PROF ABOUBAKR ELNASHAR

1. 9/3/2022
WHAT IS NEW IN
 ESHRE 2022 CONFERENCE
&
 FIGO 2022?
For General Gynecologist
Prof. Aboubakr Elnashar
Benha university hospital
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 97 sessions:
 317 oral presentations
 801 poster presentations
1. Keynote Session: 1
2. Plenary sessions: 10
3. Communication sessions: 37
 Session: ART in times of war in Europe .
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2. MALE INFERTILITY
Male fertility testing - new horizons, ideas & research
A. Salas-Huetos
 Limitations of the current semen analysis
 Alternative diagnostic approaches that effectively predict fertility
in men is urgently needed
 Novel tests are available & more important the new horizons,
ideas & research in male fertility testing.
1. Sperm functionality analyses
 Plasma membrane & acrosome integrity, plasma membrane
lipid disorder, mitochondrial membrane potential,
 Mitochondrial peroxide and superoxide levels, intracellular
levels of ROS and Ca2þ, sperm chromatin condensation
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2. The newest recommendations of European Association of
Urology 2021:
 SDF testing should be performed in RPL, or men with
unexplained infertility (Normal semen parameters) (strong recommendation)
 Varicocelectomy may be considered in men with raised SDF
with otherwise unexplained infertility or who have suffered
from RPL, RIF (weak recommendation)
3. The newly described monogenic causes (regulated by one gene or one
of a pair of allelic genes) of male infertility Next-Generation Sequencing:
increasing number of monogenic causes of male infertility
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The MiOXSYS System: This device measures ORP using only a galvanostatic
MiOXSYS analyzer (A) and disposable sensor strips (B).
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Predictive value of seminal oxidation-reduction potential
(ORP) and SDF analysis for reproductive outcomes of ICSI
Cycles
A. Morris et al
 Both SDF & seminal ORP have strong prognostic value in
predicting
 good fertilization (80%),
 blastocyst development (60%),
 CPR & LBR
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2. 9/3/2022
Sperm count is increased by diet-induced weight loss and
maintained by exercise or GLP-1 analogue treatment: RCT
Andersen et al
 An 8-w low-calorie diet-induced weight loss:
 improved sperm count, which was maintained after one year
in men who maintained weight loss.
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3. ENDOMETRIOSIS
Pathophysiology of endometriosis– what’s new?
H. Taylor.
 E is defined as a ch. gyn disease characterized by endometrial-
like tissue present outside of the uterus & is thought to arise by
retrograde menstruation.
 However, this description is outdated & no longer reflects the
true scope & manifestations of the disease.
 E is now considered a systemic disease rather than a disease
predominantly affecting the pelvis.
 E: affects metabolism in liver & adipose tissue: systemic inflammation
alters gene expression in the brain: pain sensitization &
mood disorders. ABOUBAKRELNASHAR
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 Recognition of the full scope of the disease will facilitate
diagnosis & allow for more comprehensive TT
 Progestins&low-dose COC are unsuccessful in a third of
symptomatic women {progesterone resistance}.
 Oral GnRHan
 An effective & tolerable alternative when 1st line medications
do not work
 Fewer side-effects than other therapies
 Optimize& personalize endometriosis care.
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Impact of endometriosis on the oocyte
C. Racowsky et al
 Women with E tend to have lower implantation rates
than those without E.
 Whether this is due to compromised endometrial
receptivity or reduced embryo quality remains
controversial.
 Studies support the conclusion that oocyte quality is the main
factor compromising implantation rate.
 This conclusion is consistent with documented elevations of
inflammatory cytokines, ROS & growth- and angiogenic factors
in follicular fluid&peritoneal fluid of women with E.
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Endometrioma & fertility preservation: how can we save
the oocytes. J. Donnez
 Fertility preservation is a major challenge when therapeutic
approaches of ovarian endometrioma are planned.
 How to preserve fertility in women at risk of POI due to severe
&/or recurrent ovarian E? Two main options:
1. COS,ovum pick-up & vitrification of oocytes: high cumulative
LBR in women ≤35 y: patients with endometrioma should be
encouraged to freeze oocytes at a younger age.
2. Orthotopic* auto transplantation of cryopreserved ovarian
cortex (which has led to ≥200 live births ) could be proposed to
maintain the follicular pool.
*Grafting of tissue in a natural position
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3. 9/3/2022
Evidence based management of endometriosis – what has
changed since 2013? C. Becker
 Laparoscopy is no longer the gold standard for E
 TVS performed by an experienced operator or MRI can equally
identify or rule out ovarian & most of deep E.
 Ultralong protocol is not recommended
 GnRHan seem to be effective in TT of E-associate pain&,
where available, could be considered as 2nd-line TT
 Specific chapters on
 E in adolescents and in menopausal women
 Association of E with certain forms of cancer namely
subgroups of ovarian, breast & thyroid cancer
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4. FIBROID
To remove or not to remove - debate continues
K.D. Nayar
 Both size & distance of F. from endometrial cavity are important
factors, which determine the effect of intramural F on fertility.
The production of transforming growth factor is increased as
size of F increases: impairs the endometrial receptivity.
 F. causing menorrhagia are likely to affect end receptivity.
 Myomectomy on intramural F should be individualized
 Prior to ART cycle in women with
 Reduced ovarian reserve,
 Advanced maternal age,
 RPL or RIF ABOUBAKRELNASHAR
The effect of the presence of intramural Fibroid smaller
than 6 cm on reproductive outcome in IVF treatment: a
SR and MA
E. Uyanık et al
 Non-cavity-distorting intramural myomas with the size of<6 cm
have a significant adverse effect on reproductive outcomes in
IVF.
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BMI is not associated with ovarian
response to gonadotropin during IVF/ICSI: An
evaluation of 4499 IVF/ICSI cycles
C.G. Petersen et al.
 BMI does not seem to be associated with the ovarian response
to gonadotropin.
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Cancer in Children Born after Frozen-Thawed ET: A Cohort Study
N. Sargisian et al.
 Children born after FET have a higher risk of childhood cancer
than children born after fresh ET and spontaneous conception.
 This large Nordic registry-based cohort study included 171 774 children born
after use of ART and 7 772 474 children born after spontaneous conception
during a study period of up to three decades (Denmark, Finland, Norway, Sweden).
 For cancer subgroups, higher risks of
 epithelial tumours and melanoma after any ART
 leukaemia after FET.
Incidence rate (IR) of any cancer before 18 y of age /100 000 person-years after
Spontaneous conception ART Fresh ET FET
16.7 19.3 18.8 30.1
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8. RPL
Subclinical hypothyroidism & antithyroid autoantibodies
in women with subfertility or RPL
R. Dhillon-Smith et al
 Untreated mild–moderate SCH (TSH 4.0-10.0mIU/l):
 Early pregnancy loss
 LT4 TT: improved pregnancy & LBR (low quality evidence)
 Routine preconception TSH & fT4 testing should be offered to
women with history of
 RPL or
 women undergoing ART
 Once pregnancy: women receiving LT4 TT for SCH:
 An empirical dose increase, doubling the dose on 2 days/w
 Regular TSH measurements from 7–9 W gestation.
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4. 9/3/2022
 Euthyroid TPO Ab-positive
 No benefit from LT4 TT women
 Thyroid function monitoring during pregnancy.
 Further studies are required to determine the role of
selenium or steroids in improving pregnancy outcomes
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10. OTHERS
Does advanced paternal age influence LBR independent of
woman’s age: analysis of 18, 825 fresh IVF/ICSI cycles from a
national (HFEA) database
A.K. Datta
 LBRs decline with paternal age 40 ys, but not when female
partner is<35 or40 ys.
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The pregnant outcome after laparoscopy treatment for
subtle distal fallopian tube abnormalities in infertile population:
a prospective cohort study
Zheng et al
 Subtle distal fallopian tube abnormalities: Fimbrial agglutination,
tubal diverticula, accessory ostium, fimbrial phimosis, and
accessory fallopian tube.
 The natural pregnancy rate is 46.58% after laparoscopy TT
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Comparing LNG-IUS 52mg vs hysteroscopic resection
in patients with postmenstrual spotting related to a niche in the
caesarean scar (MIHYS NICHE Trial)
D. Zhang et al.
 At the 6th month after TT, the median total bleeding days after
LNG-IUS 52mg was 4 days, shorter than 13 days after
hysteroscopic niche resection.
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The FIGO
Ovulatory Disorders Classification
System, 2022
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
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 WHO types of anovulation, 1973
 Modified
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5. 9/3/2022
 Why there is a need for a more comprehensive & updated
classification?
I. Limitations Of Existing Classification
1. Anovulation is only one extreme of ovulatory dysfunction
that includes a spectrum of manifestations that range from
isolated episodes to chronic ovulatory failure.
2. Hormone levels do not obey clear rules. E. g.
hypothalamic amenorrhea who are underweight, LH levels
are usually suppressed, while FSH levels are often in the
normal range.13,14
3. Women with PCOS often have levels of FSH & LH in the
normal range.15 ABOUBAKRELNASHAR
II. Significant advances in
 Understanding the control of ovulation & the
pathophysiology of ovulatory disorders
 Assay technology & genomics.
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 FIGO classification now includes 4 groups
 Type I: Hypothalamic
 Type II: Pituitary;
 Type III: Ovarian
 Type IV: PCOS
 Acronym “HyPO-P,”where the “P” is separated from the other
three categories recognizing that it does not reside in a single
anatomic location.
 provides practical utility and a second layer, or sub-
classification, for each of the three anatomically defined
entities, including discrete pathophysiological categories. These
can be remembered using the acronym “GAIN-FIT-PIE”
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 After the individual is
diagnosed with an
ovulatory disorder,
 1st level: allocation to type
I, II, or III disorders
according to their
presumed primary source:
hypothalamus, pituitary
gland, or ovary,
respectively. PCOS
comprises the type IV
category
 2nd level stratifies each
anatomic category (types
I–III) into the known or
presumed mechanism
acc to the “GAIN-FIT-
PIE” mnemonic ABOUBAKRELNASHAR
2. CLINICAL APPLICATION
I. Identifying individuals with ovulatory disorders
 Ovulatory disorders:
 Any alteration of ovulatory function in women in the
reproductive years
 Not synonymous with the term “anovulation.”
 Exist on a spectrum ranging from episodic to ch
 Typically, but not always: abnormalities in
menstrual parameters: frequency, regularity,
duration, volume, and, in the case of chronic
anovulation with amenorrhea
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 Exist on a spectrum that ranges from occasional failure to
ovulate to chronic anovulation.
 LUF and luteal out of phase (LOOP) disorders exist on a similar
spectrum of varying frequency.
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6. 9/3/2022
II. Further evaluations
 Necessary to identify cause
 Vary according to the clinical circumstance.
1. Ovulation predictor kits
 LH surge in urine generally accurately reflect levels of
serum LH
 Valuable tool for detecting ovulation in a given cycle.40
2. Measuring progesterone in the predicted luteal phase
 may provide satisfactory evidence supporting ovulatory
function, particularly when 1st day of the next menstrual
period is known.41
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III. Categorization
 Investigations to localize the site and the mechanism
contributing to ovulatory dysfunction. For example
 Infrequent & irregular menses, galactorrhea,
elevated prolactin, and MRI demonstrating a
pituitary tumor would categorize as a type 2 –N
(pituitary neoplasm)
 Irregular and infrequent menstruation, mild hirsutism, and
US ovarian volume: ≥10 ml or an ovary with ≥20 follicles
without a dominant follicle or corpus luteum, a circumstance
that dictates a type 4 –PCOS classification. Use of the 20-follicle threshold is
utilized only when the patient is examined with an endovaginal ultrasound transducer with a high frequency bandwidth of at least 8
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