Non invasive emNon-invasive em

Barry Behr, y ,Prof

Director, IVF/ARDirector, IVF/ARCo-Director, R

Dept ODept OStanford Universi

mbryo Evaluationmbryo Evaluation

Ph.D., HCLD,fessorRT LaboratoriesRT LaboratoriesEI/IVF Program

Ob/GynOb/Gynity Medical Center

Disclo

I am a founder of AuxI am a founder of BlasI am a founder of Blas

osure

xogynstogen/IviGenstogen/IviGen

Out

BackgroundHistoric perspectiveHistoric perspectiveCurrent approachesF t t h l iFuture technologies

tline

What’s ImThe Patie

stimulatio

What culture system

stimulatio

What media Conditions/Exp

IVF outcome

mportant ?ent

on

Which stage

on

Which embryoertise

e

IVF Field AwaitingIVF Field Awaiting

“Young fertilitYoung fertilitfigure out wmake a babThat will reThat will remultiples bsuccess ratwhich curresurprisinglyhis team wDr. Howard Georgeanna Jones,

First IVF Baby and First IVF Clinic in the US

Epstein, Randi Hutter. “Pioneer Reflects o

g a Breakthroughg a Breakthrough

ty investigators today shouldty investigators today should which one embryo is likely to by rather than transfer several.educe costs, the number ofeduce costs, the number of births and significantly increase es of in vitro fertilization, ently hover around 30%‐‐y close to the 28% success rate as seeing in the 1980s.”

5

on Future of Reproductive Medicine.”, 22,March,2010 

Risks of Multiple Em

Short‐ and long‐term risks to offsprin– Increased chance of miscarriage

Lo birth eight (LBW) and pre term b– Low birth weight (LBW) and pre‐term b

– 80% of infant mortalities result from 8%

Risks to the mother– Pre‐eclampsia / hypertensive disorder

– Pregnancy‐induced diabetes

– Miscarriage and other prenatal complic– Miscarriage and other prenatal complic

Selective fetal reduction

mbryos Transferred 

ng

irth occ r 7 and 5 resp (Barker H pothesis)irth occur 7x and 5x, resp. (Barker Hypothesis)

% LBW, 13% pre‐term births

cations often requiring hospitalizationcations often requiring hospitalization

Whichh one?

Traditional

The Balancing Act !The Balancing Act !

L k f

Culture induced s

Lack of predictability

vs.

Low Implantation

Approach

Attrition in

stress

Attrition in culture

Hi h I l t tiHigh Implantation

Problems with Em

SubjectivePoor standardizationPoor standardizationTiming dependentC i dCan compromise devePre vs Post genomic aPaternal contribution a

mbryo Assessment

l telopmentactivationassessment

What you see is noWhat you see is noge

ot always what youot always what you et!

But…morphologyy isn’t everything!

Current EmbryCurrent EmbryEmbryos are evalua

morphological assess

Step 2: Occasional monitor

Step 1: Embryos develop in Occasional monitor

and Day 3 selectioEmbryos develop in

incubator

yo Assessmentyo Assessmentated based on simplesment on days 1 and 3

Non-ViableViable Viable

Viablering

Non-ViableNon-Viable

ring on

The dilem

BOTH RESULTED

mma……..

IN A SINGLETON P.Nagy

Human Embryoo Development

Important facto

Incubation chamber pH levelspO2 levelsOil vs. open culturepVolume of mediumOocyte/Embryo densityOocyte/Embryo densityMode of fertilization

ors to considerThe time of gamete co-incubationAssisted hatchingPGDEmbryo transfer techniqueOvarian stimulation protocols

Ultimat

Achieve a healthy singTransfer fewer embryoTransfer fewer embryo

te Goal

gleton pregnancyos (1 or 2)os (1 or 2)

New TechNew Techhnologieshnologies

What can

What do you need to b– Good genesGood genes– Good metabolism

n we do?

be healthy?

Embryo SelectEmbryo SelectMost technologies lack clinical trials

improved blastocyst predicimproved blastocyst predic

GenChemistry

Approach

• Full Karyotypeimplantation GScreening (PG

y• Metabolomic profiling

• Amino Acid uptake

• Cummulus Cell analysis

Limitation

•Mosaicism?

• Experts disageffectiveness

• Invasive proc

• Technology adoption challenge

• Doesn’t fit in current workflow • Invasive proc

ion Landscapeion Landscapes. No results exist to demonstrate ction or pregnancy ratesction or pregnancy rates.

etics Imaginge ‐ Pre‐Genetic GS)

g g• Unisense/Primo Vision– Time lapse imaging of 

embryos• Olympus/Sanyo/Nikon/AstecOlympus/Sanyo/Nikon/Astec– Instrumentation

gree on s?

cedure

•No predictive parameters (yet)

•No prospective studies to show efficacy

• Lack of human data emergingcedure • Lack of human data , emerging

Amino Acid Upta

Immediate goal: 30%success rates.Ultimate goal - 50% iEmbryo Transfer ratesytwo or more embryos

ake: Novocellus

% increase in IVF

ncrease in Single s to match those with replaced

Novoc

Need to use proprietarCulture in micro volumCulture in micro volum

cellus

ry mediamesmes

“Omics” eOmics e

Economics GenomicsGenomicsProteomics

eraera……….

The “oThe o

Functiona

omics”omics

al Phenotype

Proteo

Current approaches:– Not user friendlyNot user friendly– Not rapid– Not high through putNot high through put

omics

Proteo

Most proteins are NOTProteins used for interProteins used for inter

omics

T secretedrnal processesrnal processes

MetaboMetabo

Molecular MetabMetab

olomicsolomics

Biometricsbolonbolon

Biomarker SpectraBiomarker Spectra(by N(by N(by N(by N

0 08

ance

0 06

0.08

Heme

Abs

orba

0.04

0.06

R-O

Heme

Rel

ativ

e A

0.02

0.04

CH

R

600 00 8000600 700 800

Wavelen

al Signatures al Signatures NIR)NIR)NIR)NIR)

OHOH

NH

OH

0 900 10000 900 1000ngth (nm)

Human Embryo TiPaper Published Samples

Payne et al. Hum Reproduction 1997 50

2PN • ObsHum Reproduction 2PN

Lemmen et al.RBM Online 2008 102

2PN oocytes

• Rep• Cor

preg

Mio et al. Am J Obstet Gyn 2008 286

oocytes • Obs• Rep

Wong et al 242

• Idenby DWong et al.

Nature Biotechnology 2010 2422PN

y• Dem

exp• Dev

Pribenszky et al. RBM Online 2010 5

2PN • RepRBM Online 2010 2PN p

Meseguer et al. Hum Reprod 2011 247

2PN • Eva

Hashimoto et al. 2012 80 EHashimoto et al.Fert Steril 2012 80

2PN • Eva

Swann et. al.Fertil steril 2012 10 oocytes

or zygotes • Cor

ime-lapse StudiesConclusions

served details of the fertilization process to 20 hrs

ported PN appearance & disappearancerelated synchrony in nuclei appearance after 1st cleavage with gnancy success

served details of the fertilization processported two ICMs - monozygotic twins

ntified cell cycle parameters that predict blastocyst formationDay 2ymonstrated that parameters correlate to embryo gene pression dataveloped cell tracking software

ported a live birthp

aluated cell cycle parameters to implantation

l t d ll l t f bl t t litaluated cell cycle parameters for blastocyst quality

related cytoplasmic movements with Ca2+ oscillations.

Imaging Systemg g yUnisense EmbryoScope Pri

Olympus Niko

ms (currently available in the USA)mo Vision

n Biostation Astec real time monitoring system

what is the embwhat is the embi.e. non–invasive, qua

bryo equivalent?bryo equivalent?antitative assessment

SumSumMany opportunities to interrogate emb

Time laps imaging offers a lot of prom

Parameters of the first three mitotic diindicate success to blastocyst (>93% success/failure inherited (maternal).

Defects in underlying molecular prograbehavior.

Should be able to be measured other

Improved diagnostics = (Early transferImproved diagnostics (Early transferoutcomes and increased success.

marymarybryos.

mise. Prospective trials emerging.

visions prior to embryonic activation specificity and sensitivity); suggesting

ams underlie aberrant blastomere

ways?

r) fewer embryos reduced adverser), fewer embryos, reduced adverse

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