S106 9th Annual Meeting, Mediterranean Society for Reproductive Medicine
30
Poor responders different ovarian stimulation options
T. Motrenko
Human reproduction Department, Hospital Danilo I,
Cetinje, Montenegro
There is no clear definition of poor responders, but failure
to archive multiple follicular developments after ovarian
stimulation and at least 3 mature oocytes in IVF cycle is
most widely used criteria. The incidence among treated
patients is between 15 25%, and it is demanding task
to choose stimulation protocol in order to improve IVF
result. Two major group of patients are women in advanced
reproductive age and young poor responders mostly because
diminish ovarian reserve. Numerous tests could be used to
predict poor response on COH like Inhibin B, early follicular
phase estradiol, ovarian volume, but most accurate are:
day 3 FSH, AFC, anti-Mullerian hormone, and the most
certain predictor is previous IVF cycle with poor ovarian
respond.
Standard GnRHa long protocols with increasing starting
dose of gonadotropins, agonist flare up protocols or
GnRH antagonists protocols didn’t improve IVF cycle
result, even results are slightly better in flare up
and antagonist cycles. Natural cycle IVF presume many
attempts, and certainly cost less. Combined Clomiphene or
Letrazole and gonadotropin stimulation is another treating
option. Agonist-antagonist conversion protocol is not widely
used. Growth hormone addition may improve result, but
significantly increase cost. LH addition for rFSH stimulation
in late follicular phase show beneficial effect. Also, LH
priming before stimulation in modified long protocol could
increase pregnancy rate for young poor responders.
Many stimulation protocols are still under evaluation
without clear evidence of benefit for poor responder’s
patients and randomized, well designed studies are needed
to develop ideal protocol for treating this group of
patients.
31
The reproductive significance of the fallopian tube
mucosa
D. Ovrang
Reproductive Medicine, University of London, United
Kingdom
Effective tubal transport of ova, sperm and embryos is a
prerequisite for successful spontaneous pregnancy. Although
there is much yet to be discovered about the mechanisms
involved, it is evident that tubal transit is a far more
complicated process than initially thought. Propulsion of
gametes and embryos is achieved by complex interaction
between muscle contractions, ciliary activity and the flow of
tubal secretions. Evidence is accumulating of the important
and possibly preeminent role of ciliary motion in this
process; and this review describes current knowledge about
ciliary activity and its physiological regulation. There is also
a description of the effects on ciliary function of various
pathological states, including smoking, endometriosis and
microbial infection, and how altered ciliary activity may
impact upon fertility.
32
Proximal tubal occlusion (PTO)
M. Pansky
Endoscopic Unit, AsafHarofe Medical Center, Zerifin,
Israel
Introduction:
Proximal tubal occlusion (PTO) occurs in 10 25% of women
with tubal disease, and is mainly due to amorphous
materials (mucus plags, debris ecc.), chronic salpingitis,
salpingitis isthmica nodosa (SIN), intratubal endometriosis,
tubal polyps or spasm.
Fallopian tube assessment, an essential part of an infertility
work up, is still synonymous with the performance of
either hysterosalpingography (HSG) or a laparoscopy and
dye test although some more advanced methods like
hysteroscopy and sonohydrosalpingography (SHG) were
recently described as less invasive alternatives.
Many different treatments were described, starting from
selective radiographic catheterization and cannulation, hys-
teroscopic and tactile cannulation, macro and microsurgical
tubocornual or tubo tubal anastomosis via laparotomy or
laparoscopy and in vitro fertilization (IVF).
Methods:
Relevant reports on the pathophysiology of PTO, different
diagnostic modalities, different treatment modalities and
pregnancy rates according to the primary tubal pathology
and mode of treatment were reviewed.
Results:
The total and ongoing pregnancy rate (PR) for micro and
macro surgery were 50% and 36% respectively. For the
radiographic cannulation methods and direct hysteroscopy
methods the PR was 30% and 48% respectively.
Conclusions:
Selective salpingography and trans cervical cannulation
under fluoroscopic or hysteroscopic guidance are effective
at establishing patency in appropriately selected patients
and are less invasive and costly than the surgical
alternatives.
Surgical methods should be considered when the first line
cannulation techniques fail or in cases where reversal of
sterilization in needed or tubal fibrosis is evident.
With appropriate treatment, and in the absence of
other infertility factors, these patients may anticipate a
likelihood of ongoing pregnancy of 50%.
The decision about when to choose IVF instead is not only
a pure medical one, but also a matter of availability, cost,
age and sometimes cultural and religious belief.
33
The ethics of patient-friendly ART
G. Pennings
Bioethics Institute Ghent, Ghent University, Ghent,
Belgium
Introduction:
The single embryo transfer policy of the last decade was
the first step in the direction of the global transformation
of the practice of medically assisted reproduction. The next
step in this evolution is the rise of mild stimulation IVF.