08:30 AM - 08:50 AM
GnRHa Trigger-state of ART. [Dr. Peter Humidan]
Human chorionic gonadotropin (hCG) has been used as a surrogate for the mid-cycle surge of LH for several decades due to structural and biological similarities between the two molecules. Although hCG effectively secures final oocyte maturation and ovulation, its use has several drawbacks - first and foremost a sustained luteotropic effect, facilitating ovarian hyperstimulation syndrome (OHSS).
After the introduction of the GnRH antagonist protocol, final oocyte maturation can be triggered with a single bolus of a GnRHa.
The initial studies from 2005, however, reported a poor clinical outcome when GnRHa was used to trigger final oocyte maturation in patients who received a fresh transfer. The problem appeared to be a luteal phase deficiency, despite standard luteal phase supplementation with progesterone and estradiol.
Over the years several studies have been performed, introducing the "modified" luteal phase support concept after GnRHa trigger which rescues the luteal phase, resulting in ongoing pregnancy rates similar to those of hCG trigger – and result in an almost elimination of OHSS. Thus, GnRHa trigger is likely to become the future gold standard trigger concept.
09:00 AM - 09:20 AM
Current evidence on freeze all. [Dr. Kemal Ozgur]
Purpose In segmented ART treatment or so-called ‘freeze-all’ strategy fresh embryo transfer is deferred, embryos cryopreserved, and the embryo transferred in a subsequent frozen embryo transfer (FET) cycle. The purpose of this cohort study was to compare a GnRHa depot with an oral contraceptive pill (OCP) programming protocol for the scheduling of an artificial cycle FET (AC-FET) after oocyte pick-up (OPU).
Methods This retrospective cohort study was conducted on prospectively performed segmented ART cycles performed between September 2014 and April 2015. The pregnancy, treatment duration, and cycle cancellation outcomes of 170 OCP programmed AC-FET cycles were compared with 241 GnRHa depot programmed AC-FET cycles.
Results No significant difference was observed in the per transfer pregnancy and clinical pregnancy rates between the OCP and GnRHa groups, 72.0 versus 77.2 %, and 57.8 versus 64.3 %, respectively. Furthermore, the early pregnancy loss rate was non-significantly different between the OCP and GnRH protocol groups, 19.8 versus 16.7 %, respectively.
However, nine (5.29 %) cycles were cancelled due to high progesterone in the OCP protocol group, while no cycles were cancelled in the GnRHa protocol group and the time taken
Session  Debate
09:30 - 10:00
Which Protocol in IVF?
[Dr. Dania AlJaroudi & Dr. Hisham Ayoub]
10:00 - 10:30
Role of Hysteroscopy in ART
[Dr. Abdullaziz Al Shahrani & Dr. Mamdouh Escander]
10:30 – 11:00
PGS for Gender Selection, to offer or not?
[Dr. Abdalla Salih & Dr. Saad Al Hassan]
11:00 – 11:20
Andrology Case Presentation. [Dr. Hamoud Al Matrafi]
13:30 – 13:50
Current evidence on IVF augmented with PGS. [Dr. Kemal Ozgur]
Parallel innovations in laboratory technologies and procedures over the last decade has seen the reproductive outcomes of IVF improve significantly. In vitro culture technology innovations have led to increased blastulation rates and as a result blastocyst transfers, with a concomittant increase in reported implantation rates. Cryopreservation technology innovations have led to the reporting of survival rates consistently >90%, with the use of vitrification. Comprehensive chromosome screening (CCS) innovations have led to clinically recognizable error rates of <0.5%, with single embryo transfers (SET) of screened embryos resulting in live birth rates equivalent to multi-embryo embryo transfers (ET) of unscreened embryos. Importantly, the increased survival rates of developmentally competent vitrified-warmed blastocysts have resulted in the increased use of frozen embryo transfers (FET), with implantation and live birth rates reported to be at least equivalent to those of fresh blastocyst transfers. With the reproductive outcomes of FET no longer inferior to those of fresh ET, clinicians have the opportunity to investigate how to exploit the benefits (i.e. endometrial receptivity) of FET and the optimal scheduling of procedures for transferring all embryos into physiologically normal intrauterine conditions of FET. The freeze-all strategy known as segmented-IVF has been purported to be a viable alternative to conventional IVF, especially if any conditions resulting from controlled ovarian stimulations (COS) have the potential to adversely affect the reproductive outcomes of fresh ET. Moreover, by combining blastocyst culture, blastocyst CCS, blastocyst vitrification, and blastocyst FET may achieve the best possible live birth outcomes in IVF.
14:00 – 14:20
From POR to low prognosis the new POSEIDON. [Dr. Peter Humidan]
The incidence of poor ovarian response (POR) during ART has generally been reported to vary from 9 – 24 %. Until the establishment of the ESHRE Bologna criteria for POR (2011) no strict criteria to define POR existed, hampering the conclusions drawn from clinical trials and meta-analyses. However, after their introduction even the Bologna criteria were criticized of describing a heterogenous group of patients with different success rates after ART. Importantly, no clinical recommendations for handling of the POR patient were given. In contrast, The Poseidon Group recently proposed a new stratification system in an attempt to further define the group of low prognosis patients, taking into account ovarian reserve and age, which are the two most prominent key factors to predict success in ART (Alviggi et al., 2016; Humaidan et al., 2016). In this stratification system four different sub-groups of low prognosis (POR) patients are defined as well as the suggested matching protocols and regimens, which might increase the success rate of the patient. Moreover, Poseidon introduces a new measure for successful ART treatment, namely, the number of oocytes needed in each specific patient to obtain one euploid embryo for transfer. The so-called Poseidon Calculator which is currently being developed will enable clinicians to calculate this new measure, also taking into account site specific parameters. During this lecture an updated review of strategies and adjuvants as well as future therapeutical options for the low prognosis (POR) patient will be presented. Although, the handling of the poor responder patient still represents a therapeutic challenge, there might be some light “at the end of the tunnel”.
14:30 – 14:50
Bio-Regulation of PGD in Bahrain and other GCC countries. [Dr. Mariam Dashti]
Genetic data are predictive, permanent, and extremely sensitive. Unlike infertility conditions, genetic errors in humans can not be reversed or rectified, but they can be prevented in future generations. Currently, intervention of pre-implantation genetic Diagnosis (PGD) in assisted reproduction has been used in detection of many genetic and chromosomal abnormalities. PGD is preferred to prenatal genetic testing as it imposes lower health risks to mothers and is ethically more acceptable in cultures with reservation on abortion.
Accreditation of genetic labs assists in improving patient’s care and protecting public health. The guidelines and recommendations for best practice offered by ESHRE- PGD consortium and PGDIS are quiet elaborate and are extremely helpful in establishment of an efficient PGD facility. Yet, at levels of quality assurance and service maintenance, labs offering such highly complex tests require proper accreditation by a robust program such as ISO. The College of American Pathologists (CAP), used the internationally recognized ISO 15189 to standardize labs of cytogenetics in 1976 and molecular pathology in 1991. Currently, within the regulatory framework for embryo genetic testing, ISO programs are upgraded to accommodate standardization of PGD labs.
Accordingly, Increasing numbers of countries globally are moving progressively towards acquiring CAP accreditation for their PGD laboratories as a direct indicator of quality for their services.
The main aim of PGD laboratory accreditation is to provide valid results to clients, namely: service users, clinics, clinicians, and most importantly patients. Therefore, assessment of PGT laboratory by an external auditor would ensure whether genetic testing services provided are of sufficient standard. This presentation will highlight the current situation of PGD laboratory accreditation in the countries of the Gulf Cooperation Council (GCC) and will discuss the consequences of lack of regulatory supervision and surveillance.
15:00 – 15:20
Making of OncoFertility Consortium Saudi Arabia; challenges and breakthroughs. [Dr. Ghadah Ghourab]
The oncofertility consortium Saudi Arabia (OCSA) was established in March 2018 with the vision of providing world class fertility cryopreservation services to cancer patients in Saudi Arabia.
The oncofertility consortium is an international multi-institutional group that assesses the impact of cancer and its treatment on reproductive health. It was founded by Dr. Teresa Woodruff in 2007 with a mission of expanding fertility options for cancer survivors.
In February 2018, Dr Teresa Woodruff visited Riyadh, Saudi Arabia and a meeting was held with the founding members of OCSA with the aim of developing a framework for Saudi Arabia to become a member of the International Oncofertility Consortium. This ultimately paved the way for the establishment of OCSA which has over 90 members today from all over the Kingdom of Saudi Arabia.
In the space of a few months OCSA has established all the guidelines for fertility preservation in Saudi Arabia as well as taken large strides in the process of legalizing fertility preservation in a country where this has long been illegal.
Once legalized , and with the standard operating procedures and guidelines as well as specialized centers already in place, fertility preservation can finally be offered to the thousands of cancer patients in Saudi Arabia who were previously faced with the bleak prospect of losing all hope of parenthood after cancer treatment.
15:30 – 15:50
Challenges in handling OncoFertility samples in the laboratory. [Dr. Murid Javed]
This talk will focus on handling in the laboratory, oncofertility specimens, from male and female cancer patients. Emphasis will be placed on using the proven techniques and procedures to preserve gametes or tissues. Difficulties in preserving gametes in certain situations will be highlighted. Reasons for recent storage failures will be explained and methods to prevent these disasters will be provided. Pros and cons of experimental techniques will be discussed.
16:00 – 16:20
Progesterone Support in ART. [Dr. Peter Humidan]
The luteal phase of all stimulated IVF/ICSI cycles is abnormal. The main reason for the luteal phase defect (LPD) is the multi-follicular development achieved during ovarian stimulation, leading to supra-physiological levels of steroids (progesterone and estradiol) secreted by a high number of corpora lutea during the early luteal phase, which directly inhibit the release of LH from the pituitary via feedback actions at the hypothalamic-pituary axis level. This reduction in circulating endogenous LH has a detrimental effect on the early-mid luteal phase, as LH plays a crucial role for the steroidogenic activity of the corpus luteum in terms of progesterone production. Thus, luteal phase support with progesterone remains mandatory in fresh transfer cycles after ovarian stimulation for IVF/ICSI treatment. Moreover, with the introduction of new embryo culture systems and in particular vitrification of supernumerary embryos, the live birth rate after frozen-thaw embryo transfer is now similar to, and in many cases superior to that of fresh embryo transfer. This has created a paradigm shift in stimulation policies, in which GnRHa is used for ovulation trigger, followed by segmentation and subsequent transfer in either an HRT frozen-thaw cycle or a natural cycle. For scheduling purposes many centers favor the HRT cycle. Although, poorly defined, until recently a "standard" luteal phase progesterone support was considered sufficient for all patients undergoing fresh as well as frozen-thaw embryo transfer; however, recent scientific evidence questions this policy. During the last decade personalization - or individualization became the "mantra" of ovarian stimulation, and the concept subsequently moved on to the choice of ovulation trigger. Indeed, near future suggests personalization of the luteal phase support as well. This will demand monitoring of the mid-luteal phase in terms of serum progesterone, as the mid-luteal progesterone level seems to play a pivotal role for reproductive success in ART.
16:30 – 16:50
Does duostim delivery on its promises: routine ART practice. [Dr. Kemal Ozgur
Study objective: To investigate the efficacy of DuoStim (dual phase ovarian stimulation) in infertile patients with a poor ovarian response (POR) after follicular phase ovarian stimulation (FPOS).
Background: Studies have shown that it might be possible to increase the number of oocytes retrieved in poor ovarian response patients by performing DuoStim, thereby, increasing the effectivity of a single IVF treatment.
Materials and methods: All patient-couples included in this retrospective observational study underwent autologous ICSI with the intention of blastocyst freeze-all and FET between May 2017 and August 2018. Patients underwent conventional ovarian stimulation (OS) in both the FP and luteal phase (LP), with FPOS starting on day 2 of the cycle and LPOS starting on the day of FPOS oocyte retrieval. All patients underwent a transvaginal ultrasound (TVS) clinical examination on day 2 of their cycle, to assess ovarian reserve (OR), with DOR patients counselled on the possibility of DuoStim. POR patients underwent Duostim on clinical assessment at FPOS oocyte retrieval; ≤5 oocytes were retrieved after FPOS and at least 4 antral follicles of ≥5mm were present. In Duostim patients, follicles ≤10-12mm were not aspirated at FPOS oocyte retrieval.
Results: In total 60 patients underwent DuoStim during the study period. The median age of the patients who underwent Duostim was 36.1 (32.6-38.8) years and their median antral follicle count (AFC) was 6.0 (3.0-9.0). The LPOS duration was significantly shorter than FPOS. The median oocyte number, mature oocyte rate, and blastocyst rate were not significantly different for FPOS and LPOS. More FPOS resulted in the development of blastocysts for cryopreservation (26 vs 20). There was also no significant difference in the per transfer pregnancy rates of FPOS and LPOS (70.5% vs 66.7%)
Conclusion: DuoStim increases the efficacy of IVF in POR patients, with the chance of freeze-all increasing from 43.3% to 58.3%.