Chair: Neal Mahutte, MD (Medical Director at Montreal Fertility Center)

Dre Dubuc did her medical studies at the Université de Sherbrooke and her residency in Obstetrics and Gynecology in Université de Montréal. She then completed a fellowship in Pediatric and Adolescent Gynecology at SickKids in Toronto. After her fellowship, she started her practise in Obstetrics and Gynecology and Paediatric and Adolescent Gynecology at CHU Sainte-Justine where she also teaches clinical OBGYN to undergraduate students and residents.

She pursues a PhD in Sexology at Université du Québec à Montréal and her thesis subject is the sexual function of women with urogenital malformations.

Her research and clinical interests are mullerian anomalies, gender dysphoria, female genital mutilation and cutting, congenital malformations and their impact on sexual function and sexual health in general.

Transgender Issues: What Does the REI Need to Know?

Transgender persons are more visible and encountered in the Medical practice. This conference is meant for the REI to be better prepared to offer a good quality and holistic care for these patients.

Learning Objectives

1. Know the definition of gender and the variations in gender.
2. Recognize the importance of the treatment of gender dysphoria using the minority stress theory.
3. Recommend a holistic treatment and approach for the transgender individual.

()Dr Montoro completed his psychiatry residency at McGill University and is an Associate professor at McGill University. He co-founded the McGill University Sexual Identity Centre in 1999 which offers mental health care services for individuals with issues related to their sexual orientation or their gender identity, as well being an academic centre for training of health care providers and research. His research interests include the impact of sexual orientation dimensions on suicide risk and family dynamics when a child gender transitions. He won the Innovation of the Year Award from the AMPQ (Association de médecins psychaitres du Québec) in 2000, the Exemplary Psychiatrist Award from AMI-Quebec in 2006 and the May Cohen Prize for Equity, Diversity and Gender from the AFMC (Association of Faculties of Medicine of Canada) in 2015.

Psychological Aspect of Gender Transition and Fertility Preservation

Health disparities in trans individuals have traditionally been significant, but recent studies indicate that supportive and early transitioning leads to much improved mental health outcomes. Adolescent rates of gender questioning are rising and recent epidemiological studies place the prevalence between 1 and 3%. The desire for biologically related children seems lower than cis-gendered individuals, but is still important to many. Fertility preservation prior to transition is increasingly offered but many individuals only choose to explore their fertility after they’ve started transitioning. The psychological impact of contributing gametes from the individual’s initial gendered body is varied, but generally less difficult than the extended state of pregnancy and infant feeding in individuals who do not identify as women. The experience of these individuals in the highly female world of obstetrics can be challenging both for the health care extended team, as well as for the individuals themselves. Strategies for navigating this experience successfully will be discussed.

Learning Objectives

1. Describe the diversity of gender identities in our current culture and their health disparities.
2. Integrate a gender inclusive approach to the Fertility and Obstetrical patient
3. Identify the major positive prognostic factors in psychological adjustment for pregnancy in non-binary individuals and trans men.

Coffee and snacks to be served at the atrium

Chair: Elias Dahdouh, MD (Medical Director CPA CHU Ste-Justine)

()Dr. Peter Chan is Professor of Surgery and the Director of Male Reproductive Medicine at the McGill University Health Center. He received numerous national and international recognitions in his research. He has been serving as Principal and Co-Principal investigator for more than ten research grants funded by the Canadian Institutes of Health Research (CIHR). He is Past President of the Society of Reproductive Surgeon of the American Society of Reproductive Medicine. He is a four-time recipient of the Everett C. Reid Award of Excellence in Teaching in Urology at McGill University.

Dr. Chan has published over 80 professional journal articles, book chapters and videos. He is the senior editor of a textbook entitled “Reproductive Medicine Secrets” and the second edition of “The Andrology Handbook” published by the American Society of Andrology. He is also featured in “Doctorology”, a television documentary produced by the Discovery Channel on the various medical subspecialties.

Indications of Sperm Chromatin Integrity Testing in Male Infertility

While the role of sperm chromatin or DNA integrity has been extensively studied in pre-clinical research in the past few decades, the clinical indications of obtaining sperm chromatin integrity evaluations are less clear. With the growing interest in the recent years among clinician scientists on the impact of the clinical outcomes of assisted reproduction, various groups have recommended the use of sperm chromatin integrity testing in various clinical scenarios that may modify the management strategies for infertile couples, especially those experiencing recurrent unexplained failure with assisted reproduction. It should however be noted that there are various established methodologies available that can provide information on the various aspects of sperm chromatin integrity. Each methodology has its strengths and limitations and clinicians must be informed of the values of these different assays when counseling their patients. It is certain that further investigations focusing on the impact of the sperm chromatin integrity on the outcomes of assisted reproduction, including those on the long-term developmental health of the offspring, are required to allow investigators to formulate evidence-based clinical guidelines on the indications of sperm chromatin integrity testing that can ultimately benefit infertile couples undergoing various forms of fertility management.

Learning Objectives

1. To describe the various assays available to evaluate sperm chromatin integrity
2. To outline the various clinical scenarios that requesting sperm chromatin integrity evaluations for couples undergoing fertility management are indicated
3. To discuss the limitations of the results of sperm chromatin integrity evaluation in modifying the fertility management of couples experiencing recurrent failure of assisted reproduction

()Dr. Armand Zini is Professor of Urology at McGill University and Head of the Division of Urology at St. Mary’s Hospital in Montreal.  Dr. Zini is also the Director of the Andrology Fellowship program at McGill University.

Dr. Zini received his Medical degree and completed his urologic training at McGill University in Montreal. He then completed a fellowship in Male Infertility at the New York Hospital-Cornell Medical Centre and The Population Council in New York.

Dr. Zini’s main expertise is in the area of male infertility. His clinical research interests include varicoceles, sperm retrieval techniques and the role of semen oxidants and antioxidants in male infertility. He has focused his basic research activity on the study of human sperm DNA damage and the impact of this damage on male fertility potential.

Treatment options for abnormal sperm DNA fragmentation

We have made great advances in our understanding of the organization of the sperm chromatin, the etiology of sperm DNA damage and the potential influence of sperm DNA damage on reproduction. The data show that infertile have significantly higher levels of sperm DNA damage than fertile men and this damage is associated with poor reproductive outcomes. Current treatment strategies for sperm DNA damage are aimed at correcting the underlying cause of male factor infertility and at reducing oxidative stress. However, there remains several uncertainties and future studies should be aimed at improving our knowledge of what the various sperm DNA tests measure and at evaluating the relationship between sperm DNA damage and reproductive outcomes. These studies will help establish clinically relevant sperm DNA damage thresholds and allow us to develop sound treatment approaches for infertile men.

Learning Objectives

1. Describe the characteristics of human sperm chromatin and DNA
2. Recognize the etiologies of sperm DNA and chromatin damage
3. Explain the treatment of sperm DNA damage

Lunch to be served in the atrium

Chair: François Bissonnette, MD (Medical Director at Clinique OVO)

()Togas Tulandi is Professor and Chair of the Department of Obstetrics and Gynecology, and Milton Leong Chair in Reproductive Medicine, McGill University.

Besides medical degrees, he also has MSc degree in Health Care Management from Harvard University. The author of over 350 articles, 60 book chapters, and 12 books, he is the Past President of Society of Reproductive Surgeons, the Canadian Fertility and Andrology Society and the Fellowship Board of the American Association for Gynecologic Laparoscopists (AAGL). He is an internationally known reproductive/minimally invasive gynecologic surgeon, and is the Editor-in Chief for the Journal of Obstetrics and Gynaecology Canada.

Dr. Tulandi is a recipient of many awards including the IFFS Anniversary Recognition Award for significant contributions in Infertility and Reproductive Medicine, Award of Excellence in Reproductive Medicine, Carl Nimrod Educator Award, the Society of Reproductive Surgeons (SRS) Distinguished Surgeon Award, and the American Society for Reproductive Medicine Star Award. Dr. Tulandi is listed in Best Doctors in Canada.

Manifestations of Cesarean Scar Defect in Reproductive Aged Women

Cesarean scar defect is commonly seen on transvaginal ultrasound examination, most of them are asymptomatic, and the main symptom are postmenstrual spotting or bleeding. The association between cesarean scar defect and infertility requires more studies. Treatment of uterine scar defect should be done after eliminating other causes of postmenstrual bleeding or infertility. Hysteroscopic isthmoplasty appears to be the most popular treatment. However, in the absence of randomized trial the efficacy of different surgical approaches including vaginal or laparoscopic approaches remains to be seen. Until we have concrete evidence for an effective treatment in symptomatic women with a cesarean scar defect, the treatment should be reserved for selective cases. In women who wish to conceive and the residual myometrium is less than 3 mm, laparoscopic repair is recommended.

Learning Objectives

By the end of the presentation, participants should be able to:

1. Understand the prevalence and relevance of caesarean scar defect in reproductive aged women
2. Discuss the symptoms and treatment of caesarean defect
3. Review the indication and the best type of treatment for infertile women

()Tommaso Falcone, M.D., FRCS(C), FACOG, is Professor of Surgery at the Cleveland Clinic Lerner College of Medicine and Chairman of the Obstetrics, Gynecology and Women’s Health Institute at the Cleveland Clinic.

Dr. Falcone received his medical degree from McGill University School of Medicine in Montreal, Quebec, Canada. He is certified by the American Board of Obstetrics and Gynecology and by the Royal College of Physicians and Surgeons of Canada.

Dr. Falcone has published more than 500 original manuscripts, abstracts, and book chapters. He has served on the editorial board of several journals, including Associate Editor of Fertility & Sterility and the Editorial Board of the Obstetrics &Gynecology (Green journal). He is presently editor-in-chief of JMIG. He is past President of the Society for Reproductive Surgeons (SRS) and Past Chair of the Endometriosis special interest group of the ASRM. He was a senior author on the first publication on gynecologic robot surgery and a member of the team that performed the first uterus transplant in the USA.

Endometriosis – When to Treat

Endometriosis is a common and challenging condition of reproductive-aged women that carries a high individual and societal cost. The many molecular dissimilarities between endometriosis lesions and eutopic endometrium create difficulties in the development of new drug therapies and treatments. Surgery remains the gold standard for definitive diagnosis, but it must be weighed against the risks of surgical morbidity and potential decreases in ovarian reserve, especially in the case of endometriomas. Safe and effective surgical techniques are discussed within this article for various presentations of endometriosis. Medical therapy is suppressive rather than curative, and regimens that are long-term and affordable with minimal side effects are recommended. Recurrences are common and often rapid when medical therapy is discontinued. Endometriosis in the setting of infertility is reviewed and appropriate management is discussed, including when and if surgery is warranted in this at-risk population. In patients with chronic pain, central sensitization and myofascial pain are integral components of a multidisciplinary approach. Endometriosis is associated with an increased risk of epithelial ovarian cancer, however the risk is low and currently no preventative screening is recommended. Hormone therapy for symptomatic women with postsurgical menopause should not be delayed due to concerns for malignancy or recurrence of endometriosis.

Learning Objectives

1. Discuss the impact of surgery on fertility outcome
2. Assess the pain outcome of surgical treatment of endometriosis.
3. Discuss the recurrence risk after medical or surgical management of women with chronic pelvic pain & endometriosis

Coffee and snacks to be served at the atrium

Chair: Louise Lapensée, MD (Clinique OVO, CHUM)

Greg set up his lab to study chromosome segregation in the egg and embryo at University College London in 2007, and moved the lab to CRCHUM at University of Montreal in 2014. Greg lab has made multiple contributions to understanding how the spindle coordinates this process in these specialized environments, which have been published in journals including Current Biology, PNAS, and Development. Greg lab is funded by CIHR, NSERC, CFI, and Foundation Levesque. Greg is joint Editor-In-Chief of REPRODUCTION.

Oocyte Competence and Maturation

Generation of a healthy egg that is able to be fertilized and support preimplantation development is a bottleneck in the reproductive success of many patients. Generating that precious egg depends on a complex multi step choreography that begins even before birth, termed oogenesis. See I will provide an overview of the process then focus on one key step in the process, termed ‘acquisition of meiotic competence’. I will show recent data from the lab that reveal new aspects of how this transition is achieved.

Learning Objectives

1. To understand the basic principles of folliculogenesis oocyte growth
2. To understand the mechanisms chromosome segregation during oocyte maturation
3. To understand the latest concepts in terms of acquisition of oocyte competence to undergo meiosis

()Dr. Benjamin Tsang is Professor of Obstetrics & Gynaecology and Cellular & Molecular Medicine, University of Ottawa and a Senior Scientist, Chronic Disease Program, Ottawa Hospital Research Institute. In 1980, Dr. Tsang joined the University of Ottawa as the Director, Reproductive Biology Unit and served as the Associate Chair (Research) and developed a multi-disciplinary reproductive health research program in the Department. He is an internationally recognized ovarian biologist, who is known for his translational research in cell fate regulation in women’s reproductive health and has defined the basic mechanisms governing normal ovarian follicular growth and offered important insights into the pathophysiology of anovulatory infertility, particularly in PCOS. He has contributed over 215 full-length publications and 19 reviews/book chapters. Professor Tsang has received numerous honours and awards, including the CFAS Award of Excellence in Reproductive Medicine. He served as CFAS President and Director of the Society for the Study of Reproduction.

PCOS Update: From Bench to Clinic

PCOS is a heterogeneous syndrome affecting 10% of women in reproductive age and accounts for 75% of anovulatory infertility. It is associated with hyperandrogenemia, chronic inflammation, suppressed proliferation and enhanced granulosa cell apoptosis and antral follicle growth arrest. Androgens stimulate granulosa cell proliferation and promote preantral follicle growth but suppress later stages of follicular development. As in human PCOS, female rats treated with 5α-dihydrotestosterone (DHT; to mimic hyperandrogenism) exhibit elevated serum level of the adipokine chemerin. Chemerin down-regulates ovarian estrogen synthesis, induces granulosa cell apoptosis and suppresses follicular growth, although whether its action involves immune-regulation is not clear. Immunological functions of chemerin include chemotaxis of macrophages expressing the chemerin receptor. Macrophages play key role in inflammation and the balance between M1 (inflammatory) and M2 (anti-inflammatory) macrophages determines physiological/pathological outcomes. Hyperandrogenism alters M1 and M2 macrophage balance in an ovarian follicle stage-specific and chemerin-dependent manner, leading to antral follicle arrest. Increased chemerin expression in PCOS ovaries regulates monocyte recruitment, macrophage polarization and follicle destiny. Our results suggest that androgen excess affects the immunological niche of the ovary and is important in PCOS pathophysiology. (Supported by CIHR).

Learning Objectives

1. Describe the regulation of ovarian follicular growth and the phenotypes of PCOS including the dysregulation of ovarian follicular growth;
2. Discuss the pathophysiology of anovulatory infertility in PCOS, particularly the dysregulation of the reproductive-metabolic-immunological interface;
3. Describe the knowledge transfer and potential applications in precision medicine for anovulatory infertility in PCOS patients.

Clinician: Ezgi Demirtas, MD (MUHC)

Dr. Ezgi Demirtas is a physician at MUHC Reproductive Centre. She graduated from the Hacettepe University School of Medicine in Ankara, Turkey, in 1998. She completed her residency in Obstetrics and Gynecology at the same university hospital and graduated from the program in 2003. She subsequently worked in the University IVF unit for over one year.

Dr. Demirtas practiced IVF at a private IVF center in Ankara, Turkey, before joining the MUHC Reproductive Centre as a clinical fellow July 2005. She has published many papers on infertility and reproduction. Her research interests include fertility preservation and in-vitro maturation.

()

Embryologist: Jennifer Witmer, MSc, TS (ABB) (OVO Fertilité)

Jennifer received her Masters of Science in Clinical Embryology in 2010 from the University of Leeds. Her career in Clinical Embryology began in 2006 at Genesis Fertility Centre in Vancouver. In 2009, she moved to California and had the opportunity to work at several clinics in the San Francisco area. In 2015 she moved back to Canada and joined the team at Ovo Fertilité in Montréal. Her exposure to a variety of different regulatory practices has been an interesting and valuable experience as an Embryologist. She enjoys all aspects of Embryology, and has been involved in several research projects that aim to improve techniques and outcomes for patients.

She is a certified Technical Supervisor (TS) in both Embryology and Andrology with the American Board of Bioanalysis (ABB) and a member of the Canadian Fertility and Andrology Society (CFAS).

Learning Objectives

At the end of this presentation, participants will be able to:

• Identify and evaluate the risks and benefits of performing ICSI versus conventional insemination for IVF cases of non-severe male factor infertility.
• Validate the efficacy and safety of ICSI for cases of non-severe male factor infertility.
• Demonstrate that the benefits exceed the risks of ICSI in cases of non-severe male factor infertility.

Against ICSI:

()Clinician: Jessica Lefebvre, MD (CHUL, Quebec)

Dre Lefebvre did her medical studies and residency in Obstetrics and Gynecology at Laval University in Quebec City. She then completed a 2 years fellowship in REI at the Université de Montréal. After her Fellowship, she began practicing as a gynecologist and a clinical teacher for students and residents at the CHU de Québec. She also works at Procrea Clinic, a REI clinic in Quebec City.

Her clinical interests are: minimally invasive surgery and treatment for infertile women and women with endometriosis or tubal factor, fertility preservation for patients with cancer and IVF treatments for poor ovarian responders.

Summary

Intracytoplasmic sperm injection (ICSI) has been widely applied in patients within and outside original therapeutic target groups. Pros and cons of such rapidly increasing utilization of ICSI in non-severe male factor will be addressed in this debate. Physicians and embryologists will look at clinical outcomes from current guidelines and relevant studies comparing utilization of ICSI vs conventional IFV cycles. They will also provide their input from different viewpoints. The audience will also be encouraged to participate in this debate.

Learning Objectives

• List the evidence-based indications for use of ICSI for non-severe male factor infertility.
• Evaluate the risks, costs and benefits of performing ICSI in non-severe male factor infertility
• Demonstrate that ICSI does not improve clinical outcomes in non-severe male factor infertility

()Embryologist: Sara Henderson, MSc (McGill)

Sara Henderson is currently an embryologist at the McGill University Health Centre (MUHC) Reproductive Centre, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada.

In 2014, she obtained a Master of Science in Clinical Embryology and Andrology from Eastern Virginia Medical School through the Jones Institute for Reproductive Medicine, Norfolk, USA. She received her Bachelor of Science in Anatomy and Cell Biology from McGill University, Montreal, Canada in 2009.

Prior to being appointed as an embryologist in 2010, Sara joined the MUHC Reproductive Centre in 2005 as a part-time andrologist.

Learning Objectives:

• Interpret relevant studies comparing clinical outcomes in conventional IVF vs ICSI cycles
• Understand the current guidelines concerning the use of ICSI in non-severe male factor infertility
• Identify the different aspects involved in counselling couples with non-severe male factor infertility