ASRM 2010 Meeting Update
The American Society of Reproductive Medicine Meeting (ASRM) is the major fertility meeting in the United States. The meeting is held once a year and highlights the latest developments in fertility treatment. This year, several members of the Pacific Fertility team where able to attend the conference in Denver, Colorado.
The major presentation at the meeting was an update on the FASTT (fast track and standard treatment) trial. This is a study of 500 couples with unexplained infertility in women 39 years of age or younger. Couples were randomized to either standard treatment or fast track treatment. Standard treatment was 3 cycles of clomiphene/IUI (fertility pills), 3 cycles of FSH/IUI (fertility injections), then in vitro fertilization (IVF). The fast track treatment followed the same protocol, but omitted the FSH/IUI. Couples in the fast track group achieved pregnancy sooner, with fewer treatment cycles, and at less cost.
IVF programs, like our program at Pacific Fertility Center, are achieving excellent pregnancy rates by transferring one or two embryos in an IVF procedure. This fast track approach also reduces the risk of multiple pregnancies by excluding FSH/IUI treatment; a protocol that poses a significant risk of multiples. Pregnancy rates remained good through the first 3 IVF cycles; 78% of patients became pregnant in the fast track group. When completed, this study should help couples decide between FSH/IUI treatment and IVF.
Preimplantation genetic diagnosis (PGD) continues to be an active area of research. PGD has been very effective in helping patients at risk of having a child with a genetic disorder. However, it has been controversial as to whether PGD improves pregnancy rates in couples with infertility and no genetic disorders. Older studies indicated no benefit, but we have come to realize that the older technology was inaccurate and incomplete. The older studies used fluorescent in situ hybridization (FISH) for chromosome testing. In this process, only a portion of the 23 chromosome pairs could be analyzed and the accuracy of the test was very poor.
The latest techniques are now very accurate and complete. New techniques use DNA fingerprinting technology, where all 23 pairs of chromosomes are analyzed. One of the first randomized controlled trials of PGD was presented at this meeting. In this trial, the pregnancy rate was much higher in the treatment group. Embryos were biopsied on day 5. This protocol allowed the cells for biopsy to be taken from the trophectoderm, the part of the embryo that develops into the placenta. This technique may prove to be safer for the embryo and decrease the chance of a misdiagnosis due to mosaicism. However, challenges still remain. The current technology in its most common form requires biopsy on day 5, freezing of all of the embryos, and then thawing normal embryos for transfer after the genetic diagnosis is complete. As the speed of the evaluation improves, biopsy and transfer on day 5 will become more common, and there will be no need to freeze and thaw the embryos.
PFC has been very active in helping women preserve their fertility when facing chemotherapy for breast cancer. Letrozole is a medication used to help grow eggs and keep estrogen levels low during stimulation in IVF cycles. Women have the option to do an emergency IVF cycle, which allows them to preserve their eggs or embryos and use them after their breast cancer treatment is completed. In a recent study, which proved to be very reassuring, 129 women used this protocol to collect eggs. They were followed for up to 7 years. Relapse rates of breast cancer were compared to a similar group of women who opted not to do IVF prior to chemotherapy. The relapse rate in the IVF group was lower than the group that did not undergo IVF, 2% vs. 25%. The pregnancy rates in the IVF group were very good, resulting in 36% per frozen embryo transfer. Women with breast cancer can be safely offered this protocol when undergoing fertility preservation prior to chemotherapy.
Insulin resistance is common in women with polycystic ovarian disease (PCOD). In these women, the insulin does not work as well, resulting in higher insulin levels to maintain normal blood sugar levels; similar to Type II diabetes. Metformin is a medication that improves insulin function and has been used to improve pregnancy rates in women with PCOD.
In a recent study, women with 2 previously failed IVF cycles and without PCOD were randomized. One group went through one cycle of IVF with metformin, and the other group without metformin. The metformin group had higher pregnancy rates, 33% vs. 2%. Insulin resistance is associated with aging and stress, which are common among women who repeatedly fail with IVF. As a result, metformin may help women without obvious signs of insulin resistance.
Adenomyosis was the topic of another very informative session. Adenomyosis is a benign disorder where the endometrium (the lining of the uterus) grows into the muscle of the uterus. It may be the single most common undiagnosed gynecological condition and the most common cause of gynecological pain. Adenomyosis may be a normal part of uterine aging. Adenomyosis is commonly associated with fibroids and endometriosis, and is more common in women who have already had a pregnancy. The most common symptoms are: heavy menses, painful menses, pelvic tenderness, and infertility. In the past, an MRI scan was needed to make the diagnosis. However, new studies show an ultrasound is just as accurate, both sensitivity and specificity, as MRI. Adenomyosis can be found in up to 25% of infertile women. The role of adenomyosis in causing infertility remains controversial. However, current studies indicate large areas of adenomyosis and adenomyosis near the endometrium can decrease fertility. Now that an ultrasound can be used more commonly and can accurately diagnosis adenomyosis, the impact of adenomyosis on fertility will be better defined.
Attending this annual meeting of professionals in the field of reproductive technology is always informative. We look forward to meeting with colleagues from around the country and sharing the latest research. Several of the research projects currently in progress at PFC were discussed at this meeting.