Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Life without artificial cold is hard to imagine in the developed world.
But it all started 200 years ago with some giant ice cubes
Abha Maheshwari Consultant Reproductive Medicine & Surgery
NHS GRAMPIAN
.
Future of IVF – Frozen better than Fresh ?
What is in-vitro Fertiliztion (IVF)?
Fertilisation to Embryo
Day 1 Day 2
Day 3 Day 5
Fate of Embryos
4
To achieve ...........
IVF league table
Healthy mum & a healthy baby
Long term health
How do we get eggs?
6
OHSS- A price we have to pay!
7
Safety- singleton pregnancies
Obstetric/ perinatal outcomes
Outcome Overall effect (RR, 95%CI)
APH 2.49 (2.30-2.69)
Congenital anomalies 1.67(1.33-2.09)
Hypertension 1.49 (1.39-1.59)
PPROM 1.16 (1.07-1.26)
Caesarean Section 1.56(1.51-1.60)
Birth weight < 2500gm 1.65(1.56-1.75))
Birth weight<1500gm 1.93 (1.72-2.17)
Perinatal mortality 1.87(1.48-2.37)
Delivery at < 37 weeks 1.54 (1.47-1.62)
Delivery at < 32 weeks 1.68 (1.48-1.91)
Transfer to NICU 1.58 (1.42-1.77)
Gestational diabetes 1.48 (1.33-1.66)
Induction of Labour 1.18 (1.10-1.28)
Small for Gestation age 1.39 (1.27-1.53)
Long term costs to NHS
USA data (< 35 years old)
Year Live birth/ started cycle implantation rate
2013 40.1% 39.5%
2012 40.6% 37.4%
2011 40.1% 36%
2010 41.7% 36.9%
2009 41.4% 35.6%
2008 41.3% 34.1%
2007 39.9% 32.6%
IVF is not good!
IVF is here to stay!
Something need to change!
Endometrium and
implantation
Evans et al., 2014 Hum Reprod Update
Why could success rates be better?
Ovarian
stimulation
Embryo
transfer
14
Outcome RR (95% CI)
Small Gestational Age 0.45 (0.30,0.66)
Birth Weight <2500gm 0.69 (0.62,0.76)
Delivery at <37 Weeks 0.84 (0.78,0.90)
APH 0.67 (0.55,0.81)
Perinatal Mortality 0.68(0.48,0.96)
Lower risk of ectopic
16
17
Clinical pregnancy rates –
Frozen embryo transfer
18
Graduation Gifts for future
WIN-WIN-WIN situation
Frozen embryo transfer
Healthier pregnancies
Better pregnancy
rates
OHSS free clinics
Planned weekend work load
Unknowns
• Which patients to freeze – all?
• When embryos are not good?
• Is it clinically effective?
• Is it cost effective?
• Is it acceptable?
• Recent concerns about LGA babies
21
Evidence from HFEA data
Fertil Steril . Maheshwari A, et al. 2016
FREEZE ALL
FRESH
EMBRYO
TRANSFER
To determine if a policy of freezing created embryos,
followed by thawed frozen embryo transfer is a more
clinically effective, safer and cost effective way to
provide in-vitro fertilization when compared with the
current practice of transferring fresh embryos.
24
Primary Outcome
• Healthy baby rate:
– Term
– Singleton
– Live birth
– Appropriate weight for gestation
26
Secondary Outcomes• Complication of IVF treatment
– OHSS
• Complications in pregnancy
– Miscarriage
– Pre-eclampsia
– Antepartum haemorrhage
– Multiple pregnancy
– Low birth weight
– Preterm delivery
– Small for gestational age
– Congenital anomaly
– Perinatal mortality
• Clinical effectiveness
– Live birth rate
– Pregnancy rate
• Effectiveness of the process of
freezing embryos
– Failure of embryos to survive after
thawing
• Health economic outcome
– Costs to the health service
– Modelled long-term costs (broader
societal costs)
• Evaluation of emotional state
27
Participating Centres
28
Future recruiting centres:
- King’s College Hospital
- Nurture, Nottingham
- Jessop Wing, Sheffield
Recruitment Target:
1086 Couples
Current recruiting centres:
- Aberdeen Maternity Hospital - Homerton Hospital
- Guy’s & St Thomas’ - Hammersmith Hospital
- Liverpool Women’s - St Mary’s, Manchester
- Princess Anne, Southampton - Birmingham Women’s
- St Bartholomew’s Hospital
- Oxford Fertility
29
It does not end with E-Freeze
• 90% consenting for long term follow up
• Cumulative live birth rate
• Follow up of children born 1,5,10.... years
30
31
International Collaboration