1. health and fitness
2. disease
3. infertility

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A WORK & TURN COVER
Focus on
REPRODUCTION
European Society of Human Reproduction and Embryology
// SEPTEMBER 2013 //
Another record-breaking congress
l Fertility and female obesity
l Latest on European IVF monitoring
l ESHRE journals hit the high spots
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sept13_nwp_50939 22/08/2013 13:02 Page 3
EXECUTIVE COMMITTEE
Chairman
Juha Tapanainen (FI
Chairman Elect
Kersti Lundin (SE)
Members
Helle Bendtsen (DK)
Carlos Calhaz-Jorge (PT)
Roy Farquharson (GB)
Anis Feki (CH)
Georg Griesinger (DE)
Grigoris Grimbizis (GR)
Nils Lambalk (NL)
Cristina Magli (IT)
Tatjana Motrenko (ME)
Jacques De Mouzon (FR)
Andres Salumets (EE)
Petra De Sutter (BE)
Ex-officio members
Anna Veiga (ES)
(Past Chairman)
Timur Gurgan (TR)
(SIG Sub-committee)
FOCUS ON REPRODUCTION
EDITORIAL COMMITTEE
Bruno Van den Eede
Hans Evers
Roy Farquharson
Joep Geraedts
Luca Gianaroli
Juha Tapanainen
Anna Veiga
Simon Brown (Editor)
Focus on Reproduction
is published by
The European Society of Human
Reproduction and Embryology
Meerstraat 60
Grimbergen, Belgium
www.eshre.eu
All rights reserved.
The opinions expressed in this
magazine are those of the
authors and/or persons interviewed
and do not necessarily reflect the
views of ESHRE.
SEPTEMBER 2013
CONTENTS
Focus on Reproduction September 2013
Focus on
REPRODUCTION
l Chairman’s introduction
As the new Chairman of ESHRE let me first thank all
members for trusting me with this challenging job.
ESHRE is the ‘reproduction flagship’ of Europe, with
members drawn from physicians to scientists, from
psychologists to ethicists, from nurses to lab
technicians. This gives the Society strength and values
which make it unique in reproduction.
All the signs indicate that ESHRE is in good
condition, both scientifically and socially. This is the
result of decades of steady progress, to which our
members and officers have all contributed. I would
particularly like to thank Anna Veiga and Luca Gianaroli for their efforts over
recent years. Anna will continue as Past Chairman while Luca has stepped down
after holding different positions for 14 years. Other retiring members of the
Executive Committee have all had special tasks in the team and ESHRE is very
grateful for their contributions. New friendships as well as working together make
voluntary Society work rewarding. As before, the new Executive Committee
consists of members from different disciplines in reproduction, and from two new
countries, Estonia and Montenegro.
Although ESHRE is a big society, which sometimes slows down decision-making,
it is not a static society. So, besides its proven and safe core functions, I strongly
believe that the Society should look to new forms of activity, which may involve
risk and may not always turn out as hoped for. And to this extent there are three
subjects which need attention: the development of e-learning programmes; a
facelift for our traditional workshops; and, perhaps most importantly, new ways of
publishing our journals. All will prove challenges for the Executive Committee.
The Annual Meeting was once again a huge success. Almost 1600 abstracts
were submitted and the number of registered participants in London exceeded
10,000. Thanks to a well-planned scientific programme, and expert organisation
from Bruno and his Central Office colleagues, the event was well received.
Everyone involved deserves a big thank-you.
The future of ESHRE, of course, relies on the involvement of young people.
We have already taken some initiatives to attract younger colleagues, but all new
ideas and thoughts are welcome. The opinions of members are important, and I
will do my best to ensure that all views are equally heard. Alone one cannot do
much, but co-operation can work wonders.
Juha Tapanainen
ESHRE Chairman 2013-20015
NEWS
FEATURES
4
10
13
14
16
18
19
20
26 Felice Petraglia in profile
A record-breaking annual meeting
Annual assembly of members minutes
New impact factors for ESHRE jounals
IVF monitoring 2010
A view on aneuploidy screening
Paramedical Group
From the PGD Consortium
From the Special Interest Groups
The editor of Human
Reproduction Update
talks to FoR
28 Obesity and female fertility
Jose Bellver on the ovarian,
endometrial and embryonic
effects of obesity
33 Robert Edwards
Final tributes from Luca
Gianaroli and Basil Tarlatzis
3
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ANNUAL MEETING 2013
Budget babies . . . safer babies
at a record-breaking annual meeting
The local organisers of this year’s annual meeting
in London had optimistically planned for an
attendance of 10,000, and in the event that was
just the number who took part, a total
registration of 10,007, which broke all previous
records and put the ESHRE congress squarely at
the top of world events in
reproductive medicine. In
1985, when ESHRE organised
its first annual meeting, 650
attended; who could have
foreseen such spectacular
growth in less than 30 years?
For now as never before had
so many people attended an
ESHRE event, and never
before had the sun shone on
London so gloriously for four
uninterrupted days.
4
As ever, this was a congress rich in its diversity
and authority. Reports from 223 studies (selected
from 1589 originally submitted abstracts) were
presented during 71 invited and oral
communication sessions. And it was fitting that,
in this year of the death of ESHRE’s founder, the
opening keynote lecture was
given in honour of Sir
Robert Edwards. Victor
Gomel, who last year in
Istanbul had been awarded
honorary membership of
ESHRE, described Edwards
as a giant in science but as
Victor Gomel presents the
opening keynote lecture in
commemoration of Sir
Robert Edwards.
Focus on Reproduction September 2013
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someone whose humility and kindness never let
him ignore his fellow man. Gomel, like so many in
this huge opening audience, was astounded that
honours from his native country came so late in
life to Edwards.
Following Gomel onto the opening session stage
was the Swedish (though Australian native)
embryologist Aisling Ahlström, whose Human
Reproduction keynote lecture was based on her
group’s study of the morphological parameters for
predicting blastocyst viability. Her published paper
had had the highest number of full-text downloads
during the first six months of publication in 2011,
and, in its emphasis on embryo selection in IVF,
stamped the congress with a theme which was
evident throughout the following three days.
Ahlström’s study was a retrospective analysis of
1117 fresh single blastocyst transfers and their live
birth outcome related to each of three
morphological parameters: degree of blastocoele
expansion and appearance of both the
trophectoderm and the inner cell mass. Results
showed that all three parameters had a significant
effect on live birth but, with adjustment for known
confounders, the number and cohesion of
trophectoderm cells was the only statistically
significant independent predictor of live birth.
Embryo viability was also the aim of a highscoring proof-of-principle study reported by Dagan
Wells from the NIHR Biomedical Research Centre
in Oxford, UK. His presentation described the
validation of next generation sequencing in cells
and blastocysts with known chromosomal and
genetic defects - with what Wells described as ‘an
unprecedented insight into the biology of
embryos’. Genomic sequencing, he said, could
potentially identify chromosomal, genetic and
mitochondrial abnormalities from a single test
within about 16 hours (and so without the need
for freezing while awaiting results). The final stage
of the study had been the delivery of healthy
babies to two women in the USA who had
previously had miscarriages and whose later
embryos had been assessed by genomic sequencing.
One of the potential benefits of the technique,
Wells added, is lower cost. Current genetic tests, he
said, ‘are relatively high and beyond the reach of
many patients. Next generation sequencing is a
way which could make chromosome testing more
widely available to a greater number of patients.’
This was not the only study in London to
describe genomic sequencing for embryo selection.
A study reported in the same session by Jian Li
from BGI Shenzhen in China presented an
evaluation of what he called ‘massively parallel
sequencing’ for the detection of chromosomal
Focus on Reproduction September 2013
Honorary membership of ESHRE was awarded to the Finnish embryologist Outi
Hovatta (by former ESHRE Chairman Anna Veiga) and to the UK gynaecologist Allan
Templeton (by fellow Scot and local organiser Roy Farquharson).
abnormalities. Li, also describing the technique as
‘low cost’ and powerful, reported the outcome of
testing 150 trophectoderm samples from
blastocysts, with a high detection rate and 14 live
births already recorded.
Low cost was at the heart of another proof-ofprinciple study from the Genk Institute for Fertility
Technology in Belgium, which claimed that, with a
simple two-tube Alka-Seltzer-fired incubator, a
Dagan Wells
cycle of IVF could be performed for around €200.
described
validation studies ‘This simplified lab procedure will undoubtedly
of next generation open up a new era in the history of IVF,’ said
sequencing for
investigator Elke Klerkx. ‘The method not only
embryo selection offers affordable and successful access to IVF, but
in IVF.
will make effective treatment techniques available
to a much larger part of the world’s infertile
population.’
The study was led by Willem Ombelet, coordinator of ESHRE’s Task Force for Developing
Countries and Infertility, whose aim is to make the
diagnosis and treatment of infertility available and
accessible to poor-resourced countries. The
incubator system consists of two glass tubes, the
first of which serves as the generator of CO2 from
citric acid and sodium bicarbonate. This brings
into equilibrium the culture medium in the second
tube. Low-cost results so far, said Klerkx, were
comparable with those from the hi-tech lab. In 23
of 35 cycles assessed (66%) the top quality
embryo originated from the simplified culture
system. In this low-cost group the implantation
rate was 34.8% (8/23), with an ongoing
pregnancy rate of 30.4% (7/23). Up to May this
year, 12 healthy low-cost babies had been born.
But if cost was one recurring theme of this year's
Elke Klerkx
congress, another was safety, and this year’s award
presented proof of
for the top oral presentation in clinical science was
principle that an
unanimously awarded to a huge linkage study
IVF cycle for
performed at the Institute of Child Health in
developing
countries can be London whose results showed emphatically that
the children born after ART have no greater risk
performed for
around €200 per of cancer than children conceived spontaneously.
cycle.
‘This is reassuring news for couples considering
5
B INNER
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assisted conception, their subsequent
children, fertility specialists and for the wider
public health,’ said the investigator Carrie
Williams reporting the results. This was a
large population-based linkage study between
the Human Fertilisation & Embryology
Authority (HFEA) and the UK’s National
Registry of Childhood Tumours (NRCT).
The HFEA records of all 106,381 children
born after ART in the UK from 1992 to
2008 were linked to NRCT records to calculate
the number of children who subsequently
developed cancer. Once the databases were linked,
cancer rates in the ART cohort were compared
with population rates, whilst stratifying for
potential mediating factors. The average duration
of follow up was 6.6 years. Results showed that
there was no overall increased risk of cancer in
ART children born throughout the 17-year study
period. Overall, 108 cancers were identified in the
ART children, which was comparable with the
109.7 cases which would have been expected from
general population figures.
A similar though smaller study reported in
London produced comparable findings. The
CoNARTaS cohort study from three Nordic
countries also found that children and young
adults born after IVF had no overall increased risk
of cancer when compared with children in the
general population. The study group comprised
92,809 children born after IVF between 1982 and
2007 (61,547 singletons and 31,262 multiples),
and a matched control group from the general
population four times greater in number. Data on
perinatal outcomes and cancer were obtained by
6
B OUTER
linkage to national registries. A cancer
diagnosis occurred in 143 children born after
IVF (19/1000) and in 626 (18/1000) children
in the control group. The most common
cancer diagnosis was leukaemia, which
occurred in 6/1000 children born after IVF
and in 5/1000 in the control group.
Another cohort study, this time from the
Netherlands, found that women who give
birth to multiple babies following IVF
Carrie Williams
treatment are at a higher risk of breast cancer (HR
presented an
1.44) than those giving birth to singletons or who
award-winning
remain childless. The investigators from the Omega
linkage study
emphatically
study group said the explanation may not be the
ruling out any
multiple pregnancy per se but a maternal trait
excess cancer risk related to a higher implantation potential and to
in children
breast cancer itself. Remarkably, only multiple
conceived by ART.
pregnancies conceived after the complete
implantation of all transferred embryos were
associated with an increased breast cancer risk (HR
1.86), whereas multiple pregnancies conceived after
incomplete implantation were not (HR 1.31). This
finding, said investigator Els Groenveld, supports
the hypothesis of a link between high embryo
implantation potential and breast cancer risk. That
link, she added, could be maternal serum
concentrations of vascular endothelial growth
factor (VEGF), a known protein involved in breast
cancer progression and which her group in
Amsterdam has recently found associated with
improved embryo implantation potential.
Meanwhile, a new study based on a 20-year
follow-up of one of the world’s largest study
cohorts suggests that male exposure to several
factors in utero and in early life may lead to
reduced semen parameters in adulthood - and
potentially to a decline
in male fertility. The
study found that
adverse fetal growth,
exposure to maternal
smoking, and a lower
childhood growth
Focus on Reproduction September 2013
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Annual assembly ratifies new Executive Committee for 2013-2015
ESHRE’s new Executive Committee comprises, left to right, Anis Feki (CH), Georg Griesinger (DE), Juha Tapanainen (FI, the new
Chairman), Carlos Calhaz Jorge (PT), Andres Salumets (EE), Roy Farquharson (GB), Cristina Magli (IT), Nils Lambalk (NL), Anna Veiga
(ES, Past Chairman), Jacques de Mouzon (FR), Kersti Lundin (SE, Chairman Elect), Petra De Sutter (BE), Tatjana Motrenko (ME), Helle
Bendtsen (DK, Paramedical Group Chairman), Grigoris Grimbizis (GR) and Timur Gurgan (TR, SIG Committee).
trajectory were all associated with a subsequent
decline in testicular function, with around one in
six of the men tested having sperm parameters
below the ‘normal’ WHO threshold. When these
findings were correlated with the earlier fetal
growth assessments, being consistently small in
utero was associated with a significantly greater
chance of having a sperm assessment within the
lowest quartile; men with good intrauterine
growth were less likely to be in this lowest
quartile of sperm production in adulthood. Being
exposed to their mothers’ smoking was also
associated with lower sperm production.
New introductions to the lab
One of the most entertaining hot-topic invited
sessions of the congress was the debate on the
introduction of new innovations without clinical
trial. Speaking in favour of the motion, Simon
Fishel not unreasonably invoked much of IVF’s
chequered history to his cause, noting in
particular the rapid acceptance of ICSI into
Focus on Reproduction September 2013
Els Groeneveld: A
common trait in
women with high
implantation
potential and
raised breast
cancer risk?
everyday practice without the luxury of a clinical
trial. ICSI notwithstanding, however, one
suspected that lurking in the wings of this debate
was time-lapse imaging, whose introduction has
been slipped into many IVF labs without the
benefit - as yet - of any RCT results. Sure enough,
Fishels’s opponent in the debate, Sigrid Sterckx
from the Bioethics Institute of Ghent, Belgium,
quickly brought the time-lapse case forward to
centre-stage, while noting that in ART ‘RCTs
seem to be the exception rather than the rule’.
And one reason for this paucity of trials, Sterckx
lamented, is the ever lengthening arm of
commercialisation in the field of ART. And she
too - as had the embryologist Jacques Cohen in
an RBM Online editorial just weeks before questioned the granting of ‘time lapse’ patents to
Stanford University for what seems no more than
a law of nature in the development of embryos.
‘Doubts must exist as to the validity of these
claims,’ she said. For the record the split of
opinion before the debate was roughly 50-50,
7
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For the second year,
the congress
programme was
downloadable as an
app for smart
phones and tablets.
More than 4000
copies were
downloaded from
the App Store and
Google, suggesting
that almost half this
year’s participants
were paper-free.
which, to the surprise of many, remained the
difference of opinion at the end.
This same basic question on the validity and
safety of new introductions in IVF was first raised
more than three years ago by the bioethicist Wybo
Dondorp in an opening keynote lecture at the
2010 annual meeting in Rome. Then, the issue in
question was the introduction of vitrification for
the cryopreservation of oocytes. Now, with the
technique clearly established (even in the USA and
without substantial trials) the more generic
consideration of new techniques (when to
introduce, how to define the experimental phase,
how to test validity) has come before ESHRE’s
Executive Committee and thence to a working
committee of two Special Interest Groups
More than 400 serious and not-so-serious runners
registered for Monday evening’s 5 km charity run
along the Thames bankside. The event, through entry
fees and generous sponsorship, raised more than
€1500 for ESHRE’s partner patient organisation
Fertility Europe.
8
(Ethics & Law, and Safety & Quality in ART).
The outcome of their considerations was
presented as a position paper in London with two
major proposals: first, the addition of a new
category of ‘innovative treatment’ to lie between
the ‘experimental’ and ‘established’ phases; and
second, a sequential four-criteria tool for the
consistent assessment of new treatments and
technologies based on efficacy, safety, procedure
and effectiveness. The transition between
experimental and established would thus depend
on how the technique scored in each of these four
criteria.
‘This is a conceptual framework, not a decisive
tool,’ said Veerle Provoost on behalf of the SIG
Ethics & Law. ‘Its purpose is to raise discussion
about treatments.’ Innovative treatment, she
added, could only be reached when ‘experimental’
procedures have demonstrated proof of principle
(efficacy) and reassurance in terms of safety, when
data have been reported in peer-reviewed journals,
and when patients have been offered clear
information. ‘Established’ treatment might only be
reached when multicentre data is published in
peer-reviewed journals, on which basis it is
regarded as a safe and effective therapy, and when
procedures are performed according to a standard
protocol.
Another report to emerge from an ESHRE
working group (comprising the Task Force for
Cross-border Reproductive Care and IVF
Monitoring Consortium) was on the contentious
subject of egg donation,
currently one of the most
frequent reasons why couples
travel abroad for treatment.
The study, which surveyed (by
questionnaire) 1423 egg donors
at 60 clinics in 11 European
countries to discover their
Guido Pennings: ‘The fact
motivations, found that the
that a person receives
majority of donors are keen to
compensation or money
help infertile couples for
does not mean that she is
motivated by that money.’
altruistic reasons, but that a
large proportion also expect a
personal benefit, usually financial. The extent to
which financial compensation was important
seemed dependent on country and on donor age.
The younger the donor, the more likely would
money be the motive. The study did, however,
find that altruism was the principal motive
overall. ‘The fact that a person receives
compensation or money does not mean that she is
motivated by that money,’ said Guido Pennings
presenting the results on behalf of the Task Force.
High levels of pure donor altruism were found in
Focus on Reproduction September 2013
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Award winners from ESHRE 2013. From left to right:
l Jie Li (CN) for the Clinical Science Award for poster presentation (Embryonic human chorionic gonadotropin (hCG) in
spent culture medium may tell embryo viability in IVF-ET program: a multi-center study)
l Jacky Boivin (GB) representing Hetty Ockuysen et al (NL) for the Nurses Award (Can a self-administered coping
intervention reduce anxiety in women awaiting the outcome of IVF treatment - a randomised controlled trial)
l Souraya Jaroudi (GB) for the Fertility Society of Australia Exchange Award (Assessment of telomere DNA length in
human oocytes and cleavage stage embryos: impact on aneuploidy risk and implantation potential)
l Paola Scaruffi (IT) for the Basic Science Award for oral presentation (DNA profiling of culture medium as a novel,
non-invasive tool for embryo assessment)
l Bart Desmet (BE) for the ART Laboratory Award (Evaluation of the frozen embryo stock and destination of the frozen
embryos in a large scale cryopreservation program)
l Pénélope Troude (FR) for the Basic Science Award for poster presentation (Cumulative parenthood rates in 6,507
couples treated by in vitro fertilization)
l Carrie Williams (GB) for the Clinical Science Award for oral presentation (Cancer risk in children born after assisted
conception)
Belgium (86%), Finland (89%) and France
(100%), and high levels of purely financial
motivation in Greece (39%), Russia (47%) and
Ukraine (28%).
- a reflection, no doubt, of the growing
importance of ART in these two countries.
More than 2000 took part in the precongress
courses on Sunday, also with record rating scores
(4.2 out of 5 for quality). Remarkably, more than
As ever, the scientific programme was promoted to
560 registered for the precongress course
the press by ESHRE’s Central Office, with
organised by the SIG Reproductive Endocrinology
widespread media coverage. Notably, the proofon efficacy and safety in ovarian stimulation for
of-principle study from Belgium on low cost IVF
ART.
for poor-resource countries attracted the widest
ESHRE’s survey of delegate response to the
media coverage, with reports popping up in all
overall meeting found ratings for scientific quality
corners of the world.
and educational value of around 4 (with 5 the top
For the 10,007 delegates on site in London this
rating), while overall organisation and social
was yet again a well received meeting, with high
events also scored high. Sixty per cent of those
satisfaction scores. Most participants - not
questioned said they would expect to attend
surprisingly - came from the UK (753), but
next year’s event in Munich, whose second
Congress attendance
there was also strong attendance from Italy
announcement was published in London.
Rome 2010
9,204
(484) and Spain (410). However, the
Precongress courses are already planned, and
Stockholm 2011 8,361
presence of non-European countries was this Istanbul 2012
the outline of the main invited programme in
9,066
year much in evidence, with 458
place. Will ESHRE’s congress records
London 2013
10,007
registrations from India and 300 from China
continue to fall in Bavaria?
Focus on Reproduction September 2013
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ANNUAL ASSEMBLY OF MEMBERS
// ANNUAL MEETING 2013 //
ESHRE’s Annual Assembly of Members took place at the ExCeL centre, London, on 9th
July 2013 at 18.00. The minutes of the meeting are recorded below. Matters arising and
their approval will take place at next year’s Annual Assembly in Munich.
1. Minutes of the last meeting held in Istanbul
- The minutes of the 2012 Annual Assembly of Members
(AAM), having been circulated to all members in Focus on
Reproduction (September 2012), were approved.
2. There were no matters arising.
3. Membership of the Society
- Membership of the Society now stands at 5823, a small
decline on last year’s number (6223); almost 70% of
members come from Europe. The top European
membership countries are UK (464 members), Italy (312),
Germany (280), Netherlands (272), Belgium (260) and
Spain (256). North and South America represent 9% of
total membership.
- Disciplines most prominently represented are embryology
(1943 members) and reproductive endocrinology (1734),
but there is strong membership presence in andrology,
early pregnancy, safety & quality, and reproductive
surgery. ‘ESHRE is not a society of clinicians,’ the
Chairman noted; around 50% of the membership is now
drawn from basic science, laboratory disciplines and
nursing.
4. Society activities
Training
- Campus events and precongress courses continue to
dominate the training programme, with events in 2013
comparable in number (30) with those of 2012 (32).
Events of the past two years represent a slight but planned
reduction from 2010’s peak (of almost 40 total events).
The Campus programme in 2013 comprises 15 precongress
courses and 14 individually staged stand-alone events.
- The Chairman encouraged all members to check the
Campus programme on the recently updated ESHRE
website for previews of all Campus events (under
‘Calendar’). She also praised the work of colleagues in
Central Office for upgrading the look and function of the
ESHRE website.
SIGs and Task Forces
- The Chairman announced the formation of a new Special
Interest Group (SIG) on Socio-cultural aspects of
(in)fertility. The new SIG, which was formed from a
merger of the Task Forces for Cross-border Reproductive
Care and Society & Reproduction, will be co-ordinated by
Guido Pennings, with Françoise Shenfield and Paul
Devroey as deputies. Executive Committee representative
will be Jacques de Mouzon.
ESHRE certification for reproductive surgeons
- ESHRE’s recently introduced Certification for
Reproductive Endoscopic Surgeons (ECRES) is the first
international certification scheme in the field. The aim is to
give gynaecologists with an interest in reproductive surgery
an opportunity to validate their skills and establish their
status as reproductive surgeons. The programme is now
under way, with several members already sitting the first
examinations in London.
- The Chairman, noting that this programme will run
‘similarly to that for embryo certification’, expressed her
thanks to the SIG Reproductive Surgery for making so
much progress in this venture in such a short time.
Data collection
- The Chairman praised the work of the European IVF
Monitoring Consortium (EIM) and PGD Consortium. The
EIM group, chaired up to the annual meeting by Anna Pia
Campus meetings (blue) and precongress courses (red) 2000-2013.
10
C OUTER
Focus on Reproduction September 2013
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Munich from 29th June to 2nd July. The 31st annual
meeting in 2015 will be held in Lisbon from 14-17th June.
- The next ‘Best of ASRM & ESHRE’ meeting will take
place in Cortina d’Ampezzo, Italy, on 27th February-1st
March 2014. The Chairman said that the format of the
two previous events will be maintained for 2014.
Most European countries now report ART data to ESHRE’s IVF Monitoring
Consortium. Only two countries, Belarus and Malta, have never submitted
any data. The latest report, for 2010, was based on data from 31
countries, of which 18 provided complete cycle-by-cycle data. The EIM
estimates that current reports cover 90% of all European ART activity.
Ferraretti, is now monitoring more than 500,000
European ART cycles each year, representing a cumulative
total of 971,280 babies born since the EIM began its work
in 1997. Preliminary data for 2010 presented in London
indicate for the first time in recent years a slight divergence
in pregnancy rates (per aspiration) between IVF and ICSI at 30.9% for IVF and 28.7% for ICSI. Multiple deliveries
continue to decline (from 29.5% in 1997) and have now
for the first time fallen below 20% (to 19.2%). Ten
countries reported data from IVM cycles, with Russia and
France accounting for 68% of these cycles and 46% of
deliveries. Almost 5000 cycles of oocyte cryopreservation
were reported for 2010, the majority from Italy and Spain;
there were 755 deliveries, representing a live birth rate of
15.5% per cycle.
- Data from the PGD Consortium were also described as
‘very valuable’. The Chairman said that the latest full
report, for 2009, is now ready for publication, with data
from 60 centres and 6160 cycles. PGS (in 2009) continued
to be the dominant use, though now in moderate decline
relative to PGD. Data collection XIII (for 2010) will be
published later this year, with data from 64 centres and
6116 cycles.
Guidelines
- ESHRE’s latest guideline, on the Management of women
with endometriosis, was presented during the congress,
with publication expected in Human Reproduction later
this year.
- Other guidelines in progress are on Psychosocial care in
infertility and medically assisted reproduction, expected
Autumn 2013, Premature ovarian insufficiency, expected
Spring 2014, and Recurrent miscarriage, expected Autumn
2014.
5. Future meetings
- The Society’s 30th annual meeting in 2014 will be held in
Focus on Reproduction September 2013
6. ESHRE journals
- Speaking on behalf of the Publications Sub-committee,
Hans Evers, editor-in-chief of Human Reproduction,
reported the latest impact factors for all three ESHRE
journals released just before the congress: Human
Reproduction Update from 9.234 in 2011 to 8.847 in
2012; Human Reproduction from 4.475 to 4.670, and
MHR from 3.852 to 4.582. ‘The journals are in a healthy
situation,’ said Evers, who praised the work of former
editors John Collins, André Van Steirteghem and Steve
Hillier, noting especially the ‘very steep increase’ achieved
by MHR. The three ESHRE journals now occupy the first
three positions in the category of Reproductive Biology,
while Human Reproduction Update continues to lead the
category of Obstetrics and Gynaecology, with Human
Reproduction in third place. ‘We are hoping to improve
our impact factors each year,’ said Evers, who added that
his own appointment as editor-in-chief of Human
Reproduction was one of the ‘thrills’ of his career. The
most frequently cited article from Human Reproduction in
2012 was the report from the EIM Consortium on IVF
data collection for 2007.
- Among technology developments for the journals, Evers
noted the mobile phone/tablet application with search,
browse and e-mail facilities and how its availability had
made tablet access to the journals quick and efficient.
- Evers reported that submissions to the ESHRE journals
continue to rise, with Human Reproduction now attracting
more than 2000 manuscripts per year. Reviewing times (to
a first decision) are now down to around 30 days, but an
ever expanding number of submissions means that the
rejection rate (now above 70%) is steadily increasing.
Evers reported that he and the publishers are considering
ways by which the space occupied by published papers
(either by word count or page layout) can be reduced.
7. Paramedical group
- Helle Bendtsen, the Chairman of the Paramedical Board,
reported that 12% of the total ESHRE membership (689)
were from the Paramedical Group. Paramedical members
comprise nurses, midwives, lab technicians (the largest
group), counsellors and psychologists, and ESHREcertified clinical embryologists up to BSc level. The three
most prominently represented countries are Belgium,
Denmark and the Netherlands, with more than 60
members from each country.
- Among the training events reported was a joint meeting
with the SIG SQART on the introduction of new
techniques into IVF clinics, which will be followed up later
11
sept13_nwp_50939 22/08/2013 13:03 Page 12
this year with a course on introductions to the IVF lab.
The precongress course in Munich next year will be on
special patient groups, with an emphasis on trophectoderm
biopsy. A further basic training course for paramedics will
be held in Paris in May 2014.
- As so successfully pioneered for the embryologists (and
now for reproductive surgeons), ESHRE and the
Paramedical Board are moving ahead with plans for nurse
certification. Bendtsen reported that a working group is
now in place to plot progress, with an advisory committee
also formed to offer clinical and certification expertise. The
aim now, said Bendsten, is to develop a framework which
defines all the competencies and role requirements for ART
nurses in Europe. An outline timeline for the project could
see the first certification exams being held in Lisbon in July
2015.
8. Financial report
- Past ESHRE Chairman Luca Gianaroli, who has been
Chairman of the Finance Sub-committee for the past six
years, presented his final report to the AGM summarising
the balance sheet (income and expenditure) for 2012 and
the budget for 2013. Income in 2012 (€6,865,350) was
ahead of expenditure (€5,816,638), leaving a favourable
balance of €1,048,712. Both income and the final balance
for 2012 were higher than the budget had forecast.
- Gianaroli also reviewed financial data from the past ten
years showing a positive balance in each year except 2009
(when an increase in expenditure was largely explained by
new investment in Campus events). The annual meeting
continues to provide the Society’s greatest source of income
(71%) and expenditure (55%). A budget similarly
constructed to 2012 - to provide a small positive balance has been set for 2013.
- The 2012 value of ESHRE’s assets, including stocks and
cash balances, increased by more than €800,000 from
2011, and the financial state of the Society was described
by Gianaroli as ‘very healthy’. Gianaroli, who was
formally thanked for his six years as Chairman of the
Finance Sub-committee, noted specifically that ESHRE’s
assets had increased during each of his six years as
Chairman and were now in total approaching €12 million.
‘I set out to end up with at least the same resources as we
started with, and we achieved that and more,’ said
Gianaroli.
- The financial report for the year ending 31st December
2012 and the budget for 2013 were approved by the
members.
9. Executive committee
- Nominal changes to the membership of the Executive
Committee were unanimously approved by the
membership. They were:
- Anna Veiga (ES) to step down as Chairman to become
immediate Past Chairman, Juha Tapanainen (FI) to become
the new Chairman of ESHRE, and Kersti Lundin (SE) the
new Chairman Elect.
12
Balance sheet results and budgets 2011-2013: Income (green),
expenditure (blue) and balance (pale blue), showing an actual and
planned favourable result each year.
- Stepping down from the Executive Committee after two
two-year terms in office were Miodrag Stojkovic (RS),
Anne Maria Suikkari (FI), Etienne Van den Abbeel (BE),
Antonis Makrigiannakis (GR), Ursula Eichenlaub (DE) and
Milan Macek Jr. (CZ). Stepping down as ex-officio
members were Françoise Shenfield (GB) and Luca
Gianaroli (IT). All were thanked for their tireless work and
commitment.
- Continuing for a second two-year term as members of the
Executive Committee were Carlos Calhaz Jorge (PT),
Jacques de Mouzon (FR), Roy Farquharson (GB), Anis
Feki (CH), Nils Lambalk (NL), Cristina Magli (IT) and
Helle Bendtsen (DK, PG Chairman).
- New members, whose nominations were ratified by the
meeting, were Petra De Sutter (BE), Grigoris Grimbizis
(GR), Tatjana Motrenko (ME), Andres Salumets (EE),
Georg Griesinger (DE), and Timur Gurgan (TR, SIG and
TF Coordinator, ex-officio member).
10. Election of honorary members for 2014
- The two nominees proposed by the Executive Committee
for honorary membership in 2014 were Sir John Gurdon
(international) and Professor Klaus Diedrich (national).
Both nominations were ratified by the AAM.
11. Any other business
- The new Chairman Juha Tapanainen paid tribute to his
predecessor Anna Veiga, describing her as ‘an excellent
Chairman’, and to the Executive Committee members
ending their terms of office. He also praised the
commitment and effort of Luca Gianaroli, whose work
with ESHRE went back 14 years and who had finally
stepped down from most of his committee responsibilities.
‘Luca has been one of the longest serving members the
Society has ever known,’ said the Chairman.
The next Annual Assembly will be on 1st July 2014 in
Munich at 18.00 pm.
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:03 Page 13
// ESHRE JOURNALS //
Three out of three in
latest impact factor
journal assessment
ESHRE titles continue to
dominate reproductive
biology and Ob/Gyn groups
Hans Evers took over in
January this year as editor
of Human Reproduction.
Chris Barratt, new editor of
MHR, will continue a policy
of high quality manuscripts.
For the first time ever ESHRE journals occupy the first
very highest quality manuscripts - of both primary data
three impact factor positions in the Reproductive
and reviews. And that’s how we’ll progress - by actively
Biology league table as determined by Thomson
seeking manuscripts from leading authors and putting
Reuters. The latest figures, released in June just ahead
together a series of innovative edgy reviews alongside
of the annual meeting in London, are based on journal
our original articles.’
citations for 2012. For most investigators - though not
l Felice Petraglia, editor-in-chief of Update, echoes the
all - impact factors remain the most accessible
importance of well commissioned reviews on a broad
indicator of journal quality.
range of topics - as he explains in more detail on page
Human Reproduction’s impact factor climbed from
26 of Focus on Reproduction.
4.475 (for 2011) to 4.67 (for
2012), Update declined slightly
Reproductive biology
from 9.234 to 8.847, and MHR
Title
Total cites 5-yr Imp Factor Impact Factor
continued its remarkable progress
Human Reproduction Update
5685
9.512
8.847
from 3.852 to 4.582. The three
journals now dominate the category
Human Reproduction
26733
4.596
4.67
of Reproductive Biology and
Molecular Hum Reprod
5095
4.009
4.542
occupy three of the first four
Fertil Steril
28243
3.96
4.174
positions in Obstetrics and
Biol Reprod
22250
4.139
4.027
Gynaecology. Human Reproduction
Reproduction
6975
3.512
3.555
Update remains by far the leading
Am J Reprod Immunol
3251
2.839
3.317
journal in both categories, with an
impact factor almost twice that of
Semin Reprod Med
1550
3.864
3.211
any other.
Reprod Toxicol
4264
3.94
3.141
Of the other titles in reproductive
Placenta
6187
3.179
3.117
medicine, Fertility and Sterility
rose to 4.174 and RBM Online to
Obstetrics and gynaecology
2.675.
All three editors, who took up their Title
Total cites 5-yr Imp Factor Impact Factor
posts in January this year, praised
Human Reproduction Update
5685
9.512
8.947
the work of their predecessors in the
Obstet Gynecol
25808
4.908
4.798
continuing development of the
Human
Reproduction
26733
4.596
4.67
ESHRE journals, while Chris Barratt,
28243
3.96
4.174
the new editor-in-chief of Molecular Fertil Steril
Human Reproduction, said: ‘These
Gynecol Oncol
18243
3.923
3.929
are very exciting times for the
Am J Obstet Gynecol
33759
3.821
3.877
ESHRE journals. MHR in particular
BJOG - Int J Obstet Gynecol
12405
3.754
3.76
has seen a consistent rise in impact
Ultrasound Obst Gyn
8490
3.84
3.564
factor over the past three years. This
Am
J
Obstet
Gynecol
32250
3.708
3.557
is mainly the result of implementing
Semin Reprod Med
1550
3.864
3.211
a strict policy of only accepting the
Focus on Reproduction September 2013
13
D INNER
sept13_nwp_50939 22/08/2013 13:03 Page 14
ANNUAL MEETING
// ESHRE IVF MONITORING CONSORTIUM //
Europe’s multiple
delivery rate finally
falls below 20%
Reliability of EIM database now
rests on a cumulative total of
almost one million babies born
For the first time, the data generated from European registries have
shown a fall in multiple delivery rate to below 20%. Presenting the
14th annual report of ESHRE's European IVF Monitoring (EIM)
Outgoing EIM Chairman Anna Pia Ferraretti
Consortium, outgoing Chairman Anna Pia Ferraretti said the
told the meeting that multiple delivery rate as
overall multiple rate in 2010 had fallen to 19.2%, the lowest ever
calculated from European regstries and
recorded, with a twin rate of 18.5% and triplet rate of 0.7%.
reports reached an all-time low of 19.2% in
Ferraretti explained that most centres reporting data (56.5%) still
2010. Triplet rate was no higher than 0.7%.
transferred two embryos, but the number transferring just one still
continues its steady increase - from
12% in 2001 to 26% in 2010. And
transfers in a small number of
reported since 1997, and almost 1
the number of three and more
countries.’
million babies delivered. This, she
embryo transfers fell yet again to
The annual reports of the EIM,
added, is a monumental achievement
17.5%. In Finland and Sweden,
which currently include 90% of all
and reflects the place of Europe as
where SET is agreed policy, the
European ART activity, provide
the leading region in global IVF.
number of singleton transfers was
‘transparency and confidence’ in the
This was underlined by David
around 70%, with virtually no threetreatments, said Ferraretti, and are
Adamson presenting preliminary
embryo transfers. ‘These are clear
increasingly cited in scientific studies.
results (for 2009) from the world
trends,’ said Ferraretti, ‘and we’re
Their reliability now rests on a
report of ICMART. His data showed
now only seeing consistent multiple
cumulative total of 5,312,318 cycles
that Europe (with around 500,000
cycles in 2009) performed 49% of all
global ART, with Asia contributing
22% and North America 14%.
However, North America once
again had the highest delivery rates in
2009, with 34.4% from fresh
transfers and 43.4% cumulative.
There are now five countries in
Europe performing more than 50,000
cycles a year (France, Germany, Italy,
Spain, UK).
Global trends also showed - for the
first time in recent years - a reverse,
albeit small, in the proportion of IVF
and ICSI treatments carried out. This
was also seen in the EIM European
data, where (in 2010) the number of
For the first time in recent years, the proportion of ICSI treatments (dark blue bars)
ICSI cycles performed fell in relation
relative to IVF (green bars) has begun to decrease in Europe.
to IVF. In countries with a generally
14
D OUTER
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:03 Page 15
World ART activity in 2009: the snapshot from ICMART’s global report
David Adamson, Chairman of ICMART and former President of the ASRM,
presented ICMART’s preliminary report for 2009. The highlights were:
l 1,081,851 cycles reported (an increase of 2.0% on 2008)
l An estimated 1.6 million cycles performed worldwide
l 243,927 babies born (-6,0%)
l An estimated 400,000 babies born worldwide
l An estimated ~5 million babies since the beginning
l 67.1% ICSI (-2.0%)
l 20.3% women >40 (-0.4%)
l Mean number of transferred embryos = 1.97 (-0.11)
l Delivery rate per aspiration = 19.5 % (-1.3%)
l Cumulative delivery rate per aspiration = 25.7% (+1.0%)
l Wide differences remain in availability, practice and results
low utilisation (such as Denmark
and Finland) ICSI accounts for no
more than 45% of all ART
treatments, but elsewhere (as in
Poland, Spain, Switzerland and Italy)
ICSI rates are above 80%. Overall in
Europe in 2010, ICSI accounted for
65% of treatments and IVF 35% with frozen embryos representing
28% of all transfers.
The European data also showed
for the first time a difference in
pregnancy rates between IVF and
ICSI, with IVF recording a 30.9%
pregnancy rate per aspiration in
2010, and ICSI a rate of 28.7%. In
all annual reports before 2010
outcome rates for both techniques
had always been the same.
There was, however, much
disparity in outcome (and
availability) between countries, with
pregnancy rates (per aspiration)
ranging between 21.5%
(Switzerland) and 50.2% (Czech
Republic). When stratified for age,
the pregnancy rates also emphasised
clearly the effect of age from all
treatments except egg donation.
Earlier this year new by-laws for
the EIM Consortium were approved
by ESHRE’s Executive Committee.
Availability of ART, represented here as cycles per million population, remains patchy in
Europe. Global need for ART is considered to be 1500 cycles per million population.
Focus on Reproduction September 2013
Among the developments
implemented in London was an
election process for membership of
the EIM Steering Committee, which
now comprises Markus Kupka (DE)
as Chairman, Anna Pia Ferraretti as
Past Chairman, and Karin Erb (DK),
Thomas D'Hooghe (BE), José
Antonio Castilla Alcala (ES), Carlos
Calhaz-Jorge (PT) and Christian De
Geyter (BE) as members. Former EIM
Chairman Jacques de Mouzon is the
ExCo representative. The total
Consortium membership for the first
time now represents all European
countries performing ART.
The German gynaecologist Markus Kupka
took over as Chairman of the EIM
Consortium in London.
15
sept13_nwp_50939 22/08/2013 13:03 Page 16
OPINION
// PREIMPLANTATION GENETIC SCREENING //
Still too early to take a
conclusive view on
technique or patients in
aneuploidy screening
Former PGS Task Force
chairman considers ESHRE’s
ESTEEM trial and where
opinions on PGS divide
Despite several concluded trials and others known
to be ongoing (or planned), many questions related
to aneuploidy screening of preimplantation
embryos remain unresolved. However, some
questions have been answered.
First, the reasons for aneuploidy screening
remain valid. These aim to increase the live birth
rate or decrease the miscarriage rate, to diagnose
live born trisomies or to look for the best embryo
for single embryo transfer.
Second, it has taken more than 10 years and 13
randomised controlled trials to show that the
initial PGS approach applied to both good and
poor prognosis patients did not work. In all of
these studies FISH was used to screen a limited
number of chromosomes in one or two
blastomeres biopsied during cleavage. Metaanalysis has subsequently shown that PGS using
FISH significantly lowered live birth rate after IVF
Aneuploid polar
for women of advanced maternal age.
body
as determined
Why were the results of these studies so
by array CGH
disappointing? Several reasons have been
analysis.
16
JOEP GERAEDTS; ‘THE MOST
EFFECTIVE WAY TO RESOLVE THE
DEBATES ABOUT PGS IS TO
PERFORM WELL DESIGNED
RANDOMISED CLINICAL TRIALS.’
suggested: the FISH method is not very accurate;
not all chromosomes have been tested; the
biopsied blastomere is not a true representation of
the embryo at the 8-cell stage because of
mosaicism; and the biopsy itself might cause harm
and negatively influence the developmental
potential of the embryo.
Despite these results, ESHRE remained
convinced that ‘the most effective way to resolve
the debate about the usefulness of PGS is to
perform well-designed and well-executed
randomised clinical trials’. And today there are a
number of permutations and combinations that
can be studied. FISH can be replaced by several
technical approaches which have in common the
ability to target all chromosomes at the same time.
Furthermore, several types of biopsy are possible one or both polar bodies, blastomere and
trophectoderm biopsy. It is in the selection of the
most effective technique at the most appropriate
stage of embryo development that the current
questions on PGS remain unresolved.
After ESHRE's PGS Task Force published results
from a pilot study ESHRE started a multicentre
RCT using microarray technology on both polar
bodies. Elsewhere, however, the number of other
registered multicentre trials is disappointingly low.
So it is still too early to say which approach will
prove to be the best - and the possibility that this
will very much depend on each individual
situation cannot be excluded. For example, the
indication might have to be taken into account.
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:03 Page 17
Polar body biopsy might be better suited for those
patients of a higher maternal age, while
trophectoderm biopsy might be better for
recruiting the best embryo for single embryo
transfer in younger patients.
Some authors have suggested that vitrification
and serial transfer of all embryos are likely to give
patients the best chance of successful pregnancy,
which implies they would be better off without
aneuploidy screening. It is indeed the case that a
highly effective and efficient cryopreservation
protocol such as vitrification is compatible with
the transfer of unselected embryos in subsequent
frozen replacement cycles without impairing (and
possibly improving) pregnancy rates.
However, at a higher maternal age, the time to
pregnancy is very important and can only be
reduced substantially by embryo selection.
Without selection, many costly months may be
lost. Indeed, from the results of ESHRE's pilot
study (of polar body analysis by array CGH) it
was clear that at an average maternal age of 40
years around 75% of oocytes bear chromosomal
abnormalities. This suggests that, by transferring
each embryo one by one, many menstrual cycles
will be lost unnecessarily as a result of
implantation failure or miscarriage. Furthermore,
the psychological burden of repeated implantation
failure and spontaneous abortion of a muchwanted, clinically recognised pregnancy is severe.
The aim of testing is not only to establish a
pregnancy but to select the best embryo for a
healthy singleton birth. Not all abnormalities are
lethal, and screening for aneuploidies can reveal
trisomy 21 conceptuses and other viable
chromosome abnormalities, especially in women
of increased maternal age.
Last but not least, the costs of vitrification
include two ultrasound examinations,
medications, embryo warming and culture, and
embryo transfer. Besides these direct costs, the
indirect costs, including lost wages during
treatments and child care, should also be taken
into account. On the other hand, we may well
now expect a further reduction in the costs of
array technologies or 24 chromosome screening.
PGS aims to improve the efficiency of assisted
reproduction, which can be achieved in two ways:
first to select at the level of the embryo to be
transferred; and second to select at the level of the
patient to be treated.
Both these considerations in the outcome of
ESHRE's array CGH pilot study were behind the
design of a randomised clinical trial in women
with advanced maternal age. This trial, known as
ESTEEM, has two aims: first, to assess the impact
of 24-chromosome polar body PGS on time to
pregnancy and live birth rates; and second to
estimate whether consistent oocyte aneuploidy in
one cycle is predictive of consistent aneuploidy in
future cycles.
This trial is now well under way. But if the
latter aim proves the case, almost half the patients
should be counselled to stop IVF or look for
alternative forms of treatment, such as oocyte
donation. But until the results of the trial are
known, it is still premature to put forward firm
conclusions.
Joep Geraedts
Chairman ESTEEM Steering Committee
New ESHRE guidelines on endometriosis completed
New ESHRE guidelines on the Management of women with endometriosis are now in their
final stages of correction. The guidelines are the first to be produced in accordance with
the 12-step process ESHRE’s manual for guideline development, which include the
formulation of key questions, literature search, evaluation of evidence, writing
recommendations and a broad open review. The new guidelines are based on 22
questions posed by the development group, which was chaired by Gerard Dunselman
from Maastricht University Medical Centre, and patient organisations. The final version
makes 22 grade A recommendations (from a total of 82); the 2005 version made a total
of 15 grade A recommendations (from a total of 36). The guidelines were available for
review between February and April this year and in all 61 reviewers supplied
comments. Recommendations on diagnosis, symptoms, pain relief and treatments
(including ART) are included.
Once approved by ESHRE’s Executive Committee, the guidelines will be submitted
to Human Reproduction for publication and will also be freely available to ESHRE
members via the website. After one year they will be freely available, and available
soon as a consultation app for smart phones and tablets.
Focus on Reproduction September 2013
17
E INNER
sept13_nwp_50939 22/08/2013 13:03 Page 18
// PARAMEDICAL GROUP //
Defining competencies
and role requirements
for ESHRE nurse
certification in Europe
ESHRE Nurse Certification
The working group for nurse certification is now developing
requirements for accreditation and a structure for the
programme, and planning the practical steps of design and
procedure for implementation. This month (September) there
will be an expert meeting for European nurses for which a
mailing has been sent to Committee of National
Representative (CNR) members to collect contact details of
nurses’ organisations throughout Europe. We hope to invite
one nurse from each country, who will be asked to complete
a questionnaire from which a first draft of the logbook will be
prepared.
The certification programme will be launched during next
year’s annual meeting in Munich and promoted at all
activities involving the Paramedical Group and through
national fertility societies and Fertility Europe. Certification is
not only important for the professional competence of nurses,
but also for the provision of high-quality and safe treatments
for patients. We have asked the SIGs Ethics & Law and
Psychology & Counseling and our clinical adviser Anja
Pinborg to provide samples for our pool of multiple choice
questions. We need to ensure that there is published
evidence on each correct answer. Following are some
examples, on which topics good knowledge will be required:
l Epidemiology of infertility
l Anatomy and pathology of the reproductive system
l Diagnosis
l Male and female reproduction
l Quality assurance
l Guidelines and clinic-specific standard procedures
l Legislation and ethics
l EU directives and national legislation
l Psychosocial support interventions
l Research
l Ultrasound
There will be only one level for the certification exam (and
not at senior and clinical levels as for the embryologists).
Paramedical Board membership
One of our Board members will be stepping down next year
18
E OUTER
Hands-on oocyte vitrification at this year’s precongress course.
in Munich and we will therefore require a nurse replacement.
We will see the candidates at our board meeting in Spring
2014, and the selected candidate will be confirmed as a
Board member at the Group’s Annual General Assembly in
Munich. Paramedic members of ESHRE - ideally a nurse or
midwife - are now invited to apply for this vacant position.
It’s a commitment of four years, with a possible re-election
for four more years. Those interested should contact me at
[email protected].
Annual meeting London
A total of 145 people registered for our precongress course in
London on oocyte vitrification. There was a very positive
feedback from participants, and we would like to thank the
many companies who demonstrated their different devices.
Together we had an interactive session in which delegates
were split into working groups for practice and discussion
with the companies.
There was an increase in the number of paramedical
abstracts submitted for the main programme and the quality
of the lab abstracts was much higher than in previous years.
The paramedical invited sessions were all excellent – we
would also like to thank the speakers. All the sessions were
well attended.
Seven presentations were considered for this year’s two
awards for paramedics (each of €2000) - for the best oral
presentation by a nurse, presented to Hetty Ockhuysen from
the Netherlands), and for the best oral or poster presentation
made by a laboratory technician, won by Bart Desmet from
Belgium.
Helle Bendsten
Chair Paramedical Board
Focus on Reproduction September 2013
sept13_nwp_50939 23/08/2013 10:49 Page 19
PGD CONSORTIUM
Reformed Steering Committee sets out
renewed priorities under restored full power
Last year the PGD Consortium’s Steering Committee was
unable to function on full power because of changes to its
organisation. Now, with just five elected and ‘active’
members (Jan Traeger-Synodinos, Edith Coonen, Sioban
Sen Gupta, Martine De Rycke and Céline Moutou, with
the support of ESHRE’s science manager Veerle Goossens)
the down-sized Committee is finally ready to go again!
At our recent update meeting in London, we had the
fruitful input of many of those who attended, including
the recently retired members Francesco Fiorentino,
Georgia Kokkali, Katerina Vesela and Pam Renwick. The
Steering Committee also welcomed Ursula EichenlaubRitter as the new Co-ordinator of the SIG Reproductive
Genetics. She will join the non-voting Committee
members Joyce Harper (Past Chair), Cristina Magli
(ESHRE Executive Committee liaison) and Joep Geraedts.
The collection of data XIV has continued as usual, but
the cleaning and analysis of both data XIV and data XIII
are behind schedule. However, we wish to acknowledge
the effort of all contributing centres and aim to address
the lag as soon as possible by helping Veerle Goossens,
who bears the major brunt of this gigantic task. If we
include the cycles submitted for data XIV (PGD cycles
carried out between January and December 2011 with
babies delivered up to 2012) the Consortium now has
information on almost 52,000 cycles, providing an
extremely valuable resource for data mining and for
following trends in PGD practice.
As reported in the last issue of Focus on Reproduction,
our data mining effort is looking at data collection IV
through to XI (>29,000 cycles). For future data
collections, we hope to have an on-line data submission
platform ready for the end of 2014. Celine Moutou is coordinating both of these huge projects.
However, the data collections do not represent real-time
trends in PGD. So for this reason the Steering Committee
has decided to start a working group to monitor new
technologies in PGD, chaired by Martine De Rycke. The
aim is to gather up-to-date information by the end of
2013 on developments on all aspects of PGD (IVF/ICSI,
biopsy practice and genetic testing strategies and
technologies). This will probably be done through a
questionnaire, and, to encourage Consortium-wide
participation, it was decided that centres returning
questionnaires will be included for authorship in any
publications arising from this survey. All Consortium
members should look out for the questionnaire, which we
plan to e-mail to everyone in early October, with a
deadline for completed questionnaires by mid-November.
Other new working groups are also planned to support
Focus on Reproduction September 2013
Evolution of Consortium cycle data 1997-2011, with PGS still the major
indication, albeit in slight relative decline. Cumulatively, the Consortium
now has information on almost 52,000 cycles.
the continued generation and collection of high quality
data. One plans to follow-up PGD cycles for HLA, chaired
by Jan Traeger-Synodinos. The aim is to evaluate how often
PGD for HLA achieves the ultimate clinical utility, which is
to cure a sick child with a matched bone-marrow transplant
following selection and birth of an HLA-compatible sibling.
Another plans to look at collaborative working practices
between genetics and IVF teams when delivering a PGD
service (to be chaired by Sioban SenGupta). Again all
Consortium members should look out for (e-mail)
notification of participation in both of these projects. The
Consortium Webpage is also being updated, and will be
curated by Edith Coonen.
Finally, with respect to the ‘education’ aims of the PGD
Consortium, the Steering Committee plans to make, in
collaboration with the SIG Reproductive Genetics, some
short e-lectures relating to basic aspects of PGD to be
uploaded to the Consortium webpage this autumn. In
addition the first interactive webinar to initiate exchange of
experience between PGD Consortium members is planned
before the end of this year.
The Steering Committee also wishes to emphasise that the
Consortium is an important forum for all PGD practitioners
to exchange data, experiences and valuable
expertise. Thus the new Committee wants to
encourage greater participation of member
centres, not only in the data collections but
also in other working group activities.
Joanne Traeger-Synodinos
Chair PGD Consortium
19
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SPECIAL INTEREST GROUPS
// REPRODUCTIVE GENETICS //
New report on the interface of genetics and ART
Coming up in September in
Publications
Steering committee
Prague is a Campus workshop
The results of an expert meeting in
Ursula Eichenlaub-Ritter (DE), Co-ordinator
organised by the SIG RG and PGD
March between ESHRE and the
Claudia Spits (BE), Deputy
Consortium on the Application and
European Society of Human
Tania Milachich (BG), Deputy
challenges of emerging technologies
Genetics to discuss the interface
Georgia Kakourou (GR), Junior Deputy
in preimplantation and prenatal
between ART and genetics has been
Joyce Harper (GB), Past Co-ordinator
diagnosis, with local organisers
approved by ESHRE’s Executive
Milan Macek and Katerina Vesela.
Committee and will be published
We have also applied for a Campus workshop with the
shortly in Human Reproduction and the European Journal
SIGs Stem Cells and Andrology and Task Forces Basic
of Human Genetics. Titled ‘Current issues in assisted
Science and Fertility Preservation for early summer 2014
reproduction and genetics in Europe; research, clinical
on Stem cells: origins, genetics, properties and significance
practice and policy’, the report has been authored by Joyce
for fertility preservation organised by Karen Sermon,
Harper, Karen Sermon, Milan Macek Jr, Joep Geraedts,
Ursula Eichenlaub-Ritter, Stephan Schlatt and Helen
Luca Gianaroli, Anna Viega, Claudia Spits, Gary Harton,
Picton.
Stéphane Viville, Joris Vermeesch, Inge Liebaers, Michael
However, an update workshop on PGS originally
Morris, Helena Kääriäinen, Heather Skirton, Francoise
planned for 2014 has been postponed to await completion
Shenfield, Pascal Borry, Martina Cornel, Sirpa Soini, Tanya
of several randomised trials, but the event is planned for
Milachich, and Jorge Sequeiros.
2015 organised by Francesco Fiorentino and the PGD
Another paper on the ethical issues raised by the genetic
Consortium.
screening of gamete donors and based on a joint meeting in
And a Campus course on Epigenetics in reproduction is
Maastricht last year of the SIGs RG and Ethics & Law is
planned for autumn 2014 in Lisbon (with local organiser
now in preparation.
Carlos Plancha) together with SIG Embryology and Task
Force Basic Science.
Training
We expect that the precongress course on The current
Our precongress course on Genes and epigenetic
status of PGD and PGS planned for the next annual
mechanisms of infertility and how to minimize the risks in
meeting in Munich in 2014 is likely to attract a wide
London 2013 was well attended and led to animated
audience of those working in PGD and embryology, but
discussions.
should also prompt new discussions on
outcomes after PGD/PGS, and the
consequences of aneuploidy in the
preimplantation embryo; also on the agenda
are the relevance of mitochondrial disorders
and ethical dilemmas raised by PGD/PGS.
Joyce Harper is leading our activites in elearning and we hope to have the first
modules ready by the end of 2013.
Speakers at the SIG RG precongress course in London on the genetic and
epigenetic causes of infertility with members of the steering committee:
from left to right, Thomas Haaf, Robert Feil, Wendy Dean, Stéphane Viville,
Gudrun Moore, Joop Laven, Joyce Harper, Ursula Eichenlaub-Ritter, Alan
Handyside, and Tania Milachich.
20
Organisational changes
The Steering committee is now headed by
Ursula Eichenlaub-Ritter as the new Coordinator of the SIG, replacing Joyce Harper
whose two-year term came to an end in
London. Claudia Spits and Tania Milanich
(former Junior Deputy) become the SIG’s
Deputies, while Georgia Kakourou was
confirmed as the new Junior Deputy at our
business meeting in London.
Ursual Eichenlaub-Ritter
Co-ordinator SIG Reproductive Genetics
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:03 Page 21
// REPRODUCTIVE SURGERY //
ESHRE certification
in reproductive
endoscopic surgery
off to a welcome
start in London
The highlight of this year’s annual meeting was
undoubtedly the kick-off of ESHRE’s Certification on
Reproductive Endoscopic Surgery (ECRES) programme.
The SIG RS and ECRES steering committee worked very
hard to get the programme under way and in time for
London. However, 25 doctors from various countries took
the first validated tests for their hand skill abilities in
hysteroscopy, laparoscopy and laparoscopic suturing. The
candidates were in addition tested in theoretical
examinations with 100 multiple choice questions.
A detailed description of the ECRES programme can
now be found on the ESHRE website, where an e-learning
platform will be soon available, with RS tutorials loaded
for e-learning purposes. All speakers presenting relevant
lectures at ESHRE Campus events and ESHRE annual
meetings have been asked to give Central Office five
multiple choice questions related to their presentation. This
pool of questions will be validated according to
international standards and used for learning and testing
purposes. Video presentations and classic surgery cases will
also be collected, classified and evaluated for learning
purposes.
Live surgery in London direct from the Heilig Hart hospital in Leuven,
Belgum. As ever, well attended, with much participant interest.
equipment used. Dealing with complications, they
explained their decisions and provided tips and tricks.
The oral presentations comprised the top score
submitted papers in reproductive surgery, both in
laparoscopy and hysteroscopy. The high attendance and
interest showed during discussion of the presentations
reflects the ever increasing interest in endoscopic surgery,
especially by young gynaecologists. Interesting data were
presented on the de-torsion of ovarian cysts and the
preservation of primordial follicles, even after 72 hours of
torsion. Among other topics addressed were reproductive
outcomes after the hysteroscopic treatment of uterine
malformations as determined by systematic review and
meta-analysis. The RS precongress course attracted 152
participants, our highest attendance ever.
Congenital uterine anomalies
The new classification on congenital uterine anomalies
(CONUTA) was extensively presented and discussed by
participants. Their simultaneous publication in Human
Other activities in London
Reproduction and Gynaecological Surgery raised much
The live surgery was session organised, performed and cointerest and everybody agreed that a new era for clinical
ordinated by Stephan Gordts from the Heilig Hart
research on uterine anomalies should now begin based on
Hospital in Leuven, Belgium. Top quality and state-of-thethe new classification. Already the SIG RS is planning a
art endoscopic surgery was performed by Prof Arnaud
web-based research logbook where gynaecologists with
Wattiez (FR), Michelle Nisolle (BE), Jaine Ferro (ES) and
infertile patients with uterine anomalies defined by the new
Sylvie Gordts on infertile patients with rectovaginal
classification can insert patients’ clinical data, treatments
endometriosis and endometrioma cysts. In addition
and follow-up in a prospective way. We believe that such a
hysteroscopic myomectomy, septectomy, tubal sterilisation
research programme will generate a
reversal and transvaginal endoscopy
large number of cases in a short
were also demonstrated. The live
Steering committee
period of time and be able to answer
surgery session this year was
TC Li (GB),, Co-ordinator
questions of primary importance.
attended by 800 participants, who
Antoine Watrelot (FR), Deputy
Vasilis Tanos
could take part interactively with the
Gregoris Grimbizis (GR), Deputy
Past
Co-ordinator
surgeons explaining their operation
Sotirios Saravelos (GB), Junior Deputy
SIG Reproductive Surgery
strategy prior to the procedure and
Vasilis Tanos (CY), Past Co-ordinator
demonstrating the tools and
Focus on Reproduction September 2013
21
sept13_nwp_50939 22/08/2013 13:03 Page 22
SPECIAL INTEREST GROUPS
// REPRODUCTIVE ENDOCRINOLOGY //
Record turnout for London precongress course
Our precongress course in London
lifestyle and endocrine disruptors
Steering committee
on Ovarian stimulation for ART pre- and periconception, the value of
Efstratios Kolibianakis (GR), Co-ordinator
how to achieve efficacy and safety
treating subclinical hypothyroidism,
Frank Broekmans (NL), Deputy
was the best attended of all ESHRE
immunological and endocrine
Daniela Romualdi (IT), Deputy
courses this year and, with 560
aspects of implantation, the
Tehri Piltonen (FI), Junior Deputy
participants, broke all records for
endocrinology of pregnancy, genetic
Georg Griesinger (DE), Past Co-ordinator
ESHRE workshop attendance. The
markers of early pregnancy success,
quality of the presentations and the
and early pregnancy progesterone.
high level of discussion were very
stimulating. This year we introduced an e-voting system on
SIG RE business meeting in London
controversial topics, which encouraged interaction with the
Under the existing ESHRE regulations each SIG is allowed
lectures and will be endorsed for future SIG RE meetings.
only one Campus meeting per year, which is somewhat
restricting for our group, the largest amongst ESHRE
Campus events in 2013
SIGs. On the other hand, such a regulation emphasises the
We encourage you to register for our Campus meeting in
need for a careful selection of a topic which combines
Rome on 25-26th October on Polycystic ovary syndrome: a
both high scientific value and clinical importance.
new look at an old subject, hosted by SIG RE Deputy
During this year’s business meeting in London a call for
Daniela Romualdi. The programme includes presentations
proposals for a Campus meeting in 2014 - as well as for
on emerging challenges in the diagnosis of PCOS, on new
the precongress course in 2015 in Lisbon - was made with
insights into its causes, on how to achieve and maintain a
a deadline of September 2013. Please email any comments
pregnancy in PCOS patients, and on the problems of PCOS
or ideas to me ([email protected]). Some
beyond reproduction.
proposals were put forward and discussed briefly by the
Later in the year, on 6-7th December, an equally
business meeting, where it was also proposed for the
interesting Campus will take place in Utrecht on Primary
future that all such proposals should already have been
ovarian insufficiency, an update and guideline presentation
made in writing prior to the business meeting; this would
hosted by the SIG RE Deputy Frank Broekmans. The
allow for a more detailed and productive discussion.
programme includes presentations on the basics of early
In London Georg Griesinger (DE) stepped down as Coovarian ageing, the pathophysiology of POI and the
ordinator of the SIG RE, after a very successful term, to
involved genes, the clinical condition of POI, its treatment
join ESHRE’s Executive Committee. Georg will serve as a
and care, and on the work in progress of ESHRE’s POI
Past Co-ordinator for the next two years and thus we will
guideline development group.
be able to share his valuable experience. Frank Broekmans
(NL) will continue to be active as a Deputy, together with
Precongress course 2014 Munich
Daniela Romuladi (IT) who became a Deputy after serving
The next pre-congress course in Munich will be on the
two years as Junior Deputy. Tehri Piltonen (FI) joined the
contribution of endocrinology and early pregnancy
SIG RE as the new Junior Deputy. Tehri was chosen by the
management to the success of an ART centre. The
previous steering committee members and previous Past
programme has been finalised and will focus on the
Co-ordinator Adam Balen, according to the current
association of gut and adipose hormones to human
ESHRE regulation, from several strong candidates.
reproduction, the endocrinology of obesity and its impact
Stratis Kolibianakis
on fertility, risk of miscarriage and child health, nutrition,
Co-ordinator SIG Reproductive Endocrinology
A record attendance of 560 for this year’s precongress course in London.
22
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:03 Page 23
// STEM CELLS //
Nobel prizes, major breakthroughs, exciting
courses, and a new steering committee
Benjamin Reubinoff presenting very
These are exciting times for the stem
Steering committee
promising preclinical data on retinal
cell field. Just a few months ago,
Rita Vassena (ES) Co-ordinator
regeneration with pluripotent cells. A
Shinya Yamanaka and Sir John
Cristina Eguizabal (ES), Deputy
lively debate followed, with many
Gurdon (who will be made an
Karen Sermon (BE), Past Co-ordinator
colleagues hoping to understand the
honorary member of ESHRE next
Filippo Zambelli (IT), Junior Deputy
true therapeutic value of stem cells.
year in Munich) were awarded the
To address the ever important
Nobel prize for their reprogramming
question coming from clinicans - ‘This is interesting, but
of differentiated cells towards pluripotency. This was an
what’s in it for my patients?’ - the SIG SC together with
incredible feat which turned on its head the one-way-street
the Task Force Fertility Preservation organised a well
concept of pluripotency and is now bearing its first
attended precongress course in London 2013 on
translational fruits with clinical trials announced in Japan.
Pluripotent stem cells, cancer and fertility preservation:
And now, in June 2013, another milestone in the field has
science fact or science fiction?. Here, many scientists and
been reported: Shoukhrat Mitalipov, from the Oregon
practitioners from different fields learned about the
Health & Science University, described the successful
possible applications of stem cells in fertility preservation
derivation of human embryonic stem cell lines from
for both females and males; other presentations focused on
human embryos generated by somatic cell nuclear transfer,
the epigenetics of pluripotent cells, the stimulation
a technology also known as ‘therapeutic cloning’.
protocols for cancer patients and the role of cancer stem
These findings, reported in the prestigious scientific
cells in germline cancers, and the possible risks associated
journal Cell, offer the possibility of deriving embryonicwith stem cells transplantation.
like stem cells from an adult patient; if the paper is
Considering the high level of interest that stem cells in
confirmed by independent laboratories (some minor issues
general are raising, the SIG SC has teamed up with SIGs
were found in the published data) these findings open the
Andrology, Reproductive Genetics, and the Task Force
possibility of understanding human reprogramming, and
Fertility Preservation for a new multidisciplinary Campus
the production of personalised stem cell lines without
workshop to be held later in 2014. More information will
genetic intervention.
follow in Focus on Reproduction, and on the ESHRE
Although this new technology avoids the use of IVF
website, so keep your eyes open for updated information
embryos, it still raises a series of ethical issues related to
on this outstanding learning experience.
the use of human oocytes for research, and the ethical
status of nuclear transfer-derived constructs. The Belgian
Steering committee
law on embryo research, for instance, would regard such
During the meeting in London, a few changes have come
constructs as an embryo, which would thus fall under the
about: Karen Sermon, SIG Co-ordinator since 2010, has
remit of the law.
stepped down and Rita Vassena, Scientific Director at
With such outstanding results in recent years, and the
Clinica EUGIN in Barcelona, has now taken over. Cristina
increasing investments of pharmaceutical companies in cell
Eguizabal (ES), past Junior Deputy has become Deputy.
therapy, we can say that stem cells are finally overtaking
The new junior Deputy is Filippo Zambelli (IT). There is
criticism and scepticism, with an increasing number of
now an open vacancy for the position of Deputy and three
clinical trials now ongoing around the world.
candidates have come forward for the elections: Petra
Hajkova from MRC London, a well known researcher in
Clinical applications
germ cell biology and epigenetics, Stéphane Viville from
Following this wind of change, the SIG Stem Cells is
Strasbourg, a past Co-ordinator of the SIG Reproductive
making great efforts to give visibility to the latest updates
Genetics and Björn Heindryckx from the Ghent University
in the field, and how they relate to the everyday work of
Hospital in Belgium, renowned for his research on the
reproductive scientists and physicians. The stem cell
molecular control of ESC derivation. All the members of
session in the main program of ESHRE’s annual meeting
the SIG will be shortly invited to vote and choose which
in London (Are stem cells ready for the clinic?) reflected
one will be our new Deputy.
the many novelties in the field, with a talk by Rita
Rita Vassena
Vassena detailing the incredible tool that stem cell-based
Co-ordinator SIG Stem Cells
assays are for drug discovery and disease modelling, and
Focus on Reproduction September 2013
23
sept13_nwp_50939 22/08/2013 13:03 Page 24
SPECIAL INTEREST GROUPS
// ANDROLOGY //
London reflects ‘very active’ research community
SIGA activities in London were well
precongress course programme for
Steering committee
attended. Our precongress course - Is
Munich is now finalised and is
Stefan Schlatt (DE), Co-ordinator
male fertility decreasing? The latest
titled: Treating the man with
Willem Ombelet (BE), Deputy
news suggests not… - provided a
evidence based medicine. Two
Jackson Kirkman-Brown (GB) , Deputy
wide range of interesting material
proposals for Campus workshops
Victoria Sanchez (ES), Junior Deputy
and very lively discussions on the
in 2014 have been received on
Sheena Lewis (GB), Past Co-ordinator
impact of environmental exposures.
donor sperm banking and novel
A number of sessions in the main
aspects of fertility preservation.
programme also covered a range of andrological topics,
There were several changes to the SIGA steering
including sperm factors influencing ART outcome,
committee. Sheena Lewis stepped down as Co-ordinator
regulation of sperm motility, lifestyle dangers for men’s
to become Past Co-ordinator and Stefan Schlatt the new
fertility, methods for assessment of sperm quality, and the
Co-ordinator. Willem Ombelet continues as Deputy, Lars
impact of genetics in andrology. There were also
Björndahl as SIGA education sub-committee member and
andrological angles to a number of sessions on stem cells
David Mortimer as international advisor. Jackson
and fertility preservation, including a presentation on
Kirkman-Brown will act as a new Deputy, and Victoria
advances in male fertility preservation by the new SIGA CoSanchez as new Junior Deputy.
ordinator Stefan Schlatt. Overall the representation of
The steering committee is keen to strengthen its training
research was excellent and the quality of the presented data
activities and sperm quality control programme, and
revealed a very active research community in andrology.
considered the development with other organisations
(WHO, International Society of Andrology, regional and
national societies) a curriculum for training in clinical
Steering committee
andrology and spermatology. Also discussed was a
At the SIGA business meeting outgoing Co-ordinator
registry for drugs affecting male fertility or sperm.
Sheena Lewis reported on all ongoing activities, and noted
Stefan Schlatt
room for improvement in the quality and selection of
Co-ordinator SIG Andrology
andrology abstracts submitted for the annual meeting. Our
// EARLY PREGNANCY //
Young scientists encouraged to submit abstracts for November
We are delighted to welcome Emma
Kirk from London as our new
Deputy. She will reinforce the
activities of the SIG EP. The new
steering committee is pictured
below, left to right Mariëtte
Goddijn, Siobhan Quenby, Ole B
Christiansen, Emma Kirk and
Robbert van Oppenraaij.
This year’s precongress course in
London on Risk factors for early
pregnancy loss - more pieces of the
puzzle was fully booked with nearly
200 participants, a precongress
course record for the SIGEP. The
programme covered many relevant
topics - diagnostic tools for diagnosis
of pregnancy of unknown location
(PUL), the role of lifestyle factors,
and treatment in thyroid autoim24
Steering committee
Mariëtte Goddijn (NL), Co-ordinator
Siobhan Quenby (GB), Deputy
Emma Kirk (GB), Deputy
Robbert van Oppenraaij (NL), Junior Deputy
Ole B Christiansen (DK), Past Co-ordinator
munity and recurrent miscarriage.
In November a joint Campus
meeting with the Task Force Basic
Science - From early pregnancy to
later in life - will be held in
Brussels. The concept of the
developmental origins of health and
disease attracts much attention, and
the impact of environmental and
other influences is evident in the
pre-pregnancy and early pregnancy
period. Topics to be covered are
early implantation, the prediction of
pregnancy outcome by biomarkers,
and effects from preconception. We
expect a lively debate on the
predictive value of endometrial and
embryonic markers.
Young scientists working in the
field of early pregnancy and
e
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:03 Page 25
// EMBRYOLOGY //
// PSYCHOLOGY & COUNSELLING //
Another busy agenda
New guideline progress
With a new
steering
Maria José de los Santos (ES), Co-ordinator
committee
Sophie Debrock (BE), Deputy
the SIGE
Giovanni Coticchio (IT), Deputy
has been
Susanna Apter (SE). Junior Deputy
partially
Carlos Plancha (PT), Basic science
renewed, so
Kersti Lundin (SE), Past Co-ordinator
alongside
Carlos
Plancha, our Basic Science representative and Kersti
Lundin, our Past Co-ordinator, we welcome three new
members: Susanna Apter as Junior Deputy, and Giovanni
Coticchio and Sophie Debrock as Deputies, whose
knowledge will ensure the SIGE continues efficiently.
Our aims are to promote the educational, scientific and
professional aspects of embryology by combining multiple
activities, such as workshops and precongress courses, elearning platforms, guidelines and quality control, as well
as certification of embryologists. We encourage you to visit
our new web page, with links to recommended readings,
training events, and other information.
After an extremely active precongress course in London
our next appointment is in Barcelona on 4-5th October for
a joint event with the Paramedical Group on Introducing
new techniques into the lab. Next year will bring other
exciting events, particularly our time-lapse precongress
course in Munich in which the results from ongoing RCTs
and algorithm validation studies will be presented and
discussed. In the autumn of 2014, a joint course on
epigenetics with the TF Basic Science and SIG
Reproductive Genetics will take place.
We will also keep working on our other tasks - updating
the Atlas of Embryology with new chapters – on
cryopreservation and time lapse - and hopefully with
new/improved/interactive pictures. We also expect to
review and update the ESHRE guidelines for good practice
in IVF to be beneficial to both laboratories and patients.
And last but not least our e-learning programme will be
introduced during the next few months, which will also
provide upgrade points for the certification system.
María José De los Santos
Co-ordinator SIG Embryology
Our well
Steering committee
attended
Uschi Van den Broeck (BE), Co-ordinator
precongress
Cora de Klerk (NL), Deputy
course in
Sofia Gameiro (GB),, Deputy
London was
on top quality Mariana Martins (PT), Junior Deputy
Christianne Verhaak (NL), Past Co-ordinator
psychosocial
care and the
implementation of new guidelines. Presentations included
such topics as tailored expectant management, the waiting
period, and changing lifestyles. Our new guideline on
psychosocial care, for which Sofia Gameiro chairs the
development group, was also considered in detail and will
be open for review this autumn.
The business meeting in London was also the time to
present the new steering committee, which now comprises
Uschi Van den Broeck (NL), Cora de Klerk (NL), Sofia
Gameiro (UK), and a new junior representative Mariana
Martins (PT). On behalf of the new committee, Uschi
thanked Chris Verhaak for all her hard work during her
term of office.
Next on our SIG calendar (on 14-15th March 2014) is
an ESHRE Campus symposium on Fertility preservation:
from technique to implementation in clinical practice, with
valuable multidisciplinary contributions. The course has
been jointly organised by the SIGs Ethics & Law, Safety &
Quality in Art, and the Paramedical Group. All important
aspects on the impact of cancer treatment on reproductive
funtioning will be covered, from patient information and
the decision-making process to pregnancy, from ethical and
legal issues to the experience of survivors. More detailed
information can be found on the ESHRE website.
Soon after that our precongress course will be held in
Munich. The course is titled On seeking evidence from
different perspectives: patients and professionals’ views.
We are hoping that this course will prove as popular and
rewarding as this year’s!
We are also looking forward to hearing your suggestions
- please let us know what you think our SIG could deliver
to you. We hope to see you again in Munich and Lisbon.
Mariana Martins
Junior Deputy SIG Psychology and Counselling
Steering committee
developmental origins of health and disease are
encouraged to submit an abstract for presentation during
the Young Scientist Session on 28th November. The
deadline for submission is 25th October. Four abstracts
will be selected for oral presentation, with 10 minutes
presentation and five for discussion. Some abstracts will
be selected as poster presentation. Abstracts can only be
Focus on Reproduction September 2013
submitted online. For availability of places please check
the ‘Calender’ section of the ESHRE website.
So, we hope to see you at this important Campus
meeting, and please take a look at our web page to see
what else is going on.
Mariëtte Goddijn
Co-ordinator, SIG Early Pregnancy
25
sept13_nwp_50939 22/08/2013 13:03 Page 26
IN PROFILE
continuum of women’s reproductive
health. In time a broad editorial base will
surely reflect the interdisciplinary range of
today’s reproductive medicine.
ESHRE’s review journal
Human Reproduction
Update has for several
years led the impact
factor categories of
Reproductive Biology
and Obstetrics &
Gynecology - and by a
long way. But, at a
figure of 8.857, there’s
still room for progress,
says new editor-in-chief
Felice Petraglia. He tells
Focus on Reproduction
how he hopes to take
the impact factor even
higher.
And ESHRE's core readership?
Well, we’ve already reached the top of our
core readership. You can see that in the
impact factors. In Ob/Gyn and
reproductive biology we’re at the top. But
in the other fields we’re not widely cited.
Why do the endocrine journals have more
citations - because of cardiovascular
medicine, osteoporosis . . . So what we
should declare is that Update is not only
assisted reproduction, not only infertility,
but a continuum of women’s health - from
contraception to the menopause. That’s
what I want people to know.
Uplift for Update
Editor’s prescription for a
double digit impact factor
FoR: You've almost completed your first year
as editor of the world's leading journal in
reproduction. How have you found it?
FP: It was very difficult to follow the
former editors John Collins and Bart
Fauser. They had 12 years of tremendous
success and brought Human Reproduction
Update to the very top. So my problem is
trying to improve on what they had done
already.
And has the problem been resolved?
No, but I do believe we can make some
progress by broadening the scope of the
journal. That would provide an
26
opportunity for more citations from more
journals - and of course it would extend
our readership into a broader range of
interests. This is something that Update
can realistically do, which other more
specialist journals cannot. But it won’t be
easy. There’s still a widespread belief that
Update is a journal only about IVF.
But given the past achievements of Update,
do you really think it's a good idea to
broaden its scope in this way?
In terms of readers, I think the answer is
yes. IVF doesn't exist in a vacuum, it’s
part of a much grander lifetime
And is that how you'll commission papers?
Well, the biggest change we have made is
to open submissions to everyone. So
anyone from any discipline can submit a
proposal to the journal. This has been an
important change, and we have received
more than 80 proposals during the first
six months. Yes, we have to commission,
but I also have to say that Update is open,
you don’t need an invitation.
So how will this work out? What proportion
of papers will be commissioned or offered?
I think around 60% will be openly offered
and 40% commissioned. So our priority is
not to commission but to communicate
how the journal works - that it’s open to
many clinical and scientific topics related
to reproductive health.
Update's impact factor is still very high, but
it has gone down a little from last year. Do
you see that as the start of a trend?
I said last year that my aim is to see the
impact factor in double digits, and I hope
that this is still possible. What the latest
analysis told me is that we increased the
number of papers in 2011. In the past we
were publishing 45 or so papers each year,
but in 2011 we published 65 - that’s 50%
more papers, and I’m sure that diluted the
impact of each paper.
So if you'd published fewer papers the
impact factor would not have dropped?
Exactly. So over the next few years I’d like
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:04 Page 27
to see bigger and better
reviews, but fewer of them.
More comprehensive, more
authoritative, a strong first
author - the last word, in
fact, which everyone wants
to read, download and cite.
That’s how we’ll reach an
impact factor of 10.
On a more personal note, has editing the
world's leading journal in reproduction made
a difference to your working life?
Yes, it is certainly changing. Increasingly I
feel I must check what’s happening in the
rest of the medical journals and speak to
other editors to get a feel for what’s going
on. I also like to be on the lookout for new
authors, the new young PhDs.
And this takes time?
Yes, more than I expected. It’s not just
about considering new submissions, but
looking at the broad field and thinking
how we can keep ahead. I have to be
receptive to all possibilities, to consider
topics that people are interested in.
By training and background you're an
obstetrician and gynaecologist, with a
special interest in endometriosis. Are these
the right credentials for the job?
In my early career I did a lot of work in
neuroendocrinology and stress and I’ve
followed that theme throughout my
working life - how this model of the brain,
hormones and stress can affect fertility,
pregnancy, endometriosis. I can see the
same thinking in developments in
epigenetics. So my background is varied,
but I think this variety will be helpful to
provide the link between these disciplines.
You were formerly Editor-in Chief of the
Journal of Endometriosis. How is editing
Update different?
It’s Manchester United versus Siena.
Update is the number one journal, and
most people are very happy to be involved.
Any problems about accepting the job?
It was truly a great honour. And very
unexpected, believe me. I haven’t done a
lot with ESHRE, which is why I was even
more surprised. I have in the past been
involved with the SIGs in reproductive
Focus on Reproduction September 2013
endocrinology and
endometriosis, but not much
more. So when I was invited to
edit the journal it was a great
surprise.
And Italy? Is it still difficult to be
a gynaecologist there?
The legal changes in 2004 were
difficult, and everyone working
in IVF had to adapt - but we’re
slowly moving back to where we were. I
think we adapted well and I haven’t seen
any centres fail. As in many countries,
women are going abroad for egg donation.
This is the major complaint in Italy - PGD,
embryo freezing, we’re dealing with them,
but not with egg donation. Otherwise,
medicine does well in Italy. We spend a lot
on our public health service, and there are
many public services for infertility. But we
are beginning to see consolidation of these
services, to concentrate expertise in fewer
centres. We don’t need an IVF centre every
20 kilometres.
And home?
My home is Tuscany, right in the city of
Siena. I trained there in gynaecology, but
immediately after graduating I began basic
science research in Milan, and then moved
for three years to the Salk Institute for
Biological Sciences in California. I worked
in neuroendocrinology and reproduction
before returning to Italy - and finally, after
20 years, came back to Siena as head of
Ob/Gyn.
Has editing Update taught you any more
about ESHRE?
Yes, the Society has a very broad vision in
its outlook - much more than the
American society, for example. Paramedics,
developing countries, special clinical
interests, basic science, many learning
courses - they’re all part of ESHRE.
Undoubtedly, ESHRE is now one of the
best European societies, with three top
journals and a great example how Europe
can be representative throughout the world
- as a single entity without national
borders. The Society’s aim to increase its
number of guidelines is a great opportunity
to enhance its appeal throughout the world
- and at the same time give us well cited
papers for our journals, especially Update!
The Proust questionnaire*
What's your greatest personal strength?
Self control
. . . and your greatest weakness?
Impatience
Your favourite pastime?
Reading books
If not Felice Petraglia, who else would
you be?
The Pope
What book are you reading now?
French Suite by Irène Nemirovsky
What was the last
movie you watched?
The Best Offer by
Giuseppe Tornatore
Your favourite composer
Giacomo Puccini
. . . and favourite artist?
Beato Angelico
Your favourite food?
Steak and fries
Herbal tea, or a glass of chianti?
Chianti classico riserva
Your favourite place in the world?
Tuscany
. . . and your latest holiday destination?
Boston, USA
A personal motto?
Persevere and continue
* A personal questionnaire celebrated and
originally made popular by the French
writer Marcel Proust
27
sept13_nwp_50939 22/08/2013 13:04 Page 28
FEATURE
Female obesity is
clinically challenging, and
controversial, with the
risk of subfertility far
greater in obese women
than in those of normal
weight. José Bellver from
IVI Valencia in Spain
reviews its multiple roles
in reproductive function and finds evidence of
ovulatory, endometrial
and embryonic effects.
Fertility and
female obesity
O
besity has increased sharply in both developed and developing countries
over the past decades. Recent statistics show that more than 30% of
adults and around 17% of children and adolescents in the USA are
obese, some 78 million adults and 13 million children, with a similar
distribution between male and female.1 This
is a trend apparent not only in the USA but
throughout the developed world. Moreover,
although some recent studies suggest that
levels of childhood obesity have plateau’d in
the last decade in some western countries
(USA, western Europe, Australia, Japan),
renewed increases are still anticipated over
the coming years, especially in developing
areas such as Africa.2 Such figures explain
why the prevention and control of this
pandemic have become such a worldwide
public health priority.
Conception
As a systemic disease, obesity affects every
tissue and organ of the body, inducing or
exacerbating many co-morbidities such as
cardiovascular and cerebrovascular diseases,
type 2 diabetes, sleep apnoea, gastrointestinal
diseases, osteoarthritis and cancer. The
reproductive system is similarly affected.
GETTY IMAGES
Natural conception
Different studies have shown that the risk of
sub- and infertility is almost three times
greater in obese women than in those of
normal weight. Recently, Polotsky et al
showed that adolescent obesity was related
to a four-fold increased risk of lifetime
nulligravidity (no pregnancy) and to a threefold increased risk of lifetime nulliparity (no
live birth).3 Similarly, Wise et al
demonstrated a longer time to pregnancy in
28
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:04 Page 29
overweight and obese women than in normoweight controls in an internet-based prospective
study. This effect was found to be stronger in
nulliparous than in parous women and to increase
with BMI.4
Classically, the decreased chance of conception
in obese women has been related to a higher
prevalence of ovulatory infertility. However, recent
studies have shown that even obese ovulatory
women who present with regular menses still have
a significant reduction in spontaneous conception
rates. Indeed, the cumulative pregnancy rate
within a year seems to decline by 4% for each
single unit of BMI increase over 29 (as measured
in kg/m2).5 This effect is similar to that seen with
each year of advancing maternal age. Thus, despite
the fact that ovulatory infertility is significantly
prevalent in obese women, other mechanisms
affecting the oocyte, the embryo or the uterine
environment may also be involved in their poor
reproductive outcome.
This effect seems to be even worse when both
partners are obese and share a similar lifestyle.6
Assisted conception
In some mild assisted conception treatments - such
as IUI after ovulation induction with clomiphene
citrate or gonadotropins - reduced conception
rates have been described in obese women.7,8 This
effect seems to be enhanced by the central
distribution of fat. Zaadstra et al showed in IUI
cycles with or without clomiphene citrate that, for
each 0.1 unit of increase in the waist-to-hip ratio,
the odds ratio of conception per cycle significantly
decreased by 30%.9
Similarly, higher-rank assisted conception cycles
(IVF and ICSI) have also been shown to be
affected by female BMI. In the largest published
single-centre study on the effect of female BMI on
IVF/ICSI outcome, which included 6500 cycles of
IVF and 81,581 oocytes and their corresponding
embryos, implantation, pregnancy and live birth
rates all fell with an increase in female BMI.10
Similarly, a recent meta-analysis including 33
studies and 47,967 IVF/ICSI treatment cycles
found reduced clinical pregnancy rates and live
birth rates in overweight and especially obese
women when compared with normo-weight
controls.11 Another collaborative study involving
345 US clinics and 45,163 embryo transfers also
reported a dose-response relationship between
female BMI and intrauterine gestation.12 So, the
higher the BMI, the less chance of pregnancy.
These effects may be exacerbated by obesity in
the male partner. Indeed, a recent report showed
that increased female and male BMI, both
Focus on Reproduction September 2013
independently and in combination, negatively
affected live birth rates after IVF treatment.13
However, despite a suspicion of gamete and
embryo damage induced by female or male weight
excess, no consensus has as yet been reached on
the specific alterations responsible for these
outcomes. Some authors have proposed that the
classical static morphological criteria employed in
IVF labs for gamete or embryo selection are not
useful for assessing the negative effect of obesity
on them. This is one important reason why new
means of embryo assessment such as time-lapse
analysis have been introduced in obese women although so far without success.14
Another complication associated with female
obesity is the ovary’s reduced response to
ovulation induction or controlled ovarian
hyperstimulation. A ‘gonadotropin-resistance’
syndrome was described 20 years ago and is
associated with a higher consumption of drugs,
higher cancellation rates, lower ovarian response,
and fewer oocytes and embryos available for
transfer or cryopreservation. This poor ovarian
response has also been associated with some
obesity-related metabolic disturbances, such as
insulin resistance and hyperleptinemia, whose
expensive treatments with poor results have
become an important issue, especially in public
health services.
Endometrial receptivity
The role of the endometrium in the reproductive
performance of obese women has been a matter of
debate over the past decade, mainly because of the
contradictory results from different studies using
the ovum donation model. From a clinical point of
view ovum donation is indeed the best model to
separate the effects of the oocyte or embryo from
the uterus in the assessment of any parameter of
interest, because only oocytes from healthy, young
and normo-weight donors are used. However,
Fetal/neonatal
Congenital anomalies
- Neural tube defects
- Omphalocele
- Congenital heart disease
Fetal distress
Macrosomy (>4500 g)
Hydramnios
Shoulder dystocia
Hypoglucemia
Jaundice
Postnatal
Obesity
Type 2 diabetes
Cardiovascular diseases
Metabolic syndrome
Suspected:
- Osteoporosis
- Cancer
- Neurodevelopmental delay
- Ageing
The short and long-term increased risks of maternal obesity in the offspring.
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sept13_nwp_50939 22/08/2013 13:04 Page 30
methodological problems in these studies have
hindered consensus.
This year at the ESHRE annual meeting we
described a large 12-year retrospective cohort
analysis of 9587 first cycles of ovum donation
performed in three clinics of our institution in
Spain. Only ova from normo-weight donors were
employed. Recipients included lean women with
BMI <20 kg/m2 (n = 1458; 15.2%); normo-weight
women with BMI 20-24.9 kg/m2 (n = 5706;
59.5%); overweight women with BMI 25-29.9
kg/m2 (n = 1770; 18.5%); and obese women with
BMI ≥30 kg/m2 (n = 653; 6.8%). Implantation,
pregnancy and live birth rates were all significantly
reduced as recipient BMI increased, indicating a
direct negative effect of female weight excess on
endometrial receptivity.15 We had previously
shown a dysregulation of endometrial gene
expression during the window of implantation in
obese infertile women, especially in association
with polycystic ovary syndrome, indicative of an
alteration in endometrial receptivity induced by
female obesity.16
Pregnancy
Female obesity has an impact not only on how the
pregnancy is achieved but also in how it develops.
In the first trimester of pregnancy some metaanalyses have shown an increased risk of
miscarriage in natural and assisted conceptions.
However, not all studies have observed this effect.
In addition, the main cause of first-trimester
miscarriage - chromosomal abnormalities – does
not seem to be increased in spontaneous abortions
of obese women when compared with normo-
Obesity
Natural conception
INFERTILITY
Ovulation induction
Gonadotropin
Ovarian stimulation
resistance
REDUCED PREGNANCY RATES
l Increased miscarriage rates
l Increased obstetric complications
l Reduced healthy live birth rates
The ‘bottle-neck’ effect of female obesity on conception and live birth rate.
30
JOSE BELLVER:
‘DIFFERENT STUDIES
HAVE SHOWN THAT THE
RISK OF SUB- AND
INFERTILITY IS ALMOST
THREE TIMES GREATER
THAN IN THOSE OF
NORMAL WEIGHT.’
weight controls.17 It may well be, therefore, that
an abnormal endocrine and/or metabolic
environment in which the embryo develops may
be responsible for an increased risk of miscarriage
in some specific subgroups of obese women, but
perhaps not in all of them.
An increased risk of congenital malformations
and second and third trimester obstetric
complications has also been described in obese
women after either spontaneous or assisted
conceptions. Most are an expression of the
metabolic syndrome of obesity during pregnancy
together with an underlying maternal subclinical
inflammation and vascular dysfunction.18
Complications include hypertension, gestational
diabetes, pre-eclampsia, thromboembolism, fetal
macrosomia, urinary tract infection, preterm
labour and delivery, sudden and unexplained
intrauterine death, operative vaginal deliveries,
Caesarean section delivery, shoulder dystocia,
postpartum haemorrhage, postoperative wound
infection and dehiscence and endomyometritis in
the puerperium. As a consequence, some authors
have determined a five-fold greater cost of
prenatal care in obese women than in those of
normal weight.
The combination of lower implantation and
pregnancy rates, possibly higher miscarriage rates,
and increased maternal and fetal complications
reduce the probability of a healthy live birth.
Indeed, live birth rates have been described as
significantly reduced in obese women in a doseresponse manner.12
Postnatal life
The negative influence of female obesity does not
end with the delivery of the baby. Some recent
studies have determined an increased risk of
metabolic and non-metabolic diseases during the
childhood, adolescence and adulthood of
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:04 Page 31
Strategy
Pros
Cons
Lifestyle therapy
Non-invasive
Re-education in healthy lifestyle habits
Psychological support
Proven efficacy in infertility
High abandon rate
Average time six months
Mild to moderate weight loss
Pharmacotherapy
Potential improvement in weight reduction
in association with lifestyle therapy
Little weight loss
Rapid weight regain after discontinuation
Frequent side effects
Not advised around conception
No proven benefit in fertility
Bariatric surgery
Significant weight reduction
Faster weight reduction
Long sustainable weight reduction
Reduction/elimination of co-morbidities
Improvement in quality of life
Potential improvement in fertility and
in some pregnancy complications
Invasive
High morbidity
Non-negligible mortality
5-10% failure rate
Chronic malabsorption syndrome
Controversial impact on fertility
and obstetrics
Unknown long-term effects on offspring
Waiting period before conception
Pros and cons of weight reduction strategies for obese and infertile women.
offspring of obese women. Both perinatal underand overnutrition in the mother have been related
to metabolic diseases in the postnatal life of the
descendants, probably because of epigenetic
modifications to the embryo genome - so-called
‘nutritional programming’. Indeed, several recent
reports have associated obesity in pre-pregnancy
and pregnancy with a minimum two-fold increase
in the risk of obesity, type 2 diabetes,
cardiovascular disease and metabolic syndrome in
the offspring.19 In addition, some other nonmetabolic diseases have been epidemiologically
associated with maternal obesity, which could be
related to in utero metabolic disturbances, chronic
inflammation and oxidative stress. These diseases
include breast, liver and colorectal cancer,
osteoporosis, neurodevelopmental disorders, and
ageing.
Cost implications
Wang et al recently developed a simulation model
to project the probable health and economic
consequences of the next two decades from a
continued rise in obesity in two ageing
populations - in the USA and UK – relative to
cardiovascular diseases, diabetes and cancers.
These trends project 65 million more obese adults
in the USA and 11 million more in the UK by
2030 - and, as a result, an additional 6–8.5
million cases of diabetes, 5.7–7.3 million cases of
heart disease and stroke, 492,000–669,000
additional cases of cancer, and 26–55 million
Focus on Reproduction September 2013
quality-adjusted life years lost. The combined
medical costs associated with the treatment of
these preventable diseases are estimated to increase
by $48–66 billion/year in the USA and by £1.9–2
billion/year in the UK by 2030.20
In the field of fertility, Koning et al assessed the
economic consequences of overweight and obesity
in a hypothetical cohort of 1000 women; live birth
was decreased by 14 and 15% in overweight and
obese anovulatory women, respectively, and by 22
and 24% in overweight and obese ovulatory
women, when compared to normo-weight
controls. These outcomes were also associated
with more complications, which contributed to a
cost per live birth in anovulatory overweight and
obese women 54 and 100% higher than in their
normal weight counterparts, and in ovulatory
overweight and obese women 44 and 70%
higher.21
Strategies for weight reduction
Weight reduction before natural or assisted
conception is the best isolated measure to improve
both fertility potential and pregnancy outcome in
obese women. Such a measure would also reduce
costs. Lifestyle modification, including reduced
calorie intake, adapted physical exercise and
psychological support with close monitoring from
a multidisciplinary team seems the best and most
effective way to achieve this goal.
Pharmacotherapy may cause important and
frequent side effects, with little weight loss and
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sept13_nwp_50939 22/08/2013 13:04 Page 32
rapid re-gain after discontinuation. Bariatric surgery
should be considered the last line therapy for weight
reduction in the context of reproduction. Despite the fact
that it currently constitutes the best option for a greater
and longer sustainable weight reduction, it is associated
with significant morbidity and non-negligible mortality and its effects on fertility, pregnancy and long-term
outcome in the offspring are not yet really known.
José Bellver is Associate Professor of Reproductive Medicine at
the University of Valencia and at IVI Valencia, Spain.
References
1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of
obesity in the United States, 2009-2010. NCHS Data Brief 2012;
82: 1-8.
2. Lakshman R, Elks CE, Ong KK. Childhood obesity.
Circulation 2012; 126: 1770-1779.
3. Polotsky AJ, Hailpern SM, Skurnick JH, et al. Association of
adolescent obesity and lifetime nulliparity - the Study of Women’s
Health Across the Nation (SWAN). Fertil Steril 2010; 93: 20042011.
4. Wise LA, Rothman KJ, Mikkelsen EM, et al. An internetbased prospective study of body size and time-to-pregnancy.
Hum Reprod 2010; 25: 253-2564.
5. Van der Steeg JW, Steures P, Eijkemans MJ, et al. Obesity
affects spontaneous pregnancy chances in subfertile, ovulatory
women. Hum Reprod 2008; 23: 324-328.
6. Ramlau-Hansen CH, Thulstrup AM, Nohr EA, et al.
Subfecundity in overweight and obese couples. Hum Reprod
2007; 22: 1634-1637.
7. White DM, Polson DW, Kiddy D, et al. Induction of ovulation
with low-dose gonadotropins in polycystic ovary syndrome: an
analysis of 109 pregnancies in 225 women. J Clin Endocrinol
Metab 1996; 81:3 821-824.
8. Al-Azemi M, Omu FE, Omu AE. The effect of obesity on the
outcome of infertility management in women with polycystic
ovary syndrome. Arch Gynecol Obstet 2004; 270: 205-210.
9. Zaadstra BM, Seidell JC, Van Noord PA, et al. Fat and female
fecundity: prospective study of effect of body fat distribution on
conception rates. BMJ 1993; 306: 484-4847.
10. Bellver J, Ayllón Y, Ferrando M, et al. Female obesity impairs
in vitro fertilization outcome without affecting embryo quality.
Fertil Steril 2010; 93: 447-454.
11. Rittenberg V, Seshadri S, Sunkara SK, et al. Effect of body
mass index on IVF treatment outcome: an updated systematic
review and meta-analysis. Reprod Biomed Online 2011; 23:
421-439.
12. Luke B, Brown MB, Stern JE, et al; SART Writing Group.
Female obesity adversely affects assisted reproductive
technology (ART) pregnancy and live birth rates. Hum Reprod
2011; 26: 245-252
13. Petersen GL, Schmidt L, Pinborg A, Kamper-Jorgensen M.
The influence of female and male body mass index on livebirth rates after Assisted Reproductive Technology treatment –
a nationwide register-based cohort study. Fertil Steril 2013, 99:
1654-1562.
14. Bellver J, Mifsud A, Grau N, et al. Embryos derived from
obese or normoweight infertile women do not present a
different morphokinetic pattern: a time-lapse study. Hum
Reprod 2013; 28: 794-800.
15. Bellver J, Pellicer A, García-Velasco JA, et al. Obesity and
impaired uterine receptivity: clinical experience from 9,587 first
cycles of ovum donation. Oral communication. 29th Annual
Meeting of the European Society of Human Reproduction and
Embryology (ESHRE). London 2013. Hum Reprod 2013; 28:
S1 O-175
16. Bellver J, Martínez-Conejero JA, Labarta E, et al.
Endometrial gene expression in the window of implantation is
altered in obese women especially in association with
polycystic ovary syndrome. Fertil Steril 2011; 95: 2335-2341.
17. Bellver J, Cruz F, Martínez MC, Ferro J, et al. Female
overweight is not associated with a higher embryo euploidy
rate in first trimester miscarriages karyotyped by
hysteroembryoscopy. Fertil Steril 2011; 96: 931-933
18. Catalano PM. Management of obesity in pregnancy. Obstet
Gynecol 2007; 109: 419-433.
19. Symonds ME, Sebert SP, Hyatt MA, Budge H. Nutritional
programming of the metabolic syndrome. Nat Rev Endocrinol
2009; 5: 604-610.
20. Wang YC, McPherson K, Marsh T, et al. Health and
economic burden of the projected obesity trends in the USA
and the UK. Lancet 2011; 378: 815-825.
21. Koning AM, Kuchenbecker WK, Groen H, et al. Economic
consequences of overweight and obesity in infertility: a
framework for evaluating the costs and outcomes of fertility
care. Hum Reprod Update 2010; 16: 246-254.
// TASK FORCE FERTILITY AND VIRAL DISEASES //
More evidence on sperm washing in HIV couples
A final follow-up paper on the three-step sperm washing
technique developed in Italy in 1987 has now been
published. Reproductive health clinics in Europe have since
then offered sperm washing-IUI to HIV patients, reporting
no transmission attributable to the procedure. Incomplete
follow-up, however, has been a source of uncertainty in
previous studies. Notwithstanding the existence of two large
retrospective analyses of choices and practices among
couples with HIV focusing on the efficacy of the procedure,
32
no study has previously given a definitive answer on the
safety of the sperm washing method in HIV serodiscordant couples. This study now provides such
confirmation.
Enrico Semprini
Co-ordinator Task Force Fertility and Viral Diseases
Semprini AE, Macaluso M, Hollander L, et al. Safe conception for
HIV-discordant couples: insemination with processed semen from
the HIV-infected partner. Am J Obstet Gynecol 2013; 208: 402.
Focus on Reproduction September 2013
sept13_nwp_50939 22/08/2013 13:04 Page 33
LAST WORD
Robert Edwards: the final respects
Former ESHRE Chairman Luca Gianaroli records his
own impressions from the funeral of Bob Edwards,
while Basil Tarlatzis, anothert former ESHRE
Chairman, reflects on the qualities of character on
which ESHRE and its journals were built
“
It is 25 years since I last left behind the huge lawns which
surround Bourn Hall. Back then, I was sitting in an old taxi
that was taking me to the railway station. Bob was on the
doorstep waving goodbye.
Today, I am on the back seat of an elegant sedan. But the
doorstep behind is empty, and no one is saying goodbye.
For this is also my return home from the funeral service of
Professor Robert Edwards, someone to whom I owe most
of the few things I know. It was extremely important to pay
him my last respects, both personally and on behalf of the
Society he founded almost 30 years ago.
The Chapel at Churchill College, Cambridge, where
Bob's funeral took place on 26th April, is a dramatic
modern building surrounded by lush gardens and trees.
Inside, there are many people I know, each one aware of
how important this moment is. Everyone has been allocated
a seat, each one labelled with the name of the guest. No
one is left standing.
I asked an old English friend, who formerly worked in
Bob’s lab in Cambridge, why there was a two-week wait
between Bob’s death and the funeral. Answer: there was a
long waiting-list for cremation and Bob had to wait like all
the others.
The funeral service includes many tributes from friends,
colleagues, children and grand-children. Each of them talks
of happy moments spent with Bob. There are very few tears
LUCA GIANAROLI:
‘BOB’S WORK WAS
THE CATALYST
WHICH BROUGHT
US TOGETHER - IN
SOME CASES TO BE
GOOD FRIENDS’
Focus on Reproduction September 2013
and a lot of laughter. The tributes - mostly spoken, one
played on an oboe - are interspersed with a selection of
popular and operatic music and English hymns. For this is
a service for the life of Bob Edwards, not merely a moment
of mourning.
After the service Bob is driven to Cambridge
Crematorium for his final committall. Outside the chapel,
in the sun-drenched gardens of this Spring day, friends and
colleagues stop by to exchange a word, some meeting for
the first time in many years. We talk about ourselves and
how Bob’s work was the catalyst which brought us
together - in some cases to become good friends.
Driving to the crematorium, I think about the last words
of one of the tributes . . . about something he never did
during his career. For Bob never attempted to patent any
of the techniques he developed during his career. They
were always left as discoveries freely available to everyone
. . . and I think how hard I had tried at times to patent
some instrument or some minor procedure which might at
best add no more than marginal improvement to the huge
gift that he gave so generously to all of us.
Only when the heavy green curtains of the crematorium
close behind Bob’s coffin do I finally realise that those
curtains are also closing a chapter in the life of so many
people - and in particular my own..
Before stepping down from the podium, Bob’s daughter
reminds us that at this moment there are so many other
people who are also saying goodbye to a father. And it’s
now, at this point, that I see one of Bob’s first co-workers
(now a senior figure well know for his tough lectures)
crying silently.
Later still, Bourn Hall is more charming than I ever
remember it. A wonderful English country house where
time has stopped but the miracle of life goes on day after
day. On a big screen, we see the images of Bob’s life.
Fragments pass by in front of me . . . myself 20 or 30
years ago with Bob, Alan Trounson, Jacques Cohen, Kay
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Elder, Colin Howles, Bill Walters and so many more. Now,
they are spread across the world, but today they are all
here to celebrate the life of the one man who brought us
together. What a wonderful life!
So now, in the ever buoyant atmosphere of Bourn Hall,
people talk about the future of IVF technology, about new
developments and about the young talents emerging in our
field, just as Bob would have wanted. So work as ever
invades Bourn Hall, and brings a sunny almost unreal
afternoon back down to earth.
I stop before leaving because Ruth, Bob’s wife, stares at
my surgical collar. I have recently had cervical spine
surgery, and Ruth thanks me for coming. She never
accompanied Bob to any of the scientific or social events to
which Bob was so frequently invited all over the world and
I remember the difficulties of trying to convince her to
receive Bob's Nobel prize. I promise that I will send her a
special memento of Bob that is special to me.
And only now, as the car turns to follow the sweeping
curve of the driveway and out through the Bourn Hall
gates do I sense that this chapter of my life - indeed of all
our lives - has finally closed: this is the only sad moment of
the day.
Luca Gianaroli
ESHRE Chairman 2009-2011
Scientist, visionary, mentor and friend
It has been almost 30 years since I first met Bob and I
still remember him, the evening of 17th May 1984 in
Hall B of Finlandia Hall, Helsinki, presenting his
proposals for a European society devoted to the new
field of human assisted reproduction. As always, he
was enthusiastic, passionate and convincing. After all,
that is how Bob was, irrespective of whether he was
talking about ESHRE and its journals, about science or
politics. That is what drove him and led many of us to
support him. He was a real leader. And this is what
ESHRE owes to him.
It was these same qualities, together with his
persistence, which gave him the strength to continue
his work in human IVF, despite scientific difficulties,
moral opposition and even insults. And remarkably, he
was able to describe from a very early date all possible
applications and implications of IVF - blastocyst
transfer, oocyte donation, embryo cryopreservation, in
vitro maturation, stem cells or reproductive cloning. At
the same time, he fully appreciated the ethical
implications of this new technology and he was the
first to open discussion with the public. He never
avoided this debate, always fighting for justice and
equal reproductive rights.
As a true mentor, Bob was always close not only to
his students but also to his colleagues, especially the
younger ones. He would listen carefully to their ideas,
argue with them and propose possible explanations or
alternative approaches. As the editor of the Human
Reproduction journals, he read every single paper
submitted, trying his best to identify its innovation and
value. I remember him saying that his mission was to
help young scientists, not to destroy them. I have no
doubt that this attitude played a fundamental role in
34
the phenomenal success of the journals and in their
high impact factors.
Bob was a full and unique man: a superb scientist of
the highest integrity, a visionary ready to fight for his
ideas, scientific or political, without unnecessary
compromises, and yet a humble and warm friend for
many of us, with an unforgettable full-hearted laugh.
He created a whole new scientific field of assisted
conception, which changed the life of millions of
couples and the careers of all of us, clinicians and
scientists who, inspired by him, decided to follow his
path. It gives me great pleasure that ESHRE, in
recognition of his achievements and contribution to the
Society, offered him honorary membership at the 1993
annual meeting in Thessaloniki, which was presented
by André Van Steirteghem and me. I know it meant a
lot to him and he will be remembered by all of us in
ESHRE, grateful for his vision of a European society,
and for the firm foundations he indisputably laid.
Basil C. Tarlatzis
ESHRE Chairman 1997-1999
BASIL TARLATZIS:
‘BOB WAS A FULL
AND UNIQUE
MAN, A SUPERB
SCIENTIST OF
THE HIGHEST
INTEGRITY.’
Focus on Reproduction September 2013
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The European Society of Human Reproduction and Embryology
Meerstraat 60
Grimbergen, Belgium
[email protected]
www.eshre.eu