Egyptian Fertility Sterility Society Conference 2016: What is new?

1. Egyptian Fertility
Sterility Society
Conference 2016:
What is new?
Aboubakr Elnashar
Benha University
Hospital, Egypt
ABOUBAKR ELNASHAR

2. Presentations: 82
Plenary: 22 in 4 sessions
ABOUBAKR ELNASHAR

3. II. COS
1. New Developments for Ovarian
stimulation
2. The role of LH in ovarian
stimulation
IV. Pregnancy
1. Recurrent miscarriage
2. Non-invasive prenatal testing
III. ICSI
1. Vitrification
2. freeze all
3. ART successes around the world
4. Female fertility preservation
5. Embryo Transfer Technique
I. Infertility
1. Role of laparoscopy in Infertility
2. The effect of dietary ingredients on
Endometriosis
3. New concepts in endometriosis
management
4. Refractory endometrium
5. Surgery to conserve the uterus for
diffuse adenomyosis
6. Fibroids and fertility.
7. Cardio-metabolic sequelae of PCOS.
ABOUBAKR ELNASHAR

4. I. Infertility
1.Role of laparoscopy in Infertility
2.Surgery to conserve the uterus for diffuse
adenomyosis
3.Fibroids and fertility.
4.Refractory endometrium
5.The effect of dietary ingredients on endometriosis
6.New concepts in endometriosis management
7.Cardio-metabolic sequelae of PCOS.
ABOUBAKR ELNASHAR

5. 1. Role of laparoscopy in Infertility, in the era of
ART..
Serour: Egypt
Diagnostic laparoscopy can be avoided: ART is
preferred
1. Older women
2. Women with multiple infertility causes
3. Associated severe ♂ factor
Diagnostic laparoscopy:
1. History of PID, Ectopic pregnancy, Pelvic surgery, chronic
pelvic pain
2. Unexpl infertility did not get pregnant after repeat IUI trials.
 .
During diagnostic laparoscopy.
Laparoscopic surgery for
adhesions or endometriosis
ABOUBAKR ELNASHAR

6. ART is preferred to laparoscopy in:
1. Older women
2. Reduced OR.
3. Bilateral hydrosalpinx
4. Severe hydrosalpinx
5. Proximal and distal tubal occlusion
6. Extensive and dense adhesions
Proximal tubal obstruction:
Selective tubal catheterization
under
fluoroscopic or
hysteroscopic control and/or laparoscopy to confirm the
diagnosis and potentially open the tube.
ABOUBAKR ELNASHAR

7. Laparoscopic myomectomy:
 A uterus of <18 weeks' size,
≤3 intramural or subserous leiomyomas,
Myoma ≤5 cm in diameter
.
Laparoscopic ovarian surgery
Pelvic endometriosis
Ovarian cystectomy
Fertility preservation
LOD.
should not be performed before exclusion of other causes
of infertility
male factor or
tubal factor infertility.
ABOUBAKR ELNASHAR

8. 2. The effect of diet on endometriosis.
Osuga: Japan.
Endometriosis is a chronic inflamm dis.
Impact of
Omega-3 fatty acids
vit D on endometriosis
using in vitro culture of endometriotic cells and
mouse model of endometriosis.
Omega-3 poly unsaturated fatty acids:
2 ws after inoculation
Marked decrease in number and weight of
endometriotic lesions
ABOUBAKR ELNASHAR

9. vit D3 levels
significantly lower in women with severe
endometriosis than in the controls and women with
mild endometriosis.
Dietary ingredients are novel strategies to manage
endometriosis.
ABOUBAKR ELNASHAR

10. 3. New concepts in endometriosis management.
Chapron: France.
3 phenotypes:
1. Superficial peritonel
2. Endometrioma
3. Deep infiltrating endometriosis
3 therapeutic options:
1.Surgery:
Efficient, for
pelvic pain
endometriosis-related infertility
improving quality of life
±adverse outcomes.
High potential risk for recurrence
{incomplete surgical procedures}.
2. Medical treatment
efficient for pain
3. ART
an excellent indication for infertility
ABOUBAKR ELNASHAR

11. 3 strategies for Improvement of the management:
1. Optimization of the diagnosis modalities
1. Importance of questioning
2. Imaging process
Objective:
reduce the delay between the onset of the symptoms
and the beginning of the treatment
2. Creation of referral centres for endometriosis, with
specific consultations for adolescents
3. Clearly determine the respective place of 3
therapeutic options
Objective:
To reduce the number of unnecessary and/or
inadequate surgical procedure
ABOUBAKR ELNASHAR

12. 4. Surgery to conserve the uterus for diffuse
adenomyosis.
Osada: Japan
1.Resection and removal of complete excision
adenomyosis:
The affected tissue is vertically incised, to split the area to be
excised in two, the incision is extended to the uterine cavity. The
tissue is adequately dissected free with scissors, with care taken
to retain a serosal flap with a layer of myometrium, as well as a
medial flap containing both endometrium and myometrium. The
tissue flaps, both medial and distal must be more than 5 mm in
thickness to assure adequate material for the reconstruction of the
uterine wall.
2. Reconstruction of the uterine cavity
ABOUBAKR ELNASHAR

13. 3. Reconstruction of the uterine wall:
3 flap technique
Reconstruction of the middle portion of the uterine wall
involves approximation of the myometrial musculature to
ablate the space created by the excision of diseased tissue.
The serosa including adequate myometrium is dissected free
with a scalpel to form the third flap. The serosal or distal and
third flap is then approximated to finish the reconstruction.
4. Hemostasis and application of hemostatic barriers
ABOUBAKR ELNASHAR

14. stages of the triple-flap method.
ABOUBAKR ELNASHAR

15. Results:
113 patients
65.3%subsequently conceived.
17.6%conceived spontaneously
82.4% conceived by IVF-ET.
7 spontaneous abortion
27 Term and elective CS
No uterine rupture.
Indication:
Desire for pregnancy.
IVF failures
Age ≤39 years.
(Kishi et al, 2014)
ABOUBAKR ELNASHAR

16.  Management of adenomyosis associated infertility
1. Routine infertility investigation plus ORT
Normal: long agonist protocol and natural
conception
Abnormal: IVF
2. Failed natural conception or IVF:
repeat IVF
3. Failed IVF:
conservative surgery
IVF after 3 m
(Tsui et al, 2015).
ABOUBAKR ELNASHAR

17. 5. Fibroids and fertility.
Serour: Egypt
Which myoma/s to remove?
1. Distorting uterine cavity:
submuocus or interstitial myoma
2. Not distorting uterine cavity
 The only cause of infertility
 patient is young and has multiple myoma/s
 No need to remove:
 Sumserous myoma/s
 Small interstitial myoma/s not distorting the uterine
cavity
 .
ABOUBAKR ELNASHAR

18. ART rather than myomectomy:
Small non-cavitary distorting fibroids
Advanced maternal age
Associated male or tubal factor infertility.
Myomectomy before repeat ART trial:
Patients having myoma who:
failed to get pregnant or
have had a miscarriage after ART
 COS, OPU and vetrification of embryos
Myomectomy
ET after 3-6 months.
Patients having myoma/s with
Advanced maternal age
Reduced ovarian reserve
ABOUBAKR ELNASHAR

19. 6. Management of refractory endometrium.
Elnashar: Egypt
No agreement on definition
endometrial thickness less than 7 mm
2.4% in ART cycles.
Methods for assessment:
1. US:
endom thickness, pattern, volume
Uterine and subendometrial blood flow Doppler
2. ERA
 Causes:
1. Iatrogenic: Surgical: dilation and curettage, partial ablation,
aggressive myomectomy,
Radiotherapy
2. Infections
3. Congenital Müllerian anomalies
4. Idiopathic. ABOUBAKR ELNASHAR

20. No evidence of benefit
E2
Nitroglicerin patches
L-arginine
IU Granulocyte colony
stimulating factor
Unclear effect
Systemic HCG
GnRHa
Aspirin
Vit E, Pentoxifiline
Sildenafil
IU platelet rich plasma
Stem cells
Beneficial
intervention.
Hysteroscopy
Efficacy of the different therapeutic options
Garcia-Velasco et al, 2016
ABOUBAKR ELNASHAR

21. 7. Cardio-metabolic sequelae of PCOS.
Hendrik Lehnert: Germany.
PCOS Vs non PCOS:
Higher risk of
insulin resistance, hyperinsulinemia, glucose intolerance,
dyslipidemia, and an increased prothrombotic state:
higher rate of
type 2 DM
fatty liver disease
subclinical atherosclerosis
vascular dysfunction
CVD and mortality.
ABOUBAKR ELNASHAR

22. Increased prevalence of
Sleep apnea
various changes in the secretion and/or function of
adipokines, adipose tissue-derived proinflammatory factors
and gut hormones, all of them with direct or indirect influences
on the complex signaling network that regulates metabolism,
insulin sensitivity, and energy homeostasis.
Further insight
network of factors may facilitate finding therapeutic
targets that should ameliorate not only ovarian
dysfunction but also the various cardiometabolic
alterations related to the syndrome.
ABOUBAKR ELNASHAR

23. II. COS
1.New Developments for Ovarian stimulation
2.The role of LH in ovarian stimulation
3.Cell free DNA and micro RNAs and ovarian reserve
ABOUBAKR ELNASHAR

24. 1. New Developments for Ovarian
stimulation in ART.
Klaus Diedrich: Germany
3 important new developments
1.GNRHa trigerring
prevent OHSS
ABOUBAKR ELNASHAR

25. 2. Long acting FSH- corifollitropin alfa (Elonva)
Reduce the injection frequency
Stimulate the ovaries for 7 days
Doses:
100 to 150 µg
Pregnancy
similar to conventional gonadotrophins
stimulation by daily injection
3. Biosimilars
 The action is the same as with rec FSH
 Price is much cheaper.
 .
ABOUBAKR ELNASHAR

26. 2. The role of LH in ovarian stimulation
Ioannis E: Greece
Addition of exogenous LH to an FSH regimen
unselected population:
does not improve the clinical outcome
poor ovarian response.
unclear
hypogonadotrophic hypogonadism
The only absolute indication
ABOUBAKR ELNASHAR

27. Antagonist /other day Vs. daily
No difference
. Underestimating premature lutenizaionABOUBAKR ELNASHAR

28. III. ICSI
1.Vitrification
2.Freeze all
3.ART successes around the world
4.Female fertility preservation
5.Embryo Transfer Technique
6.Complete zona pellucida removal
ABOUBAKR ELNASHAR

29. 2. Improving the outcomes of
Cryopreservation
Al-Hasani: Germany
Vitrification:
Total elimination of ice crystal formation,
both intracellular and extracellular
Cells and tissue are placed directly into
the cryoprotectant and then plunged
directly into liquid nitrogen.
Very little practical impact on ART.
{wide variety of different carriers and
vessels that have been used for
vitrification}.
CPR is comparable to fresh ET
ABOUBAKR ELNASHAR

30. 3. Freeze all: a critical appraisal.
Khalaf: UK
Benefits:
1. Decrease OHSS
2. Increase PR
3. Decrease pregnancy complications
 Risks
1. LFGA
2. Cost
3. ?Safety
The quality of evidence:
supporting fresh Vs. frozen ETs is poor
better designed RCTs are necessary that capture not
only benefits but also all the harms
ABOUBAKR ELNASHAR

31. 4. ART success rates around the world
de Ziegler: France
 ART results widely vary around the world.
Differences in
 Technology
 Demographic characteristics
 Ethnical differences:
1.Afro-American women
have lower CPR than Caucasian
(i) More fibroids
(ii) Black women are known to access to ART
later in the course of their infertility process:
poorer ART outcome.
ABOUBAKR ELNASHAR

32. 2. Asian descent
had lower ART outcome, as compared to
Caucasians.
{slower metabolism of E2: impair endometrial
receptivity}
3. American women
Better responses to similarly dosed COS
protocols
over 30% increase in oocytes retrieved
ABOUBAKR ELNASHAR

33. Female fertility preservation
TAN; Canada
Indications:
1. Medical reasons
at risk of early menopause: familial, genetic, endocrine
severe endometriosis
pre-C/T or R/T for cancer
SLE, auto-immune disorders
multiple sclerosis
Turner syndrome
2. Social reasons:
delay in childbearing
involuntary childlessness at 34y has increased
over the past 30 ys
Social fertility preservation
Useful preventative medicine
ABOUBAKR ELNASHAR

34. Methods
1. Ovarian tissue freezing:
To date about 50 babies have been born using this
method
 it requires one operation to biopsy the ovaries and a
second to transplant ovarian tissue back.
2. IVF and Oocyte vitrification (OV)
The easiest way for social fertility preservation
Results:
81% oocyte survival rate
45% CPR/cycle
40% LBR/cycle started
3. IVM
successful treatment
Over 40 healthy live births have been achieved in
Montreal and over 200 in collaborating centres using our
technique. ABOUBAKR ELNASHAR

35. Results:
similar rates of cong f defects as normal
pregnancies.
Social Oocyte vitrification
should be encouraged
one day, young women will routinely create their own
personal egg bank
ABOUBAKR ELNASHAR

36. 5. Embryo Transfer Technique: State of the ART.
Sherif: Jordan.
Steps increase the success:
1. US guided
2. Full bladder
3. Depositing the embryos in the miduterine cavity
Steps of no value:.
1. Flushing cervical canal
2. Soft catheter
3. Slow withdrawal of catheter
4. Bed Rest
5. No S intercourse
 .
ABOUBAKR ELNASHAR

37. Easy: 90%
Difficult: 5.5%
Very difficult: 3.2%
Impossible: 1.3%
Tramsmyometrial ET: Towako method
ABOUBAKR ELNASHAR

38. IV. Pregnancy
1.Recurrent miscarriage
2.Non-invasive prenatal testing
3.Sexuality in older couples
4.Sexuality during sterility treatment
5.The evolution theory
6.Cyst spillage during cystectomy
ABOUBAKR ELNASHAR

39. 1. Management of rec miscarriage
Eric Jauniaux, UK.
RM: > 3 consecutive early pregnancy losses
unexplained RM:
TLC and reassurance.
Obesity,
cigarette smoking, alcohol use, and moderate-to-heavy caffeine:
sporadic miscarriage, but its association with RM is uncertain.
However, lifestyle modification and stress reduction
significantly improve the couple's chances for a successful
pregnancy.
Vit supplements:
folic acid prior to pregnancy or in early pregnancy do not
prevent miscarriage or stillbirth.
Metroplasty
for bicornuate or septate uteri remains unproven.
.
ABOUBAKR ELNASHAR

40. Suppression of LH secretion with GnRHa prior to ovulation
induction:
no difference in outcome.
Micronized progesterone tablets 400 mg daily:
may be of some potential benefit.
Metformin
not recommended as a treatment of RM.
LMWH and aspirin:
superior to aspirin alone in achieving more live births in RM with (aPL)
syndrome but not in women with inherited thrombophilia.
.
Glucocorticoids
should not be given in aPL syndrome without connective tissue disorder.
Immunotherapy
should not be advised.
Preimplantation genetic analysis
remains unproven.
ABOUBAKR ELNASHAR

41. You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura
ABOUBAKR ELNASHAR