Advanced workshop in embryology - EXCEMEDGeneral information Venue ... • Identify new objective...

Advanced workshop in embryology29-30 November 2013 - St. Petersburg, Russian Federation

FINAL PROGRAMME AND ABSTRACT BOOK

General information

VenueThe live educational workshop takes place at the:

Courtyard By Marriott St.Petersburg Center West Pushkin 166 Griboedov's Canal, via 33 Kanonerskaya StreetSt. Petersburg, 190121 Russian Federation

LanguageThe official language of the live educational workshop is English.

Simultaneous translation English from/to Russian is provided for the live educational event.

Scientific secretariatSerono Symposia International FoundationSalita di San Nicola da Tolentino, 1/b00187 Rome, Italy

Junior Project Manager: Francesca CucciollaTel.: +39 (0)6 420 413 315 - Fax: +39 (0)6 420 413 677E-mail: [email protected]

Specialist Medical Advisor: Irene ZerbettoSpecialist Medical Advisor: Angelo Marino

Serono Symposia International Foundation is a Swiss Foundation with headquarters in 14, Rue du Rhône, 1204 Geneva, Switzerland

Organising secretariatMeridiano Congress InternationalVia Sapri, 6 - 00185 Rome (Italy)Project Coordinator: Federica RussettiPh. +39-06-88595 209 - Fax +39-06-88595 234E-mail: [email protected]

1

Register to Serono Symposia International Foundation website:www.reproductive-medicine.seronosymposia.org

follow us onSSIF_RM

http://twitter.com/SSIF_RM

Advanced workshop in embryology

Serono Symposia International Foundation live educational workshop on:

Advanced workshop in embryology29-30 November 2013 - St. Petersburg, Russian Federation

Aim of the live educational workshopAdvances in technology require continuous re evaluation of IVF laboratory practice, revision of old techniques and implementationof new methodologies and practices. This live educational workshop aims to provide the attendees with concise and authoritativereviews of new technologies and laboratory practice guidelines. It will also provide an interactive forum for discussion of topics thathave been the subject of controversy, including how to provide the optimal laboratory and culture environments for human embryos.The live educational workshop offers an interactive programme with many lectures followed by video sessions and debate on hottopics. The aim is to give participants both the latest knowledge and the opportunity to share their experiences with renownedbiologists and embryologists.

Learning objectivesBy attending this live educational workshop the learners will be able to:• Recognise new markers of gamete quality• Identify new objective criteria for selecting the embryos with the highest implantation potential• Assess the best standards for improving quality management in IVF laboratory

Target audienceThis live educational workshop is aimed at scientists and biologists with experience in this field who seek to enhance their knowledgeof new technologies.

AccreditationSerono Symposia International Foundation (www.seronosymposia.org) is accredited by the European Accreditation Council forContinuing Medical Education (EACCME®) to provide the following CME activity for medical specialists. The EACCME® is aninstitution of the European Union of Medical Specialists (UEMS), www.uems.net

The CME workshop on: “Advanced workshop in embryology” held on 29-30 November 2013 in St. Petersburg, Russian Federation,is designated for a maximum of 7 (seven) hours of European CME credits (ECMEC). Each medical specialist should claim only thosecredits that he/she actually spent in the educational activity. EACCME® credits are recognized by the American Medical Association(AMA) towards the Physician's Recognition Award (PRA). To convert EACCME® credit to AMA PRA category 1 credit, please contactthe AMA.

Serono Symposia International Foundation (SSIF) adheres to the principles of the Good CME Practice Group (gCMEp)

2

Scientific organiser

Robert FischerFertility Center HamburgHamburg, Germany

Scientific co-organisers

Alan R. ThornhillAssisted Conception Unit, Guy's Hospital, London, UKChair, ALPHA, Scientists in Reproductive Medicine

Zsolt Peter NagyReproductive Biology Associates, Atlanta, Georgia, USASecretary, ALPHA, Scientists in Reproductive Medicine

Serono Symposia International Foundation developed thisprogramme in collaboration with: ALPHA, Scientists inReproductive Medicine.

3

All Serono Symposia International Foundation programmes are organized solely to promote the exchange and dissemination of scientific and medical information. Noforms of promotional activities are permitted. This programme is made possible thanks to an educational grant received from "LLC Merck".

List of faculty members

Thomas EbnerWoman´s General HospitalDepartment of Gynecological Endocrinology & IVF UnitLinz, Austria


Marcos Meseguer Infertility Institute of Valencia (IVI)Valencia, Spain


We value your opinion!We are continually trying to develop and improve our educational initiatives to provide you with cutting-edge learning activities.Before and after this live educational event you will be asked to answer an online survey to help us to better tailor our futureeducational initiatives.

We thank you for participating!

Serono Symposia International Foundation developed this programme in collaboration with: ALPHA, Scientists in Reproductive Medicine.

Scientific programme29-30 November 2013

4

Chairs: R. Fischer (Germany) - M. Meseguer (Spain)

09.20 L1: Oocyte quality and stimulation protocolsM. Meseguer (Spain)

09.45 L2: Sperm evaluation: high magnification spermmorphologyT. Ebner (Austria)

10.10 L3: Embryo classification: time-lapse techniqueM. Meseguer (Spain)

10.35 Questions time

10.55 Coffee break

11.15 WG1: Video sessionsM. Meseguer (Spain)T. Ebner (Austria)

12.15 Lunch

Gamete and embryo evaluationSession I

Friday, 29 November

08.30 Registration

09.00 Serono Symposia International Foundation (SSIF) welcome and introductionR. Fischer (Germany)

09.10 Scientific co-organiser welcomeA.R. Thornhill (UK)

Chairs: R. Fischer (Germany) - M. Meseguer (Spain)

13.15 L4: How to identify embryos with highestimplantation potentialT. Ebner (Austria)

13.40 L5: Update on cryopreservation techniqueT. Ebner (Austria)

14.05 L6: PGS and micro-array CGH technique forembryo biopsyM. Meseguer (Spain)


14.50 Coffee break

15.10 WG2: Case studiesM. Meseguer (Spain)T. Ebner (Austria)

16.10 End of the first day

Laboratory technologies: cryopreservation and PGSSession II

Legend

L : Lecture; : Questions time; WG : Working Group;

Saturday, 30 November

Chairs: R. Fischer (Germany) - T. Ebner (Austria)

09.00 L7: Laboratory organisation: materials andtechniquesA.R. Thornhill (UK)

09.25 L8: How to implement QMS in ARTA.R. Thornhill (UK)

09.50 Video session on laboratory organisation:materials and techniquesA.R. Thornhill (UK)


10.40 Coffee break

11.00 General discussion - laboratory problems

12.00 Concluding remarks

12.15 End of the live educational workshop andclosing lunch

Laboratory setup in IVF centreSession III

5

Disclosure of faculty relationships

Serono Symposia International Foundation adheres to guidelines of the European Accreditation Council for Continuing MedicalEducation (EACCME®) and all other professional organizations, as applicable, which state that programmes awarding continuingeducation credits must be balanced, independent, objective, and scientifically rigorous. Investigative and other uses for pharmaceuticalagents, medical devices, and other products (other than those uses indicated in approved product labeling/package insert for theproduct) may be presented in the programme (which may reflect clinical experience, the professional literature or other clinical sourcesknown to the presenter). We ask all presenters to provide participants with information about relationships with pharmaceutical ormedical equipment companies that may have relevance to their lectures. This policy is not intended to exclude faculty who haverelationships with such companies; it is only intended to inform participants of any potential conflicts so that participants may form theirown judgements, based on full disclosure of the facts. Further, all opinions and recommendations presented during the programmeand all programme-related materials neither imply an endorsement nor a recommendation on the part of Serono SymposiaInternational Foundation. All presentations represent solely the independent views of the presenters/authors.

The following faculty provided information regarding significant commercial relationships and/or discussions of investigational ornon-EMEA/FDA approved (off-label) uses of drugs:

Thomas Ebner Declared no potential conflict of interest.

Robert Fischer Declared being member of the Scientific Committee of Serono Symposia International Foundation.

Marcos Meseguer Declared no potential conflict of interest.

Alan R. Thornhill Declared receipt of honoraria or consultation fees as Scientific Advisor (Auxogyn, Inc, Menlo Park, California,USA).

6

Biosketch

Biosketch

8

Assoc. Prof. Dr. Thomas Ebner graduated with honours from the University of Salzburg, Austria in 1992. After his doctorate andpostdoctoral thesis, he became a university lecturer in Salzburg and Graz. He has published more than 100 papers and bookchapters as first or co-author. His research interests include non-invasive IVF selection processes, andrology, vitrification and culturemedia. He was certified as a senior clinical embryologist by ESHRE in 2008 and re-certified in 2012. Currently, he is Executive BoardMember (Treasurer) of ALPHA - Scientists in Reproductive Medicine, head of the Embryological Forum Austria (EFA) and NationalRepresentative of Austria in the Advisory Committee of ESHRE.

Thomas EbnerWoman´s General HospitalDepartment of Gynecological Endocrinology & IVF UnitLinz, Austria

Robert Fischer is Founder and Medical Director of the IVF unit at the Hamburg Fertility Center, one of the largest and leadingGerman IVF centres. In July 1998 the Fertility Center of Hamburg was one of the first centres in Germany and worldwide to introducecertified quality management according to the ISO 9001. In 2002 the IVF laboratory was ISO 17025 certified. Prior to this he wasMedical Director of the first outpatient IVF unit in Hamburg. Author of numerous publications in national and international scientificjournals and books, as well as lectures at conferences worldwide, Dr Fischer is an active member of the American Society ofReproductive Medicine, founding member of the European Society of Human Reproduction and member of its advisory committeeas well as founding member of the “AG Gynäkologische Endokrinologie und Fortpflanzungsmedizin” and “BerufsverbandReproduktionsmedizinischer Zentren”, both in Germany.


9

Marcos Meseguer received his PhD (Obstetrics and Gynaecology) and MD from the University of Valencia, Spain, and a mastersdegree in Research Methods, Design and Statistics from Universidad Autónoma de Barcelona, Spain. From 2000 to 2004, DrMeseguer served as Co-Director of the Andrology Laboratory at the Instituto Valenciano de Infertilidad (IVI) and is currently a SeniorEmbryologist in the IVF unit of IVI Valencia. Dr Meseguer is a member of various scientific societies and has received the prize paperof the Society of Reproduction and Infertility (American Society of Reproductive Medicine), three times the Lalor FoundationInternational Award from the American Society of Andrology, and twice the research award from the Spanish Society of Fertility. Theprimary areas of his research are embryology, male infertility and assisted reproduction in HIV/VHC serodiscordant couples. AsPrincipal Investigator, his work has been funded through 10 projects sponsored by the Spanish Government and the ValencianGovernment, including two EUREKA projects (granted to high-quality technological projects) supported by the European Community.He is currently Statistics Assessor and Scientific Updater of IVI Valencia, and Associate Professor of the Master in Biotechnologyfrom the University of Valencia. Dr Meseguer has published over 85 articles and 40 reviews or book chapters, and made more than250 presentations at national and international congresses.

Marcos Meseguer Infertility Institute of Valencia (IVI)Valencia, Spain

Dr Thornhill received his PhD in Genetics from University College London in 1996 and has been an IVF Laboratory or ScientificDirector since 1999, working in the USA (Mayo Clinic) and the UK (The Bridge Centre and London Fertility Centre). He has rejoinedthe Guy’s assisted conception unit as a Consultant Clinical Research Scientist. He is an Honorary Reader in Reproductive Geneticsat the University of Kent and is currently Chair of the international society Alpha, Scientists in Reproductive Medicine and has servedas Deputy Chair of the ESHRE Preimplantation Genetic Diagnosis (PGD) Consortium. Since 2009, Dr Thornhill has been aProfessional Member of the Human Fertilisation and Embryology Authority, the body that regulates and licenses all IVF centres inthe UK, and a member of the Expert Registry (IVF devices) for the UK Medicines & Healthcare Products Regulatory Agency (MHRA).His research interests focus on reproductive genetics, preimplantation genetic diagnosis (PGD) and improving IVF outcomes. He hasover 50 peer-reviewed articles, speaks regularly to schools, lay audiences, national and international conferences and frequentlycontributes to both print and broadcast media.

Alan R. Thornhill Assisted Conception UnitGuy's Hospital, London, UKChair, ALPHA, Scientists in Reproductive Medicine

Abstracts

Evaluation of gametes and embryos in vitro has improved greatly over the past 20 years. Classical assessment has beensupplemented by evaluation of several additional morphological characteristics that allow prediction of the developmental potentialof an oocyte or an embryo and the probability of achieving pregnancy for an infertile couple. Time-lapse observation presents anopportunity for optimising this embryo selection based on morphological grading as well as providing novel kinetic parameters,which may further improve accurate selection of viable embryos. The technological advances in hi-tech research have enabled alsonon-invasive determination of proteomic and metabolic status of the embryo. Oxygen consumption measurements from oocytes andembryos could be applied routinely in the clinical embryology laboratory in order to assess quality, complementing the classicalmicroscope-based methods to select embryos.

In this lecture, we present a unique clinical study which combines oxygen consumption measurements with time-lapse imaging ofembryo development for human embryos. The study presents - to our knowledge - the largest set of transferred embryos after time-lapse analysis and thus a novel opportunity to correlate morphokinetic parameters to implantation and ongoing pregnancy. We havegenerated and evaluated a tool for the selection of viable embryos based on the exact timing of embryo development events togetherwith morphological patterns by using an automatic time-lapse system to monitor embryo development.

The parameters studied have been postulated as new markers of oocyte quality and embryo implantation but also we have observedvariations in these markers depending on stimulation protocols and procedures:

1. Oocyte oxygen consumption is being affected by stimulation protocols.

2. The type of protocol used for controlled ovarian stimulation influences embryonic developmental kinetics, but these differencesare not reflected in embryo quality, assessed on the basis of cleavage timings.

3. No significant differences in embryo developmental kinetics for any of the gonadotropin regimens evaluated have been observed.An optimal range of gonadotropin dosage and steroid concentrations within embryos can be described, showing relevantdifferences in developmental dynamics. Time-lapse video system allows us to establish kinetic variations depending on the typeand total doses of gonadotropins used for controlled ovarian stimulation. The choice and the total dose of gonadotropin impactserum levels of estradiol and progesterone which influence embryo kinetics.

11

L1. Oocyte quality and stimulation protocols

Marcos Meseguer Infertility Institute of Valencia (IVI), Valencia, Spain

It has been suggested that an oocyte/embryo’s ability to survive to the blastocyst stage and its potential to implant can be improvedby selection of a normal spermatozoon with a vacuole-free head. Intracytoplasmic morphologically selected sperm injection (IMSI),for example, allows the observation of live human spermatozoa at high magnification (at least x6300) particularly identifying spermhead vacuoles that are not necessarily seen at lower magnifications. The only prospectively randomised study on sibling oocytes didnot show a difference in oocyte fertilisation rate, nor in embryo development between high-magnification IMSI and conventional ICSI.This does not automatically exclude that there are particular subgroup of patients that might benefit from IMSI, but it questions theroutine application of IMSI in unselected artificial reproductive technology cases. Furthermore, recent evidence indicates that largeas well as smaller vacuoles are not cavities within the sperm head. Instead vacuoles appear to be superficial thumbprint-likestructures that are not related to linked DNA damage but to failure of chromatin condensation. To summarize, IMSI may not berequired for patients who produce high-quality semen.

12

L2. Sperm evaluation: high magnification spermmorphology

Thomas EbnerWoman´s General Hospital, Department of Gynecological Endocrinology & IVF Unit, Linz, Austria

The efforts aimed at improving pregnancy rates have focused on the search for additional markers of viability to supplement currentcriteria for embryo selection.

Time-lapse technology represents a powerful tool in assisted reproduction techniques evaluating embryos from a dynamic point ofview. Standard methods of embryo assessment are based on subjective morphology evaluation at discrete time points, limiting theinformation for selecting embryos. Time-lapse is based on especially designed instruments which take images of the embryos every10-15 min automatically, without removing the embryos from the incubator to minimise manipulation. This also provides additionalinformation to the embryologist, who is able to evaluate embryos from a dynamic point of view and study the exact timings of someimportant parameters of embryo development. We are presenting the largest set of transferred embryos after time-lapse analysisand thus a novel opportunity to correlate morphokinetic parameters to implantation and ongoing pregnancy. We have been able toanalyse how chromosomal abnormalities may condition embryo morphokinetics too.

Nowadays, a hypothesis has been developed in an attempt to elucidate whether time-lapse monitoring system together with embryoselection by morphokinetics is able to improve reproductive outcome.

This presentation details what is known about time-lapse imaging, providing an overview of the advantages and applications of thistechnology as well as reviewing some of the most important studies published by our group in this field.

13

L3. Embryo classification: time-lapse technique


High frequencies of embryo demise prior to the blastocyst stage indicate that the current embryo selection procedures areineffective. Time-lapse assessment introducing morphokinesis would certainly provide a more powerful tool. Applying solelymorphological criteria, however, might be helpful if used properly. In detail, assessment of syngamy and time of first cleavageprovides first predictive power. The following days of preimplantation development symmetry of blastomeres, degree offragmentation, presence of bi- and multinucleation and beginning of compaction not only allow for prediction of blastulation but alsoof implantation. Two rare phenomena were shown to negatively influence developmental speed and outcome of treatment: planarclover-like shapes and ovoid embryos In general. It has been hypothesised that later stages of embryo development had highersensitivity and specificity in the prediction of implantation. These observations suggest that there is an additional value in assessingblastocyst development for the prediction of embryo potential. It is very likely that in the near future time-lapse imaging will moreor less replace static morphological observation.

14

L4. How to identify embryos with highest implantationpotential


Hundreds of thousands of healthy human babies have been born from oocytes/embryos/blastocysts that have been cryopreservedby either slow freezing or vitrification techniques. One theoretical limitation of vitrification is that human cells are immersed directlyinto liquid nitrogen which may expose them to potential contamination by viruses or microbes. Nevertheless a growing number ofpublications demonstrated that vitrification is as good as, and usually better than, standard slow freezing. Little is known about theeffects of these technologies on oocyte and embryo gene expression. Both cryopreservation procedures negatively affected the geneexpression profile of human MII oocytes in comparison with controls but vitrification performs significantly better compared withslow freezing. Furthermore, vitrified embryos develop better overnight than slowly frozen embryos, regardless of the number of cellslost. Analysis of metabolism revealed that vitrification had less impact on the metabolic rate of the embryo than freezing, which isreflected in higher survival rate and subsequent development.

Successful cryopreservation of blastocysts from the early up to expanded blastocyst stages is also possible using a closed HS device.It has been shown that survival rates in cryopreserved expanded blastocysts could be improved by reducing the fluid content.Vitrification is comparable to slow freezing in terms of preserving follicles in human ovarian tissue. Ovarian stroma had significantlybetter morphological integrity after vitrification than after controlled-rate freezing.

15

L5. Update on cryopreservation technique


Preimplantation genetic diagnosis (PGD) is offered in many IVF centres to improve the reproductive outcome of specific groups ofpatients. PGD is used to discard affected embryos in carriers of monogenic diseases and structural chromosome anomalies.Preimplantation genetic screening (PGS) is a variant of PGD applied to the screening of numerical chromosome anomalies incouples with normal karyotype, but with infertility problems. Current indications for PGS are: advanced maternal age (AMA),recurrent miscarriage (RM), repetitive implantation failure (RIF), and severe male factor infertility (SMF). In PGS programmes, thetechnique most widely employed for the cytogenetic analysis of blastomeres has been fluorescence in situ hybridisation (FISH) fora selected panel of chromosomes. The chromosomes most commonly tested are: 13, 15, 16, 17, 18, 21, 22, X and Y, allowing thedetection of 85% of embryo aneuploidies. Using FISH protocols, an improvement in implantation and pregnancy rates has beendescribed in retrospective studies in AMA, SMF and RM patients, whereas their benefit in RIF couples has been more controversial.In recent years, prospective randomised trials (RCT) concluded that PGS should not be recommended in AMA patients. Otherauthors have argued that there are some important methodological pitfalls in the published RCTs, such us patient inclusion criteria,the embryo biopsy procedure, embryo culture conditions as well as the type of genetic analysis performed. It has been proposed thatgreater benefits would be achieved if the whole set of chromosomes could be tested. Comparative Genomic Hybridization (CGH) isthe option closer to karyotyping, and although it has been applied to clinical practice, the time required for the analysis must bereduced. The best approximation seems to be array-CGH, which would offer the most complete analysis of the embryo, givinginformation about all 24 chromosomes and extra information that can be customised. At present, aneuploidy screening introphectoderm biopsies using array analysis for 24-chromosome analysis is offering high pregnancy and implantation rates and theusefulness of PGS is being revisited. In this lecture, we will present current data with a CGH analysis for different indications.

16

L6. PGS and micro-array CGH technique for embryobiopsy


A well-organised laboratory is essential for the provision of high-quality, safe and effective IVF services. After properly trainedpersonnel, the most important factors related to organisation of the laboratory are the materials (consumables) and the equipmentused. Choice of consumables and equipment used is critical as there are many products commercially available today. Ideally atendering process should be used to ‘qualify’ suppliers prior to any purchase. In practice, choices will be based on a number offactors including cost, availability (including spare parts), CE marking or regulatory approval, word of mouth satisfaction, personaland past experience, marketing, safety and effectiveness, servicing and support. Having decided on and purchased the specificequipment and consumables for use, it is essential to provide appropriate training using these specific items and implement asystem of preventative maintenance, routine quality control and competency assessment to ensure safe and effective use. In a busylaboratory with large numbers of personnel (some of whom may be part-time) it is of both commercial and clinical importance tooperate a system of stock and batch control. All consumables should be used prior to their expiration date. European law dictatesthat all critical materials and equipment that come into contact with gametes and embryos should be traceable and this is largelyachieved via good batch control and record-keeping. Finally, all consumables and equipment should be validated prior to use in yourown laboratory. In some circumstances it is acceptable to perform retrospective validation after prolonged successful use of an item.A series of real-world examples will be used to illustrate these concepts.

17

L7. Laboratory organisation: materials and techniques


It is the cliché of the past decade in assisted reproductive technologies (ART) but quality remains the foundation for successful IVFworldwide. More specifically, quality management (QM) underpins safety and reproducible sustained success in the IVF laboratory.Quality management represents the ‘systems’ approach to clinical IVF rather than the ‘surgical’ approach, which may explain why itgenerally sits more comfortably within the laboratory than in the clinic. While quality management may never be seen as glamorous,its importance in IVF is supported by the fact that it is the backbone of almost all modern regulatory frameworks for IVF and almostall manufacturing industries. The quality management system (QMS) covers everything from staffing to standard operatingprocedures (SOPs), quality control to purchasing, and incident reporting to key performance indicators. Rather than simply providea dry overview of a generic QMS, I have chosen to use real-life examples of how an active QMS can be used to troubleshoot problemswithin the laboratory, improve outcomes and support strategic initiatives (for example reducing the number of twin births).

18

L8. How to implement QMS in ART


Improving the patient's life through medical educationwww.seronosymposia.org

Serono Symposia International Foundation Headquarters14, Rue du Rhône - 1204 Geneva, SwitzerlandRepresentative OfficeSalita di San Nicola da Tolentino 1/b - 00187 Rome, ItalyT +39.(0)6.420.413.1 - F +39.(0)6.420.413.677

Copyright © Serono Symposia International Foundation, 2013. All rights reserved.

Advanced workshop in embryology - EXCEMEDGeneral information Venue ... • Identify new objective...

Documents

Transcript of Advanced workshop in embryology - EXCEMEDGeneral information Venue ... • Identify new objective...