Lectures
Turner syndrome

Invited Speaker: Carolyn Bondy, MD

Turner syndrome

Lecture Type: Grandrounds

Turner syndrome is often not diagnosed until a woman is in her 30s, and even after diagnosis, many women do not receive essential screening for associated medical conditions, adequate counseling or treatment for ovarian failure. Modern studies show that Turner syndrome is more prevalent than appreciated, and the "characteristic" stigmata affect only a small minority of patients. Clinicians must consider Turner syndrome in the differential diagnosis of hypergonadotropic hypogonadism in women of all ages, and be informed on the most effective screening tests such as cardiac MRI to detect aortic disease and the most up-to-date recommendations on reproductive issues. The lecture will provide updates on clinical signs and diagnostic tests and review recommended screening tests upon diagnosis. Both spontaneous and assisted fertility rates and outcomes will be covered, with a summary of current guidelines for reproductive success in women with Turner syndrome.

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Are twins after IVF good or bad for America?

Speaker: Norbert Gleicher, MD

Are twins after IVF good or bad for America?

Lecture Type: Conferences

In the final lecture of CHR’s annual research update for 2013, Dr. Norbert Gleicher tackles one of the most heatedly discussed issues in reproductive endocrinology and infertility: whether a twin pregnancy represents a positive or negative outcome of infertility treatment. CHR investigators have had a very visible presence in this still ongoing dispute, mostly representing the opposing opinion to what currently is widely considered “politically correct.” In his presentation, Dr. Gleicher shares insights, drawing from data that have become available in the literature in recent months, on outcome comparisons of twin pregnancy vs. singleton pregnancy, arguing against a policy of mandatory single embryo transfers (SETs) for all women.

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Manipulation of IVF outcome reporting to SART: The status of public reporting of clinical outcomes in assisted reproductive technology [Fertil Steril 2013;100(3):736-741]

Speaker: Vitaly A Kushnir, MD

Manipulation of IVF outcome reporting to SART: The status of public reporting of clinical outcomes in assisted reproductive technology [Fertil Steril 2013;100(3):736-741]

Lecture Type: Webcasts

The U.S. government requires all IVF centers to report their IVF cycle outcomes to Centers for Disease Control and Prevention (CDC). A majority of IVF centers also report this data to the Society for Assisted Reproductive Technologies (SART). Despite CDC and SART’s warning that published IVF pregnancy rates cannot be a reliable basis for identifying a successful IVF center for a given patient due to patient selection bias, the data published by CDC and SART have become a default tool to do just that for many patients. A recent publication in Fertility & Sterility uncovered a disturbing trend against this backdrop: a small minority of IVF centers (13 out of 341 centers analyzed) exclude a disproportionately large number of IVF cycle outcomes from reporting, artificially inflating their IVF pregnancy rates. By the year 2010, these 13 IVF centers accounted for more than 50% of all IVF cycles excluded from SART/CDC reporting, and partially as a result, these centers’ U.S. market share has expanded by nearly 20% between 2005 and 2010. This live webcast, presented by Vitaly A Kushnir, MD, the lead author of the study, will provide an overview of the CDC/SART outcome reporting system, discuss the findings of the study, and give patients points to consider when choosing an IVF center that best suits their needs.

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Oocyte Control of Ovarian Follicular Development

Invited Speaker: John Eppig, PhD

Oocyte Control of Ovarian Follicular Development

Lecture Type: Grandrounds

Precise coordination between mammalian precursor egg cell (oocyte) and ovarian follicle development is essential in order to provide an egg that is fully competent to undergo fertilization and embryo development. A system of metabolic cooperation exists, in which oocytes promote the expression of genes in cumulus cells for processes that oocytes cannot carry out efficiently themselves, such as amino acid transport and glucose oxidation. In other words, the oocyte out-sources these processes to the cumulus cells. In turn, the cumulus cells pass the essential products of these processes to the oocyte for use in development. The same system allows the oocytes to regulate the metabolic pathways in the follicle cells to control the rate of follicular development. Oocytes provide the cumulus cells with signals that enable the cumulus cells to respond to preovulatory hormonal stimulus by both undergoing processes essential for ovulation and sending a return signal to the oocyte triggering the resumption of meiosis. The lecture will cover these remarkable mechanisms that coordinate the maturation of both the oocyte and cumulus cells, culminating in the ovulation of an egg ready for fertilization.

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Federally mandated IVF outcome reporting, an example of how not to do it

Speaker: Vitaly A Kushnir, MD FACOG

Federally mandated IVF outcome reporting, an example of how not to do it

Lecture Type: Grandrounds

In the second lecture for the annual CHR research update for 2013, Dr. Vitaly A. Kushnir focuses on the federally mandated IVF outcome reporting to Society for Assisted Reproductive Technologies (SART) and Center for Disease Control and Prevention (CDC). SART reporting of IVF cycle outcomes has been proposed as a possible template for outcome reporting in other medical areas under Patient Protection and Affordable Care Act (PPACA). However, SART reporting, as it is set up, fails in its purpose by allowing a small group of centers to mislead the public about their center’s performance. Dr. Kushnir explains the type of information that is and is not reported and poses questions regarding whether or not public reporting is helpful or hurtful to the public.

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Can we clinically utilize androgen-FSH synergism on granulosa cells at small growing follicle stages?

Speaker: David H Barad, MD, MS, FACOG

Can we clinically utilize androgen-FSH synergism on granulosa cells at small growing follicle stages?

Lecture Type: Grandrounds

In part one of the three lectures on CHR’s annual research update for 2013, Dr. Barad provides an updated overview of androgens’ roles in female reproduction, especially as they relate to female age and ovarian reserve. New findings at CHR’s research include the role of androgens in follicle development, in which androgens and FSH may work synergistically. Dr. Barad’s presentation will address the possibility of improving follicle recruitment through long-term, combined androgen (DHEA) and FSH exposure to improve IVF pregnancy chances for women with diminished ovarian reserve, providing further evidence that we now have the ability to therapeutically intervene into earlier stages of follicle maturation.

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What high FSH and high AMH mean for your IVF pregnancy chances? Clinical relevance of combined FSH and AMH observations in infertile women

Speaker: Norbert Gleicher, MD, FACOG

What high FSH and high AMH mean for your IVF pregnancy chances? Clinical relevance of combined FSH and AMH observations in infertile women

Lecture Type: Webcasts

Follicle-stimulating hormone (FSH) and anti- Müllerian hormone (AMH) are two of the most common fertility tests used to evaluate a woman's ovarian function. High FSH and low AMH levels, which usually go together, indicate diminished ovarian reserve (DOR), and reduced pregnancy chances with IVF.

A recent paper by investigators at the Center for Human Reproduction (CHR), published in Journal of Clinical Endocrinology and Metabolism, found that women with the somewhat unusual combination of high FSH and high AMH levels had four times more eggs retrieved, and were almost twice as likely to get pregnant after IVF, than women with all other FSH/AMH combinations.

This live webcast, presented by Norbert Gleicher, MD, Medical Director and Chief Scientist of CHR and lead author of the study, will provide an overview of the findings, as well as what various FSH and AMH levels, combined, may mean to women who are trying to get pregnant.

[Gleicher et al, J Clin Endocrin Metab 2013;98(5):2136-45]

NOTE: We apologize for the echo at the beginning of the recording; the sound improves about four minutes into the recording.

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A pilot trial of large versus small diameter needles for oocyte retrieval

Speaker: Vitaly A Kushnir, MD FACOG

A pilot trial of large versus small diameter needles for oocyte retrieval

Lecture Type: Research in Brief

Dr. Kushnir discusses a research publication in Reproductive Biology & Endocrinology that compares the efficacy of large- versus small-sized needles for egg retrieval. Reprod Biol Endocrinol 2013;11:22.

ABSTRACT

Background: This study was designed to determine whether small diameter needles for oocyte retrieval alter oocyte yields in patients undergoing IVF in comparison to standard large diameter needles.

Methods: We conducted a prospective pilot study of 21 consecutive favorable prognosis patients. In each patient one ovary was randomly allocated to retrieval with either a 20 G/ 35 mm (thin) or 17 G/ 35 mm (standard) needle, the other ovary was then retrieved with the opposite needle.

Results: The standard diameter needle was used to collect a total of 215 oocytes from 355 aspirated follicles (60.6%) compared to 203 oocytes from 352 aspirated follicles (57.7%) with the thinner needle (p=0.23). Stratifying outcomes by anti-Müllerian hormone (AMH), as indicator of ovarian reserve, and by body mass index (BMI) the oocyte yields, still, did not differ (AMH, r (17)=0.20, p=0.44; BMI, r (17) =0.02, p=0.96). Outcomes also did not vary among women with diminished ovarian reserve (p=0.17) and in women with normal ovarian reserve (p=1.00). Operating time was, however, significantly increased by 3.3 minutes per ovary (z=3.08, p=0.002) with the thinner needle.

Conclusions: Needle diameter does not affect oocyte yield, including in obese patients and patients with diminished ovarian reserve. Thinner needles appear to significantly prolong operating time.

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Mitochondrial genome during reproduction, development and aging

Invited Speaker: Shoukhrat Mitalipov, PhD

Mitochondrial genome during reproduction, development and aging

Lecture Type: Grandrounds

Inherited and acquired diseases caused by mitochondrial gene (mtDNA) pauses a significant challenge, as there is currently no curative treatment for mtDNA diseases. Dr. Mitalipov’s presentation will focus on novel reproductive approaches to prevent transmission of mtDNA mutations from parents to children. mtDNA is maternally transmitted through the oocyte. Mutated mtDNA in a patient’s oocyte can be replaced with healthy genome from a donor oocyte, and resulting oocyte can be fertilized and transplanted into the patient’s uterus.

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Starting and resulting testosterone levels after androgen supplementation determine in all ages in vitro fertilization (IVF) pregnancy rates in women with diminished ovarian reserve (DOR)

Speaker: Norbert Gleicher, MD, FACOG

Starting and resulting testosterone levels after androgen supplementation determine in all ages in vitro fertilization (IVF) pregnancy rates in women with diminished ovarian reserve (DOR)

Lecture Type: Research in Brief

Dr. Gleicher discusses a recent publication in Journal of Assisted Reproduction and Genetics that suggests testosterone levels after androgen (DHEA) supplementation as predictor of IVF pregnancy rates. J Assist Reprod Genet 2013;30(1):49-62.
Abstract PURPOSE: To investigate whether androgen conversion rates after supplementation with dehydroepiandrosterone (DHEA) differ, and whether differences between patients with diminished ovarian reserve (DOR) are predictive of pregnancy chances in association with in vitro fertilization (IVF).
METHODS: In a prospective cohort study we investigated 213 women with DOR, stratified for age (? 38 or >38 years) and ovarian FMR1 genotypes/sub-genotypes. All women were for at least 6 weeks supplemented with 75 mg of DHEA daily prior to IVF, between initial presentation and start of 1st IVF cycles. Levels of DHEA, DHEA-sulfate (DHEAS), total T (TT) and free T (FT) at baseline ((BL)) and IVF cycle start ((CS)) were then compared between conception and non-conception cycles.
RESULTS: Mean age for the study population was 41.5 ± 4.4 years. Forty-seven IVF cycles (22.1 %) resulted in clinical pregnancy. Benefits of DHEA on pregnancy rates were statistically associated with efficiency of androgen conversion from DHEA to T and amplitude of T gain. Younger women converted significantly more efficiently than older females, and selected FMR1 genotypes/sub-genotypes converted better than others. FSH/androgen and AMH/androgen ratios represent promising new predictors of IVF pregnancy chances in women with DOR.
CONCLUSIONS: DOR at all ages appears to represent an androgen-deficient state, benefitting from androgen supplementation. Efficacy of androgen supplementation with DHEA, however, varies depending on female age and FMR1 genotype/sub-genotype. Further clarification of FMR1 effects should lead to better individualization of androgen supplementation, whether via DHEA or other androgenic compounds.

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