Oral Presentations Clinical II

Meredith Vanstone1, Mita Giacomini1, Lisa Schwartz1, Leichelle Little2
1Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON; 2Health Professional Education PhD Program, Western University, London, ON

Introduction: The use of non-invasive prenatal testing (NIPT) has rapidly expanded in the past five years, both in frequency of use and scope. Ontario began public funding for NIPT in early 2014, which has brought this technology to a wider group of clinicians and pregnant women than have access in other jurisdictions.

Methods: We used constructivist grounded theory methodology to conduct interviews with 38 Ontario women who have had personal experiences with NIPT and 21 Ontario clinicians who frequently encounter NIPT in their professional lives. We used the technique of constant comparative analysis to produce a descriptive comparison of the ethical concerns about NIPT identified by women and clinicians.

Results: We will provide a broad description of the range of ethics issues identified by both women and clinicians, highlighting areas of congruence and disjuncture. In this presentation we focus on new ethical challenges presented by NIPT, including industry influence, inconsistency and uncertainty of published accuracy statistics, clinically insignificant or uncertain findings, inequity of access, potential for increasing the number of detected conditions and uncertainty about the clinical utility of particular findings. Both women and clinicians identified specific ethical concerns related to counselling about NIPT and equity of access. In terms of differences in identified issues, clinicians tended to focus on ethics concerns related to the health care system (e.g. implementation, clinical utility, cost implications) while women were more concerned with ethical issues relevant to society (e.g. “designer babies”, encouragement to terminate pregnancies when disability is identified).

Conclusions: NIPT has rapidly diffused in Ontario, and both women and clinicians express enthusiasm at the possibilities of this technology alongside concerns for a variety of ethical implications. Women and clinicians are united in call for ethics and policy considerations to keep pace with rapid technological development and expansion; our data provides specific examples where ethics and policy oversight is required.

Michael H Dahan, Rachel Bond, Tehila Fineberg, MariePierre Bastrash, Sofa Miconiatis, David V. Morris
McGill University, Royal Victoria Hospital, Montreal, QC

Objective: PCOS is a disease of hyperandrogenism and insulin resistance (IR). Adiposity combined with the PCOS associated IR can lead to pancreatic deficiency and DMII. 30-50% of men with DMII have testosterone deficiency and hypogonadism. The effect of DMII on androgen levels in PCOS has yet to be studied. Therefore, this study was performed to determine the effect of DMII on serum androgen levels in women with PCOS.

Material and methods: An observational cross-sectional analysis from a longitudinal prospective cohort study held by a University Health Centre at an endocrinology clinic was performed. Enrolment was commenced in 1987 and observations continue. IRB approval was obtained and subjects signed consents. A total of 491 women had complete information available in our database and were included for analysis; 311 women with PCOS and 180 normal ovulatory control women without PCOS. Data was confirmed for normalcy and analyzed with logistic regression analysis to control for confounding effects.

Results: When comparing the two groups, women with PCOS were significantly younger, had higher BMIs and higher levels of free and total testosterone, androstenedione, DHEA and DHEAS (P<0.0001, in all cases) than controls. Women with PCOS also had higher levels of fasting insulin (P<0.0001) than controls. Among PCOS 27 women had diabetes and 284 women did not. When controlling for age and BMI, we found that women with DMII PCOS as compared to PCOS without DMII had significantly lower levels of 30 minute stimulated DHEA (56.3 ± 47.0 vs. 62.0 ± 34.0 nmol/L, p=0.03) but higher levels of 30 minute 17-OH-Progesterone (17OHP) (6.3 ± 5.1 vs. 6.2 ± 8.1 nmol/L, p=0.001) in response to a 250mcg ACTH stimulation test.

Conclusion: DHEA levels are decreased in women with PCOS who have DMII compared to those without DMII. The reason behind why the same association was not seen with 17-OHP remains unclear.  We suggest that the loss of insulin secretion associated with the development of diabetes is associated with altered androgen precursor steroid synthesis. This hypothesis is in accord with our previous evidence that hyperinsulinemia is associated with elevated DHEA levels.

Andrew Lee1, Natalia Yasovich1, Paula Mackie1, Sergey Moskovtsev1,2, Clifford L. Librach1,2,3
1Create Fertility Centre, Toronto, ON; 2Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; 3Department of Gynecology, Women’s College Hospital, Toronto, ON

Introduction: DNA damage in sperm has been associated with a range of adverse clinical outcomes, including reduced fertility and increased miscarriage rates. Mechanisms of DNA damage are not well understood and appear to be multi-factorial. Semen preparation via density gradient centrifugation (DGC) is commonly used to achieve a high quality sperm population with enhanced motility and morphology for ART. However, controversy still exists as to whether DGC is a reliable method of selecting a low DNA damage sperm population. The aim of this study was to compare sperm DNA damage after DGC or swim-up (SU) and to examine possible underlying causes predisposing sperm to DNA damage including incomplete chromatin remodeling.

Methods: Institutional REB approval was obtained. Excess donated semen was divided and processed by DGC or SU (without centrifugation). DNA damage was reported as DNA Fragmentation Index (DFI) and assessed by flow cytometry. As a measure of chromatin maturation, spermatozoa were stained with aniline blue (AB) and chromomycin A3 (CMA3) to detect residual histones and protamine deficiency, respectively.

Results: Mean DFI of neat ejaculates was 25.7% ± 16.5. DFI decreased significantly following SU (6.4 % ± 6.9) (P< 0.006). In contrast, mean DFI increased following DGC (40.4% ±23.9). While improvement in DFI was observed across all SU samples, only 50% of samples benefited from DGC, while the rest had increased DFI (n=8). There was a positive correlation between DFI and residual histone content (P< 0.001, R=0.72, n=21), and between DFI and protamine deficiency (P<0.05, R=0.58, n=19) across all treatments. Changes in CMA3 (P=0.88, n=5) and AB (P=0.42, n=6) after swim-up or DGC compared to the neat sample were not statistically significant.

Conclusion: These preliminary results reveal a population of patients with increased DNA damage following DGC. The exact mechanism, however, remains unclear. Though evidence of residual histones and protamine deficiency were correlated to DFI, it couldn’t explain why DGC failed to reliably filter out DNA damaged sperm. Subsequent experiments underway will examine oxidative stress as a mechanism of DNA damage. DFI testing is routinely performed on neat ejaculates. However, as the prevalence of increased DNA damage post-preparation is still unknown, we plan to test spermatozoa post-preparation to ensure that a low DFI population can be isolated for ART.

Belén Herrero, Weon-Young Son, William Buckett, Peter Chan
MUHC Reproductive Centre, McGill University Health Centre, Montreal, QC

Introduction: Recurrent unexplained ICSI failure is among the most challenging scenarios in reproductive medicine. There is a growing interest in repeating ICSI using surgically retrieved testicular sperm (T-ICSI) to improve the outcomes. However, most current series demonstrated an improvement in the ART outcomes used the same couples’ previous failed ICSI cycles as a comparison. As a result, the efficacy of ICSI with testicular sperm may be inflated. The objective of our study was to evaluate the efficacy of T-ICSI outcomes in couples with recurrent failed ICSI cycles using ejaculated sperm by comparison to the outcomes of a new ejaculated sperm ICSI cycle (E-ICSI) in couples with similar history of recurrent ICSI.

Methods: From 2010 to 2015, in a university-based reproductive center, ICSI outcomes using testicular sperm in couples with primary infertility with at least two failed attempts of ICSI with ejaculated sperm were retrospectively analyzed. Comparison was made to outcomes of a new ejaculated sperm-ICSI cycle from a separate cohort of couples from the same center and study period with primary infertility with at least two failed attempts of ICSI. TESA was performed by a single surgeon. Two-tailed t-tests for unequal variance using alpha of 0.05 were used for comparison of means. Proportion data were analyzed with Barnard’s tests, using alpha of 0.05.

Results: A total of 77 testicular sperm-ICSI (T-ICSI group) and 68 ejaculated sperm-ICSI (E-ICSI group) cycles were compared. The median ages of the male (40.4 vs 40.1) and female partners (36.6 vs 36.8) were similar in both groups.  The median sperm concentrations (37.6×106/ml vs 51.3×106/ml) and percentage forward motility (23.5 vs 32.3), but not percentage normal morphology (4.2 vs 4.6), of the two groups differed significantly. The mean number of previous failed ICSI cycles (2.6 vs 2.8), average number of MII oocyte collected per cycle (6.5 vs 6.5) and mean fertilization rates (62.7% vs 63.6%) were similar.  T-ICSI group had a significantly higher pregnancy rate per cycle started (23.3% vs 8.8%) and per embryo transferred (27.9% vs 10%). The live birth rate was significantly higher with T-ICSI group (23.4% vs 11.4%). Further, contrast to men with semen parameters meeting the 2010 WHO reference values or with normal sperm chromatin quality, men with abnormal semen parameters or impaired sperm chromatin quality (TUNEL >36% or SCSA >30%) had significantly better ICSI outcomes when using testicular sperm for ICSI.

Conclusions: To our knowledge, this is the first and largest series in the literature evaluating the efficacy of testicular sperm for ICSI in men with recurrent failure of ICSI with ejaculated sperm by comparing the outcomes of a separate cohort of couples with similar history of ICSI failure entering a new ICSI cycle with ejaculated sperm. Our results indicated that in these couples, particularly those with abnormal ejaculated sperm parameters or chromatin quality, the use of testicular sperm yields significantly better ICSI outcomes. Further analyses are required to identify the efficacies of T-ICSI in other subgroups of patients with recurrent ejaculated sperm- ICSI failure.

Kim Garbedian1,2, Winnie Yan1,2, Alex Hartman3, Tom Hannam1,2
1Colorado Centre for Reproductive Medicine (CCRM)- Toronto; 2Hannam Fertility Centre, Toronto, ON, 3True North Imaging; Toronto, ON

Introduction: Subchorionic hemorrhage (SCH) is a common, often incidental, ultrasound abnormality in early pregnancy1. They often cause distress, as SCHs have been associated with spontaneous abortion (SA) and adverse obstetrical outcomes1,2. There is disagreement in the literature regarding the risk of SCH in fertility populations. Sayago et al. found a significantly higher incidence in fertility compared to normal obstetrical patients3. Whereas Rosentbluth et al. did not find a significant difference2. More specifically, Asato et al., found a significantly higher frequency in IVF compared to non-IVF patients4. This discrepancy may be because IVF, not infertility, is the risk factor for SCH. The objective of this study is to determine the incidence of SCH in our IVF population and further investigate this relationship by comparing fresh vs. frozen embryo transfer (ET).

Materials & Method: Retrospective cohort study investigating 258 clinical IVF pregnancies between January 2014 and March 2016 at a private fertility clinic in Toronto, Canada. Patients underwent standard agonist or antagonist IVF protocols with either a fresh or frozen ET. All patients with clinical pregnancies had 2-4 first trimester ultrasounds. The incidence of SCH and SA on first trimester ultrasound was determined. More specifically, the incidence of SCH and SA in fresh (n=120) vs. frozen (n=138) ET was compared.

Results: The incidence of SCH and SA in our IVF population was 36.8% and 13.6% respectively (n=258). The incidence of SCH was significantly higher in pregnancies after frozen (43.5%, n=138) vs. fresh ET (29.2%, n=120) P=0.0.017. There was no significant difference in SA in fresh (13.2%, n=120) vs. frozen ET (13.04%, n=138) P=0.966. Overall, only 4.2% (n=95) of SCHs resulted in a SA.

Conclusion: SCH is a common ultrasound finding in pregnancies conceived through IVF. Clinicians can reassure patients that very few of these pregnancies result in SA. The incidence of SCH was significantly higher in pregnancies conceived after frozen ET. However, this difference is unlikely to be clinically significant, as there was no difference in SA rates after fresh vs. frozen ET.

References:

  1. Tuuli MG et al., 2011. Obstet Gynecol. 117(5):1205-12.
  2. Rosenbluth EM et al., 2011. Fertil Steril. 96(3): S14
  3. Sayago MM et al., 2009. Fertil Steril. 90: S119.
  4. Asato K et al., 2014. Eur J Obstet Gynecol Repro Biol. 181:41-4.

Mamdoh Eskandar1, Mohamed Al-Emain2
1King Khalid University, College of Medicine, Abha, Saudi Arabia, 2Saudi Centre for Assisted Reproduction, Abha, Saudi Arabia

Introduction: Numerous factors are associated with the successful implantation after in vitrofertilization (IVF) and embryo transfer (ET), such as endometrial receptivity, the embryo quality and one the most important factor is human chorionic gonadotropin (hCG) which is linked to an important function in angiogenesis and the inflammatory response that promotes the implantation process.

Aim of the study: This is prospective, randomized clinical study investigating the effect of intrauterine human chorionic gonadotropin injection before embryo transfer (ET) on pregnancy rates in IVF\ICSI cycles.

Materials and Methods: 240 patients undergoing IVF\ICSI cycle were included in our study. Patients were divided randomly into two groups by a computer-based program. Group I (n=139) received 500 IU of hCG intrauterine 10 minutes before ET and group II (n=101) had ET without a preceding intrauterine administration of hCG.

Results: There was no significant difference between group I and group II in terms of age (32.3±2.6 and 31.5±4.2 years), infertility duration (6.2±3.2 and 5.6±3.5 years), number of oocytes (14.1±5.2 and 12.8±5.0), and number of transferred embryos (2.8±0.6 and 2.6±0.5), but The clinical pregnancy rate was significantly higher (49.5 vs. 32.0%, p 0.010) in the group received 500 IU of hCG intrauterine before ET than the control group that did not receive hCG before ET.

Conclusion: Intrauterine injection of 500 IU of hCG before ET statistically significantly improved the pregnancy rate in IVF/ICSI cycles.

Keywords: Intrauterine hCG, Pregnancy rate, IVF/ICSI.