV‐2 presence in semen samples of six patients, including two subjects who were recovering from the clinical disease, re‐opened the discussion on possible male genital tract infection, virus shedding in semen, sexual transmission and safety of fertility treatments during the pandemic period.

Objectives

To explore current data and hypothesis on the possible sites of SARS‐CoV‐2 infection in the male reproduction system.

Materials and methods

We reviewed the current literature to describe: a) the evidences on angiotensin‐converting enzyme 2 (AC2E) and transmembrane serine protease 2 (TMPRSS2) expression in the testes, accessory glands (including prostate) and the urinary tract; b) other coronaviruses’ (SARS and MERS) ability to infect these sites.

Results

The co‐expression of both ACE2 and TMPRSS2 genes was reported in spermatogonial stem cells, elongated spermatids, in at least a small percentage of prostate hillock cells and in renal tubular cells. Testicular damage was described in autopsies of SARS patients, without evidence of the virus in the specimens. Prostate is a known infection site for MERS‐CoV. SARS‐CoV‐2 was detected in urines.

Discussion

There are still al lot of open questions on the effects of SARS‐CoV‐2 infection on the male reproductive tract. The presence of receptors is not a proof that the testis provides a site for viral infection and it is still unknown if SARS‐CoV‐2 is capable to pass the blood‐testis barrier. The possibility of a prostate involvement has not been investigated yet: we have no data, but theoretically it cannot be excluded. Moreover, the RNA detected in semen could have been just a residual of urinary shedding.

Conclusion

Opening our prospective beyond the testis could be the key to better understand the possibility of a semen‐related viral transmission as well as COVID19 short and long‐term effects on male reproductive function.

Non-invasive mitochondrial DNA quantification on Day 3 predicts blastocyst development: a prospective, blinded, multi-centric study

In ART, embryo quality evaluation is routinely based on morphological criteria. We previously demonstrated that the mitochondrial DNA (mtDNA)/genomic DNA (gDNA) ratio in culture medium was significantly associated with embryo quality and viability potential. The purpose of this prospective, blinded, multi-centric study was to validate the use of mtDNA/gDNA ratio in Day 3 spent medium as a predictor of human embryo developmental competence. The mtDNA/gDNA ratio was assessed in Day 3 culture media (n=484) of embryos from 143 patients by quantitative PCR. A mixed effect logistic regression model was applied. We found that mtDNA/gDNA ratio in Day 3 culture medium combined with embryo morphology improves the prediction upon blastulation compared to morphology alone (P < 0.0001), independent of patient and cycle characteristics. With regard to routine use in clinics, we evaluated the ability of the novel, combined grading score to improve selection of developmentally competent embryos of a single cohort. Including embryos from 44 patients, the sensibility and specificity of the scoring system based on Day 3 morphological stage were 92% and 13%, respectively. Integration with the culture medium mtDNA/gDNA ratio increased the performance of the method (sensibility: 95%; specificity: 65%). The results of this study suggest the possibility of carrying out a non-invasive evaluation of embryonic mtDNA content through the culture medium. When combined with embryo morphology, it has the potential to help embryologists rank embryos and choose which embryo(s) has the greater development potential, and thus should be transferred on Day 3, among sibling embryos with the same morphological grade.

COVID-19 and ART: the view of the Italian Society of Fertility and Sterility and Reproductive Medicine

The COVID-19 pandemic is an unprecedented global situation. As assisted reproductive technology (ART) specialists, we should be cautious, carefully monitoring the situation while contributing by sharing novel evidence to counsel our patients, both pregnant women and would-be mothers. Time to egg collection and drop-out rates are critical parameters for scheduling treatments once the curve of infections has peaked and plateaued in each country. In order to reduce the values for these two parameters, infertile patients now require even more support from their IVF team: urgent oocyte collection for oncology patients must be guaranteed, and oocyte retrievals for women of advanced maternal age and/or reduced ovarian reserve cannot be postponed indefinitely. This document represents the position of the Italian Society of Fertility and Sterility and Reproductive Medicine (SIFES-MR) in outlining ART priorities during and after this emergency.

Failure modes and effects analysis for testicular sperm extraction management process

Failure modes and effects analysis (FMEA) is a proactive risk evaluation to identify and reduce potential failures that may occur during a procedure within a quality management programme. One of the procedures performed in assisted reproduction technology centres is testicular sperm extraction (TESE) as treatment of azoospermic patients. To examine the risks associated with the 'TESE management' process, we applied the FMEA method, before and after implementation of corrective measures defined in a standard operative procedure (SOP). A multidisciplinary team was formed. Possible causes of failures and their potential effects were identified, and risk priority number (RPN) for each failure was calculated. The FMEA team identified 4 process activities, 19 process steps and 19 potential failure modes. The re-evaluation after the corrective measures disclosed a reduction in the number of phases with high/moderate risk (pre-SOP: n = 13; post-SOP: n = 3). Improvements in the traceability system removed 11 out of 13 (85%) steps with a low risk of occurrence. In our experience, FMEA is efficient in helping multidisciplinary groups to strengthen knowledge and awareness on routine processes, identifying critical steps and planning practical improvements for a better compliance with criteria of traceability and conformity of biological samples and patients.

Gonadotropin Releasing Hormone Agonists Have an Anti-apoptotic Effect on Cumulus Cells

Background: Ovaries are sensitive to chemotherapy, which may lead to early depletion of primordial follicle reserve. One strategy for gonadal function preservation is temporary ovarian suppression with Gonadotropin Releasing Hormone agonists (GnRHa) during chemotherapy. To date, GnRHa protective mechanism of action remains not fully elucidated. Methods: We collected 260 immature cumulus cell-oocyte complexes (COC) from 111 women < 38 years old, with a normal ovarian reserve. The COC were randomly assigned to the following groups: (a) control; culture with the addition of (b) GnRHa; (c) cyclophosphamide; (d) cyclophosphamide plus GnRHa. After in vitro treatments, RNA and proteins were extracted from oocytes and cumulus cells (CC), separately. Potential effects of drugs were evaluated on GnRH receptors, apoptosis pathways, ceramide pathway, and glutathione synthesis by quantitative PCR and, whenever possible, by Western blot. Results: Cyclophosphamide triggered activation of the extrinsic pathway of apoptosis mediated by BAX in CC. The co-administration of GnRHa inhibited the apoptosis pathway in CC. According to our model, the GnRHa does not directly act on oocytes, which do not express GnRH receptors. Moreover, glutathione synthesis was decreased after GnRHa treatment both in CC and oocytes. Conclusion: Our data suggest that the protective mechanisms induced by GnRHa is mediated by an anti-apoptotic effect on CC.

Combined treatment with myo-inositol, alpha-lipoic acid, folic acid and vitamins significantly improves sperm parameters of sub-fertile men: a multi-centric study

OBJECTIVE

Reduction in motility and number of spermatozoa and change in their morphology are some of the most relevant causes of male infertility. Production of reactive oxygen species may affect motility, morphology and DNA stability of spermatozoa. This study aimed at evaluating the effect of combined treatment with myo-inositol, alpha-lipoic acid, folic acid, betaine and vitamins (namely, Sinopol®) on semen parameters of sub-fertile men.

PATIENTS AND METHODS

We recruited 143 sub-fertile men, 26-53 years aged, no-smokers, without any testicular pathologies, with a normal endocrinological/metabolic profile, and no concomitant consumption of drugs. Out of them, 25 patients did not meet study inclusion criteria mainly due to the history of genital diseases that came to light after Sinopol® prescription. Among the 118 men that fulfilled inclusion criteria, 10 (8.4%) patients were lost at follow-up and in 8 (6.8%) cases the partner got pregnant spontaneously. Thus, 100 patients completed the study and semen analysis was performed before and after 90 days of treatment.

RESULTS

Semen quality improved after 90 days of treatments, with a statistically significant increase of sperm concentration (p=0.0009), of number of spermatozoa (p=0.0017), of progressive motility (p=0.0047), of total motile sperm count (p=0.0010), and of normal sperm morphology (p<0.0001).

CONCLUSIONS

For the first time we reported that a combination of nutraceuticals composed of myo-inositol, alpha-lipoic acid, folic acid, betaine and vitamins improves sperm parameters in sub-fertile men. We are aware that to clarify the clinical relevance of the data studies with larger sample sizes and longer durations are needed, as well as evaluation of myo-inositol and alpha-lipoic acid co-treatment effectiveness in improving the chances to obtain a pregnancy spontaneously or following assisted reproduction.

Impact of infertility and infertility treatments on quality of life and levels of anxiety and depression in women undergoing in vitro fertilization

This study aims to evaluate levels of anxiety and depression in women, correlated with infertility per se and with infertility treatments, highlighting predictors of higher levels of distress. Two validated standardized questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Fertility Quality of Life (FertiQoL), were administered to 89 women both before their first cycle of infertility treatment and again at the end of the ovarian stimulation for in vitro fertilization (IVF). Women's levels of anxiety were significantly higher before the treatment than during the treatment itself. Stratifying the women in three groups based on principal cause of infertility (male infertility, female infertility, or both male and female), we found significantly higher levels of anxiety and general distress in patients under treatment for female infertility. Higher anxiety levels in our sample before the treatment are probably an effect of not knowing what they are expected to do to solve their problem. Moreover, when the cause of infertility is exclusively female, women experience higher levels of anxiety and general distress both before and during the treatment, probably correlated to a sense of guilt. These data help the treating physician to better counsel patients and to provide a more focused psychological support.

Presence of aggregates of smooth endoplasmic reticulum in MII oocytes affects oocyte competence: molecular-based evidence

STUDY QUESTION

Does the presence of aggregates of smooth endoplasmic reticulum (SERa) impact the transcriptome of human metaphase II (MII) oocytes?.

SUMMARY ANSWER

The presence of SERa alters the molecular status of human metaphase II oocytes.

WHAT IS KNOWN ALREADY

Oocytes presenting SERa are considered dysmorphic. Oocytes with SERa (SERa+) have been associated with reduced embryological outcome and increased risk of congenital anomalies, although some authors have reported that SERa+ oocytes can lead to healthy newborns. The question of whether or not SERa+ oocytes should be discarded is still open for debate, and no experimental information about the effect of the presence of SERa on the oocyte molecular status is available.

STUDY DESIGN, SIZE, DURATION

This study included 28 women, aged <38 years, without any ovarian pathology, and undergoing IVF treatment. Supernumerary MII oocytes with no sign of morphological alterations as well as SERa+ oocytes were donated after written informed consent. A total of 31 oocytes without SERa (SERa-) and 24 SERa+ oocytes were analyzed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pools of 8-10 oocytes for both group were prepared. Total RNA was extracted from each pool, amplified, labeled and hybridized on oligonucleotide microarrays. Analyses were performed by R software using the limma package.

MAIN RESULTS AND THE ROLE OF CHANCE

The expression profiles of SERa+ oocytes significantly differed from those of SERa- oocytes in 488 probe sets corresponding to 102 down-regulated and 283 up-regulated unique transcripts. Gene Ontology analysis by DAVID bioinformatics disclosed that genes involved in three main biological processes were significantly down-regulated in SERa+ oocytes respective to SERa- oocytes: (i) cell and mitotic/meiotic nuclear division, spindle assembly, chromosome partition and G2/M transition of mitotic cell cycle; (ii) organization of cytoskeleton and microtubules; and (iii) mitochondrial structure and activity. Among the transcripts up-regulated in SERa+ oocytes, the most significantly (P = 0.002) enriched GO term was 'GoLoco motif', including the RAP1GAP, GPSM3 and GPSM1 genes.

LARGE SCALE DATA

Raw microarray data are accessible through GEO Series accession number GSE106222 (https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE106222).

LIMITATIONS, REASONS FOR CAUTION

Data validation in a larger cohort of samples would be beneficial, although we applied stringent criteria for gene selection (fold-change >3 or <1/3 and FDR < 0.1). Surveys on clinical outcomes, malformation rates and follow-up of babies born after transfer of embryos from SERa+ oocytes are necessary.

WIDER IMPLICATIONS OF THE FINDINGS

We provide information on the molecular status of SERa+ oocytes, highlighting possible associations between presence of SERa, altered oocyte physiology and reduced developmental competence. Our study may offer further information that can assist embryologists to make decisions on whether, and with what possible implications, SERa+ oocytes should be used. We believe that the presence of SERa should be still a 'red flag' in IVF practices and that the decision to inseminate SERa+ oocytes should be discussed on a case-by-case basis.

STUDY FUNDING/COMPETING INTEREST(s)

This study was partially supported by Ferring Pharmaceuticals. The authors have no conflicts of interest to declare.

A successful healthy childbirth and an ongoing evolutive pregnancy in a case of partial globozoospermia by hyaluronic acid sperm selection

We here report a successful healthy childbirth and an ongoing evolutive pregnancy in a case of partial globozoospermia after selection of mature spermatozoa bound to hyaluronic acid (HA). The couple underwent two in vitro fertilisation (IVF) cycles. In the first attempt, 14 MII oocytes were retrieved. Randomly, seven oocytes were injected by conventional PVP-ICSI and seven by HA-ICSI. Fertilised oocytes were 2/7 and 4/7 after PVP-ICSI and HA-ICSI respectively. Transfer of two grade A embryos from HA-ICSI lead to birth of a healthy baby. The surplus embryo of the HA-ICSI group was vitrified at blastocyst stage. The two embryos from PVP-ICSI arrested their development. Two years after the childbirth, the vitrified blastocyst was transferred into the uterus, but implant failed. In the second cycle, 14 MII oocytes were retrieved and they were injected by HA-ICSI. Fertilised oocytes were 10 out of 14 injected oocytes. On day 5, two blastocysts were transferred into uterus and a single evolutive pregnancy is ongoing. On day 6, one blastocyst was vitrified. The remaining surplus embryos arrested their development. A healthy childbirth and an ongoing evolutive pregnancy in two consecutive ICSI attempts of the same couple suggest that HA sperm selection might assist in cases with partial globozoospermia.

Controlled ovarian stimulation and IVF pregnancy in a trisomy X carrier with associated hypogonadotropic hypogonadism

We describe successful controlled ovarian stimulation (COS) and the first known IVF pregnancy in a trisomy X carrier with associated hypogonadotropic hypogonadism (HH) linked to a chromosome 4 double mutation in the allele of the Gonadotropins Releasing Hormone receptor (GnRHr) gene. Previous administration of low dose of gonadotropins, as recommended in patients with HH, led to poor follicular recruitment. Since trisomy X is a risk factor for diminished ovarian reserve (DOR) and premature ovarian insufficiency (POI), higher doses of gonadotropins led to better ovarian response. The report readknowledges the importance of a correct genetic evaluation in a competent laboratory as a reliable base for treatment planning in this kind of patients.