ESHRE Research Articles

Diagnostic and treatment of endometriosis - recommendations for clinical practice

Endometriosis is characterized by endometrial tissue found outside of the uterus (primarily in the pelvic cavity), causing chronic inflammatory reaction, infertility, and pain. The impact of endometriosis on different aspects of women?s life is important, including family and social life, work, and reproduction. The usual way of examining endometriosis is history taking, recognition of typical symptoms, clinical examination, and the use of imaging techniques, but the diagnosis is made by histopathology findings, usually after laparoscopy. The aim is to represent current recommendations and guidelines referring to endometriosis diagnostics and therapy, proposed by two major societies dealing with reproductive medicine: European Society for Human Reproduction and Embryology (ESHRE) and American Society of Reproductive Medicine (ASRM). The recommendations refer primarily to the therapeutic modalities in infertility and pain problems caused by endometriosis, and represent the basis of appropriate strategy for overcoming numerous problems linked with this chronic illness.

COST-Action GEMINI and EPICONCEPT: what we learned after 8 years?

Scientific societies have a major role in facilitating and disseminating scientific discoveries. Here, we are all members of societies related to reproductive biology, such as AETE (European Association of Embryo Transfer), SRF (Society for Reproduction and Fertility) or ESHRE (European Society of Human Reproduction and Embryology). However, many of you may be unfamiliar with COST Actions. These are atypical, EU-funded temporary societies, that can have a huge impact upon the lives and careers of their members. The objective of the present paper was to capture the influence that one specific COST Action, EPICONCEPT, and to a lesser extent also the earlier COST Action GEMINI, has had on European scientists involved in animal reproduction and embryo transfer. We discuss the intrinsic value of belonging to EPICONCEPT, we focus on how EPICONCEPT advanced the careers of the scientists involved and the lessons learned. We conclude that such specific short-lived societies as granted by COST can be the basis of permanent collaborative ties and networking within Europe. Moreover, EPICONCEPT has been a very useful tool to raise awareness about epigenetics among animal scientists and breeders.

Study on the Prevalence and Characteristics of Metabolic Syndrome in Women of Reproductive Age Group with Polycystic Ovarian Syndrome

ABSTRACT Introduction Polycystic ovarian syndrome (PCOS) is an endocrine disorder affecting all age groups and presenting with myriad problems like menstrual irregularities, hirsutism, anovulatory infertility, and long-term complications like diabetes, cardiovascular problems, etc. Aim Study was aimed at finding the prevalence, characteristics, and various risk factors of metabolic syndrome (MS) in reproductive age group in our hospital. Materials and methods Using statistical table, a sample size of 131 was calculated and patients were recruited as per inclusion criteria. Polycystic ovarian syndrome was diagnosed by the American Society for Reproductive Medicine (ASRM)/European Society of Human Reproduction and Embryology (ESHRE) criteria. After informed consent, a detailed history was obtained and physical examination was carried out to assess, body weight, height, body mass index (BMI), waist—hip ratio (WHR), and blood pressure (BP). Fasting blood glucose, triglycerides, and high-density lipoprotein (HDL) were measured for each woman Results Prevalence of MS in our study was 45.8%; 26.7% of patients had a combination of increased waist circumference, raised triglycerides, and low HDL; 55.2% of patients had a fasting blood sugar (FBS) levels more than 100 mg%. Age of the patient was a statistically significant risk factor of MS with 100% of patients in the age group of 35 to 39 presenting with MC. Body mass index was also a statistically significant risk factor with 82.6% with BMI > 30 having MC. Other important risk factors include a WHR more than 0.95, presence of diabetes in mother or sister, and presence of acanthosis; 71% of patients with WHR more than 0.95 had MC. Age of menarche, duration of menstrual cycles, and hirsutism showed no significant relationship. Conclusion An outstanding fact that emerged in this study was that 94% of women with PCOS had HDL values <50 mg/dL. And 58% had triglycerides more than 150 mg/dL. Hence, lifestyle modification and early intervention will hopefully spare long-term complication of PCOS. How to cite this article Madusudhanan RR, Nambisan B, Brahmanandan M, Radha S. Study on the Prevalence and Characteristics of Metabolic Syndrome in Women of Reproductive Age Group with Polycystic Ovarian Syndrome. J South Asian Feder Obst Gynae 2017;9(4):341-347.

Patenting medical diagnosis methods in Europe: Stanford University and time-lapse microscopy

In 2013, a European Patent for the technique of time-lapse microscopy was granted by the European Patent Office (EPO) to Stanford University and was subsequently opposed by Unisense FertiliTech A/S and by the European Society for Human Reproduction and Embryology (ESHRE), Sigrid Sterckx, Julian Cockbain and Guido Pennings. ESHRE et al.'s opposition was based on the argument that Stanford's patent was directed to a method of medical diagnosis, methods that are excluded from patentability by Article 53(c) of the European Patent Convention. The Opposition Division of the EPO rejected the oppositions in November 2015, and both opponents have now filed their appeals. In this paper, we comment on the Opposition Division decision and the grounds of appeal put forward by ESHRE et al.

Prise en charge de l’endométriome par les chirurgiens gynécologues français : résultats d’une enquête de pratique

There are many national and international recommendations and guidelines for the management of patients with endometrioma. In this study, we aimed to evaluate the impact of these recommendations on the practice of French surgeons, and to assess their knowledge about the management of endometriomas. A self-questionnaire has been sent to the French members of the Society of Gynecologic Surgery and Pelvic (SCGP) in May 2015. One hundred and forty-four members of the society (36%) participated in the survey. Most of the practitioners (71%) followed recommendations of the Collège National des Gynécologues Obstétriciens (CNGOF), 38% followed the guidelines of European Society of Human Reproduction and Embryology (ESHRE). One hundred percent of the surgeons declared that they practice laparoscopy when a surgical removal of the endometrioma is indicated. About treatment with GnRH analogue, 38% of the practitioners declared that they prescribe an add back therapy immediately after the surgery, 43% at 3months, and 14% declared that they never prescribe this treatment. French surgeons consider the recommendations are useful in their clinical practice; they primarily apply the guidelines of the CNGOF.

Assisted reproductive technology in Europe, 2012: results generated from European registers by ESHRE.

The 16th European IVF-monitoring (EIM) report presents the data of the treatments involving assisted reproductive technology (ART) and intrauterine insemination (IUI) initiated in Europe during 2012: are there any changes compared with previous years? Despite some fluctuations in the number of countries reporting data, the overall number of ART cycles has continued to increase year by year, the pregnancy rates (PRs) in 2012 remained stable compared with those reported in 2011, and the number of transfers with multiple embryos (3+) and the multiple delivery rates were lower than ever before. Since 1997, ART data in Europe have been collected and re-ported in 15 manuscripts, published in Human Reproduction. Retrospective data collection of European ART data by the EIM Consortium for the European Society of Human Reproduction and Embryology (ESHRE). Data for cycles between 1 January and 31 December 2012 were collected from National Registers, when existing, or on a voluntary basis by personal information. From 34 countries (+1 compared with 2011), 1111 clinics reported 640 144 treatment cycles including 139 978 of IVF, 312 600 of ICSI, 139 558 of frozen embryo replacement (FER), 33 605 of egg donation (ED), 421 of in vitro maturation, 8433 of preimplantation genetic diagnosis/preimplantation genetic screening and 5549 of frozen oocyte replacements (FOR). European data on intrauterine insemination using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 1126 IUI labs in 24 countries. A total of 175 028 IUI-H and 43 497 IUI-D cycles were included. In 18 countries where all clinics reported to their ART register, a total of 369 081 ART cycles were performed in a population of around 295 million inhabitants, corresponding to 1252 cycles per million inhabitants (range 325-2732 cycles per million inhabitants). For all IVF cycles, the clinical PRs per aspiration and per transfer were stable with 29.4 (29.1% in 2011) and 33.8% (33.2% in 2011), respectively. For ICSI, the corresponding rates also were stable with 27.8 (27.9% in 2011) and 32.3% (31.8% in 2011). In FER cycles, the PR per thawing/warming increased to 23.1% (21.3% in 2011). In ED cycles, the PR per fresh transfer increased to 48.4% (45.8% in 2011) and to 35.9% (33.6% in 2011) per thawed transfer, while it was 45.1% for transfers after FOR. The delivery rate after IUI remained stable, at 8.5% (8.3% in 2011) after IUI-H and 12.0% (12.2% in 2011) after IUI-D. In IVF and ICSI cycles, 1, 2, 3 and 4+ embryos were transferred in 30.2, 55.4, 13.3 and 1.1% of the cycles, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (added together) were 82.1, 17.3 and 0.6%, respectively, resulting in a total multiple delivery rate of 17.9% compared with 19.2% in 2011 and 20.6% in 2010. In FER cycles, the multiple delivery rate was 12.5% (12.2% twins and 0.3% triplets). Twin and triplet delivery rates associated with IUI cycles were 9.0%/0.4% and 7.2%/0.5%, following treatment with husband and donor semen, respectively. The method of reporting varies among countries, and registers from a number of countries have been unable to provide some of the relevant data such as initiated cycles and deliveries. As long as data are incomplete and generated through different methods of collection, results should be interpreted with caution. The 16th ESHRE report on ART shows a continuing expansion of the number of treatment cycles in Europe, with more than 640 000 cycles reported in 2012 with an increasing contribution to birthrate in many countries. However, the need to improve and standardize the national registries, and to establish validation methodologies remains manifest. The study has no external funding; all costs are covered by ESHRE. There are no competing interests.

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Emre SeliEmre SeliDr Seli received his medical degree from the Istanbul Medical School in Turkey and completed his Residency in Obstetrics and Gynecology at Yale University. His postdoctoral training included a fellowship in Reproductive Endocrinology and Infertility as well as a research fellowship in molecular biology, both at Yale University. He is currently Professor of Obstetrics, Gynecology, and Reproductive Sciences at Yale School of Medicine. Dr Seli is the recipient of many National Institutes of Health and pharmaceutical industry-sponsored research grants and has trained more than 50 pre- and post-doctoral fellows. His research focuses on infertility, egg donation and gestational surrogacy, assessment of embryo viability and oocyte and pre-implantation embryo development. He is a current or past member of the editorial boards of Molecular Human Reproduction, Frontiers in Bioscience, Reproductive Sciences, and Journal of Assisted Reproduction and Genetics, and serves as a reviewer for more than 20 scientific journals including New England Journal of Medicine, Science, The Lancet, Human Reproduction, Fertility and Sterility, Molecular Endocrinology, Endocrinology, Journal of Clinical Endocrinology and Metabolism, and Journal of Clinical Investigation. He has published more than 100 scientific articles, and edited four books: Non-invasive Management of Gynecologic Disorders, Infertility, Fertility Preservation, and Human Gametes and Pre-implantation Embryos: Assessment and Diagnosis. Dr Seli is the recipient of multiple awards for teaching, clinical excellence, and research, including: American College of Obstetricians and Gynecologists Fellowship Award for Research in Endocrinology of the Postreproductive Woman, Yale University “Resident of Excellence Award” for research, Society for Reproductive Investigation (SRI) President's Presenter Award, the American Society for Reproductive Medicine (ASRM) Ira and Ester Rosenwaks New Investigator Award, and Association of Professors of Gynecology and Obstetrics (APGO)-Yale Excellence in Teaching Award. He is also an active member of numerous professional societies including SRI, Society at the Study of Reproduction (SSR), European Society for Human Reproduction and Embryology (ESHRE) and ASRM, and a frequent invited speaker who has presented at national and international medical and scientific symposia. Juan Antonio García VelascoJuan Antonio García VelascoProfessor Juan Antonio García Velasco is both the Director of the Master's program in human reproduction and a professor of obstetrics and gynecology at Rey Juan Carlos University in Madrid. He gained his degree in medicine at Complutense University, Madrid in 1990, before going on to train as a specialist in obstetrics and gynecology at La Paz Hospital, Madrid between 1992 and 1995. Professor García Velasco gained his PhD in medicine and surgery at Autónoma University, Madrid in 1995. He then became a sub-specialist in reproductive endocrinology and infertility at Yale University, USA in 1998. Professor García Velasco has published 122 scientific articles in impact journals along with 22 chapters and 4 books. He is the Principal Investigator of projects funded by the Ministry of Education and the Ministry of Health. He is a member of the Editorial Committee of Fertility & Sterility and Reproductive Biomedicine Online and SGI, ESHRE, ASRM, SEGO and SEF.

Gonadotrophin-releasing hormone antagonists for assisted reproductive technology.

Gonadotrophin-releasing hormone (GnRH) antagonists can be used to prevent a luteinizing hormone (LH) surge during controlled ovarian hyperstimulation (COH) without the hypo-oestrogenic side-effects, flare-up, or long down-regulation period associated with agonists. The antagonists directly and rapidly inhibit gonadotrophin release within several hours through competitive binding to pituitary GnRH receptors. This property allows their use at any time during the follicular phase. Several different regimens have been described including multiple-dose fixed (0.25 mg daily from day six to seven of stimulation), multiple-dose flexible (0.25 mg daily when leading follicle is 14 to 15 mm), and single-dose (single administration of 3 mg on day 7 to 8 of stimulation) protocols, with or without the addition of an oral contraceptive pill. Further, women receiving antagonists have been shown to have a lower incidence of ovarian hyperstimulation syndrome (OHSS). Assuming comparable clinical outcomes for the antagonist and agonist protocols, these benefits would justify a change from the standard long agonist protocol to antagonist regimens. This is an update of a Cochrane review first published in 2001, and previously updated in 2006 and 2011. To evaluate the effectiveness and safety of gonadotrophin-releasing hormone (GnRH) antagonists compared with the standard long protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception cycles. We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched from inception to May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to 28 April 2015), Ovid MEDLINE (1966 to 28 April 2015), EMBASE (1980 to 28 April 2015), PsycINFO (1806 to 28 April 2015), CINAHL (to 28 April 2015) and trial registers to 28 April 2015, and handsearched bibliographies of relevant publications and reviews, and abstracts of major scientific meetings, for example the European Society of Human Reproduction and Embryology (ESHRE) and American Society for Reproductive Medicine (ASRM). We contacted the authors of eligible studies for missing or unpublished data. The evidence is current to 28 April 2015. Two review authors independently screened the relevant citations for randomised controlled trials (RCTs) comparing different GnRH agonist versus GnRH antagonist protocols in women undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). Two review authors independently assessed trial eligibility and risk of bias, and extracted the data. The primary review outcomes were live birth and ovarian hyperstimulation syndrome (OHSS). Other adverse effects (miscarriage and cycle cancellation) were secondary outcomes. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic. We assessed the overall quality of the evidence for each comparison using GRADE methods. We included 73 RCTs, with 12,212 participants, comparing GnRH antagonist to long-course GnRH agonist protocols. The quality of the evidence was moderate: limitations were poor reporting of study methods.Live birthThere was no conclusive evidence of a difference in live birth rate between GnRH antagonist and long course GnRH agonist (OR 1.02, 95% CI 0.85 to 1.23; 12 RCTs, n = 2303, I(2)= 27%, moderate quality evidence). The evidence suggested that if the chance of live birth following GnRH agonist is assumed to be 29%, the chance following GnRH antagonist would be between 25% and 33%.OHSSGnRH antagonist was associated with lower incidence of any grade of OHSS than GnRH agonist (OR 0.61, 95% C 0.51 to 0.72; 36 RCTs, n = 7944, I(2) = 31%, moderate quality evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is assumed to be 11%, the risk following GnRH antagonist would be between 6% and 9%.Other adverse effectsThere was no evidence of a difference in miscarriage rate per woman randomised between GnRH antagonist group and GnRH agonist group (OR 1.04, 95% CI 0.82 to 1.30; 33 RCTs, n = 7022, I(2) = 0%, moderate quality evidence).With respect to cycle cancellation, GnRH antagonist was associated with a lower incidence of cycle cancellation due to high risk of OHSS (OR 0.47, 95% CI 0.32 to 0.69; 19 RCTs, n = 4256, I(2) = 0%). However cycle cancellation due to poor ovarian response was higher in women who received GnRH antagonist than those who were treated with GnRH agonist (OR 1.32, 95% CI 1.06 to 1.65; 25 RCTs, n = 5230, I(2) = 68%; moderate quality evidence). There is moderate quality evidence that the use of GnRH antagonist compared with long-course GnRH agonist protocols is associated with a substantial reduction in OHSS without reducing the likelihood of achieving live birth.

ESHRE Guideline: management of women with premature ovarian insufficiency.

What is the optimal management of women with premature ovarian insufficiency (POI) based on the best available evidence in the literature? The guideline development group (GDG) formulated 99 recommendations answering 31 key questions on the diagnosis and treatment of women with POI. NA. This guideline was produced by a multidisciplinary group of experts in the field using the methodology of the Manual for ESHRE Guideline Development, including a thorough systematic search of the literature, quality assessment of the included papers up to September 2014 and consensus within the guideline group on all recommendations. The GDG included a patient representative to ensure input from women with POI. After finalization of the draft, the European Society for Human Reproduction and Embryology (ESHRE) members and professional organizations were asked to review the guideline. NA. The guideline provides 17 recommendations on diagnosis and assessment of POI and 46 recommendations on the different sequelae of POI and their consequences for monitoring and treatment. Furthermore, 24 recommendations were formulated on hormone replacement therapy in women with POI, and two on alternative and complementary treatment. A chapter on puberty induction resulted in five recommendations. The main limitation of the guideline is that, due to the lack of data, many of the recommendations are based on expert opinion or indirect evidence from studies on post-menopausal women or women with Turner Syndrome. Despite the limitations, the guideline group is confident that this document will be able to guide health care professionals in providing the best practice for managing women with POI given current evidence. Furthermore, the guideline group has formulated research recommendations on the gaps in knowledge identified in the literature searches, in an attempt to stimulate research on the key issues in POI. The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the implementation of the guideline. The guideline group members did not receive payment. Dr Davies reports non-financial support from Novo Nordisk, outside the submitted work; the other authors had nothing to disclose. NA.

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women.

Many women undergoing an assisted reproductive technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good-quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as more effective techniques of embryo transfer. This review evaluates the efficacy of ultrasound-guided embryo transfer (UGET) compared with 'clinical touch' (CTET), which is the traditional method of embryo transfer and relies on the clinician's tactile senses to judge when the transfer catheter is in the correct position. To determine whether ultrasound guidance compared with clinical touch improves pregnancy outcomes in women undergoing embryo transfer during ART cycles. For the 2016 update of this review, we ran updated searches in the Cochrane Gynaecology and Fertility Group trials register (May 2015), the Cochrane Central Register of Controlled Trials (the Cochrane Library, May 2015), MEDLINE (2009 to May 2015), and EMBASE (2009 to May 2015). We also handsearched relevant conference proceedings: American Society for Reproductive Medicine (ASRM), European Society for Human Reproduction and Embryology (ESHRE), and International Federation of Gynecology and Obstetrics (FIGO). There were no language restrictions. We included only randomised controlled trials. Two review authors independently assessed eligibility and quality of trials and extracted data from those selected. We calculated odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes. No outcomes were reported using continuous data. We assessed the overall quality of the evidence for the main findings using the GRADE working group methods. This systematic review now has 21 included studies (four of which we added in the 2016 update), two studies awaiting assessment, and 47 excluded studies. In total, data for meta-analyses were available in 21 trials (n = 6218 women), of which only four reported live births.UGET was associated with an increased chance of a live birth/ongoing pregnancy compared with CTET (OR 1.47, 95% CI 1.30 to 1.65; 13 trials; n = 5859 women; I(2) = 74%; low-quality evidence). Sensitivity analysis by including only trials with low risk of selection bias or by using a random-effects model did not alter the effect. We estimate that for women with a chance of a live birth/ongoing pregnancy of 23% using CTET, this would increase to between 28% and 33% using UGET. We considered the quality of the evidence using GRADE methodology to be low.UGET was associated with an increase in the chance of a clinical pregnancy (OR 1.31, 95% CI 1.17 to 1.45; 20 trials; n = 6711 women; I(2) = 42%; moderate-quality evidence). We identified no differences between groups for the incidence of adverse events including multiple pregnancy, ectopic pregnancy, or miscarriage. These events were relatively rare, and sample sizes limited the ability to detect such differences. The evidence suggests ultrasound guidance improves the chance of live birth/ongoing and clinical pregnancies compared with clinical touch, without increasing the chance of multiple pregnancy, ectopic pregnancy, or miscarriage. Methodological limitations included: only four studies reporting details of both computerised randomisation techniques and adequate allocation concealment, only four studies reported on the outcome of live birth, and none of the nine studies that reported on ongoing pregnancy reported on live birth, suggesting possible reporting bias. Adequate reporting of randomisation and allocation concealment will improve the quality of future studies. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Variations in Multiple Birth Rates and Impact on Perinatal Outcomes in Europe.

ObjectiveInfants from multiple pregnancies have higher rates of preterm birth, stillbirth and neonatal death and differences in multiple birth rates (MBR) exist between countries. We aimed to describe differences in MBR in Europe and to investigate the impact of these differences on adverse perinatal outcomes at a population level.MethodsWe used national aggregate birth data on multiple pregnancies, maternal age, gestational age (GA), stillbirth and neonatal death collected in the Euro-Peristat project (29 countries in 2010, N = 5 074 643 births). We also used European Society of Human Reproduction and Embryology (ESHRE) data on assisted conception and single embryo transfer (SET). The impact of MBR on outcomes was studied using meta-analysis techniques with random-effects models to derive pooled risk ratios (pRR) overall and for four groups of country defined by their MBR. We computed population attributable risks (PAR) for these groups.ResultsIn 2010, the average MBR was 16.8 per 1000 women giving birth, ranging from 9.1 (Romania) to 26.5 (Cyprus). Compared to singletons, multiples had a nine-fold increased risk (pRR 9.4, 95% Cl 9.1–9.8) of preterm birth (<37 weeks GA), an almost 12-fold increased risk (pRR 11.7, 95% CI 11.0–12.4) of very preterm birth (<32 weeks GA). Pooled RR were 2.4 (95% Cl 1.5–3.6) for fetal mortality at or after 28 weeks GA and 7.0 (95% Cl 6.1–8.0) for neonatal mortality. PAR of neonatal death and very preterm birth were higher in countries with high MBR compared to low MBR (17.1% (95% CI 13.8–20.2) versus 9.8% (95% Cl 9.6–11.0) for neonatal death and 29.6% (96% CI 28.5–30.6) versus 17.5% (95% CI 15.7–18.3) for very preterm births, respectively).ConclusionsWide variations in MBR and their impact on population outcomes imply that efforts by countries to reduce MBR could improve perinatal outcomes, enabling better long-term child health.

Assisted reproductive technology in Europe, 2011: results generated from European registers by ESHRE.

The 15th European IVF-monitoring (EIM) report presents the results of treatments involving assisted reproductive technology (ART) initiated in Europe during 2011: are there any changes in the trends compared with previous years? Despite some fluctuations in the number of countries reporting data, while the overall number of ART cycles has continued to increase year by year, the pregnancy rates in 2011 decreased slightly to those reported in 2010, and the number of transfers with multiple embryos (3+) and the multiple delivery rates declined. Since 1997, ART data in Europe have been collected and reported in 14 manuscripts, published in Human Reproduction. Retrospective data collection of European ART data by the EIM Consortium for the European Society of Human Reproduction and Embryology (ESHRE); cycles started between 1 January and 31 December 2011 are collected on a yearly basis. The data are collected by National Registers, when existing, or on a voluntary basis by personal information. From 33 countries (+2 compared with 2010), 1064 clinics reported 609 973 treatment cycles including: IVF 138 592, ICSI 298 918, frozen embryo replacement (FER) 129 693, egg donation (ED) 30 198, in vitro maturation 511, preimplantation genetic diagnosis/screening 6824 and frozen oocyte replacements 5237. European data on intrauterine insemination (IUI) using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 861 IUI laboratories in 24 countries. A total of 174 390 IUI-H and 41 151 IUI-D cycles were included. In 17 countries where all clinics reported to the ART register, a total of 361 972 ART cycles were performed in a population of 285 million inhabitants, corresponding to 1269 cycles per million inhabitants. For all IVF cycles, the clinical pregnancy rates per aspiration and per transfer were stable with 29.1 and 33.2%, respectively, and for ICSI, the corresponding rates also were stable with 27.9 and 31.8%, respectively. In FER cycles, the pregnancy rate per thawing increased to 21.3% if compared with previous years. In ED cycles, the pregnancy rate per fresh transfer decreased to 45.8% (47.4% in 2010) and increased to 33.6% (33.3% in 2010) per thawed transfer. The delivery rate after IUI-H decreased to 8.3 (8.9 in 2010), and to 12.2% (13.8% in 2010) after IUI-D. In IVF and ICSI cycles, 1, 2, 3 and 4+ embryos were transferred in 27.5, 56.7, 14.5 and 1.3% of cycles, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (added together) were 80.8, 18.6 and 0.6%, respectively, resulting in a total multiple delivery rate of 19.2% compared with 20.6% in 2010, 20.2% in 2009, 21.7% in 2008, 22.3% in 2007 and 20.8% in 2006. In FER cycles, the multiple delivery rate was 13.2% (12.8% twins and 0.4% triplets). Twin and triplet delivery rates associated with IUI cycles were 9.7/0.6% and 7.3/0.3%, following IUI-H and IUI-D treatment, respectively. The method of reporting varies among countries, and registers from a number of countries have been unable to provide some of the relevant data such as initiated cycles and deliveries. As long as data are incomplete and generated through different methods of collection, results should be interpreted with caution. The 15th ESHRE report on ART shows a continuing expansion of the number of treatment cycles in Europe, with more than 600 000 cycles reported in 2011. Since 2006, the proportion of IVF to ICSI cycles has reached a plateau after a small decrease in 2009. Pregnancy and delivery rates after IVF remained relatively stable compared with 2010 and 2009. The pregnancy rate per aspiration in ICSI cycles declined for the first time by 0.9%. The multiple delivery rate is lower than ever before. The study had no external funding; all costs are covered by ESHRE. There are no competing interests.

High sensitivity-c reactive protein as an additional marker for increased risk of cardiovascular disease in patients of polycystic ovary syndrome

Background: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder affecting women of reproductive age group with a worldwide prevalence of about 4 to12%1,2. PCOS is seen in up to 25% of the Caucasians and 50% of the South Asian women respectively3,4. It is a heterogeneous disorder of unknown aetiology with a strong genetic element5. PCOS does not exclusively involve the reproductive apparatus; it has a complex number of systemic relevancy symptoms. It leads to Metabolic Syndrome with severe consequences on the cardiovascular system6. The precise cardiovascular disease (CVD) risk in women with PCOS remains unclear because there are no longitudinal studies pertaining to cardiovascular events. There is a paucity of data in regard to cardiovascular event rates and mortality in PCOS hence the present study was aimed to assess cardiovascular disease risk in women with PCOS. Aim: To evaluate cardiovascular disease risk in women with Polycystic ovary syndrome. Materials and Methods: 50 diagnosed cases of PCOS and 50 age matched healthy females were included in this study. Cases were diagnosed based on new Rotterdam criteria formulated by the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE). Blood samples were collected after overnight fasting. Serum High sensitivity-C Reactive Protein (hs-CRP), Total Cholesterol(TC), Triglycerides(TG), HDL Cholesterol(HDL-C), VLDL Cholesterol(VLDL-C), LDL Cholesterol (LDL-C) were estimated. Body Mass Index (BMI) was calculated for women in both the groups. Statistical analysis: Results were analyzed using unpaired t-test and p-value was calculated. BMI was correlated with hs-CRP using one way ANOVA test. Statistically non-significant increased levels of serum total cholesterol, Triglycerides, HDL cholesterol, LDL cholesterol, VLDL cholesterol and hs-CRP in PCOS cases as compared with control were observed. BMI was found to be significantly inc

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies.

What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. Accurate diagnosis of congenital anomalies still remains a clinical challenge due to the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, with some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available, enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. The ESHRE/ESGE Congenital Uterine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project. The consensus is developed based on (1) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy performing a systematic review of evidence and (2) consensus for (a) the definition of where and how to measure uterine wall thickness and (b) the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method. Uterine wall thickness is defined as the distance between interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynaecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional ultrasound (3D US) is recommended for the diagnosis of female genital anomalies in “symptomatic” patients belonging to high-risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine avaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the sub-group of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopy. The various diagnostic methods should be used in a proper way and evaluated by experts to avoid mis-, over- and underdiagnosis. The role of a combined ultrasound examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies.

What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. Accurate diagnosis of congenital anomalies still remains a clinical challenge because of the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. The ESHRE/ESGE CONgenital UTerine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project. The consensus is developed based on: (i) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy by performing a systematic review of evidence and (ii) consensus for the definition of where and how to measure uterine wall thickness and the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method. Uterine wall thickness is defined as the distance between the interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional (3D) US is recommended for the diagnosis of female genital anomalies in 'symptomatic' patients belonging to high risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine evaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the subgroup of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopically. The various diagnostic methods should always be used in the proper way and evaluated by experts to avoid mis-, over- and underdiagnosis. The role of a combined US examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity. None.

ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction-a guide for fertility staff.

Based on the best available evidence in the literature, what is the optimal management of routine psychosocial care at infertility and medically assisted reproduction (MAR) clinics? Using the structured methodology of the Manual for the European Society of Human Reproduction and Embryology (ESHRE) Guideline Development, 120 recommendations were formulated that answered the 12 key questions on optimal management of routine psychosocial care by all fertility staff. The 2002 ESHRE Guidelines for counselling in infertility has been a reference point for best psychosocial care in infertility for years, but this guideline needed updating and did not focus on routine psychosocial care that can be delivered by all fertility staff. This guideline was produced by a group of experts in the field according to the 12-step process described in the ESHRE Manual for Guideline Development. After scoping the guideline and listing a set of 12 key questions in PICO (Patient, Intervention, Comparison and Outcome) format, thorough systematic searches of the literature were conducted; evidence from papers published until April 2014 was collected, evaluated for quality and analysed. A summary of evidence was written in a reply to each of the key questions and used as the basis for recommendations, which were defined by consensus within the guideline development group (GDG). Patient and additional clinical input was collected during the scoping and the review phase of the guideline development. The guideline group, comprising psychologists, two medical doctors, a midwife, a patient representative and a methodological expert, met three times to discuss evidence and reach consensus on the recommendations. 120 recommendations that aim at guiding fertility clinic staff in providing optimal evidence-based routine psychosocial care to patients dealing with infertility and MAR. The guideline is written in two sections. The first section describes patients' preferences regarding the psychosocial care they would like to receive at clinics and how this care is associated with their well-being. The second section of the guideline provides information about the psychosocial needs patients experience across their treatment pathway (before, during and after treatment) and how fertility clinic staff can detect and address these. Needs refer to conditions assumed necessary for patients to have a healthy experience of the fertility treatment. Needs can be behavioural (lifestyle, exercise, nutrition and compliance), relational (relationship with partner if there is one, family friends and larger network, and work), emotional (well-being, e.g. anxiety, depression and quality of life) and cognitive (treatment concerns and knowledge). We identified many areas in care for which robust evidence was lacking. Gaps in evidence were addressed by formulating good practice points, based on the expert opinion of the GDG, but it is critical for such recommendations to be empirically validated. The evidence presented in this guideline shows that providing routine psychosocial care is associated with or has potential to reduce stress and concerns about medical procedures and improve lifestyle outcomes, fertility-related knowledge, patient well-being and compliance with treatment. As only 45 (36.0%) of the 125 recommendations were based on high-quality evidence, the guideline group formulated recommendations to guide future research with the aim of increasing the body of evidence.

Efficacy and Safety of Pergoveris in Assisted Reproductive Technology—ESPART: rationale and design of a randomised controlled trial in poor ovarian responders undergoing IVF/ICSI treatment

IntroductionThe results of a recent meta-analysis showed that adding recombinant human luteinising hormone (r-hLH) to recombinant human follicle-stimulating hormone (r-hFSH) for ovarian stimulation was beneficial in poor responders, resulting in...

The educational and professional status of clinical embryology and clinical embryologists in Europe.

What is the recognition of clinical embryology and the current status of clinical embryologists in European countries, regarding educational levels, responsibilities and workload, and need for a formal education in assisted reproductive technology (ART)? It is striking that the profession of clinical embryology, almost 40 years after the introduction of IVF, is still not officially recognized in most European countries. Reproductive medicine has developed into a sophisticated multidisciplinary medical branch since the birth of Louise Brown 37 years ago. The European Board & College of Obstetrics and Gynaecology (EBCOG) has recognized reproductive medicine as a subspeciality and has developed a subspeciality training for gynaecologists in collaboration with the European Society for Human Reproduction and Embryology (ESHRE). However, nothing similar exists for the field of clinical embryology or for clinical embryologists. A questionnaire about the situation in clinical embryology in the period of 2012-2013 in the respective European country was sent to ESHRE National representatives (basic scientists only) in December 2013. At this time, 28 European countries had at least one basic scientist in the ESHRE Committee of National Representatives. The survey consisted of 46 numeric, dichotomous (yes/no) or descriptive questions. Answers were obtained from 27 out of 28 countries and the data were tabulated. Data about the numbers of 'ESHRE Certified Embryologists' were taken from the ESHRE Steering Committee for Embryologist Certification. In 2012, more than 7000 laboratory staff from 1349 IVF clinics in 27 European countries performed over 700 000 fresh and frozen ART cycles. Despite this, clinical embryology is only recognized as an official profession in 3 out of 27 national health systems. In most countries clinical embryologists need to be registered under another profession, and have limited possibilities for organized education in clinical embryology. Mostly they are trained for practical work by senior colleagues. ESHRE embryologist certification so far constitutes the only internationally recognized qualification; however this cannot be considered a subspecialization. Data were obtained through different methods, by involving national embryologist societies and cycle registers, collecting information from centre to centre, and in some cases by individual assessment of the situation. For these reasons, the results should be interpreted with caution. This paper presents the current status of clinical embryology and clinical embryologists in Europe and is an important step towards implementation of clinical embryology as an officially recognized profession. None. No.

ESHRE PGD Consortium data collection XIII: cycles from January to December 2010 with pregnancy follow-up to October 2011.

How do data in the 13th annual data collection (Data XIII) of the European Society of Human Reproduction and Embryology (ESHRE) PGD Consortium compare with the cumulative data for collections I-XII? The 13th retrospective collection represents valuable data on PGD/PGS cycles, pregnancies and children: the main trend observed is the decrease in the routine implementation of PGS. Since 1999, the PGD Consortium has collected, analysed and published 12 data sets and an overview of the first 10 years of data collections. Data were collected from each participating centre using a FileMaker Pro database (versions 5-11). Separate predesigned FileMaker Pro files were used for the cycles, pregnancies and baby records. The study documented cycles performed during the calendar year 2010 and follow-up of the pregnancies and babies born which resulted from these cycles (until October 2011). Data were submitted by 62 centres (full PGD Consortium members). The submitted data were thoroughly analysed to identify incomplete data entries and corrections were requested from the participating centres. Records remaining with incomplete or inconsistent data were excluded from the calculations. Corrections, calculations and tables were made by expert co-authors. For data collection XIII, 62 centres reported data for 5780 cycles with oocyte retrieval (OR), along with details of the follow-up on 1503 pregnancies and 1152 babies born. A total of 1071 OR were reported for chromosomal abnormalities, 108 OR for sexing for X-linked diseases, 1574 OR for monogenic diseases, 2979 OR for preimplantation genetic screening and 48 OR for social sexing. The findings apply to the 62 participating centres and may not represent worldwide trends in PGD. The annual data collections provide an important resource for data mining and for following trends in PGD practice. None.

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Emre SeliEmre SeliDr Seli received his medical degree from the Istanbul Medical School in Turkey and completed his Residency in Obstetrics and Gynecology at Yale University. His postdoctoral training included a fellowship in Reproductive Endocrinology and Infertility as well as a research fellowship in molecular biology, both at Yale University. He is currently Professor of Obstetrics, Gynecology, and Reproductive Sciences at Yale School of Medicine. Dr Seli is the recipient of many National Institutes of Health and pharmaceutical industry-sponsored research grants and has trained more than 50 pre- and post-doctoral fellows. His research focuses on infertility, egg donation and gestational surrogacy, assessment of embryo viability and oocyte and pre-implantation embryo development. He is a current or past member of the editorial boards of Molecular Human Reproduction, Frontiers in Bioscience, Reproductive Sciences, and Journal of Assisted Reproduction and Genetics, and serves as a reviewer for more than 20 scientific journals including New England Journal of Medicine, Science, The Lancet, Human Reproduction, Fertility and Sterility, Molecular Endocrinology, Endocrinology, Journal of Clinical Endocrinology and Metabolism, and Journal of Clinical Investigation. He has published more than 100 scientific articles, and edited four books: Non-invasive Management of Gynecologic Disorders, Infertility, Fertility Preservation, and Human Gametes and Pre-implantation Embryos: Assessment and Diagnosis. Dr Seli is the recipient of multiple awards for teaching, clinical excellence, and research, including: American College of Obstetricians and Gynecologists Fellowship Award for Research in Endocrinology of the Postreproductive Woman, Yale University “Resident of Excellence Award” for research, Society for Reproductive Investigation (SRI) President's Presenter Award, the American Society for Reproductive Medicine (ASRM) Ira and Ester Rosenwaks New Investigator Award, and Association of Professors of Gynecology and Obstetrics (APGO)-Yale Excellence in Teaching Award. He is also an active member of numerous professional societies including SRI, Society at the Study of Reproduction (SSR), European Society for Human Reproduction and Embryology (ESHRE) and ASRM, and a frequent invited speaker who has presented at national and international medical and scientific symposia. Juan Antonio García VelascoJuan Antonio García VelascoProfessor Juan Antonio García Velasco is both the Director of the Master's program in human reproduction and a professor of obstetrics and gynecology at Rey Juan Carlos University in Madrid. He gained his degree in medicine at Complutense University, Madrid in 1990, before going on to train as a specialist in obstetrics and gynecology at La Paz Hospital, Madrid between 1992 and 1995. Professor García Velasco gained his PhD in medicine and surgery at Autónoma University, Madrid in 1995. He then became a sub-specialist in reproductive endocrinology and infertility at Yale University, USA in 1998. Professor García Velasco has published 122 scientific articles in impact journals along with 22 chapters and 4 books. He is the Principal Investigator of projects funded by the Ministry of Education and the Ministry of Health. He is a member of the Editorial Committee of Fertility & Sterility and Reproductive Biomedicine Online and SGI, ESHRE, ASRM, SEGO and SEF.