COGI 2018: 5 key messages

COGI is over for another year. Now we can take time to digest the information from the inspiring and thought-provoking sessions and ask ourselves: ‘what have we learnt?’

In this special edition blog we look back at five key messages and highlights from the three days.

 

1.       Time to consider HRT for primary CHD?

Research suggests that estrogen has a clear biological effect on the cardiovascular system, demonstrating beneficial effects on some of the key risk factors of Cardiovascular Heart Disease (CHD). While there is a lack of definitive evidence supporting HRT as a prevention for postmenopausal CHD, there are a growing number of epidemiological and observational studies supporting its use. In these studies, timing was shown to be a key factor with HRT demonstrating no benefit in older women. However, although there was no benefit there was also no evidence of harm.

 

2.       The role of epigenetics in long term health

Specific epigenetic input during development can produce a lasting difference in phenotype, meaning fetal programming, metabolic endocrine disruption and structural change in organs can all significantly affect the birth of a child.

For example, Caesarean Sections are linked to increases in neonatal morbidity, auto-immune diseases and metabolic disease in the offspring. Maternal obesity and smoking are also shown to be associated with long term negative outcomes for the child. In fact, research suggests that these negative effects may even cross generations.

 

3.       Fertility may be able to be preserved in women with POI

Primary ovarian insufficiency (POI) affects 1 in 100 women at the age of 40. In order to plan the most effective fertility preservation treatment, it is crucial to predict as much as possible whether POI may be imminent. While this is not simple, the condition is hereditary therefore assessing family history may help to provide important insight. Additionally, more research is taking place into the genetic basis of POI, with some evidence suggesting that reproductive health and success may be a marker for identifying POI and health outcomes later in life.  

There are many more options available for treating imminent POI than confirmed POI, including vitrification of oocytes or embryos following ovarian stimulation, freezing of ovarian tissue or a combination of the two. When treating confirmed POI, the options are more complex. While a small number of sufferers may go on to experience a spontaneous pregnancy, researchers are now considering a new technique: in vitro follicle activation (IVA). However, refinement and improvement of the technique is needed for it to lead to an effective strategy for these patients.

  

4.       The freezing debate is definitely not over!

The debate on whether freezing oocytes for non-medicinal reasons is truly beneficial contined at COGI. Speakers argued that social freezing could be seen as a purely commercial enterprise with advertising often aggressive and marred with misinformation. In fact, only 12% women actually return to the clinic and there is a far from certain chance of success.

However, freezing was shown to provide effective results in younger women seeing fertility preservation. In addition, some studies have demonstrated that freezing may be able to reduce risk of OHSS and be beneficial for groups of high responders.

 

5.       ART may be driving rates of pre-term birth

ART is associated with increased incidence of multiple pregnancy. Multiple pregnancy in turn is related with higher risk of pre-term birth and Cerebral Palsy. Using real world data we were shown that incidence of twins born at <32 weeks increased 27-fold from 1987 to 2010, with ART suggested as a main driver.

Time to give IVM a second chance?

The area of assisted reproduction has seen development of a great number of technologies. Some have come and gone, while others have established their importance and have been further developed over the years. And, while it is clear that great steps have been made in the effectiveness of assisted reproductive technology (ART), there are still some key improvements to be made. These include:

-          Reducing incidence of OHSS

-          Reducing psychological pressure

-          Reducing financial pressure

-          Increasing access to treatment

When considering how to make these improvements, we must consider the value of the procedures being offered in clinics today. Are there some that may be being overused? And are some not being used enough? At COGI 2018, we listened as a panel of expert speakers discussed these key questions.

 

Reconsidering IVM

In vitro maturation (IVM) involves the procedure of retrieving early follicles, followed by their maturation in the laboratory. The process was initially developed by Pincus and Enzmann in 1935, with Cha et al the first to successfully deliver a human live birth in 1991. However, in recent years the procedure has been relatively side-lined in clinics.  

Dr. Johan Smitz discussed why this may be. He explained there were two key reasons why IVM remains under-utilized:

-          Follicle heterogeneity - injecting hCG on the small 6-12 mm follicles can cause asynchronous maturation of the oocyte

-          Inappropriate signalling -  IVM can result in spontaneous re-initiation of meiosis

In addition, further issues are associated with IVM. There is a steep learning curve for those undertaking the procedure and a current lack of clear standard operating procedures means that there is a risk that success would not be easily standardised between centres. Also, Dr. Smitz explained that there are certain prejudices related to IVM, with many women believing that the treatment is more painful than IVF. However, this may not necessarily be the truth.

Despite these issues, IVM has a number of significant advantages. When compared with IVF, IVM requires less consultations, monitoring and injections. Dr. Smitz also explained the treatment can be more cost effective and more comfortable.

IVM is also the only ART with zero risk of OHSS. This means that the procedure could be especially suitable for women suffering from Polycystic Ovary Syndrome (PCOS).

 

How can we improve IVM?

Dr. Smitz outlined five key steps to improve the IVM procedure.

Abandon the hCG injection to avoid the issues associated with asynchronous maturation

-          Apply a positive in-vitro maturation stimulus to help to avoid the issues related with inappropriate signalling

-          Give FSH or HO-hMG Priming at 2-3 days

-          Use defining culture media

-          Use a pre-maturation culture

 

Is Capacitation – IVM a step to the future?

Adopting capacitation culture (CAPA) conditions was shown to improve success of IVM. Dr. Smitz shared data from five pilot studies demonstrating that CAPA-IVM can result in high implantation rates and increased number of embryos per oocyte-pickup. The results of these studies remain unpublished at this time however we cannot wait to read the full reports! Further study, improvement and adoption of this procedure can clearly benefit the field and we are excited to see what comes next.