修订后的Alpha/ESHRE共识(维也纳,2017)带来一个真正的答案,管理卵母细胞与平滑内质网(SERA)的聚集体?
根据目前可用的文献,对注射/授精SERA+卵母细胞的时间进行逐案处理可能对胚胎学家做出决定没有帮助,因此,我们建议对SERa+和SERa-卵母细胞进行受精,并优先考虑来自SERa-卵母细胞的胚胎。
2011年,由于文献报道的不良胎儿结局,伊斯坦布尔共识建议不注射/授精SER+卵母细胞。2017年底,一个专家小组重新考虑了这一建议,并建议采用逐案方法。因此,由于缺乏明确的建议,体外受精从业者在管理SERa+卵母细胞时仍然有不同的态度。在这种争议的背景下,更新的综述可能有助于(i)形成管理SERA+卵母细胞病例的通用语言,以及(ii)为寻求不孕症治疗或保留生育能力的患者提供最符合伦理的实践和最佳护理.
这篇综述(最后一次文献检索时间为2018年6月1日)评估了SER畸形对胚胎和新生儿结局的影响。
如果是前瞻性或回顾性队列研究或病例对照研究,则考虑纳入研究。使用关键词组合对Pubmed和Embase数据库进行电子搜索:平滑内质网,SER,卵母细胞和受精卵。包括用英语撰写的摘要和文章,仅限于人类。
检索共返回726项研究,其中21项符合纳入标准。文献并未一致支持SERA与胚胎发生之间的负关联,植入或辅助生殖治疗结果。审查的研究报告了112个移植后的新生儿结局,其中至少一个胚胎来自受SERa影响的卵母细胞。其中包括101名健康婴儿,三个畸形的活产,三例新生儿死亡,一次死产和四次怀孕中断。移植完全来自SERa+卵母细胞的胚胎后,共报告48例健康新生儿以及4例有围产期并发症(包括1例室间隔缺损)的婴儿,一次死产,1例新生儿死亡和1例多发性畸形终止妊娠。
与任何评论一样,本综述受到纳入研究质量的限制,特别是在可能的方法学限制方面,有限的样本量和研究的回顾性方面。在选定的21项研究中,7份为摘要,2份为病例报告.在剩下的14项研究中,只有三个是潜在的。用于鉴定SERa+卵母细胞的工具可能因一项研究而异,因此不能排除错误分类。考虑到光学显微镜在检测SER聚集体时分辨率较差,如果在电子显微镜或延时系统下分析,我们不确定SERa-卵母细胞是否确实表现出这种畸形。
鉴于现有数据以及受精SERa+卵母细胞与胚胎非整倍体/畸形的发生之间缺乏真正的联系,我们认为,即使在取卵当天有大量队列的患者中,丢弃SERa+卵母细胞也可能不是最符合伦理的方法.在医学伦理方面避免卵母细胞和胚胎的浪费仍然是日常IVF实践中持续关注的问题。因此,我们建议所有成熟的卵母细胞都可以受精,并且最好转移来自SERa-卵母细胞的胚胎,即使它们来自具有SERA+卵母细胞的队列。如果对怀孕和婴儿进行严格的随访,则在获得夫妇的同意后,可以认为来自SERa卵母细胞的剩余胚胎的转移优先级较低。
我们没有要申报的利益冲突,也没有收到任何资金。
不适用。
Did the revised Alpha/ESHRE consensus (Vienna, 2017) bring a real answer on managing oocytes with aggregates of smooth endoplasmic reticulum (SERa)?
According to the currently available literature, a case by case approach on the time of injecting/inseminating SERa+ oocytes may be not helpful for embryologists making a decision, so we suggest fertilizing both SERa+ and SERa- oocytes and prioritizing embryos derived from SERa- oocytes.
In 2011, the Istanbul consensus recommended not to inject/inseminate SER+ oocytes due to adverse foetal outcomes reported in literature. At the end of 2017, a panel of experts reconsidered this recommendation and advised a case by case approach. Hence, with a lack of clear recommendations, in-vitro fertilization practitioners still have heterogeneous attitudes when managing SERa+ oocytes. In this context of controversy, an updated review could be helpful in (i) forming a common language for managing cases of SERa+ oocytes and (ii) offering the most ethical practice and best care for patients seeking infertility treatment or fertility preservation.
This review (with a last literature search on 1 June 2018) evaluated the effect of the SER dysmorphism on embryological and neonatal outcomes.
Studies were considered for inclusion if they were prospective or retrospective cohort or case-control studies. Electronic searches of the Pubmed and Embase databases were done using the keyword combination: smooth endoplasmic reticulum, SER, oocyte and zygote. Abstracts and articles written in English and limited to humans were included.
The search returned a total of 726 studies among which 21 met the inclusion criteria. The literature does not unanimously support a negative association between SERa and embryogenesis, implantation or assisted reproductive therapy outcomes. The reviewed studies reported 112 neonatal outcomes after transfers where at least one embryo originated from oocyte affected by SERa. They included 101 healthy babies, three live births with malformations, three neonatal deaths, one stillbirth and four medical interruptions of pregnancy. After transfer of embryos exclusively derived from SERa+ oocytes, a total of 48 healthy newborns were reported along with four babies with perinatal complications (including one ventricular septal defect), one stillbirth, one neonatal death and one pregnancy termination for multiple malformations.
As with any review, this review was limited by the quality of the included studies especially in terms of possible methodological limitations, the limited sample size and the retrospective aspect of the studies. Among the 21 selected studies, seven were abstracts and two were case reports. Of the remaining 14 studies, only three were prospective. The tools used in identifying SERa+ oocytes may have varied from one study to another and a consequent misclassification cannot be excluded. Considering the poor resolution of light microscopy in detecting SER aggregates, we are not sure that apparently SERa- oocytes do not really exhibit such a dysmorphism if they were analysed under electronic microscopy or a time lapse system.
In the light of the existing data and the lack of a real link between fertilizing SERa+ oocytes and the occurrence of embryo aneuploidy/malformations, we think that discarding SERa+ oocytes may be not the most ethical approach even in patients with large cohorts on the day of oocyte retrieval. Avoiding the wastage of oocytes and embryos with respect to medical ethics remains a constant concern in daily IVF practice. Thus, we recommend that all mature oocytes could be fertilized and embryos originating from SERa- oocytes would be preferably transferred, even if they come from a cohort with SERa+ oocytes. The remaining embryos derived from SERa+ oocytes could be considered with a lower priority for transfer after obtaining consent from the couple if a strict follow-up of the pregnancy and the baby is performed.
We have no conflict of interest to declare and no funding was received.
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