P-629 A prospective, randomized, placebo-controlled pilot trial investigating telomere length dynamics and ovarian function in patients with diminished ovarian reserve (DOR) after danazol treatment

Study question

Could the administration of a synthetic steroid -danazol- for 3 months reactivate telomerase activity and lengthen telomeres in patients with DOR?

Summary answer

Danazol treatment resulted in an increase of the mean leukocyte telomeric length (TL) but did not improve fertility results after the nearest ovarian stimulation (OS).

What is known already

A primary molecular cause of aging is telomere attrition, given that the accumulation of critically short telomeres leads organ dysfunction. Telomere shortening can be counteracted by the telomerase enzyme, which is responsible for adding deoxyribonucleotides to the linear ends of chromosomes. In patients with DOR, TL in granulosa cells (GCs) is short and telomerase activity is absent, compromising their proliferative capacity. Previuos studies have shown that estrogens can activate telomerase gene transcription through estrogen-responsive elements located in the promoter of the telomerase gene. Therefore, telomere attrition could be reduced in patients with DOR upon telomerase reactivation.

Study design, size, duration

This blinded, placebo-controlled pilot trial was carried out at IVIRMA Madrid clinic between February 2020 and February 2022. The study included 12 patients with DOR (AMH<2ng/ml) which were randomized to danazol or placebo. Patients had 12 visits for health supervision and in vitro fertilization (IVF) treatment. Both groups received danazol (400mg per day) or placebo for 3 months. As control group, 7 patients with normal ovarian reserve (AMH≥2ng/ml) were included.

Participants/materials, setting, methods

In both groups, blood samples were collected prior (PT) and after the treatment (AT). Luteinized GCs and blood samples were obtained during oocyte retrieval, after OS. Leukocytes were purified in Ficoll gradients and then, evaluated for TL and TRF1 levels by Quantitative Fluorescent in Situ Hybridization followed by image acquisition using high resolution confocal microscope. IVF parameters were assessed according to IVIRMA standard protocols.

Main results and the role of chance

A total of 19 women were recruited: 5 in the placebo group (39.8±2.7 years), 7 in Danazol group (41.0±3.0 years) and 7 in control group (39.5±3.0 years). The Danazol group showed a trend to higher mean TL in leukocytes after the treatment (108.2±37.4 versus 99±13.2 a.u., AT vs PT). Interestingly, the percentage of long telomeres also increased with treatment (15.5±0.0 versus 10.8±8.1 a.u., AT vs PT). In addition, there was a decrease of the percentage of critically short telomeres (15.7±0.0 versus 20.8±9.9 a.u. AT vs PT). In the placebo group, mean leukocyte TL and the percentage of long and short telomeres remained constant. These findings suggest that telomeres lengthen after Danazol treatment. The protein levels of TRF1, a shelterin involved in telomere protection, were similar in both Danazol and placebo groups. Regarding fertility, there were no differences in the number of antral follicles, total and MII oocytes, fertilization rate and blastocyst formation. The control group had, as expected, signficantly higher mean follicle number after OS when compared with Danazol (16.0±1.4 and 0.7±0.9, P < 0.0001) and placebo (16.0±1.4 and 5.0±3.8, p = 0.0127) groups, and higher numbers of total oocytes retrieved (p = 0.006; control and Danazol, and p = 0.007; control and placebo).

Limitations, reasons for caution

Firstly, the number of patients included in the study is limited due to strict inclusion/exclusion criteria. Secondly, because follicle growth can take up to 150 days, danazol effects could be noticeable at later OS and not only in the first OS, which was the only one studied here.

Wider implications of the findings

Since telomeres seem to elongate in blood samples after Danazol treatment in DOR patients, we could hypothesize that this may have a positive impact for general health, including the ovaries. Thus, danazol therapy might help improving IVF outcomes, perhaps at later OS.

Trial registration number

NCT04058678

P-374 Serum progesterone levels on the of embryo transfer in replacement cycles (HRT-ET): soft capsules vs suppositories may make a difference

Study question

Are there differences in serum progesterone levels when vaginal progesterone is administered in soft capsules vs suppositories in HRT-ET?

Summary answer

Mean serum levels of progesterone in embryo replacement cycles are higher when progesterone suppositories are used instead of soft capsules.

What is known already

Serum levels of progesterone on the day of the embryo transfer has captured recent attention, as it may vary among patients and different vaginal progesterone formulations. Previous studies have suggested that natural micronized vaginal progesterone induces a comparable decidual transformation and clinical pregnancy rates to vaginal progesterone gel. However, no data exists comparing suppositories versus soft capsules.

Study design, size, duration

Prospective, observational, single center study to compare serum progesterone levels on the day of the embryo transfer in women undergoing HRT-ET and being treated with vaginal progesterone in capsules or suppositories. Also, a patient satisfaction questionnaire was given to women participating in the study to investigate patient experience. Sample size calculation estimated 50 patients per group needed for a = 0.05 and power 90%, considering standard deviation of 5.1.

Participants/materials, setting, methods

From April to October 2021, 100 patients undergoing HRT-ET were recruited. Only one type of progesterone was administered. 50 patients received soft capsules (Progeffik©, Utrogestan©) and the other half suppositories (Cyclogest©). After estradiol priming for 10-12 days and once confirmed that endometrial thickness was >7mm, 400 mg vaginal progesterone was started b.i.d. Blood was drawn on the day of embryo transfer by venipuncture and progesterone levels in blood were evaluated.

Main results and the role of chance

Mean serum levels of progesterone were significantly higher when suppositories were compared with soft capsules (16.2 ± 7 vs 12.5 ± 5.2 ng/ml, p = 0.0034). According to our previous studies we considered an adequate cut-off of progesterone of 8.8 ng/ml, and patients with a suboptimal serum level of progesterone were supplemented with subcutaneous progesterone. Of those patients receiving suppositories, only 6 out 50 (12%) required subcutaneous supplementation, whereas it was needed in 12 out of 50 (24%) women receiving soft capsules. No differences were observed in pregnancy rate (70% vs 50%) or ongoing pregnancy rate (48% vs 36%).

Regarding patient satisfaction, no differences were observed in the frequency of itching, burning, leakage of medication or drowsiness between groups.

Limitations, reasons for caution

We should consider the limited sample size and the study design, not randomized, before generalizing the results observed.

Wider implications of the findings

In luteal support of frozen embryo replacement cycles, vaginal progesterone suppositories yields superior progesterone serum levels than soft capsules.

Trial registration number

Not applicable

O-138 Covid-19 vaccine does not affect sustained implantation rates after single euploid embryo transfer, a retrospective study with 4868 cases

Study question

Is sustained implantation rate (SIR) of covid-19 vaccinated women diminished in assisted reproduction treatments due to endometrial receptivity harm?

Summary answer

SIR of euploid embryos remains constant regardless vaccination and doses applied, but impact of interval last dose-embryo transfer needs to be further evaluated.

What is known already

Little is known about the effects of both covid infection and vaccines on endometrial receptivity of women attempting motherhood.

There is a generalized concern about potential secondary effects of covid vaccine on many health areas, and assisted reproduction is not an exception. Then, it is mandatory on the current epidemic context to evaluate if either infection or its preventive treatment may interfere reproductive physiology of infertile patients.

ART offers a robust model to study this problem by controlling oocyte and embryo quality with the use of PGT-A, then enabling the study of endometrial independent contribution to reproductive success.

Study design, size, duration

Retrospective study analyzing two cohorts, historical cohort of PGT-A cases using own oocytes one year pre-pandemia, and post vaccination initiation from women already having received one or two doses.

Patients undergoing single embryo transfers (ET) after PGT-A were included, to be able to discern purely endometrial factors of sustained implantation. Means and proportions with their corresponding 95%CI (within brackets) were calculated, and crude/adjusted odds ratios calculated for the main outcomes, SIR and clinical pregnancy rate (CPR)

Participants/materials, setting, methods

A total of 4868 ET were included on this study, 3272 for the control, non vaccinated group, vs 890 from women already vaccinated with at last one dose at the time of ET.

The main outcomes were CPR per embryo transfer (presence of a sac by ultrasonography on week 7th), and SIR (fetal heartbeat at week 12th). Crude and adjusted odds ratio were calculated, using logistic regression models to control for potentially confounding variables.

Main results and the role of chance

Mean age was 38.3 years 95%CI(38.2-38.4), BMI, 23.2kg/m2 95%CI(23.1 23.4), fresh oocytes on 80%, mixed 16.4% and vitrified on 3.6% of cases. Donor sperm used on 12.8% of treatments, and testicular retrieved sperm on 2.5% of them. Day of embryo transfer was D5 on 71.3%  and D6 on 28.6% cases.

CPR per ET was 70.6% 95%CI(69.3-71.9) in the control group and 70.4%95%CI(67.4-73.4) on vaccinated, OR 0.994 95%CI(0.849-1.163), and after adjustment by patient’s age, oocyte age, source of sperm, donor sperm use, day of ET, use of vitrified oocytes and BMI, AdjOR 1.039 95%CI(0.876-1.233), while SIR in the controls was 64.3% 95%CI(62.7-66.0) vs. 62.6% 95%CI(58.8-66.4) on vaccinated, with OR 0.929 95%CI(0.777-1.110) and AdjOR 0.981 95%CI(0.807-1.192), p > 0.05.

Those patients having received only one dose or two doses by the time of ET, showed comparable results, on both CPR and SIR.

Concerning data categorized per time quartiles (from vaccine to ET), while CPR was comparable, SIR, on the first  quartile (Q1) was 66.5%, while Q2 was 68.0%, Q3 66.3%, and Q4 50.4%, and using Q1 as reference, ORQ2-Q1 1.073 95%CI(0.680-1.693), ORQ3-Q1 0.869 95%CI(0.545-1.385) and OR Q4-Q1 0.512 95%CI(0.321-0.818), p = 0.009 while after adjustment AdjORQ2-Q1 0.965 95%CI(0.585-1.594), AdjORQ3-Q1 0.834 95%CI(0.492-1.413) and AdjORQ4-Q1 0.533 95%CI(0.316-0.899), p = 0.018.

Limitations, reasons for caution

This is a retrospective study, and although controlled statistically, possible biases due to the nature of the work remain possible, and a cause-effect link cannot be purely drawn from it. Further prospective studies on the potential effect of covid vaccines on reproductive outcomes are still needed.

Wider implications of the findings

Our results send a message of reassurance to patients in the process of assisted reproductive treatment regarding the potential negative impact of the vaccine on endometrial receptivity and reproductive outcomes. Aiming motherhood is no reason for delaying vaccination against covid-19.

Trial registration number

Not applicable

O-250 Strong differences in surface molecule expression profile in both microvesicles and exosomes between patient and semen donor groups: new fertility biomarker?

Study question

Are the extracellular vesicles (exosomes and microvesicles) presented in seminal plasma a potential novel biomarkers of male infertility?

Summary answer

There are significant differences in surface molecules (CD9, CD29, CD40, CD49d, CD73, CD282 and CD284) expressed in extracellular vesicles of patient and control groups

What is known already

Male infertility has been progressively increasing in recent decades. Therefore, it is essential to find new tools that help us to diagnose the male factor. One of the potential markers could be the study of the extracellular vesicles (EV), mainly exosomes (EXO) and microvesicles (MV), present in the seminal plasma. Recent works have shown that these extracellular vesicles would have an important role in the modulation of the maternal immune system, as well as in regulating the sperm activation. Therefore, the study of the extracellular vesicles can be a useful model to increase the diagnosis of the infertile male

Study design, size, duration

This prospective study, performed between March 2019 to January 2022, included 44 semen samples from healthy semen donors (control group) and 44 semen samples from infertile males seeking infertility treatment with their partners (study group). Men under drug treatment and/or with infectious or chronic diseases were excluded from the study

Participants/materials, setting, methods

After conventional semen analysis, semen samples were ultra-centrifuged to obtain EVs enriched plasma seminal. The samples were then stained with fluorescent antibodies against the following surface molecules: CD81, CD63, CD9, CD40, CD44, CD49d, CD73, CD284 and CD29. After incubation, samples were analyzed by flow cytometry (Cytoflex cytometer) The percentage and mean expression of each molecule in EVs populations (EXOs and MVs) were determined. Statistical analysis was performed by t-Student test; significance established under 0.05

Main results and the role of chance

Conventional semen analysis showed significant differences between control and patient group in sperm concentration (77.2 · 106 vs 40.2 · 106 cells / ml, respectively, p < 0.01), percentage of progressive sperm (60 vs 40.3 %, respectively, p < 0.01) and total progressive sperm cells (170 · 106 vs 69 · 106 spermatozoa, respectively, p < 0.01). Flow cytometry analysis demonstrated that the MVs population is larger than the EXOs population in both control and patient group. With respect to the surface molecule expression in EXOs population, patient group showed significant higher expression of CD9 (31.18 vs 20.1 % control group, p < 0.01), CD40 (8.94 vs 3.84 % control group, p < 0.001), CD49d (69.07 vs 46.73 %, control group, p < 0.001), CD73 (68.17 vs 51.41 % control group, p < 0.001) and CD284 (61.48 vs 53.45 % control group, p < 0.01), and significant lower expression of CD29 (19.49 vs 29.54 % control group, p < 0.01) molecules compared to control group. When MVs populations were analyzed, significant differences between patient and control group were found in the expression of CD63 (13.01 vs 1.65 %, respectively p < 0.001), CD40 (9.23 vs 1.34 %, respectively p < 0.001), CD282 (17 vs 10.22 %, respectively p < 0.01) and CD29 (17.11 vs 7.8 %, respectively p < 0.001) molecules

Limitations, reasons for caution

This study enrolled male partners of couples seeking infertility treatment with dissimilar disorders and seminal diagnosis (astheno, oligo, and teratozoospermia). Therefore, further studies are needed lowering the heterogeneity of the study group. No data about reproductive outcome of these patients are available at this moment

Wider implications of the findings

These results suggest that the differences found in the expression profiles between men with proven fertility and infertile men may be related to molecular mechanisms implicated in sperm function, and/or female immune system modulation and, for that reason, may be used as a new potential marker of male fertility

Trial registration number

1904-MAD-045-AP

ALWAYS ICSI? A SWOT analysis

PURPOSE

Intracytroplasmatic sperm injection (ICSI) is a common procedure used to improve reproductive results, even among couples without male factor infertility. However, the evidence available is still uncertain on the possible advantages and deficiencies that this procedure may have in patients with no formal indication for ICSI.

METHODS

A SWOT (strengths, weaknesses, opportunities, threats) analysis examines the possible advantages and deficiencies of performing ICSI in these patients with no formal indication.

RESULTS

The evidence suggests that ICSI is not justified for non-male factor infertile couples requiring in vitro conception. One of the major strengths associated to the procedure is the virtual elimination of cases further complicated by total fertilization failure and a combination between IVF and ICSI on sibling oocytes has been advised in the literature. Greater technical difficulties, higher costs and performing an unnecessary invasive technique in some cases represent some of the weaknesses of the procedure, and questions regarding safety issues should not be ruled out.

CONCLUSION

Despite the widespread use of ICSI in patients without a formal diagnosis of male factor infertility, evidence demonstrating its effectiveness in this population is still lacking. Additional large and well-designed randomized controlled trials are needed to clarify definitive indications for ICSI in non-male factor infertility.

Elective and Onco-fertility preservation: factors related to IVF outcomes

STUDY QUESTION

Is the indication for fertility preservation (FP) related to success in IVF cycles after elective-FP (EFP) for age-related fertility decline and FP before cancer treatment (Onco-FP)?

SUMMARY ANSWER

Although success rates were lower in cancer patients, there was no statistically significant association between malignant disease and reproductive outcome after correction for age and controlled-ovarian stimulation (COS) regime.

WHAT IS KNOWN ALREADY

FP is increasingly applied in assisted reproduction, but little is known about the outcome of IVF cycles with vitrified oocytes in FP patients.

STUDY DESIGN, SIZE, DURATION

Retrospective, observational multicenter study of vitrification cycles for FP and of the warming cycles of women who returned to attempt pregnancy from January 2007 to May 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 6362 women (EFP = 5289 patients; 7044 cycles + Onco-FP = 1073 patients; 1172 cycles) had their oocytes vitrified for FP. A logistic regression analysis was performed to examine the impact of indication for FP corrected for age at vitrification. The protocol used for COS was also included as a possible confounder. The main outcome measures were oocyte survival and live birth. A detailed description of the baseline and clinical data is provided, with comparisons between EFP and Onco-FP. The cumulative live birth rate (CLBR) per utilized oocyte according to age at vitrification was analyzed in those patients returning to use their oocytes.

MAIN RESULTS AND ROLE OF CHANCE

Age at vitrification was significantly older in EFP patients (37.2 ± 4.9 vs. 32.3 ± 3.5 year; P < 0.0001). Fewer oocytes were retrieved and vitrified per cycle in EFP (9.6 ± 8.4 vs. 11.4 ± 3.5 and 7.3 ± 11.3 vs. 8.7 ± 2.1, respectively; P < 0.05), but numbers became comparable when analyzed per patient (12.8 ± 7.4 vs. 12.5 ± 3.2 and 9.8 ± 6.4 vs. 9.5 ± 2.6). Storage time was shorter in EFP (2.1 ± 1.6 vs. 4.1 ± 0.9 years; P < 0.0001). In all, 641 (12.1%) EFP and 80 (7.4%) Onco-FP patients returned to attempt pregnancy (P < 0.05). Overall oocyte survival was comparable (83.9% vs. 81.8%; NS), but lower for onco-FP patients among younger (≤35 year) subjects (81.2% vs. 91.4%; P > 0.05). Fewer EFP cycles finished in embryo transfer (50.2% vs. 72.5%) (P < 0.05). The implantation rate was 42.6% and 32.5% in EFP versus Onco-FP (P < 0.05). Ongoing pregnancy (57.7% vs. 35.7%) and live birth rates (68.8% vs. 41.1%) were higher in EFP patients aged ≤35 than the Onco-FP matching age patients (P < 0.05). The reason for FP per se had no effect on oocyte survival (OR = 1.484 [95%CI = 0.876-2.252]; P = 0.202) or the CLBR (OR = 1.275 [95%CI = 0.711-2.284]; P = 0.414). Conversely, age (<36 vs. ≥36 y) impacted oocyte survival (adj.OR = 1.922 [95%CI = 1.274-2.900]; P = 0.025) and the CLBR (adj.OR= 3.106 [95%CI = 2.039-4.733]; P < 0.0001). The Kaplan-Meier analysis showed a significantly higher cumulative probability of live birth in patients <36 versus >36 in EFP (P < 0.0001), with improved outcomes when more oocytes were available for IVF.

LIMITATIONS, REASONS FOR CAUTION

Statistical power to compare IVF outcomes is limited by the few women who came to use their oocytes in the Onco-FP group. The patients' ages and the COS protocols used were significantly different between the EFP and ONCO-PP groups.

WIDER IMPLICATIONS OF THE FINDINGS

Although the implantation rate was significantly lower in the Onco-FP patients the impact of cancer disease per se was not proven'. EFP patients should be counseled according to their age and number of available oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

The endometrium versus embryonic quality in endometriosis-related infertility

In spite of a great deal of effort over many decades, the mechanisms that lead to infertility in women with endometriosis remain unknown. Moreover, controversial results in the literature add even more difficulties in the understanding of this issue. Since the introduction of IVF, we have had the opportunity to study the effects of endometriosis at specific stages of the reproductive process including folliculogenesis, fertilization, embryo development and implantation. Depending on the research group, there are conflicting data on the results of IVF in patients with endometriosis. Some researchers found impaired implantation in patients with endometriosis, but such a defect in implantation may be caused by either defective embryos or altered endometrium. The observation of a higher rate of arrested embryos in patients with endometriosis compared with disease-free women, and that women with this pathological situation undergoing ovum donation had the same chance of implantation as patients without endometriosis, initially suggested that impaired oocyte/embryo quality may be responsible for reduced implantation. Further investigations on follicular components have also found differences between women with endometriosis and those without the disease. In addition, recent advances on implantation research, mainly on markers of endometrial receptivity, also show features in the eutopic endometrium of women with endometriosis that are not found in endometrium of women without the disease, although there is no agreement on this point. In this review, we will focus on infertility-related endometriosis based on our own research and the available literature.

Increasing the length of the middle crura for better tip projection in primary rhinoplasty

Cartilage grafts have been a very popular method for achieving tip projection in difficult noses. Sometimes asymmetries and graft visibility are undesirable complications. Remodeling the alar cartilages, using a cartilage flap from the lateral crura, rotated over the original domes, is another alternative for achieving tip refinement and projection. The surgical technique is described and clinical results are presented.

Nose surgery and the vomeronasal organ

The latest reports on the anatomical and functional characteristics of the vomeronasal organ (VNO) are evaluated. The high incidence of identification of the vomeronasal organ in normal individuals indicates that the vomeronasal organ in normal individuals indicates that the vomeronasal system is a universal feature of the adult human nasal cavity. Evaluation of the neuronal connections between this organ and the central nervous system shows that the VNO is a functional chemosensory system with sexually dimorphic specificity and the ability to transduce signals that modulate certain autonomic parameters. The presence of the VNO and its clinical significance must be considered by plastic surgeons during nasal operations.