Genetics and Poor Responders

The changes that we have undergone over the last few decades have entirely transformed the role that women play in today's society. These new circumstances have led to women postponing motherhood but fertility, and above all female fertility, is not a constant and, with age, comes a gradual ageing and depletion of oocyte reserves. Taking into account that the prognosis in assisted reproduction treatment depends mainly on the number of eggs retrieved, an understanding of the cell and genetics mechanisms that lead to ovarian ageing and setting up the most adequate stimulation protocol for the patient's genetics (pharmacogenetics) are key to XXI century reproductive medicine. Lectures in the session on Genetics and Poor Responders in the second edition of Meeting the Experts will cover the following important aspects of ovarian response:

  • The factors influencing ovarian ageing has been the main line of research work carried our by Dr David Keefe. This work has demonstrated that there is a connection between the shortening of the length of chromosome telomeres and progressive ovary ageing. Controlling the genes involved in telomere length will help in attempts to postpone ovarian ageing.
  • Dr Belén Lledó, on the other hand, will lecture on progress in the understanding of genetic variants that affect ovarian response. The Poor Ovarian Response Unit at Instituto Bernabeu has carried out specific research on establishing the polymorphisms associated with poor response to ovarian stimulation. A pharmacogenetic approach of this type means that treatment can be personalised and, as such, the number of eggs retrieved can be optimised.

Biomarkers in Poor Responders

When dealing with patients who are poor responders, it's absolutely essential to carry out a correct evaluation of the situation that will then help us to determine the most reliable prognosis and clear up which treatment will give optimum success rates.

Over the last few years, enormous progress has been made in terms of predicting ovarian response and we now have access to highly reliable tests which help us to inform patients about their prognosis and also to make the best decisions during treatment.

Numerous pieces of research that have recently been published have clearly indicated that the most reliable biomarkers are anti-Müllerian hormone (AMH) and antral follicle counts (AFC) using ultrasounds. There are some differences of opinion on which of the two markers is the best.

During the second edition of Meeting the Experts, we will be fortunate enough to be joined by the people who have led the research work and the publications of the most significant pieces of work on these biomarkers. Dr Nelson led the most important pieces of research work on the reliability of AMH as biomarkers and Dr Jayaprakasan is probably one of the most respected authorities in the field of functional ultrasounds in fertility.

Their speeches and will undoubtedly shed light on the subject and the debate following the speeches will certainly clear up any doubts with a view to progressing towards improved healthcare for women with poor ovarian response. The debate will be moderated by two authorities in the field of fertility: Dr Khalar and Dr Bruna.

Ovarian Stimulation in Poor Responders

It is believed that around 35% of patients may prove to be poor responders to stimulation during in vitro fertilisation cycles. Poor responders are a medically challenging group in the field of reproductive medicine. Despite progress in this field, it has not yet been possible to determine the ideal protocol for improving the chances of pregnancy for this group of patients. Amongst other things, this is due to poor responder diagnosis that includes a varied group of patients with causal aetiology and various health characteristics behind its poor ovarian reserve. This itself limits the appropriate research that can be carried out to help clarify the panorama in terms of expectations for reproduction.

With this as the background, healthcare includes: ovarian stimulation in poor responders. We look at strategies such as individualised controlled ovarian stimulation (iCOS) for this group of patients or groundbreaking protocols and that have led to a radically different outlook. For example, stimulation during the luteal phase. The aim is to generate a debate and present treatment options that may be of help to this group of patients that present difficulties in daily clinical practice.

News Insights in the Patient with Very Poor Prognosis

Sometimes, either because of total ovarian insufficiency or the recurrent poor quality of oocytes or embryos obtained during in vitro fertilisation procedures, there is no other reasonable alternative than to opt for donor eggs.

However, there is no room for simple acceptance in science and research must be considered a priority in today's society if we are to resolve situations of this kind.

In this session of the second edition of Meeting the Experts, we will open up a debate on two lines of research that aim to provide patients with poor prognoses with options.

We will be fortunate enough to have Dr Kawamura amongst us. He is the director of the team that achieved the birth of the first child in a patient diagnosed with premature menopause further to retrieving ovarian tissue which was subjected to in vitro treatment and once again implanted into the patient. This was followed by a successful in vitro fertilisation cycle. Dr Kawamura's work will undoubtedly lead us to progress further in our understanding of how the ovary functions and it is possible that in the near future it may provide answers for patients who are poor responders.

Dr Oktay will be with is in the conference's other session. He will provide us with preliminary results on the introduction of a new technique that has been developed for treating couples that repeatedly produce embryos of poor quality in IVF treatment. Over the last year, development of this new technique has begun based on the transfer of mitochondria from the patient herself within the oocyte when fertilisation takes place and, whilst it is still in an experimental stage, it could, in the future, improve the prognosis of couples of this type. Dr Oktay is a worldwide authority in the field of research on ovarian ageing and fertility preservation.

The debate will clearly be of great interest both because of the subjects to be covered and as a result of the participation of Dr Espinós and Dr Nicopoullos who will act as moderators. The debate will undoubtedly give us an idea on what the future of assisted reproduction treatment will look like.

Fertility Assessment and Counseling of women with low ovarian reserve

In this session, we aim to respond to two key questions which all women with a low ovarian reserve diagnosis pose:

  • Could I have avoided this situation if I'd been adequately informed?
  • How can I go about dealing with the emotional impact of the diagnosis?

Dr Peterson will provide us with information on pro-fertility family planning in response to the first question. Dr Peterson is the Director of the very first public centre aimed at counselling women who do not have fertility issues so that they may be given adequate information on their reproductive future. This gives them the opportunity to make decisions such as not putting off trying for a child or holding on to their fertility through egg freezing.

We will have the pleasure of the presence of Dr Boivin in the last conference. She has managed some of the most significant research projects carried out in order to understand the emotional impact of reproduction issues. Dr Boivin will speak on emotional management of patients who face infertility with a low ovarian reserve diagnosis.

Embryo Competence

  • Session I
  • Saturday 1 October 2016
  • Jorge Ten

The first session on Saturday, 1st October is on 'embryo competence.' It's a very wide-ranging subject matter and we have, therefore, decided to cover it in three conferences that are of great interest from clinical and research points of view. The first will aim to provide a critical and realistic view of the validation of criteria for embryo classification using morphological and kinetic parameters. This is a subject which has a significant impact from a clinical point of view since it challenges current human embryo classification and selection methods.

The second conference will cover embryo screening or comprehensive chromosome screening (CCS). CCS is, without a doubt, a fundamental tool that facilitates the selection of embryos that are chromosomally normal and, therefore, helps us to improve reproduction results in couples facing serious issues such as implantation failure or recurrent pregnancy loss. However, CCS is not free of controversy because of the complexity of the techniques involved.

The third and final conference will cover studies on gene expression in embryos developed in vitro which can provide very interesting results on the transcriptome and its implications for human embryo implantation capacity. Both environmental and biological factors could play an important role in the transciptome and this information may, therefore, be of great use in the future.

Endometrium and Implantation Failure

The study of social and systemic factors affecting endometrial receptivity is been a subject of intense study in the last 20 years.
Its discovery and its real importance, is the success or failure of the implantation process. It is a controversial issue and requires constant clarification.
The aim of this session is to review the latest contributions to this field and its possible clinical applications.