Focus on Reproduction ESHRE May 2011

ESHRE’s role inEurope’s politics

of population

ESHRE’s role inEurope’s politics

of population

Focus on

REPRODUCTIONEuropean Society of Human Reproduction and Embryology // MAY 2010 //

� ESHRE news� Papers which changed the world of ART� Meet ESHRE’s next chairman

Crisis?Whatcrisis?

Focus on Reproduction May 2010 3

In my introduction to the January issue of Focus onReproduction I stated that 2010 was likely to be ahectic year for ESHRE. Four months later, I can confirmthat this is proving particularly true.

Traditionally, ESHRE has always given its firstpriority to education, but this year we have made evenextra efforts in this direction. The budget foreducational activities has been increased by more than30% over the previous year and 27 Campus symposiaand workshops have joined the annual meeting and

precongress courses to enrich the ESHRE calendar.So far, we have had extremely positive feed-back from all the activities that

have already taken place this year. Our Campus meeting on the ‘Preventionand treatment of infertility in modern society’, held in Istanbul in Februaryand reported in detail on page 28, formally inaugurated the public activities ofthe Task Force Reproduction and Society, and created much interest.

Another important event was the Campus consensus meeting on poorovarian response held in Bologna in March. This was the first ever activity tobe organised through a collaboration of all ESHRE’s SIGs. The meetingculminated with the development of common definition of poor ovarianresponse, an issue that has so far has been the subject of much debate in thescientific community.

There is also encouraging news to report from the embryology certificationcommittee, which will shortly introduce a process of certification renewalthrough a scoring system similar to the CME scheme already in place in manyEuropean countries.

As far as international relationships are concerned, a letter of intent hasbeen recently signed by ESHRE and the Chinese Society for ReproductiveMedicine to promote grants and exchanges between researchers from Europeand China. We are hopeful that this collaboration will lead to significantresults in the future.

The organisation of the annual meeting in Rome is now progressing in thebest possible way, and ESHRE 2010 will be another outstanding assembly ofclinicians, scientists and paramedics from all over the world. So I look forwardto seeing you all in Rome!

Luca GianaroliESHRE Chairman 2009-11

EXECUTIVE COMMITTEEChairman

Luca Gianaroli (IT)Chairman Elect

Anna Veiga (ES)Members

Ursula Eichenlaub-Ritter (DE)Jean-François Guerin (FR)

Timur Gürgan (TR)Antonis Makrigiannakis (GR)

Carlos Plancha (PT)Françoise Shenfield (GB)

Miodrag Stojkovic (RS)Anne-Maria Suikkari (FI)

Etienne Van den Abbeel (BE)Heidi Van Ranst (BE)

Veljko Vlaisavljevic (SL)Ex-officio members

Joep Geraedts (Past Chairman)Søren Ziebe (SIG Sub-

committee)

FOCUS ON REPRODUCTIONEDITORIAL COMMITTEE

Paul DevroeyBruno Van den Eede

Hans EversJoep GeraedtsLuca Gianaroli

Hanna HanssenAnna Veiga

Søren ZiebeSimon Brown (Editor)

Focus on Reproductionis published by

The European Society of HumanReproduction and Embryology

Meerstraat 60Grimbergen, Belgium

[email protected]

All rights reserved. The opinions expressed in this

magazine are those of theauthors and/or persons interviewedand do not necessarily reflect the

views of ESHRE.

MAY 2010

Cover picture: Getty Images/Hulton Archive

CONTENTS NEWS4 Scientific programme Rome8 Honorary members 20109 This year’s AGM agenda10 Rome to celebrate 20 years of PGD13 From the Paramedical Group14 Fertility Europe15 From the Special Interest Groups20 Sperm banking Campus report24 Consensus in poor ovarian response26 From the Task Forces

FEATURES28 Europe’s demographic crisis

Simon Brown on ESHRE’s role inEurope’s politics of population

32 Papers which changed the worldof assisted reproduction

Hans Evers with a commentary onsome of the landmark papersin the history of ART

36 Meet Anna VeigaESHRE’s Chairman Electtalks about her career and ambitions for the Society

Focus on

REPRODUCTION� Chairman’s introduction

4 Focus on Reproduction May 2010

The final programme for our annual meting in Rome isnow confirmed, and this year the International ScientificCommittee (ISC) has been faced with an unprecedentedincrease in the number of abstracts submitted. Thecommittee has received a remarkable 33% more abstractsthis year than last, a rise from 1154 in 2009 to 1539 in2010. It is also clear that there is a wealth of newdevelopments now scheduled for the free communications,either as oral or poster presentations.

The submitted abstracts were arranged in the followingcategories before review:

ANNUAL MEETING 2010

All abstracts were submitted to our standard reviewprocedure, which comprises a screening and a scoringprocess. The aim of the screening is:� to ensure that abstracts are generally designated to thecorrect topic category� to eliminate all abstracts of obviously poor quality� to eliminate abstracts that deal with topics or subjectmatters unrelated to the meeting

A total of 138 abstracts were rejected following thescreening process. In addition, there were five withdrawals.This means that 1396 abstracts underwent the completereview procedure. Of these, there were:� 359 abstracts submitted for poster presentation only� 1037 abstracts submitted for oral/poster presentationAnd from this latter total no more than 239 have now beenselected for oral presentation and 590 for poster. Thisselection was done solely on the basis of the scores fromthree reviewers scoring blinded abstracts. The 239 freecommunications have now been divided into 45 sessions,which each contains between four and seven oralpresentations.

Poster presentationsWith such a substantial increase in the number of abstractssubmitted, the ISC agreed to admit a higher percentage ofposter presentations than last year, with 590 authors nowinvited to present their posters electronically. Furthermore,each presenter this year will be offered the additonalopportunity of a paper poster. These traditional posters willbe presented in the ‘Poster Village’, according to subject, aswas done last year. The number of posters in each category

Abstractsgo through

the roof

Submissions up by anunprecedented 33%

Category TotalAndrology 208Cross-border reproductive care 17Demography, epidemiology, registries,

and health economy 54Early pregnancy 71Embryology (embryo selection) 184Endometriosis, endometrium, implantation 144Ethics and law 21Fertility preservation 105Others 202Paramedical (nursing, laboratory) 30Psychology and counselling 47Reproductive endocrinology 217Reproductive genetics 68Reproductive surgery 35Safety & Quality 112Stem cells 24Grand total 1539


as well as the days on which they will be presented in thePoster Village are indicated in the box above. In addition,each day of the meeting will feature a more formal posterdiscussion, also as indicated in the table above. The timeallocated to each presenting author will be restricted totwo minutes only and thereafter three minutes will beavailable for discussion.

Geographical distributionAs ever, abstracts were received from all over the world.This year, no fewer than 65 countries (last year 60) will berepresented. The ten most prolific countries are shownbelow:

It is interesting to note that Belgium, which is not on thislist, submitted 40 abstracts, of which 14 were selected fororal and 19 for poster presentation.

As always, the main scientific meeting begins on theMonday morning (28th June). Before that, however, nofewer than 12 precongress courses will be held on theSunday. The topics vary from ‘Patient-centred fertilitycare’, hosted by Fertility Europe, to ‘Fertility preservationin cancer’, organised by our Task Force on FertilityPreservation in Severe Diseases.

Monday starts as usual with a keynote lecture session.This year, for the first time, one of the presentations is the

Human Reproductionkeynote lecture, in honour ofthe best paper from our mainjournal. The first presenter,Gayle Jones, has beenselected on the basis of thepaper ‘Novel strategy withpotential to identifydevelopmentally competentIVF blastocysts’, which waspublished in 2008. Gayle willbegin her presentation withthe published work and thengo on to deal with morerecent developments. Thesecond keynote lecture is byWybo Dondorp, who willdiscuss the risks andresponsibilities associated

with innovative reproductive technologies.Monday morning will also feature a PGD/PGS session

during which the latest annual data from the PGDConsortium will be presented as well as the first resultsfrom the PGS pilot study staged by ESHRE’s Task Force onPGS.

In recent years our debate sessions have been well Continued over page

Topic (total posters) Poster discussion Poster Village

Andrology (91) Tuesday WednesdayCross-border reproductive care (9) MondayDemography, epidemiology, registries and health economy (17) MondayEarly pregnancy (23) TuesdayEmbryology (103) TuesdayEndometriosis, endometrium, implantation (64) Monday TuesdayEthics and Law (4) MondayFertility preservation (49) Wednesday MondayParamedical (6) TuesdayPsychology & counselling (14) TuesdayReproductive endocrinology (97) MondayReproductive genetics (27) MondayReproductive surgery (11) WednesdaySafety & quality (63) TuesdayStem cells (12) Wednesday

Total Selected Selected abstracts for oral for poster

Spain 157 19 65Italy 128 10 48United Kingdom 114 29 39USA 86 18 44Netherlands 81 23 35Japan 76 8 39France 73 16 34China 63 7 19South Korea 60 3 22Brazil 60 9 19

Where from? Selected poster presentations 2010.

Where from? Selected oral presentations 2010.


received, and this year there will be at least one a day. Thisyear’s topics include natural cycle IVF vs. stimulation,selection of male vs. female gametes and alternativemedicine.

On Tuesday our historical lecture is topically devoted to‘Catholicism and human reproduction’ and will bedelivered by Norman Ford.

The number of invited sessions totals 25, and almostevery one of ESHRE’s SIGs is represented. There are alsocompany symposia, our traditional live surgery session,and sessions covering themes related to ESHRE activities.And as last year - since it proved such a success - we are

again combining the awards ceremony with summaries ofthe award-winning presentations and the closing ceremony.

All in all, this has been an unprecedented year in termsof interest and abstract submission, and there’s little doubtwhere most investigators want to be at the end of June. Wein the ISC are looking forward to a very interesting andrewarding programme, which we feel confident will deliverpresentations of the highest quality.

Joep Geraedts,Chairman International Scientific Committee

� There is more graphic information on the geographicaldistribution of abstracts on the ESHRE website.

Scientific programme, RomeContinued from previous page

All aboard!

ANNUAL MEETING 2010

Take the bus, the train or the Metro in RomeThe congress venue in Rome, the Nuova Fiera di Roma, islocated outside the city centre, between the city andFiumicino airport, which means that all participants thisyear - even those staying in hotels near the congress centre- will need transportation.

There are three public transport systems available:

� Shuttle busesHotels officially booked by ESHRE and its agent,Meridiano Congress International, will be served by a fleetof shuttle buses running between the hotels and thecongress centre. The journey time from the city centrehotels will be around 45 minutes, so delegates planning an


early start at the congress will need tobe on their way by 7.00! � Metro + Laurentina shuttleRome’s Metro system is inexpensiveand easy to use, with just two linescrossing the city. These two lines - lineA and line B - cross at the Terministation. Those without access toofficial hotel shuttle buses may takethe line B Metro to Laurentina station(at the end of the line), where a furtherfleet of shuttle buses will run to andfrom the congress centre. More than2000 seats a day will be available onthe Laurentina shuttles.� Direct on the FR1 railwayFiera di Roma has its own stop on theFRI (Trenitalia) train line between thecity and Fiumicino airport. You canpick up the train at stations Termini,Tuscolana, Trastevere or Ostiense inthe direction of Fiumicino and get offat Fiera di Roma. Departures are every15 minutes.

We also understand that some of oursponsoring companies with large hotelallocations will be providing their owntransport between hotels and thecongress site.

Our agents in Rome, Meridiano,have now devised a bus timetable,with schedules divided according tothree clusters of hotels - ‘city centre’,‘congress area’ and ‘residential area’.The timetables are available on theESHRE website. All buses will carrythe ESHRE logo, and each will have arepresentative of Meridiano on board.

Filippo Maria UbaldiChairman Local Organising Committee

First results from ESHRE’s PGS pilotstudy to be reported in Rome

First results from thePGS pilot study stagedby ESHRE’s PGS TaskForce will be presentedin Rome in a Mondaymorning session whichalso includes new data from theESHRE PGD Consortium.

This PGS proof of principle (PoP)study, which was first announced inAmsterdam last year, began about amonth later than originally planned.However, recruitment of patientswent successfully and the technicalpart of the project will be completedsoon. A sufficient number of polarbodies have been biopsied by the twopilot centres in Bonn and Bologna.

First and second polar bodies havebeen separately processed forchromosomal analysis, which hasbeen performed at each of the twocentres using the SurePlex

amplification protocoland the 24suremicroarray technologyprovided by BlueGnomeof Cambridge, UK. Theimages have been scored

by two independent observers ineach centre. To estimate theconcordance of data between thepolar bodies and correspondingoocytes, there will be a blind analysisof those oocytes which are deemedaneuploid according to the result ofthe polar body analysis.

The study began in September2009 and it is expected that theacquisition of the data will becompleted in May. At the moment alldata are in the process of evaluationby an independent data analysis teamat the University of Amsterdam.

Joep GeraedtsCo-ordinator PGS Task Force

European Court declares Austria’s ban on gamete donation unjustified

The European Court of HumanRights has ruled in favour of twoinfertile Austrian couples whocomplained to the Court thatAustria’s ban on sperm and eggdonation in ART violated their rightto respect for family life and thatthe difference in treatment availableto them (needing gamete donation)and to other couples using ART(without gamete donation) wasdiscriminatory. On this lattercomplaint, the Court - while notingthat among EU member states therewas ‘no uniform approach’ to ARTnor any ‘obligation to allow it’ -ruled by a majority of six to one thatthe difference in treatment at issuewas not justified.

According to a 1st April pressrelease from the Court, Austrian lawallows ART only with ‘homologous’

gametes from the treated infertilecouple. Legal restrictions had beenput in place to protect children from‘unusual family relationships’ andthe exploitation of donors.

‘It’s early to say what this meansfor other countries where gametedonation in IVF is banned,’ saysESHRE’s Chairman Luca Gianaroli.‘But this ruling appears to set aprecedent that any restriction ongamete donation in IVF is a violationof two articles of the EuropeanConvention on Human Rights - onrights to family life and to non-discriminatory treatment. As in Italy,the challenge to restrictivelegislation in ART has once againcome from patients.’

The Austrian government now hasthree months in which to decidewhether to appeal the judgement.


ANNUAL MEETING 2010// HONORARY MEMBERS //

Honorary memberships have been awarded annually to twoluminaries from reproductive science and medicine at each ofESHRE’s annual meeting since 1985, one of them from thehost country. This year’s ‘local’ honorary membership will beawarded to the Italian gynaecologist Ettore Cittadini, whosince the late 1950s has worked clinically and in research ingynaecological endoscopy, infertility and family planning atseveral hospitals in Italy and abroad, including the HopitalBroca in Paris and the O&G Clinic of Palermo. ProfessorCittadini was a member of ESHRE’s first temporarycommittee, which Robert Edwards formed in 1984 to steerthe fledgling society, and of ESHRE’s first AdvisoryCommittee set up soon after.

ESHRE’s second honorary membership will be awarded tothe French biologist Professor Luc Montagnier, who in 1983led the group which first isolated the humanimmunodeficiency virus (HIV1) and identified it as thecausative agent of AIDS. In 1985 he isolated the second AIDSvirus, HIV2, from West African patients. His laboratory inParis at the Institut Pasteur was also the first to show that alarge fraction of white blood cells of HIV-infected patientswere prone to die by apoptosis, a process of programmed celldeath attributed to oxidative stress in patients, possiblyassociated with infections. Besides his involvement in thedesign of new types of HIV vaccines, his current studies areaimed at microbial and viral factors associated with cancers,neurodegenerative and articular diseases.

In 1987 Professor Montagnier was one of four guestlecturers at ESHRE’s third annual meeting, which Edwardsorganised in Cambridge, UK.

Meet ESHRE’s 2010 honorary members

ESHRE journals: HR progresses ‘in the right direction’

The publisher’s report toESHRE’s journal sub-committee for 2009 shows thatthe indices of performance forHuman Reproduction ‘have allmoved in the right direction’.The number of newsubmissions was maintainedor increased, the time to afirst decision decreased, theacceptance rate declined, the response times from associateeditors reduced, and theimpact factor increased.

During the six-month periodof July-December 2009, thejournal received a total of 851manuscripts, the vast majorityoriginal articles. The 9%acceptance rate for 2009suggests that the declineobserved over the previousfour years (19, 15, 12 and11%) may now be stabilising.

ESHRE’s two honorarymembers for 2010:

above, Italiangynaecologist EttoreCittadini, and below,

French biologistLuc Montagnier.

Continuing education for ESHRE-certified embryologistsESHRE's programme for the certification of embryologistsis now in its third year, and this year's exams will be heldin Rome on Saturday 26th June at 16.30. With thenumbers of certified embryologists - and scientificdevelopments - ever increasing, ESHRE will this yearintroduce a Continuous Embryology Education (CEE)system in which ESHRE-certified embryologists will be ableto upgrade their certification on-line. This can be donethrough� attending meetings, courses and workshops� publishing abstracts and articles� presentations at meetingsThe embryology certification pages on the ESHRE websitewill shortly contain full information.

The curriculum information on the website will also be

improved, with different parts of the curriculum beinglinked to relevant syllabi from ESHRE workshops.

A questionnaire regarding the certification procedure,and what ESHRE-certified embryologists have gained afterobtaining their certification, was sent out at the beginningof the year. The results are currently being analysed, andwill be presented shortly.

The website also contains detailed instructions about theexamination in Rome - as well as details for aspiringexaminees of eligibity and logbook submission for nextyear’s exam in Stockholm. The rules for certification ofembryologists state that the applicant must be a memberof ESHRE at the time of applying for certification.

Kersti LundinEmCC Steering Group Co-ordinator


// ANNUAL GENERAL MEETING //

Balance sheet shifts towards higher expenditure

Income

Balance

Expenditure

Financial results 2008-9; Budget 2009-10 (euro)

ESHRE’s financial report to be presented at theGeneral Assembly of Members (AGM) in Rome willshow - for the first time in many years - a smallbudget deficit for 2010.

With income continuing to rise, the shortfall infinances will be accounted for by a greatercommitment to the activities of the SIGs and TaskForces, which in 2009 are set to represent 19% ofESHRE’s total expenditure. The organisation ofCampus events, for example, of which 27 have beenscheduled for 2010, cost ESHRE 382,584 euro in2008, but 418,567 euro in 2009, an increase of8.6%. Currently, SIG and Task Force activitiesrepresent around 19% of the Society’s totalexpenditure, but generate only around 7% of totalincome. Attendance costs of Campus events are keptto a minimum to encourage participation fromstudents and young members.

The annual meeting remains ESHRE’s greatestsource of income (67%) and greatest expenditure(50%). Publications represent 16% of the Society’sincome, and membership fees 7%. However, ESHREremains financially strong - despite the economiccircumstances - and committed to its trainingprogramme and specialist groups.

This year’s General Assembly of Members will takeplace on Tuesday 29th June at 18.00 at the FieraRoma (Hall 10, Room I), Rome; the agenda is assummarised in the box opposite:

Income

Expenditure

Balance

2008

5,612,051

4,795,813

+816,238

2009

5,943,762

5,945,504

-1,742

Budget 2009

5,161,495

5,120,231

+41,263

Budget 2010

6,259,708

6,379,951

-120,243

1. Minutes of the last meeting2. Future activities of the Society3. Ratification of the honorary members for 2011:

nominees are Alan Trounson and Lars Hamberger4. Paramedical Group5. Financial report6. Membership of the Society7. Any other business8. Date of the next General Assembly of Members

Make the most of Special Interest Group membershipThere are 11 Special Interest Groups (SIGs) in ESHREand all members are asked to indicate which is theirprimary and secondary interest. Of course, this does notrestrict you to participating only in the activities of yourspecial interests, but will enable you to receive specialalerts relating to topics of interest and forthcomingCampus events and precongress courses (PCCs). TheSIGs are listed on the ESHRE website under theheading ‘Speciality Groups’. In addition, there is theParamedical Group, which was established to assemblenurses, lab technicians and other support personnelactive in the field of reproductive medicine andscience. The PMG also organises Campus workshopsand has dedicated sessions at the annual meeting.

Each SIG has a co-ordinator, who is nominated fromthe SIG committee, which usually comprises three other

members (deputies), including a junior representativeand the recent past co-ordinator. The role of the SIGcommittee is to take suggestions for Campus eventsand PCCs and organise these activities, which mayoften be combined as a joint course with other SIGs.There are 25-30 workshops each year, across a range ofsubjects and in different European countries. Theseserve to provide both training and state-of-the-artupdates. Lecture notes are available on the ESHREwebsite. The SIGs also hold a business meeting at eachannual meeting, which is open to all members. Hereyou may make suggestions for future activities.If you are not a member of a SIG (or two), pleasecontact ESHRE and express your interest.

Adam BalenCo-ordinator SIG Reproductive Endocrinology


ANNUAL MEETING 2010// PGD CONSORTIUM //

ESHRE’s PGD Consortium and SIG Reproductive Genetics are this year organising a post-congress course to celebrate 20years of PGD. The event will take place on 1st July in Rome. The first clinical PGD cases were performed at theHammersmith Hospital in London in 1989, and, although the first couple treated did not get pregnant at this firstattempt, they did deliver twins in 1990 at their second try.

However, more than 20 years before that, the first PGDhad been performed by Richard Gardner and RobertEdwards - in 1967. They biopsied a small portion of thetrophectoderm from rabbit blastocysts, sexed the embryosby identifying sex chromatin to identify females, andreplaced the biopsied blastocysts back into recipientfemales. The offspring in these experiments were found tobe of the predicted sex.1,2

The first human PGD cases were performed at theHammersmith Hospital in 1989, using cleavage stagebiopsy for embryo sexing by PCR.3 Female embryos wereselectively transferred in five couples at risk of X-linkeddisease resulting in two twin and one singleton pregnancy.A total of 21 cycles were performed in two series andincluded the above successes as well as one misdiagnosis.At that time little was known about the pitfalls of singlecell amplification, particularly allele dropout, cumulus cellcontamination or amplification failure from single cells.

In the USA several teams were also developing PGD inthe late 1980s. Yury Verlinsky did his first cases in1988/89.4 His team used the first polar body to detect amaternally transmitted alpha 1 antitrypsin deletion in onepatient. Eight eggs were collected, seven polar bodies wereaspirated, six embryos fertilised, and PCR was successful infive cases. Two embryos were transferred but the patientdid not become pregnant. In the same year Yury’s teamreported on preconception diagnosis for cystic fibrosis.5

By 1994 there were eight centres worldwide performing

Presentations from many of the central figures in PGD

The celebration of 20 years of PGD will be held as anESHRE post-congress course on Thursday 1st July inRome and includes contributions from many of the keyplayers in PGD. These include include Alan Handyside,Joep Geraedts, Karen Sermon, Joyce Harper, GaryHarton, Darren Griffin, Marilyn Monk, Montse Boada,Mark Hughes, Dagan Wells, Edith Coonen, SantiagoMunné, Cristina Magli, Luca Gianaroli, Joe LeighSimpson, Alison Lashwood, Inge Liebaers, FrancescoFiorentino, Stéphane Viville, Guido de Wert, LeeandaWilton and Anver Kuliev (who will also pay tribute tothe late Yury Verslinsky). The programme is divided intothree sessions: The past, present and future of PGD;PGD from the patient's perspective (which will includetalks by two families who have benefitted from PGDand 'saviour sibling' HLA matching); and Embryologyand ethics as they relate to PGD.

Twenty years of PGD for celebratorypost-congress course in Rome

Joyce Harper,Chair of the PGD

Consortium,demonstratingembryo biopsyduring a 1993

workshoporganised by

Leeanda Wiltonin Melbourne.

PGD, with four in the USA. A total of 83 cycles werereported of sex selection for patients carrying X-linkeddisease using PCR or FISH and 51 cycles of PGD formonogenic disorders, including cystic fibrosis. Threecentres dominated the field: the Hammersmith/UCL group, the team at Cornell University Medical College in

Gary Harton, right, Deputy Chair of the PGD Consortium, withAlan Handyside at the Genetics & IVF Institute, Fairfax, in 1995.


Accreditation the way to quality assurance in the PGD labAccording to an internationally recognised standard(ISO), accreditation is increasingly acknowledged asthe most effective route to appropriate laboratoryquality assurance, and most diagnostic and IVFlaboratories are now moving towards accreditation.

ESHRE’s PGD Consortium, and some regulatorybodies including the HFEA in the UK, recommend thatall PGD laboratories should be accredited according toISO 15189, Medical laboratories - Particularrequirements for quality and competence. The PGDConsortium working-group on accreditation has recentlydescribed each point of the ISO and how it relates toPGD.1

In order to help centres understand the benefits,advantages and profitability of being accredited, thePGD Consortium, SIG Reproductive Genetics andEuroGentest organised a second Campus workshop onaccreditation for PGD in London in March, two yearsafter the first on accreditation in Brno, Czech Republic,in 2008. Since that time the conditions, availabilityand legislation across Europe have developed at a fastpace. From January this year clearly defined national

accreditation bodies for each country have beenestablished, which will streamline the accreditationprocess.

At this year’s workshop 15 invited speakers provideda detailed overview of current best clinical/laboratoryexperience in quality management for PGD. Thisincluded training of PGD staff, auditing PGD activities,external quality assessment, key quality indicators inPGD, emerging technologies in PGD and the role of thePGD Consortium. Since the first workshop of 2008,several centres have become accredited and manyothers are working towards accreditation.

Accreditation is an ongoing issue and the Consortiumand EuroGentest are developing further workshops. TheConsortium will be conducting annual questionnaires ofits members to monitor the centres who have beensuccessful in accreditation. Successful centres will benoted in the quarterly Consortium newsletter.Katerina Vesela, Chairman Accreditation working group

Joyce Harper, Chair PGD Consortium

1. Harper JC, Sengupta S, Vesela K, et al. Accreditation of thePGD laboratory. Hum Reprod 2010; 25: 1051-1065.

Participants in the Campus workshop on accreditation for PGD held in London in March.

New York run by Jacques Cohen and Santiago Munné, andthe Reproductive Genetics Institute in Chicago run by YuryVerlinsky. The other centres were the University Hospital,Ontario, Free Univeristy Hospital Brussels (VUB), the JonesInstitute, Norfolk, USA, the Genetics & IVF Institute,Fairfax, USA, and GIEPH, Barcelona.

Joyce Harper and Gary HartonChair and Deputy Chair

ESHRE PGD Consortium

1. Edwards RG, Gardner RL. Sexing of live rabbit blastocysts.Nature 1967; 214: 576-577.

2. Gardner RL, Edwards RG. Control of the sex ratio at full termin the rabbit by transferring sexed blastocysts. Nature 1968; 218:346-349.3. Handyside AH, Kontogianni EH, Hardy K, Winston RM.Pregnancies from biopsied human preimplantation embryos sexedby Y-specific DNA amplification. Nature 1990; 344:768-770.4. Verlinsky Y, Ginsberg N, Lifchez A, et al. Analysis of the firstpolar body: preconception genetic diagnosis. Hum Reprod 1990;5: 826-829.5. Strom CM, Verlinsky Y, Milayeva S, et al. Preconception geneticdiagnosis of cystic fibrosis. Lancet 1990; 336: 306-307.* For more details about the history of PGD see PreimplantationGenetic Diagnosis, Ed Harper. JC, Cambridge University Press,2009.


ESHRE’s 2012 annual meeting - theSociety’s 28th in total - will take placein Istanbul, and for the first time inTurkey, a country which is now wellrepresented in ESHRE’s membership.The local chairman will be TimurGürgan, who has been a member ofESHRE’s Executive Committee for thepast three years.

The choice of Istanbul not onlyreflects Turkey’s substantialmembership in ESHRE and itsprominent role in reproductive

medicine, but also its location as abridge between East and West. ‘It willprovide a great opportunity for ourmembers in the Middle East, Asia andAustralia,’ says ESHRE’s managingdirector Bruno Van den Eede, ‘andmake the 2012 meeting a little moreconvenient. It’s another move in theright direction, but geographically it’sas far East as we can go.’

With congress planning now havingto consider 10,000 participants (intheory if not actually), there are a

limited number of cities in Europeable to provide what ESHRE nowexpects - sufficient high qualityconference and exhibition space,convenient transport connections andplentiful accommodation in all priceranges. Istanbul meets those criteria,with the annual meeting set to bestaged at the Istanbul Convention &Exhibition Centre, a state-of-the-artvenue whose main auditorium canseat more than 2000 ‘in armchaircomfort’.

ESHRE 2012 heads to Istanbul‘. . . as far East as we can go’

Ten years of ESHRE IVF monitoring to be marked by celebration meetingThe unique and far-reaching data collection of ESHRE’sEuropean IVF Monitoring (EIM) consortium is now in its12th year and on 11th September in Munich the groupwill celebrate the ten-year anniversary of its firstpublication. Ten-year trends reported by the EIM haveshown a continuing increase in ART pregnancy rates,despite the transfer of fewer and fewer embryos in eachcycle: from 26% to 30% for IVF and ICSI, and from 15%to 19% for frozen embryo cycles. And although thenumber of egg donation cycles remains low, pregnancyrates have increased from 27% to 42%.

The data also showed a ten-year decline in multipledelivery rates, from 29.5% when records began to 20.5%in 2005. Last year in Amsterdam, the EIM report noted

European multiple rates below 20% for the first time.However, the most striking trend in ten years of EIM

data has been the proportional increase in the use ofICSI, which is now double that of IVF in Europeanpractice. This is a complete reversal in trend from whatwas apparent a decade ago - from 65% IVF and 35%ICSI in 1997, to 37% IVF and 63% ICSI in 2005.

The September meeting programme has been puttogether by the present chairman of the EIM steeringgroup, Jacques de Mouzon, and will feature the impact ofART databases over the past decade and experience frommany of the local registries on which the annual EIMreports are based. There will also be round-table sessionson the practicalities of gathering and presenting EIM data.


NEWS// PARAMEDICAL GROUP //

Paramedic members encouraged to pursuetheir own research and submit abstractsA two-day Campus workshop on ‘Research - theory andpractice’ was staged by the Paramedical Group on 4/5thMarch in Brussels. The course, which attracted 55participants, aimed to increase the number and the qualityof abstracts submitted by paramedics, who today includenurses and laboratory technicians, counsellors, juniorscientists and junior medics.

Both the editors of Human Reproduction, André VanSteirteghem, and Human Reproduction Update, John

Collins, took part, the latter describing the skills needed towrite a meeting abstract, and the former a full manuscript.An introduction to descriptive statistics was given byOlivier Mairaisse, whose presentation covereddistributions, quantiles, measures of central tendency andvariation and standard scores.

Van Steirteghem opened the second day with theselection of papers: how abstracts are reviewed and howpapers are chosen for publication. He noted that thechances for acceptance of a congress abstract or a paperfor publication might be better if potential researchersknow which standard should be met and what quality isexpected. Herman Tournaye from the VUB in Brusselsdescribed the art of presenting data and making effectiveuse of PowerPoint.

Facilitators for the afternoon workshops were activelyinvolved in one type of research and proposed one of theirown research projects. There were specific workshops onnursing research (presented by Valerie Peddie) and researchin midwifery (covered by Mette Juhl).

The objective of the course was to help participantsunderstand the different approaches to research and toapply this knowledge in their own fields of practice. TheParamedical Board hopes that those attending will feelmore confident about their own research ideas and tosubmit their abstracts to ESHRE

Patricia Baetens and Heidi Van RanstParamedical Board

More than 50 members of the Paramedical Group took part in aCampus workshop on the theory and presentation of research in

reproduction. The course was designed to encourage research andincrease the number and quality of abstracts and papers

submitted to congresses and journals by paramedics.

The first textbook designed for nurses in reproduction

The past decade has seen the professional role of the specialist nurse evolve, through the development ofevidence-based protocols and a greater involvement inresearch. The continuing education of nurses isimportant to maintain this momentum and improvestandards of care.

As happened with our medical colleagues, more andmore nurses are now specialising in just one field ofmedicine, and in such cases a basic nursing educationis not enough to support the development of care in aspecialty such as reproductive health.

In the Netherlands, under the lead of two nurses,Metty Spelt and Nicolette de Haan, severalprofessionals have now filled a gap in the education ofnurses in reproduction with the development of atextbook, the first to be written for nurses working inreproductive health. The book provides an overview ofall the important issues - and junior doctors and labtechnicians have also found it invaluable.

However, a lack of formal education and training forparamedics working in reproduction is not just an issuein the Netherlands. Many countries in Europe areunable to provide specific training - which is whyESHRE’s Paramedical Group has developed its basictraining course as a model suitable for membersthroughout Europe. The next step in the support ofthese training efforts was a translation of the textbookinto other languages. And we are pleased to report thatthe textbook is now being translated into English andwill be ready for the annual meeting in Rome. ESHREhas generoulsy agreed that every paramedical memberwill receive a free copy of the book.

Jolieneke Schoonenberg-PomperPMG Chair elect


Fertility Europe will organise this year’s Patient Session inthe scientific programme for Rome under the title ‘Howpatient-friendly is patient-friendly?’ The session, with fourspeakers, aims to present the patient’s view of what theyconsider ‘patient friendly’ treatment to be. The perspectiveis global, and, by presenting that view from East andWestern Europe as well as from a developing country, willconsider strategies to improve the friendliness of the wholejourney that patients take in their clinical and holistic care.The first paper, presented by Guido Pennings fromESHRE’s SIG Ethics & Law, will introduce an ethicalapproach to patient-friendly treatment in terms of thepatient and society. Three other papers will be presented,by Italian psychotherapist Vincenza Zambaldi on a holisticapproach to treatment, Denisa Priadková, chair of the civilassociation Stork (Bocian) in Slovakia and vice chair ofFertility Europe, on how the rapid route to IVF is notalways in the patient’s best interest, and Gamal Serourfrom Egypt (and President of FIGO) on what patient-friendly treatment means in developing countries.

Fertility Europe will have a booth in the main exhibitionarea in Rome, so we hope all ESHRE members will passby and find out a little more about us. Our own annualmeeting will be held in Rome on Monday 28th June. And Ishould here express our appreciation to ESHRE forallowing our delegates entry to the congress and exhibition- something none of us would be able to afford withoutthe generosity of ESHRE. Patient organisations too canlearn an awful lot from the scientific sessions at the annualmeeting and contribute to them.

Our latest FE meeting in March saw a very activeattendance from representatives of full-member patientgroups in Belgium (De Verdwaalde Ooievaar NetwerkFertiliteit), Czech Republic (Nadace Materska nadeje),Finland (Lapsettomien yhdistys Simpukka ry), Israel(Chen), Italy (FIAPI), Netherlands (Freya), Norway

(Onskebarn), Poland (Nasz Bocian), Slovakia (Obcianskezdruzenie Bocian), Switzerland (Verein Kinderwunsch), andUK (Infertility Network UK), with candidate memberspresent from Austria (Wunschkind-Kinderwunsch),Bulgaria (Iskambebe and Sdruzhenie Zachatie), France(Association Maia), Greece (Kiveli), Latvia (Fertilitas),Romania (SOS Infertilitatea), Sweden (IRIS), and Spain(Genera).

It was striking to hear, from the presentations of each,how inequalities exist between East and West Europe, andhow too their issues and priorities are different. One vitalrole for Fertility Europe is to help beneficiary organisations share best practices, including information on fertility andinfertility, prevention, fundraising, increasing membershipand attracting volunteers.

Among Fertility Europe’s plans for 2010 is the launch ofour ‘Special Families’ campaign in which ‘virtual’ greetingcards become real cards with real hope. These messageswill be displayed in a central point in Rome as a reflectionof the variety and importance of fertility treatment today.

Clare Lewis-JonesChair Fertility Europe

‘Patient-friendly’treatment from thepatient point of view

Fertility Europe’s association with ESHRE

� Why should FE and ESHRE work together? We areexperts in our own fields and complement each other.Patients and professionals should work in partnershipand we both have relevant skills and experience. � We have now grown from seven members to 25thanks to ESHRE’s support.� FE is now the official partner patient organisationwith ESHRE - something we are very proud of andtake very seriously.� Statistics we have from just 11 memberorganisations show that we reach 229,400 uniquevisitors each month via our websites and 382,000 interms of total visitors per month. A fantastic reach.� It’s important that our patient organisations acrossEurope have reporting space in Focus on Reproductionto bring our activities to everyone’s attention.� Our precongress course in Rome will represent thepatient view on treatment - a fantastic opportunity forFE to inform those working in the field about patientexperience and views - exactly the sort of thing thecollaboration with ESHRE was aiming for.

Patient groups in East and West Europeare now represented in Fertility Europe


The continuous exchange ofscientific and technical dataamong embryology laboratories isoften hampered by the diversity ofexperimental conditions and termsof reference. The scoring ofoocytes and embryos is one suchexample. Of course, there aremany similarities in aspects andparameters of grading in each setting, but with largedifferences of nomenclature. It is quite clear that a moreuniform classification system would greatly help theintegration of data for a better understanding of earlyembryogenesis.

With this concept in mind, the board of the SIGEmbryology has been working towards the introduction ofa comprehensive system for oocyte and embryoclassification which could be shared throughout thescientific community. Our strategy was based on the ideaof identifying those scoring criteria which couldunequivocally describe the morphological aspect ofoocytes, pronuclear stage and embryos and thereby reachcommon definitions with a common language. We thusplanned to define an ESHRE scoring system to be sharedby all clinical embryologists - which might be realised intwo steps: first, the compilation of evidence-basedevaluation data to formulate a common scoring system;and next, the dissemination of this new system through theAtlas of Embryology.

1. Consensus The first step of theproject was to gather agroup of experts whocould produce aconsensus documentrepresenting an evidence-based guide to theevaluation of oocytes,pronuclear stage and allstages of embryoassessment. Theimportance of verifyingthe physiologicalsignificance of as many

morphological features as possiblein relation to the time ofdevelopment, and to establisheventual correlations with viabilityand implantation potential, wasemphasised. This approach wouldmake it possible to identify thoseaspects of morphology withbiological significance and for

which systematic evaluation is critically relevant. The group met for two days in February in Istanbul at a

meeting hosted by Basak Balaban, the current chair ofALPHA. A consensus document was drafted and iscurrently being edited in its final version. The documentwill be presented to the next ESHRE Executive Committeemeeting and, after approval, published as anESHRE/ALPHA document to be used as a common oocyteand embryo grading system.

2. The Atlas of EmbryologyA new Atlas of Embryology was considered the best wayto promote the new scoring system and illustrate thecriteria for assessment. Working groups have now beenorganised to address the different chapters: oocytes,pronuclear stage, embryos and blastocysts. Gayle Jones hasbeen appointed by the board of the SIG Embryology as co-ordinator of the working groups.

During the SIGE’s business meeting in Rome there will bean update on theconsensus document andon the status of theproject.

This initiative is theresult of a closecollaboration betweentwo embryology societiesand we both hope that theproposed scoring systemwill soon become widelyaccepted, reinforcing theidea that joint efforts canbe very fruitful.

Cristina MagliCo-ordinator

SIG Embryology

SPECIAL INTEREST GROUPS// EMBRYOLOGY //

Oocyte and embryo scoringThe design of a common system from ESHRE and ALPHA embryologists

OfficersCristina Magli (IT), Co-ordinatorRachel Levy (FR), Deputy Co-ordinatorKersti Lundin (SE), Deputy Co-ordinatorJosephine Lemmen (DK), Junior DeputyEtienne Van den Abbeel (BE), Past Co-ordinatorTakashi Hiiragi (DE), Basic scientist

The SIG Embryology and ALPHA consensus development group, with left to right, Alan Thornhill, Joe Conaghan, Aycan Isiklar, Lynette Scott,

Jonathan Van Blerkom, Basak Balaban, Lisa Cowan, Kersti Lundin, Thorir Hardarsson, Etienne Van Den Abbeel, Cristina Magli,

Johan Smitz, Jim Catt, Dominique Royere, Sharon Mortimer and David Mortimer. Not pictured are Santiago Munné, Thomas Ebner,

Gloria Calderon and Daniel Brison


Annual meeting RomeOur precongress course in Rome hasbeen creatively constructed aroundthe theme of debate and audienceinteraction. In the field of recurringmiscarriage there is a dearth ofevidence-based practice with no clearsystematic review to guide andinform best clinical practice (Level 1evidence). As a result, this lack ofclarity allows considerable scope foropinion to fill the vacuum. Thepurpose of our precongress activity isto clarify existing evidence and allowa more focused approach to emerge.The themes are currently hot topicsin recurring miscarriage.

The SIGEP committee wasattracted to the debate forum (a fineRoman tradition) and invited a hostof world class speakers to present acase for and against two distinctthemes. The first theme of heparin use in pregnancy will bepresented by Lesley Regan (London, GB) and Carl Laskin(Canada). This subject continues to attract a good deal ofopinion, especially as a treatment intervention inpreventing early pregnancy loss in recurring miscarriagepatients. There is emerging evidence based on RCTfindings assessing the role of heparin, with recentpublication in 2010. In addition, the indications formaternal thromboprophylaxis have recently been updated.which in turn moves the debate wider.

The second theme of selective karyotyping will bedebated by two similarly world-renowned speakers inMary Stephenson (Chicago, USA) and Mariette Goddijn(Amsterdam, NL). Historically, the investigation of earlypregnancy loss relied on parental chromosome testing and,more pertinently, failed pregnancy testing. Conventionalcell culture techniques exhibited a high rate of maternalcell contamination from failed pregnancy. With theappearance of innovative cytogenetic techniques, such asextended fluorescent in situ hybridisation (FISH), spectrum

and comparative genomichybridisation (CGH) array, thisimproved accuracy of chromosomalabnormality detection has heraldeda new era. With a wide spectrum oftreatment interventions now used inrecurring miscarriage this sessionprovides an ideal opportunity toquestion whether treatment failureremains a valid concept in theabsence of cytogenetic testing. Inparticular, it suggests a newstandard for future RCT designwhen pregnancy loss occurs. Thesetopics are hot topics, and wouldallow the promotion of high impactareas of translational research andclinical innovation.

A plenary session during thescientific programme of the meetingon Monday 28th June at 17.00 willaddress the prevention of maternal

death in early pregnancy. This session will feature twointernationally recognised experts, James Neilson onmaternal death from miscarriage and ectopic pregnancy,and Michael Greaves on thromboembolism and earlypregnancy.

Notes for your diary� ESHRE joint SIG meeting DubrovnikOn 24-25th September 2010 a joint SIG meeting with SIGsReproductive Surgery and Reproductive Endocrinologywill take place in in Dubrovnik. A full two-dayprogramme has now been developed.� ESHRE joint SIG meeting ValenciaOn 2-3rd December 2010 a joint SIG meeting with SIGsEndometriosis and Endometrium and Stem Cells - on the‘maternal embryonic interface’ - has been developed. Fullprogramme details will be available in shortly.

Roy FarquharsonCo-ordinator SIG Early Pregnancy

[email protected]

SPECIAL INTEREST GROUPS// EARLY PREGNANCY //

Clarifying the evidence in recurring miscarriage

OfficersRoy Farquharson (GB), Co-ordinatorMariette Goddijn (NL), Deputy Co-ordinatorOle Christiansen (DK), Deputy Co-ordinatorEric Jauniaux (GB), Past Co-ordinatorMarcin Rajewski (PL), Junior Deputy

SIG EP co-ordinators, left to right, RoyFarquharson, Mariette Goddijn,

Ole Christiansen and Marcin Rajewski.


Annual meeting RomeWe hope to see as many ofyou as possible at thisyear’s precongress course.Juan Garcia Velasco (ES)and Paola Vigano (IT) haveprepared an excellentprogramme on the theme of‘Endometriosis: How new technologies may help’. Thecourse will provide participants with an understanding ofnot only the pathogenesis of endometriosis but theimportance of diagnosis and non-surgical approaches tomanagement. We encourage all those involved in the careof patients with endometriosis - and particularly thosewith needs of fertility and pain management - to attend.We hope to see all SIG members there.

It is splendid that the scientific programme of the annualmeeting will provide a platform for presentations on topicsendometriosis/endometrium, with oral contributions infour sessions and a significant number of posters. Welldone all for submitting your work! The Poster Village willhave representation from our SIG on Tuesday lunchtime,and we’ll also be involved in an interactive posterdiscussion on Monday lunchtime.

Endometriosis guidelinesRevised ESHRE guidelines for the diagnosis and treatmentof endometriosis were presented and interactively discussedduring a Campus course in Budapest in February. Thecourse was organised by Attila Bokor and ThomasD’Hooghe, who also spoke at the meeting, together withother members of the Endometriosis GuidelineDevelopment Group - including Stephen Kennedy (GB),Daniela Hornung (DE), Robert Greb (DE), ErtanSaridogan (GB), Charles Chapron (F) and LoneHummelshoj (DK). The course was attended by about 65participants and rated as very good or excellent by themajority with respect to organisation, general information,educational value, and individual lectures by the invitedspeakers. This was the first time we had organised aneducational activity in Central/Eastern Europe, and we feelthat this format was interesting and can be repeatedelsewhere upon request.

Poor ovarian respsonseThe first inter-SIG Campus meeting considered poorovarian response and the contribution from the SIGEE wasdelivered by Professor TC Li, from Hallam University,Sheffield, who reported that, while the implantation ratein normal responders is ~30%, it is reduced to ~10% in

poor responders. It isaccepted, he said, that inover-responders, the veryhigh E2 levels (>20,000pmol/l) adversely affectendometrial developmentand function and reduceimplantation rate. In

normal responders, the moderately high E2 levels seem toaffect endometrial morphology but do not have any majordetrimental effect on implantation rate (usually around30%). In poor responders, however, E2 levels are lowerthan normal responders but are still higher than those innatural cycles - yet the implantation rate is reduced(~10%). Professor Li noted that there are no good qualitydata on endometrial function in poor responders, butnevertheless proposed that their reduced implantation rateis more likely a consequence of poor oocyte quality,because these same women usually have good implantationrates when they have oocyte donation.

Future activitiesA tripartite meeting of the SIGEE, SIG Early Pregnancyand Stem Cells in Valencia is now scheduled for 2-3rdDecember. This exciting event should have wide appealand provide a platform for state-of-the-art discussion oncomplementary topics of implantation, stem cell biologyand endometriosis.

We are also exploring a joint Campus meeting with theSIG Reproductive Surgery on the subject of ‘Deeplyinfiltrative endometriosis’; more details will follow in afuture edition of Focus on Reproduction. Anotherproposed Campus initiative will be on the topic of‘Scarring and adhesion formation in the femalereproductive tract’. We hope to hold this meeting inEdinburgh in late 2011/ early 2012.

Raising awareness of endometriosisEndometriosis support organisations across Europe drewmuch public attention to the disease during this year’sEndometriosis Awareness Week (8-14th March). MEP andvice-president of the European Parliament, Diana Wallis,called for more investment in research into endometriosis.Lone Hummelshoj continues to press the EuropeanParliament and Commission to acknowledge the need forinvestment in benign female diseases, especially those, suchas endometriosis, which affect women during the primeyears of their lives.

Hilary Critchley Co-ordinator SIG Endometriosis and Endometrium

// ENDOMETRIOSIS AND ENDOMETRIUM //

A high profile for endometriosis in Rome

OfficersHilary Critchley (GB), Co-ordinatorAnneli Stavreus-Evers (SE), Deputy Co-ordinator EndometriumGerard Dunselman (NL), Deputy Co-ordinator EndometriosisAnnemiek Nap (NL), Junior DeputyThomas D’Hooghe (BE), Past Co-ordinator


Professor Janos Urbancsek proveda tremendous host for our Campusworkshop, ‘Old and newhormones’, held at SemmelweisUniversity, Budapest, in Decemberlast year. We had just over 80registrants from 22 differentcountries, with a very goodrepresentation from the host country Hungary. Every talkwas of the highest standard and the meeting provided asuperb overview and update of recent advances andpotential future research.

Among a range of elegant and comprehensive reviewswere presentations on:� Current understanding of the hypothalamic-pituitary-gonadal axis (John Marshall, USA), with comment onrecently derived pathways and neuropeptides such askisspeptin, GPR 54 and neurokinin B.� Determinants of normal puberty (David Dunger, GB) onsecular changes, epidemiology and the influence ofbirthweight and early infant growth on puberty andlonger-term health.� Control of ovulation (Steve Hillier, GB), including therole of IL-1 and its regulation of enzymes such as11betaHSD1 in controlling the conversion of cortisone tocortisol and the regulation of matrix metalloproteinases onthe ovarian surface epithelium.� Hormonal control of spermatogenesis and thehypogonadal male (Richard Anderson, GB) on the actionof androgens in the testis and their control by the HPTaxis.� Hypothalamic disorders and their management (PierreBouloux, GB) on the morecommon and very rare causesof Kallmann’s syndrome andhypogonadotrophichypogonadism.� Pituitary tumours and themanagement of hyper-prolactinaemia, in whichDidier Dewailly (FR)dispelled any notion of anassociation with PCOS.

Among other presenterswere Philippe Bouchard (FR)with a fine update on FSHand LH receptorpolymorphisms, EleanorScott (GB) with twoendocrinological reviews of

the adrenal in health and disease,and current management of types1 and 2 diabetes. The Leedscontribution was completed bymyself on hyperandrogenism inwomen - diagnosis andmanagement - and not only inPCOS! Thyroid physiology and

dysfunction were covered by George Griesinger (DE),before we moved on to new data on the link between gutand adipose hormones and reproduction by Waljit Dhilo(GB).

Our host, Professor Urbancsek, gave an elegant overviewof the role of inhibins during the menstrual cycle andduring ovarian stimulation for IVF and shared many yearsof carefully collected data. His key message was thatmeasurement of inhibin B may indeed predict ovarianresponse and pregnancy, whilst measurement of the othermembers of the inhibin/activin family does not warrantroutine assessment in clinical practice. The meetingconcluded with the latest endocrine marker for ovarianreserve, AMH, delivered by Frank Broekmans (NL).Whilst more data is still required, it appears that AMH isnot only the best predictor of ovarian response andpotentially oocyte quality but also, when measured atintervals, may in future provide a better insight intodeclining ovarian reserve with age than other tests such asantral follicle count.

Future eventsOur precongress course for Rome is on ‘The lost ART ofOI’. Many of us feel that the pathway to IVF is too swift

and that a preferable aim isto treat the underlyingcauses of infertility. Specialskills are required whenperforming ovulationinduction for anovulatoryinfertility, which require adegree of subtlety notneeded for ‘controlled’ovarian hyperstimulationfor IVF. This course willcover the causes ofanovulation and deal in turnwith management protocols,predictors for response andalgorithms for treatment.

Further ahead we have ajoint Campus with the Early

Old and new hormones reviewed in Budapest

OfficersAdam Balen (GB), Co-ordinatorRichard Anderson (GB), Deputy Co-ordinatorJuan Garcia Velasco (ES), Deputy Co-ordinatorGeorg Griesinger (DE), Junior DeputyNick Macklon (NL), Past Co-ordinator

SPECIAL INTEREST GROUPS// REPRODUCTIVE ENDOCRINOLOGY //

Speakers at our Campus workshop in Budapest. Seated are SIGCo-ordinator Adam Balen (left) and local host Janos Urbancsek,

flanked by Ine Van Wassenhove and Veerle De Rijbel fromESHRE’s Central Office.


// PSYCHOLOGY AND COUNSELLING //

The SIG Psychology andCounselling has a challengingprecongress course planned forRome with topics coveringcurrent developments in ART andtheir impact on counselling. Themorning sessions will tackleethical dilemmas arising fromrecent advances, such as providing ART for HIV-affectedmen and women, egg freezing and PGD. Afternoonsessions will feature clinical issues such as counselling theinfertile man, mourning rituals for couples remainingchildless, internet-based support for infertility and finallydiscussion on whether interactive personal health recordscan empower patients. The course will be chaired by SIGCo-ordinator Petra Thorn and Deputy Chris Verhaak.

The SIG business meeting which follows welcomesmembers to join in the discussion. Topics this year willinclude collaboration on the update of guidelines as well asan overview of the first Campus workshop held in Basellast year and the upcoming event in Amsterdam later thisyear. The annual dinner in conjunction with theInternational Infertility Counsellors Organisation (IICO)will complete the day’s events in Rome. Participantsinterested in joining the dinner can contact Jan Norré formore information.

We have been well represented by Petra Thorn, our Co-ordinator, in the past few months in other Campus events.In March Petra described the psychological perspectives ofwomen diagnosed with poor ovarian response (see page24) and counselling concepts for donor insemination (page

22). In April, she introducedinfertility counselling to juniordoctors, paramedicals andembryologists in Kiev, Ukraine.This is clearly a valuablecontribition to clinical meetingsand we hope to see morecollaboration with other SIGs. We

can all benefit from a multidisciplinary approach.Our second Campus workshop in Amsterdam on

December 3-4th will be a two-day course designed toincrease knowledge and competence in psychosocial careby outlining the different perspectives of infertilitycounselling and acquiring basic communication skills inspecific situations through in-depth case work. The courseis aimed at all professionals involved in the psychosocialcare of people with infertility: psychologists, counsellors,doctors, nurses, administrative personnel and other medicalstaff. The first day will focus on more theoretical issues inthe psychology of infertility, medical treatment from apatient-centered perspective, infertility counselling from acognitive-behavioural and systemic perspective, third partyreproduction and the difference between infertilitycounselling and psychotherapy. The second day willprovide discussion targeted towards medical andadministrative staff on the one hand and psychosocial staffon the other. In-depth case work will guide the much morehands-on discussion and promote interactive participation.

Uschi Van den BroekJunior Deputy Co-ordinator

SIG Psychology and Counselling

Collaborations with other SIGs prove valuable

OfficersPetra Thorn (DE), Co-ordinatorChristianne Verhaak (NL), Deputy Co-ordinatorJan Norré (BE), Deputy Co-ordinatorPatricia Baetens (BE) Past Co-ordinatorUschi Van den Broeck (BE), Junior Deputy

Pregnancy and Reproductive Surgery SIGs, entitled‘Healthy start - The determinants of a successfulpregnancy’. This will take place in Dubrovnic, Croatia, inSeptember (on 24/25th). The meeting will start with thediagnosis of congenital anomalies of the lower genital tractand evidence for surgical approaches (whether cervicalcerclage should be vaginal or abdominal). We will move onto the problems of obesity and early pregnancy, the effectsof obesity on natural conception and fertility treatment,and the topical issue of medical and surgical approaches tothe management of obesity. Pregnancy in the older womanwill cover how we can best predict fertility, what weshould do about fibroids and endometriosis, and how theolder mother is best managed.

The third joint ESHRE/ASRM PCOS consensus meetingwill take place in Amsterdam, beginning on 18thNovember with an open meeting followed by a two-day

consensus workshop on ‘Medical problems associated withPCOS’. The first consensus in Rotterdam, in 2003provided definitions for PCOS which resulted in one of themost cited publications in our field. The Thessalonikiconsensus on the management of infertility in PCOS alsoproduced a highly cited joint publication in HumanReproduction and Fertility and Sterility, so we anticipatethat this third consensus will be equally stimulating andimportant in its outcome.

Towards the end of the year we will be running aCampus course in Madrid (3-4th December) on ‘GnRHagonists for triggering of final oocyte maturation-time for aparadigm shift’, so please mark this date in your diariestoo.

Adam BalenCo-ordinator SIG Reproductive Endocrinology

[email protected].


The fifth edition of the longawaited WHO laboratory manualfor the examination andprocessing of human semen wasfinally published on line inMarch.1

The manual was originallyexpected in 2008, but one of the reasons for its delay mayhave been that the semen parameter ‘reference’ values,previously known as ‘normal’ values, had to be subject topeer review in a journal. This finally happened at the end of2009, when the report was published on line.2

However, as with the past issues, the new reference valuesare likely to prove controversial, especially the very lowvalue of 4% morphological normal spermatozoa for sperm

morphology. The newedition has beenconsiderably extendedand contains much in detailedprocedures and notes on the different aspects ofthe whole process of the semen analysis.

As one of the main focuses of the SIG Andrology is topromote the performance of semen analyses to a high and

SPECIAL INTEREST GROUPS// ANDROLOGY //

At last, the fifth WHO manual for semen analysis has finally arrived

OfficersRoelof Menkveld (ZA), Co-ordinatorJose Antonio Castilla (ES), Deputy Co-ordinatorSheena Lewis (GB), Deputy Co-ordinatorJessica Tu (SE), Junior Deputy

// REPRODUCTIVE SURGERY //

Repeats this year and next for our popular endoscopy course

Our precongress course in Rome ison NOTES (natural orificetransluminal endoscopic surgery)and single access surgery. Interestin the course is growing followingthe revolution in endoscopicsurgical access. There have beencriticisms of this pioneeringsurgery, but not unlike the criticism 20 years ago onlaparoscopic surgery. The live surgery session in Romewill take place on 29th June.

Our course on ‘Endoscopy in reproductive surgery’ inFebruary in Leuven was a great success! As usual, it wasfully booked and participants came from 13 countries,from Czech Republic to Turkey, from Philippines toKuwait. The hands-on suturing sessions with the pelvictrainer were performed on chicken legs, pig bowel andpig bladder. For the first time the location of the coursewas at the new building of he European Academy ofGynaecological Surgery. The course will be repeated inNovember (24-26th) and twice in 2011 (23-25thFebruary and 23-25th November).

A joint meeting of SIGs Reproductive Surgery, EarlyPregnancy and Endocrinology, ‘Healthy start - the

determinants of a successfulpregnancy’, will take place inDubrovnik, Croatia, on 24-25th ofSeptember this year, followed by ajoint meeting with the SIGAndrology in Treviso on 8-9thOctober.

Next year an interesting courseon ‘Reproduction and the management of fibroids’ willbe organised in Larnaca, Cyprus, on 15-16th April2011, followed in May (6-7th) by a workshop on ‘Howsurgery can increase the success rate in ART’. Thismeeting will be held in Grado, Italy, an attractive islandin the northern Adriatic connected by a short bridge tothe mainland. Grado is also known as the ‘sunny island’and has been appreciated for its beautiful beaches sincethe country was ruled by the Habsburg Empire. Itsintricate history is linked to the history of Aquileia fromthe time of the first barbarian invasions, and to theRepublic of Venice.

Our precongress course in Stockholm in 2011 will beon the prevention and management of adhesions.

Marco GergoletCo-ordinator SIG Reproductive Surgery

OfficersMarco Gergolet (IT), Co-ordinatorVasilios Tanos (CY), Deputy Co-ordinatorRudi Campo (BE), Deputy Co-ordinatorStephan Gordts (BE), Past Co-ordinatorPietro Gambadauro (IT), Junior Deputy


uniform standard, not only in Europe but throughout theworld, our committee for training now believes that oursemen analysis courses should be run according to the newWHO guidelines. For this reason the training committee isplanning an urgent course, possibly in September 2010 inStockholm, to train the trainers. The training committeealso runs the worldwide External Quality Control (EQC)programme for basic semen analysis and this too will beupdated.

Past eventsAs reported on the following pages, the SIG Andrology hasrecenently hosted a very successful Campus meeting on‘Sperm and testicular tissue banking’ in the picturesque cityof Granada, Spain. The meeting was well attended, with atotal of 18 presentations covering a whole range of subjectsfrom basic laboratory procedures and safety, to thetheoretical aspects of sperm and tissue cryopreservationand the surgical retrieval of testicular and epididymal tissueand its use. The presentation by Petra Thorn (Co-ordinatorof the SIG Psychology and Counselling) on the counsellingof donor semen recipients was very well received andprompted a lively discussion - as well as the possibility ofcombining a joint meeting of the two SIGs.

Future eventsOne of our main focus areas now - in addition to ourprecongress course in Rome - will be to organise a semenanalysis trainers meeting later this year. This year’sprecongress course on ‘The environment and human malereproduction’ is a scientific course but has many interestingtopics for the more clinically minded congress attendee.The programme will cover what we know of thereproductive risks from occupational and environmentalpollutants. The precongress course will be followedimmediately by the SIG Andrology members businessmeeting, and later in the week will be the usual annualmeeting for participants in the external quality assessment(EQA) programme for semen analyses.

Other activities this yearwill include a basic semenanalysis course in Barcelonafrom 20-23rd September anda combined Campus meetingwith SIG ReproductiveSurgery on ‘Surgery in femaleand male infertility patients’in Treviso, Italy, from 8-9thOctober.

Roelof MenkveldCo-ordinator SIG Andrology

[email protected]

Falling birth rates are becoming a public health issuein Europe. In 2008 the European Parliamentacknowledged that reduced fertility was a majorcause of its demographic decline and that ART mightoffer one solution. However, if ART is to be includedas a substantive part of a new population policy,there will need to be a government led and fundedprogramme for its enhancement. Although Europeanlive birth rates are impressive, male infertility hasbeen long neglected, and this is the area where evenfurther rapid progress could be made. This will firstrequire a re-examination of current assessments ofmale fertility potential. Research will be needed toimprove prognostic sperm function tests with clinicalrelevance for each type of ART treatment. Since1995 research into sperm dysfunction has beensidelined by the success of ICSI. As live birth rateswith ICSI are presently as good as or better thanthose with IVF, there has been little incentive toinvest in the research and development of spermselection tests. However, in order to raise ARTsuccess and ensure the long-term health of childrenborn by ICSI, we need novel sperm tests with highprognostic strength.

Conventional semen analysis is fundamental to theinitial work-up of the male partner but is of limitedvalue in predicting outcome. In contrast, sperm DNAtesting shows much promise in ART checkpoints.However, these tests have not been brought intoclinical use because there is no funding tostandardise them and perform the necessary clinicaltrials. In a position report from a recent ESHRECampus,1 the requirement for dedicated funding forresearch was highlighted as one of fiverecommendations:'A fundamental impediment to advancement over the past three decades has been the absence of reproductivemedicine and infertility research as a strategic priority fornational governments and agencies. This has resulted in apaucity of funding. A prerequisite of achieving the aboverecommendations is for national and international agenciesto realize the importance of both basic and clinical researchin this area and, to deliver substantiallong-term financial support.'

We in the SIG Andrology sharethis view and look forward toESHRE members’ comments onhow it might be implemented.

Sheena LewisDeputy Co-ordinator SIG Andrology1. Barratt CL, Aitken RJ, Björndahl L, et al. Sperm DNA:organization, protection and vulnerability: from basicscience to clinical applications - a position report. HumReprod 2010; 25: 824-838.

Funding for research in maleinfertility seriously neglected

1.http://whqlibdoc.who.int/publications/2010/9789241547789_eng.pdf2. Cooper TG, Noonan E, von Eckardstein S, et al. World HealthOrganization reference values for human semen characteristics.Hum Reprod Update. 2009; doi:10.1093/humupd/dmp048.


Although donor insemination as a treatment for malefactor infertility has decreased considerably since theintroduction of ICSI in the early 1990s, there is still ademand for donor sperm. According to presentations at aCampus event hosted by the SIG Andrology in Granada,Spain, in mid-March, the indications today are more in thetreatment - where permitted - of single and lesbian women,and men who wish to avoid passing on genetic disorders.

However, according to a former chairman of the SIGAndrology, Chris Barratt, there still remains a shortage ofdonor sperm in many countries despite a 20% fall indemand since the 1990s. And the reasons, he proposed, arenot just about ICSI. It has, he said, always been'challenging' to recruit sperm donors, but the challenge hasgrown in recent years over the rates of compensation todonors, the attrition of donors during screening, the legaldemands of the EU's Tissues and Cells Directives, and thevexed question of anonymity. This uncertainty has meantthat many centres have simply given up their efforts torecruit donors, and hence the continuing gap betweensupply and demand.

The UK, for example, in line with some other EUcountries such as Sweden and the Netherlands, changed itslaws on donor anonymity in 2005 such that children

conceived by donor sperm (or donor oocytes) had the rightfrom the age of 18 to know the identity of the donor.Sperm banks were thus obliged to collect identifying (andnon-identifying) information from their donors and lodgethe information with the regulatory authority. The result,with almost immediate effect, was a drop in the numbersof donors, such that the British Fertility Society, inproposing a national plan for sperm donation services,described the shortage as ‘critical’.

SPECIAL INTEREST GROUPS// ANDROLOGY //

Despite falling demandfor donor insemination,sperm donors are stillin very short supply

Donor insemination UKStimulated and unstimulated cycles

As the graph above (taken from the HFEA’s database inthe UK) suggests, the decline in the use of donorinsemination seems inversely related to the increase inthe use of ICSI since the early 1990s. According toVanessa Kay from Ninewells Hospital in Scotland, thisis also reflected in a change in the profile of patientsnow receiving donor insemination. She told theGranada Campus that donor insemination is now seenmore in cases of severe male infertility and in coupleswith serious genetic conditions. However, she alsonoted an increase in use in ‘social infertility’ - in same-sex couples amd single women. She cited HFEAregister data showing an increase in DI for singlefemales from 508 treatments in 1999 rising to 705treatments in 2006, and in lesbian couples from 284treatments in 1999 to 767 in 2006. Conversely, thenumber of treatments in ‘other females’ fell from 3536in 1999 to 2392 in 2006.

However, Kay also calculated that, despite thedecreased demand, there was still a chronic shortageof sperm donors in the UK, with no more than 384formally registered with the HFEA in 2008. The resultis that clinics continue to withdraw their DI servicesand that sperm is imported from overseas sources. Thewhole question of gamete donation is now under reviewin the UK, and Kay recommended that compensationto donors should be enhanced, with those targetedlikely to be fertile and good screening candidates.

This Campus meeting in Granada was yet another in 2010to attract a full house, with 135 registered participants, areflection of ESHRE’s ongoing commitment to expandingand supporting its Campus programme. Pictured above arethe meeting’s scientific committee, from left to right,Roelof Menkveld (SIG Andrology Co-ordinator), JoseAntonio Castilla (chairman) and Matt Tomlinson. The eventmarked the 30th anniversary of Spain’s third sperm bankat Virgen de las Nieves in Granada.


Spain takes one step nearer to a formalised, national IVFregister; many clinics remain outside the voluntary schemeAlthough 2006 legislation in Spain ruled that all results from Spanish ARTcentres should be collected in a national register and a proportion audited,only one region (Catalonia) has implemented the law with any formality. Therest of the nation’s data collection and audit has been left to a voluntaryprogramme undertaken by the Spanish Fertility Society, which, according toits co-ordinator Jose Antonio Castilla, accounts for only around 65% ofSpanish clinics. Now, in recognition of the legal requirement and theongoing work of the voluntary register, the Spanish Health Ministry hasagreed to support some of the Fertility Society’s data collection and audit.‘The Ministry wants transparency,’ says Castilla, ‘so patients can see forthemselves how clinics perform. So we now have to give the data to theMinistry on a clinic by clinic basis. We are hoping to audit around 10% ofthe results.’ The latest results of the voluntary data collection - for 2007 -which have just been presented to the Ministry, recorded 54,620 treatmentcycles, with a pregnancy rate per transfer of 39%. Fresh cycle IVFrepresented 34,449 cycles, frozen embryo transfer 9089 cycles, and eggdonation 7925 cycles. Some of Spain’s clinics, however, have not supportedthe Fertility Society’s efforts, arguing that, if the Minstry wants the data, theMinstry should collect it. Others, says Castilla, have even questioned theneed for a registry at all, noting that other medical disciplines are notsubject to such demands.

Jose Antonio Castilla, organiser of theSIG Andrology Campus in Granada and

co-ordinator of the Spanish FertilitySociety voluntary IVF register

applicability, a detrimental effect on cell viability, the lowerrisk of infection from reproductive (than transplant) tissue,and the difficulty of ICSI in a Grade A environment.

However, said Björndahl, once establishments arecompliant the safe transport of donor sperm should beguaranteed and the risks to offspring minimised. Suchguarantees should make feasible the ‘hub-and-spoke’system proposed for sperm supply in the UK, theinternational transport of sperm samples as is now seenfrom Denmark, or the cross-border treatment of manycouples now seeking donor insemination abroad.

Nevertheless, Roelof Menkveld described the recruitmentof semen donors as still ‘tedious’ because of the high drop-out rate and continuing attrition. Screening requirements -as reflected in the Tissue and Cell Directives or in localguidelines - will of course help ensure safety, but Menkveldalso lamented a lack of consistent universally applicablesemen parameters for sperm donors. Even the latest WHOmanual (2010) has reduced its minimum concentrationfrom >20 million/ml in 1999 to 15 million. There is a view,said Menkveld, that semen parameters are declining, butthis is not supported by all studies, which are anywaycharacterised by ‘analytical variability’. The latest UKguidelines, developed by a consortium which included theBritish Fertility Society and British Andrology Society,recommended that only men with pre-freeze semen qualityvalues above the 1990 WHO values should be accepted asdonors, and of course providing they could meet the othersafety screening tests for medical and genetic history andbacterial and viral infection.

However, Lars Björndahl, another former chairman ofthe SIG Andrology, insisted that the EU’s Directives ontissues and cells - which by now, he said, ‘should have beenimplemented in all EU countries’ - were intended toincrease, not reduce, the availability of donor spermthroughout Europe. With the Directives setting uniformbaseline standards for air quality, quarantine,cryopreservation, transportation and traceability, themeasures should make sperm banking safer with qualityguaranteed. These standards, Björndahl explained, werebaseline, with individual member states free to raise the baras they thought appropriate.

The ‘mother’ Directive (2004:23), which had appeared in2004, had thus set standards for the 'procurement' ofsperm samples from donors which grouped spermalongside all other tissues and cells (mainly fortransplantation) and their donors as ‘voluntary’ and‘unpaid’. One of two later technical Directives (2006:17)required that non-partner donors were subject to safetyscreening through medical history and biological testing forHIV1 and 2, hepatitis B and C, syphilis, chlamydia andother diseases (including some of genetic origin).

Björndahl reported that traceability requirements withrespect to both adverse reaction disclosure and coding hadstill not been agreed, though are apparently under currentdiscussion at the European Commission. ‘Nevertheless,’ hesaid, ‘there is still no European coding system.’ Similarly,the EU’s Grade A requirements for air quality in spermbanks remain controversial, with ESHRE and somemember states raising practical objections based on


Rarely can DonaldRumsfeld, the erstwhilearchitect of the US invasionof Iraq, have been thetalisman for a meeting onreproductive medicine, norhis words cast such a longshadow. But it wasRumsfeld’s celebrated‘known unknowns’ and‘unknown unknowns’which Nick Macklon - nowback in his native UK asProfessor of Obstetrics &Gynaecology at the University of Southampton - took ashis theme to describe the black hole of predicting poorresponse to ovarian stimulation for ART.

Poor ovarian response (POR) was the challenging butever more evident theme of this first Campus course to beorganised collectively by each of ESHRE’s SIGs. And onfew other subjects could such a multidisciplined input bemore appropriate. Macklon’s case was that the emergingtests of ovarian reserve, such as measures of anti-Mullerianhormone (AMH) or antral follicle count (AFC), do have ajustified place in individualising treatment and setting astarting dose of FSH, but their value in predictingpregnancy remains less clear. So, while such prognositicfactors as AMH or AFC may well provide therapeuticopportunities, there is little they can do in the face of adramatically diminished oocyte supply or a patient ofadvanced maternal age (which, said Macklon, remains thebest predictor of a live birth). Data cited by him showedthat only at extreme cut-off levels will results of AFC,AMH and basal FSH tests occasionally predict pregnancywith accuracy. Otherwise, as his fellow speaker JuanGarcia-Velasco from the IVI clinic in Madrid suggested,ovarian reserve testing remains important for little morethan counselling on outcome, tailoring stimulationprotocols and predicting cycle cancellation.

For Velasco too, age was the only realistic (and costefficient) marker of egg quality and outcome - andincreasingly the major everyday challenge in ART. Hisclinic in Madrid performed 2047 fresh cycles in 2009, ofwhich 68% were in women over the age of 34. Inreflection of this challenge, a first polar body analysis ofmore than 5000 oocytes performed by SIG Embryology co-ordinator Cristina Magli at the SISMER clinic in Bologna

found an inverse and significant correlation between theproportion of normal (euploid) oocytes and patient age,suggesting that egg quality as well as quantity iscontributing to outcome in poor responders. The SISMERdata indicated that the viability of oocytes in poorresponders is especially compromised when associated withadvanced age, with outcome additionally related to theopportunity for embryo (and oocyte) selection.

If both age and oocyte quality are beyond repair, howmight treatment interventions help? Well, not much,according to Basil Tarlatzis, a former ESHRE chairman andjoint author of a recent systemic review of interventionsaiming to increase the chance of pregnancy in poorresponders. The study reviewed 15 interventions, rangingfrom added aspirin to added pridostigmine, from shortagonist cycles to modified antagonist cycles. Of the studiesin the review - which were characterised by different

SPECIAL INTEREST GROUPS// INTER-SIG CAMPUS //

Poor ovarian response: from the ‘unknown’ toconsensus in definition and prognostic tests

This was the first Campus meeting tobe organised by all ESHRE’s SIGs andthe timely theme attracted more than150 registered participants to Bolognain March. The two-day programme wascollated by the SIGs, with each onerepresented in the presentations. Local organiser Anna PiaFerraretti, from the SISMER centre in Bologna, proposedthat a standard definition of poor ovarian response is‘urgently needed’ not only for appropriate individualpatient management but also to provide a consistentbackground to clinical trials. ‘By using different criteria,’she said, ‘we are creating a mixed population from whichit is difficult to derive meaningful results.’


inclusion criteria, limited evidence, and multiple definitionsof poor response - only the addition of growth hormone tothe stimulation protocol made any beneficial difference tooutcome, with an odds ratio for live birth of 5.22. But,when challenged, even Tarlatzis was reluctant, on safetygrounds, to recommend GH as a reliable intervention.

So one of the challenges for this meeting was to form aconsensus on a uniform definition of POR as an aid toclinical practice and trials, and to estimate its incidence(which Tarlatzis put at between 9 and 24% of all cycles).Consensus on a definition was reached with surprising easeand the group settled on the presence of at least two of thefollowing three features:� advanced maternal age or any other risk factor for POR� a previous poor response to stimulation� an abnormal test of ovarian reserveThe POR definition was modified with the addition of‘expected’ in those cases where no previous response hadbeen recorded. In the risk factors additional to age, therecovery of four or fewer oocytes was deemed anacceptable cut-off point consistent with POR.

The consensus panel also concluded that ovarian reservetests 'may add something' when prediction is based solelyon age, with AFC and AMH deemed the most useful.However, there was little controversy in the group'sconclusion that no individual treatment protocol appears toconfer any clear advantage in POR, with the possibleexceptions of added growth hormone and modified naturalcycle IVF. The case for the latter was neatly demonstratedby Filippo Ubaldi, local chairman of this year's congress inRome, whose own clinic began natural cycle treatment inPOR patients in 2000. An analysis of 962 consecutivecycles (in 533 POR patients) achieved a pregnancy rate percycle of 10%. A subsequent prospective study with ahistorical control found no significant difference betweenclinical pregnancy rates in modified natural cycles andstimulated cycles (5.6%/cycle natural and 4.7%stimulated). However, the cost per baby was considerablyless in the natural cycles (and without the risk of OHSS ormultiples); the major drawback was the risk of prematureLH surge and spontaneous ovulation, which occurred in30-60% of cycles.

With the outlook so poor for these patients, it was fittingthat the SIGs Psychology & Counselling and Ethics & Lawwere each represented. Petra Thorn, representing theformer, said that women with POR were likely toexperience high levels of distress and self-blame, which anunderstanding of the background and of the alternativefamily options, may alleviate somewhat. FrancoiseShenfield, however, raised another salutary but harshreality of poor response in warning that the provision of‘futile treatment’ is not ethically justified. She noted thatthe ASRM has recently defined ‘futile’ as having a 1% (orless) chance of live birth, while a 1-5% chance is defined as‘very poor’. Clinicians, she added, may refuse treatment inboth cases.

Thus, with so little encouragement for POR patients andso little that conventional ART can do about age andoocyte quality, the meeting turned back to the unknown(either known or unknown) for its look to the future. Thedata on oocyte vitrification for fertility preservation weredescribed by ESHRE’s chairman Luca Gianaroli as‘promising’, with comparable outcomes reported this year(from Rome) from fresh and vitrified oocyte cycles. Thesame study, said Gianaroli, suggested that 16 vitrified eggswere needed to produce a singleton fetal heart beat.

However, there was less immediate promise in anotherpossible way to overcome POR, the generation of gametesfrom stem cells. Ana Marques-Mari, representing the SIGStem Cells, reported that one or two recent studies haddescribed both embryonic and somatic stem cell linesshowing a small number of cells carrying a marker fordifferentiation, but these, she emphasised, were still nomore than a tool for research, and still without anycertainty of safety. This indeed was the ‘unknownunknown’ at its most Rumsfeldian.

Simon BrownFocus on Reprodcution

Consensus - in definition and the use of prognostic testsof ovarian reserve - was steered by an expert groupcomprising, from left to right, Antonio La Marca, ChristinaBergh, Anna Pia Ferraretti, Bart Fauser, Geeta Nargundand Basil Tarlatzis. The ‘Bologna criteria’ defined POR (orexpected POR) as the presence of two from� advanced maternal age or any other risk factor for POR� a previous poor response to stimulation� an abnormal test of ovarian reserve‘Poor’ ovarian reserve was preferred to ‘low’, even thoughpoor is a less accurate converse of ‘high’ and rather moresubjective. Age was unanimoulsy defined as the mostpredictive measure of pregnancy, with four (or fewer)oocytes agreed as a definition of poor response tostimulation. Data presented by Anna Pia Ferraretti from ananalysis of 2000 cycles at the SISMER centre showedthat three oocytes retrieved was the cut-off point ofsignificance in the association of pregnancy rate per eggretrieval with the number of oocytes collected.


nationalbiomaterialscore, and a teamof ethicists,economists, lawscholars,educationists,social andbehaviouralscientists,patientadvocates, basicreproductivescientists, andclinicalinvestigators.

The Consortium also created mechanisms by whichpatients receive rapid information such that more are nowaware of the fertility effects of treatment. Additionally,fertility clinics have been re-engineered to meet the specialneeds of cancer patients, which often cannot be addressedusing the typical routines applied to infertility patients.

At the same time, basic research discoveries haveexpanded our knowledge of the fertility threat posed byspecific treatments, developed more robust fertilitypreservation options, and led to medical interventions thatprotect the gonads from the lethal effects of certain cancertreatments. All of this work coincides with thedevelopment of a team of healthcare providers who enablethe patient to make an informed decision about fertilityinterventions while ensuring the best outcome from cancertreatment.

Thus, the solution to the previously ‘intractable’ problemof fertility options for young cancer patients requiredprogress at the bench and bedside in concert with deepscholarship in the societal issues that frequently parallelreproductive intervention. The only way to make progressin this area was to engage the bench, bedside andcommunity in an overarching programme, which is themission of the Oncofertility Consortium.

The opportunity in EuropeIt is clear that there is substantial interest from professionalsocieties in creating a similarly robust network of cliniciansand basic scientists to provide comparable fertility optionsto those in EU countries.

ESHRE has two Task Forces committed to this specialinterest: the TF Fertility Preservation in Severe Disease hada first well attended meeting in Heidelberg in 2008; now,the TF Basic Science in Reproductive Medicine has

The Oncofertility Consortium is a network of researchers,physicians, and scholars - which includes ESHRE’s TaskForces for Fertility Preservation in Severe Disease and BasicScience in Reproductive Medicine - aiming to advancefertility preservation options for young cancer patients. Asa result of more aggressive and advanced treatment, morecancer patients are surviving their disease. However, thesetreatments are not without risks of infertility, sterility, orearly menopause. Until recently, providers and patientsalike seemed willing to tolerate these adverse effects, withthe notion that surviving the disease was the only goal andany unintended consequence of treatment should beendured. The desire to do something positive about post-cancer infertility came to the fore some ten years ago aspatients began voicing their belief that the ability to have achild of their own should not be an afterthought.

Mature technologies for both adult men (sperm banking)and women (hormonal stimulation followed by embryocryopreservation) are of course in place for cancer patientsconcerned about their fertility, but structural barriersbetween practices limit patient access. Moreover, there arefew options for young men and women unable to delaycancer treatment, and for women and girls unable toundergo hormonal intervention.

Recent advances in ovarian tissue transplantation and invitro follicle maturation offer new opportunities forfertility management. By unifying clinical teams at theintersection of oncology and reproductive medicine and byusing discovery research to create the next generation ofreproductive interventions, this trans-disciplinary team isworking to ensure that young cancer survivors areprovided the best information and methods to protect theiroptions for future families.

The Oncofertility ConsortiumThe Consortium (http://oncofertility.northwestern.edu/) isfunded by a new grant mechanism at the NationalInstitutes of Health, the NIH Roadmap InterdisciplinaryResearch Consortium. These roadmap grants provide thesignificant resources to bring together the diverse groupsnecessary to solve intractable problems. And the fertilityneeds of young men, women and children faced with acancer diagnosis and fertility-threatening treatment havebeen identified as ‘intractable’ because, first, the scienceand supporting technology are not mature, and second,solving the problem requires an interdisciplinary approachin research and clinical communities and at the NIH.

During the first three years under the grant, theOncofertility Consortium expanded to include a 50-siteNational Physicians’ Cooperative and tissue repository, a

TASK FORCES// FERTILITY PRESERVATION IN SEVERE DISEASE and BASIC REPRODUCTIVE SCIENCE //

An ambitious initiative for oncofertility in Europe

Members of the Task Forces Basic Science inReproductive Medicine and Fertility Preservation inSevere Disease met for a ‘reflection’ earlier this year

to solidify an EU-US partnership in fertilitypreservation before cancer treatment.


regulators from France, Italy, Greece, Portugal and the UK,and national society members who are committed to thecare of infertile people from Belgium, Czech Republic,Denmark, Italy, Germany, Slovenia and Spain. FertilityEurope will represent the patients, and Jacques Milliez theinterest of FIGO, whose ethics committee has recentlydiscussed the matter.

Many members of ESHRE know of, or have had,patients wishing to go abroad for all the varied reasonsconfirmed in our study, aiming either to avoid restrictivelegislation or have better access because of long waitinglists at home, always looking for quality treatment andsometimes expecting a more moderate cost. In Paris, wewill discuss the most appropriate approach to meet ouraim of high standards of care (including ethical) and safetyfor all concerned. The choice lies probably between settingup a code of practice and a certification scheme, or perhapsfirst a code and then the latter. We will also discuss themeans of informing members and others involved, and howa code or certification scheme might be implemented.

Our foremost concern, of course, is safety for patientsand participant donors, which cannot be achieved bymerely observing the EU tissue directives. Goodcommunication between professionals needs to beaddressed, as well as the matters of perennial interest suchas the prevention of multiple pregnancy.

Finally, of course, these concerns are relevant to all ourmembers, and any strong feelings on the matter should besent to the Co-ordinator of the Task Force.

Françoise ShenfieldCo-ordinator Task Force Cross-border Reproductive Care

1. Shenfield F, de Mouzon J, Pennings G, et al. Cross borderreproductive care in six European countries. Hum Reprod 2010;doi:10.1093/humrep/deq057.

The first step of our cross-border reproductive care projectis now complete with our paper published online.1 With1230 questionnaires analysed in Central Office, we haveestimated our snapshot picture, limited by the voluntarynature of our study, to represent some 12,000-15,000cycles of cross-borders treatments - ART and IUI whetherwith spouse or donor semen - over a full calendar year.Since Amsterdam, where preliminary results were reported,several researchers in the UK and France have alreadycontacted us, keen to have more details of this firstgathering of facts from several European countries, whilstthey study psychosocial or legal aspects. Press attention hasalso been sustained.

Our next step involves an important meeting in Paris inMay, where many national regulators, and /orprofessionals involved in the gathering of data for nationalsocieties, as well as other stakeholders including patientgroups, will exchange views about achieving a goodstandard of care for those seeking fertility treatmentsoutside their own national borders. Under the aegis ofESHRE, our aim is to take a lead in establishing standardsfor this phenomenon, which is not about to stop, andconsider the most appropriate means for informing andprotecting patients and other participants, such gametedonors or surrogates. We are also privileged to be joinedby a regulator from Canada, which was the host last yearto the first international forum on reproductive health care.Indeed, such cross-border exchanges are now happeningthroughout the world, not only in Europe.

It is also exciting to us that, if ESHRE can establish amodel which ensures safe care in cross-border reproductivetreatments, we might strengthen our links with otherinternational societies facing the same concerns.

The May meeting, held in the French national agencyoffices of l’Agence de la Biomedecine, will gather

// CROSS-BORDER REPRODUCTIVE CARE //

Setting consistent and safe standards of care

brought together a group of researchers from the USA andESHRE to solidify an EU-US partnership in oncofertility. Afirst ‘reflection meeting’ was organised by ESHRE inJanuary 2009 in Brussels and a landmark papersummarising the state of the art in fertility preservationtechnologies has been recently published.1

Several European research teams are joining forces tosubmit an ambitious project for EU funding which aims tosolve basic scientific problems and implement newtechnologies into the procedures of oncofertility centres.The US Consortium, being three years ahead of us in thisendeavour, has offered full support.

The next organisational meeting is being planned for

26/27th September this year, organised by Teresa Woodruff(http://oncofertility.northwestern.edu/events/2010-oncofertility-consortium-conference-international-perspectives) and two precongress courses are planned for2011 in Stockholm: one on basic research and one onorganisational issues.

Johan SmitzCo-ordinator TF Basic Science in Reproductive Medicine

1. Smitz J, Dolmans MM, Donnez J, et al. Current achievementsand future research directions in ovarian tissue culture, in vitrofollicle development and transplantation: implications for fertilitypreservation. Hum Reprod Update 2010;doi10.1093/humupd/dmp056, 2010.


Europe’s demographic crisisis over - unofficial

It’s not yet official, but Europe’s demographic crisis is over.At least, that’s the impression gathered from demographersspeaking at a symposium organised by ESHRE’s newlyrenamed Task Force on Reproduction and Society inIstanbul in February. Demographer Tomas Kucera, amember of the Task Force from Charles University inPrague, showed that, while mean age at childbirth was stillrising in the Czech Republic (to 29.5 years in 2008, thehighest ever recorded), total fertility rate, at 1.5, was nowclimbing back from its all-time low of under 1.2 in 1999.

Similarly, Tomas Sobotka from the Vienna Institute ofDemography, arguing that Europe’s universal trend forpostponed childbearing would have only a temporaryimpact on fertility rates, showed that when this ‘tempoeffect’ was applied Europe’s (EU27) adjusted fertility ratesactually began rising towards 1.5 in 2004. This tempoeffect, said Sobotka, would explain the upward trend seenin the Czech Republic.

Such news, no doubt, will be welcome to the politiciansin Brussels, who have identified Europe’s declining fertilityrate - alongside advancing life expectancy - as one of theirhot potatoes, even though a white paper for the EuropeanCommission in 2006 described Europe’s demographicdecline as a ‘challenge’, not a crisis. Overall fertility ratewas put at 1.5 children per woman, with no more than a

0.1 increase forecastby the year 2030 -and thus still wellbelow the 2.1 fertilityrate deemed necessaryfor populationreplacement. The consequences, warned the report, wouldbe a ‘spectacular’ increase in the number of old peopleneeding social and financial support, especially those intheir 80s and 90s. The impact of this greying populationwould reverberate into the labour market and economicgrowth, into social security and public finance.

However, for the clinicians of ESHRE toiling in thetreatment of infertility, there were two more immediatemessages to emerge from the demography of thissymposium: first, that despite this marginal reverse in atrend of falling fertility rates, the march towards latemotherhood continues, with no apparent change in a socialphenomenon which began in the 1970s and today showsno sign of abating; and second, the prevalence of infertilityis likely to increase as a direct result of this evolving socialtrend. Another of the Task Force members, Henri Leridonfrom INED in France, has already reported a 6% estimateof permanent childlessness when female pregnancyattempts begin at age 30, of 14% when those attemptsbegin at 35, and 35% when they begin at 40. Leridon hasalso shown that the postponement of a first conceptionattempt from age 25 to 30 years is associated with a meannumber of children reduced from 2.0 to 1.77, an increasein infertility prevalence from 9.8 to 15.8%, and an increasein the number of couples with fewer children than desiredfrom 14.8 to 24%.

For ESHRE, the purpose of this meeting was not just tocheck the demographic evidence but also for the Society’sExecutive Committee to ask if ESHRE itself had any placein this hugely political arena. Certainly, no-one wasdoubting the clinical implications of the evidence, but moredebatable was what ESHRE could do about it, other thanwitness the ever increasing age of patients and respond inits usual clinical and scientific ways.

COVER STORY// REPRODUCTION AND SOCIETY //

ESHRE seeks to clarify its role withthe population policymakers

Definitions from the demographer’s dictionary

Fertility Frequency of live births, as in- age-specific fertility rate = number of

births/population in a given age group- total fertilty rate = sum of ASFRs in a

given year = the number of children per woman

Infertility Absence of births, voluntary or involuntaryFecundity Biological ability to conceiveFecundability Monthly risk of conception

- can be measured as percentage or estimated from distribution of time toconception

from Henri Leridon


Søren Ziebe, Co-ordinator of the Task Force, inreviewing the evidence for the Executive Committee,described the whole demographic question as ‘important’,and firstly advised that ESHRE, as a reference point inreproductive medicine, should continue to forge its linkswith the EU and make public with authority the simplemessage that delaying pregnancy beyond the age of 35increases the risk of infertility. Most agreed that large-scalepublic education campaigns were beyond the resources (orremit) of ESHRE, but that need not exclude the formalstatement or position paper. Certainly, no otherorganisation in the world can say with more authority thanESHRE that ART is not the magic bullet for age-relatedinfertility or cannot be guaranteed to reverse the infertilityrisks of a delayed pregnancy attempt.

Ziebe and ESHRE’s Chairman Luca Gianaroli were alsoinsistent that the Task Force had aresponsibility to collect the data, or at leastprovide an umbrella for data collection andreview within its framework. The databasesof ESHRE - in PGD, cross-borderreproductive care and ART monitoring - arealready a valuable and unique referencesource, whether within the ART,demographic or political sectors.

However, the question of ESHRE’sresponsibilities in the prevention of infertilitywas less easily answered.Thus, while the provisionof a voice of referenceand evidence in supportwas accepted as desirableby all the Committee, thequestion of how - or even

if - ESHRE should involve itself in public educationcampaigns about sexually transmitted diseases oroccupational pollutants was less easily answered.

For example, Bill Ledger, from the University ofSheffield, UK, described the net effect of different lifestyleson fertility as ‘not much’. ‘Most people who eat too much,drink too much, smoke too much and have too much sexwith too many people,’ he said ‘don’t often end up withfertility problems.’ But even the pragmatic Professor Ledgerconceded that overweight oligospermic men or anovulatorywomen should indeed be encouraged to lose weight, just aswomen who smoke should be encouraged to stop. Butindividual advice is a big step away from a public healthcampaign. And the only public message to emerge fromLedger’s presentation was one echoed by many speakers atthis symposium (especially the clinicians), that IVF cannot

solve the fertility problems of the olderpatient. It couldn’t in 1994, when the hugedatabase of the HFEA was analysed (an 8%pregnancy rate per cycle in 40-year-olds), andstill couldn’t in 2007 (when the rate hadedged forward to 12% per cycle).

And even when millions of dollars arepoured into public education campaigns, theresults may not turn out as planned. CarinaBjartling from Malmö University Hospitaldescribed a steep rise in ectopic pregnancies

in Sweden in the 1980sand 1990s many of which,she proposed, wereassociated with earlierchlamydia infection. Yetscreening strategies forchlamydia - whether

The ‘tempo effect’ on total fertility rates: why the crisis is over?

Total fertility rate is reduced whenthe tempo of births is slowingdown, and boosted when thetempo accelerates. The very lowTFRs seen in Europe in the pasttwo decades are partly becausethe postponement of childbearingtemporarily depresses the numberof births and has a tempo effecton fertility rates. The recentincreases in total fertility rateseen in some countries - as inCzech Republic, right - is to alarge extent explained by aslowing-down in the trend topostpone fertility. However,according to Tomas Sobotka, thepostponement transition is notover yet.

BILL LEDGER: ‘MOST PEOPLE WHO EAT TOO MUCH, DRINK TOO MUCH, SMOKE TOO

MUCH AND HAVE TOO MUCH SEX WITH TOO MANY PEOPLE DON’T OFTEN END UP

WITH FERTILITY PROBLEMS.’


selective or universal - have so far proved inefficient andlargely ineffective, she said.

Similarly, the role of occupational and environmentalpollutants in male fertility remains subject to doubt,conflicting results, and tenuous associations. Jens PeterBonde from Copenhagen University Hospital agreed thatmale reproductive health was at risk from environmentalpollutants, but only in specific occupational settings. Theeffect of more generalised environmental toxins, he said,was ‘more difficult’ to measure. Thus, the effect of workingdirectly with lead might have a measurable effect on spermcounts or time to pregnancy in an exposed individual, butwould be less easily measured universally. Nevertheless,several studies - though reportedly in different populationsand with different models of assessment - have suggestedthat sperm concentrations have declined with some degreeof consistency to ‘suboptimal levels’ in some men. As yet,said Bonde, we don’t know if trace levels of pollutants inthe environment have any harmful effect on reproduction.

However, the one clear dominating theme of thissymposium was the universal trend towards delayed firstpregnancy - and that now seems a social phenomenonalmost beyond the reach of any public healthcampaign. Its cornerstones are found in thegreater availability of higher education (the linkbetween educational attainment and delayedpregnancy is unequivocal), a greater emphasison career and consumption, reducedrelationship stability, and more economicuncertainty. Moreover, as Tomas Sobotkaemphasised, even the notion of ‘family value’has changed in the past fewdecades, from one defined lessby marriage than by children assome form of self-fulfilment.Indeed, said Sobotka, ‘leisureand self-realisation’ have now

become well accepted reasons for either having or nothaving children. And these, he implied, are trends withdeep social roots, whose advance will be little influenced bydeomographers or well-meaning clinicians. Indeed, it wasstriking to hear Sobotka identify the over-40s as the onlyage group since 1985 to see an increase in fertility ratewithin the EU25 countries. Similarly, a survey conductedby Sobotka in Austria last year found that 59% of childlesswomen aged between 35 and 39 still had plans to have ababy, as had 30% of those aged 40 to 45! (And just weeksafter this symposium Britain’s national statistics officereported that conception rates decreased in all age groupsbetween 2007 and 2008, with the exception of womenover 40, where conceptions remained at 12.6 per 1000.)

And so - as ESHRE’s IVF monitoring data continue toconfirm - the demand for fertility treatment grows fromone year to the next. Anders Nyboe Andersen, a formerchairman of ESHRE’s EIM data gathering consortium,reported ART cycles in Europe rising to almost 450,000 in2006, with comparable increases found in the USA (toalmost 140,000) and Japan (to 160,000 in 2007). Theexpansion of ART in Japan, said Nyboe Andersen, has

been especially remarkable, climbing fromalmost zero in just 18 years, much of itaccounted for in frozen embryo transfers andlow-cost modified natural cycles.

The availability of such data will surely defineESHRE’s role within the ‘reproduction andsociety’ debate. And ESHRE agreed in Istanbulthat it does indeed have a responsibility to takepart, and at least represent the clinical sector.

However, there was littleenthusiasm at this meeting forthe politicising of infertilitytreatment within thatdemographic debate. Indeed,Henri Leridon cast a somewhat

The demographic effects of infertility and ART� Based on ESHRE’s IVF monitoring data(availability and outcome) for the UK andDenmark in 2002, RAND Europeestimated the empirical and potentialimpact of ART on fertility rates in thesetwo countries. At the base of thecalculation was an availability rate of2106 cycles per million population inDenmark, and 625 cycles per million inUK. Results showed that ART has thepotential to contribute to a country’sfertility rate; the study also showed thatthe costs associated with adopting ART asa population policy are comparable withthose of existing policies commonly usedby governments to influence fertility.

� Demographer Tomas Kucera reported that the demographic losses(live births) attributed to infertility were in the order of 10-11%. In theEU27 countries these losses (the ‘real consequence of infertility’)represent a shortfall of some 0.5-0.6 million live births per year,calculated at recent levels of ART performance

From Hoorens S, Gallo F, Cave JA, Grant JC. Can assisted reproductive technologies help tooffset population ageing? An assessment of the demographic and economic impact of ARTin Denmark and UK. Hum Reprod 2007; 22: 2471-2475.

ObservedTFR 2002

1.64

1.72

TFR without ART

1.62

1.65

UK TFR with DK

availability

1.68

-

Maximum TFR with ART

1.84

1.89

United Kingdon

Denmark

TOMAS KUCERA: ‘BECAUSE ANYINCREASE IN FERTILITY IN EUROPE IS

ASSUMED TO BE LOW, ALLCONTRIBUTIONS ARE WELCOME.’


and, according to the consensus of ESHRE’s ExecutiveCommittee in Istanbul, the ART sector should at least berepresented in the development of those policies.

And whatever the role of ART within the demographicsof Europe, infertility (and its treatment) does make adifference. As demographer Tomas Kucera told thissymposium: ‘Everyone counts and will count. And beauseany increase in fertility in Europe is assumed to be low, allcontributions are welcome. We should not forget that,even if the relative contribution of ART to the number ofbirths in Europe is low, it still represents the annualnumber of births of one European country with a totalpopulation of between 5 and 10 million inhabitants.’

Simon BrownFocus on Reproduction

scornful doubt on the ability of ART to have any significanteffect on fertility rates, and even on the view that infertilityis a ‘disease’ - especially today when so much of itsaetiology is age related.

Nevertheless, it remains a fact that in countries likeDenmark or Belgium, where the availability of ART permillion population lies somewhere above 2000 cycles andseems directly related to a generous funding policy, ARTdoes at least appear able to have its say in how couplesplan their families. It also remains a fact that ART is on thepolicymakers’ agenda, especially in Europe, and that theART sector requires representation. The diversity of ARTpolicy and legislation in Europe - as in Germany and theUK, Italy and Belgium - already has clinical repercussions inthe explosive pattern of cross-border reproductive care,

Playing fertility rouletteby Søren Ziebe, Co-ordinator Task Force Reproduction and Society

In most European countries too few children are beingborn. There are many reasons for this, not least theincreasing age of women at the time they decide tohave children, and the impact of lifestyle factors. Butother reasons may play a part, such as a decline insemen quality or an increase in the prevalence ofsexually transmitted diseases. They may all have aninfluence on when and if we can have children.

The main explanation for today’s increasing demandfor assisted reproduction is the older age of women asa consequence of postponing the birth of their firstchildren. Similarly, we all know and acknowledge themajor reasons for this - education, career concerns,financial demands, housing, problems, the lack of asuitable partner . . .

However, despite all we know about these socialtrends, it is important to realise that biology remainsignorant of them, and the biological clock just keepsticking no matter how people prioritise their lives.

We should also be aware that the problem is not onlyrelated to this ever increasing age of theoocytes, but also that the longer we livethe more it is likely that lifestyle factors orillness will affect our fecundity and furtherlower our chances of having children.

Clinicians working in reproductivemedicine are more aware than most thatthere is a prevalent and growing attitudeamong young couples that if they havedifficulties in conceiving they can ‘just goto a fertility clinic’. This is ofgreat concern to all of us, and,while we may be able tocompensate for some fertility

problems, we can never make oocytes younger.Those who play this waiting game with their families

are playing fertility roulette; these are choices whichdepend on biology and ultimately affect one’s chancesof parenthood. In most cases, as Professor Ledger saidin Istanbul, there is no problem. However, more andmore couples will remain involuntarily childless or havefewer children than they originally desired, even withfertility treatment.

Against this background, we believe it’s importantthat ESHRE continues to drive reproductive scienceand medicine such that the treatments available toaffected couples are effective and safe. Our statementon good clinical practice in ART published in 2008 wasa benchmark of these standards.

But ESHRE also has a social responsibility and thiswill be usefully expressed in the provision ofinformation to the public on how we can reduce thenumber of couples needing our techniques; mostimportantly, the public should be aware that we, the

fertility experts, simply cannot compensatefor any age-related decline in fecundity.

Perhaps we should all consider whatsignals each of us as parents is giving toour own children – do we advise them tohave children early or should they waituntil their education, income and housingare all in order, and then to play fertilityroulette? Of course, they will all have todecide for themselves – but we should be

aware of the potentialconsequences and enusre thatas many others as possible areas well.

SØREN ZIEBE: ‘WE CANNOTCOMPENSATE FOR AN AGE-

RELATED DECLINE IN FECUNDITY.’


1. In the beginningWell . . . moreprecisely, where tobegin? The story ofhuman IVF surelybegan with RobertEdwards, who in thesummer of 1965 spentsix weeks withHoward and

Georgeanna Jones in Baltimore where -according to Howard and despite a‘negative’ report from Edwards - ‘it seemsscarcely doubtful that human fertilizationwas indeed obtained at the Johns HopkinsHospital by Bob and his associates’.� Edwards RG, Donahue RP, Baramki TA,Jones HW. Preliminary attempts to fertilizehuman oocytes matured in vitro. Am JObstet Gynecol 1966; 96: 192–200.Hans Evers: Bob's superb monographConception in the Human Female showedme the way into reproductive medicine. Ihave devoured it. Several times. From coverto cover. The first time Bob remembered myname my heart skipped a beat.

4. The first live birthLouise Brown, born shortly beforemidnight at Oldham and District GeneralHospital, UK. Weighing 5lb 12oz (2.61 kg)the baby was delivered by Caesareansection. Since then, estimates are that morethan 4 million IVF babies have been bornworldwide.� Steptoe PC, Edwards RG. Birth after thereimplantation of a human embryo. Lancet1978; 2: 366.HE: Why were the Swedes never braveenough to give Edwards and Steptoe theNobel prize? IVF provided more insight intolife itself and produced more Quality AdjustedLife Years than any other medical treatment.

2. Ovulation inductionThe first pregnancy following ovulation induction with hMG(Pergonal) was in Israel in 1961. Carl Gemzell’s group hadreported the first gonadotrophin pregnancy in the previous year.� Lunenfeld B, Sulimovici S, Rabau E, Eshkol A. L’induction del’ovulation dans les amenorrhees hypophysaires. C R Soc Francgynecol 1962; 32: 407-415.� Gemzell CA, Diczfalusy E, Tillinger G. Human pituitary folliclestimulating hormone (FSH). Ciba Found Colloq Endocrinol 1960;13: 191. HE: There was no PubMed in the 1960s, no impact factors, soinvestigators published in obscure journals - which is why somequestions of who was first may never be answered.

5. Gonadotrophins in IVFAlthough Louise Brown and Australia’s first IVF baby were bornfollowing egg retrieval from a natural cycle, the USA’s first IVFbirth was in a cycle stimulated with hMG; Trounson in Melbourehad described the first cycles stimulated with clomiphene citrate.� Lopata A, Brown J, Leeton J, et al. In vitro fertilization ofpreovulatory oocytes and embryo transfer in infertile patientstreated with clomiphene and HCG. Fertil Steril 1978; 30: 27–35.� Trounson AO, Leeton JF, Wood C, et al. Pregnancies in humansby fertilization in vitro and embryo transfer in the controlledovulatory cycle. Science 1981; 212:6 81–682.� Jones HW, Jones GS, Andrews MC, et al. The program for invitro fertilization at Norfolk. Fertil Steril 1982; 38: 14–21.

3. The first IVF pregnanciesThe Melbourne groupof Carl Wood in 1973described two very earlyIVF pregnancies, bothlost after less than oneweek. According toAlan Trounson, whowould join the group in1977, these ‘chemical’pregnancies, signified by rising levels ofhCG, showed that IVF embryos coulddevelop in vivo and probably initiateimplantation. It is also likely that aroundnow Edwards and Steptoe had startedtransferring embryos, unreported at thetime and with no sign of implantation‘except for a few very early abortions’.� De Kretzer D, Dennis P, Hudson B, et al.Transfer of a human zygote. Lancet 1973;302: 728-729.HE: ART discoveries have followed the sametrack; first a biochemical pregnancy, then aclinical abortion, next an ectopic, and finallysomeone in a case report can boast the firstlive birth.

FEATURE// FIRSTS IN THE HISTORY OF IVF //

Original papers which changed theworld of assisted reproduction

There’s no dispute about the first report of an IVF baby, nor of the first ICSI birth. But many of theworld’s firsts in ART remain lost in the literature, their significance sometimes forgotten. With the

commentary of Hans Evers - whose Human Reproduction report on ‘100 papers to read beforeyou die’ caused so much interest - we catalogue for the record ESHRE’s own selection of worldfirsts in assisted reproduction, and the top ten reproductive biology papers from Hans Evers.


6. Ultrasound-guided aspirationOocyte collection guided by ultrasound -and not from laparoscopic puncture - wasfirst described in 1981 by Suzan Lenz andcolleagues in Copenhagen. An ultrasoundscanner with a puncture transducer guideda steel needle through a full bladder forfollicle puncture. The authors laterdescribed the technique as ‘atraumatic andinexpensive’ and therefore valuable forharvesting oocytes for IVF. � Lenz S, Lauritsen JG, Kjellow M.Collection of human oocytes for in vitrofertilisation by ultrasonically guidedfollicular puncture. Lancet 1981; 318:1163.� Gleicher N, Friberg J, Fullan N, et al.Egg retrieval for in vitro fertilisation bysonographically controlled vaginalculdocentesis. Lancet 1983; 322: 508-509. HE: Real progress in IVF came of course fromvaginal ultrasound monitoring of vaginaloocyte retrieval. And that was introduced byMatts Wikland's group in Gothenburg. Fromnow on, IVF would be a less invasiveprocedure.� Wikland M, Nilsson L, Hamberger L.The use of ultrasound in a human in vitrofertilization program. Ultrasound Med Biol1983; 2: 609-613.

9. GnRH agonists in IVFAfter the pulsatile administration of GnRHwas established as a safe and effective wayto treat hypogonadotropic hypogonadalanovulation, reports of its use for theprevention of a premature LH surge duringovarian stimulation appeared in the early1980s. Pituitary down-regulation resultedin reduced cancellation rates, improvedIVF outcome and more convenient timingof oocyte retrieval. The use of GnRHagonists in combination withgonadotrophins in IVF was highlighted bythe group of Howard Jacobs in London.� Fleming R, Adam AH, Barlow DH, et al.A new systematic treatment for infertilewomen with abnormal hormone profiles.Br J Obstet Gynaecol 1982; 89: 80–83.� Porter RN, Smith W, Craft IL, et al.Induction of ovulation for in vitrofertilisation using buserelin andgonadotropins. Lancet 1984; 324: 1284-1285.HE: Testing urine samples every four hours,detecting LH-surges at 4 am, performinglaparoscopies in the small hours of darkness,seven days a week, with ovulations on therun; everything changed when GnRH agonistswithout histaminergic side effects becameavailable. IVF got safer and more convenient.

8. Cryopreservation of embryosGerard Zeilmaker (1936-2002), pictured withRobert Edwards in 1986,recorded in his laboratorybook in Rotterdam that ahuman embryo was frozenin July 1979 and thawed inOctober; one blastomeresurvived. Of embryosfrozen from three patientsin February 1983, one transferred in May resulted in the birth ofmonozygotic twins. Zeilmaker recorded that this birth in theNetherlands ‘took place considerably before such a baby was bornin Australia’. � Trounson A, Mohr L. Human pregnancy followingcryopreservation, thawing and transfer of an eight-cell embryo.Nature 1983; 305: 707-709.� Zeilmaker GH, Alberda AT, van Gent I, et al. Two pregnanciesfollowing transfer of intact frozen-thawed embryos. Fertil Steril1984; 42: 293-296. HE: High quality embryo freezing is now a pivotal requirement for theclinical feasibility of elective single embryo transfer (eSET), atechnique introduced by the Fins that has physiologised assistedreproduction. Through eSET and cryopreservation, IVF finally becamea safe and effective way of helping infertile couples.� Vilska S, Tiitinen A, Hydén-Granskog C, Hovatta O. Electivetransfer of one embryo results in an acceptable pregnancy rate andeliminates the risk of multiple birth. Hum Reprod 1999; 14: 2392-2395.

10. Vitrification and the cryopreservation of oocytesThe first successful attempt atfreezing and thawing a human oocytewas reported by Christopher Chenfrom Adelaide in 1986. A twinpregnancy was achieved afterfertilisation and transfer. Chenreported that 80% of 40 oocytesfrozen (to -196oC) showedmorphological survival after thawing.Thirty were inseminated; 83%retained their capacity to be fertilised,and 60% proceeded to cleavagedivision.

� Chen C. Pregnancy after human oocyte cryopreservation.Lancet 1986; 327: 884-886.Experiments with embryo vitrification in animal models (mice,sheep) date back to the mid-1980s. In 1990 Stephan Gordts andcolleagues in Leuven, Belgium, described the ‘ultrarapid feezing’and thawing of 237 fertilised human oocytes, of which 34 weretransferred to 20 patients, four of whom became pregnant. Thefirst live birth following vitrification of a human oocyte wasreported by Gianaroli and colleagues from Bologna working withTrounson in 1999.� Gordts S, Roziers P, Campo R, Noto V. Survival and pregnancyoutcome after ultrarapid freezing of human embryos. Fertil Steril1990; 53: 469-472.� Kuleshova L, Gianaroli L, Magli C, et al. Birth followingvitrification of a small number of human oocytes: case report.Hum Reprod 1999; 14: 3077-3079.

7. Oocyte donationThe first report of apregnancy resultingfrom the transfer of afertilised donor oocytecame from the Monashgroup in 1983, whosereport to the BMJ raisedthe issue of what to dowith the excess eggs and

embryos generated in a stimulated IVFcycle: ‘If more oocytes are recovered thanare needed they may be left unfertilised,preserved, or donated to a recipient couplefrom whom oocytes cannot be obtained.’� Trounson A, Leeton J, Besanko M, et al.Pregnancy established in an infertile patientafter transfer of a donated embryofertilised in vitro. Br Med J 1983; 286:835-838.HE: The uterus is not a demanding organ.Provide it with estrogens and progesteroneand it will let a young donor embryo implant,even at the age of 65. Alan Trounson is anicon. From sheep (in 1974) he went to cows(1976), horses (1976), rabbits (1977), mice(1980) and humans (1980). From follicles toeggs to sperm to embryos to stem cells. Andfinally to law, ethics, religion and clinicaltranslation in the 21st century.


12. ZIFTZygote intrafallopiantransfer, another tubaltransfer technique, wasfirst reported by PaulDevroey in Brussels in1986 and was said tocombine the advantagesof IVF (proof offertilisation, exclusionof polyploid embryos) with the advantagesof GIFT (higher pregnancy rates). � Devroey P, Braeckmans P, Smitz J, et al.Pregnancy after translaparoscopic zygoteintra-Fallopian transfer in a patient withsperm antibodies. Lancet 1986; 327: 1329 HE: GIFT made way for all manner ofcombinations and permutations: ZIFT, PROST,TET, transferring gametes, zygotes orembryos via the vagina, the bladder, thetube. Not all were unequivocally successful,but this should not divert attention from thefundamental contributions of the Brusselsteam of André Van Steirteghem and PaulDevroey to the development of our specialty.

16. ICSIICSI wasdeveloped -somewhataccidentally - atthe VUB inBrussels and itrapidly tookover from SUZI as the microinjectiontechnique of choice for conception in maleinfertility. By 2006, just 14 years afterBrussels reported the first births, aroundtwo-thirds of all ART fertilisations inEurope were with ICSI.� Palermo G, Joris H, Devroey P, VanSteirteghem AC. Pregnancies afterintracytoplasmic injection of singlespermatozoon into an oocyte. Lancet 1992;340: 17-18.HE: A revolution! How did they have the gutsto do it? What about the chromosomes andthe spindles? What we do know is that 1-2%of all children born nowadays are the resultof ICSI and they seem to do well. Would westill have sperm banks if not for ICSI?

13. Microinjection and male infertilityThe first report of a pregnancy following the injection of a singlesperm cell beneath the zona pellucida of an oocyte came from theMonash group in 1987, who said ‘the technique has profoundimplications for the possible treatment of severe male infertility’.The first live birth following subzonal insemination (SUZI) camefrom Singapore the following year. Male infertility was at the timedefined as the largest diagnosed cause of infertility, accounting foraround 30% of cases (according to Hull et al, 1986).� Laws-King A, Trounson A, Sathananthan H, Kola I.

Fertilization of human oocytes by microinjection of a singlespermatozoon under the zona pellucida. Fertil Steril 1987; 48:637-642.� Ng SC, Bongso A, Ratnam SS, et al. Pregnancy after transfer ofsperm under zona. Lancet 1988; 332: 790.

11. GIFTThe first pregnancy following gamete intrafallopian transfer(GIFT) was reported from California in 1984, with a live birthannounced from the same group the following year. Two yearsearlier Ian Craft in London had reported a pregnancy from thetransfer of gametes to the uterus.� Craft I, McLeod F, Green S, et al. Human pregnancy followingoocyte and sperm transfer to the uterus. Lancet 1982; 319: 1031-1033.� Asch RH, Ellsworth LR, Balmaceda JP, Wong PC. Pregnancyafter translaparoscopic gamete intrafallopian transfer. Lancet1984; 324: 1034-1035.� Asch RH, Ellsworth LR, Balmaceda JP, Wong PC. Birthfollowing gamete intrafallopian transfer. Lancet 1985; 326: 163.HE: : It must have been the alluring acronym that made GIFT sosuccessful in some parts of the world (especially Australia). How elsecould you explain the appeal of a technique which still requiredlaparoscopy and general anaesthesia?

14. Ultrasound-guided embryo transferThe use of ultrasound to guideembryo transfer was firstdescribed by Strickler et al in1985. Ultrasonographic transferwas found to be easier andassociated with less catheterdistortion than the ‘blind’transfers which were used untilthen.� Strickler RC, Christianson C, Crane JP, et al. Ultrasoundguidance for human embryo transfer. Fertil Steril 1985; 43: 54–61HE: How world-shattering was US-guided ET? Everyone did it, itseemed to work, but did it really offer something extra? Not in thehands of an experienced operator apparently.� Kosmas IP, Janssens R, De Munch L, et al. Ulrasound-guidedembryo transfer does not offer any benefit in clinical outcome: arandomized controlled trial. Hum Reprod 2008; 23: 457-458.

17. PGDThe technique of sexing embryos from the DNA of a biopsied cellby amplification of a repeat sequence specific for the Ychromosome was first reported by Alan Handyside and colleaguesin London, who described the technique as ‘may be valuable forcouples at risk of transmitting X-linked disease’. The same groupreported the first pregnancies using this same technique in couplesat risk of transmitting recessive x-linked diseases. � Handyside AH, Pattinson JK, Penketh RJ, et al. Biopsy ofhuman preimplantation embryos and sexing by DNAamplification. Lancet 1988; 1: 347-349.HE: PGD was a formidable step ahead, both for our understanding ofearly embryo development and for clinical infertility care. Itscommercialised little nephew, PGS, was nipped in the bud by severalrobust clinical trials.

15. PZD and zona drillingThe first description ofpartial zona dissection(PZD) of humanoocytes to encouragesperm penetration inIVF (especially in maleinfertility) was firstreported from Atlantaby the group ofJacques Cohen; a report on zona drillingfollowed in the same year. In time, as aCochrane review would show, ICSI wasfound to be a much more efficienttechnique in male infertility tha PZD, zonadrilling and SUZI.� Cohen J. Malter H. Fehilly C, et al.Implantation of embryos after partialopening of oocyte zona pellucida tofacilitate sperm penetration. Lancet 1988;332: 162.� Gordon JW, Grunfeld J, Garrisi GJ, etal. Fertilization of human oocytes by spermfrom infertile males after zona pellucidadrilling. Fertil Steril 1988; 50: 68-73.


19. Surgical sperm retrievalThe first report of live biths following atechnique of sperm aspiration came fromthe Irvine group of Ricardo Asch workingwith Sherman Silber in 1988. The samegroup later confirmed the genetic linkbetween CAVD and cystic fibrosis, whileSilber, working with the VUB in Brussels,reported the first pregnancies with spermobtained from testicular biopsies in menwith CAVD or obstructive azoospermia.� Patrizio P, Silber S, Ord T, et al. Twobirths after microsurgical sperm aspirationin congenital absence of vas deferens.Lancet 1988; 332: 1362.� Silber SJ, Van Steirteghem AC, Liu J, etal. High fertilization and pregnancy rateafter intracytoplasmic sperm injection withspermatozoa obtained from testicle biopsy.Hum Reprod 1995; 10: 148-152.HE: No guts, no glory - or chance favours theprepared mind? Immature spermatozoa usedin human fertility treatment. Every cloud hasa Silber lining.

18. In vitro maturationCha and colleagues in Seoul were the firstto describe a pregnancy from an oocytematured in vitro. The paper reported that270 immature oocytes had been incubatedwith either mature follicular fluid or fetalcord serum, the former showing a highermaturation rate than the latter. Fiveembryos transferred to a woman with POFresulted in birth of ‘healthy’ triplet girls.� Cha KY, Koo JJ, Ko JJ, et al. Pregnancyafter in vitro fertilization of humanfollicular oocytes collected fromnonstimulated cycles, their culture in vitroand their transfer in a donor oocyteprogram. Fertil Steril 1991; 55: 109-113.HE: Soon after the first few publications onIVM in (ovine and bovine) animal models,the first successful human attempt wasannounced. Several more followed. Theobstetric and perinatal outcomes were good,the mean birthweight was normal, and thechildren's development has so far beeninconspicuous.

20. Fertility preservationThe restoration of fertility after thetransplantation of frozen–thawed ovariantissue was reported for the first time in thesheep in 1994, but not until 2000 wasovarian autotransplantation (orthotopicand heterotopic) described on anexperimental basis in the human.According to recent reports, there have sofar been nine deliveries from pregnanciesderived from frozen-thawed ovarian tissue.� Oktay K, Karlikaya G. Ovarianfunction after transplantation of frozen,banked autologous ovarian tissue. N Engl JMed 2000; 342: 1919.HE: Fertility preservation by freezing ovariesor eggs is ART’s answer to ever moresuccessful cancer treatments. Its 'social'application - in older women who have notyet found their Mr Right - is still elusive. A1-5% chance of a retrieved egg becoming apregnancy would require between five and25 pick-up procedures in a 35-40 year oldto take care of her 'fertility insurance'.

The top ten citation classics in ‘reproductive biology’ (so far)

1 (841)

2 (451)3 (429)

4 (428)

5 (409)

6 (390)

7 (377)

8 (375)

9 (373)

10 (321)

Rank (citations) Author, paperVan Steirteghem AC, Nagy Z, Joris H, et al. High fertilization and implantation rates after intracytoplasmicsperm injection. Hum Reprod 1993; 8: 1061-1066.Kimura Y, Yanagimachi R. Intracytoplasmic sperm injection in the mouse. Biol Reprod 1995; 52: 7097-20.Wells DN, Misica PM, Tervit HR. Production of cloned calves following nuclear transfer with cultured adultmural granulosa cells. Biol Reprod 1999; 60: 996-1005.Van Steirteghem AC, Liu J, Joris H, et al. Higher success rate by intracytoplasmic sperm injection than bysubzonal insemination. Report of a second series of 300 consecutive treatment cycles. Hum Reprod 1993; 8:1055-1060.Munné S, Alikani M, Tomkin G, et al. Embryo morphology, developmental rates, and maternal age are correlatedwith chromosome abnormalities. Fertil Steril 1995; 64: 382-391.Eppig JJ, O'Brien MJ. Development in vitro of mouse oocytes from primordial follicles. Biol Reprod 1996; 54:197-207.Pursley JR, Mee MO, Wiltbank MC. Synchronization of ovulation in dairy cows using PGF2alpha and GnRH.Theriogenology 1995; 44: 915-923.Faddy MJ, Gosden RG, Gougeon A, et al. Accelerated disappearance of ovarian follicles in mid-life: implicationsfor forecasting menopause. Hum Reprod 1992; 7: 1342-1346.Gosden RG, Baird DT, Wade JC, Webb R. Restoration of fertility to oophorectomized sheep by ovarian autograftsstored at -196 degrees C. Hum Reprod 1994; 9: 597-603.Gardner DK, Lane M, Spitzer A, Batt PA. Enhanced rates of cleavage and development for sheep zygotescultured to the blastocyst stage in vitro in the absence of serum and somatic cells: amino acids, vitamins, andculturing embryos in groups stimulate development. Biol Reprod 1994; 50: 390-400.

Journal impact factors will soon be a thing of the past. Citation scores of individual scientific papers will replace them. Pageranking, named after Larry Page, has been developed by Google for its Internet search engine that assigns a numerical weightingto each element of a hyperlinked set of documents found on the Internet with the purpose of establishing its relative importancewithin the set. By the same token, scientific publications may be ranked by their citation alone and by gathering weight fromcitation by authors who are frequently cited themselves. This may refine the present fledgling system of publication metrics andallow for the placement of scientific publications in (peer-reviewed?) web-based repositories. In order to see what these newdevelopments might mean to publishing in our specialty, I checked the citation scores of the 100 most cited papers in thereproductive biology journals. - HE � Evers JL. 100 papers to read before you die. Hum Reprod 2010; 25: 2-5.


something I could do, so I made contact with him andasked if he might have a place for me. He didn’t, but said,come along and we’ll see.’

ESHRE too, as well as IVF, has long figured in Anna’sprofessional life. Not only was Barri a founder member ofESHRE, but Anna’s PhD supervisor in Barcelona, the lategeneticist José Egozcue, would become a member ofESHRE’s first Executive Committee in 1985, andChairman of the Society ten years later. ‘I always had avery close working relationship with José,’ says Anna. ‘Wecollaborated after our first IVF pregnancies at Dexeus,when he was already becoming a prominent figure inESHRE - and I must admit that even then he raised thepossibility of me getting more involved with the Society,though I never really thought of the chairmanship. Butwhen I returned to Barcelona after being selected asChairman Elect, the first person I called was José’s widow,to tell her how happy he would have been.

‘So I was very lucky to be involved in the early days of

nna Veiga, Chairman Elect of ESHRE, seems atfirst glance to be that feisty, energetic kind ofwoman who is still driven by the fun andenthusiasm of her student days. No baggage, no

cynicism, no hidden agendas. But scratch the surface ofESHRE’s next Chairman - who will take up her post at the2011 annual meeting in Stockholm - and what you’ll findis a whole lot more than just Little Miss Sunshine. ‘I’mreally excited about being Chairman,’ she says with herusual wide-eyed enthusiasm, but mindful too that ‘fun’might not be the only challenge ahead.

For there’s an old head on Anna Veiga’s youthfulshoulders. Her experience in reproductive science goesback to the earliest days of IVF, when, as a postgraduatefrom the Universitat Autònoma de Barcelona, she madecontact in 1979 with Pedro Barri about a job at theDexeus Institute. ‘I’d read an article about Pedro, and hewas being asked about IVF,’ Anna recalls. ‘Here I was, abiologist interested in genetics, so I thought, that’s

PROFILE// ESHRE’S CHAIRMAN ELECT //

HolaAnnaESHRE’s ChairmanElect, Anna Veiga,talks to Focus onReproductionabout her careerand her ambitionsfor the Society

A


IVF and to have this connection with ESHRE.Then, of course, it was a much more concentratedsociety than today. But even then I saw ESHRE assomething trying to bring us all together.’

Luck, Anna freely admits, has played a large partin her life, but a strong vein of determination hasalso run through her career, right from her firstdays at Dexeus. Then, she recalls, there were noprecedents in a medical environment which wasquite new to her. ‘There was so much to learn,’ shesays. ‘I just had to keep training and studying. I hada couple of weeks in Vienna and Montpellier, aweek in Jacques Testart’s lab in Paris to learncryopreservation, but mainly we just had to learn aswe went along. There was so much we didn’t know.So we went forward by trial and error - withsurplus oocytes and mice but also keeping in touchwith the pioneers to make sure we were on theright track.’

That training and learning culminated in Spain’sfirst IVF pregnancy in late 1983, and first deliveryin July 1984. ‘It was a great achievement for us,’says Anna, ‘because what we put in place was thebeginning of IVF in Spain. IVF simply didn’t existbefore we began. But we built the lab and after thefirst pregnancies began teaching all the other younggroups in Spain. Most of them came to us to betrained. There was nobody else. And it struck methen that they all recognised the value of what wewere doing in the lab - IVF wasn’t just somethingfor the medical doctors. Of course, this was theoriginal the philosophy of ESHRE - that clinicalmedicine and science have to go together in IVF ifyou want good results in terms of pregnancy andpublications. Today, I would say that this is still thecase in most groups, but not in all. More and moreI see an imbalance between science and medicine.But this wasn’t our experience in Barcelona.’

There were also challenges to face in her personallife. ‘At certain times there have been difficulties,’she admits. ‘But I was lucky because my motherand father were very supportive and I could leavemy son with them when I had to be away. I wasn'thappy about it, that I wasn’t home, but I couldn’tbe home all the time. It was the support from myfamily that enabled me to be so active in myprofessional career.’

Today, more than 30 years later, Anna Veiga stillholds a position at the Dexeus University Institute -with responsibility now for the centre’s researchoutput - and still leads a life which is largely drivenby her career. But her working life is now sharedbetween Dexeus and her new role as director of thestem cell bank of the Centre for RegenerativeMedicine in Barcelona (CMRB). And luck too,smiles Anna, was behind this latest addition to her

professional life, when the CMRB made contactwith Dexeus about the derivation of stem cells fromhuman embryos. ‘It’s a natural evolution,’ she says,‘and I’m certainly not the first to move into stemcells from IVF. We have the confidence andknowledge to work with embryos, and that’s avaluable asset in a stem cell laboratory.’

Now, of course, ESHRE is set to lay even moreclaims on Anna’s time and energy. Thechairmanship, said former Chairman Arne Sunde,‘takes six years out of your life’, but Anna is notanticipating any such life-changing upheavals.‘Being Chairman will have an impact,’ she admits,‘but no more than my other commitments have had.I’ve always travelled a lot, so this is the life I’ve led.My career, what I do, has always been the drivingforce in my life, and my work is very important. ButI’m lucky to be able to work in something that Ireally like. So I don’t think being Chairman ofESHRE will make a lot of difference to my personallife, because this is the life I’ve always led.’

Anna’s more back-seat role at Dexeus means thatESHRE can now take a more prominent place inthat working life, which is what her colleagueswelcome and recognise as an honour for them and

Figures of influence� Pedro Barri, head of theDepartment of Obstetrics,Gynecology and Reproduction ofInstitut Universitari Dexeus, wasa founding father of ESHRE andmember of the original temporarycommittee under RobertEdwards. He was a member ofthe Executive Committee from1989 to 1993 and made

chairman of the first SIG sub-committee in 1990. � The record of the late José Egozcue with ESHRE wentback to the founding of the Society; he also representedSpain on the temporary committee and became a memberof the first Executive Committee in 1985. He was joint

chairman of the internationalscientific committee for thefourth annual meeting inBarcelona in 1988, a member ofthe editorial board of HumanReproduction, a founder of theSIG Reproductive Genetics in1994, and Chairman of ESHREin 1995. He was made anhonorary member of ESHRE in2003.


challenges but how we face them doesn’t justdepend on me. We are in a continuous process, andI’ll be guided by the past and present chairmen.

‘ESHRE’s relationship with the EU is somethingwe’ve been working on very hard, and I think thiswill continue. We have already been involved inimplementation of some of the Directives and withpeople working on them in Brussels. I believe thiswill continue and consolidate.

‘It’s fair to say that growth has always been oneof our goals, but I’m not sure if we really want anannual meeting of 10,000 people. What I am sureof is that you learn more at smaller special interestmeetings. Our big congresses have become more ofan event, where you meet everybody, have yourbusiness meetings, enjoy the social occasions - butit’s very difficult to learn something new. That’swhy the precongress courses have become sopopular.’

Anna Veiga will be ESHRE’s second femalechairman. The first, Lynn Fraser, began her term in1999 with a commitment to increase therepresentation of women in ESHRE’s variouscommittees, but that - as a glance at ESHRE’sactivists suggests - seems no longer necessary today,nor of concern to Anna. ‘I think women should bewhere they are because they deserve it,’ she says. ‘Ifthey belong in the SIGs or are active in committeesor are good scientists, then that’s what they’vedeserved. I don’t like the idea that there should be afixed number of women on a committee. Now inour profession there are probably more womenthan men, and it’s inevitable that they will berepresented according to their merits. But I don’tlike the idea of positive discrimination. I don’t thinkit does women any favours.

‘Of course, it can be very difficult for a womanwith young children. At least in Spain. Maybe it’sdifferent in other countries, but probably not somuch. Women still have more responsibility in thehome than men. So combining their working lifewith their domestic life can be very challenging. Icertainly found it so bringing up my own son.’

Now, however, Anna has both the time and theopportunity for ESHRE, and she’s under noillusions about what that involves. ‘ESHRE is notan exceptionally big society, but when you go to themeetings you’re aware that it is becomingsomething really important. I think there’s no doubtthat today ESHRE is the leading society inreproduction in the world. That’s for sure. We nowhave an ESHRE Campus every ten days - that’show important ESHRE is for training. And it’sthese events and the activities of the SIGs and TaskForces that are the real heart of ESHRE - and whyI’m so excited at the prospect of being the nextchairman.’

ANNA VEIGA:‘ESHRE IS IN A

CONTINUOUSPROCESS AND

I’LL BE GUIDEDBY THE PAST

AND PRESENTCHAIRMEN.’

for Spain. Now, as ESHRE’s 27th annual meeting inRome approaches, she has one more year beforebecoming Chairman in Stockholm. ‘There are manythings to be done,’ she concedes, ‘and manydirections to take. But the organisation of theSociety - with a Chairman Elect, a Chairman andPast Chairman - provides a continuous momentumwhich in a way sets the direction. So ESHRE has its

Flying the flag for SpainAnna lists two of her achievements as helping set up the Spanishassociation of clinical embryologist (ASEBIR) in 1990, whosemembership today has grown to around 800, and the MSc course inembryology now provided at Dexeus. Says Anna: ‘I have a very goodrelationship with the embryologists in Spain, and with the SpanishFertility Society. So I’m sure they’ll be very happy that I’ll beChairman of ESHRE. Spain has made important progress in ART -in the number of centres and in the quality of treatment. We arecertainly at the level of most European countries - and in manycases even better. I'd say that Spain is becoming a country which isrecognised for its standards and where things are done properly. SoI’m proud to represent Spain in ESHRE’s Executive Committee.’

The European Society of Human Reproduction and EmbryologyMeerstraat 60

Grimbergen, [email protected]

Focus on Reproduction ESHRE May 2011

Documents

Transcript of Focus on Reproduction ESHRE May 2011