Risk factors for poor oocyte yield and oocyte immaturity after GnRH agonist triggering

STUDY QUESTION

What are the potential risk factors for poor oocyte recuperation rate (ORR) and oocyte immaturity after GnRH agonist (GnRHa) ovulation triggering?

SUMMARY ANSWER

Lower ovarian reserve and LH levels after GnRHa triggering are risk factors of poor ORR. Higher BMI and anti-Müllerian hormone (AMH) levels are risk factors of poor oocyte maturation rate (OMR).

WHAT IS KNOWN ALREADY

The use of GnRHa to trigger ovulation is increasing. However, some patients may have a suboptimal response after GnRHa triggering. This suboptimal response can refer to any negative endpoint, such as suboptimal oocyte recovery, oocyte immaturity, or empty follicle syndrome. For some authors, a suboptimal response to GnRHa triggering refers to a suboptimal LH and/or progesterone level following triggering. Several studies have investigated a combination of demographic, clinical, and endocrine characteristics at different stages of the treatment process that may affect the efficacy of the GnRHa trigger and thus be involved in a poor endocrine response or efficiency but no consensus exists.

STUDY DESIGN, SIZE, DURATION

Bicentric retrospective cohort study between 2015 and 2021 (N = 1747).

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients aged 18-43 years who underwent controlled ovarian hyperstimulation and ovulation triggering by GnRHa alone (triptorelin 0.2 mg) for ICSI or oocyte cryopreservation were included. The ORR was defined as the ratio of the total number of retrieved oocytes to the number of follicles >12 mm on the day of triggering. The OMR was defined as the ratio of the number of mature oocytes to the number of retrieved oocytes. A logistic regression model with a backward selection method was used for the analysis of risk factors. Odds ratios (OR) are displayed with their two-sided 95% confidence interval.

MAIN RESULTS AND THE ROLE OF CHANCE

In the multivariate analysis, initial antral follicular count and LH level 12-h post-triggering were negatively associated with poor ORR (i.e. below the 10th percentile) (OR: 0.61 [95% CI: 0.42-0.88]; P = 0.008 and OR: 0.86 [95% CI: 0.76-0.97]; P = 0.02, respectively). A nonlinear relationship was found between LH level 12-h post-triggering and poor ORR, but no LH threshold was found. A total of 25.3% of patients suffered from oocyte immaturity (i.e. OMR < 75%). In the multivariate analysis, BMI and AMH levels were negatively associated with an OMR < 75% (OR: 4.34 [95% CI: 1.96-9.6]; P < 0.001 and OR: 1.22 [95% CI: 1.03-1.12]; P = 0.015, respectively). Antigonadotrophic pretreatment decreased the risk of OMR < 75% compared to no pretreatment (OR: 0.72 [95% CI: 0.57-0.91]; P = 0.02).

LIMITATIONS, REASONS FOR CAUTION

Our study is limited by its retrospective design and by the exclusion of patients who had hCG retriggers. However, this occurred in only six cycles. We were also not able to collect information on the duration of pretreatment and the duration of wash out period.

WIDER IMPLICATIONS OF THE FINDINGS

In clinical practice, to avoid poor ORR, GnRHa trigger alone should not be considered in patients with higher BMI and/or low ovarian reserve, balanced by the risk of ovarian hyperstimulation syndrome. In the case of a low 12-h post-triggering LH level, practicians must be aware of the risk of poor ORR, and hCG retriggering could be considered.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Fertility outcomes several years after urgent fertility preservation for breast cancer patients

OBJECTIVE

To study the fertility outcomes of women who tried to conceive after breast cancer treatment and fertility preservation.

DESIGN

Retrospective observational, bicentric cohort study.

SUBJECTS AND EXPOSURE

All patients who had undergone fertility preservation before breast cancer treatment between January 2013, and July 2019 were included (n=844). The end-point date was March 1, 2022. Patients with missing data on pregnancy attempts after cancer diagnosis (n=195) were excluded from the pregnancy analysis.

MAIN OUTCOME MEASURES

Cumulative incidences of pregnancy and live birth were calculated. For women who became pregnant, the time to conception was calculated between the first fertility preservation consultation and the estimated day of conception. For those who did not conceive, we considered the time between first fertility preservation consultation and the end-point date or the date of patient death. A Cox regression model was used to study the predictive factors of pregnancy and live birth.

RESULTS

Among the 649 patients with available data on pregnancy attempts after breast cancer diagnosis, 255 (39.3% [35.5-43.2]) tried to conceive (median follow-up 6.5 years). Overall, 135 (52.9% [46.6-59.2]) of these patients achieved a pregnancy, mainly through unassisted conception (79.3% [72.8-84.8]), and 99 reported a live birth (representing 38.8% of patients who attempted conception). In our cohort, 48 months after the first fertility preservation consultation, the cumulative incidence of pregnancy was 33.1% ([27.6-37.9]). After adjustment for age, parity, type of chemotherapy administration and endocrine therapy, only multiparity at diagnosis and absence of chemotherapy were positive predictive factors of pregnancy after cancer. Of the 793 patients who had vitrified oocytes/embryos, 68 used them (27% [21.3-32.5] of the patients who tried to conceive), resulting in 8 live births (11.8% [5.2-21.9]). Women who used their cryopreserved oocytes/embryos were older at the first consultation of fertility preservation (HR 1.71(1.42-2.21)), and chose more often to vitrify embryos (HR 1.76(1.28-2.23).

CONCLUSION

Although pregnancy rates after fertility preservation for breast cancer are low, most conceptions are achieved without medical assistance. Our findings provide useful information to advise women on the different techniques of fertility preservation, their efficacy and safety, as well as the relatively high chances of unassisted conception.

Is controlled ovarian stimulation safe in patients with hormone receptor-positive breast cancer receiving neoadjuvant chemotherapy?

INTRODUCTION

Controlled ovarian stimulation (COS) for oocyte/embryo cryopreservation is the method of choice for fertility preservation (FP) in young patients diagnosed with early-stage breast cancer (eBC). Nevertheless, some challenges still question its role, particularly in the neoadjuvant setting, where concerns arise about potential delay in the onset of anticancer treatment, and in hormone receptor-positive (HR+) disease, as cancer cells may proliferate under the estrogenic peak associated with stimulation. Therefore, this review aims to examine the available evidence on the safety of COS in eBC patients eligible for neoadjuvant treatment (NAT), particularly in HR+ disease.

METHODS

A comprehensive literature search was conducted to identify studies evaluating the feasibility and safety of COS in eBC and including patients referred to NAT and/or with HR+ disease. Time to NAT and survival outcomes were assessed.

RESULTS

Of the three matched cohort studies assessing the impact of COS on time to start NAT, only one reported a significant small delay in the cohort undergoing COS compared with the control group, whereas the other studies found no difference. Regarding survival outcomes, overall, no increased risk of recurrence or death was found, either in patients undergoing COS in the neoadjuvant setting regardless of HR expression or in HR+ disease regardless of the timing of COS relative to surgery. However, there are no data on the safety of COS in the specific combined scenario of HR+ disease undergoing NAT.

CONCLUSION

Neither the indication to NAT nor the HR positivity constitutes per se an a priori contraindication to COS. Shared decision making between clinicians and patients is essential to carefully weigh the risks and benefits in each individual case. Prospective studies designed to specifically investigate this issue are warranted.

Prospective multicenter observational real-world study to assess the use, efficacy and safety profile of follitropin delta during IVF/ICSI procedures (DELTA Study)

OBJECTIVE

To describe the use, efficacy and safety profile of follitropin delta in women undergoing IVF/ICSI in routine clinical practice after one treatment cycle.

STUDY DESIGN

This was a French multicenter, prospective, observational study conducted in 14 fertility centers between June 2020 and June 2021. During this period, 248 women undergoing IVF or ICSI were treated with follitropin delta for the first time. Women were followed up to 10-11 weeks after the first fresh or frozen embryo transfer. The main outcomes were use of dosing algorithm, follitropin delta dosing patterns, ovarian response, pregnancy, and adverse drug reactions in routine clinical practice.

RESULTS

The analyzable population consisted of 223 patients with mean ± SD age of 33.0 ± 4.4 years, body weight of 65.7 ± 11.8 kg, and the median (IQR) AMH level was 2.6 (1.5-4.0) ng/mL. For 193 patients (86.5 %) it was the first IVF/ICSI cycle and for 30 (13.5 %) the second. The algorithm was used for the calculation of the starting dose for 88.3 % of the patients. The mean daily starting dose of follitropin delta was 11.4 ± 4.1mcg for the whole analyzable population and 14.4 ± 5.2 mcg for the sub-group of 26 patients dosed without the algorithm. The mean duration of stimulation with follitropin delta was 10.8 ± 5.2 days. The mean total dose of follitropin delta administered was 122.2 ± 80.0 mcg. An antagonist protocol was used in 90.3 % of patients. The mean ± SD number of oocytes retrieved among patients that started stimulation was 11.3 ± 6.8 and 46.1 % of patients achieved the targeted response of the algorithm of 8-14 oocytes retrieved. A fresh transfer was performed for 77.6 % of patients; the mean ± SD number of embryos transferred was 1.3 ± 0.5. The implantation rate was 36.0 %. Per started cycle, clinical pregnancy was reported in 35.0 % of the patients and ongoing pregnancy in 29.6 %. In total, 5 patients (2.2 %) reported an event of OHSS.

CONCLUSION

Clinical results as collected in routine clinical practice are promising, showing a favorable effectiveness-safety profile of follitropin delta for a very varied patient population (including anovulatory PCOS, very poor responders, or non-IVF naïve patients). These real-world data complement results from clinical trials and provide useful information for usual clinical practice within a heterogeneous population group.

Dysfunction of Human Estrogen Signaling as a Novel Molecular Signature of Polycystic Ovary Syndrome

Estradiol (E2) is a major hormone-controlling folliculogenesis whose dysfunction may participate in polycystic ovary syndrome (PCOS) infertility. To determine whether both the concentration and action of E2 could be impaired in non-hyperandrogenic overweight PCOS women, we isolated granulosa cells (GCs) and follicular fluid (FF) from follicles of women undergoing ovarian stimulation (27 with PCOS, and 54 without PCOS). An analysis of the transcript abundance of 16 genes in GCs showed that androgen and progesterone receptor expressions were significantly increased in GCs of PCOS (by 2.7-fold and 1.5-fold, respectively), while those of the steroidogenic enzymes CYP11A1 and HSD3B2 were down-regulated (by 56% and 38%, respectively). Remarkably, treatment of GC cultures with E2 revealed its ineffectiveness in regulating the expression of several key endocrine genes (e.g., GREB1 or BCL2) in PCOS. Additionally, a comparison of the steroid concentrations (measured by GC/MS) in GCs with those in FF of matched follicles demonstrated that the significant decline in the E2 concentration (by 23%) in PCOS FF was not the result of the E2 biosynthesis reduction. Overall, our study provides novel hallmarks of PCOS by highlighting the ineffective E2 signaling in GCs as well as the dysregulation in the expression of genes involved in follicular growth, which may contribute to aberrant folliculogenesis in non-hyperandrogenic women with PCOS.

The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization

PURPOSE

To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other.

RESULTS

A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus).

CONCLUSION

These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

Using serum anti-Müllerian hormone levels to predict the chance of live birth after spontaneous or assisted conception: a systematic review and meta-analysis

STUDY QUESTION

Is serum anti-Müllerian hormone (AMH) level predictive of cumulative live birth (CLB) rate after ART or in women trying to conceive naturally?

SUMMARY ANSWER

Serum AMH level is linked to CLB after IVF/ICSI but data are lacking after IUI or in women trying to conceive without ART.

WHAT IS KNOWN ALREADY

Serum AMH level is a marker of ovarian reserve and a good predictor of ovarian response after controlled ovarian stimulation. It is unclear whether AMH measurement can predict CLB in spontaneous or assisted conception.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis was undertaken to assess whether serum AMH level may predict chances of CLB in infertile women undergoing IVF/ICSI or IUI and/or chances of live birth in women having conceived naturally.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A systematic review and meta-analysis was performed using the following keywords: 'AMH', 'anti-mullerian hormone', 'live-birth', 'cumulative live birth'. Searches were conducted from January 2004 to April 2021 on PubMed and Embase. Two independent reviewers carried out study selection, quality, and risk of bias assessment as well as data extraction. Odds ratios were estimated using a random-effect model. Pre-specified sensitivity analyses and subgroup analyses were performed. The primary outcome was CLB.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 32 studies were included in the meta-analysis. Overall, 27 articles were included in the meta-analysis of the relation between AMH and CLB or AMH and LB after IVF/ICSI. A non-linear positive relation was found in both cases. A polynomial fraction was the best model to describe it but no discriminant AMH threshold was shown, especially no serum AMH level threshold below which live birth could not be achieved after IVF/ICSI. After IVF-ICSI, only four studies reported CLB rate according to AMH level. No statistically significant differences in mean serum AMH levels were shown between patients with and without CLB, but with a high heterogeneity. After exclusion of two studies with high risks of bias, there was no more heterogeneity [I2 = 0%] and the mean AMH level was statistically significantly higher in women with CLB. There were not enough articles/data to assess the ability of AMH to predict CLB rate or find an AMH threshold after IUI or in women without history of infertility trying to conceive without ART.

LIMITATIONS, REASONS FOR CAUTION

The systematic review and meta-analysis had some limitations owing to the limits and bias of the studies included. In the present meta-analysis, heterogeneity may have been caused by different baseline characteristics in study participants, different stimulating protocols for ART, different serum AMH level thresholds used and the use of various assays for serum AMH. This could explain, in part, the absence of a discriminating AMH threshold found in this analysis.

WIDER IMPLICATIONS OF THE FINDINGS

Serum AMH level is linked to CLB rate after IVF/ICSI but no discriminating threshold can be established, therefore low serum AMH level should not be used as the sole criterion for rejecting IVF treatment, especially in young patients. Data are lacking concerning its predictive value after IUI or in women trying to conceive without ART. Our findings may be helpful to counsel candidate couples to IVF-ICSI.

STUDY FUNDING/COMPETING INTERESTS

No external funding was obtained for this study. There are no conflicts of interest.

REGISTRATION NUMBER

PROSPERO CRD42021269332.

Comparative effectiveness of gonadotropins used for ovarian stimulation during assisted reproductive technologies (ART) in France: A real-world observational study from the French nationwide claims database (SNDS)

This comparative non-interventional study using data from the French National Health Database (Système National des Données de Santé) investigated real-world (cumulative) live birth outcomes following ovarian stimulation, leading to oocyte pickup with either originator recombinant human follicle-stimulating hormone (r-hFSH) products (alfa or beta), r-hFSH alfa biosimilars, or urinaries including mainly HP-hMG (menotropins), and marginally u-hFSH-HP (urofollitropin). Using data from 245,534 stimulations (153,600 women), biosimilars resulted in a 19% lower live birth (adjusted odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.86) and a 14% lower cumulative live birth (adjusted hazard ratio (HR) 0.86, 95% CI 0.82-0.89); and urinaries resulted in a 7% lower live birth (adjusted OR 0.93, 95% CI 0.90-0.96) and an 11% lower cumulative live birth (adjusted HR 0.89, 95% CI 0.87-0.91) versus originator r-hFSH alfa. Results were consistent across strata (age and ART strategy), sensitivity analysis using propensity score matching, and with r-hFSH alfa and beta as the reference group.

The follicular output rate in normo-ovulating women undergoing ovarian stimulation is increased after unilateral oophorectomy

STUDY QUESTION

Does unilateral oophorectomy modify the antral follicular responsiveness to exogenous FSH, assessed by the Follicular Output RaTe (FORT) in normo-ovulating women?

SUMMARY ANSWER

Antral follicle responsiveness to exogenous FSH, as assessed by the FORT index, is significantly higher in women with a single ovary in comparison with the ipsilateral ovary of age-matched controls.

WHAT IS KNOWN ALREADY

Growing evidence indicates that the innovative FORT may be a remarkable tool to evaluate the follicle responsiveness to exogenous FSH, independently of the size of the pretreatment cohort of small antral follicles. It is conceivable that in the unclear compensating mechanisms at play in women having undergone unilateral oophorectomy, an increase in the sensitivity of antral follicles to FSH may be involved. To clarify this issue, we decided to investigate whether the responsiveness of follicles to exogenous FSH, as assessed by the FORT, is altered in unilaterally oophorectomized patients.

STUDY DESIGN, SIZE, DURATION

The study included 344 non-polycystic ovary syndrome, non-endometriotic women, aged 22-43 years old. There were 86 women who had a single ovary as a result of unilateral oophorectomy or adnexectomy (Single Ovary group; average time since surgery: 52 (8-156) months), and each of them was retrospectively matched with three patients having two intact ovaries, according to age (±1 year), year of ovarian stimulation, and FSH starting dose (±50 IU) (Control group, n = 258).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serum anti-Mullerian hormone (AMH) levels and total antral follicle count (AFC) (3-12 mm) were assessed on cycle day 3 in both groups. In all patients, follicles were counted before exogenous FSH administration (baseline) and on the day of oocyte trigger (OT) (dOT; preovulatory follicles; 16-22 mm). Antral follicle responsiveness to FSH was estimated in both groups by the FORT, determined by the ratio of the preovulatory follicle count on dOT × 100 to the small AFC at baseline. FORT in the Single Ovary group was compared to the overall FORT considering both ovaries or the index calculated on the ipsilateral ovary of matched controls.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, serum AMH levels and total AFC (1.0 (0.5-2.1) vs 1.8 (1.0-3.3), P < 0.005) and (9.0 (6.0-17.0) vs 13.0 (8.0-21.0), P < 0.001, respectively) were lower in the Single Ovary group compared to the Control group. When considering the FORT calculated on the basis of the overall ovarian response in women with two ovaries, the results were similar when compared to those obtained in patients unilaterally oophorectomized (30.4% (15.6-50.0) vs 32.5% (14.0-50.0), respectively). Interestingly, the comparison of FORT between women with a single ovary and the ipsilateral ovary of age-matched controls, revealed, after adjustment for AMH and AFC, a significantly higher ratio after unilateral oophorectomy (32.5% (14.8-50.0) vs 25.0% (10.0-50.0), P < 0.002, respectively).

LIMITATIONS, REASONS FOR CAUTION

This study was based on retrospective data in a limited population. In addition, the FORT index has inherent limitations due to its indirect assessment of follicular responsiveness to FSH.

WIDER IMPLICATIONS OF THE FINDINGS

The present investigation provides evidence that the responsiveness of antral follicles to exogenous FSH is increased in women having undergone unilateral oophorectomy when compared to the ipsilateral ovary of age-matched controls. This is consistent with the implication of a compensating phenomenon that drives the follicular changes in unilaterally oophorectomized patients. Further studies directly assessing the granulosa cell function and the density of FSH receptors in small antral follicles are required to confirm our findings.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no funding or competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Oocyte vitrification for fertility preservation following COS does not delay the initiation of neoadjuvant chemotherapy for breast cancer compared to IVM

PURPOSE

The objective of the present study was to evaluate whether oocyte vitrification following controlled ovarian stimulation (COS) for fertility preservation (FP) delays the initiation of neoadjuvant chemotherapy (NAC) for breast cancer (BC) as compared to in vitro maturation (IVM).

METHODS

We performed a retrospective cohort study including all BC patients eligible for oocyte vitrification following COS or in vitro maturation (IVM) before initiation of NAC between January 2016 and December 2020. The inclusion criteria were female patients aged between 18 and 40, with confirmed non metastatic BC, with indication of NAC, who have had oocyte retrieval for FP after COS, or IVM + / - cryopreservation of ovarian tissue (OTC). Various time points related to cancer diagnosis, FP, or chemotherapy were obtained from a medical record review.

RESULTS

A total of 197 patients with confirmed BC who had oocyte retrieval following COS (n = 57) or IVM + / - OTC (n = 140) for FP prior to NAC were included. Overall, the average time from cancer diagnosis to chemotherapy start was similar between patients having undergone COS or IVM before oocyte vitrification (37.3 ± 13.8 vs. 36. 8 ± 13.5 days; p = 0.89).

CONCLUSIONS

The indication of NAC for BC should not be considered as an impediment to urgent COS for oocyte vitrification for FP.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma

Background: The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment. Objectives: To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma. Materials and Methods: ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. Results: The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues. Conclusions: These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma

Background

The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment.

Objectives

To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma.

Materials and Methods

ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives.

Results

The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues.

Conclusions

These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

First-line surgery vs first-line ART to manage infertility in women with deep endometriosis without bowel involvement: A multi-centric propensity-score matching comparison

OBJECTIVE

To compare first-line surgery with first-line assisted reproductive techniques (ART) in infertile women with deep infiltrating endometriosis (DIE) without colorectal involvement.

STUDY DESIGN

A retrospective comparative cohort study with a propensity-score matching analysis, in four tertiary-care referral centers. The population was infertile women with DIE without colorectal involvement. The patients were managed either by first-line surgery followed by spontaneous conception attempts and/or ART, or by first-line ART. 284 patients were extracted from the databases. After matching, 92 patients were compared in each group. Clinical pregnancy rates (PR) and live-birth rates (LBR) were the primary outcomes, and cumulative pregnancy rate (CPR) and cumulative live birth rate (CLBR) were the secondary outcomes.

RESULTS

The mean number of IVF-ICSI cycles per patient was 1.4, with a significant difference between the groups: 1.6 in the first-line ART group and 1.2 in the first-line surgery group (p = 0.006). The PR was significantly higher in the first-line surgery group (72 % vs 35 %; p < 0.001). In the first-line surgery group, non-ART pregnancies occurred in 18 % (17/92) while no non-ART pregnancies was noted in the first-line ART group. The LBR was significantly higher in the first-line surgery group (61 % vs 24 %; p < 0.001). After ART, the CPR were 72 % (47/67) in the first-line surgery group, and 35 % (32/92) in the first-line ART group (p < 0.001).

CONCLUSION

After matching, our results support that first-line surgery offer higher pregnancy and live-birth rates than first-line ART in patients with DIE without colorectal involvement.

What should be done in terms of fertility preservation for patients with cancer? The French 2021 guidelines

AIM

To provide practice guidelines about fertility preservation (FP) in oncology.

METHODS

We selected 400 articles after a PubMed review of the literature (1987-2019).

RECOMMENDATIONS

Any child, adolescent and adult of reproductive age should be informed about the risk of treatment gonadotoxicity. In women, systematically proposed FP counselling between 15 and 38 years of age in case of treatment including bifunctional alkylating agents, above 6 g/m2 cyclophosphamide equivalent dose (CED), and for radiation doses on the ovaries ≥3 Gy. For postmenarchal patients, oocyte cryopreservation after ovarian stimulation is the first-line FP technique. Ovarian tissue cryopreservation should be discussed as a first-line approach in case of treatment with a high gonadotoxic risk, when chemotherapy has already started and in urgent cases. Ovarian transposition is to be discussed prior to pelvic radiotherapy involving a high risk of premature ovarian failure. For prepubertal girls, ovarian tissue cryopreservation should be proposed in the case of treatment with a high gonadotoxic risk. In pubertal males, sperm cryopreservation must be systematically offered to any male who is to undergo cancer treatment, regardless of toxicity. Testicular tissue cryopreservation must be proposed in males unable to cryopreserve sperm who are to undergo a treatment with intermediate or severe risk of gonadotoxicity. In prepubertal boys, testicular tissue preservation is: - recommended for chemotherapy with a CED ≥7500 mg/m2 or radiotherapy ≥3 Gy on both testicles. - proposed for chemotherapy with a CED ≥5.000 mg/m2 or radiotherapy ≥2 Gy. If several possible strategies, the ultimate choice is made by the patient.

P-625 In vitro maturation of oocytes: a breakthrough for treating infertility in inactivating mutation of the luteinizing hormone/choriogonadotropin receptor

Study question

How can pregnancy and live birth be achieved in patients with inactivating homozygous luteinizing hormone/choriogonadotropin receptor (LHCGR) mutation?

Summary answer

We report the first live birth after in vitro maturation (IVM) in a patient with a novel homozygous inactivating LHCGR mutation (exon 6, c.470 A&gt;G).

What is known already

LH plays a fundamental role in female reproductive physiology and is responsible for steroidogenesis, oocyte maturation, ovulation and subsequent progesterone production by the corpus luteum. LH binds to the LHCGR located on the membrane of theca cells and mature granulosa cells. Inactivating mutations of the LHCGR lead to the impossibility to obtain final oocyte maturation both during natural cycles and after ovarian stimulation for in vitro fertilization purposes. Therefore, egg donation represents the only option for treating their infertility.

Study design, size, duration

A case report.

Participants/materials, setting, methods

A 35 year-old nulliparous patient referred to our university hospital for primary infertility.

Main results and the role of chance

The 35-year-old nulliparous patient presented with primary spaniomenorrhea but timely and spontaneous onset of secondary sexual characteristics. Serum LH levels were high (ranging from 15 to 30 IU/L) and to a lesser extent so were FSH levels. The ovarian reserve was normal for age, as assessed by serum AMH levels and ultrasound. There was no argument for polycystic ovarian syndrome, 21-hydroxylase deficiency, Cushing’s syndrome or hyperprolactinemia. Two previous attempts of controlled ovarian stimulation with gonadotropins and ovulation trigger with hCG and GnRH-agonist trigger had failed, resulting in low estradiol levels despite correct follicular growth on ultrasound and absence of ovulation after trigger. However, genetic analysis identified a novel homozygous inactivating LHCGR mutation (exon 6, c.470A&gt;G) which had never been described previously. IVM was performed. A total of 7 oocytes were obtained after IVM, resulting in 4 Day 3 embryos. All embryos were frozen. Subsequently, 2 Day 3 embryos were replaced after endometrial preparation by hormone replacement therapy. The patient became pregnant and gave birth to a healthy baby. Two Day 3 embryos remain.

Limitations, reasons for caution

By definition, a case-report requires further studies to confirm our findings.

Wider implications of the findings

We describe a novel inactivating LHCGR mutation with subsequent live birth after IVM. As a growing number of gonadotropin receptor mutations are identified, this successfully achieved live birth places IVM as the only reliable option for these patients to conceive with their own eggs.

Trial registration number

Not applicable.

P-254 Is Intelligent Data Analysis-score (IDA-score) a useful tool in daily routine IVF laboratory practice to select embryos? Preliminary results of an external independent series

Study question

Is IDA-score a useful tool to accurately classify embryos?

Summary answer

IDA-score is a reliable tool to categorize embryos into top/good/poor morphological quality. However, hierarchical classification of embryos between IDA-score and embryologists was significantly different.

What is known already

Since Preimplantation Genetic Test for aneuploidy is not authorized in France, morphological scoring by embryologists is the only way to select blastocysts for transfer at Day-5. However, morphological scoring cannot perfectly predict implantation likelihood. Promising recent artificial intelligence techniques might improve both hierarchical classification and clinical outcomes. For instance, IDA-score combined with Embryoscope (Vitrolife®) has been suggested as a way to objectively compare a given embryo to a large embryo dataset and generate a score that predicts the likelihood of implantation using a deep-learning approach. So far, no external independent analysis compares the accuracy of this score with human performance.

Study design, size, duration

This retrospective-monocentric-study was performed in our reproductive medicine unit from September to December 2021. A total of 167 embryos from 58 couples undergoing ICSI were monitored on a daily-basis and scored at Day-5 by IDA-score and morphological scoring by a panel of senior-embryologists blinded from results of IDA-score. In all, 52 single embryos selected by embryologists were transferred during fresh or frozen cycles. Clinical pregnancy rates were defined by presence of fetal heartbeat on ultrasound.

Participants/materials, setting, methods

Each embryo was monitored and scored at Day-5 by both morphological scoring and IDA-score. Only the best 3 embryos were ranked and compared. Morphological score was based on Gardner-and-Schoolcraft grading system and classified according to morphological score as top-quality (≥B4BB), good-quality (≥B3BB) and poor-quality (&lt;B3BB;trophectoderm/inner-cell-mass:CC) embryos. IDA-scores were ranged from 1-10. We compared hierarchical classification by IDA-score and embryologists using appropriate statistical tests and IDA-scores of transferred blastocysts with successful implantation and those without.

Main results and the role of chance

The mean age of women was 33.96±0.66 years. Morphological scoring led to 68.8% (115/167) top quality embryos, 80.2% (134/167) good quality embryos and 19.8% (33/167) poor quality embryos. Mean IDA-scores of embryos were respectively 9.06 ± 0.48 for top-quality, 8.72 ± 0.62 for good-quality and 7.12 ± 1.34 for poor-quality blastocysts (global p  &lt;10-4). However, concerning hierarchical classification, there was a significant lack of global accuracy between IDA-scores and embryologists regarding the 3 best embryos of the cohort (68.3%; p  &lt;10-4). Similarly, there was a significant lack of accuracy to classify embryos belonging to the same quality group (67.8% (78/115) for top-quality; 64.9% (87/134) for good-quality; 81.8% (27/33) for poor-quality). We obtained a clinical pregnancy rate of 38.4% (20/52) per transfer. We failed to observe any statistically significant difference between embryos transferred that implanted (8.92 ± 0.79) and embryos that did not implant (8.69 ± 0.93; p = 0.37) according to IDA-scores. However, IDA-scores tended to be higher in case of clinical pregnancy. In order for the observed difference of 0.2 in IDA-scores to reach the level of significance, at least 674 embryos should be transferred.

Limitations, reasons for caution

These results should be interpreted with caution due to the retrospective design of the study and small effectives.

Wider implications of the findings

We present preliminary results of an external independent series to confirm the efficiency of IDA-score in daily routine practice. Since IDA-score is not consistent with human scoring concerning hierarchical classification, its performance has to be further assessed to clearly establish the input of artificial intelligence in IVF laboratory practice.

Trial registration number

not applicable

P-276 Embryo development of fresh versus vitrified metaphase II oocytes in low prognosis patients: a retrospective sibling-oocyte monocentric study

Study question

Do fresh and vitrified/warmed oocytes have the same developmental potential in low prognosis patients defined by POSEIDON criteria?

Summary answer

Embryos derived from vitrified/warmed oocytes show lower competence for embryo development when compared to those obtained from fresh oocytes in low prognosis patients.

What is known already

The strategy of oocyte accumulation has been proposed for the management of low-prognosis patients with the aim to increase the number of oocytes available for fertilization and further the number of embryos.

The effect of oocyte vitrification/warming on the embryo developmental potential has mainly been studied in oocyte donation programs. Investigations on sibling-oocyte failed to show difference in the morphological embryo development, but the evaluation stopped after 2-3 days of embryo culture. In addition, morphokinetic evaluation revealed delayed development of embryos derived from vitrified oocytes, from the first cleavage to the time of blastulation.

Study design, size, duration

Single-center sibling-oocyte retrospective monocentric study including low-prognosis patients, defined by POSEIDON criteria, who had undergone an accumulation of oocyte strategy for managing their infertility, between November 2013 and January 2021. Only patients presenting fresh and vitrified/warmed oocytes at the time of insemination were analyzed for the sibling-oocyte comparison. Main study outcomes were fertilization, cleavage, blastulation rates, day-2 and day-5 embryo quality, and the rate of embryos available for transfer/cryopreservation.

Participants/materials, setting, methods

Forty-five patients were included, with a mean age of 34.8 ± 3.4 years. Oocyte vitrification/warming was performed using the Cryotop method. Top-quality and good-quality embryos were defined at day-2 respectively as 4 and 3-5 adequate-sized blastomeres, without multinucleation and containing &lt;20% of cytoplasmic fragmentation, and at day-5 according to Gardner and Schoolcraft’s classification, top ≥B4 (AB/BA/AA) and good ≥ B3BB. Statistical analyses used mixed effects logistic regression to take into account the sibling-oocyte design.

Main results and the role of chance

A total of 656 oocytes were inseminated, 225 fresh and 431 vitrified/warmed oocytes. The oocyte survival rate after warming was 82%, 95%CI [76-87%]. There was no difference between fresh and vitrified/warmed oocytes groups regarding the degeneration rate following ICSI (5.0% vs 4.8% respectively, p = 0.95), the fertilization rate (74.6% vs 71.4% respectively, p = 0.42) or the cleavage rate on day-2 (98.3% vs 95.4% respectively, p = 0.15). However, the embryo development was significantly different from day 2, with higher day 2 top-quality and good-quality embryos rates in the fresh oocytes group when compared to the vitrified/warmed oocytes group (top-quality: 38.3% vs 24.8% respectively, p = 0.01; good-quality 58.0% vs 45.2% respectively, p = 0.02). The same results were observed on blastocysts when extended culture was decided, with a higher blastulation rate in the fresh oocyte group (56.7% vs 31.7% respectively, p &lt; 0.001) and higher top-quality and good-quality day 5 blastocyst rate (top-quality: 23.4% vs 5.6% respectively, p = 0.01; good-quality 23.9% vs 7.9%, p = 0.01).The rate of embryos available for transfer/cryostorage was similar in both groups (40,7 % vs 38,8 %, p = 0,71). The cumulative live-birth rate was 33,3% (4/45 from vitrified oocytes group, 5/45 from fresh oocytes group, 6/45 from mixed oocytes group).

Limitations, reasons for caution

The retrospective nature of the study, on a limited number of limited number of patients represents an inherent limitation. Embryo assessment was subjective, the evaluator knowing the oocyte’s source group. The impact of the morphological alterations observed in embryos derived from vitrified/warmed oocytes need to be confirmed with clinical outcomes.

Wider implications of the findings

The majority of studies comparing fresh and vitrified/warmed oocytes were performed in egg-donation programs. This study focuses on low-prognosis patients, who reflect perhaps more the patients who consult in ART centers. Further prospective studies are needed to confirm our findings.

Trial registration number

Not applicable

P-553 Response to controlled ovarian stimulation and preimplantation genetic testing for molecular disease (PGT-M) outcomes for Myotonic dystrophy type I (DM1) : A French multicentric study

Study question

Does ovarian response to controlled ovarian hyperstimulation (COH) is altered in female affected by DM1 ?

Summary answer

Ovarian response to COH is not altered in female affected by DM1 as compared to partners of affected males

What is known already

Myotonic dystrophy type 1 is the most common adult muscular dystrophy caused by a CTG trinucleotide repeat expansion which may expand across generation. As this pathology presents an autosomal dominant inheritance, PGT may be an option to achieve a pregnancy with healthy baby. There are conflicting reports about response to COH for affected female. Moreover, few data are available concerning the chance to have a healthy baby after PGT for couple with one member affected by DM1

Study design, size, duration

The present study is a retrospective observational study carried out from January 2006 through January 2020. This multicentric study was conducted in all the five centers performing PGT-M in France.

Participants/materials, setting, methods

A total of 229 couples started at least one COH cycle for the PGT procedure. The patient carrying the mutation was the female for 178 couples and the male for the 51 others. Overall, 648 COH cycles started and 560 oocytes retrieval for subsequent PGT were performed (430 for affected female and 130 for affected male). Parameters of ovarian response and PGT outcomes were compared according to the member affected by DM1.

Main results and the role of chance

Age and BMI at the first COH cycle were not significantly different between both group but female carried mutation presented lower AMH level than partner of affected male. The starting and total doses of gonadotrophin were significantly higher for mutated females. The number of retrieved and mature oocytes per cycle were not statistically different (12 [8–16] versus 11 [8–16] retrieved oocytes, p = 0.63 and 9 [6–13] versus 9 [6-13] mature oocytes, p = 0.73, respectively). In both group, more than 70% of oocyte retrieval led to embryo biopsy.

The proportion of started cycle allowing the obtention of at least one healthy embryo was significantly lower when the female was affected with DM1 (58.6% vs 70.4%, p = 0.012). In the female affected group, 49.7% of the cycles with oocytes retrieval lead to a fresh embryo transfer and a subsequent live birth rate per transfer of 21.4%. These results were not statistically different from the couple with affected male (58.5% of cycles with fresh embryo transfer (p = 0.08) and 23.6% live birth rate per transfer).

Overall, after fresh or frozen embryo transfer, 30.8% of females with DM1and 41.2% of parter of affected males had at least one live birth from PGT.

Limitations, reasons for caution

This a retrospective study included patients who were selected ovarian reserve parameters before PGT process. Moreover, the large time of inclusion may influence our conclusion.

Wider implications of the findings

Information provided herein extends knowledge about the current state of COH for DM1 affected female. Moreover, PGT results presented here allow to provide patients with proposer counseling before starting PGT process.

Trial registration number

CEROG-2020-GYN-0603

O-195 Disease-free survival is not impacted by fertility preservation techniques for breast cancer women

Study question

Do fertility preservation (FP) strategies using ovarian stimulation or not, impact long-term disease-free survival of breast cancer (BC) patients?

Summary answer

The disease-free survival of BC patients is not impacted by FP techniques whatever the timing of chemotherapy (neoadjuvant /adjuvant) and the use of ovarian stimulation.  

What is known already

Fertility is often impaired in young women treated for BC. Therefore, FP has become a major issue in this population. Cryopreservation of oocytes or embryos after controlled ovarian hyperstimulation (COH) represents the most established method in this clinical situation. However, the hormonal consequences of COH protocols still raise safety concerns, often leading oncologists to contraindicate the use of this FP technique. Although alternative FP options without exogenous hormone administration may be considered, they remain suboptimal for treating the putative future infertility.

Study design, size, duration

Retrospective bicentric cohort study including including 740 BC women, 18-43 years of age, referred for FP between 2013 and 2019.

Participants/materials, setting, methods

Overall, 328 underwent at least one ovarian stimulation cycle (STIM group) and 412 had a technique without hormonal administration (No STIM group). Log Rank test was used to compare both groups and Cox proportional-hazard model was applied for multivariable analyses.

Main results and the role of chance

Women of the No STIM group were significantly younger and present with more severe disease. Follow-up data for recurrences were available for 80.9% of the cohort and the median time to follow-up was 4.2 [2.9-5.8] vs. 5.6 [4.1-6.7] years between STIM and No STIM group (p &lt; 0.0001). According to log-rank test, the risk of recurrence did not differ between the two groups (p = 0.09) even after adjustment on age, SBR grade, triple negative status or type of planned chemotherapy.

Limitations, reasons for caution

The retrospective nature of the study represents the main limitation. The median follow-up of 4.2 to 5.6 years, might be considered short to assess the long-term safety of FP techniques. The heterogeneity between oncological centers regarding the use of COH and specific protocols may lalso be a reason for caution.

Wider implications of the findings

Our findings provide reassuring safety data on the use COH for FP in BC patients, whatever the timing of chemotherapy. However, further investigations with a longer follow-up are needed to definitely consider COH safe in particular in neoadjuvant situations. In addition, the benefit of letrozole supplementation during COH requires confirmation.

Trial registration number

Not applicable

Oncologic results of fertility sparing surgery of cervical cancer: An updated systematic review

BACKGROUND

Several techniques can be proposed as fertility sparing surgery in young patients treated for cervical cancer but uncertaincies remain concerning their outcomes. Analysis of oncological issues is then the first aim of this review in order to evaluate the best strategy.

RESULTS

Data were identified from searches of MEDLINE, Current Contents, PubMed and from references in relevant articles from January 1987 to 15th of September 2021. We carry out an updated systematic review involving 5862 patients initially selected for fertility-sparing surgery in 275 series.

FINDINGS

In patients having a stage IB1 disease, recurrence rate/RR in patients undergoing simple conisation/trachelectomy, radical trachelectomy/RT by laparoscopico-vaginal approach, laparotomic or laparoscopic approaches are respectively: 4.1%, 4.7%, 2.4% and 5.2%. In patients having a stage IB2 disease, RR after neoadjuvant chemotherapy or RT by laparotomy are respectively 13.2% and 4.8% (p = .0035). After neoadjuvant treatment a simple cone/trachelectomy was carried out in 91 (30%) patients and a radical one in 210 (70%) cases. But the lowest pregnancy rate is observed in patients undergoing RT by laparotomy (36%).

CONCLUSIONS

The choice between these treatments should be based above all, on objective oncological data that strike a balance for each procedure between the best chances for cure and the fertility results. In patients having a stage IB1 disease, oncological results are quite similar according to the procedure used. In patients having a stage IB2 disease, RT by open approach has the lowest RR. Anyway the lowest pregnancy rate is observed in patients undergoing RT by laparotomy.

What is the threshold of mature oocytes to obtain at least one healthy transferable cleavage-stage embryo after preimplantation genetic testing for fragile X syndrome?

STUDY QUESTION

What are the chances of obtaining a healthy transferable cleavage-stage embryo according to the number of mature oocytes in fragile X mental retardation 1 (FMR1)-mutated or premutated females undergoing preimplantation genetic testing (PGT)?

SUMMARY ANSWER

In our population, a cycle with seven or more mature oocytes has an 83% chance of obtaining one or more healthy embryos.

WHAT IS KNOWN ALREADY

PGT may be an option to achieve a pregnancy with a healthy baby for FMR1 mutation carriers. In addition, FMR1 premutation is associated with a higher risk of diminished ovarian reserve and premature ovarian failure. The number of metaphase II (MII) oocytes needed to allow the transfer of a healthy embryo following PGT has never been investigated.

STUDY DESIGN, SIZE, DURATION

The study is a monocentric retrospective observational study carried out from January 2006 to January 2020 that is associated with a case-control study and that analyzes 38 FMR1 mutation female carriers who are candidates for PGT; 16 carried the FMR1 premutation and 22 had the full FMR1 mutation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 95 controlled ovarian stimulation (COS) cycles for PGT for fragile X syndrome were analyzed, 49 in premutated patients and 46 in fully mutated women. Only patients aged ≤38 years with anti-Müllerian hormone (AMH) >1 ng/ml and antral follicle count (AFC) >10 follicles were eligible for the PGT procedure. Each COS cycle of the FMR1-PGT group was matched with the COS cycles of partners of males carrying any type of translocation (ratio 1:3). Conditional logistic regression was performed to compare the COS outcomes. We then estimated the number of mature oocytes needed to obtain at least one healthy embryo after PGT using receiver operating characteristic curve analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, in the FMR1-PGT group, the median number of retrieved and mature oocytes per cycle was 11 (interquartile range 7-15) and 9 (6-12), respectively. The COS outcomes of FMR1 premutation or full mutation female carriers were not altered compared with the matched COS cycles in partners of males carrying a balanced translocation in their karyotype. Among the 6 (4-10) Day 3 embryos obtained in the FMR1-PGT group, a median number of 3 (1-6) embryos were morphologically eligible for biopsy, leading to 1 (1-3) healthy embryo. A cutoff value of seven MII oocytes yielded a sensitivity of 82% and a specificity of 61% of having at least one healthy embryo, whereas a cutoff value of 10 MII oocytes led to a specificity of 85% and improved positive predictive value.

LIMITATIONS, REASONS FOR CAUTION

This study is retrospective, analyzing a limited number of cycles. Moreover, the patients who were included in a fresh PGT cycle were selected on ovarian reserve parameters and show high values in ovarian reserve tests. This information could influence our conclusion.

WIDER IMPLICATIONS OF THE FINDINGS

The results relate only to the target population of this study, with a correct ovarian reserve of AMH >1 and AFC >10. However, the information provided herein extends knowledge about the current state of COS for FMR1 mutation carriers in order to provide patients with proper counseling regarding the optimal number of oocytes needed to have a chance of transferring an unaffected embryo following PGT.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Position statement on the diagnosis and management of premature/primary ovarian insufficiency (except Turner Syndrome)

Premature ovarian insufficiency (POI) is a rare pathology affecting 1-2% of under-40 year-old women, 1 in 1000 under-30 year-olds and 1 in 10,000 under-20 year-olds. There are multiple etiologies, which can be classified as primary (chromosomal, genetic, auto-immune) and secondary or iatrogenic (surgical, or secondary to chemotherapy and/or radiotherapy). Despite important progress in genetics, more than 60% of cases of primary POI still have no identifiable etiology; these cases are known as idiopathic POI. POI is defined by the association of 1 clinical and 1 biological criterion: primary or secondary amenorrhea or spaniomenorrhea of>4 months with onset before 40 year of age, and elevated follicle-stimulating hormone (FSH)>25IU/L on 2 assays at>4 weeks' interval. Estradiol level is low, and anti-Müllerian hormone (AMH) levels have usually collapsed. Initial etiological work-up comprises auto-immune assessment, karyotype, FMR1 premutation screening and gene-panel study. If all of these are normal, the patient and parents may be offered genome-wide analysis under the "France Génomique" project. The term ovarian insufficiency suggests that the dysfunction is not necessarily definitive. In some cases, ovarian function may fluctuate, and spontaneous pregnancy is possible in around 6% of cases. In confirmed POI, hormone replacement therapy is to be recommended at least up to the physiological menopause age of 51 years. Management in a rare diseases center may be proposed.

O-113 Effectiveness and treatment cost of assisted reproduction technology for women stimulated by gonadotropin in France: A cohort study using the National Health Database

Study question

How effective is Assisted Reproduction Technology (ART) in terms of cumulative live birth rate (CLBR) in France, depending on the gonadotropin used?

Summary answer

Among 214,539 stimulations, originator follitropin-alfa was associated with significantly higher CLBR when compared to Highly Purified-Human Menopausal Gonadotropin (HP-HMG) and biosimilars.

What is known already

Deciding which type of gonadotropin to prescribe for a woman undergoing controlled ovarian stimulation (COS) remains difficult. The effectiveness of different gonadotropins is one factor to consider. However, studies comparing r-hFSH-alfa, its biosimilars and HP-HMG are scarce and are mostly based on a single ART treatment cycle and fresh embryo transfers. Some clinical trials have shown similar pregnancy, pregnancy loss, and live birth rates after fresh embryo transfer (ET) between HP-HMG and r-hFSH. However, because more oocytes are retrieved with r-hFSH when compared to HP-HMG, it is logical to hypothesize that the CLBR is higher with r-hFSH.

Study design, size, duration

A non-interventional study based on the French National Health System (SNDS) database was designed to assess the CLBR and treatment costs from the national payer perspective of four gonadotropin groups (originator follitropin-alfa (r-hFSH-alfa), its biosimilars, HP-HMG and r-hFSH-beta) used for COS cycles leading to oocyte pick-up (OPU) between 01/01/2013 and 31/12/2017 with a follow-up period up to 31/12/2018. The study compared CLBR, with originator r-hFSH-alfa as the reference.

Participants/materials, setting, methods

Women with COS cycles resulting in OPU with one of the specified gonadotropins were included. Data were extracted from billing and reimbursement records of outpatient healthcare consumption and national hospital discharge databases using a unique, anonymized patient number. CLBR was estimated using an Andersen–Gill model, adjusted for clinical baseline, stimulation and ET variables. Costs were reported as secondary outcomes.

Main results and the role of chance

135,752 women (mean age 34.1), underwent 214,539 stimulations leading to OPU and contributed one (61.5%), two (24.8%), three (9.4%) or four (3.2%) COS cycles. COS cycles were stimulated with either Originator r-hFSH-alfa (46%), HP-HMG (29%), r-hFSH-beta (21%) or r-hFSH-alfa biosimilars (4%). Over the study period, CLBR reached 20.5%; 21.9% with originator r-hFSH-alfa, 17.9% with HP-HMG, 21.3% with r-hFSH-beta and 18.4% with r-hFSH-alfa biosimilars. After adjusting for age, pre-treatment, GnRH analog, ovulation triggering, luteal phase support, previous COS, fresh or frozen ET and type of center, as possible cofounding variables, the adjusted hazard ratio (HR) for CLBR (delivery [originator r-hFSH-alfa as reference]) was 0.88 (95% CI 0.86 to 0.95, p &lt; 0.0001) with HP-HMG; 0.98 (95% CI 0.95 to 1.00, p = 0.1020) with r-hFSH-beta, and 0.84 (95% CI 0.79 to 0.90, p &lt; 0.0001) with r-hFSH-alfa biosimilars. Although the mean acquisition cost of r-hFSH-alfa during the study was 33% higher than HP-HMG and 20% higher than r-hFSH-alfa biosimilars, the global ART management costs were only 4% higher than HP-HMG, 3% higher than r-hFSH-beta, and similar to r-hFSH-alfa biosimilars.

Limitations, reasons for caution

Patients were included only from oocyte pick-up, due to missing data in the SNDS database, meaning that it was not possible to estimate the proportion of cancelled cycles. Furthermore, as r-hFSH-alfa biosimilars were only available since 2015, results for biosimilars should be interpreted with caution.

Wider implications of the findings

This population-wide French study confirms other Real-World and meta-analysis evidence that CLBR is higher with originator r-hFSH-alfa than with HP-HMG or r-hFSH-alfa biosimilars, respectively, and are relevant for healthcare professionals to support gonadotropin treatment decision making. To further support this, the cost analysis should be completed by a cost-effectiveness analysis.

Trial registration number

Not applicable

O-180 Oocyte vitrification for fertility preservation does not delay the initiation of neoadjuvant chemotherapy for breast cancer

Study question

Does oocyte vitrification for fertility preservation (FP) delay the initiation of neoadjuvant chemotherapy for breast cancer?

Summary answer

The indication of neoadjuvant chemotherapy for breast cancer should not be considered as an impediment to urgent oocyte vitrification for FP.

What is known already

FP is considered as one of the most important issues to address for young breast cancer patients. Cryopreservation of oocytes or embryos may be considered after controlled ovarian hyperstimulation (COH) or in vitro maturation (IVM). Pregnancies have been reported after reutilization of oocytes frozen following both procedures. Although oocyte competence is better after COH, this strategy requires on average 13 days to be achieved. In addition, the safety of ovarian stimulation before tumor removal is currently not formally established. In case of neoadjuvant chemotherapy, the risk-benefit balance of COH is not well known.

Study design, size, duration

Retrospective cohort study including all breast cancer patients eligible for oocyte vitrification following COH or IVM before initiation of neoadjuvant chemotherapy between January 2016 and December 2020.

Participants/materials, setting, methods

Inclusion criteria were: female patients with confirmed non metastatic breast cancer, 18 to 40 years of age, with indication of neoadjuvant chemotherapy, who have had oocyte retrieval for FP after COH or IVM +/- cryopreservation of ovarian tissue. Various time-points related to cancer diagnosis, FP or chemotherapy were obtained from medical record review.

Main results and the role of chance

A total of 198 patients with confirmed breast cancer who had oocyte retrieval following COH (n = 57) or IVM +/- cryopreservation of ovarian tissue (n = 141) for FP prior to neoadjuvant chemotherapy were included. Although women in IVM group were significantly younger as compared to patients who underwent COH (31.7 ± 4.2 vs. 33.3 ± 4.0 years, p = 0.019), ovarian reserve parameters, BMI and cancer stage did not differ between the two groups. Overall, the average time from cancer diagnosis to chemotherapy start was similar between patients having undergone COH or IVM before oocyte vitrification (37.3 ± 13.8 vs. 36.9 ±13.5 days in COH and IVM groups respectively, p=0.857).

Limitations, reasons for caution

The time from referral to FP consultation may have influenced the type of FP. In addition, the retrospective nature of the present analysis may constitute a limitation. Moreover, the efficiency and security of the different FP strategies used has not been analysed.

Wider implications of the findings

Oocyte vitrification following COH or IVM was not associated with delayed breast cancer treatment in the neoadjuvant setting, so long as there was a prompt FP referral. Young patients undergoing neoadjuvant chemotherapy should be informed of these findings to avoid unnecessary anxiety due to concern for delays.

Trial registration number

Not applicable

O-107 Searching for the optimal number of oocytes to reach a life birth following in vitro fertilization: a systematic review with meta-analysis

Study question

To investigate the relationship between the number of oocytes and both the live birth rate after fresh embryo transfer and the cumulative live birth rate.

Summary answer

Above a 15-oocyte threshold, live birth rate (LBR) following fresh transfer plateaus, whereas a continuous increase in cumulative live birth rate (CLBR) is observed.

What is known already

Several lines of evidence indicate that number of oocytes represents a key point for in vitro fertilization (IVF) success. However, consensus is lacking regarding the optimal number of oocytes for expecting a live birth. This is a key question because it might impact the way practitioners initiate and adjust COS regimens.

Study design, size, duration

A systematic review and meta-analysis was performed. MEDLINE, EMBASE, and Cochrane Library were searched for studies published between January 01, 2004, and August 31, 2019 using the search terms: “(intracytoplasmic sperm injection or icsi or ivf or in vitro fertilization or fertility preservation)” and “(oocyte and number)” and “(live birth)”.

Participants/materials, setting, methods

Two independent reviewers carried out study selection, quality assessment using the adapted Newcastle-Ottawa Quality Assessment Scales, bias assessment using ROBIN-1 tools, and data extraction according to Cochrane methods. Independent analyses were performed according to the outcome (LBR and CLBR). The mean-weighted threshold of optimal oocyte number was estimated from documented thresholds, followed by a one-stage meta-analysis on articles with documented or estimable relative risks.

Main results and the role of chance

After reviewing 843 records, 64 full-text articles were assessed for eligibility. A total of 36 studies were available for quantitative syntheses. Twenty-one and 18 studies were included in the meta-analyses evaluating the relationship between the number of retrieved oocytes and LBR or CLBR, respectively. Given the limited number of investigations considering mature oocytes, association between the number of metaphase II oocytes and IVF outcomes could not be investigated. Concerning LBR, 7 (35.0%) studies reported a plateau effect, corresponding to a weighted mean of 14.4 oocytes. The pooled dose-response association between the number of oocytes and LBR showed a non-linear relationship, with a plateau beyond 15 oocytes. For CLBR, 4 (19.0%) studies showed a plateau effect, corresponding to a weighted mean of 19.3 oocytes. The meta-analysis of the relationship between the number of oocytes and CLBR found a non-linear relationship, with a continuous increase in CLBR, including for high oocyte yields.

Limitations, reasons for caution

Statistical models show a high degree of deviance, especially for high numbers of oocytes. Further investigations are needed to assess the generalization of those results to frozen mature oocytes, especially in a fertility preservation context, and to evaluate the impact of female age.

Wider implications of the findings

Above a 15-oocyte threshold, LBR following fresh transfer plateaus, suggesting that the freeze-all strategy should probably be performed. In contrast, the continuous increase in CLBR suggests that high numbers of oocytes could be offered to improve the chances of cumulative live births, after evaluating the benefit–risk balance.

Trial registration number

Not applicable

P–595 Systematic dydrogesterone supplementation of artificial endometrial preparation cycles for frozen-thawed embryo transfer during Covid–19 pandemic: a good way to limit monitoring visits and optimize outcomes

Study question

Does systematic dydrogesterone supplementation in artificial cycles (AC) for frozen-thawed embryo transfer (FET) during Covid–19 pandemic modify outcomes compared to prior individualized supplementation adjusted on serum progesterone (P) levels ?

Summary answer

Systematic dydrogesterone supplementation in AC for FET is associated with similar outcomes compared to prior individualized supplementation in patients with low P levels.

What is known already

In AC for FET using vaginal P for endometrial preparation, low serum P levels following P administration have been associated with decreased pregnancy and live birth rates. This deleterious effect can be overcome by addition of other routes of P administration. We obtained effective results by adding dydrogesterone to vaginal P and postponing FET by one day in patients with low P levels. However, in order to limit patient monitoring visits and to schedule better FET activity during Covid–19 pandemic, we implemented a systematic dydrogesterone supplementation without luteal P measurement in artificial FET cycles.

Study design, size, duration

This retrospective study aimed to analyse outcomes of 394 FET after 2 different protocols of artificial endometrial preparation. From September 2019 to Covid–19 lockdown on 15th March 2020, patients had serum P level measured on D1 of vaginal P administration. When P levels were < 11 ng/ml, dydrogesterone supplementation was administered and FET was postponed by one day. From May to December 2020, no P measurement was performed and dydrogesterone supplementation was systematically used.

Participants/materials, setting, methods

In our university hospital, endometrial preparation was performed using sequential administration of vaginal estradiol until endometrial thickness reached >7 mm, followed by transdermal estradiol combined with 800 mg/day vaginal micronized P started in the evening (D0). Oral dydrogesterone supplementation (30 mg/day) was started concomitantly to vaginal P in all patients during Covid–19 pandemic and only after D1 P measurement followed by one day FET postponement in patients with P levels <11 ng/ml before the lockdown.

Main results and the role of chance

During the Covid–19 pandemic, 198 FET were performed on D2, D3 or D5 of P administration with dydrogesterone supplementation depending on embryo stage at cryopreservation. Concerning the 196 FET before lockdown, 124 (63%) were performed after dydrogesterone addition from D1 onwards and postponement by one day in patients with serum P levels <11 ng/ml at D1 while 72 were performed in phase following introduction of vaginal P without dydrogesterone supplementation in patients with P > 11 ng/ml. Characteristics of patients in the 2 time periods were similar for age (34.5 + 5 vs 34.1 + 4.8 years), endometrial thickness prior to P introduction (9.9 + 2.1 vs 9.9 + 2.2 mm), number of transferred embryos (1.3 + 0.5 vs 1.4 + 0.5) , embryo transfer stage (D2/D3/blastocyst: 8/16/76% vs 3/18/79%). No significant difference was observed between both time periods [nor between “dydrogesterone addition and postponement by 1 day” and “in phase” FET before lockdown] in terms of positive pregnancy test (39.4% vs 39.3% [44% vs 30.5%]), heartbeat activity at 8 weeks (29.3% vs 28% [29% vs 26.4%]) and ongoing pregnancy rates at 12 weeks (30.7% but truncated at end of October 2020 vs 25.5% [26.6% vs 23.6%]).

Limitations, reasons for caution

Full results of the Covid–19 period will be further provided concerning ongoing pregnancy rates as well as comparison of live birth rates and obstetrical and neonatal outcomes.

Wider implications of the findings: These results suggest that systematic dydrogesterone supplementation is as effective as individualized supplementation according to serum P levels following administration of vaginal P. This strategy enabled us to schedule easier FET and limit patient visits for monitoring while maintaining optimal results for FET in AC during the Covid–19 pandemic.

Trial registration number

Not applicable

O-082 The ratio AMH/antral follicle count varies according to the etiologies of diminished ovarian reserve suggesting differences in follicular health

Study question

Does diminished ovarian reserve (DOR) and its etiology impact the AMH/AFC ratio?

Summary answer

AMH/AFC ratio varies according to the etiology of DOR in young women, suggesting different impact on the follicular health, and further oocyte quality.

What is known already

Anti-Müllerian hormone and antral follicle count currently represent the two most accurate markers of the follicular ovarian status. Even though they may diagnose a reduction in the follicular stockpile, low values remain inefficient for predicting poor oocyte quality, in particular in young women. Since AMH is produced by the granulosa cells of follicles ranging from primary to small antral follicles, we hypothesized that the etiology of diminished ovarian reserve might differently impact the follicular health and their capacity of producing this peptide.

Study design, size, duration

From November 2018 to December 2021, we conducted a monocentric, retrospective study including a total of 484 infertile patients &lt; 37 years with DOR.

Participants/materials, setting, methods

All patients underwent measurement of AMH levels and AFC. DOR was diagnosed according to the Bologna criteria (AMH &lt; 1.1 ng/mL and AFC &lt; 7). AMH/AFC ratio was compared to values obtained in 154 tubal or male infertility patients matched for age and BMI, with AMH and AFC in the normal ranges. This ratio was studied according to the etiology of DOR: genetic (n = 26), post-chemotherapy (n = 102), idiopathic (n = 215) or ovarian diseases (ovarian cyst or history of ovarian surgery, n = 141).

Main results and the role of chance

Overall, median age of women with DOR was 30 (18-37) years. As expected, age and BMI were comparable in women with DOR and those having normal ovarian reserve tests. In addition, the AMH/AFC ratio failed to show any difference between these 2 groups (0.143 ± 0.22 vs. 0.166 ± 0.11, NS, respectively). Among women with DOR, the etiology was significantly associated with different AMH/AFC ratio. Indeed, patient with DOR of surgical origin (ovarian diseases group) displayed higher mean values (0.283 ± 0.32 ng/mL/ Foll) when compared with those included in genetic (0.079 ± 0.15 ng/mL/ Foll, p &lt; 0.01), idiopathic (0.103 ± 0.16 ng/mL/ Foll, p &lt; 0.03) or post-chemotherapy (0.084 ± 0.20 ng/mL/ Foll, p &lt; 0.01) groups. Moreover, genetic and post-chemotherapy DOR was also associated with lower AMH/AFC ratio in comparison with idiopathic DOR.

Limitations, reasons for caution

Despite interesting results, the retrospective nature of the present study may represent a limitation. Moreover, AMH/AFC ratio constitute an indirect method for assessing per follicle AMH production. We hypothesized that this ratio might reflect the follicular health. Its impact on natural conception and assisted reproductive technologies outcome is not known.

Wider implications of the findings

AMH/AFC ratio may represent an innovative tool aiming to indirectly assess follicular health and possibly oocyte quality in young women with DOR. The etiology of DOR differently impacts the follicular function as reflected by AMH/AFC ratio. Further data on live birth rates following natural or medically assisted pregnancies is needed.

Trial registration number

N/A

P–440 Seven years’ experience using oocyte vitrification/warming from in vitro maturation or controlled ovarian hyperstimulation cycles to preserve fertility for oncologic indications

Study question

Do oocytes vitrified following in vitro maturation (IVM) or controlled ovarian hyperstimulation (COH) for oncologic fertility preservation (FP), lead to similar biological/clinical outcomes after thawing?

Summary answer

IVM is a valid option when chemotherapy is urgent or COH is contraindicated. We report the second live-birth worldwide after IVM in a cancer patient.

What is known already

FP aims at maintaining in cancer survivors, the possibility of childbearing using their own gametes. Currently, oocyte vitrification after COH remains the gold standard but IVM has recently emerged as an option for young women seeking FP, when COH is contraindicated or when cancer therapy is urgent. However, the actual competence of oocyte vitrified after IVM in cancer patients is not established. To date, only one live birth has been reported following frozen/warmed oocytes from an IVM cycle and no data is available comparing biological/clinical outcomes of warmed oocytes resulting either from IVM or COH cycles in cancer survivors.

Study design, size, duration

This retrospective cohort study from a single IVF unit aimed to analyze outcomes of all oocyte warming cycles in 38 cancer survivors having undergone oocyte vitrification for FP after COH or IVM. All of them had oocyte retrieval before administration of gonadotoxic treatment and returned after being cured for assisted reproduction treatments with their oncologist agreement, between January 2014 and December 2020.

Participants/materials, setting, methods

Thirty-eight oocytes warming cycles followed by ICSI respectively from 18 COH and 22 IVM cycles were analyzed. Survival, degeneration following ICSI, fertilization, top-quality and good-quality embryos, defined at day–2 respectively as 4 and 3–5 adequate-sized blastomeres, without multinucleation and containing &lt;20% of cytoplasmic fragments, implantation, biochemical (hCG&gt;100 UI/mL), clinical (intrauterine sac with fetal heart beat) and live birth rates were compared between IVM and COH cycles using appropriate statistical tests. Significance was set at 5%.

Main results and the role of chance

The indications for FP were breast cancer (n = 32), hematologic malignancies (n = 3), BRCA1 mutation (n = 2), borderline ovarian tumor (n = 1). The mean age and antral follicle count (AFC) at the time of FP was similar in both groups. The number of cryopreserved oocytes was significantly lower in the IVM group (5.7 ± 9.1) when compared with the COH group (11.4 ± 3.3; p = 0.009). Oocyte survival rates were similar in IVM (70 ± 24%) and COH groups (73 ± 28%). Although not significant, we reported a trend to better results in the COH group when compared with those of IVM group in terms of degeneration rate following ICSI (6 ± 10% vs. 14 ± 20%; p = 0.16), fertilization (72 ± 35% vs. 54 ± 27%; p = 0.08), day 2 top-quality (38 ± 32% vs. 21 ± 31%; p = 0.15) and good-quality embryo (46 ± 30% vs. 25 ± 30%; p = 0.06), implantation (18 ± 35% vs. 14 ± 36%; p = 0.79), biochemical (28 (5/18) vs. 14% (3/22); p = 0.26), clinical (22% (4/18) vs. 9% (2/22); p = 0.24), live birth rates (22% (4/18) vs. 5% (1/22); p = 0.06).

Limitations, reasons for caution

Caution is needed when interpreting these retrospective data obtained from a limited number of frozen-thawed cycles. Statistical power to compare IVF outcomes after COH and IVM is limited by the few women who return for oocyte reutilization.

Wider implications of the findings: The present investigation is the largest evaluating the IVM-oocyte frozen-thawed cycles in a oncologic population. It suggests that a higher oocyte yield may be necessary in IVM, since fertilization/embryo-quality rates seem lower. Success rates and limiting factors of oocyte vitrification in this context is needed for providing proper oncofertility counseling.

Trial registration number

Not applicable

Could hormonal and follicular rearrangements explain timely menopause in unilaterally oophorectomized women?

STUDY QUESTION

Does unilateral oophorectomy modify the relationship between serum anti-Müllerian hormone (AMH) levels and antral follicle count (AFC)?

SUMMARY ANSWER

No altered 'per-ovary' and 'per-follicle' AMH production and antral follicle distribution was evident in unilaterally oophorectomized women compared to matched controls.

WHAT IS KNOWN ALREADY

The age of menopause onset is relatively unchanged in patients having undergone unilateral oophorectomy. Mechanisms that occur to preserve and maintain ovarian function in this context remain to be elucidated.

STUDY DESIGN, SIZE, DURATION

Forty-one infertile women, with no polycystic ovary syndrome (PCOS) and no endometriosis, aged 19-42 years old, having undergone unilateral oophorectomy (One Ovary group; average time since surgery: 23.8 ± 2.2 months) were retrospectively age-matched (±1 year) with 205 infertile women having two intact ovaries and similar clinical features (Control group).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serum AMH levels, 3-4 mm AFC, 5-12 mm AFC, and total AFC (3-12 mm) were assessed on cycle Day 3 in both groups. Hormonal and ultrasonographic measurements obtained from patients in the Control group (i.e. having two ovaries) were divided by two to be compared with measurements obtained from patients of the One Ovary group (i.e. having one single remaining ovary). To estimate per-follicle AMH production, we calculated the ratio between serum AMH levels over 3-4 mm AFC, 5-12 mm AFC, and total AFC (3-12 mm), and the strength of the correlation between serum AMH levels and total AFC. The main outcome measure was to assess Day 3 AMH/Day 3 AFC ratio and hormonal-follicular correlation.

MAIN RESULTS AND THE ROLE OF CHANCE

As expected, before correction, mean serum AMH levels (1.46 ± 0.2 vs 2.77 ± 0.1 ng/ml, P < 0.001) and total AFC (7.3 ± 0.6 vs 15.1 ± 0.4 follicles, P < 0.0001) were lower in the One Ovary group compared to the Control group, respectively. Yet, after correction, per-ovary AMH levels (1.46 ± 0.2 vs 1.39 ± 0.1 ng/ml) and total AFC (7.3 ± 0.6 vs 7.5 ± 0.2 follicles) values were comparable between the two groups. Consistently, per-follicle AMH levels (3-4 mm, 5-12 mm, and total) were not significantly different between the two groups (0.39 ± 0.05 vs 0.37 ± 0.02 ng/ml/follicle; 0.69 ± 0.12 vs 0.59 ± 0.05 ng/ml/follicle, and 0.23 ± 0.03 vs 0.19 ± 0.01 ng/ml/follicle; respectively). In addition, the prevalence of 3-4 mm follicles was comparable between the two groups (66.7% for One Ovary group vs 58.8% for Control group, respectively). Finally, the correlation between serum AMH levels and total AFC was similar for patients in the One Ovary group (r = 0.70; P < 0.0001) compared to those in the Control group (r = 0.68; P < 0.0001).

LIMITATIONS/REASONS FOR CAUTION

The retrospective character of the analysis might lead to potential bias.

WIDER IMPLICATIONS OF THE FINDINGS

The present investigation did not provide evidence of altered 'per-ovary' and 'per-follicle' AMH production and antral follicle distribution in unilaterally oophorectomized women compared to matched controls. Further studies are warranted to support the hypothesis that follicle-sparing mechanisms are clearly at stake in remaining ovaries after unilateral oophorectomy to explain their long-lasting function and timely menopausal onset.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no funding or competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Perspectives on the development and future of oocyte IVM in clinical practice

Oocyte in vitro maturation (IVM) is an assisted reproductive technology designed to obtain mature oocytes following culture of immature cumulus–oocyte complexes collected from antral follicles. Although IVM has been practiced for decades and is no longer considered experimental, the uptake of IVM in clinical practice is currently limited. The purpose of this review is to ensure reproductive medicine professionals understand the appropriate use of IVM drawn from the best available evidence supporting its clinical potential and safety in selected patient groups. This group of scientists and fertility specialists, with expertise in IVM in the ART laboratory and/or clinic, explore here the development of IVM towards acquisition of a non-experimental status and, in addition, critically appraise the current and future role of IVM in human ART.

Borderline ovarian tumors: Guidelines from the French national college of obstetricians and gynecologists (CNGOF)

It is recommended to classify Borderline Ovarian Tumors (BOTs) according to the WHO classification. Transvaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended to perform a pelvic MRI (Grade A) with a score for malignancy (ADNEX MR/O-RADS) (Grade C) included in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being BOT (Grade C). It is recommended to evaluate serum levels of HE4 and CA125 and to use the ROMA score for the diagnosis of indeterminate ovarian mass on imaging (grade A). If there is a suspicion of a mucinous BOT on imaging, serum levels of CA 19-9 may be proposed (Grade C). For Early Stages (ES) of BOT, if surgery without risk of tumor rupture is possible, laparoscopy with protected extraction is recommended over laparotomy (Grade C). For treatment of a bilateral serous ES BOT with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended where possible (Grade B). For mucinous BOTs with a treatment strategy of fertility and/or endocrine function preservation, unilateral salpingo-oophorectomy is recommended (grade C). For mucinous BOTs treated by initial cystectomy, unilateral salpingo-oophorectomy is recommended (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). For ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only in case of a macroscopically pathological appendix (Grade C). Restaging surgery is recommended in cases of serous BOTs with micropapillary architecture and an incomplete abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended for mucinous BOTs after initial cystectomy or in cases where the appendix was not examined (Grade C). If restaging surgery is decided for ES BOTs, the following procedures should be performed: peritoneal washing (grade C), omentectomy (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix and appendectomy in case of a pathological macroscopic appearance (grade C) as well as unilateral salpingo-oophorectomy in case of a mucinous BOT initially treated by cystectomy (grade C). In advanced stages (AS) of BOT, it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). For AS BOT in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed (Grade C). Restaging surgery aimed at removing all lesions, not performed initially, is recommended for AS BOTs (Grade C). After treatment, follow-up for a duration greater than 5 years is recommended due to the median recurrence time of BOTs (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). If the determination of tumor markers is normal preoperatively, the routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of an initial elevation in serum CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In case of conservative treatment, it is recommended to use transvaginal and transabdominal ultrasound during follow up of a treated BOT (Grade B). In the event of a BOT recurrence in a woman of childbearing age, a second conservative treatment may be proposed (Grade C). A consultation with a physician specialized in Assisted Reproductive Technique (ART) should be offered in the case of BOTs in women of childbearing age (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). In the case of optimally treated BOT, there is no evidence to contraindicate the use of ART. The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After management of mucinous BOT, for women under 45 years, given the benefit of Hormonal Replacement Therapy (HRT) on cardiovascular and bone risks, and the lack of hormone sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). Over 45 years of age, HRT can be prescribed in case of a climacteric syndrome after individual benefit to risk assessment (Grade C).

Double-in vitro maturation increases the number of vitrified oocytes available for fertility preservation when ovarian stimulation is unfeasible

When ovarian stimulation is unfeasible, in vitro maturation (IVM) represents an alternative option for fertility preservation (FP). This retrospective study aims to evaluate the feasibility of performing within a short time frame two IVM cycles for FP. Seventeen women with breast cancer, 18-40 years of age, having undergone 2 cycles of IVM followed by oocyte vitrification were included. Non parametric analyses were used. No difference was observed between IVM1 and IVM2 outcomes. No complication was reported. The respective contributions of IVM1 and IVM2 for the number of cryopreserved oocytes were comparable irrespective of the delay between both procedures, even when performed during the same menstrual cycle. Those findings suggest that repeating IVM cycles may constitute a safe option for increasing the number of vitrified mature oocytes for FP. These two retrievals may be performed during the same cycle, providing additional argument for a physiologic continuous recruitment during follicular development.

National survey on the opinions of French specialists in assisted reproductive technologies about social issues impacting the future revision of the French Bioethics laws

INTRODUCTION

France is known for its conservative and unique position in assisted reproductive technologies (ARTs). At the eve of the future revision of French Bioethics laws, we decided to conduct a national survey to examine the opinions of French specialists in ARTs about social issues.

MATERIAL AND METHODS

Descriptive study conducted in May 2017 in a university teaching hospital using an anonymous online questionnaire on current issues in ARTs. The questionnaire was sent by email to 650 French ARTs specialists, both clinicians and embryologists.

RESULTS

After 3 reminders, 408 responses were collected resulting in a participation rate of 62.7% (408/650). Concerning pre-implantation genetic testing, 80% of the physicians were in favor of expanding the indications, which in France are presently limited to incurable genetic diseases. Authorizing elective Fertility Preservation was supported by 93.4% of the specialists, but without social coverage for 86.3% of them. Concerning gamete donation, 77.4% of the French ARTs specialists were in favor of giving a financial compensation to donors, 92% promoted preserving their anonymity and 80.9% were against a directed donation. ARTs for single heterosexual women were supported by 63.4% of the French specialists and by 72.5% for lesbian couples. The legalization of surrogacy was requested by 55.2%.

DISCUSSION

Pending the revision of the French Bioethics laws, this survey provides an overview of the opinion of the specialists in ARTs on expanding ARTs for various social indications.Because of the evolution of social values, a more liberal and inclusive ART program is desired by the majority of ART specialists in France.

In vitro maturation of oocytes for preserving fertility in autoimmune premature ovarian insufficiency

OBJECTIVE

To test whether in vitro maturation (IVM) of oocytes is an option for preserving the fertility of women diagnosed with premature ovarian insufficiency (POI).

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 36-year-old amenorrheic patient was referred for fertility preservation (FP) counseling with a diagnosis of autoimmune POI. Serum follicle-stimulating hormone (21.0 and 36.3 mIU/mL) and luteinizing hormone (35.0 and 60.0 mIU/mL) levels taken 4 weeks apart were around the menopausal range. Although serum antimüllerian hormone level was low (0.76 and 0.65 ng/mL), total counts of antral follicles remained unexpectedly normal (24 and 22). Significant levels of serum antiperoxidase, anti-21-hydroxylase, and antiovary antibodies led to the diagnosis of autoimmune polyendocrinopathy. Due to the unknown time before follicular exhaustion, we undertook a FP program.

INTERVENTION(S)

After unsuccessful follicular growth following a trial of ovarian stimulation using recombinant follicle-stimulating hormone (300 IU/day for 10 days), we decided to try IVM of immature oocytes aspirated from the remaining antral-stage follicles.

MAIN OUTCOME MEASURE(S)

Obtention of immature oocyte capable of maturing in vitro in a context of acute ovarian dysfunction.

RESULT(S)

Two cycles of IVM were performed, leading, after human chorionic gonadotropin priming, to six and 10 cumulus-oocyte complexes recovered and four and eight metaphase II oocytes. Finally, after intracytoplasmic sperm injection, a total of eight cleavage-stage embryos were frozen. When the patient presented in the clinic 1 year later for reutilization of the cryopreserved embryos, thyroid and adrenal functions were controlled with levothyroxine and hydrocortisone. Endometrium was primed with 17ß-estradiol (2 mg/day, vaginally) for 14 days. Progesterone (600 mg/day, vaginally) was subsequently combined with E₂. Two embryos were thawed and further transferred into the uterus. The patient became pregnant and uneventfully delivered two baby boys at term.

CONCLUSION(S)

We report the first pregnancy and live birth achieved using IVM for FP in a woman diagnosed with autoimmune POI. The confirmation of our results would lead to modification in the management of young women diagnosed with autoimmune POI, who are usually not considered candidates for FP and often referred for egg donation when seeking pregnancy.

Priming Before In Vitro Maturation Cycles in Cancer Patients Undergoing Urgent Fertility Preservation: a Randomized Controlled Study

In vitro maturation (IVM) of oocytes retrieved at germinal vesicle stage, followed by vitrification of mature oocytes, has emerged as a fertility preservation (FP) option. This technique was first developed for patients with polycystic ovarian syndrome. In this population, providing LH activity prior to oocyte collection has been associated with better IVM outcomes. However, the benefit of this treatment in normo-ovulatory breast cancer (BC) patients undergoing IVM for FP purpose has never been investigated. To assess if the absence of therapeutic intervention prior to oocyte retrieval for IVM modifies IVM outcomes in BC patients undergoing urgent FP, we performed a non-inferiority, randomized controlled trial. The main outcome was the total number of mature oocytes obtained and cryopreserved after IVM. A total of 172 normo-ovulatory women, suffering from BC, 18 to 39 years of age received no injection or a subcutaneous injection of hCG or GnRH agonist (GnRHa) 36 h before oocytes retrieval according to randomized allocation. The total number of cryopreserved oocytes were 5.1 ± 3.8, 5.4 ± 3.8, and 6.0 ± 4.2 oocytes, respectively in the without, hCG and GnRHa groups. Mean differences were not significant between the three groups (- 0.5; CI 97.5% [- 2.03:1.02] and - 0.22; CI 97.5% [- 1.75:1.32], respectively). Intention to treat analyses failed to show non-inferiority in the "without injection group" in comparison with hCG or GnRHa groups. Our results are not conclusive enough to modify our practices and to stop administering hCG or GnRHa before IVM cycles for FP. The study was retrospectively registered to clinical trial (ID NCT03954197) in May 2019.

BRCA1/2 gene mutations do not affect the capacity of oocytes from breast cancer candidates for fertility preservation to mature in vitro

STUDY QUESTION

Are the maturation rates of oocytes recovered from small antral follicles different between breast cancer patients presenting with or without a BRCA 1/2 gene mutation?

SUMMARY ANSWER

BRCA 1/2 gene mutations do not affect the capacity of oocytes from breast cancer candidates for fertility preservation to mature in vitro.

WHAT IS KNOWN ALREADY

Mutations in the BRCA1 and BRCA2 genes are associated with an increased risk for developing breast and ovarian cancer. Controversy exists about fertility and ovarian reserve in BRCA mutation carriers. Studies suggest that these patients may have low ovarian reserve and poor response to ovarian stimulation. The impaired ability of the mutated BRCA gene to repair double-strand breaks in DNA may prompt oocyte aging, apoptosis and meiotic errors. IVM of oocytes retrieved at germinal vesicle stage, followed by vitrification of metaphase II (MII) oocytes has recently emerged as an option for young women seeking fertility preservation, when ovarian stimulation is unfeasible.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study involving 329 breast cancer candidates for fertility preservation using IVM between January 2014 and December 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were: age 18-40 years; two ovaries present; no history of chemotherapy; test for BRCA 1/2 mutations performed. Before immature oocyte retrieval, all follicles measuring 2-9 mm in diameter were precisely counted on both ovaries and serum anti-Müllerian hormone (AMH) was measured irrespective of the phase of the cycle. Number of cumulus oocyte complexes (COC) retrieved, maturation rate and number of MII oocytes cryopreserved were compared according to BRCA mutation status.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, BRCA-mutated women (n = 52) and BRCA-negative women (n = 277) were comparable in terms of age (31.7 ± 3.9 versus 32.3 ± 3.8 years, respectively, P = 0.3), BMI (23.4 ± 4.7 versus 22.6 ± 3.7 kg/m2, respectively, P = 0.3) and ovarian reserve tests (antral follicle count: 20.5 ± 11.4 versus 21.7 ± 12.1 follicles, P = 0.5; serum AMH levels: 3.6 ± 2.9 versus 4.1 ± 3.6 ng/ml, P = 0.3, respectively). The number of COCs retrieved did not differ significantly between both groups (8.9 ± 6.9 versus 9.9 ± 8.1 oocytes, P = 0.5). After similar IVM rates (67 ± 24 versus 62 ± 23%, P = 0.2), the number of MII oocytes cryopreserved was similar in patients presenting BRCA mutation or not (5.1 ± 3.8 versus 6.1 ± 5.1, P = 0.1, respectively).

LIMITATIONS, REASONS FOR CAUTION

Given the low incidence of the mutation, these preliminary findings should be confirmed by further multi-center studies.

WIDER IMPLICATIONS OF THE FINDINGS

Although BRCA mutations are known to alter DNA repair mechanism, it does not seem to impair oocyte capacity to mature in vitro.

STUDY FUNDING/COMPETING INTEREST(s)

None.

In vitro maturation is a viable option for urgent fertility preservation in young women with hematological conditions

Fertility preservation embraces different techniques developed to improve young women chances of becoming mothers after healing. Among them, in vitro maturation (IVM) procedure is based on oocyte retrieval without any gonadotropin treatment, feasible under locoregional or local anesthesia, with very low operative complications. The present retrospective analysis of a preliminary case series of 25 women diagnosed with Hodgkin or non-Hodgkin lymphoma aims to evaluate the feasibility of IVM for urgent fertility preservation purposes in hematological context. A median of five mature oocytes was cryopreserved after one cycle of IVM, performed without delaying the start of the chemotherapy (median delay from histological diagnosis to start of the chemotherapy 17.5 days). No association was found between lymphomas' characteristics and the number of recovered or frozen oocytes. Although experimental, this technique could be relevant when fertility preservation has to be performed within a short time frame and without additional surgery nor any risk of malignant cells reintroduction.

[Oncofertility and breast cancer]

Over the past decades, progresses in oncology have improved the recovery rates after numerous malignant diseases, including breast cancer, that strike young adults in childbearing age. Quality of life of young cancer survivors has become a major issue. However, anticancer therapies can have a detrimental impact on fertility. It is now well-established that all patients should receive information about the fertility risks associated with their cancer treatment and the fertility preservation options available. These techniques aim to limit the negative impact of chemotherapy on the ovaries or to preserve gametes before treatment. Currently, oocyte or embryo freezing after controlled ovarian hyperstimulation represents the most effective method for preserving female fertility. Over the past years innovative protocols of ovarian stimulation have been developed to enable breast cancer patients to undergo oocyte or embryo cryopreservation irrespective of the phase of the cycle or without exogenous follicle-stimulating hormone related increase in serum estradiol levels. When controlled ovarian hyperstimualtion cannot be implemented, other techniques such as cryopreservation of ovarian cortex, in vitro maturation or the use of GnRH agonists may be proposed. However, it is important to inform patients that all these fertility preservation techniques do not represent a guarantee of pregnancy.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Fertility]

OBJECTIVES

Borderline ovarian tumours (BOT) represent around 15% of all ovarian neoplasms and are more likely to be diagnosed in women of reproductive age. Overall, given the epidemiological profile of BOT and their favourable prognosis, ovarian function and fertility preservation should be systematically considered in patients presenting these lesions.

METHODS

The research strategy was based on the following terms: borderline ovarian tumour, fertility, fertility preservation, infertility, fertility-sparing surgery, in vitro fertilization, ovarian stimulation, oocyte cryopreservation, using PubMed, in English and French.

RESULTS AND CONCLUSIONS

Fertility counselling should become an integral part of the clinical management of women with BOT. Patients with BOT should be informed that surgical management of BOT may cause damage ovarian reserve and/or peritoneal adhesions. Nomogram to predict recurrence, ovarian reserve markers and fertility explorations should be used to provide a clear and relevant information about the risk of infertility in patients with BOT. Fertility-sparing surgery should be considered for young women who wish preserving their fertility when possible. There is insufficient evidence to claim a causal relation between controlled ovarian stimulation (COS) and BOT. However, in case of poor prognosis factors, the use of COS should be considered cautiously through a multidisciplinary approach. In case of infertility after surgery for BOT, COS can be performed without delay, once histopathological diagnosis of BOT is confirmed. There is insufficient consistent evidence that fertility drugs and COS increase the risk of recurrence of BOT after conservative management. The conservative surgical treatment can be associated to oocyte cryopreservation considering the high risk of recurrence of the disease. In women with BOT recurrence in a single ovary and in women with bilateral ovarian involvement when the conservative management is not possible, other fertility preservation strategies are available, but still experimental.

Fertility preservation: should we reconsider the terminology?

The term 'fertility preservation' embraces techniques that are actually mostly based on gamete and gonadal tissue cryopreservation. While the efficiency of these techniques in terms of live births remains difficult to establish, it is remarkable that this ambiguous terminology is routinely used and seems currently well accepted. In order to limit false hopes about the real chances of truly preserving fertility, our medical community should discuss qualifying the term 'fertility preservation'. 'Gamete or gonadal tissue cryopreservation' could appear as a more unambiguous and realistic term. However, it probably captures only a segment of a more global 'fertility preservation' process. Discussing how and when to use which terminology, and even finding a more realistic and unifying term, should be further explored.

Predicting the likelihood of a live birth for women with endometriosis-related infertility

OBJECTIVE

Endometriosis affects 10% of women in reproductive age and alters fertility. Its management is still debated notably the timing of surgery and ART in infertility. Several tools have been created to guide the practitioner and the couple yet many limitations persist. The objective is to create a nomogram to predict the likelihood of a live birth after surgery followed by assisted reproductive technology (ART) for patients with endometriosis-related infertility.

STUDY DESIGN

All women in a public university hospital who attempted to conceive by ART after surgery for endometriosis-related infertility from 2004 to 2016 were included. We created a model using multivariable linear regression based on a retrospective database.

RESULT

Of the 297 women included, 171 (57.6%) obtained a live birth. Age, duration of infertility, number of ICSI-IVF cycles, ovarian reserve and the revised American Fertility Society (rAFS) score were included in the nomogram. The predictive model had an area under the curve (AUC) of 0.77 (95% CI, 0.75-0.79) and was well calibrated. The external validation of the model was achieved with an AUC of 0.71 (95% CI, 0.69-0.73) and calibration was good. The staging accuracy according to AUC criteria for the nomogram compared to the currently used Endometriosis Infertility Index to predict live births were 0.77 (95% CI, 0.75-0.79) and 0.60 (95% CI: 0.57-0.63), respectively.

CONCLUSION

This simple tool appears to accurately predict the likelihood of a live birth for a patient undergoing ART after surgery for endometriosis-related infertility. It could be used to counsel patients in their choice between spontaneous versus ART conception, or oocyte donation.

French-style genetics v. 2.0: The "e-CohortE" project

In the digital age, a genetics cohort has become much more than a simple means of determining the cause of a disease. Two‐sided markets, of which 23andMe, Ancestry DNA and MyHeritage are the best known, have showed this perfectly over the last few years: a cohort has become a means of producing massive amounts of data for medical, scientific and commercial exploitation, and for genetic use in particular. French law does not currently allow these foreign private companies to develop on French national territory and also forbids the creation of similar entities in France. However, at least in theory, this same law does not preclude the creation of new types of cohorts in France inspired by the success of two‐sided markets but retaining features specific to the French healthcare management system. We propose an optimal solution for France, for genomic studies associated with multi‐subject questionnaires, still purely theoretical for the moment: the development, with no need for any change in the law, of France's own version of “Genetics v.2.0”: “e‐CohortE.”

[Dual trigger with gonadotropin-releasing hormone agonist and hCG to improve oocyte maturation rate]

OBJECTIVE

This study investigates dual trigger with GnRHa and hCG as a potential treatment in patients with a history of ≥25 % immature oocytes retrieved in IVF/ICSI cycles.

METHODS

This is a retrospective case-control study performed between October 2008 and December 2017. Forty-seven patients who experienced high oocyte immaturity rate (≥25 %) during their first IVF/ICSI cycle (analyzed as control group) and received a dual trigger for their subsequent cycle, were involved. During dual trigger cycles, patients received antagonist protocol and ovulation triggering using triptorelin 0.2mg and hCG. Primary endpoint was maturation rate (MR). Secondary endpoints were fertilization, D2 top quality embryo (TQE) rates, clinical pregnancy rate per fresh embryo transfer and cumulative clinical pregnancy rate per couple.

RESULTS

A significant increase in MR was achieved in case of dual trigger (71.0 %) when compared to control group (47.8 %; P<0.0001). Moreover, cumulative clinical pregnancy rate yielded 46.8 % in dual trigger group, which was statistically higher than 27.6 % obtained in control group (P=0.05). However, fertilization, D2 TQE rates and clinical pregnancy rates/transfer were statistically similar when compared between the two groups.

CONCLUSION

Dual trigger seems efficient for managing patients with high oocyte immaturity rate.

Impact of letrozole supplementation during ovarian stimulation for fertility preservation in breast cancer patients

Objectives

Oocyte and/or embryo vitrification after controlled ovarian stimulation (COS) represents the most established method of fertility preservation (FP) before cancer treatment. However, traditional COS regimens are associated with supraphysiologic serum estradiol and are therefore not recommended in estrogen-sensitive diseases such as breast cancer (BC). To protect the patients from the potential deleterious effects of elevated estrogen levels during COS for FP, protocols using aromatase inhibitors (letrozole) were developed. The present study aims at investigating whether COS with letrozole supplementation (COSTLES) modifies ovarian response in BC patients.

Study design

One hundred and seventy-seven BC patients candidates for FP using oocyte and/or embryo vitrification following COS referred to our center between July 2013 and December 2016 were included in this retrospective case-control study. 94 patients underwent COSTLES while 83 had standard GnRH antagonist protocol. The number of oocytes retrieved, oocyte maturation rates, number of oocytes vitrified and follicle responsiveness to FSH assessed by the Follicular Output Rate (FORT) were assessed.

Results

Women in both groups were comparable in terms of age and ovarian reserve tests leading to a similar number of oocyte recovered (13.1 ± 10.0 vs. 12.2 ± 8.0 oocytes, respectively, NS). However, oocyte maturation rates were significantly lower in COSTLES compared to standard protocol (64.9 ± 22.8 vs. 77.4 ± 19.3%, p < 0.001). As a result, the number of mature oocyte vitrified was lower in COSTLES group (7.8 ± 5.3 vs. 10.3 ± 8.5 oocytes, p < 0.001 respectively)

Conclusion

Despite similar response to exogenous FSH, BC patients having undergone COSTLES show reduced oocyte maturation rates in comparison with those having received standard stimulation regimen.

Abstract P6-16-02: Fertility preservation in young breast cancer patients: Real life data on 1390 patients treated in the Institut Curie

Introduction: Adverse effects of chemotherapy on fertility are a critical concern for young breast cancer (BC) patients. Fertility preservation (FP) is currently offered to BC patients, though literature data concerning reproductive outcomes are scarce. Also, very few data are available on whether these procedures are associated with delay to treatment, or whether they impact oncologic outcomes. The objective of our study is to evaluate: (i) efficacy of FP procedures in terms of stored material and pregnancy rates, (ii) safety regarding time from BC diagnosis to chemotherapy, and oncologic outcomes in a large real-life cohort of BC patients.

Methods: We retrospectively analyzed medical charts of all consecutive patients aged between 18 and 43 diagnosed with invasive BC between 01/01/2011 and 30/09/2017 and treated with chemotherapy at Institut Curie (Paris and Saint Cloud). Baseline factors (antral follicle count (AFC), AMH), details on fertility preservation procedures, and results (number of frozen oocytes and embryos) were retrieved in 3 academic hospitals (Jean Verdier, Antoine Béclère and Cochin). All medical charts were reviewed in March 2018 to assess time from diagnosis to surgery / chemotherapy, pregnancy outcomes, recurrence and survival. We compared time from first consultation to start of chemotherapy (time diagnosis-to-CT) in case of neoadjuvant chemotherapy (NAC between patients who had or who did not have PF.

Results: On 1.390 patients identified, 622 had NAC, 768 had adjuvant CT. Median age at diagnosis was 38.8 y.o. 136 were BRCA mutated.

- 264 patients (19%) underwent a FP procedure: In Vitro Maturation (IVM) (58%, n=154); ovarian stimulation protocol (STIM) (31%, n=82); others (10%, n=28). The mean number of oocytes preserved was 5 [0-36] and was not different between IMV and STIM.

- Delays from diagnosis to CT were not different in patients who had FP than those who did not, neither in patients with NAC (no FP: 24.1 days VS FP: 22.8, p=0.24) nor in patients with adjuvant CT (no FP: 70.6 days VS FP : 66.8, p=0.11).

- 39 patients had at least one pregnancy: 28 spontaneous, 6 without information, and 5 from oocyte/embryo donation. The pregnancy rate was higher in patients in FP group (n=16 ; 6%) than in no FP group (n=23 ; 2%). 3 reused material : 2 without pregnancy and one had a miscarriage.

- About oncologic outcomes, 90 patients underwent relapse (6,4%), and this rate was not significantly different in the 2 groups (n=12, 4,5% VS n=78, 6.9%).

- Patients with BRCA mutation (BRCAm) had lower AMH (2.9 VS 4.1 ng/mL ; p = 0,03) and antral follicle count (17.6 VS 24 ; p = 0.01). However, there was no difference on the stored material, and pregnancy rate was higher than in patients with no mutation or unkwnown status (7.6 VS 2.6% ; p = 0,01).

Conclusion: Pregnancy rate was higher in patients with FP, however majority of pregnancies was spontaneous, and no live birth was observed after material reuse. FP procedures were not associated with delay to treatment. Though bias cannot be excluded, preliminary data do not show an adverse impact of FP on oncologic outcome. Further follow-up is needed.

Citation Format: Hamy-Petit A-S, Toussaint A, Sautter C, Coussy F, Donnadieu A, Rouzier R, Saule C, Frank S, Bensen A, Grynberg M, Scarabin-Carre V, Santulli P, Balezeau T, Guerin J, Reyrat E, Jamain C, Hours A, Lecourt A, Reyal F. Fertility preservation in young breast cancer patients: Real life data on 1390 patients treated in the Institut Curie [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-16-02.

Serum antimüllerian hormone is associated with the number of oocytes matured in vitro and with primordial follicle density in candidates for fertility preservation

OBJECTIVE

To assess whether serum antimüllerian hormone (AMH) levels and antral follicle count (AFC) can predict primordial follicle density within ovarian cortex and the number of oocytes cryopreserved after in vitro maturation (IVM).

DESIGN

Retrospective analysis of a case series of patients.

SETTING

University hospital.

PATIENT(S)

Fifty-four women, 18 to 35 years of age, with breast cancer who were candidates for fertility preservation (FP) using ovarian tissue cryopreservation (OTC) associated with oocyte vitrification after unstimulated IVM between July 2013 and December 2016.

INTERVENTION(S)

Serum AMH levels and transvaginal AFC evaluated before FP, cumulus-oocyte complexes (COC) recovered under ultrasound guidance and incubated for IVM, and ovarian tissue laparoscopically harvested and cryopreserved.

MAIN OUTCOME MEASURE(S)

Univariate and multivariate analysis between ovarian reserve tests, number of recovered and in vitro matured oocytes, and primordial follicle density histologically obtained within ovarian cortex.

RESULT(S)

Univariate analysis showed a statistically significant correlation between AMH or AFC and primordial follicle density. Multivariate analysis showed a predominant statistically significant correlation of serum AMH with density. Antimüllerian hormone also correlated with the number of COC and in vitro matured oocytes.

CONCLUSION(S)

Serum AMH levels may reflect the primordial follicle stockpile and may predict outcomes of IVM and OTC when performed for FP. Further analyses are required to evaluate the relevance of performing such procedures in young women who have low values on ovarian reserve tests.

A cost-effectiveness analysis comparing the originator follitropin alfa to its biosimilars in patients undergoing a medically assisted reproduction program from a French perspective

OBJECTIVE

To assess the cost-effectiveness (CE) of the originator follitropin-α (Gonal-F) in patients undergoing a medically assisted reproduction (MAR) program in comparison to its biosimilars Bemfola and Ovaleap in a French context.

METHODS

A CE model was developed for France with a National Health Service (NHS) perspective. Clinical, safety, and dosage data were derived from pivotal clinical trials that compared Gonal-F to Ovaleap and Bemfola. Costs pertaining to drugs, hospitalizations, specialist visits, and examinations were retrieved from the French Programme de Médicalisation des Systèmes d'Information (PMSI) hospital database, literature review, and French clinical experts using 2017 Euro tariffs. In order to test the robustness of results, deterministic one-way sensitivity analyses were carried out on the main variables to assess the impact of treatment cost, probability of birth, ovarian hyperstimulation syndrome (OHSS) rates, and dosage.

RESULTS

The average incremental cost per live birth with OHSS and without OHSS was €259.56 and €278.39, respectively for Gonal-F compared to the pooled biosimilars (i.e., Ovaleap and Bemfola). GONAL-F had an incremental efficacy of 0.06 over the pooled biosimilars. The incremental cost-effectiveness ratio for Gonal-F with OHSS ranged from €3,274.80 to €4,877.76 compared to the pooled biosimilars, owing to the additional live births reported with Gonal-F. Sensitivity analyses also supported results from the base case analyses, with Gonal-F being cost-effective or the dominant strategy in most cases.

CONCLUSION

Gonal-F seems to be a cost-effective strategy compared to its biosimilars Ovaleap and Bemfola, irrespective of the incidence of OHSS events, but further data are needed to confirm these results.