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Advanced workshop in embryology25-26 October 2013 - Dubai, UAE

FINAL PROGRAMME AND ABSTRACT BOOK

General information

VenueThe live educational workshop takes place at the:

Towers Rotana Dubai Sheikh Zayed RoadPO Box 30430 Dubai, U.A.E.

LanguageThe official language of the live educational workshop is English.

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

Associate Project Manager: Simona PantaleoniTel.: +39 (0)6 420 413 569 - Fax: +39 (0)6 420 413 677Mobile +39 334 6403640E-mail: [email protected]

Specialist Medical Advisor: Irene ZerbettoSpecialist Medical Advisor: Angelo Marino

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

Organising secretariatJLM ConsultantsBlock B, 2nd Floor, 225Al Attar Centre, KaramaTrade Centre RoadDubai, United Arab EmiratesP O Box 114955Tel: +971 4 3979753, Fax: +971 4 3979758Contact: Rosetta LoboE-mail: [email protected]

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Advanced workshop in embryology

Serono Symposia International Foundation live educational workshop on:

Advanced workshop in embryology25-26 October 2013 - Dubai, UAE

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

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

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

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

The CME workshop on: “Advanced workshop in embryology” held on 25-26 October 2013 in Dubai, UAE, is designated for amaximum of 7 (seven) hours of European CME credits (ECMEC). Each medical specialist should claim only those credits that he/sheactually spent in the educational activity. EACCME® credits are recognized by the American Medical Association (AMA) towards thePhysician's Recognition Award (PRA). To convert EACCME® credit to AMA PRA category 1 credit, please contact the AMA.

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

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Scientific organiser

Robert FischerFertility Center HamburgHamburg, Germany

Scientific co-organisers

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

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

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

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

List of faculty members

Thomas EbnerIVF UnitWomen’s General HospitalLinz, Austria


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

Karen TurnerOxford Fertility UnitInstitute of Reproductive SciencesOxford Business Park NorthOxford, UK

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

We thank you for participating!

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

Scientific programme25-26 October 2013

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Chairs: R. Fischer (Germany) - K. Turner (UK)

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

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

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

10.25 Coffee break

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

11.45 Questions time

12.05 Lunch

Gamete and embryo evaluationSession I

Friday, 25 October

08.30 Registration

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

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

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

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

14.50 Coffee break

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

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


16.55 End of the first day

Laboratory technologies: cryopreservation and PGSSession II

Legend

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

Saturday, 26 October

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

09.00 L7: Laboratory organization: materials andtechniquesK. Turner (UK)

09.25 L8: How to implement QMS in ARTK. Turner (UK)

09.50 Video session on Laboratory organization:materials and techniquesK. Turner (UK)


10.40 Coffee break

11.00 Discussion on laboratory

12.00 Concluding remarks

12.05 End of the live educational workshop andclosing lunch

Laboratory setup in IVF centreSession III

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Disclosure of faculty relationships

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

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

Robert Fischer Declared no potential conflict of interest.

Marcos Meseguer Declared benefit from a relationship as speaker at Merk Serono Symposia.

Karen Turner Declared no potential conflict of interest.

The following faculty have provided no information regarding significant relationship with commercial supporters and/or discussionof investigational or non-EMEA/FDA approved (off-label) uses of drugs as of 15 October 2013.

Thomas Ebner

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Biosketch

Biosketch

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

Thomas EbnerIVF UnitWomen’s General HospitalLinz, Austria

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


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

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

As an experienced embryologist, Karen joined Oxford Fertility Unit to lead the laboratory team in 2002. The Unit now performs over2000 cycles per annum. Previously, Karen has lead laboratory teams at both Sheffield Fertility Centre and Burton Centre forReproductive Medicine. Karen is a State Registered Clinical Scientist. She was Chair of the Association of Clinical Embryologists(ACE), the UK professional body for Embryologists, from 2000 to 2003 and was an External assessor on the Training Committee fora number of years. Karen was the first embryologist to sit on the British Fertility Society committee and has previously been anexternal advisor for the HFEA. She has recently become the first President of the ACE.

Karen Turner Oxford Fertility UnitInstitute of Reproductive SciencesOxford Business Park NorthOxford, UK

Abstracts

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

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

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

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

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

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

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L1. Oocyte quality and stimulation protocols

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

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

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L2. Sperm evaluation: high magnification spermmorphology

Thomas EbnerIVF Unit, Women’s General Hospital, Linz, Austria

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

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

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

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

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L3. Embryo classification: time-lapse technique


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

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L4. How to identify embryos with highest implantationpotential


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

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

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L5. Update on cryopreservation technique


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

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L6. PGS and micro-array CGH technique for embryobiopsy


The planning process of a new laboratory within an IVF unit is crucial to the subsequent successful running and organisation of notjust the laboratory but the IVF unit itself due to its central role within the clinical process of IVF. It must meet with local planning andgovernment licensing regulations and must conform to IVF specific certification/accreditation and health and safety requirements.In addition to this, the work flow and personnel flow within the laboratory must be considered so that sub-optimal conditions forgametes and embryos (eg temperature, pH changes etc) are kept to a minimum.

Staffing levels and skill mix within the laboratory need to be appropriate for the volume and the type of work performed. On a basiclevel the laboratory may perform IVF procedures from egg collection through to embryo transfer and perhaps freezing. At a moreadvanced level, laboratories may perform more complex procedures like embryo biopsy, IVM, IMSI etc. Equipment therefore needsto be fit for purpose eg microscope magnification, type etc and take account of the need to work within a contamination freeenvironment. The equipment within the laboratory will depend on the techniques and procedures performed and it should beappropriately sited within.

The materials and equipment used both in the design of the laboratory and the IVF process itself can have a major influence on thesubsequent performance of the laboratory. Since the primary objective of an embryologist is to provide a controlled, stress-freeenvironment for gametes and embryos, these factors need to be taken into consideration. These factors may be environmental egair quality and temperature; physical eg type of incubator or chemical eg culture media.

Finally patients need to be fully informed about the processes and procedures that both they and their gametes and embryos will besubjected to. Thus it is important that patients have access to Patient Information sheets that adequately describe the proceduresthey will be going through, with any associated risks explained. In addition, they should give written consent to these procedurestaking place. Both the information and consenting process should take place so that couples have a minimum of 24 hrs to considerthe procedures involved and have the opportunity to ask questions.

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L7. Laboratory organization: materials and techniques

Karen TurnerOxford Fertility Unit, Institute of Reproductive Sciences, Oxford Business Park North, Oxford, UK

The introduction of the EU Directive on human tissues and cells in 2006 had a major impact on the functioning of IVF laboratoriesin the UK as this specifies that a Quality Management System should be in place in all centres offering IVF. The world’s largestdeveloper of standards is ISO (International Organisation for Standardisation). Oxford Fertility Unit first obtained its ISO QualityManagement certification (ISO 9001:2008) in 2004 and we have been running the Quality Management System ever since with annualISO inspections.

A Quality Management System aims to ensure that an organisation can consistently deliver a product that meets the customer’srequirements and enhances their satisfaction. In the case of an IVF Unit this will not only be the care and treatment outcome thatpatients receive but the service provided to referring GPs and to its own staff. Quality Management covers everything that anorganisation does from its management structure, training and standard operating procedures (SOPs) to its reference manuals,reporting forms and the measurement and monitoring of equipment and performance by audit.

This talk will give our experience in implementing and running the ISO Quality Management System and the impact it has had onour working practice. It will also explain how we have addressed the specific ISO standards and how we have maintained them.Whilst it was initially a long, hard process for us to go through, we are feeling the benefits and our unit has undergone a dramatictransformation. Documents and forms are now controlled and easily accessible. Staff responsibilities are clearer. Communicationhas been vastly improved and we now have regular and minuted meetings at all levels. Our existing training standards have beenformalised for all areas and we have developed a mechanism for setting, monitoring and achieving specific goals. Finally it hasenabled us to constantly monitor our performance through audit and respond to sub-optimal outcomes in our key performanceareas.

Quality Management is a relatively new concept in IVF but it can be an extremely effective tool in helping to run and improve anorganisation. By its very nature, it involves and affects all staff at all levels and therefore understanding Quality Management isrelevant to everyone working within an IVF Unit.

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L8. How to implement QMS in ART


This session will consist of a series of photographs to support the earlier lecture on this subject in more depth. Laboratory layoutand flow of both personnel and gametes/embryos will be demonstrated. The location and use of equipment, both for fundamentalIVF procedures as well as more advanced ones will be discussed. Finally, the materials used, both in design and in the IVF processitself, will be shown so that participants can appreciate the importance of the quality of the materials used in order to try to achievethe best results for their patients.

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Video session on Laboratory organization: materials andtechniques


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