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4 Hot Fertility Questions at ASRM 2016

By David Kreiner MD

November 7th, 2016 at 7:45 am

The theme for the 2016 ASRM (American Society for Reproductive Medicine) conference in Salt Lake City, Utah was “Scaling New Heights in Fertility”.  As one whose life on Long Island sheltered me from views of snow-capped mountain tops, the perspective of the attendees appeared to climb higher and perhaps to possibilities never previously conceived.

I summarize here 4 Hot Fertility Questions that were debated and discussed in the conference:

1)      Should PGS screening be routine for all IVF patients?

2)      Should all IVF transfers be restricted to blastocysts only?

3)      Should we freeze all embryos and transfer in an unstimulated cycle?

4)      What is the best treatment for the patient with diminished ovarian reserve?

Should PGS screening be routine for all IVF patients? 

The theoretical benefit of Pre-Implantation Genetic Screening, or“PGS”, testing is that it allows one to select a single “tested normal” embryo in the presence of multiple embryos which is more likely to implant and less likely to miscarry.  Absent testing the chromosome number of the embryos, to insure a similar chance of conception one might transfer two embryos– increasing the likelihood that twins would result in a pregnancy at greater risk for prematurity and complications affecting the health of the babies.  Most miscarriages are the result of abnormal chromosomes and if the embryos had normal chromosomes then there should be less of a chance the pregnancy would result in miscarriage.

The argument against routine PGS testing is based mainly on the fact that the test is not 100% accurate or predictive of either normalcy or abnormalcy in addition to not obtaining a result in some cases.  It is argued that the error rate is only 1% but there is a phenomenon called mosaicism where an embryo may have more than one cell line. It is not rare that an embryo which has an abnormal cell line in addition to a normal one can, during development, shed the abnormal cells and evolve normally.  However, PGS testing may pick up only the abnormal cell or detect both normal and abnormal and then there is the question of what to do with the mosaic embryos since there is no current way to predict whether these embryos will ultimately be normal.

Another argument against routine PGS testing is that most abnormal embryos never implant anyway and that perhaps the reduction in miscarriages with PGS is not as great as predicted.  Still another argument that holds true for younger patients in particular is that the pregnancy rate for a single blastocyst transfer is nearly as high without PGS testing and that one can achieve equal success without the risk of discarding potentially normal embryos.

Should all IVF transfers be restricted to blastocysts only?

In addition to improving the ability to select the best embryo, the proposed advantages of a blastocyst transfer (typically 5-6 days old) versus a cleaved embryo transfer (usually 3 days old) include the following:

  • an embryo transferred 5-6 days after ovulation is closer to the natural physiologic state
  • there are thought to be fewer uterine contractions 5-6 days post ovulation than 3 days;
  • blastocysts have a larger diameter and are thought to be less likely to be pushed into the fallopian tubes—which may lead to a lower ectopic pregnancy rate;
  • there is a shorter time to implantation and therefore less opportunity for a deleterious event to occur to an embryo in the uterus.

However, there are some patients, in particular older or those with more fragile embryos, which have been shown to fail to conceive on multiple occasions after a blast transfer but successfully get pregnant and deliver healthy babies after transfer of cleaved embryos.  Furthermore, there is evidence that in some of these cases embryos that may have been destined to otherwise result in a normal pregnancy may fail to develop to blast in the laboratory.

Should we freeze all embryos and transfer in an unstimulated cycle?

There is a growing consensus nationally among IVF programs that the endometrium is less receptive to embryo implantation during a stimulated cycle–especially one in which the estradiol and/or progesterone levels are high.  Although convincing patients to delay transfer to a subsequent unstimulated cycle is a challenge, growing evidence is pushing the field in this direction.

What is the best treatment for the patient with diminished ovarian reserve?

Optimal treatment of the patient with diminished ovarian reserve remains a challenge to the IVF program.  There is growing evidence that adjuvant therapy, including such things as acupuncture and Chinese herbs as well as supplements such as CoQ10 and DHEA, may improve a patient’s response to stimulation and improve pregnancy rates.  Other strategies include sensitizing follicles with estradiol and/or Growth Hormone pre-treatment and banking embryos from multiple cycles with transfer during an unstimulated cycle.  Still another strategy is milder stimulation in an attempt to improve the quality of the retrieved egg/s.

There were many heights achieved during this meeting and to this boy from Queens I was impressed not just with the science and the breathtaking vistas of the regal mountains forming a horseshoe around Salt Lake City but also with the most pleasing goodness of the people native to the city who genuinely offered their time to help make our experience a pleasant one.

 

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