(Postings are ongoing)

Improving Patient Safety: A Necessary Achievable Goal in Obstetrics Today
Chervenak FA, Grunebaum A, Weill Medical College of Cornell University, New York, NY, USA
Now more than ever perinatologist throughout the world must optimize patient safety. At Weill Cornell Medical Center we have been successful in reducing professional liability and improving patient safety. This topic will have increasing importance throughout the world in the years to come. Practical guidance will be given to help with this emerging challenge to the practice of obstetrics.
Labor and Delivery team training is invaluable in improving poor communication. A chain of communication is essential to ensure patient safety. A standardized oxytocin labor induction and stimulation protocol minimizes confusion as does premixed and safety color-coded labeled magnesium sulfate and oxytocin solutions. Obstetric emergency drills prepare for the unexpected.

To maximize the outcome of IVF treatment, every embryo should undergo PGS: What are the risks? – No 
Norbert Gleicher, USA
Preimplantation genetic screening (PGS) was first introduced to routine IVF over a decade ago (PGS#1). The procedure's hypothetical promise of eliminating chromosomal abnormal embryos prior to embryo transfer was logical, promising improved implantation and pregnancy rates after IVF. Unsurprisingly, IVF centers all around the world jumped at the opportunity, and started using the procedure routinely despite some cautionary voices opposing the practice based on the failure of a number of small prospectively randomized studies to show effectiveness in improving IVF outcomes. Only after a prospectively randomized Dutch study actually demonstrated reduced pregnancy chances in association with PGS in older IVF patients, did professional organizations around the world, finally, speak up and declared PGS, rather unanimously, to be ineffective in improving IVF outcomes in association with IVF and in decreasing miscarriage rates.

As of that point the utilization of PGS declined but, somewhat surprisingly, the procedure remained more popular among many physicians and patients than one would expect after formally having been declared inefficient by ASRM and other professional organizations around the globe.

The worldwide utilization of PGS, indeed, received another boost a number of years ago, when a number of laboratories started utilization of a new form of PGS (PGS#2), which they claimed was superior to PGS#1 because of improved accuracy in determining ploidy of embryos. Moreover, proponents of PGS#2 claimed that this improved form of PGS, indeed, fulfilled earlier promises of improving IVF outcomes. Unfortunately, a careful analysis of published claims reveals them to be misleading.

It, therefore, is our interpretation of so-far published literature that the new PGS#2 offers the same shortcomings as PGS#1, improving IVF outcomes, at best, only in a small number of so-called "good-prognosis" patients (in average IVF centers representing <20% of patients). In all other IVF patients PGS#2, indeed, achieves neutrality in outcomes or even reduces pregnancy chances in so-called "poor-prognosis" patients. Reductions in pregnancy chances will be observed in women with relatively small oocyte and embryo numbers; i.e., either older women or in younger women with low functional ovarian reserve.

Since "good-prognosis" patients even without PGS achieve excellent IVF pregnancy rates, it remains to be seen whether a small incremental gain in pregnancy chance warrants the quite significant additional expense of PGS in an already very expensive IVF cycle. Since, however, at least 80% of patients in an average IVF center either do not benefit from PGS or see their pregnancy chances even decline, in these patients PGS, indeed, appears absolutely contraindicated. An additional reason why PGS in "poor-prognosis patients" is contraindicated is that their frequent failure to reach embryo transfer (because their embryos do not survive to blastocyst stage when trophectoderm biopsy is performed in PGS#2) or because they are found to have no euploid embryos leads to premature referral of such patients into oocyte donation.

We, therefore, consider the rapid expansion of PGS utilization in worldwide IVF practice inappropriate, and not in the best interest of most IVF patients, and urge caution in how the option of PGS is presented to infertile women undergoing IVF.

To maximize the outcome of IVF treatment, every embryo should undergo PGS 
Gab Kovacs, Monash University, Melbourne, Australia

The first series of IVF pregnancies ever reported came from the Monash IVF group in 1980:

Even in these early days, the biggest barrier to success was the step from embryo transfer to pregnancy (15/97 or 15.5%).
In the latest data from the Australian NPSU shows that the implantation rate (live birth rate) in 2012 was only 21% per transfer.
What determines whether an embryo will implant?
There are three factors:

  1. Normality of the embryo with respect to chromosome content
  2. The ability of the embryo to implant and develop its placental system
  3. The receptivity of the endometrium

Studies from aborted pregnancies suggest that the most common reason for early pregnancy loss is aneuploidy. We can therefore extrapolate, that a common cause of failing to implant is that the embryo has an abnormal chromosomal makeup. One can therefore conclude that if embryos were screened prior to transfer, and only euploid ones were transferred, the outcome of IVF would be “maximized”.
This is the suggestion from a paper by Lee et al in Human Reproduction, February 2015. “Aneuploidy is a leading cause of implantation failure, miscarriage and congenital abnormalities in humans, and a significant cause of ART failure. Preclinical evidence of PGD-A indicates that the selection and transfer of euploid embryos during ART should improve clinical outcomes.”
First what do we mean by “outcome from IVF”. To me this the number of “take home babies” per initiated cycle preferably or at least per oocyte collection. The late David Healy was a great advocate for the singleton, term gestation, live birth rate per cycle initiated (intended oocyte collection): the BESST (Birth Emphasizing a Successful Singleton at Term) endpoint for assisted reproduction.
Although PGS will not improve these figures it would avoid the transfer of aneuploid embryos which have no chance of resulting in a BESST. A woman will have X number of oocytes collected which will result in Y embryos. Z of these will be euploid, whereas A will aneuploid. If we only transfer euploid embryos, the pregnancy rate per embryo transfer (ET) will be higher, and she will avoid the cost of cycles and trauma of cycles that have no chance giving her a BESST.

If we transfer all the embryos, fresh or frozen, the abnormal ones will often give a transient feeling of success, when the pregnancy test is positive, but will only end in disappointment when the pregnancy does not develop, miscarries, or has to be terminated after first trimester screening, and certainly not resulting in a normal term birth.

One may suggest that there is a degree of natural selection in the incubator. One may presume that the euploid embryos are more likely to grow to blastocyst, and be judged to be suitable for freezing. It was hoped that this may be further enhanced by time lapse photography, but there is no evidence for correlation between morphology and euploidy. However Renzi and colleagues have recently shown that “No evidence of association between blastocyst aneuploidy and morphokinetic assessment in a selected population of poor-prognosis patients: a longitudinal cohort study”. (RBM Online, January 2015).

So time lapse will not replace PGS. What evidence is there that PGS improves outcomes? A systematic review just published (Lee E1, Illingworth P2, Wilton L3, Chambers GM4.The clinical effectiveness of preimplantation genetic diagnosis for aneuploidy in all 24 chromosomes (PGD-A): systematic review. Hum Reprod. 2015;30:473-83) concludes that “of the five studies that included a control group and reported implantation rates, four studies (including two RCTs) demonstrated improved implantation rates in the PGD-A group. Of the eight studies that included a control group, six studies (including two RCTs) reported significantly higher pregnancy rates in the PGD-A group, and in the remaining two studies, equivalent pregnancies rates were reported despite fewer embryos being transferred in the PGD-A group. The three RCTs demonstrated benefit in young and good prognosis patients in terms of clinical pregnancy rates and the use of single embryo transfer.This is the best evidence we currently obtain recommend PGS to maximise the outcome of IVF treatment.

Whilst there is a concern that not all embryos can be biopsied and screened, the ESHRE Consortium data for 2009 shows that 95% of nearly 19000 embryos were successfully diagnosed. There were only 2 misdiagnoses of the nearly 18000 embryos studied.No guarantee.

To conclude, again to quote from Lee 2015 “Given the uncertain role of PGD-A techniques, high-quality experimental studies using intention-to-treat analysis and cumulative live birth rates including the comparative outcomes from remaining cryopreserved embryos are needed to evaluate the overall role of PGD-A in the clinical setting. It is only in this way that the true contribution of PGD-A to ART can be understood”. As this is unlikely to happen as fee paying patients will not agree to be randomised, with what we know today, we would depriving our patients of an available treatment that is likely to shorten the time and the number of attempts they need to undertake to conceive, if we did not offer PGS. The cost-effectiveness of PGS has to be taken into consideration, and individualised decision making is recommended.

ted serum thyroid-stimulating hormone is associated with decreased anti-Müllerian hormone in infertile women of reproductive age 
Keiji Kuroda, Department of Obstetrics & Gynecology, Juntendo University, Japan

Thyroid dysfunction and autoimmune thyroiditis are known adverse risk factors for pregnancy and fertility in reproductive aged women. In particular, hypothyroid women are at an increased risk of menstrual disorders and infertility (1). The prevalence of subclinical hypothyroidism, characterized by aberrant high serum thyroid-stimulating hormone (TSH) levels with normal free thyroxine (FT4) levels, in infertile women is reported to be approximately 20% and it is a primary cause of subfertility and diminished ovarian reserve (2-4). Levothyroxine replacement therapy for subclinical hypothyroidism in infertile patients may improve implantation and miscarriage rates, leading to successful pregnancy (5). Expectedly, ovarian function may be affected by impaired thyroid function, although this association has not been elucidated. Therefore we evaluated the relationship between thyroid function and anti-Müllerian hormone (AMH) levels.

Materials and Methods
Between 2012 and 2013, we recruited 251 Japanese infertile women and 27 normal fertile women without history of infertility or thyroid disorders. We measured thyroid-related hormone and AMH levels in the infertile and fertile women. We excluded 184 patients with factors that impact thyroid hormone and ovarian function, including polycystic ovary syndrome (PCOS) (n=50), premature ovarian insufficiency or failure (n=24), treated thyroid dysfunction (n=12), endometriosis (n=53), ovarian tumor (n=21), post-ovarian surgery (n=25), smoking (n=17) and ≥40 years (n=66). Sixty-four patients fulfilled 2–4 exclusion criteria. We included newly diagnosed thyroid abnormality. Informed consent was obtained from all participants and the study protocol was approved by the ethics committee of Juntendo University.
To investigate the relationship between thyroid function and AMH levels, we matched patients by age and body mass index (BMI) as confounding factors using 1:1 matching for statistical analysis of fertile and infertile women. Results were compared using Student’s t-test or the Mann–Whitney U-test, as appropriate. Independent variables such as age, BMI, AMH, prolactin, TSH and FT4 levels, which strongly correlate with infertility, were estimated by stepwise logistic regression analysis. A p-value of <0.05 was considered statistically significant.

We finally enrolled 67 infertile and 27 healthy fertile women aged <40 years. As shown in Figure 1, serum TSH levels in the infertile patients were inversely correlated with AMH levels. To compare between the characteristics of infertile and fertile women, we used 1:1 matching of age and BMI. Consequently, 23 infertile patients were extracted by 1:1 matching (Table 1). In post-matched characteristics, AMH levels were significantly lower in infertile patients than in fertile women, whereas TSH and FT4 levels were comparable.

We used multivariate logistic regression model to evaluate independent variables strongly correlated with infertility in post-matched patients and included the following covariates: age, BMI, AMH, TSH, FT4 and prolactin levels. Stepwise logistic regression analysis showed that AMH levels strongly correlated with infertility (p=0.011). Next, we evaluated covariates that were strongly correlated with AMH levels in 23 post-matched infertile patients using multiple regression analysis. Two covariates showed a p-value of <0.10 in univariate regression analysis: TSH and patient age (p=0.002 for both). Multiple regression analyses showed that both TSH levels and age significantly impacted AMH levels in infertile patients (TSH levels and age: p=0.036 and 0.003, respectively) (Table 2). However, single regression analysis of AMH levels in post-matched fertile women showed no correlation with all covariates.

The results of this study showed that AMH levels in infertile patients, but not healthy fertile women, were inversely correlated with patient age and TSH levels (Figure 1), and patient age and TSH levels were shown to impact AMH levels in infertile patients (Table 2). In a previous study, TSH was identified as a significant predictor of fertilization failure in women undergoing IVF (6). Therefore, TSH may be a factor influencing ovarian reserve in infertile patients. Given that subclinical hypothyroid women are at an increased risk of infertility, elevated TSH levels may have deleterious effects on ovarian function. Michalakis et al also reported clinical data in high prevalence of diminished ovarian reserve in the infertile patients with elevated TSH levels (4). Hypothyroid rats revealed that hypothyroidism may impact on ovarian folliculogenesis, granulosa cell differentiation and steroidogenesis (7). In addition, TSH directly suppressed follicle development in a concentration-dependent manner (8). However, TSH levels in infertile patients were almost within the normal range; therefore, ovarian function of infertile patients is somehow more susceptible to TSH compared with that of healthy fertile women. In conclusions, we showed an inverse relationship between serum TSH and AMH levels in infertile women. These findings may influence current infertility treatment strategies.

Conventional laparoscopic bowel resection to prevent surgical complications in the management of deep endometriosis 
Peter Lukovich, Semmelweis University, Budapest, Hungary

Introduction: The number of patients operated on with endometriosis increase, and at 10-40% of the cases the urological organ and the bowels are involved beside the gynaecological organs.

Patients and method: At 224 from 383 patients with endometriosis preoperative sigmoidoscopy detected bowel endometriosis, and 127 patients were operated on from 14.07.2009 to 13.01.2014 at the 1st Gynaecological Department of the Semmelweis University. All the operation was made by the same gynaecologist and surgeon. 

Results: Segment resection of the bowel was made at 120 cases, local resection at 2 cases and shaving at 2 cases. The involved part of the bowels were rectum at 46 cases, rectosigmoid at 68 cases, sigmoid bowel at 30 cases, coecum at 4 cases, appendix at 2 cases and the small intestine at 2 cases. There were resection of the bladder (9 cases) resection of the ureter (2 cases) and ureterolysis (26 cases) because of the infiltration of the urological organs. There was only one conversion because of bleeding from the epigastric artery, and laparoscopic suture of the anastomosis was made on the day of the operation because of bleeding. The specimen was extracted transvaginally at 16 patients and transanally at 13 patients. There were anastomosis insuffitienty at 2 patients and rectovaginal fistula at 4 patients, where the all the reoperations (creation and closing the stoma) were made by laparoscope. 

Conclusion: The treatment of the bowel endometriosis suggested with segment resection by multidisciplinary team, where the invasivity can be decreased by transanal specimen extraction.

Semen Quality Studies (SEMQUA) 
David Mortimer, Canada

The usefulness of studies on semen quality extends beyond the diagnosis and prognosis of male (in)fertility and sperm (dys)function, it is an important tool in epidemiological studies of environmental impact and even constitutes a biomarker of overall male health. The debate on deteriorating semen quality has been going on for more than two decades , and has become a public health policy issue. Unfortunately, the application of widely varying study designs and laboratory methodologies distorts the results of meta-analyses and multicentre studies, and the conclusions drawn from them.

To determine the relevance and significance of publications in this area of andrology readers must be fully informed of the study design and of the analyses applied – the credibility of any research depends on the critical appraisal of its strengths and weaknesses by scientific experts. In the absence of specific standards for evaluating studies concerning semen quality, there was a need to create a tool for evaluating both potential error or bias and the results obtained.
The guidelines developed by the ESHRE Special Interest Group for Andrology (SIG-A) for the evaluation of SEMinal QUAlity studies (SEMQUA) [1] are an extension or implementation of previous guidelines and comprise a series of recommendations concerning the information that should be included when publishing a semen quality study. They are embodied in an 18 item checklist covering participants, laboratory methods, statistical methods and results. Their prospective application ranges from the study design phase through its analysis and reporting, to the peer-review process; retrospectively they can be employed for educational purposes or as a tool to evaluate the quality of published research reports.
More recently, the severe lack of standardization in semen analysis methods and their performance, and the recognition that with poor laboratory services not even the best-designed clinical study can provide reliable, useful results (which massively undermines evidence-based medicine in this field), the ESHRE Journals have commissioned a set of guidelines to be applied when considering for publication any study involving results from the analysis of human semen [2]. The guidelines are in the form of a detailed, 43 item, technical checklist (which follows ESHRE SIG-A semen analysis methodology rather than current WHO guidelines [3]) to be used by those designing studies, performing semen analyses, reviewing manuscripts reporting such data, and editors deciding to publish such studies.
By expecting strict adherence to robust methodology, established requirements for training and competence of those performing semen analysis, and the inherent need for quality control and quality assurance (all generally in line with the expectations of ISO 15189:2012 Medical Laboratories – Requirements for Quality and Competence), the Journals will be promoting the quality of science in andrology. As a result, published studies will include high quality results (improved accuracy and prevision, reduced measurement uncertainty) that can not only be understood and interpreted between clinics and researchers, but also support sound multicentre studies and permit robust meta-analyses.

The Quest for the Ultimate Sperm Function Test 
David Mortimer, Canada

Identifying and understanding the role of sperm dysfunction in the aetiology of male infertility has been negatively impacted to a massive extent by two widespread clinical attitudes: (1) the ready availability of ICSI has caused many ART practitioners to essentially ignore the male partner and consider him just as a source of sperm to be injected to make zygotes; and (2) the disappointment that there is no perfect sperm function test. This presentation will (a) review the strengths and limitations of available sperm function tests, (b) based on an understanding of sperm physiology, debunk the myth that there could ever be an “ultimate” test of sperm function, and (c) review how readily available assessments of sperm function can be used to manage couples presenting with subfertility by balancing risk, cost and technology to achieve and maintain world class success rates.

Certainly it is true that many male infertility patients do not really care about understanding exactly why their sperm “don’t work”, but this should not be taken as an excuse to ignore sperm functional competence when deciding on a couple’s treatment plan. IUI is still a valid first-line treatment modality in many couples, and can be far more cost-effective than IVF. Furthermore, when ICSI is used for men whose sperm are IVF-competent the couple will suffer reduced outcomes compared to efficacious IVF, and ICSI also has several inherent risks [1]. With careful investigation of sperm functional competence (which costs less than the typical ICSI supplemental fee) the incremental risk of low or no fertilization at IVF can be reduced to 1–2% above the level inherent in cases where ICSI is required (~2%). An enlightened ART practice employing “structured management” principles would give patients the appropriate information for them to make their own informed decision as to whether they could accept IVF or they actually need ICSI.
It is unfortunate that many clinics still do not have, or do not have access to, a competent andrology laboratory that operates according to established standards, and this has also been used to justify the default use of ICSI in order to avoid having to deal with numerous cases of IVF fertilization failure. This presentation will conclude by introducing a framework for a specialized pre-ART treatment sperm functional assessment that is largely CASA (computer-aided sperm analysis) based and can be performed by a broader range of ART technologists and embryologists.

Should we supplement Magnesium in pregnancy? 
Dalton L1, Ní Fhloinn D1, Gaydadzhieva G1, Mazurkiewicz O1, Mooney G1, Leeson H2, Wright C PhD2
1Institute of Health Sciences, Ireland. 2Glenville Nutrition, Ireland. 

Problem: Magnesium (Mg) has numerous roles, some of which are extremely important during pregnancy. Mg is essential for the synthesis of nucleic acids and proteins, for intermediary metabolism and for specific actions in the neuromuscular and cardiovascular systems. It is also pivotal in the regulation of vascular tone and heart rhythm and is considered nature's physiological calcium channel blocker and thus essential for bone formation. 
A high percentage of women of child-bearing age consume less than the RDA of Mg (USDA, NDNS). Thus it is likely that they would fail to meet the increased nutritional demands of pregnancy. Indeed dietary requirements in pregnancy are not fully understood and the increased RDA put forward in the US is based solely on the relative increase in body mass. 
Accurate measurement of magnesium is problematic. The most commonly used measurement in the clinical setting is serum magnesium which has major limitations (Arnoud, 2008). Specifically only 0.3% of magnesium is found in serum with >99% existing intracellularly. Extracellular Mg homeostasis is critical for cardiovascular function and thus Mg levels in the serum are maintained by rapid release from bone surface (60% of body stores). In cases of deficiency, serum Mg concentrations can change slowly over periods of up to four months from depletion before the onset of adverse symptoms. By the time latent Mg deficiency is clinically recognised based on serum (less than 0.75 mmol/L), the deficiency may already be moderate to severe. 
Mg deficiency has been linked with pre-term labour, pre-eclampsia, intra-uterine growth restriction (IUGR), and gestational diabetes (GDM) amongst others. Pre-term labour is the leading cause of perinatal morbidity and mortality. Both IUGR and GDM have lasting effects on the health of the progeny. Measuring intracellular Mg levels is uncommon but represents a more accurate way to assess Mg levels in critical states such as pregnancy. 

Methods: We carried out a literature review to assess the evidence for the role of magnesium in pregnancy. Major limitations were identified, with inaccurate measurement being a primary cause for the lack of reliable data in this field.

Results: Magnesium status may be related to incidence of pre-term labour, pre-eclampsia, IUGR and GDM but there is a marked absence of well-designed trials in this field.

Conclusions:  Due to the important role of magnesium in pregnancy, we propose that women at risk of these conditions i.e. early symptomatic, family or previous history, or displaying risk factors such as obesity, hypertension or impaired glucose tolerance should be tested for Mg levels. Intracellular testing of RBC or platelets is recommended and appropriate supplementation and dietary advice should be given to correct deficiency.

Sperm DNA damage caused by oxidative stress: can it be modified by changes in lifestyle? 
Leeson H1, Wright C PhD1
1Glenville Nutrition, Ireland. 

Problem: Sperm DNA fragmentation is linked with infertility, spontaneous abortion, failed ART cycles and a reduction in live birth rate. Where high DNA fragmentation has been identified, the couple should be advised to utilise ICSI. Importantly however, whilst ICSI has higher delivery rates, there may be an increased risk of inheritance of damaged DNA by the offspring. Where possible, DNA fragmentation should be addressed and minimised before ART despite the potential for success with ICSI.
Oxidative stress is the primary cause of DNA fragmentation in spermatozoa. Some major sources of oxidative stress such as infection, inflammation or varicocele should be treated medically/ surgically. In addition, there are a number of environmental or lifestyle patterns that contribute to oxidative stress which can be easily modified without risk, even in the absence of definitive evidence. This may include avoidance of smoking, toxic metals, xenobiotics, testicular heat, mobile phone radiation and a reduction in body mass.
Nutritional sources of antioxidants, through diet or supplements, may play a significant role in the reduction or neutralisation of oxidative stress or reactive oxidative species (ROS). The ‘Western diet’ is very low in antioxidants and both cultivation and food processing techniques have resulted in marked reductions of the nutrient values of our food.

Methods: We carried out a literature review to assess the evidence for the role of lifestyle and nutritional modifications and supplemental antioxidants in the treatment of DNA fragmentation. We have utilised our published recommendations and modifications with clients of our nutrition clinic in Ireland.

Results: In the absence of larger clinical trials, it could be argued that it is premature to advise major lifestyle changes in couples with other causes of infertility. However where high DNA fragmentation has been identified, it may be cautious to avoid the above sources of oxidative stress, and there are no risks involved in doing so.
Nutritional sources of antioxidants are critical to the reduction of oxidative stress. However some pro-oxidative processes are essential to spermatozoan function such as capacitation, initiation of the acrosome reaction and ultimately fertilisation. High levels of antioxidant supplementation may therefore have risks and should only be carried out where deficiency or necessity has been determined by relevant tests. Food source antioxidants are low-risk and the diet should be easily modifiable to include sources of zinc, selenium, carotenes, vitamin C and E at a minimum.

Conclusion: We have incorporated recommendations for lifestyle and nutritional modifications into our practice with success. This includes avoidance of environmental sources of oxidative stress, increasing food sources of antioxidants and supplementation with Vitamin C, E, zinc and selenium where deficiency is identified.