COMMITTEES - FACULTY...2 PRESIDENTS MESSAGE...3 SCIENTIFIC PROGRAMME GENERAL INFORMATION ACKNOWLEDGEMENTS...10 ORAL PRESENTATIONS...

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3 C o n t e n t s page COMMITTEES - FACULTY...2 PRESIDENTS MESSAGE...3 SCIENTIFIC PROGRAMME GENERAL INFORMATION ACKNOWLEDGEMENTS...10 ORAL PRESENTATIONS INVITED SPEAKERS ABSTRACTS

4 C o m m i t t e e s Meeting Chairman Professor Antonis Makrigiannakis (Greece) MSRM Executive Board Chairman: A. Makrigiannakis (Greece) Chairman Elect: I. Messinis (Greece) General Secretary: O. Sefrioui (Morocco) Treasurer: A. Demirol (Turkey) Members: P. Barri (Spain) P. Inaudi (Italy) K. Mahmoud (Tunisia) H. Sallam (Egypt) V. Tanos (Cyprus) Founding Members: T. Gurgan (Turkey) A. Makrigiannakis (Greece) H. Sallam (Egypt) A. Watrelot (France) Local Organizing Committee Scientific Committee M. Asmarianaki N. Drakaki P. Drakakis S. Kalantaridou A. Karamani Th. Kiventidis I. Koutoulakis D. Koutroulakis Ι. Kritsotakis D. Loutradis G. Manidakis M. Marazaki N. Martavatzis S. Mavrogiannaki S. Megoulas I. Messinis M. Nikolaou G. Petsas A. Pontikaki M. Psarakis S. Sifakis A. Timotheou K. Tzelepis E. Vardaki T. Vrekoussis A. Zervakis K. Zioutos P. Drakakis (Greece) D. Loutradis (Greece) A. Makrigiannakis (Greece) I. Messinis (Greece) B. Tarlatzis (Greece) A. Watrelot (France) Invited Speakers / Chairmen F o r e i g n M. Aboulghar (Egypt) Ch. Blockeel (Belgium) A. Feki (Switzerland) L. Gianaroli (Italy) P. Inaudi (Italy) U. Jeschke (Germany) Kh. Mahmoud (Tunisia) T. Motrenko (Montenegro) N. Radunovic (Serbia) H. Sallam (Egypt) O. Sefrioui (Morocco) F. Shenfield (UK) V. Tanos (Cyprus) B. Urman (Turkey) A. Veiga (Spain) V. Vlaisavljevic (Slovenia) A. Watrelot (France) G r e e k G. Adonakis T. Agorastos K. Dafopoulos P. Drakakis I. Giakoumakis G. Grimbizis S. Kalantaridou T. Katasos E. Kolibiannakis A. Loufopoulos D. Loutradis E. Makrakis A. Makrigiannakis I. Messinis S. Mousourakis M. Nikolaou E. Papadakis N. Paparistidis E. Paraskevaidis M. Paschopoulos G. Petsas S. Sifakis B. Tarlatzis N. Vlachos N. Vrachnis T. Vrekoussis K. Zikopoulos 2

5 W e l c o m e L e t t e r D e a r C o l l e a g u e s a n d F r i e n d s, We are honoured to welcome you at the International Meeting of the Mediterranean Society for Reproductive Medicine (MSRM) which will be held in Crete, Greece from the 20 th to the 22 nd of September 2013 at the Daios Cove Hotel in Vathi, Agios Nikolaos, Crete. The MSRM Meeting is providing the opportunity for professionals, practitioners and specialists alike from across the globe to gather for meaningful discussions, exchange ideas and opinions and learning throughout plenary sessions, invited lectures, symposia and panel sessions. The theme of the Meeting is: "Imaging in Reproductive Medicine" and its main topics are: Ultrasound Hysteroscopy Laparoscopy Fertiloscopy Endometriosis Implantation Endometrium Ovarian stimulation We welcome you to what promises to be a rich and educational Scientific Program, taking place in the ideal setting of the island of Crete - an island with long history and culture, where the Minoan civilization flourished. Wishing and hoping to share with you this scientific and cultural experience in this historical site. Professor Antonis Makrigiannakis, MD, PhD Meeting Chairman 3

6 Final Scientific Programme Friday, 20 September, R E G I S T R A T I O N Oral Presentations I O.P.1 O.P.2 Ο.P.3 Ο.P.4 Ο.P.5 Ο.P.6 Ο.P.7 Chair: M. Nikolaou - T. Vrekoussis HELA CELLS, AN IN VITRO MODEL OF HUMAN CERVICAL CANCER AND ENDOMETRIOTIC CELLS, BOTH EXPRESSES THE STRESS-RELATED PEPTIDES; CRH, UCN AND THEIR RECEPTORS E. Taliouri, A. Vergetaki, E. Tsentelierou, T. Vrekoussis, E. Stathopoulos, T. Agorastos, A. Makrigiannakis THE EXPRESSION OF FASL IS TIME-DEPENDENTLY REGULATED BY CRH IN HELA CELLS, AN IN VITRO MODEL OF HUMAN CERVICAL CANCER E. Taliouri, E. Vergetaki, E.A. Papakonstanti, A. Makrigiannakis ANTIBIOTIC PROPHYLAXIS IN DIAGNOSTIC HYSTEROSCOPY: OUR EXPERIENCE AND REVIEW OF THE LITERATURE M. Nikolaou, S. Fiorentzis, K. Xanthakis, N. Nafpliotis, Ch. Theodorakopoulos, M. Alexandraki, G. Datseris, Th. Katasos CONTROVERSIES ABOUT THE EFFECT OF DIAGNOSTIC HYSTEROSCOPY IN INFERTILE WOMEN BEFORE IVF: OUR EXPEREINCE AND REVIEW OF THE LITERATURE M. Nikolaou, St. Fiorentzis, K.Xanthakis, N. Nafpliotis, Ch.Theodorakopoulos, M. Alexandraki, G.Datseris, Th.Katasos CRH, UCN AND THEIR RECEPTORS ARE EXPRESSED IN ENDOMETRIOSIS AND REGULATE GALECTIN-1, CSF-1 AND FASL IN ISHIKAWA CELL LINE AND MACROPHAGES A. Vergetaki, U. Jeschke, E. Taliouri, L.Sabatini, E. A. Papakonstanti, A.Makrigiannakis ENDOVAGINAL ULTRASOUND TO EXCLUDE ENDOMETRIAL PATHOLOGY G. Stratoudakis, A. Zisiou, H. Polyzou, V. Christoforaki, D. Konstantinidis, G. Daskalakis SONOGRAPHIC FINDINGS OF OVARIAN CANCER ARISING IN ENDOMETRIOID CYSTS G. Stratoudakis, A. Zisiou, H. Polyzou, V. Christoforaki, D. Konstantinidis, G. Daskalakis Oral Presentations IΙ O.P.8 Ο.P.9 Ο.P.10 Ο.P.11 Ο.P.12 Ο.P.13 4 Chair: G. Petsas - T. Vrekoussis ULTRASONOGRAPHIC FINDINGS OF ABDOMINAL WALL ENDOMETRIOSIS G. Stratoudakis, A. Zisiou, H. Polyzou, V. Christoforaki, D. Konstantinidis, G. Daskalakis T REGULATORY CELLS IN FOLLICULAR FLUID IN WOMEN WITH FERTILITY PROBLEMS I. Lykakis, P. Verginis, A.Makrigiannakis A PATERNAL INFLUENCE ON THE EMBRYONIC CAPACITY FOR IMPLANTATION OBSERVED IN A SURROGATE MOTHERHOOD PROGRAM I. Giakoumakis, D. Daphnis, M. Solanou, E. Vlachopoulou, K. Zotos, G. Daligkaros, N. Sofikitis IS THE ULTRASOUND ONLY APPROACH AN ADEQUATE TOOL FOR CONTROLLED OVARIAN STIMULATION MONITORING? J. Knez, B. Kovačič, V. Vlaisavljević VALUE OF TRANSVAGINAL HYDROLAPAROSCOPY IN INFERTILITY EVALUATION M. Reljič, V. Vlaisavljević CAN SPERM MOTION PARAMETERS, ASSESSED BY CASA HELP IN CHOOSING BETWEEN IVF OR ICSI METHOD FOR OOCYTE INSEMINATION? B. Kovačič, B. Breznik-Pregl, V. Vlaisavljević

7 Final Scientific Programme Friday, 20 September, Session I Chair: A.Makrigiannakis - B. Tarlatzis Gametes from Stem Cells. A. Veiga Cytokines and Reproduction. U. Jeschke Can genomics be used to predict the most suitable stimulation protocol? Role for pharmacogenetics in IVF Reproductive rights and ART: Is there a right to reproduce in Europe? D. Loutradis F. Shenfield Saturday, 21 September, Session II Chair: I. Messinis - F. Shenfield Role of ultrasound monitoring in ovarian stimulation. I. Messinis Antral Follicle count and Follicle development in natural cycle. Echographic evidence Blood flow in uterus and ovaries. What is the clinical significance of perifollicular vascularization. K. Mahmoud V. Vlaisavljevic Ultrasonographic aspects of PCO and PCOS/MCO. T. Motrenko DISCUSSION C O F F E E B R E A K SATELLITE SYMPOSIUM SPONSORED BY FERRING «Time to personalize: the prospects of individualizing ART» Chair: E. Makrakis - K. Zikopoulos The heterogeneity of gonadotrophins and its implications on Art. K. Dafopoulos The evolving importance of AMH: Building future inroads for a tailor made approach of ART. B. Urman 5

8 Final Scientific Programme Saturday, 21 September, SATELLITE SYMPOSIUM SPONSORED BY MERCK SERONO «Drugs and beyond» Chair: I. Messinis - K. Zikopoulos Recombinant hfsh plus recombinant hlh VS recombinanant Hfsh alone in ART Repeated Implantation Failure. Novel therapies before embryo transfer. B. Tarlatzis A. Makrigiannakis L U N C H Session III Chair: G. Adonakis - P. Inaudi Functional / Endometriotic cysts in ART patients. Clinical Significance. N. Radunovic Endometriosis and fertility: when to operate and when refrain. A. Feki Congenital uterine anomalies. The role of 3D. Should it be a gold standard? G. Grimbizis Contrast salpingosonography to evaluate tubal patency. S. Mousourakis Antral follicular count. O. Sefrioui DISCUSSION C O F F E E B R E A K Session IV LECTURE I Chair: A. Loufopoulos - E. Paraskevaidis HPV. Prevention and early diagnosis. T. Agorastos LECTURE II Chair: D. Loutradis Imaging of human embryos. The best embryo for transfer. A. Veiga BOARD MEETING W E L C O M E R E C E P T I O N 6

9 Final Scientific Programme Sunday, 22 September, LECTURE III Chair: P. Drakakis VTE prevention in pregnancy and peripartum. Where do we stand. E. Papadakis Session V Chair: T. Katasos - A. Makrigiannakis - N. Vrachnis The role of Fertiloscopy in ART. A. Watrelot The role of ultrasound in guiding embryo transfer. H. Sallam What future prospects for ovarian stimulation: to produce only eggs or also improve embryo implantation. M. Aboulghar Is there a role for U/S in the diagnosis of POF? S. Kalantaridou From gametes to patients: the chaos of imaging. L. Gianaroli DISCUSSION LECTURE IV Chair: Β. Tarlatzis Corifollitropin Alfa into Clinical Practice today. Ch. Blockeel SPONSORED LECTURE BY MSD C O F F E E B R E A K Session VI Chair: I. Giakoumakis - S. Sifakis - V. Tanos Ultrasonography in reproductive medicine. P. Drakakis Spectral Hypervision in Hysteroscopy. M. Paschopoulos Assherman syndrome: new options of management. Ν. Vlachos Surgery of hydrosalpinges and Implantation Rate. (Salpiggectomy, salpingostomy, ligation, essure, etc). V. Tanos The role of progesterone in the late follicular phase. S. Kolibiannakis DISCUSSION 14:00-14:30 C L O S I N G R E M A R K S / A. Makrigiannakis 7

10 General Information Crete, the island of king Minos in the southern part of the Aegean Sea, is full of natural beauties to explore and enjoy. Picturesque ports and sandy beaches with transparent waters will help you relax and at the same time discover the continuing fascination and attraction of the island. The temperature of the sea in September is ideal for swimming and Cretan beaches have been awarded the European blue flag for clean waters and care for the environment. Venue: The Meeting will be held in Agios Nikolaos, Crete at Daios Cove Hotel. Address: Vathi 72100, Crete, Greece, Tel.: , Fax: , Web site: Dates: The Meeting will be held on September Scientific Program: The Scientific program consists basically of State of the Art Presentations, Round Tables, Lectures, Case Studies, Oral and Poster Presentations Scientific presentations: The Meeting Hall will be equipped with slide projectors for single or double projections 50 x 50 mm slides (24 x 36 mm transparencies), overhead projector, Screen, Data display projector for Power Point presentation, laser pointers etc. Slide and PC Reception: A slide and PC reception desk for acceptance and checking of slides and PC disks will be located nearby the Meeting Hall. All slides and PC disks should be clearly labeled with the author s name and session s name. Speakers are kindly requested to hand out their slides or their PC disks at least 2 hours prior to their respective presentation. Continuing Medical Education: The MSRM International Meeting Ιmaging in Reproductive Medicine has been accredited by the European Accreditation Council for Continuing Medical Education (EACCME-UEMS) with 10 CME-CPD credits. Certificate of Attendance: A certificate of attendance will be given to each registered participant, at the end of the Meeting. Secretariat and Hospitality Desk: The Meeting Secretariat desk will be located nearby the Meeting Hall and will operate throughout the Meeting hours. Language: ENGLISH is the official language of the Meeting. Trade Exhibition: An exhibition of scientific products, pharmaceuticals, instruments, equipment and relevant materials will be organized at the Meeting Venue. Key Dates: Deadline for abstract submission: July 15 st, 2013 Deadline for reduced registration fees: August 31 st, 2013 Full payment for Reservations: September 7 th,

11 General Information Registration Fees Those wishing to attend the Meeting should complete the enclosed registration form. Description Until August 31 st, 2013 After September 1 st, 2013 General Participation The registration fees for all Participants cover: Access to the Scientific Sessions and Exhibition Meeting material Welcome Reception Coffee breaks & light lunch Accommodation Package For All Participants 280 Rate includes: 2 nights accommodation bed & breakfast at the Daios Cove Hotel, in single room Accompanying Person 100 Rate includes: 2 nights accommodation bed & breakfast at the Gran Melia Hotel, in double room with participant and the Welcome Dinner Cancellation and Payment conditions are included in the Registration /Reservation Form on the Meeting s web site. Web site For more detailed instructions regarding the abstract format and the most update information about the Meeting, please visit the official website or contact the Meeting Secretariat by (info@era.gr) or by telephone ( ). Secretariat and Travel Agency For all inquiries regarding: Meeting Activities and functions, Registration, Letter of invitation, Accommodation and Travel Reservations, Technical Services, Exhibition, Sponsoring, please contact: ERA Ltd., 17, Asklipiou Str., Athens, Greece, Tel.: Fax: , info@era.gr, Web site: 9

12 Acknowledgements The Organizing Committee of the MSRM International Meeting Imaging in Reproductive Medicine Expresses its gratitude to the below Companies that generously contributed to its materialization G o l d e n S p o n s o r S p o n s o r s 10

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14 Oral Presentations O.P.1 HELA CELLS, AN IN VITRO MODEL OF HUMAN CERVICAL CANCER AND ENDOMETRIOTIC CELLS, BOTH EXPRESSES THE STRESS-RELATED PEPTIDES ;CRH, UCN AND THEIR RECEPTORS E. Taliouri 1, A. Vergetaki 1, E. Tsentelierou 2, T. Vrekoussis 1, E. Stathopoulos 2, T. Agorastos 3, A. Makrigiannakis 1 1 Laboratory of Human Reproduction, Department of Obstetrics & Gynecology, School of Medicine, University of Crete, Greece 2 Laboratory of Pathology, School of Medicine, University of Crete, Heraklion, Greece 3 4th Dpt of Obstetrics & Gynecology Clinics, School of Medicine, Aristotle University of Thessaloniki, Greece BACKGROUND: Neuroendocrine system is a good mediator candidate for many of the diseases linked to chronic stress. Cancer development and progression can also be considered a stress condition and life stressors have been implicated in the reactivation of latent viruses (Herpesviruses, HIV, HPV), faster progression of the disease caused by virus and the increased risk for CIN progression. Corticotropin-releasing hormone (CRH) is one of the most important Neuropeptides, which acts as a stressormediator in the human reproductive system. Its receptors CRH-R1, CRH-R2 which are the result of cell-stress situations (cancer development and progression) can also bind with UCN, another important member of CRF protein family. AIM: To compare the similarities of CRH, CRH-R1, CRH-R2, UCN expression in the in vitro model used of cervical cancer and endometriosis. MATERIALS & METHODS: Immunohistochemistry was carried out in order to evaluate the expression of CRH, CRH-R1&R2, UCN in human cervical carcinoma and endometriotic tissues. As a cell model, HeLa cervical cancer cell line was used, which are human papilloma virus (HPV) positive. Indirect Immunofluorescence was performed. RNA extraction and RT-PCR was conducted. Western Blot analysis was also performed. RESULTS: In our experiments, CRH has been detected in-vitro in HPV infected cells (HeLa). CRH induces FasL expression in cervical carcinoma cell lines. New data of our experiments indicate that UCN and the CRH-Rs are also expressed in the same in vitro model. In correlation with new already published data of our lab, CRH, UCN and its receptors are expressed also in endometrium and endometriotic sites. CONCLUSION: Those findings may indicate that inflammation pathway during cervical cancer development and endometriosis stimulates the expression of the same stress-related peptides; CRH, UCN and their receptors. O.P.2 THE EXPRESSION OF FASL IS TIME-DEPENDENTLY REGULATED BY CRH IN HELA CELLS, AN IN VITRO MODEL OF HUMAN CERVICAL CANCER E. Taliouri 1, E. Vergetaki 1, E.A. Papakonstanti 2, A. Makrigiannakis 1 1 Laboratory of Human Reproduction, Department of Obstetrics & Gynecology, Medical School, University of Crete, Heraklion, Greece 2 Department of Biochemistry, Medical School, University of Crete, Heraklion, Greece BACKGROUND: FasL is a type-2 transmembrane protein. Binding of FasL to its receptor Fas initiates an apoptotic cascade in Fas-expressing cells. The expression of FasL is reported in different tumors and has also been associated with the clinical course 12

15 Oral Presentations of the diseases. Recently, the expression of FasL has been studied in cervical carcinoma. The fact that the FasL expression was reported to induce T-cell apoptosis, facilitating thus tumor immunoescape, highlighted the contribution of FasL to cervical carcinogenesis and progression. More specifically, the expression of FasL was shown to be gradually increased during cervical carcinogenesis from cervical intraepithelial neoplasia to cervical carcinoma. Additionally, FasL-expressing cervical carcinoma cases have been shown to correlate with an unfavorable disease outcome (shorter disease-free survival). AIM: To determine whether FasL expression is regulated by CRH and how this regulation is managed over time in vitro. MATERIALS&METHODS: RNA extraction and RT-PCR were conducted. Western Blot analysis was also performed. As a cell model the HeLa cervical cancer cell line was used which are human papilloma virus (HPV) positive. RESULTS: We show, for the first time, that CRH regulates the expression of FasL in a cervical cancer in vitro model. We provide the first evidence that cervical carcinoma immunoescape may be linked to stress. The data of our study obtained by Western Blot analysis and RT-PCR, indicate that the expression of FasL is time-dependently regulated by CRH. Indeed, incubation of HeLa cells with 10µΜ CRH for 8h lead to increased expression of FasL. We confirmed that the effect of CRH was specific by the use of antalarmin in the presence of which FasL expression was decreased after 8h incubation of HeLa cells with 10µΜ CRH. CONCLUSION: Our data suggest that the expression of both CRH and FasL might correlate to human papilloma virus (HPV) infection. Given that cervical cancer is attributed to HPV infection which is also a stress condition and that FasL is expressed by dysplastic precancerous cervical epithelia, it is possible that the expression of both CRH and FasL could be the end result in a time-depended manner of interactions between the cervical epithelial cells and the HPV-related proteins. O.P.3 ANTIBIOTIC PROPHYLAXIS IN DIAGNOSTIC HYSTEROSCOPY: OUR EXPERIENCE AND REVIEW OF THE LITERATURE Marinos Nikolaou 1, Stelios Fiorentzis 1, Kostas Xanthakis 1, Nikos Nafpliotis 1, Christos Theodorakopoulos 1, Maria Alexandraki 2, Georgios Datseris 2, Theodoros Katasos 1 1 Department of Obstetrics & Gynecology, Unit of Hysteroscopy, General Hospital of Agios Nikolaos, Crete, Greece. 2 Department of Pathology, General Hospital of Agios Nikolaos, Crete, Greece. Background: Post-operative pelvic infection constitutes a common complication after gynecological procedures. There exists lack of strong evidence in the current literature about the efficacy of routine antibiotic prophylaxis in hysteroscopy. Aim: The aim of this observational study was to assess the incidence of infectious complications and the protective effect of antibiotic administration during hysteroscopy. Methods: From fifty-four women who underwent diagnostic hysteroscopy, 24 (44%) women had abnormal uterine bleeding (AUB), 4 (7.4%) had post-menopausal bleeding (PMB), 4 (7.4%) ultrasound findings of increased thickness of the endometriun, 8 (14.8%) endometrial polyps, and 14 (25.9%) women as a routine examination prior to 13

16 Oral Presentations in vitro fertilization (IVF) or intra-cytoplasmic injection (ICSI) treatment. Results: The mean age of the women was 40.2 years. Of the 54 women who underwent diagnostic hysteroscopy during this two-year study period, 29 received pre- and post operative antibiotic prophylaxis, whereas 25 women underwent the procedure without prophylaxis. In the second group of women, 2 (8%) post-operative pelvic infections occurred. Antibiotics were prescribed in women and the infective process resolved in few days. None of these women developed serious infections with development of tubal-ovarian abscess as confirmed by clinical and ultrasounds evaluation. Conclusions: We found high prevalence of post-operative infections after diagnostic hysteroscopy in cases without routine antibiotic prophylaxis. The results of the current study are not in accordance with recommendations of other researchers suggesting not to prescribe routine antibiotic administration in the case of hysteroscopy due to very low risk of infectious complications 1-3. References: 1. Kasius JC, Broekmans FJ, Fauser BC, Devroey P, Fatemi HM. Antibiotic prophylaxis for hysteroscopy evaluation of the uterine cavity. Fertil Steril Feb;95(2): Gregoriou O, Bakas P, Grigoriadis C, Creatsa M, Sofoudis C, Creatsas G. Antibiotic prophylaxis in diagnostic hysteroscopy: is it necessary or not? Eur J Obstet Gynecol Reprod Biol Aug;163(2): Nappi L, Di Spiezio Sardo A, Spinelli M, Guida M, Mencaglia L, Greco P, Nappi C, Filippeschi M, Florio P. A multicenter, double-blind, randomized, placebo-controlled study to assess whether antibiotic administration should be recommended during office operative hysteroscopy. Reprod Sci Jul;20(7): O.P.4 CONTROVERSIES ABOUT THE EFFECT OF DIAGNOSTIC HYSTEROSCOPY IN INFERTILE WOMEN BEFORE IVF: OUR EXPEREINCE AND REVIEW OF THE LITERATURE Marinos Nikolaou 1, Stelios Fiorentzis 1, Kostas Xanthakis 1, Nikos Nafpliotis 1, Christos Theodorakopoulos 1, Maria Alexandraki 2, Georgios Datseris 2, Theodoros Katasos 1 1 Department of Obstetrics & Gynecology, Unit of Hysteroscopy, General Hospital of Agios Nikolaos, Crete, Greece. 2 Department of Pathology, General Hospital of Agios Nikolaos, Crete, Greece. Background: Evaluation of uterine cavity is a basic investigation of infertile women. Hysteroscopy is the most accurate method for diagnosing intrauterine abnormalities and it is frequently performed as a routine procedure prior to IVF. Aim: The aim of this study is to present the prevalence of intrauterine pathologies in women that underwent diagnostic hysteroscopy before entering or after failed IVF procedures. Material: A total of 14 hysteroscopy procedures were performed women from March 2012 until June 2013 in asymptomatic, infertile women prior or after IVF, In addition, a systematic literature review search using MeSH terms for hysteroscopy and IVF was performed in MEDLINE. These included RCT or controlled studies on diagnostic or operative hysteroscopy and pregnancy rates in subfertile women treated by IVF. Results: A total of 12 women had a normal uterine cavity, while 2 (14.2%) women with previous ART failures had abnormal hysteroscopy findings in the form of small en- 14

17 Oral Presentations dometrial polyp. The procedure was quick, safe and well tolerated with no reported complications. The prevalence of unsuspected uterine abnormalities diagnosed by hysteroscopy prior to IVF has been reported to be 11-45% with a normal TVS or hysterosalpingography 1. It is growing evidence in the literature that after hysteroscopy treatment of intracavitary abnormalities, an increase of 9-32% in ongoing clinical pregnancy rate in women with recurrent IVF failure was observed 2. However, currently there is no consensus on the effectiveness of hysteroscopy in improving prognosis of subfertile women, because of a lack of strong evidence 3. Conclusions: This small case series study showed that, in asymptomatic infertile women, hysteroscopy may have important implications in diagnosis of intrauterine abnormalities prior IVF. Referrences: 1. Fatemi HM, Kasius JC, Timmermans A, van Disseldorp J, Fauser BC, Devroey P, Broekmans FJ. Prevalence of unsuspected uterine cavity abnormalities diagnosed by office hysteroscopy prior to in vitro fertilization. Hum Reprod Aug;25(8): Smit JG, Kasius JC, Eijkemans MJ, Koks CA, Van Golde R, Oosterhuis JG, Nap AW, Scheffer GJ, Manger PA, Hoek A, Kaplan M, Schoot DB, van Heusden AM, Kuchenbecker WK, Perquin DA, Fleischer K, Kaaijk EM, Sluijmer A, Friederich J, Laven JS, van Hooff M, Louwe LA, Kwee J, Boomgaard JJ, de Koning CH, Janssen IC, Mol F, Mol BW, Torrance HL, Broekmans FJ. The insight study: costs and effects of routine hysteroscopy prior to a first IVF treatment cycle. A randomised controlled trial. BMC Womens Health Aug 8;12: Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol BW, Mathieu C, D'Hooghe T. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update Jan-Feb;16(1):1-11. O.P.5 CRH, UCN AND THEIR RECEPTORS ARE EXPRESSED IN ENDOMETRIOSIS AND REGULATE GALECTIN-1, CSF-1 AND FASL IN ISHIKAWA CELL LINE AND MACROPHAGES Aikaterini Vergetaki 1, Udo Jeschke 2, Eirini Taliouri 1, Luca Sabatini 3, Evangelia A. Papakonstanti 4, Antonis Makrigiannakis 1 * 1 Department of Obstetrics and Gynecology, Medical School, University of Crete, Greece 2 Department of Obstetrics and Gynecology, Innenstadt campus, Ludwig Maximilians University of Munich, Germany. 3 Centre for Reproductive Medicine, St Bartholomew's Hospital, London, United Kingdom 4 Department of Biochemistry, Medical School, University of Crete, Greece BACKGROUND: Endometriosis is an aseptic inflammatory disease, characterised by ectopic endometrium. Its symptoms (mostly pain and infertility) are reported as constant stressors. Corticotropin releasing hormone (CRH) and urocortin (UCN) are neuropeptides related to stress and inflammation. The effects of CRH and UCN are mediated through CRHR1 and CRHR2 receptors which act as inflammatory components in reproductive functions. Galectins which play important role in cell adhesion and have a pro- or anti- inflammatory role and a modulating role on T cells, affect immunological mechanisms such as this of endometriosis. Galectin-1 has been found to be expressed in human endometrium and decidua apart from other tissues. As endometriosis is an inflammatory disease, there are several cytokines and growth fac- 15

18 Oral Presentations tors that are implicated in this disease and endometriotic women are characterised by increased number of peritoneal macrophages and increased CSF-1 and FasL expression. AIM AND METHODS: The aim of this study was to examine the expression of CRHR1 and CRHR2 in endometriotic sites and to compare their expression in eutopic endometrium of endometriotic women to that of healthy women. The relative expression of CRH, UCN, CRHR1 and CRHR2 in ectopic and eutopic endometrium of endometriotic women was examined. Galectin-1 and CSF-1 expression in eutopic and ectopic endometrium of endometriotic women and in eutopic endometrium of healthy women was tested. It was evaluated how CRH, UCN and CSF-1 regulate galectin-1, CSF-1 and FasL expression in Ishikawa cell line and macrophages. The mrna expression of these molecules was tested via RT-PCR, and concerning their protein expression immunohistochemistry, immunofluorescence and western blotting were used. RESULTS AND CONCLUSIONS: This current study shows for the first time that CRHR1 and CRHR2 are expressed in endometriotic lesions and that CRH, UCN, CRHR1 and CRHR2 are significantly more abundant in endometriotic lesions than in eutopic endometrium. These receptors are more highly expressed in eutopic endometrium of endometriotic women compared to healthy individuals. These findings point to a new immunomodulatory pathway, in which CRH, UCN, CRHR1 and CRHR2 are involved, in eutopic and ectopic endometrium affecting the pathogenesis and infertility profile of endometriosis. This study shows that galectin-1 is expressed in endometriotic tissue. Galectin-1 showed an abundant expression in ectopic rather than in eutopic endometrium suggesting its vital role in endometriosis. CRH, UCN and CSF-1 have been found to upregulate galectin-1, CSF-1 and FasL expression in Ishikawa cell line and macrophages. As all the peptides are implicated in endometriosis and in reproductive functions, these results could possibly set new light to the immune disequilibrium of endometriosis and the infertility profile of endometriotic women. Showing that the upregulative effect of CRH is mediated by CRHR1, the potential use of Antalarmin could be reinforced in accessing the immune disequilibrium of eutopic and ectopic endometrium of endometriotic women. O.P.6 ENDOVAGINAL ULTRASOUND TO EXCLUDE ENDOMETRIAL PATHOLOGY Stratoudakis G, Zisiou A, Polyzou H, Christoforaki V, Konstantinidis D, Daskalakis G. Department of Obstetrics & Gynecology of General Hospital of Chania, Kriti, Greece Background: In women without abnormal uterine bleeding (AUB), when a thick endometrium is discovered there is a clinical dilemma as to which strategy should be chosen and what is the real value of these endometrial thickness measurement in the same women. Aim: To assess the diagnostic value of transvaginal sonographic (TVS) measurement of endometrial thickness for diagnosing focal intrauterine pathology in women without AUB. Methods: A random selection of 560 women aged years were invited to participate and 229 women were eligible and accepted inclusion (143 pre- and 86 postmenopausal). The women underwent TVS measurement of endometrial thickness. Diagnostic dilation and curettage with histopathology was performed when focal 16

19 Oral Presentations intrauterine pathology was suspected. We excluded women with AUB, a scan that was not in the follicular phase and users of sequential hormone therapy or selective estrogen receptor modulators. Results: The 143 premenopausal women included in the study were aged years and the 86 postmenopausal women were years. Focal intrauterine pathology was confirmed in 7.69% (11/143) of premenopausal and 16.28% (14/86) of postmenopaual women and included 19 cases of polyps, five of submucosal myomas and one of polypoidal growing endometrial cancer. Conclusions: In women without AUB, TVS measurement of endometrial thickness is a poor diagnostic test, but is apparently efficacious in excluding focal intrauterine pathology, especially in postmenopausal women. The 4-5mm threshold conventionally used to exclude endometrial malignancy in women with postmenopausal bleeding is not transferable to women without AUB for excluding focal intrauterine pathology. O.P.7 SONOGRAPHIC FINDINGS OF OVARIAN CANCER ARISING IN ENDOMETRIOID CYSTS Stratoudakis G, Zisiou A, Polyzou H, Christoforaki V, Konstantinidis D, Daskalakis G. Department of Obstetrics & Gynecology of General Hospital of Chania, Kriti, Greece Background: Endometriosis, defined as the presence of ectopic endometrial tissue, is a common gynecological disease with an estimated prevalence of 5-15% in women of reproductive age. There is molecular, biological and epidemiological evidence to suggest an association between endometriosis and ovarian cancer ( %). Aim: To describe sonographic characteristics of malignant transformation in endometrioid cysts. Methods: Women with a histological diagnosis of ovarian endometrioid cysts, borderline tumors arising in endometrioid cysts and carcinoma arising in endometrioid cysts, preoperatively examined sonographically, were included in this retrospective study. Gray-scale and Doppler ultrasound characteristics of the endometrioid cysts were compared with those of the borderline tumors and primary cancers arising in endometrioid cysts. The performance of an experienced examiner in classifying the masses was also assessed. Results: Of 32 cases collected for the study, 30 lesions were classified before surgery as endometrioid cysts, one as borderline tumors arising in endometrioid cysts and one as carcinoma arising in endometrioid cysts. Women with malignant findings were older than those with benign endometrioid cysts. All malignant tumors were characterized by the presence of solid tissue. The prevalence of solid tissue with positive Doppler signals was higher (100%) in malignant tumors than in benign cysts (7.3%). Papillary projections were a more frequent sonographic finding among malignant lesions (81.5%) than among benign endometrioid cysts (14.3%). Conclusion: Borderline tumors and carcinomas arising in endometrioid cysts show a vascularized solid component at ultrasound examination and might not represent a specifically difficult category of ovarian masses for assessment by ultrasound. 17

20 Oral Presentations O.P.8 ULTRASONOGRAPHIC FINDINGS OF ABDOMINAL WALL ENDOMETRIOSIS Stratoudakis G, Zisiou A, Polyzou H, Christoforaki V, Konstantinidis D, Daskalakis G. Department of Obstetrics & Gynecology of General Hospital of Chania, Kriti, Greece Background: Abdominal wall endometriosis (AWE) is used to indicate the presence of ectopic endometrium located far from the peritoneum, embedded in the subcutaneous fatty tissue and the abdominal wall muscle layers. Aim: To describe the sonographic and clinical features of abdominal wall endometriosis. Methods: This was a retrospective study of 11 consecutive women with pathologically proven endometriosis of the abdominal wall. Ultrasonographic and Doppler examinations were performed, before surgery, with a high-frequency transducer. Results: At ultrasound, all the nodules appeared as discrete solid masses that were less echogenic than the surrounding hyperechoic fat. The nodules had a median diameter of 20 mm and in 8 cases the nodules had a round/oval shape. In six women the AWE was located at the umbilicus, in two it was between the transverse suprapubic line and the umbilicus, in two it was found along the scar of a previous cesarean section and in one it was in the right inguinal canal. The content was homogeneously hypoechoic in eight women and inhomogeneous in the other three. The outer borders were invariably ill defined. Scarce blood vessels were found by power Doppler. Cyclic or continuous spontaneous pain at the level of the AWE was present in 9/11 cases and two patients were asymptomatic. Conclusions: Hypoechoic round/oval nodules with ill defined borders and a hyperechoic rim should raise the suspicion of abdominal wall endometriosis, even in patients with no history of endometriosis or previous laparotomic surgery. O.P.9 T REGULATORY CELLS IN FOLLICULAR FLUID IN WOMEN WITH FERTILITY PROBLEMS Lykakis Ioannis 1, Panos Verginis 2, A.Makrigiannakis 1 1 Laboaratory of Human Reproduction, Dpt of Obstrectics and Gynecology, School of Medicine, University of Crete, Greece 2 Laboratory of Autoimmunity and Inflammation, School of Medicine, University of Crete, Greece BACKGROUND: Infertility is a common disorder that involves both genders and it is found in 25% of couples. Female factor infertility which is the most common is associated with gynecological disorders such as polycystic ovary syndrome (PCOS) and endometriosis. CD4 + CD25 + regulatory T cells (Treg) is a subpopulation of T cells responsible for the modulation of immune system. A systematic expansion of Treg is observed during pregnancy and prevents fetal rejection. Abnormal levels of T regulatory cells are associated with gynecological disorders such as endometriosis, also reduced levels of Treg cells are found in peripheral blood in women with fertility problems. AIM: To examine and compare the levels of T regulatory cells in follicular fluid in women with PCOS, unexplained infertility and male factor infertility. MATERIALS AND METHODS: Flow cytometry was performed in order to identified the levels of Tregulatory cells. RESULTS: In our experiments, T regulatory cells are found in follicular fluid in women 18

21 Oral Presentations with fertility problems, Also the number Tregs was not statistical significant between three groups. Finally we found that the number of activated Tregs was significant decreased in women with PCOS comparing with male factor infertility (control). CONCLUSION: Those findings may indicate that reduced activation of Treg in PCOS women may be associated with infertility. O.P.10 A PATERNAL INFLUENCE ON THE EMBRYONIC CAPACITY FOR IMPLANTATION OBSERVED IN A SURROGATE MOTHERHOOD PROGRAM I. Giakoumakis, D. Daphnis, M Solanou, E Vlachopoulou, K. Zotos., G. Daligkaros, N. Sofikitis Objective: We evaluated the influence of semen quality on the outcome of a surrogate motherhood program (SMP). Materials and Methods: Twenty two couples (group A) with normal semen parameters (i.e., sperm concentration, % motile spermatozoa, and % morphologically normal spermatozoa) of semen analysis participated in our SMP. Another group of 28 couples (group B) with an abnormal value in at least one semen parameter was also included in this SMP-study. All female partners underwent ovarian stimulation and semen samples were collected from the male partners. These women asked to participate in our SMP because of a history of hysterectomy or the presence of malignant hypertension, sickle cell anemia, chronic renal failure, or liver insufficiency (among others). ICSI techniques were performed in all mature oocytes of each couple of groups A and B. One surrogate woman underwent transfer of one embryo generated from each couple of groups A and B. Thus 22 surrogate women received embryos from the group A and 28 surrogate women received embryos from the group B. In addition, 31 couples (group C) with normal semen parameters participated in our SMP asking additionally for donor oocytes. Another group of 26 couples (group D) with an abnormal value in at least one parameter of semen analysis was also included in this SMP-study asking additionally for donor oocytes. The % fertilized oocytes (at 18 hours post-icsi), the % cleaved oocytes (at 36 hours post-icsi), and the % 8-12-cell stage embryos (at 72 hours post-icsi) were significantly lower (P<0.05; Chi square test) in group B than in group A and in group D than in group C. The proportion of [the pregnant surrogate women] to [the total number of the surrogate women who underwent embryo transfer] was significantly lower in group B (8/28) than in group A (8/22) (P<0.05; Chi square test) and in group D (10/26) than in group C (14/31). Couples requesting to participate in an SMP with at least one abnormal parameter of semen analysis have worse prognosis to achieve pregnancy suggesting that paternal factors affect detrimentally the outcome of SMP. Paternal factors affecting the last events of the fertilization process (such as oocyte activating factor, reproducing element of the centrosome, among others) and early embryonic development or embryonic capacity for implantation (i.e. paternal DNA fragmentation, sperm nuclear proteins, paternal chromosomal aberrations, among others) may be the connective links between decreased semen quality and less optimal outcome in an SMP. 19

22 Oral Presentations O.P.11 IS THE ULTRASOUND ONLY APPROACH AN ADEQUATE TOOL FOR CONTROLLED OVARIAN STIMULATION MONITORING? Jure Knez, Borut Kovačič, Veljko Vlaisavljević Department of Reproductive Medicine and Gynaecologic Endocrinology, University Medical Centre Maribor The monitoring of controlled ovarian stimulation (COS) in patients undergoing assisted reproductive procedures has traditionally included echographic as well as endocrinologic monitoring. This approach was considered to maximize the success rates of the treatment and simultaneously ensure a low incidence of ovarian hyperstimulation syndrome (OHSS). However, intensive monitoring can be arduous, because it is time consuming, expensive and inconvenient for the patient. Thus, an ultrasound only approach is a feasible option when planning infertility treatment. A systematic review has shown that adding the measurement of oestradiol levels to ultrasound monitoring does not improve pregnancy rates. Meanwhile, the ultrasound is reliable, safe, patient friendly, reduces treatment expenses and is therefore appropriate as a single tool for controlled ovarian stimulation monitoring. However, identifying the adequate development of growing follicles and optimizing the timing of final oocyte maturation triggering is challenging. The follicular diameter corresponds to maturity and subsequent fertilising and cleavage capability of the oocytes. Nevertheless, human chorionic gonadotrophin administration practices vary widely and are still based on clinical impression due to limited available scientific evidence. Although the number of adequately sized follicles has been suggested to be more important than the size of the leading follicles, the triggering criteria are usually based on the latter. With the recent advances of ultrasound technology, also the three-dimensional, automated follicle monitoring is a promising option for novel, objective, volumebased criteria for triggering final oocyte maturation. O.P.12 VALUE OF TRANSVAGINAL HYDROLAPAROSCOPY IN INFERTILITY EVALUATION Reljič M., Vlaisavljević V. Department of Reproductive Medicine and Gynaecologic Endocrinology, University Medical Centre, Maribor, Slovenia Aim: The aim of our retrospective study was to evaluate the usefulness and accuracy of transvaginal hydrolaparoscopy (THL) in infertility evaluation. Methods: Consecutive 535 patients without obvious pelvic pathology undergoing THL between 2001 and 2012 were included in the study. The main outcome measures were the rate of the successful access to the pouch of Douglas and the rate of complications. In the first 165 procedures also findings in term of tubal pathology, pelvic adhesions and endometriosis were monitored. Laparoscopy was followed immediately after THL in first 52 patients and concordance of both techniques was evaluated. Results: The rate of successful access to the pouch of Douglas was 98.9%. Apart from four cases of transitional febrile condition and two bleeding from vagina, we had no complications. The rate of complete evaluation of all the pelvic structures was

23 Oral Presentations (143/165). In 112 patients (67.9 %) the THL procedure has shown a morphological normal pelvic examination. There were some abnormalities seen in the remaining 53 patient as follows: 45 patients had adhesions, 22 endometriosis and 7 double sided tubal occlusion. Among 112 patients with normal THL findings 47 (42.0%) conceived spontaneous or after intrauterine insemination. The morphologically findings using THL and laparoscopy were strictly concordant in 42 patients (79.2%). The concordance in tubal patency was 88.6%. Discordances were always limited to one tube. In all cases the discordant findings were considered not to have any clinical impact. Conclusion. THL is safe and accurate procedure that may be considered as an alternative to diagnostic laparoscopy in the routine assessment of infertile patients. O.P.13 CAN SPERM MOTION PARAMETERS, ASSESSED BY CASA HELP IN CHOOSING BETWEEN IVF OR ICSI METHOD FOR OOCYTE INSEMINATION? Kovačič B, Breznik-Pregl B, Vlaisavljević V Department of Reproductive Medicine and Gynecologic Endocrinology, University Medical Centre Maribor, Slovenia Background: The decision for choosing the right method for oocyte insemination is mostly taken on the basis of only three classic sperm parameters. Computer assisted sperm analysis (CASA) offers additional information about sperm functionality. Aim: The aim was to evaluate if CASA motility parameters: VCL (curvilinear velocity), VSL (straight line velocity), VAP (avarage path velocity), LIN (linearity), STR (straightness), WOB (wobble) and BCF (beat cross frequency) in native, washed or after inducing hyperactivation, correlate with fertilization in conventional IVF. Methods: We studied 133 couples with diagnosed normo-, mild oligo- or asthenozoospermia who underwent IVF treatment. Only cycles with more than 6 oocytes and at least 6 million washed motile sperm/ml obtained, were included. Sperm motility was assessed with the Sperm Class Analyzer (Microptics). Hyperactivation was induced with pentoxifylline and progesterone. The correlation between semen characteristics and the fertilization rate (FR) was calculated by using linear regression. Results: All CASA sperm motility parameters of native semen samples correlated with FR (p<0.05). In washed semen, VCL, VSL and VAP correlated with FR (p=0.05). After inducing the hyperactivation, only VCL (p=0.012) and percentage of induced hyperactivated spermatozoa (p=0.029), were in correlation with FR. For VCL in washed semen sample, actually used for insemination, we set the cut off value at µm/s with sensitivity 62.5% and specificity 58.6% (AUCROC=0.650±0.054), for distinguishing between samples that are able to achieve the fertilization rate of more or less than 50% after IVF. Summary: CASA sperm motility parameters, in native or washed semen, are predictable for fertilization after IVF and could be useful when making decision whether to use IVF or ICSI for oocyte insemination. 21

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26 SESSION I Invited Speakers Abstracts F R I D A Y, 2 0 S E P T E M B E R GAMETES FROM PLURIPOTENT STEM CELLS (PSC) Anna Veiga Institut Universitari Dexeus, Centre de Medicina Regenerativa de Barcelona. Spain Stem cell research is one of the most promising areas in biomedicine. Embryonic stem cells (ESC) an induced pluripotent stem cells (ips) hold pluripotency and self renewal characteristics and have the possibility to differentiate in any cell type. The generation of gametes from stem cells constitutes a tool to study gametogenesis and male and female meiosis. PSC may constitute a future source of artificial gametes for research and future potential therapeutic applications. A number of studies have been performed in the mouse both in the male and in the female, with relevant results and healthy offspring. In the human, Primordial germ cells and haploid cells that express markers from spermatogonia, spermatocytes and spermatids have been generated with and without overexpression of genes related to spermatogenesis.. Reconstitution of the essential steps of PSC-based gamete production in vitro has been established both in the male and in the female. The functionality of such gametes has been assessed in the mouse model. Abnormal methylation patterns and offspring arise when the process is completed in in vitro conditions while normal healthy offspring with normal methylation pattersn are observed if gametogenesis is resumed in vivo. The use of gametes produced from PSC for clinical application remains a distant prospect. CAN GENOMICS BE USED TO PREDICT THE MOST SUITABLE STIMULATION PROTOCOL? ROLE FOR PHARMACOGENETICS IN IVF Dimitris Loutradis 1 st Department of OB/GYN Athens Medical School.Division of Human Reproduction. Greece Investigators have focused on identifying a genetic tool that could predict the response to gonadotropin stimulation, by implementation of a patient s genetic profile in the process of ovulation induction. Pharmacogenetics is the study of the relationship between individual gene variants and variable drug effects. In other words, it contemplates the impact of the differences in DNA sequence on the drug response, in terms of efficacy and /or adverse events. Pharmacogenetics is a rapidly evolving field that can provide numerous public health benefits. In this context, several genes have been studied, including those of the molecules involved in the estrogen pathway and the follicle-stimulating hormone (FSH) receptor LHR,AMH receptor. Many polymorphisms of the FSH receptor gene have been discovered, but the most studied are the Ser680Asn and Thr307Ala ones. The Ser680Asn polymorphism of the FSH receptor gene 24

27 Invited Speakers Abstracts has been found to influence the ovarian response to FSH stimulation in women undergoing IVF, as the FSH receptor in women carrying the Ser/Ser genotype appeared to be more resistant to FSH action. The clinical implications of this finding are highly important and the ultimate goal is the application of genetic markers as routine diagnostic tests before ovarian stimulation in order to predict the ovarian response, determine the required FSH dose and avoid the possible complications related to FSH stimulation. We have examined the frequency distribution of the Ser680Asn polymorphism of the FSHR, in ovarian dysfunction (OD) infertile women, poor responders (PR) and normo-ovulatory controls (good responders, GR) of Greek origin. This study demonstrates that for OD patients the FSHR Ser/Ser variant was more prevalent (45.5%), while the Asn/Ser variant is correlated with more follicles and oocytes. Furthermore, data from the three different groups leads to the suggestion that the Ser/Ser variant is related with a higher level of serum FSH while the Asn/Ser variant with a lower. Furthermore, in the GR group, patients belong more often in the Asn/Ser genotype. A hypothesis that a discrete set of genes including FSHR, ESR1 and ESR2 genotype patterns may explain the poor response to FSH, in order to investigate this hypothesis we using a specific biostatistical programs, if they provided significant evidences of genetic interaction between FSHR, ESR1 and ESR2 markers in relation to COH outcome, supporting the hypothesis that a set of genes, all related to the FSH hormone mechanism of action, may participate along with other factors to the control of the ovarian response to FSH. In that direction, a more recent observational molecular study by our department focused on the ESR1 Pvu II, ESR2 Rsa I and Ser680Asn polymorphism of the FSH receptor in a Greek population of women undergoing IVF/ICSI, alone and in combination, concerning the ovarian stimulation outcome and pregnancy rate. This study brings to light evidence that the patients carrying the polymorphisms in an homozygous state in both ESR1 and FSHR genes (simultaneously) are over-presented in the poor responders group in a statistically significant way (p=0.038). This is supported also by the fact that this certain genotype combination presents the worst ovulation induction profile when compared with the rest of genotype combinations, considering the total amount of gonadotrophins used, the peak E2 and the number of follicles produced (p<0.05) ]. Luteinizing hormone (LH) exerts its actions through its receptor (LHR), which is mainly expressed in theca cells and to a lesser extent in oocytes, granulosa and cumulus cells. The aim of the present study was the inves- tigation of a possible correlation between LHR gene and LHR splice variants expression in cumulus cells and ovarian response as well as ART outcome. Forty patients undergoing ICSI treatment for male factor infertility underwent a long luteal GnRH-agonist downregulation protocol with a fixed 5-day rlh pre- treatment prior to rfsh stimulation and samples of cumulus cells were collected on the day of egg collection. RNA extraction and cdna preparation was followed by LHR gene expression investigation through real-time PCR. Cumulus cells were investigated for the detection of LHR splice variants using reverse transcription PCR. Concerning LHR expression in cumulus cells, a statistically significant negative association was observed with the duration of ovarian stimulation (odds ratio , p ). Interestingly, 6 over 7 women who fell pregnant expressed at least two specific types of LHR splice variants (735 bp, 621 bp), while only 1 out of 19 women that did not express any splice variant achieved a pregnancy. However the present study provide a step towards a new role of LHR gene expression profiling as a biomarker in the prediction of ovarian response at least in terms of duration of stimulation and also a tentative role of LHR splice variants expression in the prediction of pregnancy success. AMH (as a paracrine product of immature follicles) is a more direct measure of ovarian status compared with other endocrine reproductive hormones. AMH is primarily produced by the preantral and small antral follicles, and correlates with the number of primordial follicles at the gonadotrophin-independent stage of follicular development. The inhibitory action of 25

28 Invited Speakers Abstracts AMH on the physiology of ovaries is due: a) to the initial recruitment of follicles independently of FSH b) to the cyclic recruitment: rescue of a restricted number of antral follicles from atresia. In the absence of AMH primordial follicles are recruited at a faster rate, resulting in premature exhaustion of the primordial follicle pool and consequently to a premature menopause. The first end point in our study was to examine the distribution of AMH and AMHRII SNPs in the Greek population and the second end point to investigate the possible association between the presence or not of polymorphisms and the different parameters of ovarian stimulation in women undergoing IVF. Women of IVF group heterozygotes or homozygotes for ΑΜΗ polymorphism (Ile/Ser και Ser/Ser) showed statistically significant higher Ε 2 values at ovulation compared to women without the polymorphism (Ile/Ile) (p-value = 0.009). Women of IVF group carriers of AMHRII SNP (A/G και G/G) showed: statistically significant lower levels of Ε 2 at ovulation (p-value = 0.009). Statistically significant lower number of follicles (p-value = 0.026).Statistically significant lower number of oocytes (p-value = 0.034) Our conclusions are :1.AMH SNP and without AMHRII SNP probably have a better prognosis regardιng the outcome of ovarian stimulation.2 : Women carriers of the AMHRII SNP perhaps should be treated as poor responders modification of gonadotrophin dose according to the genetic profile of each patient. In conclusion the impact of these factors (Genetics) may be small. In order to ensure that a beneficial effect is achieved, an array of molecular tools will be needed and hundreds of thousands of polymorphisms must be examined in appropriate phenotypic groups such as poor responder patients. Genotyping of patients scheduled for ovarian stimulation could be an attractive tool to individualize FSH dosage according to the genetic differences in ovarian sensitivity. REFERENCES 1. Poor responder protocols for in-vitro fertilization: options and results. Loutradis D, Vomvolaki E, Drakakis P. Curr Opin Obstet Gynecol Aug;20(4): Pharmacogenetics in ovarian stimulation--current concepts. Loutradis D, Vlismas A, Drakakis P, Antsaklis A. Ann N Y Acad Sci Apr;1127: Different ovarian stimulation protocols for women with diminished ovarian reserve. Loutradis D, Drakakis P, Vomvolaki E, Antsaklis A. J Assist Reprod Genet Dec;24(12): FSH receptor gene polymorphisms have a role for different ovarian response to stimulation in patients entering IVF/ICSI-ET programs. Loutradis D, Patsoula E, Minas V, Koussidis GA, Antsaklis A, Michalas S, Makrigiannakis A. J Assist Reprod Genet Apr;23(4): ESR1, ESR2 and FSH Receptor Gene Polymorphisms in Combination: A Useful Genetic Tool for the Prediction of Poor Responders. Anagnostou E, Mavrogianni D, Theofanakis C, Drakakis P, Bletsa R, Demirol A, Gurgan T, Antsaklis A, Loutradis D. Curr Pharm Biotechnol Mar 1;13(3): Genetic Profile of SNP(s) and Ovulation Induction. Loutradis D, Theofanakis C, Anagnostou E, Mavrogianni D, Partsinevelos GA. Curr Pharm Biotechnol Mar 1;13(3):

29 Invited Speakers Abstracts S A T U R D A Y, 2 1 S E P T E M B E R SESSION II ULTRASONOGRAPHIC ASPECTS OF PCO AND PSOS Tatjana Motrenko Simic Human Reproduction Centre, Budva. Montenegro PCOS is complex endocrynopathy of normogonadotrophic normoestrogenic anovulation as a result of ovarian dysfunction, represented in 5-10% (by Rotterdam criteria up to 33%) of women reproductive age. It is a heterogenic group of patients with clinical manifestation of menstrual irregularities, androgen excess signs, obesity, elevated serum LH, insulin resistance and metabolic syndrome. Diagnostic criteria for PCOS differ among societies, NIH/1999 simultaneously require both criteria - chronic anovulation and clinical and/or biochemical signs of hyperandrogenism (with exclusion of other aetiologies). Revised Rotterdam ESHRE/ASRM 2003 criteria mean 2 out of 3 criteria: oligo and/or anovulation, hyperandrogenism (clinical and/or biochemical signs), polycystic ovarian morphology (PCOM). Androgen Excess and PCOS Society/2009 requires the simultaneous presence of: hyperandrogenism (clinical and/or biochemical) and ovarian dysfunction (ovulatory dysfunction and/or polycystic ovarian morphology). Ultrasonography provides valuable information about ovarian morphology, following several parameters as well as relations with clinical manifestation: total ovarian volume, follicle number, ovarian stromal changes-echogenicity and area, ovarian stromal area/ total area ratio (S/A ratio), follicle distribution and blood flow Doppler. The standard for imaging PCO is transvaginal high resolution 2D probe and scan should be performed in early follicular phase or in olygo-amenorrhoic patient s random, without previously used oral contraception or hormonal therapy. If dominant follicle >10 mm persist or cyst, scan should be repeated. Polycystic ovarian morphology requires that even one ovary fit the criteria: more than 12 follicles between 2-9 mm on one ovary, or ovarian volume above 10 ccm, echogenic stroma. Mostly AFC and OV are used as parameter. Increased quality of ultrasound equipment high resolution probes, 3-4 D, additional programs- provide more accurate view and allowed visualization of even smallest follicles resulting in increased incidence of PCO morphology in reproductive women population, especially younger, since AFC is age related. What only PCO morphology mean? Underlying PCOS, or increased risk of hyperandrogenism, metabolic syndrome or Infertility problems? Since age related, how to interpret? Age related -higher incidence was found in younger population by Rotterdam AFC criterion, in age group 18 22, PCOM is 69-84% (Rotterdam criteria based on studies with patients in late twenties, early thirties). Maybe it is more appropriate to adjust criteria to different age groups (Duijkers IJ, Klipping C, 2010). Comparing US and age, TT, A, LH, AMH, ovarian volume and AFC in non-pcos ovulatory women without HA, two homogenous clusters were found: I non PCOM non PCOS, and II PCOM, non PCOS. ROC Curve analysis was applied to distinguish non PCOM non PCOS from PCOS and the best compromise between sensitivity and specificity was: OV - at 7 ml, AFC the best threshold value was 19 follicles (sensitivity 81 and 92%) and specificity (92 and 97%), for area under the curve 0,949 and 0,97, AMH threshold 35 pmol/l or 5 ng/ml. (Kristensen.S.L. 2010) AFC decrease by time in both group - ovulatory and PCOS women ( Piltonen, 2005). PCO morphology could become normal ovary - 50% of women with PCOM at mean age of 30 will have normal ovary in 8 year period (Murphy MK. 2006). Most PCOS have PCO morphology. But PCOM do not necessary mean PCOS, just minority part of them is unrecognized PCOS. Non hirsute eumenorrhoic patients with PCOM are functionally distinct but heterogeneous population. Majority - 53% have normal ovarian function (normal endocrine function), in 25% was occult PCOS (asymptomatic hyperandrogenemia, 27

30 Invited Speakers Abstracts higher BMI, waist circumference, DHEA-S, lower SHBG) and 22% represent intermediate subgroup with17ohp hyperresponsiveness to GnRHag without hyperandrogenemia -younger, leaner, less PCOS biochemical abnormalities (Mortensen M,2009). Adolescent population still remain with diagnostic challenges, starting from use of transabdominal sonography, normally high incidence of cycle irregularity, transitory hyperandrogenemia signs, insulin resistance and PCOM. In conclusion, sonography is significant tool in diagnosis of PCOM and PCOS. PCOM prevalence is age dependent, but PCOM appearance is not prerequisite for diagnosis of PCOS, even is positively correlated with biochemical signs of PCOS. There is a need for additional tests in PCOM population since they are heterogeneous group of patients. PCOM in ovulatory women without hyperandogenism have no metabolic significance. SATELLITE SYMPOSIUM FERRING THE HETEROGENEITY OF GONADOTROPHINS AND ITS IMPLICATIONS IN ART Konstantinos Dafopoulos Associate Professor of Obstetrics & Gynecology, Department of Obstetrics & Gynecology, University of Thessalia, Larissa. Greece The pituitary gonadotrophins, luteinizing hormone (LH) and follicle stimulating hormone (FSH), the human chorionic gonadotrophin (HCG) from the placenta and the thyroid stimulating hormone (TSH) belong to the family of glycoproteins. The gonadotrophins have a heterodimeric structure in which an α subunit, common to FSH, LH, HCG and TSH, is noncovalently joined to a β-subunit, which confers biological specificity to the hormone. Both subunits are glycosylated and contain N-linked and, in the case of HCG β-subunit, O-linked carbohydrate chains. Terminal sialylation and/or sulfation of the oligosaccharide attachments determine metabolic clearance and in vivo biopotency. There are significant sex- and age-related variations in terminal glycosylation of gonadotrophins, as well as during the normal menstrual cycle, resulting mainly from the regulatory role of sex steroids. Τhe carbohydrate component is important in a variety of functions, such as regulation of metabolic clearance, facilitation of the correct folding of the subunits, intracellular sorting of the hormones into separate secretory granules, regulation of receptor binding activity, signal transduction and modulation of hormone potency. Methods for quantification of gonadotrophins activity include immunoassay, in vitro and in vivo bioassays, although the prediction of gonadotrophin efficacy in ART treatment is not standardized. THE EVOLVING IMPORTANCE OF AMH: BUILDING FUTURE INROADS FOR A TAILOR MADE APPROACH OF ART Urman Bulent Department of Obstetrics and Gynaecology, Koç University, Faculty of Medicine, Istanbul. Turkey Ovarian stimulation for IVF is traditionally performed based on patient s age previous response to gonadotropins and results of ovarian reserve tests. Classical markers of ovarian reserve 28

31 Invited Speakers Abstracts such as follicular phase FSH and estradiol unfortunately suffer from poor accuracy, cycle-tocycle variation, and lack of power to predict the occurrence of pregnancy. It is proposed that patients lying at the extremes of ovarian reserve (ie poor and hyper-responders) may benefit from a more tailored approach based on AMH and antral follicle count. AMH has a better predictive value for hyperstimulation and lack of pregnancy in patients undergoing IVF. Patients with high AMH levels that are usually associated with polycystic ovaries require extra caution with gonadotropin treatment. Antagonist protocol with low dose gonadotropins ( IU/day) preferably hp-hmg should be used in these patients. Women with insulin resistance should receive Metformin concomitant with gonadotropins. Women with very low or undetectable AMH levels should be counseled regarding third party reproduction options. However, when the periods are regular and FSH levels are <10 IU/mL a stimulated or a modified natural cycle may be undertaken. Patients should be recruited in an optimal cycle that can be selected according to antral follicle counts. In women with low but detectable AMH levels antagonist protocol combined with FSH should be the choice. Late luteal phase estrogen administration of the use of long protocol may decrease the incidence of follicular asynchrony. Patients with normal AMH levels should be stimulated with an antagonist protocol using IU of FSH or HMG. The literature shows that pregnancy rates can be improved and hyperstimulation rates decreased or altogether eliminated using an AMH based ovarian stimulation. Normo-responders may benefit in terms of gonadotropin costs and possible enhancement of implantation due to prevention of a hyperestrogenic milieu. Poor responders may benefit from lower cancellation rates and non-responders may benefit from not taking on a treatment that is associated with very low success rates. SATELLITE SYMPOSIUM MERCK SERONO REPEATED IMPLANTATION FAILURE.NOVEL APPROACHES Professor A.Makrigiannakis MD, PhD, Chairman of Ob/Gyn Department University of Crete. Greece The immunological relationship between mother and conceptus still remains a mystery, although the recent advances in molecular biology have lighten a lot of the parameters that participate in feto-maternal cross talk during implantation. The atypical expression of major histocompatibility complex (MHC),the specific role of some hormones and cytokines, as well as the modified function of cellural constituents of the feto maternal interface,represent substantive parameters of fetomaternal immunotolerance during implantation. However the implantation process is currently considered the most important limiting factor for the establishment of a viable pregnancy and the fertility physician is often called upon to perform the unpleasant task of counselling an infertile couple after repeated implantation failure. (RIF)Aetiology is often not clear and treatment options are indistinct. Some of these include hysteroscopic treatment, myomectomy,preimplantation genetic diagnosis for aneuploidy screening (PGS),assisted hatching, blastocyst transfer, zygote intra -Fallopian transfer (ZIFT),salpingectomy of hydrosalpinges and immunological treatment. Since some of these remedies have not been proven to be effective (the evidence behind some of these is robust), assisted reproduction programmes should resist offering treatment options that are not evidence based at least until well designed randomized studies show the value of what are today considered as empirical treatments. 29

32 SESSION IΙΙ Invited Speakers Abstracts THE ROLE OF 3D ULTRASOUND IN THE DIAGNOSIS OF CONGENITAL UTERINE ANOMALIES: SHOULD IT BE A GOLD STANDARD? Assoc Professor Grigoris F. Grimbizis Assoc. Professor of Obstetrics & Gynecology, Aristotle University of Thessaloniki. Greece Female genital anomalies represent a common benign entity resulting from embryological maldevelopment of Mullerian ducts. Their prevalence in the general population varied between 4 and 7% and it is even higher in selected populations reaching more than 15% in recurrent aborters. Anatomy is the basis of their classification. According to the new ESHRE/ESGE classification they are categorized into 5 main classes based on the uterine anatomy; Class U1: dysmorphic uterus, Class U2: septate uterus, Class U3: bicorporeal uterus, Class U4: hemi-uterus and Class U5: aplastic uterus. Cervical and vaginal anomalies are classified independently into 4 subclasses each to be combined with uterine main classes in cases of complex anomalies. Their diagnosis could be done only with the exact evaluation of the anatomy of the female genital system: the vagina, the cervix, the uterine cavity, the uterine wall, the external uterine contour and the intraperitoneal structures. Historically, this was based on gynecological examination and hysterosalpingography (HSG). It is noteworthy to mention that most of the anomalies are the uterine ones, and mainly those affecting the normal anatomy of uterine cavity, thus HSG was a very useful tool in their evaluation in the absence of other non-invasive or minimally invasive techniques. The estimated overall diagnostic accuracy of HSG was found to be ~85%. Nevertheless, HSG was unable to detect anatomy deviations of the uterine wall and of the external uterine contour, thus differential diagnosis between the several uterine categories and complex anomalies was not feasible with the use of HSG. At that time, the introduction of hysteroscopy and laparoscopy gave the solution in their exact diagnosis and treatment being the gold standard of the diagnostic work-up of women with suspected female genital anomalies. However, although endoscopy is minimally invasive, it is not non-invasive. The use of a new tool, 2D ultrasound (2D US), opened a new era in the diagnostic approach of this category of patients. Classical 2D US, and mainly the use of transvaginal approach, allowed the estimation not only of the uterine cavity but, also, the uterine wall and the external uterine contour. On the other hand, the availability only of transverse and sagittal sections as well as the restricted representation of the cavity represented potential disadvantages of the method limiting its diagnostic accuracy. Thus, despite the potential diagnostic advantages of 2D US, its estimated overall accuracy was found to be again ~85%. In an effort to increase the diagnostic accuracy of classical 2D US, the use of ultrasound contrast medium was proposed during ultrasound examination and the new technique took the name hydrosonography (HSG). This method increased significantly our ability to detect more accurately uterine cavity as well as uterine anatomy and, thus, the overall diagnostic accuracy increased to ~95%. However, the other disadvantages of 2D US remained and the estimation remained still subjective. At that point advances in ultrasound technology had as a result the introduction of a revolution in the non-invasive diagnostic approach of uterine anatomy: 3D US technology gave the possibility of an objective representation of any examining organ. The potential diagnostic capabilities of this new method are the estimation of uterine and cervical anatomy in 30

33 Invited Speakers Abstracts the transverse, sagittal and coronal planes and the non-subjective estimation of all the desired dimensions of the organ studied. The overall diagnostic accuracy of this non-invasive technique was found to be 100%. Furthermore, clear advantages of 3D US vs endoscopy, which was considered until now to be the gold standard in the diagnosis of uterine anomalies, are the non-invasive character of this method and the absolute objectivity of the measurements. Having these advantages, it could become the real new diagnostic gold standard. However, in some complex anomalies where more than one organs of the female genital tract and/or more than one embryological maldevelopment are implicated, 3D US could not be sufficient by its own to elucidate the exact anatomical status. In those cases, a supplementary examination with another new and sophisticated technique might be necessary; Magnetic Resonance Imaging (MRI) could offer the diagnostic information necessary for a non-invasive estimation of the patient. However, this is an issue, which needs further investigation in terms of indications and diagnostic accuracy. CONTRAST SONOSALPINGOGRAPHY TO EVALUATE TUBAL PATENCY Stavros Mousourakis, MD, DMRD, FRCR, CCT Clinical Radiologist, Hrakleion Crete. Greece In this presentation I review the technique, indications, contraindications, associated side effects, and the diagnostic capabilities, limitations and pitfalls of the imaging method of hysterosalpingo-contrast-sonography (HyCoSy). Damage to the fallopian tubes is a frequent cause of female infertility, mainly due to ascending pelvic inflammatory disease from sexually transmitted infections. The evaluation of tubal patency is an important part of the diagnostic work-up of infertility. Established tests for assessing fallopian tube patency include laparoscopy with chromopertubation (lap & dye) and the time-honoured radiographic method of hysterosalpingography. Laparoscopy with chromopertubation is considered the gold standard for tubal patency assessment. The procedure also allows surgical restoration of pelvic pathology, such as the excision of lesions of endometriosis. Adding hysteroscopy to the test permits assessment of the intrauterine cavity. These invasive procedures require regional or general anaesthesia and incur operative costs, the need for postoperative recovery, and risks of morbidity and even mortality. Radiographic hysterosalpingography is widely accepted as an effective method of tubal patency evaluation. However, hysterosalpingography gives no ovarian or adnexal information, and provides limited views of the internal architecture of the uterine cavity. Patients frequently experience bleeding or pelvic pain during or after the procedure. Significant pain may lead to premature termination of the procedure and vasovagal reactions. Hysterosalpingography exposes the patient to ionizing radiation and allergenic iodinated contrast media. Adverse reactions to the contrast media used range from urticaria to bronchospasm and laryngeal oedema. Pelvic radiation exposure during hysterosalpingography is also quoted as a concern, with gonadal radiation doses of up to 5 mgy. In hysterosalpingo-contrast-sonography (HyCoSy) three imaging techniques must be combined: transvaginal ultrasound, sonohysterography and sonosalpingography. Transvaginal ultrasound provides excellent images of the uterus, endometrial lining, and adnexal morphology. Ultrasound is widely used in infertility investigations and procedures: endometrial assessment, follicle maturation monitoring, oocyte retrieval, and management of 31

34 Invited Speakers Abstracts ovarian tumours, evaluation of pelvic pain, and the detection of the kind of hydrosalpinx associated with reduced IVF success. Further improvements in imaging of the endometrium and intrauterine cavity can be achieved with the method of saline infusion sonohysterography. Sonohysterography is a technique that involves placing a catheter into the uterine cavity through the external cervical os to inject sterile saline. The saline distends the cavity, pushing the walls of the endometrium apart. The anechoic fluid is contrasted against the echogenic endometrium, giving hysteroscopic quality images of the uterine lining. Indications for sonohysterography include the evaluation of abnormal uterine bleeding; uterine pathology such as leiomyomas, polyps, and synechiae; abnormalities detected on transvaginal ultrasound, including focal or diffuse endometrial or intracavitary abnormalities; congenital uterine anomalies; infertility; and recurrent pregnancy loss. The procedure should not be performed in a woman who is pregnant or who could be pregnant or who has an active pelvic infection. Performing the procedure between menstrual cycle days 6 and 11 helps to ensure the absence of pregnancy and facilitates maximum uterine cavity visibility with a thin, proliferative phase endometrium. The secretory phase must be avoided because of potential false positive findings from transient folds and wrinkles in the normal endometrium. Sonohysterography is a mildly invasive procedure suitable for outpatients. Associated side effects include procedural discomfort and pain, post-procedure vaginal bleeding, vasovagal reactions, and referred shoulder pain. The pain experienced is related to the cervical manipulation from placement of a tenaculum, uterine distension from the instilled fluids which may initiate uterine cramps, and peritoneal irritation from spillage of the infused media through the fallopian tubes. Additional mechanisms may include catheter irritation and/or balloon distension in the cervical canal or uterine cavity. The fallopian tube is a poor ultrasonic reflector, lacking interfaces that produce clear tissue outlines. To evaluate the fallopian tubes by ultrasound, a sonographic contrast medium must be infused, in a technique known as sonosalpingography. These positive contrast agents outline the course of the lumen of the fallopian tubes, producing a hyperechoic appearance in real time. The simplest contrast medium is saline solution mixed with air. When this solution is shaken, it generates a suspension of air bubbles that can be identified sonographically when injected into the uterine cavity and fallopian tubes with spillage around the ovaries. However, image quality is crude and unpredictable and the passage of air is painful, commonly leading to vasovagal reactions. Pharmaceutical grade ultrasound contrast media are more stable and have a more hyperechoic appearance, making them easier to visualize moving through the tubes. The latest contrast media, gas microbubbles, show a substantial harmonic response at low acoustic pressure making them clearer and visible for longer. The shell material affects the microbubble s mechanical elasticity. The more elastic the material, the more acoustic pressure the microbubble can withstand without bursting. This increases the time available for imaging. Currently, microbubble shells are composed of albumin, galactose, lipids, or polymers. In the second generation of contrast agents developed, the air in the bubble has given its place to higher molecular weight gases resulting in more stable bubbles. SonoVue, Optison, and Luminity / Definity are the main representatives of the newer, second generation agents. SonoVue is characterized by a microbubble structure consisting of a gas of low solubility (sulfur hexafluoride) stabilized by a phospholipid monolayer shell and has been clinically tested for hysterosalpingo-contrast-sonography. Several prospective and retrospective studies support HyCoSy as a reliable and reproducible screening procedure for subfertility. According to various meta-analyses, the overall HyCoSy detection of occlusion and patency approaches 100% and 85%, respectively. Concordance for patency between the HyCoSy and comparative diagnostic tests is quoted as 86% for la- 32

35 Invited Speakers Abstracts paroscopy and 84% for hysterosalpingography. Technical difficulties in completing a HyCoSy procedure must be expected in obese patients, when the uterus is acutely retroverted or oblique, in the presence of large fibroids projecting over the adnexal regions, when multiple loops of bowel are present, or the ovaries are located beyond the penetration of the ultrasound beam. Causes of false HyCoSy findings include: observed echogenic flow in one segment of the tube without confirmation of distal flow over the adjacent ovary (distal occlusion overlooked); presence of a tubal fistula where free tubal passage may mimic flow from the fimbria; and conversely, false positive result for occlusion secondary to tubal spasm. The fallopian tube cannot be seen completely in a single scanning plane due to its tortuosity. Visualization of the entire tube requires multiplanar scanning by an experienced sonographer who is able to quickly manipulate the transvaginal probe to visualize the different anatomical parts of the tubes. A learning curve of a few hundred HyCoSy procedures is necessary to optimize technique. Combining three-dimensional (3D) ultrasonography with HyCoSy overcomes some of the limitations inherent in two-dimensional (2D) HyCoSy. Automated 3D volume acquisition allows visualization of the contrast medium flow throughout the entire tubal length. Coded contrast imaging (CCI) software with coded phase-inversion technology enables differentiation of contrast medium in the tubes and around the ovaries from the adjacent tissue and organs. It optimizes the use of ultrasound contrast medium and enhances visualization of the fallopian tubes by allowing the operator to distinguish between the harmonic response of the contrast medium and the broadband ultrasonic signals from pelvic organs. Another advantage is that it produces static images of the tubes similar to those from radiographic hysterosalpingography that can be easily shared with other clinicians. Hysterosalpingo-contrast-sonography combines principles of transvaginal ultrasound and sonohysterography with those of radiographic hysterosalpingography, while maintaining competitive diagnostic accuracy. It is well-suited as a screening tool in the initial imaging of subfertility, allowing simultaneous evaluation of ovarian reserve and morphology, uterine cavity contour and myometrial structure, and tubal anatomy and patency. 33

36 LECTURE III Invited Speakers Abstracts S U N D A Y, 2 2 S E P T E M B E R VTE PREVENTION IN PREGNANCY AND PERIPARTUM. WHERE DO WE STAND Dr. Emmanouil Papadakis, Greece Women during pregnancy are exposed to increased risk for vascular thromboembolism, both venous and arterial. Pulmonary embolism (PE) remains the leading cause of maternal mortality in Developed Countries, since it accounts for 1.2 to 4.7 deaths per 100,000 pregnancies yearly. Pulmonary Embolism consists in addition one of the most common causes of maternal mortality in the developing world, the leading being peri-partum hemorrhage, despite the marked decrease in mortality over the last 50 years. Although not precisely estimated the incidence of Venous Thromboembolism during pregnancy ranges from 0.13 to 2.3 events per 1000 deliveries. Compared to age-matched, non-pregnant controls the relative risk for VTE rises up to three- to tenfold in pregnancy and up to X15 to X35fold postpartum. After delivery the thrombotic risk returns to the non-pregnant levels at least after 6 weeks postpartum. A meta-analysis showed that two-thirds of cases of deep vein thrombosis (DVT) occur antepartum, distributed equally throughout in all three trimesters. In contrast, 43% to 60% of pregnancy related PEs occur after birth at 4 to 6 weeks postpartum. Findings from the largest Registry of Patients with Venous Thromboembolism [Computerized Registry of Patients with Venous Thromboembolism (RIETE)] unveil interesting aspects regarding clinical aspects of pregnancy related VTE. With this study RIETE emphasizes the need to administer thromboprophylaxis as soon as possible in pregnant women at risk for thrombotic events. Virchow s triad, published 150 years ago, the everlasting pathophysiological framework that categorizes risk factors of VTE into three elemental categories namely venous stasis, vascular damage, and hypercoagulability provides a causal link between pregnancy and VTE. Venous capacitance and outflow are mechanically and hormonally affected progressively through pregnancy, while vascular injury especially during puerperium augments the thrombotic risk. Hypercoagulability rises as the most important cause for VTE risk during pregnancy. During normal pregnancy increased concentrations of coagulation factors are observed, while free protein S, the active, unbound form of a natural anticoagulant, is markedly decreased during pregnancy. Apart from risk factors for VTE that pregnancy itself carries, pre-existing and transient risk factors synergize too. Among the most significant are thrombotic history, inherited thrombophilia, certain medical conditions, and complications of pregnancy and delivery. Despite the increased risk for VTE in pregnancy, most women do not require anticoagulation. Exceptions are women already on anticoagulation with current or a history of thrombosis, women with thrombophilia and women at high risk for thrombosis postpartum. While the anticoagulant armamentarium has expanded with the advent of newer anticoagulants, the mainstay both for VTE pharmaceutical prophylaxis and treatment remain heparins, with Low Molecular Weight Heparins (LMWH) being used more often. Unique aspects of anticoagulation in pregnancy include both maternal and fetal issues. For fetal safety heparin compounds are the preferred anticoagulant agents during pregnancy. Over the recent years LMWH proved to be at least equally efficacious but safer and easier handled than Unfractionated Heparin. The medical specialist dealing with VTE risk and thromboprophylaxis during pregnancy and postpartum faces several trivial questions: Are women who are at greater risk easily identifiable? Is pregnancy-related VTE preventable? When is the best time to start thromboprophylaxis? How is thromboprophylaxis optimally manipulated during intervention or delivery? 34

37 Invited Speakers Abstracts Medical societies, among them ACCP with its recently updated guidelines, provide usefull resources for the optimal balancing of reduction of VTE risk from increased bleeding risk due to pharmacologic thromboprophylaxis. Newer LMWH compounds, including Bemiparin a second generation LMWH, are gaining in the setting of VTE management during pregnancy with successfully performed experimental and clinical studies SESSION V THE ROLE OF FERTILOSCOPY IN ART A.Watrelot Hôpital Natecia, Lyon. France Since its original description in1997, Fertiloscopy has step by step found its place in ART: -first as a mini-invasive tool and in this respect, fertiloscopy through the FLY study (Fertiloscopy versus laparoscopy-published in Human Reproduction in 2003)has demonstrated its accuracy when compared to the gold standard laparoscopy, and even a superiority by allowing a very thorough evaluation of the tubal mucosa with salpingoscopy which is much easier to perform by fertiloscopy than laparoscopy. -However when compared to laparoscopy the safety and mini-invasivenss of the procedure makes it non only very acceptable but mandatory in the infertile work up to decide the best method of ART,knowing that all the non invasive test such as Hysterosalpingography have a false negative rate between 20 to 40%according the meta analysis of Schwartz. -then operative capacities appeared and allowed to perform non solely adhesiolysis but also ovarian drilling which is now well recognized as a very effective secondary tool in PCOS patients. -Finally it has been demonstrated that subtle tubal lesions may have an important role in infertility and Fertiloscopy seems today the best tool to detect and treat such abnormalities very often missed by laparoscopy. So in all Fertiloscopy doesn t compete with ART and especially IVF but is a complementary tool which,if practised early in the infertile diagnosis, allows to propose the best therapeutic option without delay, which is critical to distressed infertile patients THE ROLE OF ULTRASOUND IN GUIDING EMBRYO TRANSFER Hassan N. Sallam, MD, FRCOG, PhD (London) Professor in Obstetrics and Gynaecology, the University of Alexandria, and Clinical Director, Alexandria Fertility Center, Alexandria. Egypt Despite numerous developments in assisted reproduction (IVF and ICSI), the implantation rate of replaced embryos remains low. It has been estimated that 85% of embryos replaced during ET do not implant. The causes of this low implantation rate have been blamed on (i) 35

38 Invited Speakers Abstracts diminished implantation capacity of the embryos, (ii) diminished uterine receptivity, and (iii) suboptimal ET technique. Various approaches have been suggested in order to optimize the ET technique. Of these, ultrasound-guided ET has been proposed and practiced by numerous infertility specialists. Most of these specialists reported the use of transabdominal 2D ultrasound, while some reported the use of transvaginal ultrasound. More recently, 3D and 4D ultrasound-guided ET was also reported. Meta-analysis of randomized trials has shown that trans-abdominal ultrasound-guided embryo transfer (ET) is associated with significantly higher clinical pregnancy (OR = 1.42; 95% CI = ), on-going pregnancy (OR = 1.49; 95% CI = ) and implantation (OR =1.82; 95% CI = ) rates in patients treated with in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), compared to the "clinical touch" technique. These results were recently confirmed in a Cochrane review. Ultrasound guidance during ET (US-ET) offers the following advantages (1) it helps overcome intrauterine pathological obstacles to successful implantation, (2) it helps overcome resistance at the utero-cervical angle, (3) it helps in choosing the appropriate catheter, (4) it helps deposit the embryo in the site with the best potential for implantation, (5) it helps insure that the embryo did not move after catheter withdrawal, (6) it can be used to detect uterine contractions during and following embryo transfer, (7) it helps determine the potential for implantation and (8) it is very useful in the management of difficult embryo transfers. IS THERE A ROLE FOR U/S IN THE DIAGNOSIS OF PREMATURE OVARIAN FAILURE? Sophia Kalantaridou Professor of Obstetrics & Gynecology and Reproductive Endocrinology, Department of Obstetrics and Gynecology, Medical School, University of Ioannina, Ioannina. Greece Premature ovarian failure (POF), also referred to as hypergonadotropic hypogonadism or primary ovarian insufficiency, is a condition characterized by sex-steroid deficiency, amenorrhea, infertility, and elevated gonadotropins in women younger than 40 years of age. It affects 1% of women by age 40 and 0.1% by age 30. POF occurs in 10% to 28% of women with primary amenorrhea and 4% to 18% of women with secondary amenorrhea. At one time, POF was considered irreversible and was described as premature menopause. However, menopause is the permanent cessation of menses following the loss of ovarian follicular activity. It is a natural physiologic event in a woman s life that occurs at an average age of 51 years and results from ovarian follicle depletion. In contrast, POF is characterized by intermittent ovarian function, and pregnancy may occur many years after the diagnosis. POF is a heterogeneous disorder and may occur as a result of decreased initial follicle number, ovarian follicle dysfunction, or ovarian follicle depletion. Indeed, a wide range of defects may lead to POF, including autoimmune, genetic, iatrogenic, and metabolic causes. In most cases (approximately 90%), the etiology of ovarian insufficiency cannot be identified. Rare causes of POI include autoimmune ovarian damage, chromosomal and genetic abnormalities involving the X chromosome or autosomes, and iatrogenic damage following pelvic surgery and cancer therapy (chemotherapy or radiotherapy). Infertility is a major issue for young women with POF. However, women with spontaneous POF produce estrogen intermittently and may ovulate despite the presence of high gonadotropin concentrations. Spontaneous pregnancies have occurred in 5% to 10% of women after the diagnosis of POF. Ovarian function is notably unpredictable, and some residual ovarian activity may be present many years after the initial diagnosis. It has been shown that ultrasonography is not predictive of the presence of follicular structures within the ovary. However, clinical, biological and 36

39 Invited Speakers Abstracts ovarian ultrasonographic features may allow an assessment of the presence of ovarian activity, but are not necessarily correlated with a higher ovulation or pregnancy rate. In conclusion, although there are no proven therapies to improve ovarian function and increase fertility rates in women with POF, it appears helpful to characterize these patients to determine whether some of them could be candidates who benefit from a particular investigational therapeutic strategy. SESSION VI ULTRASONOGRAPHY IN REPRODUCTIVE MEDICINE Peter Drakakis, Ass. Professor Ob/Gyn Ekaterini Domali, Lecturer, Ob/Gyn, Specialist in Gynecologic Ultrasonography 1 st OB/GYN Dept, Athens University Medical School, ALEXANDRA Maternity Hospital Athens, Greece Head of Dept: Professor Dimitris Loutradis Ultrasonography represents the first line diagnostic instrument of gynecologists in the evaluation of the pelvis. It is a method simple to be applied, easy to be performed, cost effective and familiar for both women and MDs. Since recent years, rapid development of technology enriched classical ultrasonography with newer modalities altering it into a dynamic tool in the daily clinical practice. Multiplanar approach via static 3D and real time 4D scans, STIC application, inversion mode, niche mode and TUI software allow ultrasonographers to evaluate thoroughly the female pelvis during transabdominal, transvaginal, translabial and transrectal ultrasonography where appropriate. Subfertility`s diagnostic workup ordinarily contains a combination of ultrasonography, hysterosalpingography, hysteroscopy, MRI and laparoscopy. Enhanced ultrasonography is able to offer detailed and specific diagnostic information during subfertility investigation. It could be proposed that ultrasound scans could hide the potential to replace the other diagnostic modalities in the investigation of subfertility. Hysteroscopy delineates via direct vision the structure of endometrial cavity, the homogeneity of myometrium, the formation of uterine horns and the clarity of interstitial part of the tubes. Multiplanar ultrasonography of endometrial cavity describes the triangular shape of endometrial cavity significantly differentiated during the normal menstrual cycle and notably eliminated during postmenopausal status. Congenital anomalies are regularly identified and in detail described. Myometrial deformation caused by the presence of myomas and / or adenomyomas can be clarified via elastographic evaluation; via elastography, dominance of blue color indicates the existence of hard tissue, meaning myomas and the prevalence of red color implies the occurrence of adenomyosis. The relationship of myomas vs the endometrial cavity that could influence the implantation procedure is clearly defined by hydrosonography; injection of fluid in the endometrial cavity leads in dissection of endometrial lips and reveal of endometrial and / or subendometrial lesions such as submucus myomas and / or polyps. Hysterosalpingography is mainly performed in order to examine the tubal channel concerning direction, patency, mobility and possible presence of adhesions. It represents a really informative method, well standardized, and improved since last decade. But it must be mentioned that subfertile young woman are exposed to radiation that could not be characterized as in not detectable amounts. In addition severe degree of pain has been reported by investigated women. It has been also shown that contrast media could provoke complications such as allergic reactions, inflammatory actions and in rare cases miscarriages and abnormal bleeding. Finally, it is a method 37

40 Invited Speakers Abstracts performed by radiologists; the last means that another appointment should be organized and therefore further delay in the diagnostic process is obliged. During enhanced ultrasonography the presence of adhesions could be identified during real time 2D scans via following the responsiveness of uterine and adnexal mobility to probe`s movements. HyCoSy ultrasonography describes the anatomical structure of the endometrial cavity, the patency profile of the tubes and the presence or not of the existence of adhesions in the pelvis. Moreover, based on investigated women`s reports, it is a diagnostic procedure that is performed without provoking pain. Up to the moment, neither allergic reaction nor inflammatory complications have been recorded. Laparoscopy offers excellent images of the anatomy of pelvis delineating the relationship of the included anatomical structures, the external regularity of the body of the uterus as well as the presence or not of adnexal irregularities. Laparoscopy enhanced by chromo perturbation clarifies the free passage of the contrast media through the tubes. But it is an operative method that could provoke morbidity of the investigated woman, really expensive, that demands operative time, specialized equipment and doctors. Furthermore it adds significant delay in the diagnostic workup of subfertility. Ultrasonographic approach by experts based on subjective impression, the so called pattern recognition, is really informative; the structural construction of the body of the uterus might be in detail described via 3D software; the functional relationship of the pelvic organs could be investigated via 2D and 4D real time scans; adnexal masses could be identified and precisely characterized as benign or malignant via application of IOTA rules as well as inversion mode analysis. Finally, passage model of the tubes is well detected via the application of contrast media as reported above. MRI is a well known and established imaging technique which is applied since several years. Its main usefulness in subfertility workup is the identification of endometriotic deep nodes that could be really hided in the pouch of Douglas or between rectum loops. It is a really expensive imaging technique performed by radiologists that demands expensive equipment and further appointments to be performed. The presence of deep nodes even in small dimensions of mm can be identified via transvaginal ultrasonography enhanced by contrast gel and / or transrectal scan well tolerated by the women if it is applied by experienced ultrasonographer. Based on the above gathering data, we believe that ultrasonography performed by experienced doctor could simplify the diagnostic workup of subfertility. SPECTRAL HYPERVISION IN HYSTEROSCOPY M. Paschopoulos Prof. of Obstetrics and Gynecology, Medical School of the University of Ioannina. Greece Hysteroscopy is a method of studying the endometrial cavity and endocervix, under direct vision after dilatation. Ηysteroscopy, combined with optical biopsies is the golden standard in studying the endometrial cavity 1. There are some limits, however, concerning the equipment, the dilatation medium and the subjectivity of the hysteroscopist. The first attempt of hysteroscopical depiction is placed at the beginning of the 19 th century 2. During all these years a lot of scientists were occupied with the development of hysteroscopy and the need of the evolution of its technic and methodology 3,4. Hysteroscopy is a dynamic method, which can provide images of endometrial cavity, without giving objective results. The explanation of the images depends of the experience and the skills of the hysteroscopist 5. So the objectivity of hysteroscopy has not be yet overtaken. The purpose of this study is to introduce a new method of hysteroscopy, affordable to gynecologist, which quantifies hysteroscopic findings and increases the diagnostic accuracy of 38

41 Invited Speakers Abstracts the method. Trying to achieve this, we used for first time Hyperspectral imaging in endometrial cavity. Hyperspectral hysteroscopy is for the very first time attempted in clinical practice. In this study participated patients who visited the Obstetrician and Gynaecological clinic of University Hospital of Ioannina and more specific the endoscopical department. In this study were included only women with abnormal uterine bleeding. At first, women had transvaginal ultrasound regardless of the phase of the menstrual cycle. Then, in case of the presence of clinical symptoms or the identification of endometrial pathology, visible on ultrasound, patient were submitted to diagnostic office hysteroscopy without sedation or using any analgesic drugs. During hysteroscopic examination, digital image of the uterine cavity was recorded and stored. Then the images stored by the system of hyperspectral hysteroscopy were collected and finally took place the processing of these data. This processing had as result the pseudocolour map, depending on the properties of the tissue after the exposion to various length of waves of light. The colours were decided by chance, depending on the properties of the tissue to appliance of the light. So we have decided that the colours used for the pseudocolours maps are the red, blue, green, purple and yellow.patients with an intrauterine pathology scheduled for operative hysteroscopy, such as to remove the endometrial pathology. Finally, results of the histological examination were compared with the results of hyperspectral hysteroscopy and the pseudocolour map. By using hyperspectral hysteroscopy in women with abnormal uterine bleeding, we had the opportunity to find out the existence of different types of endometrial pathologies, such as endometrial polyps, submucous myomas, hyperplasia and enodmetrial cancer. The pseudocolour map which was dominated by blue-purple, had more inflammatory elements and rich angiogenesis. Therefore this type of map characterized the functional polyps. In the other case, dominated by fibrous tissue, the dominated colour was the red and the images corresponded to non-functional polyps. In spectral hysteroscopy submucous myomas were well distinct in relation to the rest of the intrauterine cavity. There was a variety of colors in pseudocolour map, such as blue-purple, less green and red. The colours of the pseudocolour map that dominated in this case was the pinkred and the yellow. In case of pseudocolour map which was dominated by the dark green and red color, should be suspected ednometrial cancer. This image is similar to that of complex hyperplasia, which has an increased likelihood of progression to endometrial cancer. According to the above this study is about a new hysteroscopical technic which uses the abilities of hyperspectral hysteroscopy. This gives the possibility of understanding the structural and functional characteristics of tissue, according to their properties after different length of waves of light. Hyperspectral hysteroscopy is a promising method which demands bigger number of data and a bigger clinical trial, such as to be entered in the daily clinical practice and have the best results for womens health. Reference 1. De Angelis C, Carnevale A, Santoro G, Nofroni I, Spinelli M, Guida M, Mencaglia L, Di Spiezio Sardo. Hysteroscopic Findings in Women With Menorrhagia. A.J Minim Invasive Gynecol Jan 4. doi:pii: S (12) /j.jmig [Epub ahead of print] 2. Vale RF. Development of hysteroscopy: from a dream to a reality and its linkage to the present and future. Am Assoc Gynecol Laparosc 2007;14: Palmer R. L hysteroscopie cervicale. Rev Fr Gynecol Obstet 1942;403: Tsimpanakos I, Gkoutzioulis A, Moustafa M, Mohamed M, Magos Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. A.BJOG Aug;117(9): Cooper NA, Smith P, Khan KS, Clark TJ. Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. BJOG Apr;117(5):

42 Invited Speakers Abstracts ASHREMAN S SYNDROME: NEW OPTIONS OF MANAGEMENT Nikos F Vlahos, Assoc. Professor of gynecology and Obstetrics Aretaieio Hospital, Athens. Greeece Intrauterine adhesions (IUA) were described initially by Fritsch (1894). Asherman (1948) brought more attention to the condition which bears his name. Some authors prefer that the term Asherman s syndrome (AS) be restricted to patients with amenorrhoea, to those whose uteri are obliterated completely or to those whose scarring follows surgery on the gravid or recently gravid uterus. Others use the term IUA ; this term is more clear and more descriptive, but it excludes those with surface deficiencies of the endometrium without fibrous bridges between the uterine walls. These women suffer the same menstrual aberrations, infertility, recurrent pregnancy loss, intrauterine growth restriction (IUGR), errors of placental implantation and other complications of pregnancy as those with adhesions. Those with extensive basal layer damage, called endometrial sclerosis, have little or no functioning endometrium and thus a more dire situation. Although affixing the eponym Asherman s to a condition with varying symptoms, manifestations and pathology may invite resistance, there cannot be one single definition of AS with strict inclusion and exclusion criteria: using the term Asherman s syndrome signifies an endometrial disorder of great significance and one with important consequences, reproductive and other. The sine qua non for the development of IUA is endometrial trauma. Adhesions occur most often following curettage during or shortly after pregnancy. Friedler et al. (1993) performed hysteroscopy 4 6 weeks after dilation and sharp curettage following spontaneous first-trimester abortion. Twentyeight (19.0%) patients had IUA: 16 of 98 (16.3%) had mild, filmy adhesions occupying more than one-quarter of the cavity after one abortion; three of 21 (14.3%) had IUA after two abortions, but after three or more nine of 28 (32.1%) had IUA. In the latter two groups, 58% of the IUA were more severe. IUA have followed evacuation of a molar pregnancy, Caesarean section, diagnostic curettage, myomectomy, metroplasty or radiation. Taskin et al. (2000) detected IUA following the hysteroscopic removal of a single myoma in 31.3% of cases. This rose to 45.5% if a multiple myomectomy was performed. IUA followed hysteroscopic resection of a septum in 6.7% of the cases. These adhesions become more dense as time passes (Shokeir et al., 2008). IUA have been diagnosed with increasing frequency over the past three decades; however, it is unclear whether the incidence is rising secondary to the performance of a greater number of, as well as more complex, uterine surgeries or if this phenomenon is secondary to increased awareness and more sensitive diagnostic procedures. There are three types of pathology (Foix et al., 1966). Most common is avascular fibrous strands joining uterine walls. IUA may be accompanied by deep adenomyosis. Myometrium may be present. Muscular adhesions are more dense and indicate a deficient endometrial basalis and a poorer prognosis. Some patients have only a sclerotic, atrophic endometrium and thus the worst prognosis. The menstrual pattern and extent of IUA do not correlate perfectly. Toaff and Ballas (1978) reported amenorrhoea in some women with minimal IUA of the internal os and/or endocervix and suggested that a neuroreflex mechanism in that region may cause the endometrium to be unresponsive to ovarian hormones. Polishuk et al. (1977) performed pelvic angiography in 12 patients with reduced or absent menses after curettage. Seven had reduced myometrial blood flow and widespread vascular occlusion. These findings could explain endometrial atrophy, recurrent abortion, fetal death in utero and IUGR. Although most of the study centre s patients had amenorrhoea, 87 (6.8%) of 1287 women had cyclic, painless menses of normal flow and duration including 2.5% of those who had 40

43 Invited Speakers Abstracts extensive scarring. Taylor et al. (1981) detected IUA in 22% of normally menstruating infertile patients. Therefore, IUA cannot be excluded in women with normal menses or in those amenorrhoeic women who have withdrawal bleeding after hormone administration. Those with hypomenorrhoea or amenorrhoea after uterine surgery should be considered to have IUA. Amenorrhoea plus premenstrual molimina or evidence of ovulation as well as the failure to have withdrawal bleeding after progestin or sequential oestrogen progestin treatment is almost diagnostic of IUA. Another symptom is infertility caused by obstruction of the tubal ostia or endocervix. Others have subclinical recurrent abortion caused by poor endometrial receptivity. The consequences of AS are not limited to reproductive problems. Those with amenorrhoea or hypomenorrhoea often have scarring of the cervix or lower uterine segment. If there is functioning endometrium above these sites, the patient may have cyclic pain and, if treatment is delayed and at least one Fallopian tube is patent permitting prolonged retrograde menstruation, endometriosis may develop. Diagnosis If the uterine cavity cannot be sounded, scars involve at least the endocervix. However, the upper cavity may also be obliterated. Sonography can assess endometrial development, can identify areas of calcification as well as hyperechoic areas which correlate with dense adhesions and may detect a haematometra. Lo et al. (2008) reported very thin endometrium without haematometra in most women with outlet obstruction caused by IUA. Schlaff and Hurst (1995) reported that the pre-operative endometrial thickness correlated with the outcome of treatment. If uterine sounding fails, hysteroscopy should be performed rather than hysterosalpingography (HSG) or saline infusion sonogram (SIS). If a sound won t pass, neither will iodine contrast nor saline. Hysteroscopy allows direct inspection of the uterine cavity for diagnosis, classification and treatment. The American Society of Reproductive Medicine Classification (1988) is a modification of this system and includes menstrual history. The clinicohysteroscopic scoring system proposed by Aboul Nasr et al. (2000) combines features of both and adds prior reproductive history, thereby enhancing its prognostic value. These systems also allow the value of different adjunctive therapeutic measures to be compared. Prevention of Asherman s syndrome: This principle is applied in two different ways depending upon whether or not the patient is pregnant or was so recently. If faced with intrauterine fetal demise (IUFD), assess the need for surgical evacuation. If the loss occurred early, the author prescribes misoprostol shortly after the diagnosing IUFD because the likelihood of successful medical therapy decreases as the interval between demise and evacuation increases (Zhang et al., 2005). If there has been a presumed passage of the products of conception an ultrasound is performed. If passage appears to be complete, 0.2 mg methylergonovine maleate is prescribed orally every 4 h for a total of six doses. If the ultrasound suggests retained POC after one dose of misoprostol, the regimen is repeated. If the treatment regimen fails, removal of the retained POC under hysteroscopic guidance is recommended. This regimen is employed up to a gestational age of 10 weeks. Expectant or medical management after IUFD is both acceptable to patients and is as efficacious as curettage in assuring complete evacuation (Blohm et al., 1997 and Smith et al., 2009). Pregnancy rates after non-surgical management of spontaneous abortion are excellent (Fontanarosa et al., 2007). Tam et al. (2002) randomized 82 patients with spontaneous incomplete abortion to observation, medical or surgical management. Outcomes were similar and hysteroscopy 6 months later detected IUA only in the post-curettage group. A high rate of spontaneous, complete expulsion of the POC following IUFD in early pregnancy has been reported in multiple studies if surgical intervention was delayed for 1 week after fetal loss had been diagnosed (Wieringa-de Waard et al., 2002). The pregnancy rate after medical management of abortions 41

44 Invited Speakers Abstracts is over 80% at 1 year (Smith et al., 2009). In addition to IUA, prior uterine curettage has been reported to increase significantly the incidence of retained placenta after vaginal delivery, setting the stage for another curettage (Panpaprai and Boriboonhirundarn, 2007). If surgery is required, it should be performed sooner rather than later because the likelihood that IUA will develop following surgery increases as the interval between IUFD and D and C is prolonged. Adhesions were found after curettage in 30.9% of women who had a missed abortion, compared with only 6.4% of those whose curettage was performed because of an incomplete abortion (Adoni et al., 1982). In women with a missed abortion, retained placental remnants may induce fibroblast activity and collagen formation before endometrial regeneration occurs. Thus, the study centre has used 3 weeks as an arbitrary cut-off period between the diagnosis of IUFD and surgical intervention. Removal of POC under hysteroscopic guidance is preferred by many but few physicians utilize this procedure. As an alternative, perform curettage under ultrasound guidance, a technique which assures that evacuation is complete and allows the surgery to be terminated as soon as complete evacuation has been documented. A post-partum curettage is most likely to result in IUA if it is performed between 2 and 4 weeks after delivery (Eriksen and Kaestel, 1960). Within the first 48 h after delivery, the uterus is much less vulnerable to IUA formation after curettage (Eriksen and Kaestel, 1960). Women who breastfeed are at higher risk of adhesion formation because they remain oestrogen deficient for a long time, delaying endometrial proliferation (Buttram and Turati, 1977). In these instances, consider recommending that nursing be discontinued and prescribe oestrogen. With respect to uterine surgery at a time unrelated to pregnancy, four factors are associated with a greater frequency of post-operative IUA formation, as discussed below. Gonadotrophin-releasing hormone agonist Many surgeons prescribe a gonadotrophin-releasing hormone agonist (GnRHa) prior to abdominal myomectomy and various types of hysteroscopic surgery. However, as the drug-induced oestrogen deficiency progresses, the endometrium atrophies and may be damaged more easily as fibroids are separated from the overly thinned endometrium. Hypogonadotrophic hypogonadism has been shown to be associated with extensive IUA formation and so-called senile adhesions have been found in post-menopausal women who had no prior instrumentation (Buttram and Turati, 1977 and Panayotidis and Ranjit, 2002). The best of both worlds may be achieved by scheduling the myomectomy 7 8 weeks after the last injection of a medication such as depot leuprolide acetate. This brief delay allows ovarian function to resume, initiating endometrium regrowth and allowing less traumatic fibroid removal at a time prior to the resumption of menses or tumour regrowth. Some (Mencaglia and Tantini, 1996) prescribe a GnRHa prior to hysteroscopic surgery in order to cause thinning of the endometrium, thereby affording a more clear view of the uterine interior, a benefit also gained by scheduling the surgery shortly after menses end. Following the induction of endometrial atrophy the basal layer is more susceptible to damage. A shorter operating time and a reduction in the amount of fluid absorbed during surgery has been reported following the administration of GnRHa prior to various types of hysteroscopic surgery (Parazzini et al., 1998), a claim disputed by others (Mavrelos et al., 2010). Irrespective of which claim is correct, the benefits claimed by Parazzini et al. (1998) were not of any clinical significance. Taskin et al. (1996) reported a high rate of IUA formation after hysteroscopic myomectomy and metroplasty when pretreatment with a GnRHa was used. Hence, for this indication, preoperative GnRHa treatment is not necessary and potentially harmful. Hysteroscopic myomectomy Hysteroscopic myomectomy is usually performed with a resectoscope. By using the lowest effective power setting and delivering the energy in the pure-cut mode, this risk is reduced greatly. 42

45 Invited Speakers Abstracts New instrumentation and technologies The introduction of new instrumentation and technologies into the field of reproductive surgery benefits all. Initial studies to prove safety and efficacy are performed by expert surgeons. However, after these instruments are marketed, they are often used by those with little or no training, increasing the risk of excessive uterine damage. With the advent of oocyte donation and gestational carriers, some practitioners have concluded that the need to protect reproductive organs from further damage is less important. Thus, the emphasis upon meticulous reproductive surgery has diminished. Comprehensive therapy For decades, the study centre has used a multifaceted approach to the treatment and follow-up of AS (Table 3). Repair of the uterus under direct visualization was proven (Levine and Neuwirth, 1973) to be superior to blind curettage in the early 1970s. Lysis of adhesions under direct vision permits the surgeon to cut only scar tissue, reducing trauma to normal endometrium; thus, it is safer and more complete than blind curettage. A continuous-flow hysteroscope is used and the cavity is distended with a low-viscosity fluid. Miniature scissors incise rather than excise each adhesion, because excision risks further injury to the endometrial basalis. Complete adhesiolysis can be achieved even in women with extensive disease. In some instances, even after extensive hysteroscopic adhesiolysis, intrauterine landmarks remain obscure; in others, entry into the uterus is not possible and thus the risk of uterine perforation is high should the hysteroscopic approach continue unassisted. Two alternatives provide safety and reduce the risk of perforation. In these instances and for those who have suffered one or more uterine perforations previously, the study centre performs simultaneous laparoscopy. Following a survey of the pelvis and correction of any endometriosis and/or pelvic adhesions, the intensity of the light source for the laparoscope is reduced markedly. The hysteroscopic adhesiolysis is begun and the laparoscopist monitors the intensity of the hysteroscopic light which is transmitted through the uterine wall. If the uterus glows uniformly, it is presumed that the hysteroscopist is in the proper plane of dissection and that the risk of perforation is low; if instead, a bright, well-focused beam of light shines through the uterine muscle, it is likely that perforation is imminent and the plane of dissection is altered. With this combined approach, only one perforation has occurred. The complication rate has been low: 64 complications in 1493 procedures. In 46 women there was bleeding at the site of tenaculum placement. Two others had intrauterine bleeding which was controlled with placement of a balloon for 24 h. Seven patients were hospitalized for fluid overload. Six of these had received at least 600 ml of high-molecular-weight dextran (a medium no longer used for hysteroscopic surgery) to distend the uterus and also had disseminated intravascular coagulation. There were eight midline fundal perforations, none of which required treatment. One patient became febrile 2 days after surgery and received antibiotics. Others have reported complication rates to be between 1.1% and 9%, with perforation and haemorrhage being the most common complications (Yu et al., 2008). This approach has resulted in an overall success in restoring uterine architecture to normal (as judged by HSG or in-office hysteroscopy) of 77.4% and a pregnancy rate of 61.6% (Table 4). As would be expected, those who had one prior attempt at cure elsewhere had a significantly poorer anatomic outcome and a lower pregnancy rate. These results were even worse if two prior attempts elsewhere had been unsuccessful. Others use ultrasound to image the endometrium and provide a target for the hysteroscopic dissection (Dabirashrafi et al., 1992). This approach is of value for those with significant lower segment scarring but whose upper cavities are damaged only moderately or less. If there is significant lateral or marginal scarring, the ultrasound images may not prevent dissection into the myometrium and even uterine perforation. Pressure lavage under guidance involves adhesion disruption by continuous intrauterine in- 43

46 Invited Speakers Abstracts jection of saline under ultrasound guidance (Coccia et al., 2001). This technique may disrupt mild, filmy adhesions but the data are too few to recommend its general application. Hysterotomy is performed rarely for patients whose extensive adhesions of the endocervical canal and lower uterine segment prevent access to the upper fundus even under laparoscopic or ultrasound guidance (Reddy and Rock, 1997). Pre-operative ultrasound or MRI is essential to verify that a pocket of normal endometrium is present. If none can be detected, complete obliteration can be diagnosed and surgery is unwarranted. The pre-operative imaging study allows the surgeon to plan the site of entry into the uterus. The lower uterine segment and endocervical canal adhesions are disrupted from above with a dilator and a stent is placed into the uterus. The stem of the stent is passed into the vagina in order to splint the endocervical canal and to prevent readherence. Antibiotics are prescribed while the stent is in place. Serum may ooze from the areas of the freshly dissected scars, promoting scar reformation. Thus, a non-reactive uterine stent is placed in the uterine cavity in order to keep the raw, freshly dissected surfaces separated during the initial post-operative healing phase. Polishuk et al. (1969) reported that by following adhesiolysis with IUD placement, the rate of adhesion reformation was only 10%. In contrast, in a prior series of patients treated without an IUD, the recurrence rate was above 50%. Previously, the study centre has used an inert Lippes Loop IUD. This device is no longer available in the USA. T -shaped devices have a surface area too small to maintain separation of the uterine walls and thus prevent adhesion reformation. Those which contain copper induce an excessive inflammatory reaction. Devices which release a progestin into the endometrium prevent the desired proliferation produced by the post-operative oestrogen therapy. Therefore, their use is not advised. A Cook balloon uterine stent which, because of its triangular shape, conforms to the configuration of a normal uterus and maintains separation at the margins of the uterine cavity, which is where reformation is most common, is placed immediately after completing adhesiolysis. If the scarring is limited to the endocervical canal and region of the internal cervical os, a 12 French Foley catheter is used. After inflating the Foley balloon, heavy silk ligatures are placed around the catheter as it emanates from the cervix and the distal end is removed. The duration that a stent remains in place is based upon the extent and density of the scarring. A broad-spectrum antibiotic is prescribed during the time that the stent is in place. The use of oestrogen to promote endometrial overgrowth and re-epithelialization of the scarred surfaces is standard. Oral micronized oestradiol, 2 mg twice daily, is prescribed for days and medroxyprogesterone acetate, 10 mg daily, is added during the last 5 days of oestrogen therapy. The importance of a post-operative study to verify normalcy of the cavity prior to permitting conception cannot be overemphasized. Severe obstetric complications have been reported in patients who conceived prior to having post-operative studies performed to document complete resolution of the adhesions. The spontaneous abortion rate (15.6%) is not higher than that among women who conceive without a history of IUA. The same is true for the frequency of prematurity which was 7.0% in this series. This rate is considerably lower than the 25 50% reported in some series (Roge et al., 1997 and Zikopoulous et al., 2004). However, 13 pregnancies (1.9%) were complicated by cervical incompetence versus an expected rate of % (Lindegaard, 1994). Presumably, the repeated cervical dilations from both the curettage(s) which preceded the development of IUA as well as the dilation(s) performed during therapy contributed to cervical insufficiency. Therefore, careful monitoring of cervical length (Owen et al., 2004) as well as funnelling of the membranes (Novy et al., 2001) should be part of the obstetric management for patients who have had multiple cervical dilations. Placenta accreta occurred in 1.9% of pregnancies and four of these 13 patients underwent hysterectomy. Although the incidence of placenta accreta was one in 30,000 deliveries 50 years ago, this rate is increasing, pre- 44

47 Invited Speakers Abstracts sumably because of the increasing incidence of Caesarean section and myomectomy and of increasing maternal age (Al-Serehi et al., 2008 and Miller et al., 1997). Although the frequency reported herein is well above the baseline incidence, it is lower than the 5 31% incidence reported in other series of post-asherman s pregnancies (Jewelewicz et al., 1976 and Schenker and Margalioth, 1982). The overall pregnancy rate following treatment of IUA is approximately 30 75% (Yu et al., 2008). Valle and Sciarra (1988) reported that the pregnancy and term pregnancy rates were significantly higher in those with minimal disease (93.0% and 87.5%, respectively) compared with those with severe IUA (57.4% and 55.6%, respectively). Some authors have reported that although more than 62% of those under age 35 conceived, only 23% or less of those over 35 did so (Capella-Allouc et al., 1999 and Fernandez et al., 2006), a finding disputed by others (Zikopoulous et al., 2004). Unfortunately neither the ages of those who did not conceive nor data about the presence or treatment of other infertility factors were reported. In neither report was a correlation made between the results of surgery and pregnancy occurrence or outcome. Roge et al. (1997) identified one or more additional infertility factors in 60% of those who did not conceive initially and stressed the need for a complete evaluation. In the study centre s experience, a normal post-operative study has forecasted a high pregnancy rate. The gestational outcome among those with a normal uterus has been identical irrespective of the pretreatment extent. Five series have demonstrated a marked improvement in the gestational outcome after lysis of adhesions in patients with previous poor outcomes, improving a pretreatment successful pregnancy outcome of 25.7% (260 of 1013 pregnancies) to 79.3% (237/299 pregnancies) (Caspi and Perpinial, 1975, Lancet and Kessler, 1988, March and Israel, 1981, Oelsner et al., 1974 and Valle and Sciarra, 1988). Katz et al. (1996) reported similar results. Four factors independently reduce significantly the success of treating IUA: (i) the use of a GnRHa prior to hysteroscopic myomectomy; (ii) breastfeeding for 3 or more months among those who underwent post-partum curettage; (iii) post-partum curettage 2 4 weeks after delivery; and (iv) the presence of myometrium in the curettings of those who underwent postpartum D and C. The latter may be a finding which is under-reported (Beuker et al., 2005). Pre-operative GnRHa therapy and post-partum breastfeeding may be considered together because both induce and maintain an atrophic endometrium, facilitating significant damage to the endometrial basalis. If used prior to abdominal myomectomy, GnRHa therapy causes the planes of dissection to be difficult to separate, thus facilitating endometrial damage during dissection of myomas which are near to, or impinge upon, the endometrial cavity (Deligdisdi et al., 1997). If used prior to hysteroscopic myomectomy, the electrical energy is applied closer to the endometrial basalis, increasing the risk of permanent damage. Post-partum breastfeeding maintains oestrogen deficiency and facilitates damage to the endometrial basalis at a time when resumption of ovarian function may have been protective. Curettage 2 4 weeks after delivery was demonstrated by Eriksen and Kaestel (1960) to be associated with a high rate of amenorrhoea and scar formation, perhaps because of the marked inflammatory process at this time and because the walls of the involuting uterus are maintained in close apposition at this time. Eriksen and Kaestel (1960) did not comment upon breastfeeding or the presence of myometrium in the curettings as an additive cofactor in inducing post-curettage amenorrhoea. The presence of myometrium in curettings is evidence of permanent damage to the uterine interior with an area of deficient endometrium. This same deficiency occurs after hysteroscopic myomectomy and may facilitate the development of placenta accreta in subsequent pregnancies. Investigation Asch et al. (1991) inserted oestrogen fibre-wrapped IUD into the uteri of castrated rhesus monkeys. The devices induced marked endometrial proliferation and the authors suggested that such a device might provide the same efficacy as oral oestrogen treatment but without the systemic side effects. Tourgeman et al. (1999) demonstrated that the vaginal ad- 45

48 Invited Speakers Abstracts ministration of micronized oestradiol was more effective in raising endometrial concentrations of oestradiol than was the oral route of administration. Despite the restoration of uterine architecture by surgery, the problems of adhesion reformation and endometrial deficiency remain. One approach to adhesion reformation is the use of stents which maintain the freshly dissected surfaces apart during the immediate post-operative period. Others perform frequent office hysteroscopies soon after the initial procedure when any reforming scars are thin and filmy and easily lysed (Robinson et al., 2008). This approach seems ideal but involves more cost and perhaps risks. Randomized trials of these approaches are needed. The uterine cavity has also been filled with the abdominal anti-adhesion barrier SprayGel (mainly polyethylene glycol) after adhesiolysis (Abbott et al., 2004). The material is absorbed slowly over the next 7 21 days. Data regarding efficacy are sparse and no trials of SprayGel for this purpose have been initiated in the USA. Mohamed and Abd-El-Maeboud (2006) placed amniotic membrane around a balloon catheter. Success was limited and the data are very sparse. Seprafilm (hyaluronic acid and carboxymethylcellulose), used commonly after abdominal surgery, is not practical for intrauterine use (Tsapanos et al., 2002). Hyaluronic acid gel is also under investigation (Acunzo et al., 2003). High-dose oestrogen therapy has been the prime method of stimulating endometrial growth after surgery. Not all patients respond and in some, the benefit is only transient. Women who fail oestrogen therapy may be those with damage to the endometrial basalis, those with myometrial fibrosis and those with vascular insufficiency, e.g. after uterine artery embolization. Some studies using sildenafil (Viagra), 100 mg vaginally or 6 mg of l-arginine (which may strengthen blood vessels) daily have shown increased endometrial thickness and an improvement in radial artery-resistance indices (Takasaki et al., 2008). There are encouraging, but scanty data demonstrating thickened endometrium after 6 months use of pentoxifylline (800 mg/day) and vitamin E (1000 IU/day). Some of those who had benefited had undergone radiation therapy, raising the possibility that these medications may bypass or reverse fibrosis. Vitamin E may also improve glandular epithelial growth, development of blood vessels and vascular endothelial growth factor protein expression in the endometrium (Acharya et al., 2009). The Asherman s Online Community ( and the website are valuable resources for patients. These sites and continuing medical education courses and the literature should guide most patients and their physicians through the daunting process of prevention, anticipation, diagnosis, treatment and follow-up. A comprehensive approach to IUA including early diagnosis, meticulous surgery, modalities to reduce scar reformation, documentation of cure prior to permitting patients to try to conceive and ongoing surveillance of pregnancies up to and including delivery has been demonstrated to optimize outcome. Among those who have suffered repeated spontaneous pregnancy loss, a comprehensive evaluation of the couple in order to detect other causes for repeated miscarriage is mandatory. SURGERY OF HYDROSALPIGES AND IMPLANTATION RATE: SALPIGGECTOMY, SALPINGOSTOMY, LIGATION, ESSURE Vasilios Tanos MD PhD, Director IVF unit, Aretaeio Hospital, Nicosia. Cyprus The frequency of tubal and pelvic pathology among infertile women is 30-40%. Infertility due to tubal factor increases with age and infertility duration (Am.Soc.ReprMed A Practice Com 46

49 Invited Speakers Abstracts Report 2000). The risk of subsequent tubal infertility after pelvic inflammatory disease is 10-12% after 1 episode, increases to 23-35% after 2 episodes, reaching to 54-75% after 3 episodes (Westrom LV et al Sex Transm Diseas 1994). Fibrial and ampular mucosal subtle adhesions importance has not yet fully validated by prospective studies and it is difficult to interpret and compare (Al-Inany H Acta Obs Gynec Scand 2001). Distal Tubal Occlusion presents a wide spectrum of severity a) Aglutinated fibria and adherent fibrial folds, b) Various degrees of phimosis, partial up to severe form c) complete obstruction and d) hydrosalpinges. Chlamydia antibody test can be as accurate as HSG in detecting tubal pathology (Rowland AS et al Epidemiology 2002) (Mol BW ASRM Birmingham, AL 2001). Chlamydia antibody test is recommended for unexplained infertility, with normal HSG, those suspected to have tubal factor (Johnson NP et al BJOG 2000). The 2D, 3D Ultrasound, hydrosonography and HSG cannot reliably detect or accurately define lesser degrees of disease when the tubes are still open. However trans vaginal endoscopy and standard laparoscopy provide the definitive diagnosis and treatment options. Data clearly demonstrates that laparoscopic salpingectomy or tubal occlusion increases IVF success rates by 2-fold and should be recommended to all women with hydrosalpinges planning IVF. In 2010 reviewing 5 RCTs, overall of 646 patients underwent salpingectomy or Tubal Ligation pregnancy rate was double and neither of the procedures was superior to the other (Johnson NP, et al. Cochrane Database Syst Review 2010). Younger women with mild distal tubal occlusion (DTO) reconstructive laparoscopic surgery, fibrioplasty and neosalpingostomy may be recommended and wait for spontaneous pregnancy for the first post-operative year. Unilateral salpingostomy in women with a contra lateral patent tube also improves fertility. Selection of patients is based on salpingoscopy, evaluating mucosal architecture and degree of adhesions versus healthy tissue. Adhesiolysis, eversion of fimbrial mucosa and securing stoma with suturing are usually performed laparoscopically. The live birth rate in mild forms of DTO postoperatively is over 50% but for severe ones LBR is 10-35% (Taylor RC, et al. Fertil Steril 2001). Tubal ligation is reserved for difficult cases whereas more radical surgery can compromise ovarian vascularization and functionality. Another option is micro-insert proximal end occlusion by hysteroscopy. Essure-coil placement prior to IVF, in 13 infertile women with hydrosalpinges, reported easy placement in all patients, 1 pop complication (pyosalpinx), 64% PR, and no micro-insert related complication during pregnancy and delivery (Thebault N et al. J Gynecol Obstet Biol Reprod [Paris] 2012). Review of 7 studies found the hysteroscopic placement of Essure in ambulant setting, to be feasible and safe, and a good alternative to laparoscopic approach with encouraging fertility results (Sonigo C et al. in 2013 in Gyn Obst Fertil [Fr]). However, the risk to perforate the tube, delayed occlusion up to 3 months, need of X-ray confirmation of occlusion and cost effectiveness are the main concerns for the hysteroscopic approach which still is under research. In conclusion, unilateral and bilateral hydrosalpinges reduce pregnancy rates. Age, past history and tubal heath condition will indicate the treatment option for mild forms of DTO. Severe forms of DTO salpingectomy is preferable when feasible. In case that ovarian vascularity is at risk consider tubal ligation or micro insert hysteroscopic PTO. Fibrioplasty and Salpingostomy where appropriate, offer a chance upto 50% PR for spontaneous pregnancy as compared to 7-10% in non-treated cases. The PR in IVF treated women after salpingectomy and tubal ligation can be as high as 25-37%. 47

50 Invited Speakers Abstracts THE ROLE OF PROGESTERONE IN THE LATE FOLLICULAR PHASE Stratis Kolibianakis MD MSc PhD Ass Professor in Obstetrics / Gynaecology and Assisted Reproduction Unit for Human Reproduction, Medical School, Aristotle University. Greece The introduction of ovarian stimulation has been followed by a constant effort to fine-tune the physiology of the stimulated cycle and optimize the probability of pregnancy after IVF. In this respect, the role of progesterone elevation (PE) on the day of hcg administration in GnRH analogue cycles has been under the spotlight for over 20 years. The issue is still far from resolved. Certain clinicians highly doubt the presence of an association between PE and the probability of pregnancy and do not monitor progesterone on the day of hcg, while others have implemented specific strategies in order to avoid or manage PE. A literature search in MEDLINE, SCOPUS, COCHRANE CENTRAL and ISI Web of Science was performed aiming to identify studies comparing the probability of pregnancy in patients with or without PE after ovarian stimulation with gonadotrophins and GnRH ana- logues. Standard meta-analytic methodology was used for the synthesis of results and meta-regression for exploration of heterogeneity. Sixty-three eligible studies were identified evaluating fresh IVF cycles, nine studies evaluating 7229 frozen thawed cycles and eight studies evaluating 1330 donor/recipient cycles. In fresh IVF cycles, a decreased probability of pregnancy achievement was present in women with PE (when PE was defined using a threshold 0.8 ng/ml) when compared with those without PE. The pooled effect sizes were ng/ml: odds ratio (OR) ; ng/ml: OR ; ng/ml: OR ; ng/ml: OR: 0.68 (P, 0.05 in all cases). No adverse effect of PE on achieving pregnancy was observed in the frozen thawed and the donor/recipient cycles. Based on the analysis of more than cycles, it can be supported that PE on the day of hcg administration is associated with a decreased probability of pregnancy achievement in fresh IVF cycles in women undergoing ovarian stimulation using GnRH analogues and gonadotrophins. On the other hand, an adverse effect of PE does not seem to be present in frozen thawed and donor/recipient cycles. 48

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