Knowledge Sharing

2013.02.08

Experience report of 2010 American Society of Reproductive Medicine

Dr. Tsung-Hsien Lee of Infertility

The American Society for Reproductive Medicine (ASRM) annual conference this year is held in Denver, Colorado. Our poster is accepted and published in the annual meeting this year. Denver is located on the Rocky Mountains, just one mile above sea level, and is called "The Mile High City". Itis at the gateway to the Rocky Mountains in the United States. I have visited the Canadian Rocky Mountains National Park in summer and winter, and the scenery is well worth a second visit. However,the sightseeing road leading to Rocky Mountain was closed due to snow in mid-October, so it was a pity that we were unable to visit the magnificent mountain views of North America this time.

In my opinion, the topics in the conference this year are more like the physiological and pathological mechanisms of infertility related diseases from the perspective of translational medicine or basic medicine. For example, the physiological and pathological roles of gonadal hormone receptors are discussed in the first session. Receptors of gonadal hormone are nuclearreceptors, and have different function by binding to different cofactors in different tissues. For example, estrogen promote cell growth in endometrium, but helps to maintain bone mineral density is skeletal tissues; The correlation between endometriosis and gonadal hormone receptors, as well as clinical applications are the topic of the second session. The speaker reported in the cells of endometriosis tissue, estrogen receptor beta; ERβ and steroidogenic factor 1 (SF-1) paly important roles. SF-1 is increases female hormones by prostaglandin stimulation, also promote estrogen synthesis through increasing aromatase expression, it also activates estrogen receptor to promote the development of endometriosis tissue. Therefore, in addition anti-inflammatory painkillers and oral contraceptives, aromatase inhibitors are also suggested for the treatment of endometriosis. The third session was quite special. A surgeon was invited to describe the surgery-related technology that is still under development. He also mentioned the robotic surgical devices currently available in a few hospitals in Taiwan, as well as to the application of virtual reality.

The fourth session explores the impact of gender differences on cardiovascular disease, and the application of reproductive medicine in this issue. Sex differentiation begins with the SRY gene on the Y chromosome, and then male hormones secreted by testis further promote gender differentiation in the reproductive system. However,male hormone receptor gene is located on the X chromosome.In women, one of the two X chromosomes has to be inhibited to prevent excess gene expression. In addition, differences in sex chromosomes also lead to the differences in mitochondrial respiratory function, angiogenesis, and apoptosis, all related to different hormone concentrations in men and women. Furthermore, metabolisms of epinephrine and estrogen are closely related, which made the speaker believe that the occurrence of cardiovascular disease is not only related to gender, but also affected by hormones. The fifth session was to study the correlation between genotype and polycystic ovary syndrome. The reports indicate that brothers or the next generation of patients with polycystic ovarian syndrome tended to have high levels of male hormones, that is, family cluster effect, which may also be related to their gene expression, especially genetic polymorphism, for example, genetic polymorphism of Fibrillin 3 and Follistatin are closely related to polycystic ovary syndrome. The sixth session is to discuss pelvic adhesions, starting from cellular hypoxia, a series of discussion of molecular interactions in the oxidative stress and extracellular martrix-relatd signal pathways are addressed. Quite amazing!

In addition to the conference speeches, there are 14 oral presentations by the winners of the excellent paper awards every year, which is also one of the highlights of the annual conference. In this year, there are more clinical studies and less study in animal model in the outstanding paper awards. More than one third (5 in 14) are randomized clinical trials. The first is a comparison study of treatment strategies for patients with unknown reasons of infertility, particularly focused on the pregnancy rate of IVF treatment. The procedure in traditional (control) groupis three oral ovulation stimulation drugs andIUI, plus three ovulation stimulation injections and IUI. IVF is scheduled only if all six IUIs failed. The procedure in acceleration (experimental) group is IVF after three ovulation stimulation drugs/IUI. Results showed no differences in the pregnancy rate of the first three IVF cycles. The second study is to compare two suture methods after laparoscopic myomectomy. One is continuous suture with intracorporeal knots, and the other is barbed suture in a single direction without intracorporeal knots. The results favored barbed suture as it reduced the time required and intraoperative blood loss.

The third clinical trial study worked on the effects of preimplantation genetic diagnosis, especially on the increase of IVF pregnancy rate. The preimplantation genetic diagnosis was carried out with embryo biopsy of trophoblasts at day 5 blastocyst, followed by quantitative PCR of 24 chromosomal abnormalities. The results can be obtained in four hours, therefore the embryo transfer can be performed on the same day of diagnosis. Two embryos were transferred in this study, and the pregnancy rate was increased from 60% (9/15) to 92% (12/13). The fourth clinical trial study is to compare different endometrial preparations for egg donor recipients or for frozen embryo transfers. One is traditional GnRH agonist and the other is GnRH anatagonist protocol. Results showed comparable pregnancy and implantation rate between two protocols, however, using antagonist rather than agonist improved patient satisfaction by decreasing the number of injections. The firth clinical trial is a double-blind trial on the drug effect. During the induction of final oocyte maturation of IVF treatment, subjects were randomized to FSH (450IU) versus placebo, and results showed increase, albeit not significant, in both fertilization and pregnancy rate.

In addition to five randomized clinical trials, there are three studies of SART (Society for Assisted Reproduction Technology) databases, two of which are large-scale retrospective generation studies, One SART study explores current status of preimplantation genetic diagnosis in the United States. The results showed a reduced utilization of preimplantation genetic screening (PGS), probably due to the fact that pregnancy rate was not improved by FISH. However, the ratio in gender screening has increased. In the states with subsidized PGS,an over 60% utilization rate was reported, which is also worthy of further study. The other study investigated the factors related to the successful pregnancy of male infertility patients who received IVF treatment.The results showed lower pregnancy rate associated with ICSI without the presence of male factors; the pregnancy rate increased only when ICSI is performed because of male infertility. Another study is the analysis of cost-effectiveness of tubal reconstruction and IVF based on the live birth data from SART. At present, retrospective research requires a large number of samples to be accepted or valued by outstanding journals,research and analysis based on national databases is also a direction worthy of our consideration.

The aforementioned eight award-winning papers are all typical clinical studies, and the remaining six include: a prospective generational study to explore the effect of different chemotherapy drugs on ovarian reserve after lymphomatreatment. An article explores serum diagnostic markers for patients with ectopic pregnancy. There is also a study on the psychological counseling for egg donors. The clinical research section covers the aforementioned 11 articles. In contrast, there are only three in the basic medicine section. One used rats as an animal model to study the relationship between hypolipidemic drugs and ovarian hormone synthesis, another investigated drug effects in uterine fibroid cell lines, the other is testicular sperm stem cell culture from patients with lymphoma.

Taken together, the ACRM this year focused on clinical research and the pathophysiology of infertility-related diseases. Compared with previous years, the proportion of basic medical research or new laboratory related technologies has indeed decreased significantly. Nevertheless, we still learned a lot about the current research direction and trends of technological development inreproductive medicine in the United States. In the future, we look forward to improving the level of reproductive medicine in Taiwan and serve the infertile patients here with theadvanced world-class medicine.