Factors influencing IVF Factors influencing IVF outcomesoutcomes

Peking University Third Hospital

Qiao Jie

Factors Affecting Conception• Production of healthy sperm

• Healthy eggs by the woman

• Unblocked fallopian tubes

• The ability for the sperm to fertilize the egg

• The ability for the embryo to implant in the uterus

IVF success rate

• Despite the progress in IVF, people undertaking IVF often face a considerable risk of failure.

-- Pregnancy rate per transfer remained 30%-35% in 2006.

-- Delivery rate by OPU was 15%-30% in fresh cycle in 2005.

Data from ESHRE

Factors affecting IVF results• AgeAge• Causes of infertilityCauses of infertility• Responsiveness to ovulation Responsiveness to ovulation

inductioninduction• Different stimulation protocols• EmbryoEmbryo qualityquality• Sperm qualitySperm quality• Embryo transfer Embryo transfer techniquetechnique• Luteal phase supportLuteal phase support

Factors affecting IVF results• AgeAge• Causes of infertilityCauses of infertility• Responsiveness to ovulation Responsiveness to ovulation

inductioninduction• Different stimulation protocols• EmbryoEmbryo qualityquality• Sperm qualitySperm quality• Embryo transfer Embryo transfer techniquetechnique• Luteal phase supportLuteal phase support

Endometriosis and IVF• Lower pregnancy ratesLower pregnancy rates (Barnhart et al., 2002, P.Kuivasaari et al.2005, De Hondt A, et al,2005; Azem F De Hondt A, et al,2005; Azem F

et al,1999et al,1999)

• Reduced fertilization rate (Bergendal et al. 1998, Azem et al., 1999, Yamashita Y, et al,2002, Al-Fadhli R, et al,2006; Barnhart Yamashita Y, et al,2002, Al-Fadhli R, et al,2006; Barnhart

K, et al,2002K, et al,2002 )

• Decreased implantation ratesDecreased implantation rates ((Azem et al., 1999; Barnhartet al., 2002; Kuivasaari et al., 2005; Kumbak B Kumbak B

et al,2008) et al,2008)

• A lower number of oocytes retrievedof oocytes retrieved (Bergendal et al. 1998, Azem et al., 1999, Suzuki T, et al,2005; Kumbak B et al,2008; Suzuki T, et al,2005; Kumbak B et al,2008;

Barnhart K, et al,2002Barnhart K, et al,2002 ; ; Nakahara K et al, 1998Nakahara K et al, 1998)

• A lower ovarian response to gonadotrophins (Azem et al,1999;Al-Azemi et al,2000; Aboulghar,2003;Barnhart et al,2002;Kuivasaari et al,2005;Al-Al-

Fadhli R,et al,2006; Kumbak B et al,2008Fadhli R,et al,2006; Kumbak B et al,2008)

Endometriosis and IVF• Poor Poor embryo quality (Barnhartet al., 2002; Kuivasaari et al., 2005; Kumbak B et al,2008Kumbak B et al,2008)

• Higher rate of early pregnancy lossHigher rate of early pregnancy loss (Yanushpolsky EH et al,1998)(Yanushpolsky EH et al,1998)

• Reduced birth rate per cycleReduced birth rate per cycle (Azem F et (Azem F et

al,1999)al,1999)

• Pregnancy rates for women with severe Pregnancy rates for women with severe endometriosis were significantly lower than endometriosis were significantly lower than for women with mild diseasefor women with mild disease

(Barnhart K, et (Barnhart K, et al,2002 )al,2002 )

Endometriosis and IVF

• Lower VEGF gene expression in granulosa Lower VEGF gene expression in granulosa cells may adversely affect oocyte cells may adversely affect oocyte development and maturationdevelopment and maturation

(Yamashita Y, et al,2002)(Yamashita Y, et al,2002)

• Altered folliculogenesisAltered folliculogenesis

(Tummon IS,et al,1988)(Tummon IS,et al,1988)

• Embryo toxicityEmbryo toxicity (Damewood MD et al,1990; Simon C et (Damewood MD et al,1990; Simon C et

al,1992)al,1992)

• Increased apoptosis in granulosa cellsIncreased apoptosis in granulosa cells (Nakahara K et al, (Nakahara K et al,

1998)1998)

Endometriosis and IVF• Decreased expression of biomarkers of

implantation -- decreased expression of HOXA10HOXA10 ((Wei Q et al,2009; Taylor HS et al, 1999;Browne H et al, 2006))

-- decreased expression of glycodelin A (Kao LC,2003; Wei Q et al,2009; Burney RO et al,2007)

-- decreased expression of osteopontin (Burney RO et al,2007; Wei Q et al,2009)

-- -- decreased expression of lysophosphatidic acid receptor 3

((Wei Q et al,2009))

-- -- decreased expression of integrindecreased expression of integrin ((Lessey BA et al,1994; Khorram O et al,2002) Khorram O et al,2002)

• Alterations in endometrial apoptosisAlterations in endometrial apoptosis ((Gebel HM et al,1998; Bergqvist A et al,1993)

Hydrosalpinx and IVF• Reduced clinical pregnancy rate

(Sims et al.1993; Vejtorp et al,1995;Katz et al,1996;

Andersen et al,1994; Zeyneloglu HB et al,1998 ) • Higher miscarriage rate

(Sims et al.1993; Strandell et al,1994; Andersen et al,1994; Zeyneloglu HB et al,1998 )

• Lower ongoing pregnancy rate

(Sims et al,1993)

Hydrosalpinx and IVF• Reduced implantation rate

(Strandell et al,1994; Katz et al,1996; Andersen et al,1994; Freeman et al,1996; Zeyneloglu HB et al,1998 )

• Fewer blastocysts developing

(Freeman et al,1996)

• Improved pregnancy, implantation and delivery rates after salpingectomy for hydrosalpinges before IVF

(Strandell A, et al 2001; Johnson NP.et al, 2002; Fleming and Hull 1996;Murray DL,et

al,1998; Johnson et al., 2004)

Hydrosalpinx and IVF• Hydrosalpinx fluid may contain cytokines,

prostaglandins or other inflammatory compounds. These compounds may have either direct embryo-toxicity or adversely affect the endometrium.

(Meyer et al., 1997)

• Simple mechanical flushing of embryos from

the uterine cavity. (Mansour RT, et al, 1991)

Hydrosalpinx and IVF• Embryotoxic effects -- -- lower lower rate of of the embryos reaching the morula stage and the blastocyst stage (Schenk et al. 1996; Sachdev R,Et al,1997; Koong MK,et al,1998)

-- higher fragmentation and degeneration rate of the embryos

(Schenk et al. 1996; Mukherjee T.et al,1996)

-- poor cavitation rates (Mukherjee T. et al. 1996)

-- retardation of mouse embryo development (Beyler et al,1996; Mukherjee T.et al,1996)

Hydrosalpinx and IVF• Reduce endometrial receptivity -- lower levels of integrins αVβ3 in the endometrium

(Lessey et al. 1994; Meyer W et al,1997)

-- diminished expression of HOXA10 in the endometrium (Daftary GS et al, 2002; Daftary GS et al,

2007)

-- reduced LIF level in the endometrium (Seli E et al,2005)

--increase of integrin αVβ3 expression after surgical

correction of hydrosalpinx (Meyer W et al,1997)

Hydrosalpinx and IVF• Changes in endometrial pattern and

endometrial blood flow -- patients with hydrosalpinx had a significantly

higher proportion of the non-multilayered endometrial pattern and significantly lower endometrial and subendometrial blood flows

Ng EHY. et al, 2006

Intra-ovarian Factors in Polycystic

Ovary Syndrome (PCOS):

Impact on Oocyte Maturation and

Embryo Developmental

Competence

PCOS patients’ typical characterization In IVF

• Increased number of oocytes

• Lower fertilization, cleavage rates

• Lower implantation rates

• Higher miscarriage rates

Poor quality of oocytes and embryos

Human Reproduction Update, Vol.12, No.1 pp. 13–21, 2006

PCOS

during folliculogenesis and follicle maturation

• abnormal endocrine/paracrine factors

• metabolic dysfunction

• intrafollicular microenvironment alterations

Impaired oocyte maturation and embryonic developmental competence

Seminar Reprod Med 2008; 26:53-61

Transforming growth factors (TGF-β)

• Anti-Müllerian hormone (AMH)• Growth differentiation factor (GDF9)• Inhibins • Activitins• Bone morphological protein-15 (BMP15)

TGF-β——AMH

serum AMH levels reduces

throughout reproductive life

Serum AMH levels stable

throughout the menstrual cycle

Human Reproduction Update, Vol.16, No.2 pp. 113–130, 2010

Mean AMH serum levels• significantly higher

in PCOS patients

• associated with increased development of antral follicles and follicular arrest in PCOS patients

• lower in POF patients

Trends in Endocrinology and Metabolism Vol.19 No.9

PCOS-IVF——AMH

PCOS patients:

• higher levels of follicular MIS

• follicular MIS level correlating with a greater number of immature oocytes retrieved

Fertil Steril. 1997 May;67(5):962-5

• PCOS in IVF: Serum and FF AMH significantly higher

• The AMH levels significantly lower patients who began a pregnancy

(22.0 vs. 50.5 pMol/L, P=0.018)

• a negative link between AMH and final oocyte maturation， possibly because of impaired access of FSH to follicles

Fertil Steril. 2010 Jun;94(1):198-204

TGF-β——Inhibins

Inhibins

• produced by the dominant follicle

• stimulate theca cell androgen production for E2 synthesis

In IVF patients,higher FF inhibin A and B levels(measured on the day of oocyte retrieval)

• better oocyte maturity and fertilization rates

• higher pregnancy rates

Europ J Obstet Gynecol Reprod Biol 2004; 115: 194–199

PCOS——Inhibins

• FF inhibin A and inhibin B concentrations are significantly reduced in PCOS compared with those in size-matched follicles from normal women (J Clin Endocrinol Metab. 2005 Oct;90(10):5582-7）

• FF inhibin B levels are significantly correlated to embryo quality

(Hum Reprod. 2002 Jul;17(7):1724-8 )

TGF-β——GDF 9

• GDF9, an oocyte-secreted factor

• promotes granulosa cell proliferation and preantral follicle growth

• its deficiency impairs granulosa cell proliferation and causes follicular arrest at the primary follicle stage

Semin Reprod Med. 2008 January ; 26(1): 53–61

PCOS——GDF 9• PCOS oocytes GDF9 mRNA levels reduced

• Impaired follicle growth

• Lead to premature luteinization

• Decrease luteal generation

• Maybe altered granulosa cell-oocyte signaling

J Clin Endocrinol Metab 2002;87:1337-1344

Insulin-like growth factors

multifunctional polypeptides with insulin-like activity

• two receptor ligands (IGF-I and IGF-II)

• two surface-receptors (IGF1R and IGF2R)• six high-affinity IGF binding proteins

(IGFBP 1-6) PCOS • IGF-I levels in immature follicles is decreased • IGF-II and IGFBP-1 levels lower • lower IGFBP-1 leading to follicular arrest

Expert Rev Endocrinol Metab 2007; 2(2):215-223

IGF

• serum and follicular fluid

IGF-I/IGFBP-1 higher in women who became pregnant

• The ratio IGF-I/IGFBP-1 may reflect oocyte quality

J Assist Reprod Genet 2003; 20:167-176

PCOS——IGF

IGF-I plays a key role in oocyte maturation in PCOS patientsAlterations in IGFBP-3 concentration during stimulation may

be a critical mechanism in modulating IGF-I activity

PCOS patients : Mean serum IGF-I and IGFBP-3 levels increased during stimulation

Serum IGF-I levels decreased higher mean number of immature

oocytes retrieved

(4.8±1.1 vs. 2.4±0.4; P.02)

Serum IGFBP-3 levels increase greater pregnant (P.03) ongoing pregnancy (P.02)

Fertil Steril 2007;88:139–44

Cytokine Familya large family of soluble polypeptide regulators

• interleukins (IL1~35)

• Leukemia Inhibitory Factor (LIF)

• Tumor necrosis factor-alpha (TNFα)

• Soluble Fas (sFas)

• Soluble Fas ligand (sFasL)• regulating ovarian function• exerting an influence on proliferation, differentiation, follicular maturation, steroidogenesis and apoptosis

Best Practice and Res Clinical Obste and Gynaecology. 2004; 18:755-771

PCOS undergoing IVF

• 1) higher serum and FF interleukin-6 and TNF-α

• 2) cytokine concentrations : FF ＞ serum

• 3) FF TNF-α concentrations were inversely correlated to the estradiol levels， indicative poor quality oocytes and embryos

Obstet Gynecol 2003; 101:1177– 82

CK——TNFα

Exposure of porcine oocytes to an elevated TNF-a a reduction in their maturation from GV stage to MII stage increased the proportion of oocytes with abnormal chromosome alignment and cytoskeleton structure

PCOS patients treated with pioglitazone during COSFF TNF-a and IL-6 levels significantly lower The clinical pregnancy rate higher

Fert Steril 2009; 92(suppl) :s104-105

Fertil Steril 2010;93:920–6

CK——LIF• LIF enhances embryonic development and increases blastocyst formation,decreasing the rate of embryo degeneration

FF concentrations of PCOS during IVF

• The LH/FSH ratio negatively correlated with LIF • PCOS: Implatation rates lower • FF LIF appears to function as an embryotrophic agent

PCOS Control Donor P

LIF(pg/ml) 265 816 749 <0.001

Hum Reprod. 2001 Oct;16(10):2073-8

CK——Fas FasL

• sFas and sFasL ,anti-and pro-apoptotic factors, respectively

PCOS in IVF

• serum sFas ↓

treated with metformin

• serum sFas ↑

FF sFasL ↓

• reduce GC DNA fragmentation

• increase implantation and clinical pregnancy rates

Hum Reprod. 2005 Sep;20(9):2391-5

Homocysteine(Hcy)• a homologue of the amino acid cysteine

• recycled into methionine or converted into cysteine in the presence of B-vitamins

• serum and FF homocysteine levels elevated are inversely associated

with oocyte and embryo quality

Hum Reprod 2006; 21:1725–1733

PCOS——Hcy

52 PCOS patients underwent GnRHagonist / r-FSH treatment

higher FF Hcy group: • Grade 3 oocyte↓• Grade 1–2 embryo↓ • fertilization rate↓

Hum Reprod. 2009 Sep;24(9):2293-302

• multiple linear regression analyses ： FF Hcy is an independent determinant of oocyte quality and embryo quality

Hum Reprod. 2009 Sep;24(9):2293-302

PCOS pregnance after IVF or ICSI

• FF Hcy levels negatively associated with FF E2

• The E2-enriched follicular fluid positively correlated

with oocyte fertilization, cleavage and implantation

• higher follicular fluid Hcy levels may suppress E2

production and interfere with the development of

dominant follicles,oocyte maturation and fertilization

in women with PCOS undergoing assisted reproductionHum Reprod. 2009 Sep;24(9):2293-302

Leptin

• 16kDa protein hormone

• regulating energy intake, energy

expenditure, and their balance

• high FF and serum leptin levels

closely associated with decreased

oocyte maturity, poor fertilization

and embryo quality, and lower

pregnancy ratesReproduction 2005; 130: 917–921

PCOS undergoing ART——Leptin

variable ART success ART failure smokers PCOS

Age 34.1 35.0 34.7 31.5

Serum oestradiol(pg/ml)

1456.3 1639.6 1344.2 1781.0

Oocytes retrieved(n) 11.1 10.5 11.8 16.8

FF leptin(ng/ml) 11.94 17.00 17.23 20.87

Serum leptin(ng/ml) 16.46 19.03 22.24 31.79

ART success group: low FF and serum leptin

PCOS group: higher FF and serum leptin

elevated leptin levels may block E2 production,

disturbing follicular development and oocyte maturation

Hum Reprod. 2000 Mar;15(3):539-44

VEGF and FGF• Vascular endothelial growth factor (VEGF)

• a homodimeric glycoprotein

• angiogenesis, follicular vascularization and intrafollicular oxygenation

• Fibroblast growth factors (FGF)

• A group of polypeptides

• play a fundamental role in development, cell growth, tissue, regulator of FSH action

Human Reproduction 2005; 20, 1562–1568

Expert Rev Endocrinol Metab 2007; 2(2):215-223

PCOS patients undergoing IVF• serum and follicular fluid VEGF and bFGF levels

Gynecol Endocrinol. 2006 Aug;22(8):465- 70

PCOS——FGF

• follicular fluid bFGF levels inversely correlated with the percentage of mature oocytes collected (p=0.034)

• bFGF seems to be an FSH-dependent growth factor

Gynecol Endocrinol. 2006 Aug;22(8):465- 70

PCOS undergoing ICSI using a GnRH antagonist or a GnRH agonist protocol

• between the GnRH antagonist and the GnRH agonist

• MII oocytes VEGF concentrations statistically significant

• (log 3.20 ±0.21 versus 3.34 ± 0.15, corresponding mean VEGF 1774 and 2316 pg/ml, respectively) (P < 0.001)

Reprod Biomed Online. 2009 Jan;18(1):21

PCOS undergoing ICSI using a GnRH antagonist or a GnRH agonist protocol

• higher oestradiol concentrations were related to embryos of higher quality (P = 0.037)

• PCOS: GnRH antagonists decrease follicular oestradiol and VEGF concentrations and the number of retrieved MII oocytes

Reprod Biomed Online. 2009 Jan;18(1):21

Conclusions

• AgeAge• Causes of infertilityCauses of infertility• Responsiveness to ovulation Responsiveness to ovulation

inductioninduction• Different stimulation protocols• EmbryoEmbryo qualityquality• Sperm qualitySperm quality• Embryo transfer techniqueEmbryo transfer technique• Luteal phase supportLuteal phase support

Thank you for attention