Live birth rate after female fertility preservation for cancer or haematopoietic stem cell transplantation: a systematic review and meta-analysis of the three main techniques; embryo, oocyte and ovarian tissue cryopreservation

STUDY QUESTION

What are the chances of achieving a live birth after embryo, oocyte and ovarian tissue cryopreservation (OTC) in female cancer survivors?

SUMMARY ANSWER

The live birth rates (LBRs) following embryo and oocyte cryopreservation are 41% and 32%, respectively, while for IVF and spontaneous LBR after tissue cryopreservation and transplantation, these rates are 21% and 33%, respectively.

WHAT IS KNOWN ALREADY

Currently, fertility preservation (FP) has become a major public health issue as diagnostic and therapeutic progress has made it possible to achieve an 80% survival rate in children, adolescents and young adults with cancer. In the latest ESHRE guidelines, only oocyte and embryo cryopreservation are considered as established options for FP. OTC is still considered to be an innovative method, while it is an acceptable FP technique in the American Society for Reproductive Medicine guidelines. However, given the lack of studies on long-term outcomes after FP, it is still unclear which technique offers the best chance to achieve a live birth.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review and meta-analysis of published controlled studies. Searches were conducted from January 2004 to May 2021 in Medline, Embase and the Cochrane Library using the following search terms: cancer, stem cell transplantation, FP, embryo cryopreservation, oocyte vitrification, OTC and reproductive outcome.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 126 full-text articles were preselected from 1436 references based on the title and abstract and assessed via the Newcastle-Ottawa Quality Assessment Scale. The studies were selected, and their data were extracted by two independent reviewers according to the Cochrane methods. A fixed-effect meta-analysis was performed for outcomes with high heterogeneity.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 34 studies were used for this meta-analysis. Regarding cryopreserved embryos, the LBR after IVF was 41% (95% CI: 34-48, I2: 0%, fixed effect). Concerning vitrified oocytes, the LBR was 32% (95% CI: 26-39, I2: 0%, fixed effect). Finally, the LBR after IVF and the spontaneous LBR after ovarian tissue transplantation were 21% (95% CI: 15-26, I2: 0%, fixed-effect) and 33% (95% CI: 25-42, I2: 46.1%, random-effect), respectively. For all outcomes, in the sensitivity analyses, the maximum variation in the estimated percentage was 1%.

LIMITATIONS, REASONS FOR CAUTION

The heterogeneity of the literature prevents us from comparing these three techniques. This meta-analysis provides limited data which may help clinicians when counselling patients.

WIDER IMPLICATIONS OF THE FINDINGS

This study highlights the need for long-term follow-up registries to assess return rates, as well as spontaneous pregnancy rates and birth rates after FP.

STUDY FUNDING/COMPETING INTEREST(S)

This work was sponsored by an unrestricted grant from GEDEON RICHTER France. The authors have no competing interests to declare.

REGISTRATION NUMBER

CRD42021264042.

P-286 Can laser assisted hatching help implantation of warmed blastocysts in presence of fragmented cells ?

Study question

Does laser assisted hatching (LAH) following warming of blastocysts containing fragmentated cells improves blastocyst expansion and implantation?

Summary answer

The application of LAH does not improve blastocyst expansion and implantation regardless the presence or absence of fragmented cells.

What is known already

The absence of natural hatching is one of the hypotheses of implantation failure after cryopreservation, a process that could lead to hardening of the zona pellucida. Another theory is the fact that cellular fragments inside the zona pellucida, surrounding the trophectoderm, could impairs the exit of the blastocyst through the zona decreasing its chances of implantation. Available data regarding the effect of LAH on blastocysts after vitrification are inconclusive and limited to small samples. Evaluating the effectiveness of LHA performed at the time of blastocyst warming when cellular fragments are present could elucidate its impact on hatching and implantation

Study design, size, duration

A bicentric prospective randomized study including 344 successive FET cycles from January 2020 until March 2021. Patients were enrolled only once in the study. Patients underwent a natural cycle or hormonal replacement treatment for FET. Blastocysts graded ≥ BL3BB (Gardner scoring) underwent artificial collapse and were vitrified on D5 or D6. Only blastocysts surviving post-warming were considered in the analysis. Primary end point was clinical pregnancy rate.

Participants/materials, setting, methods

Patients ≤42 years with ≤3 previous oocyte retrievals scheduled for the first elective single embryo transfer (eSET) with vitrified/warmed blastocysts. Survived blastocysts were randomized immediately after warming to LAH group (n = 172) or to control group (no-LAH, n = 172). Cellular fragmentation was annotated as a percentage of the total volume of the embryo (0%, ≤25%, ≤50%, >50%) and LHA was performed on the opposite side. Embryo expansion was annotated at time of transfer, at 3 hours post-warming.

Main results and the role of chance

Patients age were similar between LHA (33.1±9.3) and controls (34.8±7.5). Patients in LAH and controls had similar pregnancy rates (hCG >100) (46% versus 52%, respectively), CPR (37% versus 36%, respectively) (NS) and miscarriage rates. No difference was observed in CPR in relation to patients age. A significant increase in implantation was observed when blastocyst expansion took place 3 hours after warming, independently whether allocated in LAH (47% versus 17%, p < 0.01) or no-LAH group (51% versus 33%, p < 0.01). LAH did not influence cell expansion (83% in LAH versus 85% in no-LAH), however more blastocysts underwent hatching in LAH group (27% versus 12% in no-LAH, p < 0.06). Significantly more embryos that had hatched in LAH group led to pregnancy compared to no-LHA (83% versus 67%, respectively) (p = 0.05).

Extra-cellular (EC) fragmentation not did not impact implantation in neither of the groups. LAH group had 46% of embryos implanted when absence of fragmentation, 40% when EC was present at ≤ 25%, 58% when EC was present at > 25% (NS). In no-LAH group, 52% of embryos implanted when absence of fragmentation, 49% when EC was present at ≤ 25%, 65% when EC was present at > 25% (NS).

Limitations, reasons for caution

A sample size of 700 blastocysts was first chosen calculating a 10% difference in clinical pregnancy rate (CPR) between LAH-group and no-LAH group. The study was interrupted following this interim analysis. Live birth outcomes should be considered in a further analysis to conclude on the null impact of LHA post-warming.

Wider implications of the findings

This study adds to the evidence of the existence of a limited potential of the application of LAH on vitrified-warmed blastocysts and its impact in terms of clinical pregnancy rates.

Trial registration number

not applicable

P–756 Predictive factors influencing multiple live births in cumulative IVF cycles: retrospective analysis of over 265000 embryo transfer procedures from the national French registry

Study question

What are the factors that could predict the number of embryos to be transferred in order to diminish risk of multiple pregnancies?

Summary answer

Single embryo transfer (SET) is advisable for <38 year-old women in fresh cycles and for <35 year-old women in FET whatever the IVF number attempts.

What is known already

Multiple pregnancies are associated to increased maternal and perinatal complications. Risks associated to multiple implantations are significantly reduced with SET policy. However, while SET is more assertive with a lesser negative impact in younger patients (<35 years), its feasibility is less evident for the older population, whom oocyte quality is likely compromised. A double embryo transfer (DET) could improve chances of implantation and shorten their time to pregnancy. Identification of risk factors for multiple pregnancies could help in decision making for a double or SET and reduce chances for multiple gestations without reducing the chances to achieve pregnancy.

Study design, size, duration

A retrospective study from the national French data registry provided and approved by the Agence de la Biomédecine was performed. A total of 196530 fresh and 68913 frozen cycles from women aged 18–43 year-old were included (2014–2017). Risk factors assessed included women’s age, number of attempts, number of oocytes, fertilization rate, embryo stage, number of embryos transferred, number of supernumerary embryos frozen. Secondary infertility, oocyte donor, oocyte freezing, PGT, freeze-all and IVM cycles were excluded.

Participants/materials, setting, methods

Cumulative cycles derived from 65% of ICSI, 32% of IVF and 3,2% IVF/ICSI. The distribution of patients age at oocyte retrieval was 60% < 35, 21% < 38, 11% < 40, and 8% ≥ 40 years old. Multivariable logistic regression was conducted to calculate adjusted odds ratios with 95% confidence intervals for live birth chance and multiple live birth risk associated with each risk factor.

Main results and the role of chance

The chances of obtaining a cumulative live birth decreases with increased patients age (OR 0.71 for 35–38 years and 0.47 for 38–40 years, p < 0.00001), with increased number of attempts (from OR 0.87 for attempt = 2 to OR 0.74 for attempt ≥ 4, p < 0.00001), and for frozen embryos transferred (OR 0.14, p < 0.00001). The chances of live birth increases with the increased number of oocytes (from OR 1.33 for 4–12 to OR 1.52 for > 18, p < 0.00001 in all cases), with a fertilisation rate >40% (OR 1.29, p < 0.00001), with blastocyst transfer (OR 1.29, p < 0.00001), with the increase on the number of frozen embryos (OR 7.37 for >1, OR 13.08 for >2, and OR 16.92 for >6, p < 0.00001 in all cases) and number of embryos transferred (OR 1.42 for 2 embryos and OR 1.39 for >2 embryos, p < 0.00001 in all cases).

In case of live birth, the risks of multiple births when two embryos were transferred decreases in patients aged >38 years (OR 0.50, p < 0.00001) and for frozen embryos transferred (OR 0.65, p < 0.00001). The risk increases with a fertilisation rate >60% (OR 1.30, p < 0.00001), with blastocysts transfer (OR 1.34, p < 0.00001) and when at least one supernumerary embryo is frozen (OR > 1.30, p < 0.00001).

Limitations, reasons for caution

This study is limited in only providing a risk-benefit balance for multiples on the choice of transferring one or two embryos. Clinical data such as stimulation protocols and doses of gonadotropins were not considered in this evaluation.

Wider implications of the findings: This study provides help to develop a strategy for the medical staff in the decision making for the number of embryos to be transferred. It may also serve as a patient’s information aid and help to improve their chances of achieving a health singleton if pregnant.

Trial registration number

Not applicable

[Regional state-of-the-art of the access to oncofertility consultation for young women with breast cancer]

OBJECTIVES

According to the 2004 Bioethics Act, oncofertility counselling must be systematically offered to all women of childbearing age before they are exposed to potentially gonadotoxic treatment. The main objective of this study was to evaluate the proportion of women under 40 years of age treated with chemotherapy for breast cancer in Midi-Pyrénées who have received an oncofertility consultation. A secondary objective was to assess practitioners' knowledge on the subject.

METHODS

A cross-reference was made between the databases of the oncology network in Midi-Pyrénées and the two approved centres for the preservation of fertility in the region. A computerized practitioner questionnaire was sent to all surgeons and oncologists who could manage these patients.

RESULTS

From 2012 and 2017, 667 women aged≤40 years received (neo)adjuvant chemotherapy treatment: only 156 (23.4%) had access to an oncofertility consultation and 58 (8.7%) received preservation. This rate (23.4%) varied according to the age of the patients, ranging from 56.9% for those aged 25-29 to 13.4% for those aged 35-39 and the managing institution. Of the 85 practitioners surveyed, 45 (55%) responded to the questionnaire, and of these 20 (44%) knew that ovarian stimulation treatment could be used even in hormone-dependent breast cancer situations and 13 (29%) of practitioners believed that the time required to preserve fertility was more than 1 month.

CONCLUSION

Our study revealed a significant disparity in access to oncofertility consultation. It is essential to set up information and awareness-raising actions on the subject.

Exacerbations de BPCO: Audit de pratique dans les services d’urgences en France

INTRODUCTION

Exacerbations of COPD are potentially serious events, the recognition and treatment of which appear to be poorly understood by both patients and doctors. The aim of this study is to describe, on the basis of two case histories, the management of exacerbations of COPD in emergency departments, to compare it with the current guidelines and to evaluate the extent of use of non-invasive ventilation in decompensated COPD.

METHODS

The study took place between February and June 2004. Two case histories describing one moderate and one severe exacerbation with respiratory failure were written by the authors of the study and submitted to an emergency physician in a university hospital and a district hospital in each region.

RESULTS

110 questionnaires were returned from 20 university hospitals and 25 district hospitals. Only 38% of the episodes were identified correctly. 20% of doctors did not regard dyspnoea as a clinical sign of an exacerbation. 22% of doctors never prescribed bronchodilators, even in severe cases. Finally, non-invasive ventilation (NIPV) was used for only 9% of the moderate and 56% of the severe exacerbations.

DISCUSSION

This study, although limited by certain factors, illustrates a number of points in need of improvement in the recognition and treatment of exacerbations of COPD in emergency departments, the use of NIPV, and the collaboration between emergency physicians, intensivists and respiratory physicians.

[Rheumatologic manifestations of chronic myelomonocytic leukemia. Presentation of 2 cases]

We describe two patients with chronic myelomonocytic leukemia (CMML) and associated rheumatic manifestations. The first patient presented an acute seronegative arthritis one month before the diagnosis of CMML and another bout one month after the diagnosis had been made. No specific cause was found after complete laboratory and roentgenographic studies. The second patient was diagnosed of Sjögren's Syndrome two years before the CMML became apparent. Although immunologic abnormalities are frequently observed in CMML, after a thorough bibliographic research we have found scarce reports describing associated rheumatic conditions.

Inhibitory effect of aryl thienyl-ketones and -thioketones on arachidonic acid-induced malondialdehyde formation in human platelets: biological data and molecular modelling

A series of anti-thrombotic aryl thienyl-ketones and -thioketones was assayed in vitro for their inhibitory effect on malondialdehyde (MDA) production induced by arachidonic acid in human platelets. For several compounds MDA formation was strongly inhibited indicating that the anti-platelet target was situated on the cyclooxygenase pathway. A comparison between the inhibition constant Ki and the IC50 values revealed competitive inhibition kinetics. The molecular structure of one active compound was analysed by X-ray diffraction and theoretical calculations to provide information on its electronic and lipophilic properties.