P-274 Immune profile of Sudanese women with conception disorders: possible role for T-helper Cytokines

Abstract

Study question

This study aims to determine the cytokines profile of Sudanese women with infertility and recurrent abortions.

Summary answer

Sudanes women with conception disorders showed predominantly Th1 type of immune response in peripheral blood mononuclear cells (PBMCs) when stimulated with trophoblastic antigen compared to women who had a history of normal pregnancy.

What is known already

Successful pregnancy may depend, at least in part, on the bias of the maternal immune response shifting away from Th1 type responses towards a Th2 phenotype, both in murine models and humans. An abnormal Th1-type cellular immune response is the basis for a recent hypothesis for immunological reproductive failure in women.Unexplained conception disorders, premature delivery and pregnancy-induced hypertension may all, in some cases, be linked to immune and cytokine networks of early pregnancy.

Study design, size, duration

This prospective, case-control, cross-sectional and hospital-based study.25 women with a history of unexplained conception disorders (15 infertile women, 10 women with recurrent miscarriages) were compared with 75 pregnant women with history of success pregnancy as controls, during 2006-2008.

Participants/materials, setting, methods

Women with a history of unexplained conception disorders and pregnant women, Blood samples and peripheral blood mononuclear cells (PBMCs) were stimulated by phytohaemaglutinin (positive controls) and trophoblast antigen in an in vitro culture system and secreted cytokines were determined using the ELISA technique.

Main results and the role of chance

Mean INF-γ level among women with histories of normal pregnancies (6.20 ± 4.51) was significantly lower than among infertile women (33.45 ± 8.14) and women with recurrent miscarriage (35.79 ± 13.1). (P = 0.00). Mean INF- γ levels among infertile women were statistically similar to women with recurrent miscarriage,mean IL-4 level among women with histories of normal pregnancies (14.05 ± 6.50) were significantly higher than among infertile (11.51 ± 3.60) and women with recurrent miscarriages (9.24 ± 4.95) (p = 0.04) Mean IL-4 levels among infertile women and women with recurrent miscarriage were statistically similar (p = 0.33).

Limitations, reason for caution

Observational studies like ours, needed a large sample size and well-controlled.

Wider implications of the findings

Large scale studies are needed to further elucidate the role of Th1 immune response bias in female infertility and recurrent spontaneous abortions in Sudanese women. The role of immune modulation in the treatment of unexplained female infertility and recurrent spontaneous abortions should be seriously investigated as a possible treatment modality.

Study funding/competing interest(s)

None

Trial registration number

None

P-275 One-to-one donor egg recipients and egg sharer recipients: a comparison study in IVF/ICSI success rates

Abstract

Study question

Do women having IVF/ICSI with egg donation, where the recipient receives all available eggs from an egg donor have higher IVF/ICSI success rates compared to patients receiving half the number of eggs from an egg sharer (ES)?

Summary answer

Women receiving donor eggs (DE) from an ES have comparable pregnancy (PR) and live birth rates (LBR) to those having one-to-one donation (OTOED).

What is known already

Numbers of egg donors in the UK have declined due to limitations in compensation and lack of complete anonymity following recent changes in legislation. Egg sharing has reduced waiting times for women requiring DE, who might otherwise consider egg donation overseas. This offers affordable IVF to ES, benefiting both donor and recipient. Concerns remain as to whether a reduction in the number of DE available from an ES affects IVF success rates in the recipient.

Study design, size, duration

Data was prospectively collected of women undergoing IVF/ICSI through egg donation between January 2007 and January 2012. Information was recorded electronically. 186 OTOER and 457 ESR cycles were included in the analysis. ES were deemed suitable to donate if strict selection criteria were met, this included age ≤35 years.

Participants/materials, setting, methods

Recipients had DE through either anonymous OTOED or the egg sharing programme. Egg sharing DE recipients (ESR) were suitably matched and received 50% of eggs from an ES for an IVF/ICSI cycle. Cycle outcomes were compared between OTOER and ESR using a cross tabulation t-test and ANOVA was performed.

Main results and the role of chance

OTOER were of a higher mean age (40.5; ESR, 43.2) (P < 0.05). Cycle cancellation rate (OTOER, 6.4%; ESR, 6.6%), fertilisation rate (OTOER, 68.6%; ESR, 69.8%) and average number of embryos transferred (OTOER, 1.6; ESR, 1.6) did not differ between the two groups (P > 0.05). Mean number of DE and available embryos for transfer were higher for OTOER compared to ESR (9.6 and 6.25, 6.3 and 4.2 respectively), but this did not reach statistical significance (P > 0.05). No significant difference in PR (OTOER, 54.3%; ESR, 56.5%), LBR (OTOER, 36.6%; ESR, 39.2%) or rate of miscarriage (OTOER, 32.7%; ESR, 30.6%) was demonstrated. OTOER were more likely to have embryos available for cryopreservation at the end of their cycle compared to ESR (41.1% and 25.4%, P < 0.05).

Limitations, reason for caution

None

Wider implications of the findings

This study demonstrates that despite receiving a lower number of DE from an appropriately selected ES, IVF success rates are not compromised for recipients, having demonstrated comparable PR and LBRs in these women. OTOER may however have more embryos available for cryopreservation, hence increasing their chances for a future pregnancy.

Study funding/competing interest(s)

None

Trial registration number

Not applicable

P-276 

Abstract

Abstract withdrawn from poster presentation

P-277 Comparison of clinical pregnancy outcome for endometrial preparation in vitrified frozen thawed cycles with GnRH + Estradiol and only Estradiol

Abstract

Study question

To analyse the reproductive outcome using endometrial preparation protocols with either luteal phase down regulation combined with estradiol or with only estradiol either in increasing doses or fixed dosage in frozen embryo transfer cycles (FET).

Summary answer

Luteal phase down regulation with GnRH agonist followed by estradiol administration in frozen embryo transfer cycles is a better method of optimising treatment outcome as FET should be carried out during a period of optimal endometrial receptivity.

What is known already

In natural cycle FET the endometrium develops under endogenous hormonal stimulation where it is timed after triggering ovulation induction or determination of the spontaneous LH surge. In an artificial cycle estrogens and progesterone are administered to prepare the endometrium for implantation. Currently available data show no significant difference in pregnancy rates between the two methods.

Study design, size, duration

A prospective non randomised study of two hundred and thirty seven (237) frozen embryo transfer cycles from September 2010 to September 2012 was done.

Participants/materials, setting, methods

In 130 patients endometrial preparation was done by luteal phase down regulation and estradiol while only estradiol was used in either a step up dose from 2 mg to 6mg or a fixed dose of 6mg/day in 107 patients. Vaginal progesterone 600mg/ day was started once endometrium was 9–10mm. Vitrification was the method used for freezing. Embryo transfer was done after 3 days of progesterone. Beta hCG was done 15 days after the embryo transfer.

Main results and the role of chance

Statistically significant higher pregnancy rates were observed in the group where frozen embryo transfer was done after luteal phase down regulation followed by estradiol and progesterone than in the group where no luteal phase down regulation was done and endometrial preparation was done only with estradiol and progesterone (42.3% versus 33.63%). There was no difference in the clinical pregnancy rates whether the estradiol was given in a step up dose (2mg, 4mg and 6 mg) or started with 6mg/day. Presence or absence of polycystic ovarian disease did not change the clinical pregnancy outcome in patient cycles who underwent down regulation (52.73% versus 47.27%)

Limitations, reason for caution

To the best of our knowledge this is the first study which has prospectively looked at the best protocol for frozen embryo transfer which leads to better clinical outcome. Till date most of the studies have evaluated natural cycle or clomiphene induced cycles. However a wider study comparing the natural cycle with atrificially prepared cycles with a bigger sample size would give better insight.

Wider implications of the findings

The study was mainly aimed at identifying a protocol for frozen thawed cycles which gives the optimal window of endometrial receptivity and results in better clinical pregnancy outcome.

Study funding/competing interest(s)

There was no competing interests nor was any funding solicited for the study

Trial registration number

None

P-278 Predictors of ovarian response in women treated with corifollitropin alfa for IVF/ICSI

Abstract

Study question

To identify predictors of ovarian response in women undergoing ovarian stimulation with corifollitropin alfa in a GnRH antagonist protocol and determine specific thresholds for the prediction of low and excessive responders.

Summary answer

Anti-müllerian hormone (AMH) and antral follicle count (AFC) are the best predictors for low and excessive response in women treated with corifollitropin alfa in an antagonist protocol. The optimal thresholds for the prediction of excessive response are 3.52ng/ml for AMH and 16 for AFC. Similarly, the optimal thesholds for predicting low responders are 1.37ng/ml for AMH and 8 for AFC.

What is known already

In both GnRH agonist and antagonist cycles AMH and AFC are strongly associated with oocyte yield and can predict low and excessive response to stimulation. Recently, corifollitropin alfa, a long acting gonadotropin, has been introduced in clinical practice. However, no data are available regarding potential predictors of ovarian response after treatment with this novel gonadotropin

Study design, size, duration

In this retrospective cohort study 210 infertile patients underwent ovarian stimulation with corifollitropin alfa in an antagonist protocol for IVF/ICSI between February 2011 and October 2012.

Participants/materials, setting, methods

Eligible patients (210 women) were treated with a single dose corifollitropin alfa (150 or 100 µg), followed by initiation 0.25mg of a GnRH antagonist 5 days later. On day 7 of the stimulation daily injections of rFSH or hMG were administered at doses ranging between 100-300IU. As soon as 2-3 follicles were observed in transvaginal ultrasound, ovulation triggering was performed with im injection of 10.000 IU of hCG Patients’ at risk of developing ovarian hyperstimulation syndrome were triggered with either 5000IU hCG or with a bolus of GnRH agonist (0.2mg).

The primary outcome was to identify baseline parameters (age, FSH, AMH, AFC) that may predict in isolation or in combination low (≤ 3 oocytes retrieved) and excessive (>20 oocytes retrieved) response to stimulation.

Main results and the role of chance

Baseline characteristics were associated with oocyte yield; age ρ= -0.552, p < 0.0001, basal FSH ρ =-0.497, p < 0.0001, AMH ρ =0.722, p < 0.0001 and AFC ρ =0.635, p < 0.0001. However, in logistic regression analysis AMH and AFC were the only independent predictors for low and excessive ovarian response. In prediction of excessive response, the ROCAUC(95%CI) for AMH was 0.890 (0.832-0.947) and 0.897 (0.829-0.964) for AFC. The optimal thresholds for identifying excessive responders were 3.52ng/ml for AMH, (sensitivity 89.5, specificity 83.8) and 16 for AFC (sensitivity 80.0, specificity 84.5). AMH and AFC also predicted low ovarian response; AMH ROCAUC 0.836 (0.783-0.889) and AFC 0.830 (0.767-0.894). The optimal thresholds for predicting low response were 1 .37ng/ml for AMH (sensitivity 74.1, specificity 77.5) and 8 for AFC (sensitivity 72.2 and specificity 84.6). For both excessive and low ovarian response a logistic regression model combining the biomarkers was associated with improved discrimination.

Limitations, reason for caution

Misclassification of response category may have occurred due to a higher corifollitropin alfa dose being administered in expected poor responders, and subsequent gonadotropins daily dose varied considerably according to patient age and previous response. However none of these parameters qualified to enter in the logistic regression models, suggesting that their influence in determining excessive and low responders is limited.

Wider implications of the findings

Utilizing AMH and AFC to select suitable candidates for treatment with corifollitropin alfa may result in a safe and convenient treatment.

Study funding/competing interest(s)

Scott Nelson has received honorarium from Beckman Coulter and Roche Diagnostics to participate in Advisory boards regarding AMH.

The Center for Reproductive Medicine receives unconditional research grants unrelated to this study from Ferring Pharmaceuticals, Merck Serono, and Merck Sharp and Dohme Corporation.

Trial registration number

None

P-279 Simple parameters monitored in cumulus cells: relevant correlations with oocyte status, fertilization and patient age

Abstract

Study question

The goal of the present study was to determine whether simple parameters monitored incumuluscells from individual oocytes such as cell density, viability and apoptosis have any predictive value and thus correlate with clinically relevant parameters, including oocyte maturity and quality, fertilization status, embryo quality and patient age.

Summary answer

Our data suggests that valuable insights can be obtained by analysingcumuluscells from single oocytes, namely that simple apoptotic markers such as caspase activity and annexin V staining may be helpful in selecting better quality oocytes. These assays can be easily applied in a minimal clinical setting.

What is known already

Proper granulosa cell density is essential for development during oocyte maturation, and is translated intocumuluscell density upon ovulation. However, the relationship betweencumuluscell density and relevant clinical outcomes in single oocytes has not been firmly established. Furthermore, sincecumuluscells-oocyte signalling mediates maturation and developmental competence, apoptosis in these cells may have an impact on oocyte function, although the literature on this subject remains contradictory.

Study design, size, duration

From January 2012 to January 2013, a total of 97 human oocytes from 31 patients were separately denuded, in order to evaluate cumuluscell density, viability (using propidium iodide) and apoptosis level (through the annexin V assay and detection of caspase-3/7 activity).

Participants/materials, setting, methods

Cumuluscells were obtained from patients undergoing ICSI treatment at the Human Reproduction Service of University Hospitals of Coimbra, andcumulus-oocyte complexes were recovered by follicular puncture. Oocytes were denuded through micropipette manipulation and enzymatic treatment and the cumulus cells subsequently tested using the assays noted in the previous section.

Main results and the role of chance

In what we believe is a novel estimate, our results indicate that a human oocyte is surrounded by 13583 ± 1751 cumulus cells. In addition, mature oocytes have a higher number of cumulus cells, with a higher percentage of viable cells and a lower percentage of apoptotic cells than unviable oocytes. However, limited cumulus cell apoptosis seems important for the successful use of mature oocytes, as it correlates with oocyte developmental competence. Indeed, mature oocytes that fertilized after ICSI had a higher caspase activity in the surrounding cumulus cells than mature oocytes that did not fertilize. Furthermore, younger patients (with theoretically higher quality oocytes) showed enhanced cumulus cells caspase activity and more cumulus cells positive for the apoptotic marker annexin V than older patients.

Limitations, reason for caution

More data must be collected, and correlations established with parameters such as pregnancy and baby delivery rates, before general application of these results is warranted.

Wider implications of the findings

Our data suggests that cumulus cell number and status plays a role in determining the developmental competence of the enclosed oocyte, and that limited apoptosis in cumulus cells from mature oocytes may be beneficial in this development, and thus used as a biomarker for oocyte quality. Importantly, the approach tested here is based on simple assays that can be quickly performed in a minimal clinical setting.

Study funding/competing interest(s)

There was no specific funding for this study and there are no competing interests that might bias the analysis or interpretation of the results.

Trial registration number

Non-applicable.

P-280 Follicle size does not reflect oocyte competency

Abstract

Study question

We evaluated maturity and competency of oocytes in relation to their originating follicle's size and volume. It was elucidated whether retrieval of oocytes from very small follicles is advisable and beneficial. Additionally, our strategy of hCG-administration timing was challenged by analyzing yield of fertilized oocytes in relation to follicle pool.

Summary answer

Although the probability to retrieve oocytes from very small follicles <2ml volume was slightly lower, a high percentage of MII-oocytes is obtained showing same competency as compared to oocytes retrieved from larger follicles.

What is known already

Various protocols for ovarian hyperstimulation are employed, their efficiency being crucial for oocyte yield. The time-point of hCG-administration for final oocyte maturation is highly important and commonly performed when the three leading follicles measure >20mm (about 4ml). However, the optimal follicle size to yield a competent oocyte, duration of hormone substitution, and optimal growth patterns of follicle pools are still under debate, the question whether it is beneficial to puncture also very small follicles discussed.

Study design, size, duration

This retrospective study included 67 couples coming to our center for an IVF-cycle from January- November 2012. Only cycles where ICSI was performed were included.

Participants/materials, setting, methods

For all patients, ovarian hyperstimulation was performed using the long-protocol. During OPU size and volume of 651 follicles were measured by 3D-ultrasound. Retrieved oocytes were kept in single-cell-culture to monitor maturity and competency. Quality of oocytes and fertilization rate were compared with follicle volume.

Main results and the role of chance

Of 651 follicles measured, 334 contained volumes between 2-6 ml. In 24.3% (81 follicles) no oocyte could be retrieved, from the remaining follicles 232 MII-oocytes were collected (91.7%). Of 159 follicles >6ml, 118 MII (94.4%) were harvested and 34 follicles did not yield oocytes (21.4%). From 158 follicles <2ml, 53 did not yield oocytes (33.5%), from the remaining follicles 73 MII were harvested (69.5%). No difference in fertilization rates between the groups was observed. 76.7% of MII originating from follicles 2-6 ml were fertilized as compared to 76.3% from follicles >6ml and 74.0% from follicles <2ml. Rate of abnormal fertilized oocytes was inconspicuous. Although oocyte yield and harvest of MII oocytes is lower in very small follicles, they show similar fertilization rates.

Limitations, reason for caution

Our observation only included patients stimulated with the long protocol.

Wider implications of the findings

In contrast to earlier findings, we observed no differences in the oocyte competency as evaluated by fertilization rate of oocytes originating from very small follicles (<2ml volume). In future, the optimal time of hCG administration has to be reevaluated also taking into account length of follicle stimulation and the different growth patterns of follicle pools and not mainly focusing on the size of the leading follicles.

Study funding/competing interest(s)

None

Trial registration number

None

P-281 Live birth rates in “Bologna” poor responders treated with intensified ovarian stimulation for IVF/ICSI

Abstract

Study question

To determine the efficacy of intensified ovarian stimulation in poor ovarian responders fulfilling the 'Bologna criteria' developed by 'The ESHRE working group on Poor Ovarian Response Definition' and identify parameters related with live birth rates

Summary answer

Live birth rates in ‘Bologna poor responders' treated with intensified ovarian stimulation are consistently low irrespective to patients' age and treatment protocol. Only the number of oocytes retrieved appears to significantly affect live birth rates. Women ≥40 years who do not fulfill the Bologna criteria have similarly low live birth rates.

What is known already

The first published trials including poor ovarian responders fulfilling the Bologna criteria demonstrated very low pregnancy rates, either after treatment with natural cycle IVF or after treatment with novel treatment molecules. However, no attempt has been made to determine the reproductive potential of poor ovarian responders according to the Bologna criteria after treatment with intensified ovarian stimulation for IVF/ICSI and examine parameters that may be related to live birth rates.

Study design, size, duration

This retrospective cohort study included 1204 patients undergoing 2007 treatment cycles with maximum stimulation (≥300IU of gonadotropins) for IVF/ICSI between 2009 and 2011. Overall, 813 cycles referred to patients fulfilling the Bologna criteria for poor ovarian response, whereas 1194 cycles to patients who did not fulfill these criteria.

Participants/materials, setting, methods

Patients were considered eligible, irrespective of the treatment protocol used, if they were planned to undergo ovarian stimulation for IVF/ICSI with a starting dose of gonadotropins ≥300IU. Patients files were manually scrutinized and were classified as poor responders or not based on the Bologna criteria.

Main results and the role of chance

Live birth rates were significantly lower in women who fulfilled the Bologna criteria compared to patients who did not meet the criteria, per cycle 5.7 vs 13.6%, p < 0.0001 and per patient 9.3 vs 22.7%, p < 0.0001.

In ‘Bologna poor responders live birth rates were not related with the type of protocol or type of gonadotropins used. Live birth rates were equally low between women <40 and ≥40 years old, either per cycle (6.7 vs 5%, p = 0.32) or per patient (11.9 vs 7.5%, p = 0.13).The only parameter which was significantly associated with live birth rate was the number of oocytes retrieved with an OR 2.01 95%CI (1.06-3.8) for women having more than 3 oocytes retrieved, compared to women having 1-3 oocytes retrieved.

Finally, women of advanced age ≥40 years demonstrated low clinical pregnancy rates with no difference between patients fulfilling the Bologna criteria and women in the control group, per cycle (7 vs 5%, p = 0.26) and per patient (12.2 vs 7.5%, p = 0.11)

Limitations, reason for caution

Despite numerous efforts, data regarding live births could not be retrieved for 39 treatment cycles. However, given that the difference observed for all groups also persisted in the analyses for ongoing and clinical pregnancies, it is unlikely that missing data might have altered our results.

Wider implications of the findings

This is the first study to examine live births in poor ovarian responders fulfilling the Bologna criteria. The

low live birth rates observed in this population, irrespective of the treatment protocol and patients age, highlight the limited prospects for this group of patients. Future research should focus towards treatment options that may increase the oocyte yield in these women, given that number of oocytes retrieved is a strong determinant of live birth rates. Furthermore, considering that women of advanced age experience equally low live birth rates irrespective of the fulfillment of the criteria, future trials should preferably focus only on women < 40 years old, if any benefit is to be anticipated.

Study funding/competing interest(s)

The Center for Reproductive Medicine receives unconditional research grants unrelated to this study from Ferring Pharmaceuticals, Merck Serono, and Merck Sharp and Dohme Corporation.

Trial registration number

Non applicable

P-282 Gamma-tocotrienol supplementation improves embryo development and fetal survival rate in nicotine-treated pregnant mice

Abstract

Study question

Does gamma-tocotrienol (γ-TCT) supplementation concurrently with nicotine protect post-implantation embryo development, intrauterine foetal growth, pregnancy outcome and survival rate of the newborn by combating nicotine-induced oxidative stress in mice?

Summary answer

γ-TCT supplementation concurrently with nicotine sustains post-implantation embryo development, intrauterine foetal growth, pregnancy outcome as well as survival rate of the newborn by combating free radial generation and sustaining appropriate levels of plasma progesterone (P4) and estrogen (E2) in mice.

What is known already

Nicotine induces oxidative stress through increased lipid peroxidation, impairs enzymatic anti-oxidative defense system, alters embryo development, implantation and pregnancy outcome. γ-TCT, a potent antioxidant, repairs nicotine-induced ultrastructural damage of the preovulatory oocyte, increases the number of retrieved embryos, reduces lipid peroxidation, and sustains levels of enzymatic antioxidant glutathione peroxidase (GPx) and superoxide dismutase (SOD) in the kidney.Nicotine of 3.0 mg/kg bw/day is equivalent to moderate-heavy smoking between 16 and 30 cigarettes/day.γ-TCT of 60 mg/kg bw/day effectively lowers malondialdehyde (MDA) levels in plasma during preimplantation embryo development.

Study design, size, duration

Thirty two (6 – 8 weeks old) female mice (Mus musculus) were equally divided into 4 groups, injected (s.c.) with either 0.9% saline or 3.0 mg/kg bw/day nicotine, or gavaged with either 60 mg/kg bw/day γ-TCT or 60 mg/kg bw/day of γ-TCT concurrently with 3.0 mg/kg bw/day nicotine from day 1 through day 7 of pregnancy (p.c.)

Participants/materials, setting, methods

Fifty percent animals from each group were anesthetized and laparotomized on day 8 p.c. to count and compare implantation sites.On sacrifice (day 10 p.c.); plasma, ovary and fallopian tube were subjected to MDA, GPx, SOD, catalase (CAT), P4 and E2 assays.Intrauterine fetal outcome and survival rate of the newborn until the age of 14 days were evaluated in the remaining animals.

Main results and the role of chance

The intrauterine fetal and neonatal survival rates were significantly reduced in the nicotine-treated groups. Supplementation of γ-TCT in the nicotine-treated animals improved fetal outcome and neonatal survival rates almost similar to controls.Plasma, ovarian and fallopian tube MDA significantly increased in the nicotine treated groups with corresponding decreases in plasma, ovarian and fallopian tube GPx, CAT and SOD. Plasma P4were decreased with a corresponding rise in plasma E2.Plasma, ovarian and fallopian tube MDA, GPx, CAT and SOD concentrations were found to be almost identical to controls in animals treated with nicotine concurrently with γ-TCT. Plasma P4 and E2 levels were also found to be identical to controls. Nicotine treatment during pregnancy developed oxidative stress which was evident by increase in MDA with corresponding decrease in enzymatic antioxidants activity, accompanied by attenuated levels of plasma P4 and E2 and pregnancy wastage. Conversely, supplementation of γ-TCT in the nicotine-treated pregnant mice decreased MDA levels, accelerated enzymatic antioxidants activity and pregnancy outcome by normalizing the levels of plasma P4 and E2.

Limitations, reason for caution

Although previous research findings have suggested that nicotine-induced oxidative stress exerts deleterious impact at different stages of embryo development and pregnancy outcome, yet subsequent supplementation of γ-TCT along with nicotine on metabolomic profiles and cytoskeletal structures during the various stages of pre- and post-implantation embryonic development have not yet been explored. The involvement of hypothalamo-pituitary-gonadal-axis also warrants further investigation.

Wider implications of the findings

Tocotrienol possesses powerful anti-cancer, neuroprotective and hypocholesterolemic properties. Moreover, oral tocotrienol protects against stroke-associated brain damage in vivo and is also bioavailable to all vital organs. In addition, our findings suggest the protective efficacy of tocotrienol in stress-associated reproductive dysfunction.

Study funding/competing interest(s)

This work was supported by Fundamental Research Grant Scheme (FRGS - 600-IRDC/ST/FRGS.5/3/1343), Research Excellence Fund (600-RMI/ST/DANA 5/3/DST.333/2011) and FRGS - 600-RMI/S/FRGS5/3/SFT.71/2010)

Trial registration number

Not applicable

P-283 Homologous intrauterine insemination (iui-h): six years of data (2005-2010) collection from the Italian Assisted Reproductive Technologies (ART) register

Abstract

Study question

To evaluate the appropriateness of the application of Homologous Intra Uterine Insemination (IUI-H) treatments on women of different age classes in Italy and to analyse if its use was different between public and private clinics.

Summary answer

Aggregate data on 184.416 cycles of IUI-H from 364 ART clinics were collected and analysed by the Italian Assisted Reproductive Technologies Register (IARTR) from 2005 to 2010. We found that about 20% of all IUI-H cycles were performed on women aged 40 years old or more showing very low pregnancy rates. Moreover, in private clinics the recorded pregnancy rate was higher than in public centres.

What is known already

IUI-H with or without stimulation is the most common artificial insemination technique in the world. However, parameters affecting its success have not consistently reported, especially in older women.

Study design, size, duration

The IARTR, each year, has collected retrospective data. In this study we analyzed a total number of 184.416 IUI-H cycles performed on 112.227 patients during the six-year study period.Publics clinics (164) represent the 45,1% of the total centers and performed 64,2% (118.329) of the cycles. Private clinics (200) did only 35,8% (66.087) of the ART cycles.

Participants/materials, setting, methods

All ART centres which at least once during the study period have sent data on IUI-H cycles.

Parameters regarding the type of service offered to the couples (public covered by the National Health Service versus/private), number of patients, number of cycles, treatment indications, age classes, pregnancies and live births were analysed.

Data were statistically analysed using SPSS statistic 17.0

Main results and the role of chance

Significant difference (public vs private) was observed in pregnancy rates per cycle, on couples with comparable infertility causes, (9,3% vs 12,8%; p < 0,000) even when the number of IUI-H cycles with controlled ovarian hyper stimulation and the distribution age of patients were comparable (87,2% vs 84,6%; 35,00 years vs 35,17 years). The number of multiple pregnancies were similar (9,8% vs 10,5%; p = 0,0858). During the study period 12.817 babies were born after this procedure (public 7.024 vs private 5.793).This analysis shows that IUI-H represent an important part of infertility treatments since, within six years, 39,7% of all reported cycles are IUI-H treatments (184.416). Nearly 20% of the cycles were performed on women over 40 years, with a pregnancy rate per cycle of 6.7% and 3% for women aged 40-42 old and over 43 years old, respectively. This observation stress the importance to discuss the efficacy of IUI-H treatments in older women. We also observed that private clinics had a slightly higher pregnancy rate per cycle which was statistically significant. The reason(s) for this difference remains to be determined.

Limitations, reason for caution

In this study the data were collected in aggregate form only, in compliance with Italian law, and this has limited the variety and depth of analysis. So then the cause of infertility cannot be related to the success of treatment. The difference in pregnancy rates observed in public and in private clinics has to be taken with caution due to the modality of data collection.

Wider implications of the findings

Our findings based on the analysis of a very large number of IUI-H cycles could contribute to promote the discussion on the efficacy of IUI-H procedures in older women given the very low percentage of pregnancy rate achieved on women aged 40 years old or more

Study funding/competing interest(s)

none

Trial registration number

none

P-284 A randomised controlled trial of fallopian tube sperm perfusion compared with standard intrauterine insemination for women with non-tubal infertility

Abstract

Study question

Does fallopian tube sperm perfusion (FSP) result in better pregnancy and live birth rates than standard intrauterine insemination (SIUI) for couples with non tubal infertility with or without gonadotrophin or clomiphene stimulation.

Summary answer

There was no evidence of improvement in live birth with fallopian tube sperm perfusion.

What is known already

Previous randomized controlled trials suggested improved live birth rates but were small. A systematic review published in 2004 suggested heterogeneity.

Study design, size, duration

A pragmatic, multicentre, randomised controlled trial comparing SIUI and FSP of 417 women with non-tubal infertility.

Participants/materials, setting, methods

Fertility clinics in New Zealand, Australia and the United Arab Emirates.

Main results and the role of chance

17 women were randomised (SIUI = 210, FSP = 207). Data were available for analysis in 198 women in the SIUI group and 198 women in the FSP group. There were 19 women with incomplete data because of cycle cancellation and withdrawals and 2 women who conceived prior to completing treatment. There were no significant differences in live births between the two groups with 27 (12.8%) in the SIUI group and 20 in the FSP group (10.1%) (OR 1.28, 95%CI 0.71 to 2.39, p = 0.48). Two ectopic pregnancies were reported in the SIUI group and one in the FSP group.

Limitations, reason for caution

Different ovulation protocols were used in the different clinics. Ten percent of the cycles included donor sperm and five percent did not complete the assigned intervention.

Wider implications of the findings

There was no evidence of an improvement in live birth with fallopian tube sperm perfusion.

Study funding/competing interest(s)

The study was funded in part by the A+ trust of the Auckland District Health Board. No commercial funding was received.

Trial registration number

ANZCTR Number ACTRN12612001303831

P-285 Relationship between serum and follicular levels of glucose and lipids, oocyte lipids and in vitro fertilisation (IVF) outcome

Abstract

Study question

What is the relationship between serum and follicular levels of lipids and glucose, oocyte lipids and IVF outcome?

Summary answer

Follicular glucose and insulin correlated with serum levels, while, the lipid content in mature unfertilised oocytes had significant correlation with serum low density lipoprotein cholesterol (LDL-C).

What is known already

Glucose and lipids are essential energy substrates for oocyte maturation, and disturbances in follicular glucose and lipids equilibrium affects the oocyte quality,embryo development and hormone production. Studies have shown that obese mice have more oocyte lipids, alteration of mitochondrial function, oxidative stress and fewer blastocysts.

Study design, size, duration

Cross-sectional study of 84 women who underwent ovarian stimulation and IVF at FertilitySA, Australia from February 2011 to August 2011. The demographic data, IVF outcome and follicular and serum glucose and lipids were analysed with Spearman's correlation and t-test.

Participants/materials, setting, methods

Blood and follicular fluid from 84 women were collected on the day of oocyte aspiration and analysed for glucose and lipids (triglyceride, cholesterol and fatty acids). Unfertilised oocytes were collected from 67 women and stained with BODIPY lipid stain and HOESCHT nuclear stain.

Main results and the role of chance

The follicular glucose and insulin correlated with the serum levels (r= 0.32, p= 0.02 and r = 0.58, p< 0.001). The immaturity rate of the retrieved oocytes correlated with the follicular glucose (r= 0.26, p= 0.009) and total fatty acid (r= 0.19, p= 0.04). Although, the unfertilised oocyte fluorescence lipid had lots of variability among individual oocytes, women who had a high level of serum LDL-C (n = 10) had lower mature oocyte lipids when compared to women who had normal serum LDL-C (n = 35) (54.6 ± 19.3 and 72.5 ± 23.4, p = 0.03). Pregnant women (biochemical) also had lower levels of serum LDL-C (1.98 ± 0.6 and 12.31 ± 0.65 mmol/L, p= 0.02) and follicular fatty acid (0.22 ± 0.05 and 0.26 ± 0.09 mmol/L, p= 0.03).

Limitations, reason for caution

There was not much variability of body weight among participating women as approximately fifty percent of them (43) had a normal weight. More women in different body mass indexes and oocyte pools may be needed in further studies for better comparison of oocyte lipid, follicular insulin, glucose and lipid metabolism.

Wider implications of the findings

Follicular glucose and fatty acids affect oocyte maturation. There have been studies that reveal the significance of the LDL-C receptor which affects the number of retrieved oocytes and fertilised oocytes. The LDL-C and fatty acids may affect the oocyte quality and lipid content which is the major source of oocyte energy. Further study on lipid metabolism is needed to improve IVF outcomes.

Study funding/competing interest(s)

The study received a grant from the National Health and Medical Research Council (NHMRC) of Australia.

Trial registration number

none

P-286 Endometrial thickness is a predictor of success in modified natural cycle IVF (mnIVF)

Abstract

Study question

To determine if endometrial thickness on the day of ovulation triggering has an impact on clinical outcomes in mnIVF. In this protocol, patients are started on gonadotropin, GnRH antagonist and NSAID when the leading follicle reaches 15mm until day of hCG trigger when the leading follicle is at least 18mm.

Summary answer

An endometrial thickness of at least 8mm is positively correlated with increasing pregnancy rates in mnIVF.

What is known already

Previous smaller studies provided contradictory findings regarding the impact of ultrasound assessment of the endometrium on the prediction of conception in natural cycle IVF. Several authors have reported on minimal endometrial thickness required in stimulated IVF cycles, varying between 5 and 8mm, however# a threshold endometrial thickness does not exist in the literature for natural cycle IVF.

Study design, size, duration

Single-centre retrospective cohort study, 641 patients, July 2005-December 2011

Participants/materials, setting, methods

All mnIVF cycles leading to successful oocyte retrieval performed in our institution over this period were analyzed. Only first cycle attempts were included. Results were stratified according to endometrial thickness on day of ovulation triggering. The main end-points were clinical pregnancy rates per cycle started and per embryo transfer.

Main results and the role of chance

A total of 641 patients were included in our study. Results are stratified into 2 groups according to endometrial thickness on the day of ovulation triggering: ≥ 8mm (75.9% of the patients studied) and < 8mm (24.1% of patients). Clinical pregnancy rate per cycle started was significantly higher in the group of patients with an endometrial thickness ≥ 8mm compared to < 8mm, 19.5% vs. 12.8%, respectively (p = 0.03). Clinical pregnancy rate per embryo transfer was also superior in the group with an endometrial thickness ≥ 8mm, 37.5% vs. 22.9%, respectively, and this also reached statistical significance (p = 0.02). The statistical power of our sample is higher than 80%, thus decreasing the role of chance in our results.

Limitations, reason for caution

Endometrial thickness is one of several predictors of success in mnIVF. In this study only patients with a leading follicle size of 18mm or more on the day of hCG were analyzed.

Wider implications of the findings

mnIVF has become an increasingly desired protocol that is low-risk and patient friendly. An endometrial thickness of at least 8mm on the day of ovulation triggering significantly predicts successful outcome in mnIVF.

Study funding/competing interest(s)

None

Trial registration number

Not applicable

P-287 Prediction of total fertilization failure - a case-control study of 304 consecutive couples with fertilization failure after IVF compared with 304 controls

Abstract

Study question

Can characteristics of the couple with an apparently normal sperm quality be used as predictors of total fertilization failure (TFF) to improve the primary allocation to either IVF or ICSI?

Summary answer

Predictors of TFF were a) female smoking, b) few oocytes, c) non-tubal factor infertility and d) lower post gradient progressive motile spermatozoa, whereas female age, duration of infertility, reproductive history and earlier in vivo conceptions did not predict TFF.

What is known already

TFF occurs in 5 -15 % of couples undergoing in vitro fertilization (IVF) despite an apparent normal sperm quality. Couples with unexplained infertility, few oocytes retrieved or poor sperm morphology (strict criteria) in the male may be more prone to TFF.

Study design, size, duration

A retrospective case-control study including 304 couples with TFF and 304 controls with fertilization after IVF during a 10-year period (2000 to 2010).

Participants/materials, setting, methods

The cases participated with their first TFF. The controls were the patients with minimum one fertilized oocyte just prior to the cases. The criteria for IVF as fertilization method was a post gradient sperm count ≥ 2 mio. Multivariate logistic regression was used to evaluate the predictors of TFF.

Main results and the role of chance

Female age, BMI, duration of infertility, earlier natural conceptions or conceptions during IUI were not predictors of TFF. The following factors were independent predictors of TFF: Female smoking (AOR 1.63 CI 1.04- 2.55), tubal factor infertility (AOR 0.50 CI 0.34-0.75), number of oocytes (AOR 0.83 CI 0.79-0.88), progressive motile spermatozoa after preparation (AOR 0.38 CI 0.25-0.56). In the TFF cases the sperm quality decreased significantly with increasing oocyte count. In the cycle subsequent to the TFF cycle, IVF was re-used in 37% (mainly in low responders with ≤ 3 oocytes) while the remaining 63% had ICSI. Fertilization was achieved in 86.5% overall. The ongoing pregnancy rate in the subsequent cycle was 17% after TFF versus 32% in the cycle of the controls (p< 0.001).

Limitations, reason for caution

This study has the inherent limitations of all retrospective analyses conducted during a long period of ten years.

Wider implications of the findings

TFF remains an occasional finding which is difficult to predict. The anticipated predictive parameters like advanced female age, duration of infertility and earlier in vivo conception within the same couple proved not to have any predictive value. Despite adjustment of stimulation regime, the use of ICSI in the majority and the fact that almost 90 % of the TFF couples achieved fertilization in the subsequent cycle the pregnancy rate remain poor.

Study funding/competing interest(s)

The Fertility Clinic, section 4071, Copenhagen University Hospital covered all the expenses.

Trial registration number

No trial registration number

P-288 Title: AMH is affected by smoking and oral contraceptive use: results from a large population based study

Abstract

Study question

To address the role of reproductive and lifestyle determinants of AMH in a large population-based cohort of women.

Summary answer

Current oral contraceptive (OC) use, menstrual cycle irregularity, current pregnancy, and current smoking are associated with significantly lower age-specific AMH values. Higher parity was associated with a higher age-specific AMH.

What is known already

Anti-müllerian hormone (AMH) is an ovarian reserve marker that is increasingly applied in clinical practice as a prognostic and diagnostic tool. Despite increased use of AMH in clinical practice, large scale studies addressing the influence of possible determinants on AMH levels are scarce.

Study design, size, duration

Cross-sectional study in the Doetinchem Cohort. Using general linear modelling with CG-LMS (the usual method to calculate growth curves for children) age-specific AMH percentiles were calculated. The effect of female reproductive and life-style factors on shifts in age-specific AMH percentiles was studied. The AMH Gentech II assay was used.

Participants/materials, setting, methods

Participants: 2,320 premenopausal women from the general population.

Methods:Using general linear modelling with CG-LMS (the usual method to calculate growth curves for children) age-specific AMH percentiles were calculated. The effect of female reproductive and life-style factors on shifts in age-specific AMH percentiles was studied. The AMH Gentech II assay was used.

Main results and the role of chance

In comparison to women with a regular menstrual cycle, current oral contraceptive (OC) use, menstrual cycle irregularity and current pregnancy were factors that were associated with significantly lower age-specific AMH percentiles (for OC use 11 percentiles lower, for cycle irregularity 11 percentiles lower and for current pregnancy 17 percentiles lower (p-value for all <0.0001)). Age at menarche and age at first childbirth were not associated with the age-specific AMH percentile. Higher parity was associated with 2 percentiles higher age-specific AMH (p = 0.02).Of the lifestyle factors, current smoking was associated with 4 percentiles lower age-specific AMH percentiles (p = 0.02), irrespective of the smoking dose. BMI, waist circumference, alcohol consumption, physical exercise and socioeconomic status were not significantly associated with age-specific AMH percentiles.

Limitations, reason for caution

Only one measure of AMH was available per woman.

Wider implications of the findings

This study demonstrates that several reproductive and lifestyle factors are associated with age-specific AMH levels. The lower AMH levels associated with OC use and smoking seem reversible, as effects were confined to current use of OC or cigarettes. It is important to give careful consideration to the effect of such determinants when interpreting AMH in a clinical setting and basing patient management upon AMH.

Study funding/competing interest(s)

none

Trial registration number

n/a

P-289 Myeloid cell population alterations within the ovary occur in a gonadotropin dose dependent manner in a murine model of ovarian hyperstimulation syndrome

Abstract

Study question

We sought to determine whether alterations in ovarian myeloid cell populations, i.e immature myeloid cells (IMCs) and/or dendritic cells (DCs), are associated with increased gonadotropin stimulation in a murine model of ovarian hyperstimulation syndrome (OHSS).

Summary answer

Ovarian hyperstimualtion is associated with proangiogenic- myeloid cell alterations, reflected by a gonadotropin dose dependent increase in IMCs and decrease in DCs populating the mouse ovary.

What is known already

Ovarian hyperstimulation syndrome (OHSS) is associated with increased angiogenesis and vascular leakage. IMCs are bone marrow derived cells that expand under several conditions such as pregnancy and malignancy. DCs are antigen presenting cells that regulate the immune response. We and others have previously shown that IMCs and DCs are actively involved in angiogenesis in several disease models in mice and humans. Nevertheless little is known on the role of these myeloid cells in the ovary.

Study design, size, duration

Animal experiment (4 week old pre-pubertal C57Bl/6 female mice), treatment- versus controls: High dose stimulation(n = 4): 20U pregnant mare serum gonadotropins (PMSG) for 2 days; Low dose stimulation(n = 5): 5U PMSG for one day; Sham injected controls (n = 4). On day 3 human chorionic gonadotropin (HCG) (5U) was injected to induce ovulation.

Participants/materials, setting, methods

48 hours after HCG, mice were sacrificed and the ovaries were harvested, weighed and enzymatically digested. Single cell suspensions were immunostained using fluorescently labeled: anti-CD11b, Gr-1, CD11c, MHCII and CD45 and analyzed by flow cytometry. Histological sections were similarly stained along with PECAM1+endothelial cells and examined by confocal microscopy.

Main results and the role of chance

When compared to non-stimulated controls, ovarian weight was higher in both high- and low dose gonadotropin stimulated groups: 21.7 ± 5.8 mg (high dose), 22.1 ± 0.8 mg (low dose) and 4.4 ± 2.4 mg (sham)(n = 4,5,4; ANOVA; p < 0.001). Upon increased gonadotropin dose and ovarian stimulation, the percentage of CD11b+Gr1+IMCs out of total CD45+ovarian myeloid cells within the ovary was higher: 22.6 ± 8.1% (high dose), 7.2 ± 1.6% (low dose), and 4.1 ± 0.3% (sham)(n = 4,5,4; ANOVA p = 0.001); This increase in IMCs paralleled a decrease in the percentage of CD11c+MHCII+DCs out of total CD45+ovarian myeloid cells: 15.1 ± 1.9% (high dose), 20.7 ± 4.8% (low dose), 27.3 ± 8.2% (sham) (n = 4,5,4; ANOVA, p = 0.037). Interestingly, on histological sections we detected only CD11b+Gr1+IMCs and not CD11c+MHCII+DCs, localized adjacent to PECAM1+endothelial cells at sites of angiogenesis.

Limitations, reason for caution

This is an animal experiment and its findings need to be further validated also in humans.

Wider implications of the findings

OHSS is an iatrogenic disorder associated with marked morbidity. Therapies that target the pathophysiology of OHSS, namely vascular permeability and angiogenesis are needed. Our study indicates that gonadotropin stimulation and OHSS are associated with proangiogenic-myeloid cell alterations, reflected by a dose dependent increase in ovarian IMCs and a parallel decrease in DCs. Furthermore, IMCs are strategically located along ovarian blood vessels. Targeting ovarian IMC influx may be a promising strategy to prevent and/or treat OHSS.

Study funding/competing interest(s)

Israeli Science Foundation grant 142/09. No competing interests.

Trial registration number

NA

P-290 Predicting pregnancy outcomes after IVF/ICSI cycles using the vascular endothelial growth factor (VEGF) gene polymorphism

Abstract

Study question

Can the VEGF gene polymorphism be used to predict ongoing pregnancy rate (OPR) outcomes in ART?

Summary answer

The VEGF-1154-AA allele may be a susceptibility factor for identifying patients who are likely to have an ongoing pregnancy after IVF/ICSI.

What is known already

VEGF is essential for angiogenesis and is a crucial member of the endometrial vascular remodelling regulatory system during placenta formation. VEGF is secreted by the maternal corpus luteum and the embryonic trophoblast in early implantation. SNPs in the VEGF encoding gene can affect protein production and uptake. Furthermore, SNPs have been implicated in implantation failure. However, the results of various studies are inconsistent.

Study design, size, duration

A prospective cohort study was conducted from 02/2011 to 06/2012 in 102 infertile women who were subjected to IVF/ICSI protocols. Fisher's exact test and one-way analysis of variance (ANOVA) was used to analyse the data. Patients were evaluated for the presence of VEGF-1154A/A(n = 15;Group A), VEGF-1154A/G(n = 35;Group B) and VEGF-1154G/G(n = 52;Group C).

Participants/materials, setting, methods

The DNA of all participants was extracted from peripheral blood. VEGF gene SNPs (-1154 A/G, rs71815284) were genotyped using real-time PCR with the Taqman Universal PCR Master Mix and Taqman SNP genotyping assays.

Main results and the role of chance

Age, the total number of oocytes and the number of transferred embryos did not significantly differ between Groups A, B and C (P > 0.05). The implantation rate in Group A (40%) was significantly higher than Groups B + C (19.8% P < 0.05). The OPR in Group A was significantly higher compared with Group B (53.3% vs. 22.8%, respectively; P < 0.05). In addition, the OPR was significantly higher (P < 0.05) in Group A compared to Group C (53.3% vs. 21.1%, respectively). The OPR of Group A was significantly higher compared with Groups B + C (53.3% vs. 21.8%, respectively; P < 0.05).

Limitations, reason for caution

Despite recruiting all eligible participants during the study period, the sample size was limited. Differences in the genetic background of various ethnic populations should be considered.

Wider implications of the findings

Predicting pregnancy outcomes during IVF/ICSI treatment based on genetic markers could encourage patients to undergo additional ART cycles if they belong to a group with an improved prognosis for achieving pregnancy. The reduction in the number of transferred embryos in this group is an additional advantage.

Study funding/competing interest(s)

The authors declare that they have no competing interests.

Trial registration number

Not applicable. The local ethics committee authorised this study.

P-291 A prospective evaluation of the effect of herpesvirus-associated ubiquitin-specific protease (HAUSP) gene polymorphism genotypes on implantation failure

Abstract

Study question

Are the HAUSP polymorphism genotypes in couples and their embryos a susceptibility factor for recurrent implantation failure (RIF) after IVF/ICSI?

Summary answer

Differences did not exist between the frequencies of the HAUSP polymorphism in couples with RIF and the controls. In addition, embryonic HAUSP polymorphisms were not associated with RIF. Currently, this polymorphism should not be considered a susceptibility factor for RIF.

What is known already

HAUSP cleaves and stabilises ubiquitin from its substrates. HAUSP is a direct antagonist of MDM2, the E3 ubiquitin ligase for the tumour suppressor protein TP53. There is evidence that HAUSP polymorphisms are associated with RIF after IVF/ICSI in women. However, the results are inconsistent. In addition, there is no information regarding the relationship between embryonic HAUSP polymorphism genotype possibilities and RIF.

Study design, size, duration

A case-control study of 326 people recruited from March/2011 to August/2012 was conducted. A total of 108 couples with RIF (>4cleaved embryos transferred/minimum two embryo transfers). The control group consisted of 55 couples who had experienced at least two live births (history of no more than one miscarriage was accepted).

Participants/materials, setting, methods

The DNA of all participants was extracted from peripheral blood. HAUSP gene SNPs (rs1529916) were genotyped using real-time PCR with the Taqman Universal PCR Master Mix and Taqman SNP genotyping assays. The data were analysed using StatsDirect software, and genotype/allele distributions were evaluated using the χ2test.

Main results and the role of chance12

Table I.

Genotypes and allele frequencies of the HAUSP polymorphism in women and men with RIF and the controls

 Women
 
Men
 
 Women (RIF)
n = 108 
Controls
n = 55 
P Men (RIF)
n = 108 
Controls
n = 55 
P 
Genotype:G/G
Genotype:G/A
Genotype:A/A 
51.85% (56/108)
36.11% (39/108)
12.04% (13/108) 
52.73% (29/55)
40% (22/55)
7.27% (4/55) 
0.61 52.78% (57/108)
36.11% (39/108)
11.11% (12/108) 
34.55% (19/55)
54.54% (30/55)
10.91% (6/55) 
0.06 
Allele:G
Allele:A 
69.91% (151/216)
30.09% (65/216) 
72.73% (80/110)
27.27% (30/110) 
0.69 70.83% (153/216)
29.17% (63/216) 
61.82% (68/110)
38.18% (42/110) 
0.13 
 Women
 
Men
 
 Women (RIF)
n = 108 
Controls
n = 55 
P Men (RIF)
n = 108 
Controls
n = 55 
P 
Genotype:G/G
Genotype:G/A
Genotype:A/A 
51.85% (56/108)
36.11% (39/108)
12.04% (13/108) 
52.73% (29/55)
40% (22/55)
7.27% (4/55) 
0.61 52.78% (57/108)
36.11% (39/108)
11.11% (12/108) 
34.55% (19/55)
54.54% (30/55)
10.91% (6/55) 
0.06 
Allele:G
Allele:A 
69.91% (151/216)
30.09% (65/216) 
72.73% (80/110)
27.27% (30/110) 
0.69 70.83% (153/216)
29.17% (63/216) 
61.82% (68/110)
38.18% (42/110) 
0.13 
Table II.

Genotype possibilities of HAUSP polymorphism in embryos of RIF and fertile couples

Couples Genotypes RIF
n = 108 
Controls
n = 55 
P Offspring Genotype 
G/GxG/G 25.92 %(28/108) 23.64%(13/55) 0.89 100%G/G 
G/GxG/A 42.59%(46/108) 36.36%(20/55) 0.55 50%G/G
50%G/A 
G/GxA/A 10.19%(11/108) 3.64%(2/55) 0.24 100%G/A 
G/AxG/A 10.19%(11/108) 21.82%(12/55) 0.075 25%G/G
50%G/A
25%A/A 
G/AxA/A 9.26 %(10/108) 14.54%(8/55) 0.45 50%A/A
50%G/A 
A/AxA/A 1.85%(2/108) 0%(0/55) 0.79 100%A/A 
Couples Genotypes RIF
n = 108 
Controls
n = 55 
P Offspring Genotype 
G/GxG/G 25.92 %(28/108) 23.64%(13/55) 0.89 100%G/G 
G/GxG/A 42.59%(46/108) 36.36%(20/55) 0.55 50%G/G
50%G/A 
G/GxA/A 10.19%(11/108) 3.64%(2/55) 0.24 100%G/A 
G/AxG/A 10.19%(11/108) 21.82%(12/55) 0.075 25%G/G
50%G/A
25%A/A 
G/AxA/A 9.26 %(10/108) 14.54%(8/55) 0.45 50%A/A
50%G/A 
A/AxA/A 1.85%(2/108) 0%(0/55) 0.79 100%A/A 

Limitations, reason for caution

Because this was a pilot study, additional validation of the SNPs analysed (including both parents and their reproductive characteristics) is needed to provide more information regarding the potential use of this polymorphism as an aspect of implantation failure screening.

Wider implications of the findings

To date, this is the first study to investigate the association between embryonic HAUSP(rs1529916) genetic polymorphism possibilities and RIF. To obtain a consistent predictive value for clinical application, additional SNP genotyping should be combined with multiple markers because the cause of RIF can be multifactorial. To address the ethical constraints of working with human embryos, this prospective non-invasive investigation was conducted using genotype assessments of potential couples and should encourage new research using similar principles.

Study funding/competing interest(s)

The authors declare no conflicts of interests.

Trial registration number

Not applicable. An ethics committee authorised this study, and written informed consent was obtained from all participants.

P-292 Low serum basal AMH level is not always of poor prognostic in ART. Analysis of 10753 consecutive cycles

Abstract

Study question

The objective of the study is to analyze the impact of low ovarian reserve (OR), assessed by serum anti mullerian hormone (AMH) on the outcome of assisted reproductive technology (ART) cycles.

Summary answer

In this large cohort, the present study demonstrates the value of ovarian reserve testing using AMH to predict ovarian response to stimulation, but not the outcome. Some patients, particularly those < 30 years may have a correct response, and an acceptable delivery rate even in case of low response.

What is known already

Low basal AMH is usually associated to poor prognosis in ART. However, AMH is more considered as a marker of quantitative ovarian reserve than a qualitative one, and its impact on implantation and pregnancy rate is questionable. Moreover, the use of AMH as an ovarian reserve marker is still conflicting, particularly in comparison with sonographic antral follicular count.

Study design, size, duration

A retrospective cohort analysis was performed on all cycles with AMH assessment between cycle day1 and Day5 (n = 10753) performed from 2006 to 2010 included in a single private laboratory collaborating with 2 ART clinics.

Participants/materials, setting, methods

AMH was measured using AMH/MIS enzyme-linked immunosorbent assay kit (Beckman Coulter). AMH values were regrouped in 2 categories (<1.5 vs. ≥ 1.5 pg/ml). Main confounders were considered: women's age, cycle rank, BMI, stimulation protocol, oocytes, embryos numbers, ART technique, blastocyst culture. Finally a ROC curve was built for OR.

Main results and the role of chance

Low AMH (<1.5) was more frequent in older women (.40.9% if ≥ 42 years vs, 9.0% if < 30 p < 0.001). AMH was related to cycle rank (through age). For AMH < 1.5, total gonadotropins UI were higher, oocyte and embryo numbers lower, as pregnancy rate (PR), delivery rate (DR) and implantation rate (IR), p < 0.001. However, PR and DR remained acceptable in case of age <30 for low AMH (30.0% and 25%). Also, in case of low AMH, if ≥ 6 oocytes were collected (34.2%), PR and DR were acceptable (21.5% and 15.5%), especially for women aged < 30 (30.0% and 28.0%, respectively). Finally, ROC curve showed a limit of 1.5pg/ml for AMH for ovarian response prediction (sensibility 97%, specificity 45%), but DR prediction was impossible.

Limitations, reason for caution

The study concerned 50% of potential participants, because all women did not have an AMH dosage, and has an observational retrospective cohort design, meaning that potential bias cannot totally be ruled out. However, the large number, the consideration of major confounders (age, BMI, protocol, ovarian response. …) reinforce the results.

Wider implications of the findings

AMH is an indirect marker of cycle outcome, through ovarian response. Low AMH is strongly related to low ovarian response, and a limit of 1.5 pg/ml is predictible. However, acceptable PR and DR can be obtained in case of correct ovarian response and/or young age. Thus its use for selecting patients in ART must be cautious and considered together with other clinical variables.

Study funding/competing interest(s)

This study was performed in a single lab without external funding. There was for any of the authors

Trial registration number

Not applicable

P-293 What affects total dose of gonadotrophins and how does the total dose used affect the outcome of IVF/ICSI treatment

Abstract

Study question

To identify factors which influence the total dose of gonadotrophin necessary to complete ovarian stimulation in readiness for oocyte retrieval, and to determine how the total dose of administered gonadotrophin affects outcome in IVF/ICSI treatment.

Summary answer

Individually tailored gonadotrophin dose for ovarian stimulation in a woman undergoing an IVF/ICSI treatment cycle takes into consideration several relevant parameters. Awareness of the significance of the particular factors influencing drug dosage may help to refine appropriate dosage, with a view to optimising desirable treatment outcomes and implementing cost effectiveness.

What is known already

Higher total gonadotrophin dose adversely affects clinical pregnancy in normo-responder patients undergoing IVF/ICSI cycles. Individualisation of gonadotrophin dose and protocol selection according to predicted ovarian reserve is likely to be cost effective. Determining the optimal gonadotrophin dose requires multifactorial consideration.

Study design, size, duration

This was a prospective observational study of 734 women who reached oocyte retrieval. The primary outcome measures were to identify the correlations between the total dose of gonadotrophin administered and various patient characteristics (specifically weight and BMI), and if there was further correlation between total dose and the treatment's outcome.

Participants/materials, setting, methods

Data was obtained from our computerised database. Pregnancy test was performed approximately 16 days after oocyte retrieval. Clinical pregnancy was confirmed by ultrasound, 2-3 weeks following a positive urinary pregnancy test. Results were analysed using linear and logistic regression statistical models.

Main results and the role of chance

Age (OR 1.39; P < 0.0001), FSH (OR 1.45; p < 0.0001), number of previous cycles (OR 1.50; p < 0.003) and number days of ovarian stimulation (OR 1.42; p < 0.0001) were predictive of total gonadotrophin dose. Weight and BMI had a predictive value when a linear regression model was used (p = 0.045 and p = 0.01 respectively), but not with a logistic regression model (OR 1.01, p = 0.99, and OR 1.058, p = 0.99 respectively). The number of oocytes retrieved showed a significant inverse association with the total gonadotrophin dose (OR 0.99; p = 0.0001), and basal serum FSH showed positive correlation (OR 0.88; p = 0.002). Age, weight and BMI were not predictive of the number of oocytes retrieved when controlled for other factors. Total gonadotrophin dose had a significant negative correlation with clinical pregnancy (OR 0.99; p = 0.001).

Limitations, reason for caution

Our Unit's guidance for choosing a gonadotrophin dose takes into account age, basal serum FSH and BMI. These factors would have influenced the total dose. Larger studies are required to identify the effect of increasing dosage on outcome. Randomised studies can be limited by inclusion and exclusion criteria and need to include all patients.

Wider implications of the findings

The total gonadotrophin dose was inversely associated with the number of oocytes retrieved and the clinical pregnancy rate when controlled for age, basal serum FSH and BMI. Body weight alone gives the same prediction of total dose as BMI. In individualised protocols there may be a need to reduce the total dose of gonadotrophin used, as higher doses may result in significantly lower clinical pregnancy rates, with the additional burden of higher cost.

Study funding/competing interest(s)

None.

Trial registration number

None.

P-294 Role of thrombophilia in female fertility: a systematic review and meta-analysis

Abstract

Study question

To ascertain the prevalence of inherited and acquired thrombophilias in infertile versus fertile women and to determine the association between thrombophilia and in-vitro fertilisation (IVF) outcome.

Summary answer

There was a significantly higher prevalence of Factor V Leiden mutation and acquired thrombophilia in infertile women compared to fertile controls. There is no significant difference in clinical pregnancy, miscarriage or live birth rates following IVF in women screened positive compared to women screened negative for inherited or acquired thrombophilias.

What is known already

Inherited and acquired thrombophilia have been implicated in adverse pregnancy outcomes and recurrent miscarriage. The relationship between thrombophilia and female fertility has been widely debated in the literature. It is speculated that in women undergoing assisted reproduction, thrombophilia may have an association with poor reproductive outcomes. Despite the paucity of evidence, interventions like heparin and aspirin are being offered to women undergoing assisted reproduction.

Study design, size, duration

We conducted a systematic review and meta-analysis of studies to evaluate the association between inherited and acquired thrombophilia with female fertility and IVF outcomes. Searches were conducted on MEDLINE, EMBASE, Cochrane Library (from dates of inception to November 2012). Study selection and data extraction were conducted independently by two reviewers.

Participants/materials, setting, methods

Twenty observational studies compromising 3974 women were included in the review. The Newcastle –Ottowa scale was used for quality assessment for the included studies. Statistical analyses were performed using RevMan 4.2 (Cochrane Collaboration, Oxford, UK). We performed sensitivity analyses where possible and appropriate to address the clinical and methodological variations.

Main results and the role of chance

Meta-analysis of nine studies showed a significantly higher prevalence of Factor V Leiden mutation in infertile versus fertile women (RR2.09, 95% CI 1.34, 3.28; p = 0.001). Meta-analysis of 10 studies showed a significantly higher detection of acquired thrombophilia in women with recurrent implantation failure versus fertile controls (RR3.89, 95% CI 2.34, 6.45; p < 0.00001).

Meta-analysis of studies of inherited and acquired thrombophilias showed no significant differences in clinical pregnancy (RR 0.92 95%CI 0.64, 1.34; p = 0.68 and RR 1.26 95%CI 0.95, 1.67; p = 0.11 respectively), miscarriage (RR 1.58 95%CI 0.80, 3.12; p = 0.19 and RR 1.53 95%CI 0.80, 2.90; p = 0.19 respectively) and live birth rates (RR 1.26 95%CI 0.88, 1.81; p = 0.21 and RR 1.09 95% CI 0.76, 1.57; p = 0.65 respectively) in women undergoing IVF and screened either positive or negative.

Limitations, reason for caution

There was clinical and methodological heterogeneity among the included studies. Studies were of small sample sizes and varied in their criteria for ascertainment of a positive thrombophilia screen.

Wider implications of the findings

This is the first comprehensive systematic review that estimates the prevalence of inherited and acquired thrombophilia and evaluates their role on IVF outcome. The role of inherited thrombophilia especially the role of factor V Leiden mutation in women with recurrent implantation failure merits further explanation. Current evidence does not support the use of empirical heparin treatment in these women. The role of other appropriate interventions in women with recurrent implantation failure needs to be explored.

Study funding/competing interest(s)

None

Trial registration number

None

P-295 Efficiency and cost effectiveness analysis of hepatitis b core antibody testing in assisted conception

Abstract

Study question

Since the enforcement by the Human Fertilisation and Embryology Authority (HFEA) of Hepatitis B core antibody (Anti-HBc) testing prior to Assisted Conception in January 2012, what proportion of patients were found to be positive and what have the cost implications been?

Summary answer

The percentage of patients that screened positive for Anti-HBc was 1.5 (7/465). The additional cost since the introduction of Anti-HBc testing at our unit in April 2012 was £1004 to the National Health Service (NHS), UK.

What is known already

Anti-HBc in the absence of HBsAg is a marker of resolved Hepatitis B virus (HBV) infection. Patients with active HBV infection occasionally screen negative for HBsAg but positive for Anti-HBc. This is occult infection.

Annex III of Commission Directive 2006/17/EC states that screening for HBV must include serological testing for both of Hepatitis B surface antigen (HBsAg) and Anti-HBc. In October 2011, the HFEA clarified that centres must screen for both HBsAg and Anti-HBc.

Study design, size, duration

This was a retrospective audit (April 2012-15 January 2013) of all patients attending for NHS funded Invitro fertilisation/ Intracytoplasmic sperm injection (IVF/ICSI) treatment since the introduction of Anti-HBc screening in April 2012 at the Regional Fertility Centre (RFC) Belfast.

Participants/materials, setting, methods

All patients who were screened positive for anti-HBc were identified. A protocol for the management of these patients was devised. The extra cost to the NHS for each patient if the test was positive or negative was analysed.

Main results and the role of chance

Of the 547 patients who had ART, 465 were screened for anti-HBc in addition to HBsAg. Of these, seven were screened positive (1.5%). Two of these were false positives, three were immune (as confirmed by high titres of Anti-Hbs) and two were not considered as immune. The extra cost to the NHS for Anti-HBc testing per test was calculated to be two pounds. This along with a repeat test with a different assay to rule out false positives along with Hepatitis B virus DNA testing for non immune patients (Anti Hbs titres < 100mIU/ml) would have potentially costed £1004.

Limitations, reason for caution

The Safety of blood, tissue and organs (SaBTO) guidance for organ transplant consider Anti-Hbs titres of < 10mIU/ml as non immune but not for reproductive cells. In our protocol, Hepatitis b viral DNA testing for non immune patients (Anti Hbs titres < 100mIU/ml) might incur unnecessary tests but errs on the side of caution.

Wider implications of the findings

1.1% patients are screened true positive for Anti-HBc. 0. 4% in the population might be nonimmune with potential occult Hepatitis B viral infection and hence not suitable for embryo storage. With an expense of about £1000 to NHS we could potentially pick two cases with occult Hepatitis B viral infection.

Study funding/competing interest(s)

Nil

Trial registration number

NA

P-296 High serum progesterone levels on the day of hCG administration are associated with low pregnancy rates in women treated with GnRH-antagonist IVF cycles

Abstract

Study question

Is pregnancy outcome affected by rising progesterone (p4) levels on day 7 (D7) and day 9 (D9) of controlled ovarian stimulation (COS) and on the day of human chorionic gonadotrophin administration (DhCG) in gonadotrophin releasing hormone (GnRH) antagonist IVF cycles.

Summary answer

Rising serum p4 on the DhCG is believed to indicate premature luteinisation and is associated with lower pregnancy (PR) and live birth rate (LBR) through an adverse effect on endometrial receptivity. p4 levels taken during COS are unrelated to pregnancy outcome however higher levels may predict elevated p4 on DhCG.

What is known already

There is a widespread controversy surrounding rising level of serum p4 and pregnancy outcome in COS GnRH-antagonist IVF cycles. High p4 levels are believed to impair endometrial receptivity leading to implantation failure and if present on DhCG, have been shown to have a negative impact on IVF treatment outcome. There are no studies to date to determine whether rising p4 levels during COS effect PR and LBR.

Study design, size, duration

Retrospective analysis on prospectively collected data of women undergoing GnRH-antagonist IVF/ICSI cycles at a private fertility clinic between January 2011 and December 2012. Women had serum p4 levels (nmol/L) taken on D7, D9 and DhCG (n = 192).

Participants/materials, setting, methods

Cycle characteristics and pregnancy outcomes (Pr = pregnant; NPr = not pregnant) were evaluated. A receiver operator characteristic (ROC) curve was plotted to determine the threshold value for p4 and pregnancy outcome was compared using cross tabulation and Fisher's exact significance testing.

Main results and the role of chance

PR for all GnRH antagonist cycles was 50.0% (96/192). There was no correlation between pregnancy outcome and mean p4 levels taken on D7 (Pr 1.67nmol/L, NPr 1.68nmol/L; p > 0.05) and D9 (Pr 1.92nmol/L, NPr 2.09nmol/L; p > 0.05). High mean p4 levels on DhCG were found to be significantly associated with an adverse pregnancy outcome (Pr 2.39nmol/L, NPr 3.08nmol/L; p < 0.05).

In women who had p4 levels taken on DhCG, ROC curve demonstrated that a cut-off level of ≥4.0nmol/L was associated with a significantly poorer pregnancy outcome; PR with p4 < 4.0nmol/L was 54.9% (90/164) compared p4 ≥ 4.0nmol/L being 21.4% (6/28) (p < 0.001). There were no pregnancies in women with p4 > 5.0nmol/L on DhCG.

Limitations, reason for caution

None

Wider implications of the findings

High serum p4 on DhCG may indicate premature luteinisation and is associated with lower PR and LBR through an adverse effect on endometrial receptivity. Elevated serum p4 levels during COS have not shown to correlate with pregnancy outcome however higher levels may predict an elevated p4 on DhCG. In cases where p4 levels are predicted to be above 4nmol/L on DhCG, patients could be counseled regarding freezing all embryos for future transfer.

Study funding/competing interest(s)

None

Trial registration number

Not applicable

P-297 Luteinizing hormone supplementation from Day 1 versus 6 of ovarian stimulation in women aged 36ñ40 years: results from an open-label, randomized, multicentre, multinational trial

Abstract

Study question

In women aged 36–40 years, how many oocytes are retrieved using two controlled ovarian stimulation (COS) treatment strategies: (Group A) recombinant follicle-stimulating hormone (r-hFSH) plus recombinant luteinizing hormone (r-hLH) (2:1) from Day 1 or (Group B) r-hFSH from Days 1–5, then r-hFSH plus r-hLH (2:1) from Day 6?

Summary answer

The primary endpoint was not met: mean (standard deviation; SD) number of oocytes retrieved was 9.7 (6.9) in Group A and 10.9 (6.5) in Group B (estimate of difference: –1.21 oocytes, 95% confidence interval [CI]: –3.07, 0.66).

What is known already

The 2:1 formulation of r-hFSH and r-hLH was launched in the European Union in 2007 for the treatment of women with hypogonadotrophic hypogonadism. r-hLH supplementation of r-hFSH for COS has been shown to have benefits for patients aged ≥35 years (Hill MJ et al, Fertil Steril 2012).

Study design, size, duration

This Phase IIIb, randomized, open-label (PERSIST; PERgoveriS In Stratified Treatment for ART) trial was performed in 30 sites (11 countries) from May 2011 to October 2012; 229 patients were screened. The primary endpoint was the number of oocytes retrieved. Secondary endpoints included clinical pregnancy rate per started cycle.

Participants/materials, setting, methods

A total of 202 eligible women aged 36–40 years without poor response to ≥2 previous assisted reproductive technology (ART) cycles were randomized to either Group A (n = 103) or Group B (n = 99). All starting doses were 300 IU; doses could be adjusted from Day 6.

Main results and the role of chance

A total of 101/103 patients in Group A and 98/99 patients in Group B met human chorionic gonadotrophin (hCG) criteria (≥1 follicle ≥18 mm and two ≥16 mm), received recombinant hCG (r-hCG) and underwent oocyte pick-up 34–38 hours post r-hCG administration. Embryo transfer was performed in 93 and 90 patients, respectively. The mean (SD) number of oocytes retrieved was 9.7 (6.9) in Group A and 10.9 (6.5) in Group B; equivalence (defined as a treatment difference within +/-3 oocytes) was not shown (estimate of difference: –1.21 oocytes [95% CI: –3.07, 0.66]). The numbers of clinical pregnancies (confirmed by foetal heart beat on ultrasound) per started cycle were 32/101 (31.7%) and 17/97 (17.5%), respectively (p = 0.0241).

Limitations, reason for caution

Patients/physicians were aware of assigned treatment (open-label), but this was not considered to affect observed outcomes. The difference in clinical pregnancy rates between groups should be regarded with caution as the study was not powered to test the secondary endpoint. Also, the primary efficacy analysis null hypothesis was not met.

Wider implications of the findings

Although a difference in numbers of oocytes was not observed between groups, administration of r-hFSH and r-hLH in a 2:1 ratio from Day 1 might provide an alternate treatment strategy for optimizing pregnancy rates in women aged 36–40 years who are undergoing ART. Further studies would be necessary to verify this.

Study funding/competing interest(s)

Merck KGaA funded the study. Medidata Germany handled study management, including data management and analysis. Editorial assistance for abstract preparation was supported by Merck Serono S.A. – Geneva, Switzerland.

Trial registration number

Clinicaltrials.gov identifier: NCT01297465.

P-298 B-hcg level on day 7 of spontaneously hatched blastocyst transfer (shbt) can predict pregnancy outcome in terms of live birth rate in ivf cycles

Abstract

Study question

To evaluate b-hCG level on day 7 after spontaneously hatched single blastocyst transfer (SHBT) as a biomarker to predict pregnancy outcome in terms of live birth rate in IVF cycles of good prognostic women as no such study has ever been carried out till date.

Summary answer

b-hCG level on day7 of blastocyst transfer is a robust predictive marker of pregnancy outcome in good prognostic women undergoing IVF as b-hCG >40 mIU/ml indicates successful implantation and live birth; b-hCG 10-40 mIU/ml predicts implantation but weakly correlates with live birth whereas b-hCG <10 mIU/ml indicates only biochemical pregnancy.

What is known already

Human chorionic gonadotropin (hCG) is secreted by syncytial trophoblast and appears in maternal circulation approximately 6–8 days after fertilization. It is well documented that levels of b-hCG in early pregnancy (usually day14 of embryo transfer) are predictive of pregnancy outcomes. However, with the advent of day5/6 blastocyst transfer as against the routine day3 embryo transfers in IVF, there has to be a paradigm shift in day of b-hCG measurement to predict pregnancy outcome.

Study design, size, duration

In this retrospective cohort study,468 women undergoing fresh non-donor IVF cycles received single spontaneously hatched blastocyst transfers during April 2008 to March 2012. b-hCG level in serum on day7 after transfer was measured to evaluate the pregnancy outcome. Implantation and live birth Rates (LBR) were correlated with these levels.

Participants/materials, setting, methods

Standard ovarian stimulation protocol was used in 468 women with good prognosis (<38 years) undergoing their first non-donor IVF-ET cycles. Blastocysts formed using extended culture were allowed to hatch spontaneously after which a single hatching/hatched embryo was transferred on day6/7. Serum b-hCG level on day 7 of transfer was measured.

Main results and the role of chance

34.6% LBR was obtained with spontaneously hatching/hatched blastocyst transfer. Serum b-hCG level measured on day 7 of ET ranged from 5-230 mIu/ml in 233/468 women. These women (n = 233) were divided arbitrarily into seven groups: 5-10,11-20,21-30,31-40,41-50,51-60 and >60 mIu/ml of b-hCG. No pregnancy or implantation was found in 5-10 range. Number of live births in 11-20 range (n = 33), 21-30 range (n = 25) and 31-40 range (n = 18) were found to be 8, 5 and 4 out of 17, 6 and 7 pregnancies respectively. All pregnancies in 41-50 range (n = 10), 51-60 range (n = 24) and >60 range (n = 105) resulted in live birth. Age, infertility period, body-mass-index and blastocyst grades were comparable in all groups. ROC threshold for LB was found to be >39.5 mIU/ml b-hCG on day7 of transfer (Sensitivity = 93.2%;Specificity = 93.1 %).

Limitations, reason for caution

Our study is retrospective in nature with small cohort size. Also, since to our knowledge, this is arguably the first ever study on day7 b-hCG thresholds predictive of LB involving SHBT, there is no available reference in literature to compare our results with.

Wider implications of the findings

The results of our study show that spontaneously hatching/hatched blastocyst transfers (SHBT) are significantly associated with several favourable cycle parameters like younger age and better ovarian reserve and overall better pregnancy outcomes and LB rates. Our study indicates that b-hCG levels can predict implantation resulting in live birth at a very early stage i.e. on day7 of embryo transfer itself.

Study funding/competing interest(s)

This retrospective study did not have funding from any source and there are no competing interests whatsoever.

Trial registration number

Not Applicable

P-299 Follicular-fluid dehydroepiandrosterone-sulphate (FF DHEAS) is a poignantly credible biomarker of oocyte fertilization potential and pregnancy outcome in conventional IVF cycles of non-PCOS women

Abstract

Study question

To investigate if in-situ levels of follicular-fluid dehydroepiandrosterone-sulphate (FF DHEAS), an essential prohormone in ovarian follicular steroidogenesis, influences oocyte competence to fertilize and produce a viable pregnancy in IVF cycles.

Summary answer

FF DHEAS is a plausible biomarker of oocyte fertilization potential and an effective indicator of pregnancy outcome in conventional IVF cycles of normal responder, non-PCOS women.

What is known already

Most studies have either comparatively evaluated DHEA levels among PCOS/non-PCOS women or have found that exogenous DHEA augments ovarian function in poor responders through increased oocyte production and higher fertilization rates. Although it is known that DHEA is produced by ovarian theca cells and released in follicular-fluid, no study so far has focused on in-situ FF DHEAS as a marker of oocyte fertilization potential and as an indicator of pregnancy outcome in IVF cycles.

Study design, size, duration

This prospective cohort study involving 249 conventional down regulation-stimulation protocol IVF cycles in non-PCOS, normal responder women was carried out at our academically affiliated private infertility clinic from January 2011 to March 2012. Severe male factor abnormality cycles requiring ICSI were excluded.

Participants/materials, setting, methods

FF DHEAS levels were estimated in fluid pooled from follicles from which oocytes had been retrieved. Fertilization failure cycles (n = 13) were excluded while comparing pregnancy rates. Cycles were divided into pregnant and non-pregnant cycles and into high and low FF DHEAS groups. Main outcome measures were Fertilization rate and live-birth rate.

Main results and the role of chance

Levels of FF DHEAS (1504 ± 108.3 vs. 1018 ± 48.05ng/ml; p < 0.0001), FF E2 (244500 ± 54090 vs.105500 ± 11490pg/ml; p= 0.016) and Fertilization rate (85.15 ± 17.00 vs. 78.90 ± 21.79%; p= 0.0455) were significantly higher in pregnant (n = 58) compared to non-pregnant (n = 178) cycles.

High (>920ng/ml) FF DHEAS group (n = 122) showed significantly higher levels of FF E2 (185800 ± 27690 vs. 109600 ± 11790pg/ml; p= 0.0133), fertilization rate (85.56 ± 16.82 vs. 75.35 ± 22.76%; p= 0.0001), clinical pregnancy (35.59 vs. 14.41%; p= 0.0002) and live birth rate (20.38 vs. 7.29 %; p < 0.0001) compared to low (≤ 920ng/ml) FF DHEAS group (n = 127). Fertilization failure cycles depicted significantly lower levels of FF DHEAS compared to fertilization success cycles (551.9 ± 83.69 vs. 1106 ± 43.21ng/ml; p= 0.0015).

Limitations, reason for caution

Our study is limited by a small sample size. Also, since pregnancy is a multifactorial phenomenon and ours is not a randomized control trial, there may be a possibility of some unknown factors contributing to the observed results.

Wider implications of the findings

This is the first ever study involving measurement of endogenously present, in-situ levels of DHEAS in pooled FF obtained from a cohort of follicles from which oocytes had been retrieved in each IVF cycle. FF DHEAS may be an efficient and reliable marker of fertilization. Also, pooled FF represents a more comprehensive follicular-fluid micro-environmental milieu. Therefore, evaluating components in pooled follicular-fluid offers a novel promising concept.

Study funding/competing interest(s)

The study was self funded. The authors have no competing interests to disclose.

Trial registration number

Not Applicable

P-300 Risk factors of recurrent pregnancy loss do not affect in-vitro fertilization success

Abstract

Study question

Do risk factors of recurrent pregnancy loss, such as antiphospholipid antibodies, affect the success rate of assisted reproductive technology (ART)?

Summary answer

Surprisingly, the outcomes of ART in patients with risk factors of recurrent pregnancy loss were better than those in the negative risk factor group. Therefore, risk factors of recurrent pregnancy loss do not affect in-vitro fertilization (IVF) success.

What is known already

Risk factors of recurrent pregnancy loss, such as antiphospholipid antibodies, inhibit the proliferation and differentiation of trophoblast cells. The causal relation between infertility and the risk factors of recurrent pregnancy loss are not clear. However, the risk factors have been predicted to inhibit implantation at an early stage.

Study design, size, duration

This prospective clinical study included 320 women (age, >40 years) treated in 2012.

We measured lupus anticoagulant, anti-cardiolipin IgG/IgM, anti-phosphatidyl ethanol amine IgG/IgM, blood coagulation factor XII, protein C/S, and NK cell activity before ART. The positive risk factor group included patients with at least 1 risk factor.

Participants/materials, setting, methods

We analyzed 54 fresh embryo transfer cycles and 74 frozen-thawed embryo transfer cycles among 90 patients who underwent blastocytembryo transfer. Clinical pregnancy was defined as the detection of a gestational sac. We prospectively analyzed the effects of the risk factors on the outcomes of ART.

Main results and the role of chance

The positive and negative risk factor groups included 22 and 68 women, respectively. There were no significant differences in clinical backgrounds (age, FSH levels, and the number of pre-antral follicles, embryo transfer cycles) between the groups. The clinical pregnancy rates were 68.1% and 44.1% in the positive and negative groups, respectively (P = 0.09). Furthermore, for the positive detection of antiphospholipid antibodies, the clinical pregnancy rates were 80.0% and 44.0% in the antiphospholipid antibody positive and negative groups, respectively, indicating a significantly higher pregnancy rate in the positive group than the negative group (P < 0.05).In addition, there were no significant differences in the positive rates of risk factors between the recurrent implantation failure group (≥2 failures) and the pregnant group (with first embryo transfer).

Limitations, reason for caution

The small sample size in the prospective study and nonselection of the first IVF cycle at our center.

Wider implications of the findings

The findings of this study raise the possibility that there is a difference in the pathological mechanism between recurrent pregnancy loss and infertility. The facile administration of anticoagulants to infertile patients should be avoided.

Study funding/competing interest(s)

This study received no funding, and there are no conflicts of interests to be declared.

Trial registration number

Not applicable.

P-301 Egr-3 exhibits a unique subcellular localization in mouse oocytes during meiotic maturation

Abstract

Study question

Does Egr-3 exhibit a unique function other than transcriptional regulation during the process of meiosis in mouse oocytes?

Summary answer

Localization of Egr-3 protein is microtubule-dependent and it may function during the process of meiotic spindle formation and microtubule organizing center (MTOC) in mouse oocytes.

What is known already

Among four members of Egr transcription factors, Egr-1 plays a role in folliculogenesis and ovulation by regulating luteinizing hormone responsiveness. Egr-4 null mice are infertile in male. Egr-3 is an estrogen-responsive gene, but its role in female reproduction has not been investigated.

Study design, size, duration

To investigate Egr-3 expression and localization during meiotic maturation, cultured oocytes were processed for Western blotting and immunofluorescence staining at different stage (prophase I, promethaphase I, methaphase I, and metaphase II).

Participants/materials, setting, methods

Germinal vesicle (GV) oocytes were collected from ICR mice at 48 hr after PMSG injection. Oocytes were cultured in vitro and were processed for Western blotting and immunofluorescence staining at different time points. To investigate whether cytoskeletons are associated with Egr-3 localization, we used nocodazole, taxol, or cytochalasin D

Main results and the role of chance

We found that Egr-3 protein is present in mouse oocytes and that it is specifically localized in MTOCs and meiotic spindle during maturation. This type of cytoplasmic localization of Egr-3 has never been described in any system. Localization of Egr-3 in MTOCs and spindle is microtubule-dependent, but is independent of actin filaments. Co-staining with gamma-tubulin antibody further revealed that Egr-3 is closely located with gamma-tubulin ring complex during oocyte maturation.

Limitations, reason for caution

Our study is limited to the description of Egr-3 protein localization in oocytes. Functional experiments using siRNA or antisense technology should follow to address the implication of unique Egr-3 localization. Further investigation is needed if this type of Egr-3 localization is seen in male germ cells and other cellular systems.

Wider implications of the findings

These results provide the first evidence that Egr-3 in mouse oocytes may exhibit a unique role other than transcriptional regulation. This finding will help gain deeper understandings on meiotic maturation of oocytes and offers a novel marker of cytoskeleton and spindle complex in mouse oocytes.

Study funding/competing interest(s)

This study was supported by a grant of the Korea Health technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A120080).

Trial registration number

N/A

P-302 Comparison of embryo transfer in egg donation recipients with transvaginal and transabdominal ultrasound: a randomized pilot study

Abstract

Study question

Are there any differences between transvaginal (TV) and transabdominal (TA) ultrasound-guided embryo transfer (ET) in terms of ease of use, patient satisfaction, and treatment outcome?

Summary answer

TA and TV ultrasound-guided ET can be used with comparable ease and tolerated equally well by patients. Further studies are needed to test whether the outcome of egg donation treatment is affected by the type of ultrasound guidance.

What is known already

TA ultrasound guidance is the golden standard for ETs. TV ultrasound guidance was proposed recently to provide better visualization and reduce patient discomfort as ET can be performed with an empty bladder in this case.

Study design, size, duration

Randomized controlled non-blinded study performed on 100 consecutive patients undergoing egg donation (ED) treatment with ET of 2 embryos on day 3, between February and December 2012, in a private infertility clinic.

Participants/materials, setting, methods

Based on previous results showing decreased pregnancy rates in women with submucous or >3 cm intramural fibroids, Turner syndrome patients, and black recipients, women meeting these criteria were excluded. Patients were randomized to TA ultrasound-guided ET with the Cook SoftTrans catheter or TV-ultrasound guided ET with the Kitazato long ET catheter. Transfers were performed by five experienced gynecologists, using the afterloading technique.

Main results and the role of chance

Groups were comparable regarding patient's and partner's age, BMI, number of previous ED attempts, distribution of indications, proportion of cases with sperm anomalies, length of endometrial preparation with estrogens, donor's age, number of donated and fertilized eggs. Patients reported a similar level of menstruation-like pain (mean ± SE: 1.22 ± 0.01 [TA group] vs. 1.32 ± 0.01 [TV group] on a three-level scale [1-3]), discomfort related to vesical distension (1.66 ± 0.16 vs. 1.51 ± 0.14) and overall discomfort (1.49 ± 0.11 vs. 1.49 ± 0.01). Operators faced a comparable level of difficulty using both techniques (1.25 ± 0.01 vs. 1.29 ± 0.11), and catheterization time was also comparable between groups (92.4 ± 25.9 s vs. 79.0 ± 18.5 s). Operators decided to convert to the opposite technique less frequently in patients assigned to the TA arm (10.6% vs. 21.3%), although the difference did not reach statistical significance. Similar pregnancy (55.3% vs. 54.7%), clinical pregnancy (53.2% vs. 50.4%) and ongoing pregnancy rates (46.8% vs. 44.0%) were observed in both groups.

Limitations, reason for caution

In view of the differences not reaching statistical significance, sample size seems to be a major limitation of our study, for which further recruitment of patients is underway in order to gain adequate power.

Wider implications of the findings

Both techniques are well accepted both by patients and operators. At present, we see the option of TV ultrasound-guided ET as an important alternative to the TA technique especially in difficult transfers or in cases with limited visibility (e. g., obese patients or retroverted uteri).

Study funding/competing interest(s)

None.

Trial registration number

NCT01805505

P-303 Study of triple CGG repeats (FMR1 gene) in 41 patients with a reduced ovarian response to gonadotropin stimulation: no correlation found with four ovarian parameters

Abstract

Study question

To study the triple CGG repeats (FMR1gene) in patients with a poor response to ovarian hormone stimulation, known as “low responders” and to assess whether the number of CGG repeats correlates with 4 ovarian reserve parameters (FSH; anti-Müllerian hormone (AMH); antral follicle count and the number of oocytes retrieved).

Summary answer

The results of this study suggest that women with poor response to ovarian hormone stimulation might be at risk of carrying alleles in the premutation (PM) range (>55 triple CGG repeats), but it appears that triple repeat counts doesn't correlate with the four ovarian reserve parameters studied.

What is known already

Fragile X Syndrome is the most common inherited cause of intellectual disability and is caused by the expansion of a CGG triplet in theFMR1gene. Alleles carrying a number of CGG repeats between 56 and 200 are called PM. Primary ovarian insufficiency has been confirmed as a phenotypic characteristic of PM carriers and it has even been suggested that alleles with more than 30 repeats increase the risk of having a diminished ovarian reserve.

Study design, size, duration

This prospective, controlled cohort study was performed on 41 poor responders (<6 oocytes retrieved) undergoing intracytoplasmic sperm injection (ICSI) treatment in the Human Reproduction Unit (Hospital Universitario Cruces) from January 2012 to January 2013. All participants were informed regarding the purpose of the study and signed the written informed consent.

Participants/materials, setting, methods

DNA from patients was analysed in the Molecular Genetic Laboratory of the Genetics’ Service (Hospital Universitario Cruces) using a commercial triplet CGG assay (AmplideX FMR1 PCR kit from Asuragen). Correlation analysis with the four ovarian reserve parameters was performed using the Statistical Package for Social Sciences (SPSS) version 20.0.

Main results and the role of chance

One of the 41 poor responding patients (2.4%) had a PM (64 repeats); the remainder 40 had CGG repeats in the normal range (23-43 repeats), because we consider that alleles with <46 CGG are normal. Among them, 4 patients (9.7%) had alleles >40 repeats (41, 42, 43 and 43) that would have been considered intermediate alleles by the American College of Obstetricians and Gynaecologists.

The results of FSH, AMH, antral follicle count and the number of oocytes retrieved using medians and standard deviations as descriptive measures were 8.2 (1.5-85.4); 0.3 (0.1-7.5); 6 (2-24) and 4 (1-6) respectively. Spearmen correlation was used to assess whether the number of CGG repeats correlates with these four clinical parameters but no correlation was found for any of them.

Limitations, reason for caution

The results presented here are preliminary. They represent only one year of a research project work, which we have for three years. Hence, the limitation of this study is the small sample size.

Wider implications of the findings

This study demonstrates the need to carry out the triplet CGG repeat study in patients with poor response to ovarian hormone stimulation, because they might be at risk of carrying alleles in the PM range. We therefore agree with published papers that said that FMR1 testing should be considered before infertility treatments are initiated. Nevertheless, our study doesn't confirm previous studies that said that over 30 CGG repeats the risk toward infertility increases.

Study funding/competing interest(s)

This work was financially supported by FIS (ISCIII) grant No. PI10/00550.

The authors declare .

Trial registration number

This study is not a clinical trial

P-304 Impact of estradiol and homocysteine concentrations from follicular fluid and peripheral blood on the outcome of assisted reproduction treatment

Abstract

Study question

To correlate serum and follicular levels of estradiol and homocysteine in infertile women with results of assisted reproduction

Summary answer

We observed that higher estradiol levels, better the embryonic parameters. Except for endometriosis, an estrogens dependent disease with high circulating levels of these hormones, the serum levels of estradiol are sufficient to determine this correlation.

What is known already

Functionally in a cycle, estrogens are responsible for oocyte maturation, fertilization, embryo development and helps maintain the pregnancy. Homocysteine?? is a product of the folate metabolism linked to important physiological processes as impaired cell division, production of inflammatory cytokine and high rates of apoptosis. Thus, decreased or increased levels of homocysteine ??and estrogens in the serum or in the follicular fluid could be related to infertility and associated to assisted reproduction techniques (ART) outcomes.

Study design, size, duration

Cross sectional comprised 29 women with idiopathic infertility (GI) and 44 patients with endometriosis (GII). A control group (GIII) was composed by 35 fertile women whose partner presents male infertility.

Participants/materials, setting, methods

All women underwent ART at Faculdade de Medicina do ABC, Brazil. The analysis of serum and follicular fluid was performed by measuring the concentrations of estradiol and homocysteine. Statistical analyses was done by Person's correlation and considered significant when p < 0.005.

Main results and the role of chance

In GI group the serum and follicular estradiol levels were positively correlated with the number of follicles observed by US (p = 0.0001; p = 0.0011), oocytes retrieved (p = 0.0001; p = 0.0006), oocyte maturation (p = 0.0006; p = 0.0013), fertilization rates (p = 0.0212; 0.0267) and number of embryos for transfer (p = 0.0036; p = 0.0078). For GII group the estradiol serum levels were only correlated with oocyte maturation (p = 0.0331). Considering GIII we observed a positive correlation serum levels of estradiol with the number of follicles observed by US (p = 0.0001), oocytes retrieved (p = 0.0001) and oocyte maturation (p = 0.0008). Fertilization rates and embryos for transfer were not evaluated in GIII. Regarding homocysteine levels, serum and follicular, we did not observe difference in the parameters evaluated.

Limitations, reason for caution

Number of patients is low.

Wider implications of the findings

We observed that higher estradiol levels, better the embryonic parameters. Except for endometriosis, an estrogens dependent disease with high circulating levels of these hormones, the serum levels of estradiol are sufficient to determine this correlation.

Study funding/competing interest(s)

FAPESP (Fundação de Amparo a Pesquisa do Estado de São Paulo) no. 2010/16274-4 and CNPq no. 476116/2010-4

Trial registration number

Not applicable.

P-305 Hysterosalpingography plus ultrasound versus hysteroscopy plus ultrasound in the work-up of donor oocyte recipients: a diagnostic accuracy study

Abstract

Study question

In the work-up of potential donor oocyte recipients, what is the best combination of imaging studies: hysterosalpingography plus ultrasound or hysteroscopy plus ultrasound?

Summary answer

Given the high prevalence of structural pathology in potentially eligible recipients of donor oocytes, the combination of hysteroscopy plus ultrasound yields a much better diagnostic performance, without medical complications.

What is known already

The actual recommendation for the initial work-up of infertile women is to include hysterosalpingography plus ultrasound. This recommendation is extrapolated to the study of potentially eligible recipients of donor oocytes. Hysteroscopy is the gold standard for the exploration of the uterine cavity, but its role as a routine procedure in infertile patients is controversial. It is not known if hysterosalpingography or hysteroscopy (both coupled with ultrasound) is the best imaging study method for oocyte recipients.

Study design, size, duration

Study design: prospective diagnostic accuracy study. Size: 110 consecutive patients were included, receiving hysterosalpingography, ultrasound and hysteroscopy in a period no longer than six months. Duration: from 06/01/2011 to 12/31/2012. All participants signed a written informed consent.

Participants/materials, setting, methods

Eligible patients were infertile women to be studied as recipient of donor oocytes. Setting: Fertility division, Hospital Italiano de Buenos Aires, Argentina. Pathological findings of hysterosalpingography plus ultrasound or from hysteroscopy plus ultrasound were compared to a gold standard histopathological diagnosis. Operators were blinded to other study results.

Main results and the role of chance

We included 110 women. The mean (SD) age was 42.5 (4.3) years. The prevalence of structural pathology was 56.4% (95%CI 46.9%-65.8%). The sensitivity and specificity (95%CI) for hysterosalpingography plus ultrasound (HSG + US) was 40.0% (28.2%-52.7%) and 74.0% (60.6%-84.7%), respectively. For hysteroscopy plus ultrasound (HC + US) was 100% (95.1%-100%) and 94.0% (84.5-98.5%). The positive and negative predictive values for HSG + US were 64.9% (48.6%-78.9%) and 50.7% (39.3%-62.0%), respectively. For HC + US were, 95.2% (87.6%-98.8%) and 100% (93.8%-100%). There were no adverse consequences with any study method.

The most frequent abnormalities found were endometrial polyps (18.2%; 95%CI 10.9%-25.5%), endocervical synechiae (10.9%; 95%CI 4.99%-16.8%) and endocervical polyps (9.1%; 95%CI 3.6%-14.5%).

Limitations, reason for caution

There was a maximum gap of six months between the initial HSG + US and the gold standard method including histopatological diagnosis. There was a chance, although very low, for the development of new abnormalities between studies.

Wider implications of the findings

In this population of oocyte donation recipients there was a high prevalence of structural abnormalities. HSG + US showed poor sensitivity and low negative predictive value. On the contrary, hysteroscopy had an excellent performance for detecting and ruling out disease.

Facing the diagnostic advantage of hysteroscopy, with its additional therapeutic opportunity in the same procedure, routine hysteroscopy could be considered as a first line option (instead of HSG) if it is available and financially feasible.

Study funding/competing interest(s)

Funded by Hospital Italiano de Buenos Aires. The authors declare no competing interests.

Trial registration number

P-306 Use of partial AUC to evaluate progesterone elevation on the day of HCG administration reveals basal progesterone as the main prognostic factor

Abstract

Study question

Is it possible to identify early predictors of progesterone rise on the day of hCG triggering, using a non-arbitrary threshold limit of clinical impact?

Summary answer

We found that Partial Area Under the Curve (pAUC) analysis permits to identify a non-arbitrary progesterone cut-off value on the day of hCG defined as detrimental for occurrence of pregnancy, basal progesterone was shown to be the main and independent prognostic factor for progesterone elevation at induction.

What is known already

Elevated serum progesterone before hCG administration was recently associated with reduced pregnancy after controlled ovarian stimulation (COS) cycles; a source of controversy is related to the different cut-off levels used to define ‘high progesterone'. Basal FSH level, doses of FSH, duration of stimulation, serum E2 and LH levels on day of hCG administration and number of oocytes retrieved were related to progesterone rise but, being linked to the stimulation, they can be only partially adapted.

Study design, size, duration

This non-interventional, retrospective, observational, single-centre cohort study involved 303 patients undergoing their first COS cycle and fresh day-3 embryo transfer following routine practice from January to December 2012. No inclusion/exclusion criteria were applied on baseline characteristics of patients.

Participants/materials, setting, methods

Receiver operating characteristic (ROC) curve analysis was performed and pAUC was calculated for high specificity regions above the median value of progesterone. Multivariate logistic regression analysis was conducted on all possible factors related to progesterone rise above the detrimental threshold for pregnancy.

Main results and the role of chance

Partial Area Under the Curve analysis of progesterone level on day of hCG could statistically predict pregnancy (pAUC = 0.58, 95% CI = 0.51-0.66,P =0.01). We found that a level > 1.35 ng/ml was the optimal value to predict a negative impact on pregnancy. The detrimental effect of progesterone on the day of hCG > 1.35 ng/ml was seen both on positive β-hCG rate (OR = 2.46, 95%CI 1.29-4.70,P =0.005) and on clinical pregnancy rate (OR = 2.24, 95%CI 1.05-4.79,P =0.03). On multivariate analysis, using progesterone level on day of hCG >1.35ng/ml as dependent variable, significant OR (95%CI) of 12.51 (1.78-87.75), 1.04 (1.02-1.07) and 1.83 (1.28-2.62) were observed for each increasing unit of basal progesterone level, number of 75IU doses of rFSH and E2level, respectively.

Limitations, reason for caution

The limits of this study are represented by the low number of patients considered and by his retrospective nature, that makes difficult to exclude interferences from various confounding factors. However, being serum progesterone level difficult to be subjectively intervened in vivo, also prospective studies can hardly exclude interferences.

Wider implications of the findings

This study suggests that IVF centres, even those with a relatively small number of patients, should consider to evaluate their data in order to define progesterone cut-off levels that may predict pregnancy outcome. Since basal progesterone was shown to be the main and independent prognostic factor for progesterone rise at induction we suggest to take it into account, adopting alternative strategies to subvert the unfavourable effect of elevated progesterone.

Study funding/competing interest(s)

This study did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. The authors declare no conflicts of interest.

Trial registration number

N/A.

P-307 FSH receptor gene polymorphisms are associated with ovarian response in Chinese IVF/ICSI patients

Abstract

Study question

To detect the FSH receptor gene mutations and polymorphisms in Chinese IVF/ICSI patients, and to explore its effect on ovarian response, ovarian reserve and pregnancy outcome.

Summary answer

In Chinese IVF/ICSI patients, rs1394205 (G-29A) and rs6166(A2039G, Asn680Ser) sites of FSH receptor gene are related to ovarian response. rs6165 (A919G,Thr307Ala) site is associated with ovarian reserve. No relationship was found between FSH receptor gene polymorphisms and pregnancy outcome.

What is known already

The management of poor response to ovarian stimulation is one of the difficult chanllenges in assisted reproduction. Patients identified as poor responders often have high rates of cycle cancellation and poor pregnancy outcome. However, the currently available data for poor responders shows that controversy still exists regarding the optimal predictive index of ovarian response. The associations of FSH receptor gene polymorphisms have been studied in European and American. No results of Chinese patients were reported.

Study design, size, duration

A total of 236 women were enrolled from June 2011 to December 2011.

Participants/materials, setting, methods

Inclusion criteria: 1st-2nd IVF/ICSI cycle, age ≤ 35 years, regular cycle (25-35 days), BMI 18-23 kg/m2, FSH < 12 IU/L. Exclusion critieria: ovulatory dysfunction, history of ovarian surgery, any systemic, metabolic or endocrinological disorder. All patients were received a long GnRH agonist (triptorelin acetate) protocol. The stimulation started with recombinant FSH (r-FSH) at a dose of 150-225IU. The dose of r-FSH was adapted according to ovarian response and r-LH supplementation was increased to 75IU/L when one or more follicles measuring ≥10mm in diameter were observed. Chorionic gonadotrophin was administered for final oocyte maturation. Blood samples were obtained and detected for FSH receptor gene polymorphisms:rs1394205, rs6165, rs6166. Patients were divided into groups according to different genotypes. The ovarian response, ovarian reserve and pregnancy outcome were compared. Data were analysed by ANOVA, Kruskal-Wallis test.

Main results and the role of chance

A total of 236 patients completed the study.

In rs1394205 (G-29A) site of FSH receptor gene, the genotype frequency was 28.81% for GG, 47.03% for GA, 24.15% for AA. Antral follicle count (AFC) were fewer in AA than GG and GA (GG vs GA vs AA,16.46 vs 16.80 vs 14.86,P = 0.052). FSH doses and FSH level (IU/L)on HCG day were lower in GG (GG vs GA vs AA,1787.62 vs 1989.20 vs 1987.02,p = 0.068), (GG vs GA vs AA,14.58 vs 16.68 vs 16.50,P = 0.026). No significant difference was found in number of mature oocytes and top quality embryos, and clinical pregnancy outcome.

In rs6165 (A919G,Thr307Ala) site of FSH receptor gene, the genotype frequency was 46.61% for AA(Thr/Thr), 44.49% for AG(Thr/Ala), 8.90% for GG(Ala/Ala). AMH(ng/ml) in GG (Ala/Ala) was lower (Thr/Thr vs Thr/Ala vs Ala/Ala, 3.53 vs 3.70 vs 2.13, p =0.046).

In rs6166(A2039G, Asn680Ser) site of FSH receptor gene, the genotype frequency was 47.46% for AA(Asn/Asn), 41.10% for AG(Asn/Ser), 11.44% for GG(Ser/Ser). Basal FSH (IU/L) level was higher in GG(Ser/Ser) (Ser/Ser vs Asn/Ser vs Asn/Asn, 8.30 vs 7.82 vs 7.28, p = 0.014). Patients with GG(Ser/Ser) had fewer mature oocytes (Ser/Ser vs Asn/Ser vs Asn/Asn, 10.56 vs 11.93 vs 13.56, p = 0.042) and top quality embryos (Ser/Ser vs Asn/Ser vs Asn/Asn, 6.81 vs 7.36 vs 9.00, p = 0.015).

When rs6165(A919G, Thr307Ala) and rs6166( A2039G, Asn680Ser) sites were combined, 9 types of genotypes were detected: 106(rs6165-rs6166)TT-AA, 94 TA-AS, 19 AA-SS, 6 TA-AA, 5 TA-AA, 2 TT-SS, 2 TT-AS, 1 AA-AA, and 1 AA-AS. When compared with TT-AA and TA-AS, patients with AA-SS had lower AMH(ng/ml) (TT-AA vs TA-AS vs AA-SS, 3.55 vs 3.46 vs 2.07, p = 0.047), higher basal FSH (IU/L) (TT-AA vs TA-AS vs AA-SS, 7.22 vs 7.78 vs 8.10,p = 0.032), fewer mature oocytes (TT-AA vs TA-AS vs AA-SS, 13.45 vs 12.02 vs 10.11, p = 0.039) and fewer top quality embryos (TT-AA vs TA-AS vs AA-SS, 8.84 vs 7.41 vs 6.58, p = 0.045). No significant difference was found in clinical pregnancy rates.

Limitations, reason for caution

Larger sample may be needed for further study.

Wider implications of the findings

No.

Study funding/competing interest(s)

The study was supported by the Science Technology Research Project of Guangdong Province (2010B031600058),the new teacher fund of Chinese Ministry of Education (20090171120072), 5010 project of Sun Yat-sen University (2007-017).

Trial registration number

No.

P-308 IVF success rates in egg sharers compared to women having self-funded IVF

Abstract

Study question

Does egg sharing (ES), in which women donate fifty percent of their eggs reduce the chances of success compared to women having self-funded (SF) IVF/ISCI cycles?

Summary answer

In appropriately selected egg sharer, despite a lower number of eggs and embryos being available for the sharer, IVF success rates are comparable to women having SF cycles.

What is known already

Despite government funding in the UK, some couples may be ineligible for assisted reproduction treatment (ART). For some, privately funded ART is the only option for achieving a pregnancy may be unaffordable. Egg sharing offers free standard IVF to women willing to share half of their eggs produced, in order to assist a recipient woman suffering from egg-factor infertility. This gives both women an opportunity to achieve a pregnancy.

Study design, size, duration

Data was prospectively collected on women undergoing consecutive IVF/ICSI cycles through SF and through ES at an IVF unit between January 2007 and January 2012. 3071 SF and 387 ES cycles were performed during the study period.

Participants/materials, setting, methods

ES criteria included women ≥ 21 and ≤35 years of age. ES were required to produce ≥8 eggs, of which fifty percent were donated to an anonymous recipient. Outcome data was recorded electronically (pregnancy (PR), live birth (LBR), miscarriage (MR) rates) and results compared using cross tabulation t-test and ANOVA.

Main results and the role of chance

There was no difference in mean age (SF (32.4 ± 2.2), ES (31.3 ± 2.6)). Average number of eggs collected in SF and ES cycles was 9.7 and 11.6 respectively (P > 0.05), of which fifty percent of ES eggs were retained for self-use. There was no significant difference in fertilisation rate (SF,69%; ES,70%) or number of embryos transferred (SF,1.6; ES,1.7). SF cycles had a greater number of available embryos for transfer compared to ES cycle (6.6 and 4.6 respectively) but PR (SF,54.6%; ES,57.9%), LBR (SF,41.5%; ES,41.9%) and MR (SF,23.7%; ES,27.2%) were similar in both groups (P > 0.05). Women having SF cycles were more likely to have embryos available for cryopreservation compared to women having ES cycles (30.8% compared to 19.4% respectively, P < 0.05).

Limitations, reason for caution

None

Wider implications of the findings

ES has shown to be a highly successful venture offering incentives for both ES (/donor) and recipient. We have shown that despite a lower number of eggs and embryos available, IVF success rates in ES are comparable to women having SF cycles, hence offers women needing ART an opportunity to achieve pregnancy without it compromising their rate of success. SF cycles may however have more embryos available for cryopreservation in order to achieve future pregnancies.

Study funding/competing interest(s)

None

Trial registration number

Not applicable

P-309 Detection of two urinary hormones by a new home ovulation test to identify the wider fertile window: a randomised comparative laboratory study of home ovulation tests

Abstract

Study question

A new home ovulation test (Clearblue dual-hormone digital test) detects both the urinary rise in estrone-3-glucuronide (E3G) and luteinising hormone (LH). The device aims to identify a wider fertile period than other home ovulation tests. This study examines the number of fertile days detected by a variety of home ovulation tests.

Summary answer

The new test typically identifies 4 fertile days in at least 80% of cycles, compared with 2 days for comparitor home ovulation tests. The LH surge was accurately detected in 90% of cycles, no other ovulation test was more accurate.

What is known already

Conventional home ovulation tests detect the LH surge, enabling women to time intercourse to their two most fertile days to assist conception. However, the fertile phase begins before the LH surge, and its onset can be determined from the rise in urinary E3G. A new home ovulation test that measures these two hormones should provide information on the wider fertile window. A fertility monitor similarly detecting both LH and E3G demonstrated a more rapid time to conception. Therefore a new home ovulation test that measures these two hormones should be provide information on the wider fertile window.

Study design, size, duration

87 women provided complete menstrual cycles of daily urine samples. These were tested by laboratory technicians with 6 commercially available home ovulation tests (2 digitally read, 3 visually read and the new dual-hormone digital test) in a random order and compared to the reference LH surge (AutoDELFIA). Only cycles with a reference surge were included in the analysis.

Participants/materials, setting, methods

Volunteers were all 18-45 with no reported history of infertility. Testing was conducted in the laboratory by experienced technicians blinded to the samples.

Main results and the role of chance

The dual-hormone test displayed at least 2 additional day of fertility (displayed as 'High Days') prior to the LH surge (displayed as 'Peak Days') in 80% (95% CI: 69-88%) of cycles. No other test was able to identify this wider fertile window. Surge detection ranged from 86% to 95% with the different ovulation tests, but for some tests, the surge was inaccurately identified compared with the reference method. Therefore, accurate surge detection rate ranged from 78% to 90%, with the dual-hormone test matching that of the best LH only test at 90%. Although characteristics of the menstrual cycles collected compare to published data, the exact percentages reported in this study may vary slightly with a different sample set. This study included 18 cycles (21%) where maximal levels of LH did not exceed 40mIU/ml (complete quantitative data only available on 85 cycles). This is a higher proportion than that seen in other studies, so in a wider population, accurate surge detection may be greater.

Limitations, reason for caution

All cycles used were non-conceptual (as cycle length data was needed), although some volunteers had been seeking to conceive. Some of these cycles may have had abnormal endocrinology, as although a surge was identified using the reference method in all cycles tested, for some cycles maximal LH was low (lowest peak level 14.6mIU/ml).

Wider implications of the findings

The new dual-hormone ovulation test provides a woman with more information on her fertile window and this advanced warning of ovulation may provide several benefits; identifying more days where pregnancy is possible to maximise chances of a natural conception, to better plan natural conception which can be important for fitting in with modern lifestyle, remove the focus of intercourse on just the day of ovulation which may benefit relationships and in planning of artificial insemination.

Study funding/competing interest(s)

Study was funded by SPD Development Company Ltd., a wholly owned subsidiary of SPD Swiss Precision Diagnostics GmbH, the manufacturer of Clearblue pregnancy and ovulation tests. S Johnson, S Godbert and S Hart are employees of SPD Development Company Ltd.

Trial registration number

Laboratory study so not applicable

P-310 Uterine contraction after embryo transfer and outcome of in-vitro fertilization and embryo transfer cycles

Abstract

Study question

To determine whether uterine contraction (UC) immediately after embryo transfer will affect the outcome of in-vitro fertilization (IVF) and embryo transfer (ET)

Summary answer

High-frequency UC after embryo transfer adversely affects the IVF-ET cycle outcome.

What is known already

Implantation of embryos remains the greatest barrier to improve the success rates of IVF-ET cycle. For IVF-ET cycles, a stepwise decrease in implantation rates has been demonstrated in groups with higher uterine contractility measured before embryo transfer. However, whether the UC after embryo transfer also play an important role for IVF-ET cycles outcome is not yet known.

Study design, size, duration

This was a prospective observational study. 123 Infertile women who under 38 year-old and underwent first IVF-ET cycle with at least one good quality day 3 embryo transferred were recruited from the Assisted Reproduction Technology unit in Prince of Wales Hospital, Hong Kong from July 2011 to July 2012.

Participants/materials, setting, methods

Ultrasound of uterus were record for 5 minutes immediately after embryo transfer and UC frequency was assessed by visualizing the accelerated sequences of images. Low and high frequency UC group were defined as < 3 and > 3 UC per minute respectively. The primary outcome was clinical pregnancy rate.

Main results and the role of chance

53 and 70 patients were classified as low frequency UC group and high frequency UC group respectively. Low frequency UC group had significant higher level of serum progesterone on day of embryo transfer (97.55ng/ml vs 80.03ng/ml,P = 0.030). The overall pregnancy rate was 54.5%. There were significant higher clinical pregnancy rate in low frequency UC group than high frequency UC group (66% vs 45.7%,P = 0.029).

For other clinical parameters, there were no significant different in clinical demographic data between groups including age, basal follicle-stimulating hormone hormone, body mass index, duration and type of infertility. There were also no significant different in controlled ovarian hyperstimulation outcome including the amount of gonadotropin consumption, days of stimulation, number of oocytes retrieved and number of embryos transfer.

Limitations, reason for caution

Type of uterine contraction as well as quantitative measurements of wave amplitude should also be evaluated in future research.

Wider implications of the findings

The results demonstrated that UC immediately after embryo transfer did adversely affected clinical pregnancy rate in IVF-ET cycle. Therefore, effort should be done in order to avoid triggering of uterine contraction during embryo transfer. More studies are required to investigate whether the administration of uterine relaxing substances might effectively reduce UC frequency after ET and hence increase IVF-ET outcome.

Study funding/competing interest(s)

This study was self-funded by Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Hong Kong. There have no competing interests in this study.

Trial registration number

Chinese Clinical Trial Registry: ChiCTR-OCH-12002733

P-311 Aromatase inhibitors for subfertile women with PCOS

Abstract

Study question

To evaluate the effectiveness and safety of use of aromatase inhibitors (AI) for treatment of subfertility in women with polycystic ovary syndrome.

Summary answer

The results suggest that subfertile women with PCOS treated with letrozole have improved pregnancy outcomes than those treated with clomiphene citrate (CC), as live birth rates were improved and multiple pregnancy rates are reduced.

What is known already

AIs are a novel class of drugs that were introduced for ovulation induction in 2001. Over the last ten years data from many clinical trials have reported that the AI letrozole might be at least as effective as the first-line treatment clomiphene citrate. A recent meta-analysis published in HRU in 2012 did not find letrozole to be superior to CC for pregnancy outcomes.

Study design, size, duration

Twenty one studies of 2966 infertile women with PCOS were identified that met our inclusion criteria.

Participants/materials, setting, methods

We searched for all published and unpublished RCTs studying use of aromatase inhibitor(s) (alone or in conjunction with other medical therapies) for ovulation induction in WHO (World Health Organisation) group II anovulatory women (a type of subfertility where hormone levels remain to be normal) with PCOS.

Main results and the role of chance

Fourteen studies compared letrozole with clomiphene citrate with or without adjuncts in women with anovulatory PCOS but only eight reported live birth rates. Our analysis showed an increased live birth rate in favour of letrozole (Risk Ratio (RR) 1.46, 95% CI 1.18-1.81, 8 RCTs, 1033 women, I2 = 16%). Furthermore, pregnancy rate was also increased (RR 1.20, 95% CI 1.05 to 1.38, 14 RCTs, 1965 women, I2 = 31%). Additionally, letrozole was associated with reduced multiple pregnancy rates (RR 0.28, 95% CI 0.11 to 0.76, 10 RCTs, 1534 women, I2 = 0%). A risk difference analysis for OHSS showed no evidence of a difference (RR 0.00, 95% CI -0.01 to 0.01, I2 = 0%).

Limitations, reason for caution

The effectiveness of letrozole is most likely overestimated as demonstrated by a significant subgroup difference (P = 0.01) by allocation bias and also because of the smaller risk ratios for clinical pregnancy than for live birth.

Wider implications of the findings

Our meta-analysis shows some evidence for increased live birth rates in favor of letrozole when compared to clomiphene citrate in women with PCOS. This is in contradiction to other reviews that showed no difference in the past (Misso 2012), but this is most likely due to more trials included in the analyses.

Study funding/competing interest(s)

The funding was provided by the University of Auckland, New Zealand. None of the authors have any conflicts of interest.

Trial registration number

No clinical trial

P-312 Effect of severity of endometriosis on prioritisation for infertility treatment in New Zealand

Abstract

Study question

To what degree does severity of endometriosis correlate with the chance of treatment-independent (spontaneous) pregnancy in infertile couples waiting for ART (assisted reproductive technology) or who decided not to pursue ART?

Summary answer

Treatment-independent live-birth rates were similar for minimal, mild, and moderate endometriosis, and not different from unexplained infertility.

What is known already

Although the impact of endometriosis on fertility is uncertain, the American Society for Reproductive Medicine (ASRM) endometriosis classification carries the concept of increasing severity and hence biological impact. Laparoscopy is considered the ‘gold standard' for assessing the pelvis, and has been incorporated into systems for fertility diagnosis, such as New Zealand's clinical priority access criteria (CPAC) (WR Gillett et. al. Human Reproduction, 27 131–141, 2012) which determines eligibility for publicly funded ART.

Study design, size, duration

Prospective observational study of 1386 couples referred between 1998 and 2005 for infertility with follow-up of at least 5 years. Laparoscopy was performed in 663 women and diagnosis of endometriosis made in 283 and fully unexplained infertility in 63. Each couple was assigned a CPAC score.

Participants/materials, setting, methods

Tubal, ovulation and male factor were given 1, 2, 3 or 6 points for minimal, mild, moderate or severe presentation, modelled on the ASRM endometriosis classification, and combined to give a diagnostic score. Live-birth rates were evaluated by Cox's proportional hazards regression adjusted for diagnostic score, age and infertility duration.

Main results and the role of chance

Minimal endometriosis was diagnosed in 136 women, mild (75), moderate (38) and severe (34). In 213 (71%) women other causes of infertility coexisted, with a mean diagnostic score of 3.5.

Compared to unexplained cases adjusted treatment-independent live-birth rates were similar for minimal, mild, moderate and severe endometriosis: 0.77 (95%CI, 0.43 to 1.38, P 0.37), 0.65 (0.33 to 1.26, P 0.20), 0.61 (0.28 to 1.36, P 0.23) and 0.30 (0.09 to 1.05, P 0.06) respectively. Increasing diagnostic score and age significantly reduced hazard ratios.Treatment dependent live-birth pregnancy rates for women with minimal, mild and moderate endometriosis were similar but significantly reduced for severe endometriosis: 0.30 (0.12 to 0.75, P 0.01). The mean time to IVF treatment was 17.9 months.

Limitations, reason for caution

The diagnostic classification has not been evaluated by others and has the potential for variation in interpretation. In this study only two clinicians contributed to diagnosis and so variation was minimised. Relatively few participants had moderate or severe endometriosis, reducing power.

Wider implications of the findings

This study questions the impact of minimal, mild or moderate endometriosis on pregnancy rates with or without fertility treatment. In absence of pain, diagnosis of less than severe endometriosis may have little clinical value. Severe endometriosis has a poor outcome but it may be ascertained by clinical history and/or imaging. The CPAC diagnostic score is a novel tool for investigating the impact of multiple fertility factors on prognosis, and hence when or whether to treat.

Study funding/competing interest(s)

Nil

Trial registration number

The Lower South Regional Ethics Committee approved the evaluation component of the study, LRS/10/EXP/026

P-313 The fate of implanted embryo which showed low early serum þ- hCG level in IVF-ET

Abstract

Study question

To investigate the outcomes of fresh or frozen thawed IVF-ET cycles which showed low serum β-hCG levels checked at 12 days after ovum retrieval, and to evaluate the low limited value of these serum β-hCG which can be expected to ongoing normal pregnancies

Summary answer

Our data would be useful to predict the outcomes of IVF-ET which showed low early serum β-hCG level, and can be used to counsel to patients who wish to know the fate of implanted embryo more earlier.

What is known already

The hCG appears in maternal blood approximately 6-8 days after fertilization and it is reliable marker to predict pregnancy outcome after IVF-ET. The hCG level dynamically increases during early gestation.

Study design, size, duration

We retrospectively analyzed our fresh (n= 893) and frozen thawed (n= 383) IVF-ET cycles, which resulted in biochemical pregnancy and ongoing pregnancy between December 2008 and February 2011. The IVF-ET cycles resulted in spontaneous abortion, ectopic, heterotopic, multiple pregnancies and undergone IVF-ET cycles for the purpose of PGD were excluded.

Participants/materials, setting, methods

The serum β-hCG checked at 12(initial) and 14days(second) after ovum retrieval were compared between biochemical and normal single pregnancy. The initial β-hCG were further analyzed to determine low limit value to expect ongoing normal pregnancy. The correlation between degree of increasing β-hCG in two days and their outcomes were analyzed.

Main results and the role of chance

The lowest cut-off value of initial serum β-hCG level which can be expected normal pregnancy was determined as 21.5 IU/L with a sensitivity of 93.2% and a specificity of 74.5% in fresh cycles. In the group of low initial serum β-hCG level below 21.5 IU/L, the biochemical pregnancy rate showed 85.5% and was significantly higher than that of groups (12.5%) who showed initial serum β-hCG levels above 21.5 IU/L (OR: 41.2, 95% CI: 26.0 ∼ 65.1, P= .000). Among the fresh cycles which showed low initial serum β-hCG levels below 21.5IU/L, the increase of hCG level in two days was 4.3 fold in group with normal pregnancy results and was significantly higher than that of groups resulted in biochemical pregnancy (2.8 fold) (P= .000).

Limitations, reason for caution

This study is retrospective.

Wider implications of the findings

Our data focus biochemical pregnancy and single pregnancy. Many other studies based on the embryo transfer day, but we check the serum β-hCG levels at 12 days and 14 days after ovum retrieval.

Study funding/competing interest(s)

none

Trial registration number

none

P-314 Follicular fluid anti-Mullerian hormone, inhibin-A, progesterone and estradiol levels in patients with different ovarian response

Abstract

Study question

Do follicular fluid components of Anti-Mullerian hormone, inhibin-A, progesterone and estradiol levels differ in patients with different ovarian response?

Summary answer

Follicular fluid components of anti-Mullerian hormone, inhibin-A, progesterone and estradiol levels are similar in patients with different ovarian response and can not predict pregnancy outcome.

What is known already

Recent studies try to find a marker of ovarian reserve in assisted reproduction. It is thought that steroid or glycoprotein levels may reflect suitability of an oocyte for IVF. In some studies, follicular fluid levels of progesterone, AMH, inhibin-A and estradiol were studied to correlate with oocyte maturity (recovery and fertilization rate). But there is no direct link was found between these molecules and prediction of pregnancy.

Study design, size, duration

A prospective study. In 2 months period 64 patients who applied for IVF treatment in Gazi University Faculty of Medicine Obstetrics and Gynecology Infertility Center were included. Patients evaluated in three groups.

Participants/materials, setting, methods

Three groups were designed for patient's controlled ovarian stimulation response; poor-responder (number of retrieved oocytes <5, n = 18), normo-responder (number of retrieved oocytes 5-15, n = 26) and high-responder (number of retrieved oocytes >15, n = 20). Dominant follicle's follicular fluid was collected during the oocyte retrieval. Quantitative measurement was made by Enzyme-linked Imunosorbent Assay. Clinical pregnancy was defined as the presence of gestational sac by ultrasonography.

Main results and the role of chance

There was statistically significant difference in age between groups which was 36.3 in poor-responder, 31.5 in normo-responder and 29.5 in high-responder group ( p < 0.05). Of the 64 patients, 14 (21.9%) were pregnant. Pregnancy rates were 11,1%, 27,0%, and 16,7% respectively poor,normo and high-responder groups, but difference was not statistically significant.

Inhibin-A (pg/ml) and anti-Mullerian hormone (ng/mL) levels detected higher in non pregnant than pregnant patients but no statistically significant relationship was found (p > 0,05). Follicular fluid AMH, inhibin-A, estradiol (pg/ml) and progesterone (ng/ml) levels between groups were found to be similar (p > 0,05). There was no statistically significant relationship was found to predict pregnancy between groups with inhibin-A, AMH, estradiol and progesterone.

Limitations, reason for caution

In our study we collected one follicle's fluid for each patient. Steroid and glycoprotein levels can differ with follicle's maturation status and size. More follicles in same patient can be studied to exclude this factor. Serum levels of progesterone, AMH, inhibin-A and estradiol would be evaluated at same time.

Wider implications of the findings

Recent studies have failed to provide direct information on ovarian responsiveness and pregnancy outcomes as there are patients who show a poor response to stimulation therapy despite having normal ovarian reserve tests. In our study hormone and glycoprotein changes in different ovarian stimulation responders was not effective for predicting the pregnancy outcome. Future studies may focus on less invazive and early detectable parameters.

Study funding/competing interest(s)

The authors report no conflicts of interest.

Trial registration number

0

P-315 Protein c global assay in the evaluation of infertile women undergoing ivf-et treatment ñ implications to perinatal risks

Abstract

Study question

To gain insight into Protein C (ProC) Global assay in infertile women eligible for assisted reproductive technologies (ART) treatment, before starting hormonal therapy, and to compare its level to healthy fertile women.

Summary answer

ProC Global assay level was found to be significantly lower in infertile women before starting ART treatment, as compared to fertile controls. This finding support the notion that the increased perinatal risks encountered following ART is related to infertility per se and not only to the technology.

What is known already

More evidence is emerging to point out at an increased rate of prematurity and low birth weight in singleton pregnancies following ART. Whether this increased rate of adverse pregnancy outcome in singleton pregnancies is related to ART practice or to infertility per se, is still an open question. ProC Global assay is a novel screening assay of the global anticoagulant Protein C pathway. The majority of thrombophilias associated with placental vascular complications during pregnancy have been related to the protein C pathway.

Study design, size, duration

Ninety-five consecutive infertile women before ART were prospectively evaluated and compared to 77 matched healthy fertile controls.

Participants/materials, setting, methods

The study was conducted in a university affiliated reproductive medicine unit. Women in both groups did not have a history of venous thrombo-embolism, known acquired or congenital thrombophilia, a history of repeat pregnancy loss or previous vascular gestational complication and did not receive heparin or low molecular weight heparin upon recruitment or during a previous pregnancy. Protein C Global assay levels were investigated in both groups. As well, full thrombophilic workup was performed in the infertile population and its association to ProC global assay was investigated.

Main results and the role of chance

ProC Global assay level was significantly lower in the infertile group, before starting ART treatment, as compared to the fertile group, corresponding to 0.78 ± 0.18 and 0.88 ± 0.16 respectively (P < 0.01). Low ProC global assay (< 0.8) correlated significantly with activated protein C resistance, factor V Leiden and combined thrombophilia.

Limitations, reason for caution

Since it a preliminary study, the first that we know of in the literature, more similar studies are encouraged to be performed to substantiate these findings.

Wider implications of the findings

If these results are substantiated,the association between ProC Global assay, prematurity, low birth weight and other vascular complications during singleton pregnancies following ART should be investigated. Study funding/competing interest(s)none

Trial registration number

no

P-316 Outpatient hysteroscopy prior to the first IVF cycle ñ a systematic review and meta-analysis

Abstract

Study question

To systematically review the evidence related to the impact of outpatient hysteroscopy (OH) when performed in women with normal uterine cavity undergoing their first IVF treatment cycle.

Summary answer

OH performed in woman with normal uterine cavity immediately prior to their first IVF cycle could be associated with higher clinical pregnancy (CPR) and live birth (LBR) rates.

What is known already

The incidence of unsuspected uterine pathology in asymptomatic IVF population is reported to be 11-50%. There is evidence that performing OH significantly increases the chance of pregnancy in the subsequent IVF cycle in women with recurrent implantation failure. However, the use of OH prior to the first IVF cycle has not been systematically studied.

Study design, size, duration

A systematic review and meta-analysis of randomised and non-randomised controlled trials. We searched MEDLINE (1950–December 2012), EMBASE (1980– December 2012), PubMed, Cochrane Library, ISI conference proceedings after 1990, data bases for registration of ongoing and archived randomized controlled trials such as ISRCTN register and mRCT for the relevant studies.

Participants/materials, setting, methods

The study group were women with normal uterine cavity, as assessed by transvaginal sonography or hysterosalpingogram, who underwent OH just prior to their first IVF or ICSI treatment cycle, while the control group were women who started their first IVF or ICSI cycle without prior OH. The outcome measures were the CPR, LBR and complication rate. The results were pooled and expressed as relative risks (RR) with 95% confidence intervals (CI).

Main results and the role of chance

Six studies (One randomized and five non-randomized controlled studies) including a total of 3,179 participants satisfied the selection criteria. Pooled results from five studies reporting on CPR showed a significantly higher CPR in the OH group compared to the control group (RR = 1.44; 95% CI 1.08, 1.92; P = 0.01). Pooled results from four studies reporting on LBR showed significantly higher LBR in the OH group compared to the control group (RR = 1.30; 95% CI 1.00, 1.67; P = 0.05). The number needed to treat (NNT) to achieve one additional clinical pregnancy was 10 (95% CI 6.8 to 13.9) and one additional live birth was 11 (95% CI 7.4 to 16.5). Complications included 1% failure rate due to severe cervical stenosis and 1% risk of uterine injury.

Limitations, reason for caution

Only one RCT was identified during our literature search. There are methodological concerns about some aspects of the included studies; namely the differences in study design, technique of OH and the definition of the outcome measures used in different studies.

Wider implications of the findings

Existing data suggest that performing OH in women with normal uterine cavity immediately prior to their first IVF/ICSI cycle could be associated with improved IVF outcome. Further robust randomized trials to confirm these findings remain necessary to further guide clinical practice.

Study funding/competing interest(s)

none

Trial registration number

not applicable