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.

Social freezing - A debate

 Traditionally oocytes were only frozen for the purpose of fertility preservation, including for women who may be undergoing chemotherapy.

However, in recent years the concept of social freezing has flourished, where oocytes are frozen for non-medical reasons. This decision to delay conception and pregnancy may be taken for a number of different reasons. Indeed overall, research suggests that both age of marriage and pregnancy are generally rising in high economic countries.

At COGI we were treated to an engaging debate on the key discussions surrounding social freezing, considering whether it truly is a benefit or whether it should be seen as a purely commercial function.

Dr. Ana Cobo opened the discussion, explaining that social freezing can provide effective results in younger women. Oocyte quality is affected by age, therefore the younger the age when the oocyte frozen, the better the chance of a positive clinical outcome later on. However, Dr. Cobo discussed that the majority of patients desiring social freezing were over 35 years old. 16% were 40 years or older. She explained that the outcomes in older women were significantly reduced and that the quality of the oocytes would be severely impacted.

Even in younger healthy women, there is not a complete success rate, with survival failure still a risk. Dr. Cobo shared data from a cohort of younger women which also demonstrated that after a single cycle failure, risk of a second cycle failure was 4x greater. It is therefore important to manage expectations and provide clear information to all women desiring to undertake social freezing.

 

Is social  freezing a purely commercial product?

In his presentation, Dr. Norbert Gleicher reiterated the importance of providing women with accurate and evidence based information in order for them to make an informed decision before undertaking social freezing.

He argued that social freezing can be seen as a purely commercial product. In the US, misinformation and aggressive advertising results in misunderstanding that oocytes can be frozen at any age and will be able to be used to deliver a healthy child when desired. Dr. Gleicher explained that social freezing is often advertised as an insurance, when in fact the success of the process is much less certain.

We must also consider the low number of returning women to actually use the frozen oocytes. In one framework, Dr. Gliecher discussed that only 12% women actually returned. With the high upfront costs associated with freezing oocytes, the low level of returning women and the uncertain level of success, we can see why it is so important to understand why ensuring a high level of informed consent and transparency is so important.

 

Is social freezing cost effective?

Dr. Zion Ben Rafael closed the debate by arguing that social freezing is not cost effective. He explained that the cost is an estimated $1million per birth and that the process is only cost effective after the age of 37. However, with live birth rates known to be lower in women over 35, while the process may be cost effective there is no guarantee of success. While success rates are higher in younger women, Dr. Rafael explained that the younger a woman is, the less likely it is that they will use their frozen oocytes as it more likely that they will have a natural birth.