REDLARA EN VIVO 2020 . PROGRAMACIÓN e INFORMACIÓN by REDLARA-oficial

congreso online

05 REDLARA EN VIVO 06 REDLARA 08 QUIENES SOMOS 16 SESIÓN INAUGURAL 18

COMO TEMOS TRABALHADO EM TEMPOS DE PANDEMIA

RECEPTIVIDAD ENDOMETRIAL: ERA, EMMA, ALICE, SON IMPRESCINDIBLES?

NUEVAS ESTRATEGIAS PARA DESENCADENAR LA MADURACIÓN OVOCITARIA Y PARA EL BLOQUEO

ENDOMETRIAL PREPARATION FOR FROZEN EMBRYO TRANSFER: NATURAL CYCLE VS ARTIFICIAL CYCLE

COSTO EFICIENCIA DEL USO DE PGT EN MUJERES MENORES DE 38 AÑOS

INVASIVE PGT-A (IPGT-A) X NONINVASIVE PGT-A (NIPGT-A) -PROS AND CONS

¿TRANSFERENCIA DE UNO O DOS EMBRIONES EN MUJERES MENORES DE 35 AÑOS O SOMETIDAS A OD? EVALUACIÓN DE LA CALIDAD ESPERMÁTICA: ESPERMATOZOIDES TESTICULARES EN HOMBRES CON FRAGMENTACIÓN DEL DNA ELEVADA?

40 42 PROGRAMA CIENTÍFICO 48

ASSISTED REPRODUCTIVE TECHNIQUES IN LATIN AMERICA: THE LATIN AMERICAN REGISTRY, 2017

REDLARA EN VIVO Un año para reinventarse, generar nuevas formas de estar con aquellos que queremos, seguir aprendiendo y superar los desafíos de una pandemia sorpresiva y sin precedentes que nos ha llegado a todos. Nuestro continente Latinoamericano ha sido siempre una mezcla de colores, culturas increíbles y gente bella, que trabaja cada día y se supera en creatividad y voluntad. Es esta fuerte voluntad la que nos ha movido a crear REDLARA EN VIVO - una nueva marca de REDLARA, que hará con que podamos acercarnos cuando no es posible, cuando la distancia no nos permita dar este abrazo lleno de energía que es tan peculiar en nuestra comunidad. REDLARA EN VIVO puede ser un congreso, una clase, una discusión, un espacio de encuentro que promueve que nuestra comunidad siga creciendo y aprendiendo, y lo más importante, conviviendo y acompañándonos. Esta primera experiencia REDLARA EN VIVO • congreso latam, brinda a los profesionales de toda Latinoamérica - nuestra comunidad, la oportunidad de participar de discusiones de temas que generan aún controversia en nuestro medio, con conferencistas invitados de nuestro continente y también nuestro invitado europeo, el Professor Siladitya Bhattacharya. Siempre hay maneras de ser y estar. Bienvenidos a REDLARA EN VIVO! congreso online

REDLARA - Red Latinoamericana de Reproducción Asistida

REDLARA - Red Latinoamericana de Reproducción Asistida La Red Latinoamericana de Reproducción Asistida (REDLARA) es una asociación sin ánimos de lucros, que se dedica a la educación continuada, a la acreditación de centros de reproducción asistida, a colectar y distribuir la información de los procedimientos que realizan los centros que son parte de REDLARA. Estas actividades de REDLARA garantizan que acciones correctivas sean establecidas rápidamente, para la seguridad, salud y bienestar de las parejas que acceden nuestros centros para tratamientos de fertilidad, y a su descendencia. Fue creada en el año 1990, por las manos de su primer presidente e idealizador: Dr. Fernando Zegers-Hochschild, quien reunió 50 centros de reproducción asistida en Latinoamérica y publicó la primera edición del Registro Latinoamericano de Reproducción Asistida (RLA). Ya son 30 años de publicación ininterrumpida de esta importante y reconocida actividad de REDLARA, que es el primer Registro multinacional y el primer que realiza registro caso a caso en el mundo. Siete años más tarde, con la finalidad de promover veracidad a la información reportada, para acompañar y educar a los centros que reportaban al RLA, nace el programa de acreditación de centros. En los últimos años, esta actividad ha sido perfeccionada: durante la visita de acreditación, se realiza una atenta y cuidadosa revisión de las instalaciones físicas, equipos, documentación y registros que el centro realiza. Como bien decía nuestro querido e inolvidable Dr. Roberto Coco (in memoriam) - ex Vicepresidente de REDLARA: “la acreditación no es una actividad policíaca, y sí una oportunidad de educar y acompañar los centros que muchas veces necesitan apoyo, crecer juntos y garantizar que los procedimientos que realizan sean adecuados y confiables”.

La continua atención a los profesionales de nuestra comunidad se realiza a través de nuestros programas de educación - cursos y congresos. Otra fuerte marca de REDLARA: PEC Online, vigente y activo desde el año 2003. Fue gracias a la visión del Dr. Franco Junior, ex-presidente de REDLARA, la creación de esta herramienta de educación continuada a médicos, embriólogos, biomédicos, biólogos y geneticistas. En la actual gestión de la Dra. Maria do Carmo Borges de Souza, se expande, gana un bello logotipo y abre la oportunidad a que enfermeros, matronas, obstetrices e instrumentadores quirúrgicos también puedan perfeccionarse en el área. Aún dentro de nuestro programa de educación continuada, está nuestro programa de Certificaciones Profesionales a las siguientes categorías: Médico en Reproducción Asistida, Director Médico de Centro de Reproducción Asistida, Embriólogo de Laboratorio de Reproducción Asistida,, Directores de Laboratorio de Reproducción Asistida, Geneticista en Reproducción Asistida, Laboratorista en Andrología, Enfermero, Matrona y Obstetriz en Reproducción Asistida, Psicólogo en Reproducción Asistida. Esta actividad fue desarrollada en el año 2014, por los Drs. Roberto Coco (in memoriam), Soledad Sepúlveda (in memoriam), María Teresa Urbina y María Teresa Olivieri. Estar certificado por REDLARA asegura que el profesional posee la adecuada formación, conocimientos y habilidades apropiadas para el ejercicio de su profesión. Es un certificado de pericia que garantiza la experiencia en determinada área. Es una garantía de excelencia. En REDLARA, nuestros miembros no solamente pertenecen a una institución científica internacional de altísima calidad: ellos son la institución! Es por eso, y mucho más, que REDLARA es una única!

by REDLARA

CONSEJO DIRECTIVO

Presidente Dra. Maria do Carmo Borges de Souza | Brasil Vicepresidente Dr. A. Gustavo Martínez | Argentina Director Región Brasil Dr. Adelino Amaral Silva | Brasil Director Región Cono Sur Dr. Diego Masoli Illanes | Chile Director Región México Dr. José María Mojarra Estrada | México Director Región Noroeste Dra. Natalia Posada | Colombia Administración Lic. Marina Dias | México

REGISTRO LATINOAMERICANO

Director Dr. Fernando Zegers-Hochschild | Chile Asesor de laboratorio Dr. Javier Crosby | Chile Asesor computacional Ing. K.W.Schwarze | Chile Administración Bq. Carolina Musri | Chile

CENTROS

ARGENTINA CEGYR - Centro de Estudios en Ginecología y Reproducción | Buenos Aires Centro de Medicina Reproductiva Bariloche | Bariloche Centro de Reproducción | La Plata Centro Médico FERTILAB | Buenos Aires CER Centro Especializado en Reproducción | Buenos Aires CIGOR Centro Integral de Ginecología, Obstetricia y Reproducción | Córdoba CIMER, Centro de Investigaciones en Medicina Reproductiva | Buenos Aires CRECER - Centro de Medicina Reproductiva y Genética Humana | Mar del Plata Fecunditas | Buenos Aires Fertilidad San Isidro | Buenos Aires Fertya | Rosario Fundación Fecundart | Córdoba GENS - Centro Especializado en tratamientos para la mujer | Buenos Aires Gestar | La Plata Halitus Instituto Médico | Buenos Aires Hospital Italiano de Buenos Aires | Buenos Aires Instituto de Fertilidad Asistida Dr. Julio Colabianchi | Rosario Instituto Prefer | Buenos Aires Mater Medicina Reproductiva | Salta Nascentis, Especialistas en Fertilidad y Genética Reproductiva | Córdoba Pregna Medicina Reproductiva | Buenos Aires PROAR - Programa de Asistencia Reproductiva de Rosario | Rosario

Procrearte - Red de Medicina Reproductiva y Molecular | Buenos Aires SARESA - Centro de Salud Reproductiva Salta | Salta Seremas | Buenos Aires Servicio de Medicina Reproductiva, Instituto Gamma | Rosario Vitae Medicina Reproductiva | Salta BOLIVIA Cenalfes - Centro Nacional de Fertilidad y Esterilidad | Cochabamba Embriovid | La Paz ISARE Instituto de Salud Reproductiva | Santa Cruz de la Sierra BRASIL Androfert - Clínica de Andrologia e Reprodução Humana | Campinas Androlab Clínica e Laboratório de Reprodução Humana e Andrologia | Curitiba Bios - Centro de Medicina Reprodutiva do Ceará | Fortaleza CEERH - Centro Especializado em Reprodução Humana | São Paulo Cegonha Medicina Reprodutiva | Belo Horizonte CENAFERT - Centro de Medicina Reprodutiva | Salvador Centro de Ensino e Pesquisa em Reprodução Assistida do Hospital Materno Infantil de Brasília - CEPRA - HMIB | Brasília Centro de Fertilidade do Hospital Moinhos de Vento | Porto Alegre Centro de Reprodução Humana Monteleone | São Paulo Centro de Reprodução Humana Prof. Franco Junior | Ribeirão Preto Centro de Medicina da Reprodução | Rio de Janeiro Clínica de Fertilidade Geare | Recife Clinica Matrix | Ribeirão Preto Clinica Origen | Rio de Janeiro Clínica Pro Genesis | Santos Clinica Pró-Nascer | Rio de Janeiro CLINIFERT | Florianópolis Conceber Centro de Medicina Reprodutiva | Curitiba Conception Centro de Reprodução Humana | Caxias do Sul Conceptus - Centro de Reprodução Assistida do Ceará | Fortaleza Centro de Reprodução Humana de São José do Rio Preto | São José do Rio Preto Embrios Centro de Reprodução Humana | Bento Gonçalves Embryolife Instituto de Medicina Reprodutiva | São José dos Campos Fecunda Reprodução Humana | Uberlândia FELICCITA Instituto de Fertilidade | Curitiba Fertibaby Medicina Reprodutiva | Belo Horizonte FERTICLIN - Clínica de Fertilidade Humana | São Paulo

Fértil Reprodução Humana | Montes Claros Fertilcare - Centro de Reprodução Humana | Brasília Fértile Reprodução Humana | Goiânia Fertilitat Centro de Medicina Reprodutiva | Porto Alegre Fertility - Centro de Fertilização Assistida | São Paulo Fertility - Centro de Fertilização Humana Assistida de Campo Grande | Campo Grande Fertipraxis | Rio de Janeiro FERTIVITRO - Centro de Reprodução Humana | São Paulo Fertway Reprodução Humana | Curitiba FIVMED Instituto de Reprodução Humana | Campinas Generar Reprodução Humana | Porto Alegre Genesis - Centro de Assistência em Reprodução Humana | Brasília Genesis Centro de Reprodução Humana | Passo Fundo Genics Medicina Reprodutiva e Genômica | São Paulo Gera - Grupo de Endoscopia e Reprodução Assistida | São Paulo Gerar Vida Centro de Reprodução Humana | Rio de Janeiro Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto | Ribeirão Preto Humana Medicina Reprodutiva | Goiânia Huntington - Centro de Medicina Reprodutiva - Unidade Campinas | Campinas Huntington Centro de Medicina Reprodutiva - Unidade Ibirapuera | São Paulo Huntington - Centro de Medicina Reprodutiva - Unidade Vila Mariana | São Paulo IMR - Instituto de Medicina Reprodutiva e Fetal | São José do Rio Preto Insemine Centro de Reprodução Humana | Porto Alegre Instituto Ideia Fértil de Saude Reprodutiva | Santo André Instituto Verhum | Brasília Jules White Medicina Reprodutiva | Vitória Life Reprodução Humana | Cuiabá Materbaby - Reprodução Humana e Genética | Maringá Nascer Medicina Reprodutiva | Recife Nidus Medicina Reprodutiva | Juiz de Fora Nilo Frantz Medicina Reprodutiva | Porto Alegre Origen - Centro de Medicina Reprodutiva | Belo Horizonte Originare Centro de Reprodução Humana | São Paulo Serviço de Reprodução Humana do Hospital Maternidade Santa Joana | São Paulo Primordia Medicina Reprodutiva | Rio de Janeiro Procriar - Centro de Medicina Reprodutiva e Diagnósticos | Blumenau Pró-Criar Medicina Reprodutiva | Belo Horizonte Proser - Clínica de Fertilidade e Reprodução Assistida | Porto Alegre

Reproferty - Centro de Reprodução Humana, Saúde da Mulher e Saúde do Homem | São José dos Campos Vida Centro de Fertilidade | Rio de Janeiro CHILE Centro de Diagnóstico Sanatorio Alemán | Concepción CER Centro de Estudios Reproductivos Nevería | Santiago Clinica de la Mujer Medicina Reproductiva | Viña del Mar Clínica de Reproducción Humana de la Universidad Valparaiso | Valparaiso Clínica Las Condes - Unidad de Medicina Reproductiva | Santiago Unidad de Medicina Reproductiva, Antofagasta | Antofagasta Unidad de Medicina Reproductiva, Clínica Alemana | Santiago Unidad de Medicina Reproductiva, IDIMI | Santiago Unidad de Medicina Reproductiva, Monteblanco | Santiago COLOMBIA Asociados en Fertilidad y Reproducción Humana | Bogotá Clinica Machicado | San José de Cucuta Conceptum - Unidad de Fertilidad del Country | Bogotá FECUNDAR | Cali Fertivida - Unidad de Fertilidad | Bogotá Inser, Instituto de Fertilidad Humana - Sede Bogotá | Bogotá Inser, Instituto de Fertilidad Humana - Sede Medellín | Medellín Inser, Instituto de Fertilidad Humana Eje Cafetero | Pereira Instituto de Reproducción Humana PROCREAR | Barranquilla Procreación Médicamente Asistida | Bogotá Profamilia Fertilidad | Bogotá Unidad de Medicina Reproductiva - Centro Médico Imbanaco | Cali ECUADOR BIOGEPA - Centro de Reproducción Humana | Cuenca CERHVALENCIA Centro Ecuatoriano de Reproducción Humana Dr. Pablo Valencia | Quito Clínica INFES | Quito Concebir Unidad de Fertilidad | Quito INNAIFEST - Centro Nacional de Reproducción Asistida | Guayaquil Unidad de Fertilidad Drs. Valdivieso | Guayaquil GUATEMALA Centro de Reproducción Humana CER | Ciudad de Guatemala

NICARAGUA Centro de Fertilidad de Nicaragua | Managua PANAMÁ IVI | Panamá Instituto de Salud Femenina | Panamá IVF Panamá - Centro de Reproducción Punta Pacífica | Panamá PARAGUAY Neolife Medicina y Cirugía Reproductiva | Asunción PERÚ CEFERGIN - Centro Especializado de Fertilidad y Ginecología | Arequipa CEFRA - Centro de Fertilidad y Reproducción Asistida | Lima CFGS Centro de Fertilidad y Ginecología del Sur | Cusco Clinica Miraflores | Lima CLINIFER | Chiclayo FERTILAB Laboratorio de Reproducción Asistida | Lima Grupo Pranor del Instituto de Ginecología y Reproducción | Lima INMATER - Clínica de Fertilidad y Reproducción Asistida | Lima Instituto de Medicina Reproductiva Clínica Ricardo Palma | Lima Laboratorio Pranor | Trujillo Nacer, Centro de Reproducción Humana de Lima | Lima Pranor San Isidro | Lima REPÚBLICA DOMINICANA Instituto de Reproducción y Ginecología del Cibao | Santiago de Caballeros PROFERT Programa de Reproducción Asistida y Medicina Perinatal | Santo Domingo URUGUAY CEM - Centro de Esterilidad Montevideo | Montevideo CERHIN - Centro de Reproducción Humana del Interior | Salta VENEZUELA Clínica de Fertilidad del Centro Médico Docente La Trinidad | Caracas EMBRIOS - Centro de Fertilidad y Reproducción Humana Asistida | Caracas FERTILAB Venezuela | Caracas Instituto Venezolano de Fertilidad | Valencia Laboratorio In Vitro Venezuela | Maracaibo Unidad de Fertilidad Unifertes | Caracas

REDLARA En Vivo Presidir a cerimonia de abertura de um congresso nestes tempos inesperados de COVID-19 é uma honra, mostra a força latino-americana que resiste, que não se deixa abater e que luta pela VIDA! Fazemos projetos, pensamos e discutimos idéias, juntos, mais unidos que nunca! Vamos ver diferentes ângulos das questões que hoje trabalhamos no nosso dia-a-dia, buscando se não as respostas mais claras, por agora, pelo menos, caminhos mais bem fundamentados. Das terras mexicanas à Patagônia, a palavra a ser ecoada será a Ciência, por nós exercida a serviço da Reprodução Assistida. Na primeira sessão, são 2 pontos imperdíveis: A América Latina mostra sua experiência em relação à transferência única de blastocistos, o que os centros têm tido como experiência. Os nossos dados, condensados no Registro Latinoamericano, nos permitem vislumbrar as bases de uma política bem definida de transferência única eletiva. Fernando Zegers vai conduzir uma avaliação critica dos dados. A seguir, uma visão de caminhos preditores da gravidez almejada, buscando o equilíbrio harmônico entre eficácia e segurança, na experiência de nosso convidado especial, o Prof Siladitya Bhattacharya, da Escócia. 16

Enseñanzas del Registro Latinoamericano: hacia la transferencia de un embrión y Marcadores y predicción de los resultados de TRA. Acompanhando 30 anos de trajetória, assim como a experiência que temos acumulado, seja nos estudos observacionais, meta-análises e/ ou revisões sistemáticas, a área de reprodução assistida tem trazido avanços, mas restam lacunas. A cada momento buscamos os melhores indicadores para a prática diária, com o objetivo de chegar ao melhor resultado: o encantamento se realiza quando de uma gestação saudável, riscos diminuídos para a mãe e o bebê, nascido vivo saudável. Assim, esta sessão torna-se imprescindível, é muito bemvinda e esperamos que traga reflexão. Assisted reproductive techniques in Latin America: The Latin American Registry, 2017 Fernando Zegers, Javier A Crosby, Carolina Musri, Maria do Carmo B. de Souza, A. Gustavo Martinez, Adelino Amaral Silva, José María Mojarra, Diego Masoli, Natalia Posada. JBRA Assist. Reprod. 2020; 24 (3):362-378 doi: 10.5935/1518-0557.20200029 Maheshwari A, Pandey S , Raja EA , Shetty A, Hamilton A & Bhattacharya S Is frozen embryo transfer better for mothers and babies? Can cumulative meta-analysis provide a definitive answer? Hum Reprod Update 2018 Jan 1;24(1):35-58. doi: 10.1093/humupd/dmx031.

Dra. Maria do Carmo Borges de Souza Presidente da REDLARA Diretora da Fertipraxis

1:00 PM* PRESENTACIÓN DEL CONGRESO VIRTUAL 2020 Dra. Maria do Carmo Borges de Souza | Brasil

SESIÓN INAUGURAL Coordinadora: Dra. Maria do Carmo Borges de Souza | Brasil 1:10 PM* ALGUNAS ENSEÑANZAS DEL REGISTRO LATINOAMERICANO: HACIA LA TRANSFERENCIA DE UN EMBRIÓN. Dr. Fernando Zegers-Hochschild | Chile 1:30 PM* MAKING PREGNANCY PREDICTABLE: HARMONIZING EFFICACY AND SAFETY IN ART Prof. Siladitya Bhattacharya | Scotland 1:50 PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 12:00pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 11:00am. Guatemala, Nicaragua: la sesión inicia a las 10:00am. 17

FERNANDO ZEGERS-HOCHSCHILD | Chile Fundador y primer presidente de la Red Latinoamericana de Reproducción Asistida (REDLARA), del que actualmente es Consejero Honorario. Fundador y director responsable del Registro Latinoamericano de Reproducción Asistida (RLA), que reporta anualmente los procedimientos de reproducción asistida realizados en Latinoamérica. En 2017, recibe el grado de Profesor Emérito de la Universidad Diego Portales de Chile, en Santiago de Chile. Director del Programa de Ética y Políticas Publicas en Reproducción Humana, de la Universidad Diego Portales, Chile. Co-Fundador de Clínica Las Condes y miembro senior de la Unidad de Medicina Reproductiva de la misma.

SILADITYA BHATTACHARYA | Scotland MBBS, MD, FRCOG, Professor and Head of School of Medicine Medical Sciences and Nutrition at the University of Aberdeen. A graduate of Calcutta University, he trained in Obstetrics and Gynaecology in the United Kingdom, obtaining his MRCOG in 1991, MD in 1997, Subspecialty accreditation in 2000 and FRCOG in 2006. He is Editor in Chief of Human Reproduction Open and his main research interests include reproductive epidemiology and health services research in reproductive health.

Como temos trabalhado em tempos de pandemia

À medida que a COVID-19, doença do novo coronavírus-SARS-CoV-2, se espalha pelo mundo e pelo Brasil, os profissionais de saúde, em particular os da Reprodução Humana Assistida (RHA), médicos e embriologistas, procuram a melhor maneira de prosseguir, de forma segura, com os tratamentos de infertilidade, tanto para os profissionais quanto para pacientes. A pandemia apresenta às clínicas de RHA e a seus pacientes uma série de desafios. Conhece-se pouco sobre os efeitos da pandemia da COVID-19 na fertilidade, nos tratamentos de RHA e na gestação. É fundamental assegurar que os laboratórios de saúde utilizem práticas apropriadas de biossegurança, cujo conceito é a condição de segurança alcançada por um conjunto de ações destinadas a prevenir, controlar, reduzir ou eliminar riscos inerentes às atividades que possam comprometer a saúde humana, animal e o meio ambiente. Qualquer procedimento de RHA deve ser realizado em laboratórios devidamente equipados e por profissionais treinados nos procedimentos técnicos e de segurança aplicáveis. As diretrizes nacionais de biossegurança laboratorial devem ser respeitadas em toda e qualquer circunstância. É necessário garantir de forma segura o atendimento e o apoio aos pacientes que necessitam dos serviços de RHA e, ainda assim, salvaguardar toda a equipe técnica e pacientes das possíveis complicações da atual pandemia. Cerca de 80% das pessoas se recuperam da doença sem precisar de tratamento especial ou internações hospitalares. Comorbidades como doença cardiovascular, diabetes, doença respiratória crônica, hipertensão e câncer são fatores de risco para a COVID-19 e pacientes sem comorbidades terão complicações dependendo da carga viral recebida. O período de incubação do SARSCoV-2 é de 2 a 14 dias e todos os grupos de pessoas são considerados susceptíveis à doença, independentemente do sexo ou da idade. American Society For Reproductive Medicine. American Society For Reproductive Medicine (Asrm). Patient management and clinical recommendations during the Coronavirus (Covid-19) Pandemic update #4 (may 11, 2020 through june 8, 2020), p. 1–09, 2020b. ANVISA. Agencia Nacional De Vigilância Sanitária. Nota Técnica Nº 23/2020/Sei/Gstco/Dire1/Anvisa. Brasília, 2020F. REDLARA - Red Latinoamericana De Reproducción Asistida; SBRA, S. S. B. D. R. A. Nota conjunta com atualização de posicionamento sobre a Covid-19 e os tratamentos de reprodução assistida informações complementares à nota emitida em 21 de março de 2020. [S.L: S.N.].

RICARDO AZAMBUJA | Brasil Médico Veterinario. Maestría en Zootecnía por la UFRGS. Ph.D. en Fisiología de la Reproducción por Texas A&M University (Texas/Estados Unidos). Post doctorado por Genetics and IVF Institute (Virginia/Estados Unidos). Embriólogo y director del Laboratorio de Embriología de la Clínica Fertilitat. Coordinador del Comité de Acreditación de REDLARA.

SEGUNDA SESIÓN CÓMO HEMOS TRABAJADO EN TIEMPOS DE PANDEMIA Coordinador: Dr. Ricardo Azambuja | Brasil 2:20PM* FERTILIDAD Y SARS-COV2: TRABAJAR EN FORMA NORMAL O SELECTIVA Y CON RESTRICCIONES Dra. Stella Lancuba | Argentina 2:30PM* PROATIVIDADE EM TEMPOS DE COVID-19: AÇÕES PARA EQUIPES E PACIENTES Dra. Hitomi Nakagawa | Brasil 2:40PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 1:20pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 12:20pm. Guatemala, Nicaragua: la sesión inicia a las 11:20am.

STELLA LANCUBA | Argentina Doctor en Medicina y Diploma de Honor por la Universidad de Buenos Aires. Especialista en Ginecología y Medicina Reproductiva. Certificación por Academia Nacional de Medicina y extensa trayectoria en el campo de reproducción humana. Se desempeña actualmente como Directora Médica de CIMER, Centro de Investigaciones en Medicina Reproductiva, Instituto de Fertilidad de Buenos Aires Argentina y Directora científica del Banco de Gametos. Actual Presidente de la Sociedad Argentina de Medicina Reproductiva – SAMeR por período 2019-2020. Miembro actual del Comité científico de SAMeR. Miembro asesor del comité científico de Ministerio de Salud de la Nación. Trainer e instructora de postgrado en simuladores otorgados por ASRM. Autora de numerosas publicaciones nacionales e internacionales, en el área de fertilización asistida, donaciones de gametos, gestión clínica y de laboratorio, aspectos éticos y sociales en la especialidad.

HITOMI NAKAGAWA | Brasil Presidente da SBRA – Sociedade Brasileira de Reprodução Assistida (2016-2021). Diretora científica e responsável técnica da Genesis – Centro de Assistência em Reprodução Humana. Membro do Núcleo de Reprodução Assistida - Câmara Técnica de Ginecologia do CFM. Fellowship/research & trainee program em Reprodução Assistida e Cirurgia Endoscópica na Tohoku University School of Medicine – Sendai/Japão.

Receptividad endometrial: ERA, EMMA, ALICE, son imprescindibles? A pesar del vertiginoso avance en el conocimiento de los cambios endocrinológicos en los tratamientos de reproducción asistida así como de las técnicas y variables para mejorar los resultados reproductivos, la receptividad endometrial sigue teniendo un papel fundamental en el estudio para mejorar las tasas de implantación embrionaria. A través de los nuevos ensayos para conocer la expresión génica y microbiota del endometrio, permitirán transferir el embrión en la ventana de implantación de una manera personalizada así como generar las condiciones de la microbiota más adecuadas para facilitar la implantación. En la sesión discutiremos si es imprescindible llevar a cabo estos estudios en todas las pacientes sometidas a tratamientos de reproducción asistida de alta complejidad o solo aquellas con falla repetida de la implantación. 20

EMMA (short for Endometrial Microbiome Metagenomic Analysis). ALICE is a fast and inexpensive diagnostic tool that allows for the identification of culturable and nonculturable endometrial pathogens associated with chronic endometritis. Moreno I, Codoñer FM, Vilella F, Valbuena D, Martinez-Blanch JF, Jimenez-Almazan J, Alonso R, Alama P, Remohi J, Pellicer A, Ramon D, Simon C. Evidence that the endometrial microbiota has an effect on implantation success or failure. Am J Obstet Gynecol. 2016; 215:684-703. Moreno I, Cicinelli E, Garcia-Grau I, Gonzalez M, Bau D, Vilella F, De Ziegler D, Resta L, Valbuena D, Simon C. The diagnosis of chronic endometritis in infertile asymptomatic women: a comparative study of histology, microbial cultures, hysteroscopy, and molecular microbiology. Am J Obstet Gynecol. 2018, DOI: 10.1016/j.ajog.2018.02.012. Human Microbiome Project Consortium. Structure, function and diversity of the healthy human microbiome. Nature 2012; 486:207–14. Patricia Díaz-Gimeno, Maria Ruiz-Alonso, David Blesa, Nuria Bosch, José A. Martínez-Conejero, Pilar Alamá, Nicolás Garrido, Antonio Pellicer, and others. Fertili Streisand 2012;99 (2):508–517.

DR. JOSÉ MARÍA MOJARRA ESTRADA | México Médico cirujano, especialista en Ginecología y Obstetricia. Director de la Red Latinoamericana de Reproducción Asistida Región México (REDLARA) Director de la Comisión Estatal de Bioética del Estado de Sonora. Director de la Unidad de Reproducción Asistida del Hospital CIMA, de Hermosillo.

SEGUNDA SESIÓN RECEPTIVIDAD ENDOMETRIAL: ERA, EMMA, ALICE, SON IMPRESCINDIBLES? Coordinador: Dr. José María Mojarra Estrada | México 2:55PM* SON IMPRESCINDIBLES Dr. Juan Luis Giraldo | Colombia 3:10PM* NO SON IMPRESCINDIBLES Dr. Juan Enrique Schwarze | Chile 3:55PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 1:55pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 12:55pm. Guatemala, Nicaragua: la sesión inicia a las 11:55am

JUAN LUIS GIRALDO | Colombia Médico Ginecólogo Especialista en Reproducción Humana. Médico cirujano, Ginecólogo y Obstetra de la Universidad Pontificia Bolivariana; fellowship en Infertilidad y Endoscopia Ginecológica de la Universidad de Yale en los Estados Unidos. Autor del libro–guía Buscando un Bebé. Director del programa internacional de Reproducción Humana del Grupo InSer, Colombia. Profesor en el área de la medicina reproductiva de la Universidad de Antioquia, el CES y la Universidad Pontificia Bolivariana.

JUAN ENRIQUE SCHWARZE | Chile Medico Ob.Gin. subespecialista en medicina reproductiva e infertilidad. Tratante en la Unidad de Medicina Reproductiva de Clínica Las Condes. Prof. Asociado de Ob.Gin. de la Universidad De Santiago. Post-doctorado en Biología de la Reproducción en la Universidad de Pensilvania. Magister en Epidemiologia en la Universidad de los Andes. Linea de investigación, actualmente, se centra en modelos de causalidad sin randomización, y revisiones sistemáticas.

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Nuevas estrategias para desencadenar la maduración ovocitaria y para el bloqueo

Desde el inicio de las técnicas de reproducción asistida, unos de los grandes desafíos fue la adecuada programación de la aspiración folicular y la sincronización con el pico de LH, que permitiría la obtención de ovocitos maduros y listos para su fertilización, aproximadamente 36 horas después. En los primeros años se iniciaba la estimulación ovárica con gonadotropinas, luego se detectaba esta elevación espontánea de LH en sangre u orina y se programaba la Aspiración Folicular a la hora y el día que fuera. Con la aparición de los Agonistas de GnRH, los ciclos de estimulación ovárica se pudieron controlar de mejor manera, inhibiendo el pico de LH endógeno hasta obtener folículos de un tamaño adecuado y luego gatillar la maduración final de manera exógena, pudiendo programar, de esta forma, el día y el horario de la aspiración folicular con mucha más precisión. Posteriormente, se logró sintetizar antagonistas de GnRH lo que permitió mantener la programación y los resultados obtenidos con el uso de agonistas, pero haciendo los ciclos de estimulación más amistosos para las pacientes al requerir menos inyecciones. Desde entonces, ha persistido la búsqueda de métodos de inhibición del pico endógeno de LH que impliquen menor monitorización hormonal y ecográfica y mayor facilidad de uso, como el uso de progestágenos orales. En paralelo a esto, la maduración folicular final antes de la culdocentesis se puede lograr de distintas maneras, dependiendo del tipo de respuesta ovárica de la paciente a la que nos enfrentamos y haciendo un balance entre el riesgo de una complicación como el Síndrome de Hiperestimulación Ovárica y el riesgo de no obtener una suficiente cantidad de ovocitos maduros para fertilizar. Buscando una óptima eficiencia y una mínima tasa de complicaciones, es que se han utilizado técnicas como el gatillo con Agonistas de GnRH y el Dual Trigger.

DR. DIEGO MASOLI ILLANES Médico especialista en Medicina Reproductiva, staff de Clínica Las Condes, Chile. Director de la Red Latinoamericana de Reproducción Asistida Región ConoSur (REDLARA).

TERCERA SESIÓN NUEVAS ESTRATEGIAS PARA DESENCADENAR LA MADURACIÓN OVOCITARIA Y PARA EL BLOQUEO Coordinador: Dr. Diego Masoli | Chile 3:55PM* DISPARO CON AGONISTAS, DUAL TRIGGER Dr. Marcos Horton | Argentina 4:10PM* BLOQUEIO HIPOFISÁRIO COM PROGESTERONA X ANTAGONISTAS Dr. Roberto Antunes | Brasil 4:25PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 2:55pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 1:55pm. Guatemala, Nicaragua: la sesión inicia a las 12:55pm.

MARCOS HORTON | Argentina Médico, graduado en Argentina (UBA), con entrenamiento en Obstetricia y Ginecología en el Hospital Británico de Buenos Aires y postgrado en Reproducción Asistida en EEUU (HRC, Pasadena), especialista en Medicina y Cirugía Reproductiva ( SAMeR), y Ultrasonografista (SAEGU). Actual Director del Laboratorio de Reproducción Asistida en Pregna Medicina Reproductiva, Buenos Aires, Argentina.

ROBERTO ANTUNES | Brasil Ginecologista e Obstetra formado pela Universidade Federal do Rio de Janeiro, Mestre em Fisiologia Endócrina pela Universidade Federal do Rio de Janeiro, Coordenador do Ambulatório de Infertilidade Conjugal do HUCFF-UFRJ, Diretor Médico da FERTIPRAXIS - Centro de Reprodução Humana, Diretor da Sociedade de Ginecologia e Obstetrícia do Rio de Janeiro, Diretor da Sociedade Brasileira de Reprodução Assistida, Membro do Conselho de Educação da REDLARA.

Endometrial preparation for frozen embryo transfer: natural cycle vs artificial cycle

The use of frozen-thawed embryo transfer (FET) has increased over the past decade with improvements in technology and increasing live birth rates. FET facilitates elective single-embryo transfer, reduces ovarian hyperstimulation syndrome, optimizes endometrial receptivity, allows time for preimplantation genetic testing, and facilitates fertility preservation. Endometrium preparation schemes designed for the thawed embryo generally include natural cycles (NCFET) and artificial cycles (AC-FET), in which the endometrium is artificially prepared with exogenous steroid hormone therapy. For NC- FET, the time of ovulation can be estimated based on the detection of the luteinizing hormone (LH) surge in either blood or urine (constituting ‘true’ NC-FET) or after triggering ovulation of the dominant follicle using human chorionic gonadotrophin (hCG) (‘modified’ NC-FET) or with support of the luteal phase with progesterone (natural cycle with luteal phase support (NC-LPS)). An AC is advantageous for patients with irregular cycles as it reduces the frequency of clinic visits, helps to schedule the date of FET, and decreases ET cancellation rates. For these reasons, many eumenorrheic women undergo AC-FET. FET cycles have been associated, however, with an increased risk of hypertensive disorders of pregnancy for reasons that are not clear. Recent evidence suggests that absence of the corpus luteum (CL) could be at least partly responsible for this increased risk. Despite the widespread use of FET, the optimal protocol with respect to live birth rate, maternal health, and perinatal outcomes has yet to be determined. Future practice regarding FET should be based on high-quality evidence, including rigorous controlled trials.

DRA. NATALIA POSADA VILLA Médico especialista en Medicina Reproductiva, In Ser Colombia. Directora de la Red Latinoamericana de Reproducción Asistida Región Noroeste (REDLARA).

TERCERA SESIÓN PREPARACIÓN ENDOMETRIAL PARA TRANSFERENCIA DE EMBRIONES CRIOPRESERVADOS: CICLO NATURAL O CICLO SUPLEMENTADO Coordinadora: Dra. Natalia Posada | Colombia 4:40PM* CICLO NATURAL Dra. Virginia Chaquiriand | Uruguay 4:55PM* CICLO SUPLEMENTADO Dr. Roger Molinas | Paraguay 5:10PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 3:40pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 2:40pm. Guatemala, Nicaragua: la sesión inicia a las 1:40pm.

VIRGINIA CHAQUIRIAND | Uruguay Doctora en Medicina por Facultad de Medicina de la Universidad de la República, Uruguay. 27 Especialista en Ginecologia y Obstetricia, por la Escuela de Graduados de la Facultad de Medicina, UdelaR (Uruguay). Master en Reproducción Humana, Universidad Rey Juan Carlos de Madrid e IVI. Profesora Adjunta de Ginecologia de la Clínica Ginecotocológica B, Hospital de Clinicas, Facultad de Medicina, UdelaR. Trabaja desde 2005 en Reproducción Asistida como Especialista en Medicina Reproductiva y Fertilidad en numerosas instituciones de Uruguay.

ROGER MOLINAS | Paraguay Doctor en Medicina y Cirugía por la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción (Asunción, Paraguay - 1991). Médico rural en el Centro Materno Infantil Hermann Gmainer (Hohenau, Paraguay - 1992-1995). Especialización en Ginecología y Obstetricia en el Hospital de Clínicas de la Universidad Nacional de Asunción (Asunción, Paraguay - 19951998). Entrenamiento en endoscopía ginecológica en la Katholieke Universiteit Leuven (KUL, Lovaina, Bélgica), donde obtuvo su Master en 1998 con la tesis “Endoscopic surgery and adhesion formation in the rabbit model” y su PhD en el 2003 con la tesis “Pneumoperitoneum is a cofactor in postoperative adhesion formation after laparoscopic surgery”. Fellowship en Medicina y Cirugía Reproductiva en el Leuven Institute for Fertility and Embryology (LIFE). Instructor de cirugía endoscópica ginecológica del Center for Surgical Technologies de la KUL (Lovaina, Bélgica). Coordinador Científico de la European Academy of Gynaecological Surgery (2004-2010). Autor de diversas publicaciones científicas. Es socio de varias sociedades internacionales en el área de la Medicina y Cirugía Reproductiva y la Endoscopía Ginecológica (ESGE, ASRM, ESHRE, SAMER, REDLARA). Es miembro del consejo editorial de Gynaecological Surgery y revisor de importantes revistas ginecológicas como Human Reproduction, Fertility and Sterility, The Journal of Minimally Invasive Gynecology, American Journal of Obstetrics and Gynecology. Fundador y director de NEOLIFE – Medicina y Cirugía Reproductiva en Asunción, Paraguay.

Costo eficiencia del uso de pgt en mujeres menores de 38 años

En la búsqueda de un método de evaluación que permita determinar cuál es el mejor embrión para transferir han sido desarrolladas diversas técnicas. Si bien hasta el momento ninguna ha logrado reemplazar totalmente la evaluación morfocinética que realiza el embriólogo en el momento de la transferencia, algunas de estas técnicas son de gran ayuda para completar en forma precisa la selección de ese embrión. Entre ellas, la evaluación genética preimplantacional (PGT) es quizás la técnica más difundida en los centros de reproducción asistida. En particular el uso del PGT-a, con el cual se busca determinar qué embriones están libre de aneuploidías, ha ganado mucho lugar en la práctica diaria. Si bien empleando el PGT-a se logra transferir embriones con la dotación normal de cromosomas, esto no asegura que se produzca la implantación, pero si se evita la transferencia de embriones con muy alta probabilidad de no implantarse o detener su desarrollo una vez implantado, acortando el tiempo de espera de los pacientes (Maxwell y col. 2016). Dado que la tasa de aneuploidías en los embriones aumenta con la edad materna, es claro que este grupo de pacientes puede beneficiarse con el empleo del PGT-a (Harton y col. 2013). Pero lo que se discute aún es el real beneficio que puede aportar a pacientes jóvenes. Es por eso que en la sesión “Costo eficiencia del uso del PGT en mujeres menores de 38 años”, discutiremos sobre el tema, tratando de encontrar respuestas para esta controversia.

Harton GL, Munné S, Surrey M, y col. Diminished effect of maternal age on implantation after preimplantation genetic diagnosis with array comparative genomic hybridization. Fertility and Sterility 2013; 100:16951703. Maxwell SM, Colls P, Hodes-Wertz B, y col. Why do euploid embryos miscarry? A case-control study comparing the rate of aneuploidy within presumed euploid embryos that resulted in miscarriage or live birth using next-generation sequencing. Fertility and Sterility 2016; 106:1414-1419.e5.

DR. A. GUSTAVO MARTÍNEZ | Argentina Vicepresidente de la Red Latinoamericana de Reproducción Asistida (REDLARA). Director del Laboratorio de Biología de la Reproducción de Fertilis Medicina Reproductiva, Argentina. Asesor científico de Vitae Medicina Reproductiva, Argentina.

CUARTA SESIÓN COSTO EFICIENCIA DEL USO DE PGT EN MUJERES MENOS DE 38 AÑOS Coordinador: Dr. A. Gustavo Martínez | Argentina 5:40PM* A FAVOR PGT Dr. Ernesto Escudero | Perú 5:55PM* EN CONTRA Dr. Émerson Cordts | Brasil 6:10PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 4:40pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 3:40pm. Guatemala, Nicaragua: la sesión inicia a las 2:40pm.

LUIS ERNESTO ESCUDERO VELANDO | Perú Médico cirujano por la Universidad Autónoma de Guadalajara (Jalisco-México) Especialidad en Ginecología y Obstetricia por la Universidad San Martín de Porras (Lima-Perù). Sub especialidad en Infertilidad. Master en Reproducción Humana por la Universidad de Valencia (Valencia-España). Instituto Valenciano de Infertilidad (Valencia-España). Director Medico de Inmater, Centro de Reproducción Asistida. Past-President de la Sociedad Peruana de Fertilidad.

EMERSON BARCHI CORDTS | Brasil Médico ginecologista, especializado em Cirurgia Vídeo-Endoscópica e Reprodução Humana pela Febrasgo. Mestre e doutor em medicina reprodutiva pela Faculdade de Medicina do ABC (FMABC), diretor clínico do Instituto Ideia Fértil de Medicina Reprodutiva (FMABC) e da Embryo Genesis Reprodução Humana. Professor associado da Disciplina de Saúde Sexual, Reprodutiva e Genética Populacional da FMABC. Membro da comissão de ética da SBRA e da comissão de educação médica da REDLARA. Sócio da ESHRE e da ASRM.

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Invasive PGT-A (iPGT-A) X Noninvasive PGT-A (niPGT-A) pros and cons

The use of pre-implantation-genetic testing for aneuploidy (PGT-A) is one of the tools that we are using in IVF to select euploid embryos for transfer. The main indications are: advanced age, implantation failure and recurrent pregnancy loss. The technique most used today is performed through a biopsy of the trophectoderm in embryos in the blastocyst stage (iPGT-A). The DNA extracted from the cells obtained in the biopsy is amplified and sequenced by the Next-generation sequencing (NGS) technique. Recently, a new technique is being incorporated into clinical practice, which consists of isolating the embryo’s DNA in the spent culture medium, without the need to manipulate the embryo (noninvasive pre-implantation-genetic testing for aneuploidy (niPGT-A). Preliminary studies comparing the two techniques show that they are equivalent. The main problems of PGT-A are false positives and negatives, as well as embryonic mosaicism. Its real application is far from consensus. The Practice Committees of the American Society for Reproductive Medicine say that at the moment there is not enough evidence to indicate this technique as a routine for all infertile patients. We will discuss the pros and cons of the two techniques and we are sure that it will be a very profitable and enriching debate.

DR. ADELINO AMARAL SILVA | Brasil Médico especialista en Medicina Reprodutiva, Genesis. Diretor da Red Latinoamericana de Reproducción Asistida Região Brasil (REDLARA).

CUARTA SESIÓN PGT INVASIVO VS NO INVASIVO: PROS Y CONTRAS - RESULTADOS Coordinador: Dr. Adelino Amaral Silva | Brasil 6:25PM* PGT INVASIVO Dra. Ana Palma Govea | Panamá 6:40PM* PGT NÃO INVASIVO Dra. Cláudia Petersen | Brasil 6:55PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 5:25pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 4:25pm Guatemala, Nicaragua: la sesión inicia a las 3:25pm.

ANA ELENA PALMA GOVEA | Panamá Licenciatura en Tecnología Médica (análisis clínico) por la Universidad de Panamá. Responsable del laboratorio de Andrología y Análisis clínicos en IVI Panamá (2008-2009). Máster en embriología clínica por la Universidad de Valencia, España. Directora de los laboratorios de Andrología, clínico y embriología, y por el departamento de calidad de la clínica IVI Panamá.

CLAUDIA PETERSEN | Brasil A embriologista clínica Cláudia Petersen é graduada em Biologia pela Universidade de São Paulo, São Carlos, com maestria em Embriologia Clínica pela Universidade de Leeds, UK e doutorado em Ginecologia, Obstetrícia e Mastologia pela UNESP de Botucatu - Brasil. Trabalha no campo da reprodução humana há mais de 20 anos no Laboratório de Embriologia do Centro de Reprodução Humana Prof. Franco Junior, em Ribeirão Preto/SP. É investigadora do Centro Paulista de Diagnóstico e Pesquisa, Ribeirão Preto - Brasil. Foi diretora presidente da Pronúcleo (Núcleo Brasileiro de Embriologistas em Medicina Reprodutiva) por dois mandatos consecutivos (2006-2008/2009-2010).

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¿Transferencia de uno o dos embriones en mujeres menores de 35 años o sometidas a od?

El objetivo de las técnicas de reproducción asistida debe ser el nacimiento de un hijo sano a término y una mujer o madre sana en casa. Uno de los principales problemas de las técnicas de reproducción asistida es la alta tasa de embarazos múltiples. El embarazo múltiple tiene que tomarse en la actualidad como una complicación de estos tratamientos debido a los problemas médicos asociados. El parto pretérmino ocurre en más del 50% de los partos de mellizos, en el 90% de los trillizos. La probabilidad de un gemelo y de un trillizo son siete y más de 20 veces mayores respetivamente de morir durante el primer mes de vida. La prematuridad está asociada con un riego aumentado de síndrome de distress respiratorio, hemorragia intracraneal, parálisis cerebral, ceguera, bajo peso al nacer y mayor mortalidad neonatal. Las pacientes con embarazos múltiples tiene más riesgo de preeclampsia, diabetes gestacional, parto prematuro y anormalidades placentarias asociadas a hemorragias maternas. También hay que tener en cuenta los altos costos de las unidades neonatales. Debido a los avances en los sistemas de cultivo embrionario que incluye mejores incubadoras, mejores medios de cultivo que soportan el desarrollo embrionario hasta el día 5 o 6 de cultivo, y a la mejora en las técnicas de selección embrionaria, es muy importante disminuir el número de embriones que se van a transferir en especial en paciente de buen pronóstico y en óvulo donado. En este tipo de pacientes el transferir 2 embriones no mejora las tasas de embarazo de forma significativa pero lo que si se aumenta son las tasas de multigestación. Recomendamos seguir las guías de las ASRM sobre el número de embriones a ser transferidos. Guidance on the limits to the number of embryos to transfer: a commitee opinión. Fertil Steril 2017;107:901-3

DR. PABLO VALENCIA Médico ginecólogo especialista en Medicina Reproductiva. Director del Centro Ecuatoriano de Reproducción Humana. Ex acreditador de centros por parte de la REDLARA. Ex tutor del curso PEC Online REDLARA. Actual presidente de ALMER Asociación Latinoamericana de Medicina Reproductiva.

QUINTA SESIÓN ¿TRANSFERENCIA DE UNO O DOS EMBRIONES EN MUJERES MENORES DE 35 AÑOS O SOMETIDAS A OD? Coordinador: Dr. Pablo Valencia | Ecuador 7:25PM* UN EMBRIÓN Dra. Marcela Tapia | Bolivia 7:40PM* DOS EMBRIONES Dr. Alberto Kably Ambe | México 7:55PM* PREGUNTAS *Horario para Argentina, Brasil. Uruguay, Bolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 6:25pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 5:25pm. Guatemala, Nicaragua: la sesión inicia a las 4:25pm.

MARIELA TAPIA CUELLAR | Bolivia Licenciada en Farmacia de la Universidad Autónoma Gabriel René Moreno. Embrióloga en el laboratorio de reproducción asistida en el Instituto de Salud Reproductiva (Santa Cruz-Bolivia). Cursos en el Instituto Valenciano de Infertilidad: Genética y reproducción, Multiplicación de embriones y gametos. Desde hace 8 años, parte del equipo de Reproducción Asistida Embriovid.

ALBERTO KABLY AMBE | México Médico ginecoobstetra y biólogo de la reproducción. Expresidente del Consejo Mexicano de Ginecología y Obstetricia, de la Asociación Mexicana de Endoscopía Ginecológica, del Consejo Mexicano de Ginecología y Obstetricia y Federación Mexicana de Colegios de Obstetricia y Ginecología. Fundador de la especialidad de Biología de la Reproducción en México y actual coordinador por parte de la UNAM del Comité de residencias médicas de Biología de la Reproducción. Miembro de varias sociedades médicas, destacando American Fertility Society y European Society of Reproductive Medicine. Sócio emérito de la Academia Mexicana de Cirugía y de la Asociación Mexicana de Medicina de la Reproducción. Autor de más de 200 trabajos sobre la especialidad. Actualmente, es director de la revista Ginecología y Obstetricia de México y Profesor titular del curso de alta especialidad en biología de la reproducción en la UNAM.

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¿Por qué California Cryobank?

Por que o California Cryobank?

9 Consultores hispanohablantes 9 Muestras de alta calidad 9 Procesos rigurosos de selección de donantes

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9 Nuestros donantes de DNA Advantage son evaluados para detectar más de 260 condiciones genéticas 9 Extensa información de donantes que incluye los datos genealógicos de DNA (disponibilidad limitada)

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Visite nuestro sitio web para obtener más información o remita a sus pacientes a: www.criobanco.com (en español) www.cryobankbrasil.com (en portugués)

Consultores falantes da língua espanhola Amostras de alta qualidade Processos rigorosos de triagem de doadores Os doadores de nosso programa DNA Advantage passam por uma triagem que analisa mais de 260 condições genéticas Informações abrangentes dos doadores, inclusive relatórios de linhagem de DNA (disponibilidade limitada) Envio internacional para mais de 40 países

Compartilhe o código promocional: REDLARA20 com seus pacientes. Eles terão acesso gratuito a uma Assinatura das informações de doadores de nível 3 por 90 dias, onde poderão ler informações sobre mais de 400 doadores, visualizar suas fotos e receber uma lembrança do doador para seu futuro filho. Isso inclui arquivos digitais do histórico médico do doador, resumo de testes genéticos, redações pessoais e mais. A oferta termina em 31 de dezembro de 2020.

Acesse nosso site para saber mais ou direcione seus pacientes para: www.criobanco.com (em espanhol) www.cryobankbrasil.com (em português)

Evaluación de la calidad espermática: espermatozoides testiculares en hombres con fragmentación del DNA elevada?

El proceso reproductivo tiene un fuerte contexto sociocultural y económico; por lo cual, al no presentarse, las parejas acuden a evaluación médica; esto es diferente entre países desarrollados donde los cónyuges difieren la búsqueda del embarazo utilizando métodos anticonceptivos hasta sentir un equilibrio profesional y/o económico, a países en vías de desarrollo donde las parejas acuden a evaluación entre el primer y segundo año de convivencia marital al no lograr el embarazo; (Ashok Agarwal, 2015) con patologías causales diferentes en ambas poblaciones. En el estudio del varón, el análisis del semen es el estándar de oro que nos da a conocer de forma indirecta el potencial de fertilidad (la forma directa es el logro de la gestación); donde cada parámetro evaluado, refleja la fisiología y función de los órganos genitales masculinos. (WHO, 2010). Sin embargo, no proporciona las características génicas, proteómicas y metabolómicas espermáticas, consideradas actualmente como calidad seminal y pronósticas del éxito reproductivo. Uno de los estudios propuestos para ello es el porcentaje de fragmentación de DNA espermático (SDF). La SDF se produce (favorecida por factores como estilo de vida, envejecimiento, algunas enfermedades, fármacos o drogas ilícitas, infecciones y contaminantes) mediante tres mecanismos principalmente: apoptosis, deterioro de la maduración de la cromatina espermática y estrés oxidativo. La apoptosis y los defectos en la maduración de la cromatina espermática parecen actuar en los testículos, y el estrés oxidativo (incremento de especies reactivas de oxígeno) lo hace durante el tránsito del espermatozoide en el tracto genital. (Monica Muratori, 2019). Independientemente del método analítico, la SDF es muy común en espermatozoides de hombres infértiles con alteración seminal y con parámetros de semen normales (20% al 40%). En 30% de parejas que utilizan ICSI (técnica desarrollada principalmente para alteraciones seminales) tuvieron SDF alto. (Sandro C Esteves, 2017). Esto favorece cuestionarnos con base a la fisiología espermática (motivo del debate): ¿Al realizar ICSI los espermatozoides obtenidos mediante biopsia testicular presentan menor SDF que los del eyaculado? ¿El éxito reproductivo mejora al utilizar espermatozoides testiculares? Ashok Agarwal, A. M. (2015). A unique view on male infertility around the globe. Reproductive Biology and Endocrinology, 13(37), 1-9. doi:10.1186/s12958-015-0032-1. C Sigg, O. P. (Agosto de 1985). Increased desquamation of immature germ cells in the ejaculate of infertile men. Hautarzt, 36(8), 441-8. Monica Muratori, S. M. (2019). Sperm DNA Fragmentation: Mechanisms of Origin. Adv Exp Med Biol, 1166, 75-85. doi:10.1007/978-3-030-21664-1_5. Sandro C Esteves, M. R. (2017). Reproductive outcomes of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with high levels of DNA fragmentation in semen: systematic review and meta-analysis. Fertil Steril, 108(3), 456-467. doi:10.1016/j.fertnstert.2017.06.018 WHO. (2010). WHO laboratory manual for the Examination and processing of human semen (5TA EDICION ed.). World Health Organization (WHO).

Dra. Mirna Echavarría | México Médico cirujano, especialidades: gineco-obstetra, biólogo de la reproducción, sexólogo clínico y terapeuta sexual, andrólogo clínico. Maestría en Ciencias Médicas, Educación y Andrología. Miembro de la Academia Europea de Andrología. Médico andrólogo clínico en INPER e HISPAREP.

QUINTA SESIÓN EVALUACIÓN DE LA CALIDAD ESPERMÁTICA: ESPERMATOZOIDES TESTICULARES EN HOMBRES CON FRAGMENTACIÓN DEL DNA ELEVADA? Coordinadora: Dra. Mirna Echavarría | México 8:10PM* A FAVOR Dr. Cristian Álvarez Sedó | Argentina 8:25PM* CONTRA Dr. Edson Borges Jr. | Brasil 8:40PM* PREGUNTAS *Horario para Argentina, Brasil. UruguayBolivia, Chile, Paraguay, Rep. Dominicana, Venezuela: la sesión inicia a las 7:10pm. Colombia, Ecuador, México, Panamá, Perú: la sesión inicia a las 6:10pm. Guatemala, Nicaragua: la sesión inicia a las 5:10pm.

CRISTIAN ALVAREZ SEDO | Argentina Lic. en Ciencias Biológicas y Máster en Bioquímica de la Universidad Nacional Mayor de San Marcos (Perú). Doctorado en Bioquímica en la Universidad de Buenos Aires (Argentina). Especialista en Embriología Clínica de la Sociedad Argentina de Medicina Reproductiva y Red Lara). Especialista en Andrología Clínica de la Sociedad Argentina de Andrología y Red Lara). Certificación de Genetista Reproductivo (Red Lara). Ex Director del Laboratorio de Biología y Genética Reproductiva de CEGYR. Ex Director del Laboratorio de Andrología de CEGYR. Ex Director Científico de Reprogenetics Argentina y NOVAGEN. Actual Director del Laboratorio de Embriología y Andrología de FERTILIA (Tucumán-Argentina). Director del Curso Superior de Biología de la Reproducción de SAMER. En la actualidad es miembro de la comisión directiva de SAMER y ALMER.

EDSON BORGES JR. | Brasil Doutor em Urologia pela UNIFESP. Doutor em Ginecologia pela UNESP. Coordenador do Curso de Pós-graduação em Medicina Reprodutiva do Instituto Sapientiae. Diretor Científico do Fertility Medical Group.

Argentina, Brasil, Uruguay | 1:00 PM - 9:05 PM

1:00 - 2:05 pm Primera sesión 1:00 - 1:05 pm Vídeo Presentación Taller General de 2021 5 min 1:05 - 1:10 pm Presentación del Congreso Virtual 2020 Dra. Maria do Carmo Borges de Souza (Brasil) 5 min 1:10 - 2:05 pm Sesión inaugural Coordinadora: Dra. Maria do Carmo Borges de Souza 1:10 - 1:30 pm Algunas enseñanzas del Registro Latinoamericano: hacia la transferencia de un embrión Dr. Fernando Zegers-Hochschild (Chile) 20 min 1:30 - 1:50 pm Making pregnancy predictable: harmonizing efficacy and safety in ART Prof. Siladitya Bhattacharya (Escocia) 20 min 1:50 - 2:05 pm Preguntas 2:05 - 2:20 pm Break 1 15 minutos 2:20 - 3:40 pm Segunda sesión 2:20 - 2:55 pm Cómo hemos trabajado en tiempos de pandemia Coordinador: Dr. Ricardo Azambuja 2:20 - 2:30 pm Fertilidad y SARS- COV2: trabajar en forma normal o selectiva y con restricciones Dra. Stella Lancuba (Argentina) 10 min 2:30 - 2:40 pm Proactividad en tiempos de COVID-19: acciones para equipos y pacientes Dra. Hitomi Nakagawa (Brasil) 10 min 2:40 - 2:55 pm Preguntas 15 min 2:55 - 3:40 pm Receptividad endometrial: ERA, EMMA, ALICE , son imprescindibles? Coordinador: Dr. José María Mojarra 2:55 - 3:10 pm Son imprescindibles Dr. Juan Luis Giraldo (Colombia) 15 min 3:10 - 3:25 pm No son imprescindibles Dr. Juan Enrique Schwarze (Chile) 15 min 3:25 - 3:40 pm Preguntas 15 min 3:40 - 3:55 pm Break 2 15 min 3:55 - 5:25 pm Tercera sesión 3:55 - 4:40 pm Nuevas estratégias para desencadenar la maduración ovocitaria y para el bloqueo hipofisario Coordinador: Dr. Diego Masoli 3:55 - 4:10 pm Disparo con agonistas, dual trigger Dr. Marcos Horton (Argentina) 15 min

4:10 - 4:25 pm Bloqueo hipofisario con progesterona x antagonistas Dr Roberto Antunes (Brasil) 15 min 4:25 - 4:40 pm Preguntas 15 min 4:40 - 5:25 pm Preparación endometrial para transferencia de embriones criopreservados: Ciclo natural o ciclo suplementado Coordinadora: Dra. Natalia Posada 4:40 - 4:55 pm Ciclo natural Dra. Virginia Chaquiriand (Uruguay) 15 min 4:55 - 5:10 pm Ciclo suplementado Dr. Roger Molinas (Paraguay) 15 min 5:10 - 5:25 pm Preguntas 15 min 5:25 - 5:40 pm Break 3 15 min 5:40 - 7:10 pm Cuarta sesión 5:40 - 6:25 pm Costo eficiencia del uso del PGT en mujeres menores de 38 años Coordinador: Dr. A. Gustavo Martínez 5:40 - 5:55 pm A favor PGT Dr. Ernesto Escudero (Perú) 15 min 5:55 - 6:10 pm En contra Dr. Emerson Cordts (Brasil) 15 min 6:10 - 6:25 pm Preguntas 15 min 6:25 - 7:10 pm PGT invasivo vs no invasivo: Pros y Contras – Resultados Coordinador: Dr. Adelino Amaral Silva 6:25 - 6:40 pm PGT invasivo Dr. Ana Palma (Panamá) 15 min 6:40 - 6:55 pm PGT no invasivo Dra. Claudia Petersen (Brasil) 15 min 6:55 - 7:10 pm Preguntas 15 min 7:10 - 7:25 pm Break 4 15 min 7:25 - 9:05 pm Quinta sesión 7:25 - 8:10 pm ¿Transferencia de uno o dos embriones en mujeres menores de 35 años o sometidas a OD? Coordinador: Dr. Pablo Valencia 7:25 - 7:40 pm Un embrión Dra. Mariela Tapia (Bolivia) 15 min 7:40 - 7:55 pm Dos embriones Dr. Alberto Kably Ambe (México) 15 min 7:55 - 8:10 pm Preguntas 15 min 8:10 - 8:55 pm Evaluacíon de la calidad espermática: espermatozoides testiculares en hombres con fragmentación del DNA elevada? Coordinador: Dra. Mirna Echavarria (México) 8:10 - 8:25 pm A favor Dr. Cristian Álvarez Sedó (Argentina) 15 min 8:25 - 8:40 pm En contra Dr. Edson Borges (Brasil) 15 min 8:40 - 8:55 pm Preguntas 15 min 8:55 pm Conclusiones y cierre del congreso Dra. Maria do Carmo Borges de Souza 10 min

FICHA TÉCNICA REDLARA | CONSEJO DIRECTIVO Presidente

Dra. Maria do Carmo Borges de Souza Vicepresidente

Dr. A. Gustavo Martínez Director Región Brasil

Dr. Adelino Amaral Silva Director Región Cono Sur

Dr. Diego Masoli Illanes Director Región México

Dr. José María Mojarra Estrada Director Región Noroeste

Dra. Natalia Posada Administración

Lic. Marina Dias

RLA | REGISTRO LATINOAMERICANO Director

Dr. Fernando Zegers-Hochschild Asesor de laboratorio

Dr. Javier Crosby Asesor computacional

Ing. K.W.Schwarze Administración

Bq. Carolina Musri

DISEÑO TID, Graphic Studio

PLATAFORMA DE TRANSMISIÓN ATMO

SAVE THE DATE

¡Tenemos una cita! En la maravillosa ciudad de Río de Janeiro, el mar, el Sol y el Cristo Redentor te esperan con los brazos abiertos, para una vez más y juntos dar alas a la innovación científica, al conocimiento y la constante búsqueda por la excelencia, en el área de la reproducción asistida. REDLARA y SBRA - juntos, en un evento majestuoso!

JBRA Assisted Reproduction 2020;24(3):362-378 doi: 10.5935/1518-0557.20200029

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Assisted reproductive techniques in Latin America: The Latin American Registry, 2017 Fernando Zegers-Hochschild1,2,3, Javier A. Crosby1,3, Carolina Musri1,3, Maria do Carmo B. de Souza3,4, A. Gustavo Martinez3,5, Adelino Amaral Silva3,6, José María Mojarra3,7, Diego Masoli1,3, Natalia Posada3,8 On behalf of the Latin American Network of Assisted Reproduction (REDLARA) Unit of Reproductive Medicine, Clínica Las Condes, Santiago, Chile Program of Ethics and Public Policies in Human Reproduction, University Diego Portales, Santiago, Chile 3 Latin American Network of Assisted Reproduction (REDLARA), Montevideo, Uruguay 4 Fertipraxis, Rio de Janeiro, RJ, Brazil 5 Fertilis Medicina Reproductiva, San Isidro, Buenos Aires, Argentina 6 Genesis Centro de Assistência em Reprodução Humana Ltda, Brasília, DF, Brazil 7 URA, Unidad de Reproducción Asistida de Hospital CIMA Hermosillo, Hermosillo, Sonora, Mexico 8 INSER, Medellín, Colombia 1 2

ABSTRACT

redlara.com. This report provides information on utilization/availability, effectiveness, safety and perinatal outcomes of ART treatments initiated between January 1st and December 31st, 2017, and babies born up to September 2018.

Research question: What was the utilization, effectiveness and safety of assisted reproductive techniques performed in Latin America during 2017. Design: Retrospective collection of multinational data on ART performed in 188 institutions from 15 Latin American countries. Results: We are reporting 93,600 initiated cycles, 16,976 deliveries and the birth of 20,404 babies. ART utilization was 221 cycles/million inhabitants (15 to 535). Despite women aged ≥40 represented 30.5% of fresh IVF/ ICSI, after removing freeze-all cycles, delivery rate per oocyte retrieval was 19.9% for ICSI and 20.2% for IVF. Overall, single embryo transfer (SET) represented 26.9% of fresh transfers, with 18.2% delivery rate per transfer; increasing to 32.3% in elective SET. Delivery rate in double embryo transfers (DET) was 28.3% increasing to 37.3% with elective DET. This 5% increment in births in eDET over eSET resulted in10-fold increase in twin births, almost 3 weeks’ shorter gestations and 3-fold increase in perinatal mortality. Delivery rate in frozen/thawed SET, reached 25.5% increasing to 30.8% with DET; the majority being blastocysts transfers. Of all births, 67% were singletons, 31.4% twins, and 1.6% triplets and higher. Overall, preterm deliveries reached 9.5% in singletons, 64.3% in twins and 97.9% in triplets; and perinatal mortality was 9.4‰ in singletons, 25.3‰ in twins, and 63.3‰ in high-order multiples. Conclusions: The number of initiated cycles slowly increases. Frozen embryo transfers, blastocyst transfers and SET are also increasing. Our data shows that especially in young women and oocyte recipients, when there is more than one blastocyst for transfer, elective SET should be the rule.

MATERIALS AND METHODS Data on ART were collected from 188 centers in 15 countries in Latin America (Supplementary Table 1), covering fresh autologous cycles of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI); Preimplantation genetic testing (PGT); frozen embryo transfer (FET); oocyte donation (OD) including the transfer of both fresh and frozen/thawed embryos; fertility preservation (FP); and frozen/warmed oocyte cycles, both autologous and heterologous (FTO). This report includes treatments started between 1 January 2017 and 31 December 2017. Data on pregnancy and perinatal outcomes are obtained from follow-up of cohorts treated during this period. As part of the accreditation program, all participating institutions agree to have their data registered and published by the RLA. Therefore, no other consent form was requested for the scientific disclosure of these data. The method of collecting data in 2017 resembles previous years (Zegers-Hochschild et al., 2019), making results comparable. Definitions used refer to the latest publication of the International glossary on Infertility and Fertility Care (Zegers-Hochschild et al., 2017). When calculating clinical pregnancy or delivery rates per oocyte pick-up, cases of total embryo freezing were not included in the calculation. Cumulative live birth rate was calculated, as described by Maheshwari et al. (2015) from cycles taking place between 2012 and 2017. We considered the first delivery after transfer of either fresh and/or frozen/thawed embryos obtained after a reference oocyte pick up. A personal identification number and date of birth identified each patient. The identification number is not universal in Latin America, so not all patients could be followed and it is also possible that cross border reproductive treatments could partially influence results, but the numbers should be small. Furthermore, only data provided by institutions using a consistent and reproducible ID number were used throughout the study period (2012 and 2017). For the purpose of reporting cumulative births, 166 institutions in 13 countries were included making sure that the use of an identification number remained throughout the study period (Paraguay and Nicaragua were excluded).

Keywords: Assisted reproductive technology, Latin American Registry, ART utilization, success rates, perinatal outcome

INTRODUCTION This is the 29th report of the Latin American Registry of Assisted Reproduction (RLA) established in 1990 as the first multinational and regional registry of assisted reproductive techniques (ART). Since 2012, reports are published simultaneously in Reproductive BioMedicine Online and in JBRA Assisted Reproduction, the official journal of the Latin American Network of Assisted Reproduction (REDLARA). Results from previous years can be downloaded from www.

Received February 13, 2020 Accepted February 13, 2020

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Table 1. Assisted reproduction techniques reported in Latin America, 2017 Country Argentina Bolivia

Centers

FRESH

FET

FTO

Total

842

9,582

4,660

4,533

437

20,054

391

206

654

Brazil

2,491

20,065

12,282

3,069

1,235

39,142

Chile

278

1,778

1,059

710

163

3,988

Colombia

1,218

449

558

2,364

Ecuador

116

622

278

317

1,406

Guatemala

128

229

Mexico

399

7,222

3,030

4,905

233

15,789

Nicaragua

118

148

Panama

468

205

177

915

Paraguay Peru

114

243

976

2,356

1,161

1,545

741

6,779

Rep. Dominicana

159

Uruguay

751

321

313

1,419

Venezuela Total

126

123

311

188

5,256 (5.6)

45,031 (48.1)

23,685 (25.3)

16,597 (17.7)

3,031 (3.2)

93,600

FP, fertility preservation; FRESH, initiated fresh autologous IVF/ICSI cycles; FET, frozen autologous embryo transfer; OD, transfer of fresh or frozen embryos due to oocyte donation; FTO, includes embryo transfer cycles using autologous and donated vitrified-warmed oocytes. In order to test for the effect of age, number of embryos transferred and state of embryo development at transfer on the delivery rate per embryo transfer, logistic regression analysis was performed in both fresh and OD cycles. When appropriate, a chi-squared test was used to analyze independence of categorical variables. A p-value less than 0.05 was considered statistically significant.

RESULTS Participation 188 centers in 15 countries reported 93,600 ART procedures performed during 2017. This represents more than 70% of centers in the region. The majority of centers were located in Brazil (n=63), followed by Mexico (n=38) and Argentina (n=28) (Table 1). In comparison with 2016, 6 centers which had stopped reporting resumed their participation; 9 centers either closed or stopped reporting, mainly in Venezuela and 13 centers were newly incorporated in 2017 contributing with more than 4,900 of the 8,126 new cycles reported in this period. Size of participating institutions and number of treatment cycles per technique The 93,600 initiated cycles reported this year (9.5% more than 2016), correspond to the sum of IVF/ ICSI, PGT, FET, OD, FP and FTO. The mean number of initiated cycles by institution was 497.9, with wide variation; 12.8% performed โ ค100 cycles; 33.5% between 100 and 300 cycles; 18.1% between 301 and 500 cycles; 20.7% between 501 and 1000 cycles, and 14.9% >1000 cycles. Overall, the major contributors were Brazil followed by Mexico and Argentina. Out of 93,600 initiated cycles, 45,031 corresponded to IVF/ICSI (48.1%); 23,685 corresponded to FET (25.3%); 16,597 to OD (17.7%), 5,256 to FP (5.6%), and 3,031 cycles reported as FTO (3.2%) (Table 1). Figure 1 provides a detailed description of the sequence of events that need to be considered when looking at outcome of any specific technique (IVF/ICSI, OD, FET,

etc.), starting from initiated cycle, cancellations prior to follicular aspiration; aspirations with or without mature oocytes; freeze all oocytes and /or embryos; number of fertilized oocytes or failed fertilization, viability of embryos for transfer or normality of embryos after PGT. It is only after all these events have been considered and adjusted that pregnancy and delivery rates can be calculated with a well-established denominator, being initiated cycle, aspirated cycle, transfer cycle, etc. Needless to say, this detailed description is only possible in a cycle-based registry. ART Utilization in Latin America Utilization of ART is expressed as the total number of cycles performed per million inhabitants (ESHRE Capri Workshop Group, 2001). Considering that not all cycles performed in every country were reported to the Latin American registry, the best possible estimate of the non-reported cycles was obtained through information provided by regional directors of REDLARA, biologists, clinicians and industry representatives. The magnitude of the estimates, which constitutes a potential source of error, was expressed as degrees of confidence according to Dyer et al. (2019). If the number of cycles reported to the registry exceeded 95% of the total number of cycles performed in the country, the report was considered complete. If the number of cycles reported to the registry included 64 to 94% of the total or estimated total number of cycles performed in that country, the estimate (number of cycles/million inhabitants) was considered to be of high confidence. When the proportion of cycles reported fell between 33% and 65% of the estimated total number of cycles performed in the country, results were considered of modest confidence; and if less than 33% of all cycles done in a country were reported to our registry, we assumed our numbers had low confidence. As seen in Figure 2, the RLA collects between 70 to 90% of ART cycles performed in most countries in the region, and this is specially so with the major contributors in Latin America. Overall, Argentina and Uruguay, two countries with laws providing universal

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Figure 1. Events that affect the outcome of Fresh IVF/ICSI, Oocyte donation (OD), and Frozen/thawed embryo transfer (FET). Latin America, 2017.

Figure 2. Utilization of ART. Estimated number of initiated cycles per million inhabitants by country in Latin America, 2017.

care to ART have the highest utilization with 535 cycles per million followed by Chile without law but with recent public policies providing partial reimbursement with 349 cycles per million. Brazil is the major contributor in the region but its utilization is still poor. Age distribution The mean age of women undergoing IVF/ICSI was 36.9 years (SD 4.57). The majority of cycles were performed in women aged 35 to 39 years (41.7%), followed by women aged ≥40 years (30.5%). Therefore, 72.2% of women using autologous ART were ≥35 years. In the past five years the trend is of an aging population. As seen in Figure 3,

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there has been a steady drop in the proportion of women aged ≤34, reaching only 27.8% in 2017 while the proportion of women ≥40 have increased from 26.2% in 2013 to 30.5% in 2017. On the other hand, the mean age of women undergoing OD was 41.8 (SD 4.98); and the majority of cycles (57.3%) were performed in women aged ≥42 years. Outcome of pregnancies and deliveries Fresh IVF and ICSI cycles In 2017, there were 45,031 initiated IVF/ICSI. As seen in Figure 1, after discarding aspirations without oocyte or absence of mature oocytes; and 14,694 cases of total embryo freezing; there were 27,464 oocyte retrievals exposed to the chance of

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Figure 3. Age distribution of Female partner in IVF/ICSI. Latin America, 2000 - 2017.

achieving pregnancy and 21,836 embryo transfer cycles, generating 7,523 clinical pregnancies (CPR/OPU 27.4%). Of these pregnancies there were 81 ectopic pregnancies (1.07%), 12 induced abortions and 1,342 miscarriages (17.8%). There were 601 losses to follow-up (7.9%) and 5,487 deliveries. Table 2 shows the clinical pregnancy rate (CPR) and delivery rate (DR) per oocyte pick-up (OPU) in IVF and ICSI cycles. ICSI represents 85.6% of fresh procedures and there were no differences in CPR or DR per oocyte retrieval between ICSI and IVF (27.3% and 27.7%. and 19.9% and 20.2%, respectively. When calculated by transfer (3359 in IVF and 18477 in ICSI), the differences in the DR per ET in IVF and ICSI, 28.3% and 25.4%, respectively, were higher than in 2016 and in the border of significance (p=0.0519 95% CI 0.0048% to 3.17%). Oocyte donation cycles As seen in Figure 1, in 2017 there were 16,597 initiated cycles, and after removing freeze all cycles (oocytes and embryos) and those without suitable embryos to transfer there were 12,663 transfer cycles. As expected, both CPR and DR per ET much higher (CPR p<0.0001 95% CI 11.32% to 14.08%; DR p<0.0001 95% CI 7.01% to 9.6%) after the transfer of donated oocytes (OD) than in autologous reproduction, reaching 47.2% and 33.4%, respectively. Although CPR in Fresh/OD transfers was significantly higher than FET/ OD (p=0.0001 95%CI 1.75% to 5.24%), the DR/ET was similar in both groups (Table 3). As expected, compared with autologous transfers, outcome after OD is only marginally affected by the age of the recipient (Figure 4). Frozen embryo transfer cycles In 2017 there were 23,685 FET cycles representing 25.3% of all cycles performed. This represents an increment of more than 20.8% compared with 2016, while the mean number of embryos transferred has remained in 1.9, since 2016 (Figure 5). Of all initiated FET cycles, 700 cycles were discontinued. Reasons for

discontinuation were non-survival and/or lack of chromosomally normal embryos (n=507; 2.1%) or abnormal endometrium (n=193; 0.8%). Therefore, out of 22,985 FET cycles, the overall CPR and DR per transfer was 37.8% and 28.4%, respectively (Table 3), which is significantly higher than 2016 (p=0.0006) and also, significantly higher than the CPR and DR after fresh transfers (p<0.0001). The higher PR and DR in FET compared with Fresh transfers are observed across all number of embryos transferred, especially in SET (Table 4 and Supplementary Table 2). Number of embryos transferred, deliveries and multiple births after IVF/ICSI according to the age of women In women ≤34 years, there were 6,309 fresh transfers. The mean number of embryos transferred was 1.87 (range 1 to 6). In this age group, 23.1% were single embryo transfers (SET), of which 45.6% were elective (eSET). Double embryo transfers (DET) corresponded to 66.8% of transfers, of which 49.6% were elective (eDET). The transfer of three embryos (TET) and 4 or more, was performed in 9.8% and 0.3% of cases. In women aged 35 to 39 years, there were 9,692 fresh transfers. The mean number of embryos transferred was 1.89 (range 1 to 6). In this age group, 26.4% were SET, of which 28.7% were eSET. DET corresponded to 58.1% of transfers and 39.3% were eDET. The transfer of three embryos (TET) and 4 or more, were performed in 14.9% and 0.6% of cases. In women ≥40 years of age, there were 5,835 fresh transfers. The mean number of embryos transferred was 1.89 (range 1 to 6). In this age group 31.9% were SET, of which only 12.9% were eSET, 50.9% DET, 24.8% eDET and 14.3% TET; while the transfer of four or more embryos occurred in 2.9% of transfers.

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Table 2. Clinical pregnancy rate and delivery rate in fresh autologous IVF/ICSI cycles in 2017 Assisted reproduction technique procedure

Oocyte retrievala

Clinical pregnancy rate per oocyte retrieval (%)

Delivery rate per oocyte retrieval (%)

ICSI

23,503

6,426 (27.3%)

4,688 (19.9%)*

IVF

3,961

1,097 (27.7%)

799 (20.2%)*

TOTAL

27,464

7,523 (27.4%)

5,487 (19.97%)

p-valueb a

0.7980

Oocyte retrieval with at least one mature oocyte, excluding freeze-all cycles.

0.9856 b

For IVF versus ICSI. (*) = NS

Table 3. Clinical pregnancy rate and delivery rate by embryo transfer in oocyte donation and FET cycles in 2017 Assisted reproduction technique procedure

Embryo transfer

Clinical pregnancy per embryo transfer (%)

Delivery rate per embryo transfer (%)

Fresh oocyte donation (OD)

6,433

3,039 (47.2%)*

2,148 (33.4%)**

Frozen-thawed embryo transfer (OD)

6,230

2,725 (43.7%)*

2,116 (33.9%)**

Frozen-thawed embryo transfer (Own)

22,985

8,696 (37.8%)

6,539 (28.4%)

(*) p<0.0001; (**) p=0.5643

Figure 4. Delivery rate per embryo transfer according to age of female partner in fresh autologous IVF/ ICSI and fresh and cryopreserved oocyte donation (OD) cycles. Latin America, 2017.

Table 4 summarizes the overall number of embryos transferred and multiple births after IVF/ICSI. The mean number of embryos transferred was 1.89 (range 1 to 6). There were 5,881 SET (26.9%), and 12,798 DET (58.6%), there were 3,157 transfers with 3 or more embryos (14.5%). Overall, the CPR and DR per ET reached 34.5% and 25.1%, respectively. In terms of multiple births, of the 5,487 IVF/ICSI deliveries registered, 82.2% were singletons, 17.3% were twins, and 0.5% were triplets or more. Given that SET constitutes a heterogeneous group, Table 5 further stratifies IVF and ICSI outcome after transferring eSET over oSET (only 1 embryo available for transfer) and eDET over oDET (only 2 embryos available for transfer). There are huge differences both in DR/ET in both eSET and eDET over oSET and oDET; furthermore, the rate of twins and triplets increase with eDET, while eSET by itself does not seem to increase the rate of monozygotic twins.

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Number of embryos transferred, deliveries and multiple births after OD and FET Supplementary Table 3 summarizes the number of embryo transfers and multiple births in OD (fresh and FET), where the mean number of embryos transferred reached 1.86 (range 1 to 5). There were 3,550 SET, which correspond to 28.0% of ET and 1,012 were eSET, representing 28.5% of SET and 8% of all ET/OD. There were 7,409 DET, which correspond to 58.5% of ET, and 2,143 were eDET, representing 16.9% of all transfers in OD. Overall, the CPR and DR per ET were 45.5% and 33.7%, respectively. Of the 4,264 deliveries registered, 75.0% were singletons, 24.2% twins and 0.8% were triplets and higher. Furthermore, DR/ET was only slightly affected by the age of the oocyte recipient (OR 0.98 95% CI 0.97-0.98) (Figure 4).

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367

Figure 5. Trends in the number of frozen/thawed embryo transfer (FET) cycles and mean number of embryos transferred (ET). Latin America, 1996–2017.

In FET cycles the mean number of embryos transferred was 1.71 (range 1 to 5). Supplementary Table 2 shows there were 8,755 SET, which correspond to 38.1%, and 12,268 DET corresponding to 53.4%. Overall, the CPR and DR per ET reached 37.8% and 28.5%, respectively. Of the 6,539 deliveries registered, 83.3% were singletons, 16.1% were twins, and 0.6% were triplets and higher. Total embryo freezing 14,694 cycles of total embryo freezing were reported, 15.4% more than in 2016. On average 4.3 embryos (SD 3.1) were cryopreserved and a mean of 1.7 (1 to 4) embryos transferred. Aspirations followed by total embryo freezing gave rise to 5,856 FET cycles resulting in 1,891 deliveries and a DR/ET of 32.3%; this was higher than the DR/ET of 28.4% observed in non-freeze-all FET cycles (p<0.00001). A second FET attempt was reported in 1,162 cases from the same cohort, with 312 subsequent deliveries, the DR/ET in this attempt was 26.9%. Therefore, adding all transfers from this subset of total embryo freezing, the DR/ET adds to 37.3%. The mean age of women was 35.5±4.5. When stratified by number of embryos transferred, DR/ET was 29.1% in SET and 34.7% in DET. Influence of stage of embryo development at transfer Overall, 58.2% of ET were performed at the blastocyst stage, representing a 17% increment over 2016. The proportion of blastocysts transfers in FET (70.8%) almost doubled the proportion in Fresh IVF/ICSI (37.5%) This is important to consider when comparing outcome after fresh and frozen thawed transfers. In OD cycles (both fresh and frozen), the proportion of blastocyst transfers reached 69.4% which is 30% more than in 2016. Blastocyst transfer was always associated with higher DR when compared with cleavage-stage embryos, irrespective of whether fresh or frozen and the number of embryos transferred. In IVF/ICSI, the DR after 8,185 blastocyst transfers was 31.16% compared with 21.77% after the transfer of 13,629 cleaving embryos (p<0.0001). In OD, the DR/ ET

was 37.1% in blastocyst transfers and 25.9% in cleaving embryo (p<0.0001); and in FET, the proportion was 31.9% and 20.0%, respectively (p<0.0001). Preimplantation genetic testing (PGT) The RLA registers PGT-M and PGT-A together. 132 centers reported these procedures in 5.193 fresh cycles (11.8% of OPU); 2.353 using frozen-thawed embryos (8.1% of transfers) and 571 (8.9% of transfers) in OD. The mean age of women undergoing PGT was 38.0 (SD 4.2) among fresh cycles and 38.1 (SD 4.3) in FET. In fresh autologous cycles, the mean number of normal embryos was 1.1 over a mean of 3.1 (SD 2.3) embryos biopsied. In FET cycles, the mean number of normal embryos was 1.9 over a mean of 3.4 biopsied. In OD, the mean number of normal embryos increased to 2.7 over a mean of 4.8 embryos biopsied. The DR/ET was 23.9% in fresh IVF/ICSI, 37.9% in FET and 43.6% in OD. Miscarriage Miscarriage rate in 7,523 pregnancies resulting from autologous fresh embryo transfer and 8,696 pregnancies of FET were 17.8% and 17.4%, respectively. As expected, miscarriage rate in a total of 3,039 OD was lower both in fresh transfers (15.6%) and in frozen/thawed OD (15.0%). Furthermore, in 672 cases of OD using FTO, miscarriage rate was also 15.0% The miscarriage rate using PGT reached 12.3% in pregnancies after FET and 14.8% in OD-FET. Table 6 provides information on the effect of PGT on miscarriage rate after FET in different age groups. When comparing miscarriage after autologous FET with and without PGT, the rate of miscarriage is significantly diminished when PGT is performed in women ≥40 from 23.7% to 9.3% (p<0.0001); the difference is also significant in women age 35 to 39, but in women < 35, PGT does not seem to lower the chances of miscarriage (p>0.3989). Furthermore, in 250 pregnancies resulting from PGT performed in FET/OD, there were 37 miscarriages (14.8%) compared with a miscarriage rate of 15.0% in FET/OD without PGT.

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1.2

JBRA Assist. Reprod. | v.24 | nº3 | Apr-May-Jun/ 2020

100

7,523

1,064

4,902

1,481

Number

34.5

30.0

36.6

38.3

25.2

Clinical pregnancy

5,487

749

3,615

1,070

Number of deliveries

25.1

20.9

25.8

28.3

18.2

Delivery rater per embryo transfer (%)

4,509

576

2,845

1,044

Singleton (n)

82.2

83.0

76.9

78.7

97.6

Singleton (%)

Deliveries

948

159

756

Twin (n)

17.3

13.2

21.2

20.9

2.4

Twin (%)

≥Triplets (n)

1,638

7,770

5,028

eSET

oDET

eDET

39.3

60.7

27.9

72.1

2,494

2,408

692

789

Number

49.6

31.0

42.2

18.6

Clinical pregnancy

1,876

1,739

529

541

Number of deliveries

37.3

22.4

32.3

12.8

Delivery rater per embryo transfer (%)**

1,395

1,450

516

528

Singleton (n)

74.3

83.4

97.5

97.6

Singleton (%)

Deliveries

472

284

Twin (n)

* oSET or oDET: non elective single or double embryo transfer; eSET or eDET: elective single or double embryo transfer. ** DR/ET: oSET and eSET p<0.0001 95% CI 17.01% to 22.03% DR/ET: oDET and eDET p<0.0001 95% CI 13.26% to 16.54%

4,243

Number

oSET

Number of transferred embryos*

Total embryo transfer

25.2

16.3

2.5

2.4

Twin (%)

≥Triplets (n)

0.5

0.3

≥Triplets (%)

0.5

3.8

1.9

0.4

≥Triplets (%)

Table 5. Clinical pregnancy rate, delivery rate and gestational order in elective and non-elective SET and DET in fresh autologous IVF/ICSI in 2017

21,836

253

Total

≥4

2,904

58.6 13.3

12,798

26.9

5,881

Number

Number of transferred embryos

Total embryo transfer

Table 4. Clinical pregnancy rate, delivery rate and gestational order according to the number of embryos transferred in fresh autologous IVF/ICSI in 2017

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Table 6. Effect of PGT on miscarriage rate after FET in different age groups. FET with PGT

FET without PGT

<35

12.8%

15.3%

p=0.3989

35 to 39

13.9%

17.8%

p=0.0724

>39

9.3%

23.7%

p<0.0001

Fertility preservation (FP) A total of 5,256 initiated cycles for FP were reported in 2017 representing 20% increase over 2016. The mean age of women was 36.1 years (≤34=27.1%, 35-39=48.7% and ≥40=24.2%). No oocytes were available for freezing in 247 follicular aspirations (4.7%). The mean number of oocytes cryopreserved was 7.5 with huge variations depending on the age of women (≤34=10.2, 35-39=7.3, and ≥40=4.9). In cases where the indication for FP was recorded, the majority were related to the desire to postpone pregnancy (3,024 cases representing 60.4%), while cancer-related factors were reported in 343 cases (6.8%); risk of premature ovarian insufficiency in 289 (5.8%) cases and other reasons in 1,353 cases (27.0%). More than 10 oocytes were cryopreserved in only 30% of women expressing the desire to postpone fertility, 39% in women having cancer and as expected, the proportion dropped to only 6% in women with risks of premature ovarian insufficiency. Cumulative delivery rate (CDR) We were able to follow up the outcome of fresh embryo transfers and their consecutive FET in 47,492 patients between 2012 and 2017. This cohort included only women having surplus frozen embryos resulting from their fresh transfer, and only the first delivery after either fresh or frozen transfers. Taking all patients together, the DR/ET increased from 37.6% after fresh embryo transfer to a cumulative rate of 43.5% (RR 1.104; 95% CI 1.09 to 1.12; p<0.0001). The cumulative DR per ET stratified by the age of female partner at the time of OPU is shown in Figure 6. The increment in DR when adding FET over fresh transfers was inversely correlated to the age of the female partner. The OR for delivery was 1.3 in women <35 years (95% CI 1.2 to 1.3); 1.2 in women 35 to 39 (95% CI 1.1 to 1.3) and 1.1 in women >39 (95% CI 1.1 to 1.3). Perinatal outcome and complications Table 7 summarizes perinatal mortality. Data was available from 16,760 births and 20,093 babies born. The perinatal mortality increased from 9.4‰ births in 13,532 singletons, to 25.3‰ in 6,250 twins and 63.3‰ in 311 triplets and higher. With 1911 more babies born than in 2016, multiparity increased perinatal death in similar proportion to previous years. Gestational age at delivery was reported in 14,804 deliveries (87.2% of all deliveries). The mean gestational age at delivery was 37.7 (SD 2.3) weeks in singletons, 35.2 (SD 2.9) weeks in twins, and 31.7 (SD 2.9) weeks in triplets and higher. The overall risk of preterm birth (gestational weeks 22-36) increased from 9.5% in singletons, to 64.3% in twins, and 97.9% in triplets and higher. Furthermore, the risk of very preterm birth (gestational weeks 22-27) increased from 0.81% in singleton to 3.0% in twins and to 9.3% in triplets and higher. Table 8 shows the weight of babies born after fresh, frozen/thawed and fresh OD treatments, according to the order of gestation. As it has been reported previously (Pinborg et al., 2014; Schwarze et al., 2015), the weight of singletons born after FET (3,164±539) is significantly higher than babies born after fresh transfer (3,075±566; p<0.0001). A similar situation occurs after the birth of twin.

369

DISCUSSION This is the 29th report on ART procedures performed in Latin America. The number of new centers reporting to RLA continues to grow. Between 2016 and 2017,13 new centers were incorporated contributing to almost 5000 of the 8,126 new cycles reported in this period (8.7%). As seen in Figure 2 the majority of the 15 countries voluntarily report around 70% to 90% of the cycles performed in each country. This constitutes a noteworthy commitment of centers, which have freely kept reporting year after year for nearly 30 years. The rise in the number of initiated cycles, results in part by a 20% increment in FP, 20.8% increment in FET cycles and 15.4% rise in freeze all cycles. However, in spite of this, the drop in the proportion of twins and high order multiples has been very poor. The mean ART utilization in 12 countries where data is reliable (Figure 2) is only 221 initiated cycles/million population which is very much under the threshold of 1,500 cycles per annum per million inhabitants proposed by the ESHRE Capri Group, in order to fulfil the needs of a population (The ESHRE Capri Workshop Group, 2001). Utilization of health services is closely associated with economic affordability. Argentina and Uruguay with laws providing universal coverage for infertility treatments have increased their utilization rate reaching 535 cycles /million inhabitants; Chile, with partial public coverage is also increasing its utilization rate but at a slower pace with only 349 cycles /million; and Brazil the largest contributor in the region, with proportionally little public support, provides less than 200 cycles/million population. This relationship confirms the importance of financial affordability in the utilization of ART. In countries with strong economic inequalities, the numbers of couples who can afford treatment are few. Public policies providing partial or complete financial support to persons requiring ART are pivotal in order to increase utilization and decrease the burden generated by infertility per se, as well as the burden which results from lack of access in a society with profound socio-economic disparities. The reporting of efficacy in ART can be presented in many different ways. While there is overall agreement, that a proper outcome for ART is delivering a healthy livebirth, the main difficulty lies in what to use as denominator and how to reach international agreement in order to compare results from different latitudes. By incorporating Figure 1, we have tried to acknowledge this difficulty. If the chosen denominator is an “initiated cycle”, the freeze all cycles need to be removed because those women were not exposed to the risk of pregnancy. That accounts for 14,694 out of 45,031 fresh IVF and ICSI cycles, which leaves us with 30,337 initiated cycles where women had the real intention of becoming pregnant in that treatment. However, for the various reasons mentioned in Figure 1, only 21,836 cycles/women (72%) were in fact exposed to the chance of a livebirth after having at least one embryo transferred. This is very much dependent on the age and overall health of the population treated. In cases of young and healthy oocyte donors (OD) the proportion of dropouts due to lack of oocytes or abnormal embryos is much lower. If the freeze all cycles are removed in OD, there were 12,663 transfers which represent 94.9% of the initiated cycles exposed to the chance of pregnancy. All these clinical and biological variables need to be considered both for counseling patients and for the purpose of making results comparable. When using large data base to provide evidence-based counselling to patients, the denominator must be initiated cycle after discarding freeze all cycles. On the other hand, if the objective is to compare the efficacy of different treatment interventions such as fresh over FET transfers or freeze all over FET that results from a failed fresh cycle, the preferred denominator is “embryos transferred”. When

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Figure 6. Cumulative delivery rate per embryo transfer (cDR/ET) and delivery rate per fresh embryo transfer (DR/ET) according to the age of female partner in women with surplus frozen embryos resulting from their fresh transfer. Latin America, 2017.

Table 7. Perinatal mortality according to gestational order in 2017 Singleton

Twin

≥ Triplets

Livebirth*

13,532

6,250

311

Stillbirth

Early neonatal death

Perinatal Mortality**

9.4‰

25.3‰

63.3‰

(*) Early neonatal death are excluded (**) Perinatal Mortality = (stillbirth + early neonatal death) /(livebirth + stillbirth + early neonatal death) comparing DR after fresh transfers in Table 4 with frozen /thawed transfers in Supplementary Table 2 it is evident that FET is more efficient in both SET and DET. However, the question is whether they are comparable considering that only 37.5% of fresh transfers were blastocysts compared with 70.8% in FET. When efficacy is measured after transferring only blastocyst, the DR/ET was almost identical; 31.16% in fresh and 31.9% in FET. One can also be tempted to assume that the most efficient option is the delayed transfer after a freeze all cycle. In fact, after 5,856 FET originated from a freeze all procedure, the overall DR/ET was 32.3% compared with an overall 28.4% FET following a fresh cycle, with similar proportion of blastocysts transferred. This difference is even greater after SET (29.1% in freeze all and 25.5% in FET after a fresh cycle). Again, these two are difficult to compare. Firstly, the mean age of women during the fresh cycle that originated FET was 36.9 years while the mean age of women having freeze all was 35.5. Secondly, we must assume that in the case of a FET cycles that follows a fresh attempt, the best embryos were used in the fresh attempt and the woman was not pregnant, so the cohort of embryos left for FET from those women have a negative selection, while in the case of freeze all cycles, the best embryo is selected in the first attempt.

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What can reasonably be said is that the transfer of frozen thawed embryos does not jeopardize the chances of becoming pregnant and delivering a term livebirth as seen in Supplementary Table 2 and Table 8. Another factor worth considering when analyzing efficacy is that providing global results for SET or DET can be misleading. As seen in Table 5 only 27.9% of SET were eSET and only 39.3% of DET were eDET. The differences in DR/ET are highly significant when the embryo selected for transfer belongs to a larger cohort of embryos available (eSET, eDET) instead of transferring one or two embryos because there were no more embryos available for transfer (oSET, oDET). The DR/ET in 1,638 eSET reached 32.3% with 2.5% of monozygotic twins. On the other hand, the transfer of eDET increased DR by only 5% over eSET, but generated 25% of twins and 0.5% triplets with severe impact in preterm births and perinatal mortality (Tables 7 and 8). When examining cumulative livebirths in our cohort of 47,492 patients followed between 2012 and 2017 (Figure 6). All patients were selected because they had an elective transfer during their fresh cycle, in fact, that was the reason to include them in the study of cumulative livebirths. When these curves were compared with the DR/ET in all fresh transfers in 2017 (Figure 4) the differences are huge and the results of fresh transfers in the cumulative group more closely resemble those of the fresh transfers in oocyte recipients which are mostly women with numerous embryos for transfer. Preimplantation genetic testing (PGT) is also increasing in Latin America. Overall, 8,117 procedures were reported by 132 out of 188 institutions (ten more institutions and 2,970 more procedures than the previous year). When examining the efficacy of PGT and taking into consideration the older population treated (mean age: 38.1±4.3 years), the DR/ET, was significantly higher when comparing 1,745 cases of FET with PGT (37.9%) with 6,539 of FET without PGT (28.5%) (p<0.0001). The number of cases in OD and fresh transfers were too small to allow for meaningful comparisons. Furthermore, miscarriage took place in 17.6% of 16.219 pregnancies after fresh and frozen/thawed autologous cycles. This dropped to 12.8% in 845 pregnancies with PGT. In order to see the relative benefit of PGT in

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Table 8. Gestational age and weight at birth acccording to gestational order in 2017 ART procedure

Singleton

Twin

≥Triplets

Weeks of gestation

Weight grams±SD

Weeks of gestation

Weight grams±SD

Weeks of gestation

Weight grams±SD

Fresh autologous IVF/ICSI

37.73

3,074.5±565.5

35.06

2,246.4±568.3

31.33

1,468.1±514.2

Autologous FET

37.83

3,164.3±538.9

35.35

2,370.2±559.7

31.97

1,674.7±574.6

Fresh and frozen/ thawed OD

37.36

3,008.4±582.7

35.13

2,292.2±571.6

32.07

1,641.6±464.3

different age categories, miscarriage was compared with and without PGT in a standard group of only FET cycles. As seen in Table 6, there is clear benefit with PGT in women ≥40, but the benefit in younger women, although consistent, does not reach mathematical significance. The numbers are still relatively low but more and more women and men in Latin America are seeking for the illusion of certainty in delivering “normal” offspring, even in cases of OD where surprisingly 3.9% of cycles used PGT. The concept of fertility preservation deserves special attention. When examining the data gathered in women vitrifying oocytes in order to postpone gestation, 73% were ≥35 (24% ≥40 years), and 70% of these women had less than 10 oocytes collected. This implies that a large proportion of women are living with the unrealistic expectation of becoming mothers when they so wish. The concept of fertility preservation should perhaps be replaced by oocyte preservation and at the same time, especially in emerging economies where fertility is delayed due to heavy academic or work environments, advocacy groups should contribute contribute to educating young women and simultaneously facilitate the establishment of public policies to provide gamete preservation at younger age. Latin America has much room to improve. Starting with increasing access to treatment, which shall not only decrease the burden of disease, but also bridge the abysm between the rich and the poor who suffer from infertility. However, independently from many related considerations, multiple births is still a problem that needs to be dealt with on a global basis considering that of all babies born in the region, only 66.9% were singletons, while 31.4% twins, and 1.6% triplets and higher. The mean number of embryos transferred has remained quite stable in 1.9, however there are huge differences among countries in the region. While Argentina, Uruguay and Bolivia transfer a mean of 1.6 embryos, the mean number of embryos transferred in Brazil and Mexico, the two major contributors, are 2.0 and 2.2 embryos, respectively. There is indirect evidence that when access to ART is facilitated, the number of SET cycles increase, and “success” is procured as the result of cumulative events such as fresh plus frozen transfers (Chambers et al., 2018). Instead, when women have only one chance in their life, the number of embryos transferred increase in order to secure pregnancy in that unique event. Nonetheless, after a critical look at these regional data, there are numerous improvements to be made in order to increase the proportion of blastocyst transfers, especially in young women, facilitating a higher proportion of eSET. Also, the good results with FET are expressed in the cumulative livebirth rates, which for young women can be as high as 50%. Any series of actions directed at facilitating access to treatment, and at the same time implementing strict quality control systems in the laboratories in order to ensure efficient long-term embryo culture and good cryopreservation techniques should be pivotal in lowering the number of embryos needed to achieve birth. The 32.3% birth rate

after fresh eSET is indeed reassuring and should become a standard especially considering that when 2 embryos are electively transferred, the rise in births is only 5%, while there is a 10-fold rise in multiple births with severe impact in preterm births and perinatal mortality. Role of funding source The Latin American Registry of ART is the recipient of an unrestricted educational grant from Ferring Pharmaceutical.

ACKNOWLEDGEMENTS The authors gratefully acknowledge all centers that voluntarily report their data year after year to the Latin American Registry of ART. We also thank Ferring Pharmaceuticals for their continuous support to our Registry and Mr. Kurt Schwarze for the development and permanent updating of our cycle based regional registry.

CONFLICT OF INTEREST None of the authors declare financial or commercial conflicts of interest. Corresponding author: Fernando Zegers-Hochschild Unit of Reproductive Medicine Clínica Las Condes Santiago, Chile. E-mail: fzegers@clc.cl

REFERENCES Chambers G, Fitzgerald O, Dyer S, Zegers-Hochschild F, Adamson D. Gender inequality and utilization of assisted reproductive technology: an international analysis. Hum Reprod. 2018;33:i65. Dyer SJ, Chambers G, Zegers-Hochschild F, Adamson GD. Access to ART: Concepts indicators, impact. Hum Reprod. 2019;34:i65-6. ESHRE Capri Workshop Group. Social determinants of human reproduction. Hum Reprod. 2001;16:1518-26. PMID: 11425841 DOI: 10.1093/humrep/16.7.1518 Maheshwari A, McLernon D, Bhattacharya S. Cumulative live birth rate: time for a consensus? Hum Reprod. 2015;30:2703-7. PMID: 26466912 DOI: 10.1093/humrep/dev263 Pinborg A, Henningsen AA, Loft A, Malchau SS, Forman J, Andersen AN. Large baby syndrome in singletons born after frozen embryo transfer (FET): is it due to maternal factors or the cryotechnique? Hum Reprod. 2014;29:61827. PMID: 24413766 DOI: 10.1093/humrep/det440

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Schwarze JE, Crosby JA, Zegers-Hochschild F. Effect of embryo freezing on perinatal outcome after assisted reproduction techniques: lessons from the Latin American Registry of Assisted Reproduction. Reprod Biomed Online. 2015;31:39-43. PMID: 25982094 DOI: 10.1016/j. rbmo.2015.03.006 Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, Rienzi L, Sunde A, Schmidt L, Cooke ID, Simpson JL, van der Poel S. The International Glossary on Infertility and Fertility Care, 2017. Hum Reprod. 2017;32:1786-801. PMID: 29117321 DOI: 10.1093/humrep/dex234

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Zegers-Hochschild F, Schwarze JE, Crosby JA, Musri C, Urbina MT. Assisted reproductive techniques in Latin America: The Latin American registry, 2016. JBRA Assist Reprod. 2019;23:255-67. PMID: 31364341 DOI: 10.5935/15180557.20190037

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Supplementary Table 1. List of centers by country, reporting to the Latin American Registry of ART in 2017. ARGENTINA •

Servicio de Medicina Reproductiva, Instituto Gamma

•

Instituto de Fertilidad Asistida

•

Centro de Estudios en Ginecología y Reproducción (CEGYR)

•

Centro de Salud Reproductiva (CER)

•

Instituto Tersoglio

•

Centro Integral de Ginecología, Obstetricia y Reproducción (CIGOR)

•

Centro de Investigaciones en Medicina Reproductiva (CIMER)

•

Centro de Medicina Reproductiva Bariloche, Fertility Patagonia

•

Centro de Estudios en Reproducción y Procedimientos de Fertilización Asistida (CRECER)

•

FECUNDITAS

•

FERTILAB

•

GESTAR

•

Centro de Reproducción Fertilequip

•

Fertya

•

Hospital de Clínicas

•

FECUNDART

•

Centro de Reproducción, servicio de Ginecología Hospital Italiano

•

Mater, Medicina Reproductiva

•

Nascentis, Medicina Reproductiva

•

HALITUS, Instituto Médico

•

Instituto Médico de Ginecología y Fertilidad PREFER

•

PREGNA, Medicina Reproductiva

•

Programa de asistencia reproductiva PROAR

•

PROCREARTE

•

Fertilidad San Isidro

•

SARESA, Salud reproductiva Salta

•

SEREMAS

•

VITAE, Medicina Reproductiva

BOLIVIA •

CENALFES

•

Instituto de Salud Reproductiva (ISARE)

•

EMBRIOVID, centro integral de reproducción y especialidades médicas

BRAZIL •

ANDROLAB, Clinica y Laboratorio de Reproducción Humana y Andrología

•

ANDROFERT, Centro de Referencia en Reproducción Masculina

•

FERTIVITRO, Centro de Reproducción Humana

•

BIOS, Centro de Medicina Reproductiva

•

FIV-MED

•

Centro de Medicina Reproductiva, Clinica Geare

•

VIDA, Centro de Fertilidad

•

Clinica FERTWAY

•

NASCER, medicina reproductiva ltda.

•

ORIGINARE, Centro de Investigación y Reproducción Humana

•

CLINIFERT, Centro de Reproducción Humana

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•

CONCEPTUS, Centro de Reproducción Asistida de Ceara

•

CONCEBER, Centro de Medicina Reproductiva

•

Clinica Origen

•

Clinica Pro-Genesis

•

Centro de reproducción humana CONCEPTION

•

Centro de Reproducción Humana MONTELEONE

•

Fértile Diagnósticos

•

CEERH, Centro especializado en Reproducción Humana

•

Embrios, centro de reproducción humana

•

EMBRYOLIFE, Instituto de Medicina Reproductiva

•

Centro de Reproducción Humana, Endoscopia y Medicina Fetal de Bahía (CENAFERT)

•

Instituto VERHUM

•

Clinica FERTIBABY BH

•

Fertilcare, Medicina reproductiva

•

FECUNDA, Reproducción Humana

•

FELICCITA, Instituto de Fertilidad Ltda.

•

HUMANA, Medicina Reproductiva

•

FERTILITY, Centro de Fertilización Asistida de Campo Grande

•

FERTILITY, Centro de Fertilización Asistida

•

FERTIL Reproduccion Humana

•

REPROFERTY

•

FERTICLIN, Clínica de Fertilidad Humana

•

GENESIS, Centro de Asistencia en Reproducción Humana

•

Clinica Genics, medicina reproductiva y genómica

•

FERTIPRAXIS, Centro de Reproducción Humana

•

GERA, Grupo de endoscopia y Reproducción Asistida

•

Clinica GERAR VIDA

•

Instituto de Saude Da Mulher, Cegonha Medicina Reproductiva

•

IVI Sao Paulo, Chedid Grieco S.A.

•

HUMANA (PRIMORDIA, Medicina Reproductiva Huntington RJ)

•

Hospital de Clínicas de Riberao Preto

•

HUNTINGTON Campinas

•

HUNTINGTON, Centro de Medicina Reproductiva (Sao Paulo)

•

JULES WHITE, Centro de Medicina Reproductiva

•

HUNTINGTON Vila Mariana

•

Ideia Fertil

•

IMR, Instituto de Medicina Reproductiva e Fetal

•

Servicio de Reproducción Humana Del Hospital y Maternidad Santa Johana

•

Life reproducción humana

•

FERTILITAT, Centro de Medicina Reproductiva

•

Clínica MATRIX

•

Pro-criar Monte Sinaí

•

Centro de Reproducción Humana Nilo Frantz

•

Clínica ORIGEN

•

Procriar, Clinica de Fertilización Asistida, Blumenau

•

Clínica PRO-CRIAR, Medicina Reproductiva BH

•

Clínica PRO NASCER

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374

Assisted reproductive techniques in Latin America - Zegers-Hochschild, F.

•

Clinica de Reproducción PROSER SS

•

Centro de Reproducción Humana De San Jose de Rio Preto

•

GENESIS, Centro de Reproducción Humana

•

Centro de Reproducción Humana Prof. Franco Junior

•

Centro de Ensino y Pesquisa en Reproducción Asistida (Centro de Rep. Asist. Hospital Da ASA SUL)

375

CHILE •

UMR Clínica de la Mujer Antofagasta

•

Centro de Estudios Reproductivos (CER)

•

Unidad de Medicina Reproductiva, Clínica Alemana

•

Unidad de Medicina Reproductiva, Clínica las Condes

•

Unidad de Medicina Reproductiva, Clínica de la Mujer

•

UMR clínica Indisa

•

Programa e Fertilización Asistida I.D.I.M.I.

•

Clínica Monteblanco

•

Centro de Fertilidad y Medicina Reproductiva Concepción S.A.

•

Centro de reproducción humana, Valparaiso

COLOMBIA •

Centro FECUNDAR, Cali

•

Unidad de fertilidad del Coutry ltda. CONCEPTUM

•

Asociados en Fertilidad y Reproducción Humana

•

FERTIVIDA

•

Clinica Machicado SAS

•

Centro Médico IMBANACO

•

Instituto de Fertilidad Humana S.A.S. (INSER)

•

IN SER, Instituto Antioqueño de Reproducción

•

Procrear

•

Profamilia Fertil

•

Unidad de Fertilidad, Procreación Medicamente Asistida

•

Union temporal IN SER eje cafetero

ECUADOR •

Clínica de Medicina Reproductiva BIOGEPA

•

Centro Ecuatoriano de reproducción humana

•

Clínica INFES

•

Instituto Nacional de Investigación de Fertilidad y Esterilidad (INNAIFEST)

•

Instituto de Reproducción Humana Guayaquil

•

CONCEBIR, Unidad de Fertilidad y Esterilidad

•

Unidad de Fertilidad Hospital Alcívar

•

PROCREAR

GUATEMALA •

Centro de Reproducción Humana S.A. (CER)

MEXICO •

Centro de Diagnóstico Ginecológico

JBRA Assist. Reprod. | v.24 | nº3 | Apr-May-Jun/ 2020

REDLARA Pages

•

Biofertility Center

•

URA, Unidad de reproducción asistida de Hispital CIMA Hermosillo

•

Centro de Cirugía Reproductiva y Ginecología, Unidad de Fertilización In Vitro (REPROGYN)

•

Instituto de Innovación Tecnológica y Medicina Reproductiva CITMER

•

Instituto para el estudio de la Concepción Humana IECH

•

Centro de Reproducción Asistida del Hospital Español (HISPAREP)

•

Centro de Reproducción Asistida del Occidente

•

Centro de Reproducción Asistida de Saltillo

•

Centro Universitario de Medicina Reproductiva

•

Fertility Center Cancún

•

Genesis Centro de Fertilidad (Culiacan)

•

Ginecología y Reproducción Asistida GYRA

•

Grupo de reproducción y genética AGN y asociados

•

Instituto para el estudio de la concepción humana de Baja California

•

Instituto Mexicano de Alta Tecnología Reproductiva S.C. (INMATER)

•

Instituto de medicina reproductiva del Bajío IMER, sede Guadalajara

•

Instituto IMER de Tijuana

•

Instituto Médico de la mujer (RED CREA)

•

Instituto de Ciencias en Reproducción Humana, sede Guadalajara

•

Instituto de Ciencias en Reproducción Humana, sede Matamoros

•

Centro especializado para la atención de la mujer (CEPAM)

•

INGENES DF

•

INGENES Guadalajara

•

Ingenes Monterrey

•

Instituto de Ciencias en Reproducción Humana (VIDA), sede León

•

Medica Fertil, Querétaro

•

Instituto de ciencias en reproducción humana del Sureste (Vida Merida)

•

Clinica Nascere

•

Centro de Medicina Reproductiva FILIUS

•

Plenus, Reproducción Asistida

•

PROGEN, Reproducción asistida y medicina fetal

•

Centro de Reproducción Asistida Santa Fe SA de CV (PRONATAL)

•

Clinica de Infertilidad y reproducción asistida de Toluca SA de CV

•

Centro especializado en esterilidad y Reproducción Humana (CEERH)

•

Instituto de Ciencias en reproducción humana VIDA, ciudad de Mexico.

•

VILTIS

•

Vida, Instituto de Reproducción Humana del Noroeste, Tijuana

NICARAGUA •

Centro de Fertilidad de Nicaragua

PANAMA •

IVI Panamá S.A.

•

Centro de reproducción Punta Pacífica

•

Instituto de salud femenina

PARAGUAY

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Assisted reproductive techniques in Latin America - Zegers-Hochschild, F.

•

377

Neolife, Medicina y cirugía reproductiva

PERU •

Clínica CEFRA, Centro de Fertilidad y Reproducción Asistida

•

CERFEGIN

•

Centro de Fertilidad y Ginecología del Sur (CFGS)

•

Clinica de fertilidad del norte, Clinifer de Chiclayo

•

FERTILAB, Laboratorio de Reproducción asistida

•

Inmater, Clinica de fertilidad

•

Instituto de Reproducción de la Clinica Ricardo Palma

•

Clinica Miraflores

•

Nacer

•

Grupo Pranor, Clínica CONCEBIR

•

Grupo Pranor, Instituto de Ginecología y Reproducción

•

Pranor, laboratorio de medicina reproductiva sede trujillo

REPUBLICA DOMINICANA •

Instituto de reproducción y ginecología del Cibao (IREGCI)

•

PROFERT

URUGUAY •

Centro de Esterilidad Montevideo (CEM)

•

Centro de Reproducción Humana del Interior

VENEZUELA •

FERTILAB

•

EMBRIOS, Centro de Fertilidad y Reproducción Humana, Hospital de Clínicas de Caracas

•

Instituto Venezolano de Fertilidad

•

Laboratorios In Vitro de Venezuela

JBRA Assist. Reprod. | v.24 | nº3 | Apr-May-Jun/ 2020

1,872 90

≥4

JBRA Assist. Reprod. | v.24 | nº3 | Apr-May-Jun/ 2020

100.0

0.4

8.1

53.4

38.1

8,696

702

4,968

3,000

Number

37.8

28.9

37.5

40.5

34.3

Clinical pregnancy

6,539

518

3,775

2,229

Number of deliveries

28.4

18.9

27.7

30.8

25.5

Delivery rater per embryo transfer (%)

5,450

361

2,883

2,195

Singleton (n)

83.3

64.7

69.7

76.4

98.5

Singleton (%)

1050

138

873

Twin (n)

Deliveries

16.1

29.4

26.6

23.1

1.5

Twin (%)

≥Triplets (n)

0.6

5.9

3.7

0.5

0.0

≥Triplets (%)

≥4

12,663

1,674

Total

3,550

7,409

Number

Number of transferred embryos %

100.0

0.3

13.2

58.5

28.0

Total embryo transfer

5,764

825

3,499

1,427

Number

45.5

43.3

49.3

47.2

40.2

Clinical pregnancy

4,264

637

2,585

1,033

Number of deliveries

33.7

30.0

38.1

34.9

29.1

Delivery rater per embryo transfer (%)

3,199

376

1,803

1,013

Singleton (n)

75.0

77.8

59.0

69.7

98.1

Singleton (%)

Deliveries

1,032

239

772

Twin (n)

24.2

22.2

37.5

29.9

1.8

Twin (%)

≥Triplets (n)

0.8

0.0

3.5

0.4

0.1

≥Triplets (%)

Supplementary Table 3. Clinical pregnancy rate, delivery rate and gestational order according to the number of embryos transferred in fresh and frozen oocyte donation cycles in 2017

22,985

12,268

Total

8,755

Number

Number of transferred embryos

Total embryo transfer

Supplementary Table 2. Clinical pregnancy rate, delivery rate and gestational order according to the number of embryos transferred in FET in 2017

REDLARA Pages

378

REDLARA EN VIVO 2020 . PROGRAMACIÓN e INFORMACIÓN

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