TAQITAQI

Consultant Consultant OB/GYN,Infertility,IVFOB/GYN,Infertility,IVF

Operative laparoscopy,and Operative laparoscopy,and UltrasonographyUltrasonography..

AS-SALMA HospitalAS-SALMA Hospital

22

Over the years Over the years Patient Patient ExpectationsExpectations have not have not

changedchanged……

‘to become Pregnant and to have a healthy Baby’

What are our chances of What are our chances of having a babyhaving a baby??

ObjectiveObjective

To highlight the rationale, principles and different To highlight the rationale, principles and different protocols of ovarian stimulation in cases of I.V.F protocols of ovarian stimulation in cases of I.V.F

There is no golden standards, guidelines There is no golden standards, guidelines or protocol.or protocol.

Any of the following slides is packed up Any of the following slides is packed up with hundreds of reputed studies.with hundreds of reputed studies.

But …..still can be logically criticizedBut …..still can be logically criticizedAs there is no golden rule,inuction of As there is no golden rule,inuction of

ovulation depends largely on the provider ovulation depends largely on the provider experience and patients merits.experience and patients merits.

Think twice before starting induction, and Think twice before starting induction, and avoid the routine.avoid the routine.

From “one size fits all” to taylor made COS

Taylor made for perfect individualization

1st step for success: Take the exact measurements

77

Many variables can impact Many variables can impact treatment successtreatment success

Patient characteristicsPatient characteristicsAgeAgeType of infertilityType of infertilityPsychological stressPsychological stress

Oocyte / Embryo CompetenceOocyte / Embryo CompetenceLaboratory ConditionsLaboratory ConditionsEmbryo transfer procedureEmbryo transfer procedureType of stimulation regimenType of stimulation regimenType of gonadotrophin Type of gonadotrophin

preparationpreparationKeck RBM Online , 2005

Aim of COHAim of COH

Regulated superovulation by turning off the patient’s own HPO Regulated superovulation by turning off the patient’s own HPO system (down regulation) followed by stimulation.system (down regulation) followed by stimulation.

1.1. Recruiting multiple folliclesRecruiting multiple follicles

2.2. Control timing of ovulation (eggs can be surgically Control timing of ovulation (eggs can be surgically retrieved before they are ovulated)retrieved before they are ovulated)

3.3. Prevention of premature LH surgePrevention of premature LH surge

4.4. To time the inseminationTo time the insemination

5.5. Increase the pregnancy rateIncrease the pregnancy rate

MonitoringMonitoring

To time HCG injectionTo time HCG injection Decreases OHSSDecreases OHSS Decreases multiple pregnancyDecreases multiple pregnancy Follicular monitoring from D9Follicular monitoring from D9 S. estradiol levels did not give any additional S. estradiol levels did not give any additional

information in various studiesinformation in various studies

Monitoring ovarian stimulation

Transvaginal ultrasound scanning: . No. & size of follicles . Pattern & thickness of endometrium

Estrogen blood level

Traditional COHTraditional COH

HMG or FSHHMG or FSH 300 IU on 2° day cycle300 IU on 2° day cycle

HCGHCG 10.000 IU on leading follicle >17 10.000 IU on leading follicle >17 mm and at least two follicles >15 mmmm and at least two follicles >15 mm

Pick-upPick-up after 33-36 hafter 33-36 h

PP44 50 mg i.m. for luteal supplementation50 mg i.m. for luteal supplementation

Traditional Traditional COHCOH

FSH remain elevatedFSH remain elevated

recruitment and growth of ovarian recruitment and growth of ovarian follicles continues throughout follicles continues throughout treatmenttreatment

* *Filicori M: Filicori M: Characterization of the physiological pattern of episodic Characterization of the physiological pattern of episodic gonadotropin secretion throughout the human menstrual cycle gonadotropin secretion throughout the human menstrual cycle . . J Clin J Clin

Endocrinol Metab Endocrinol Metab . 1986;62:1136–1144. 1986;62:1136–1144

This FSH serum pattern profoundly divergesThis FSH serum pattern profoundly diverges from the spontaneous menstrual cyclefrom the spontaneous menstrual cycle

Traditional COHTraditional COH

heterogeneous size cohortsheterogeneous size cohorts of of follicles are often found at hCG dayfollicles are often found at hCG day

the optimal outcome of COH would the optimal outcome of COH would be the selective attainment of be the selective attainment of numerous large mature numerous large mature homogeneous follicles.homogeneous follicles.

* *Arnot AM , Vandekerckhove P , DeBono MA , Rutherford AJ . Arnot AM , Vandekerckhove P , DeBono MA , Rutherford AJ . Follicular volume Follicular volume and number during in-vitro fertilization (association with oocyte developmental and number during in-vitro fertilization (association with oocyte developmental

capacity and pregnancy rate) capacity and pregnancy rate) . . Hum Reprod Hum Reprod . 1995;10:256–261. 1995;10:256–261

Gn-RH-a protocolsGn-RH-a protocols

long protocollong protocol short (“flare-up”) protocol short (“flare-up”) protocol ultrashort protocolultrashort protocolmicrodose flare protocolmicrodose flare protocol

Long protocolLong protocol::

1. Avoid pre-menses FSH surge2. Follicles timing3. Avoid premature LH surge4. Higher follicular recruitment

(synchronization)5. Improvement immune attitude6. Expensive cost

High respondersHigh respondersPCOSPCOS

short protocolsshort protocols

1. follicles timing 2. avoid premature LH surge3. lower follicular recruitment4. make procedures easier

Poor respondersPoor responders

PR/transfer in Gn-RH-aPR/transfer in Gn-RH-a

FIV nel periodo 92-96 (da FIV-NAT ’97) sec. FIV nel periodo 92-96 (da FIV-NAT ’97) sec. Barrière et al. Barrière et al. 19991999

Flare-up Flare-up protocolprotocol19.2%19.2%

Long protocol Long protocol 25.7%25.7%

without without analoguesanalogues23.2%23.2%

Gn-RH-a Long protocol Gn-RH-a Long protocol 11

Gn-Rh-a depot 3.75 mg in one dose on 21Gn-Rh-a depot 3.75 mg in one dose on 21stst day only day only of previous cycle or of previous cycle or

Gn-Rh-a low-dose daily on the 21Gn-Rh-a low-dose daily on the 21stst day of previous day of previous cicle to HCG day:cicle to HCG day:

Buserelin (Suprefact fl 5.5 ml) 0.3 ml fl s.c. Buserelin (Suprefact fl 5.5 ml) 0.3 ml fl s.c. Buserelin nasally 1 buff x 3/d (300 Buserelin nasally 1 buff x 3/d (300 μμg)g) Leuproreline (Enantone die fl s.c.) 0.2 ml/dayLeuproreline (Enantone die fl s.c.) 0.2 ml/day Triptoreline (Decapeptyl die fl s.c.) 0.2 mlTriptoreline (Decapeptyl die fl s.c.) 0.2 ml

oror

on any day when:on any day when: LH <0.5 LH <0.5 EE22 <30 <30 No ovarian cyst >10 mmNo ovarian cyst >10 mm

Gn-RH-a long protocol Gn-RH-a long protocol 22

•FSH/HMG 300-650 IU/day on 2FSH/HMG 300-650 IU/day on 2ndnd cycle day to HCG day cycle day to HCG day

•HCG 10.000 IU on the least two follicles >18 mmHCG 10.000 IU on the least two follicles >18 mm

•Pick-up after 33-36 hoursPick-up after 33-36 hours

•P4 supplementationP4 supplementation

•HCG 5.000 IU six days after E-THCG 5.000 IU six days after E-T

Short (flare-up) protocolShort (flare-up) protocol

Gn-RH-a 3.75 mg depot ½ fl i.m. on 2° Gn-RH-a 3.75 mg depot ½ fl i.m. on 2° cycle day onlycycle day only

FSH 225-600 IU/d on 3FSH 225-600 IU/d on 3thth day (step- day (step-down regimen)down regimen)

HCG 10.000 IU (18 mm + 15-16)HCG 10.000 IU (18 mm + 15-16) Pick-up after 33-36 hPick-up after 33-36 h HCG (+ P4)HCG (+ P4)

Gn-RH-a flare low dose protocolGn-RH-a flare low dose protocol

on 1on 1stst cycle day at HCG day: cycle day at HCG day: Triptoreline (decapeptyl die) 0.2 ml (0.1 mg) s.c. dailyTriptoreline (decapeptyl die) 0.2 ml (0.1 mg) s.c. daily Leuproreline acetate (enantone die) 0.2 ml (1 mg) s.c. dailyLeuproreline acetate (enantone die) 0.2 ml (1 mg) s.c. daily Buserelin (Suprefact flac 5.5 ml) 0.3 ml s.c.Buserelin (Suprefact flac 5.5 ml) 0.3 ml s.c. Buserelin nasally 3 buff/day (300 Buserelin nasally 3 buff/day (300 μμg)g)

oror on any day when:on any day when:

LH <0.5 LH <0.5 EE22 <30 <30 No ovarian cyst >10 mmNo ovarian cyst >10 mm

r-FSH/HMG 300-650 UI/d on 3r-FSH/HMG 300-650 UI/d on 3rdrd cycle day cycle day

•EE-P for 1-2 cyclesEE-P for 1-2 cycles

on 1° days Gn stimulation on 1° days Gn stimulation

on 5°-6° dayson 5°-6° days

one leading follicle one leading follicle ≥14 mm≥14 mm

•HMG or FSH + HMG or FSH + LH addedLH added

Antagonists protocolAntagonists protocol

Fixed and early start of the antagonist is probably more Fixed and early start of the antagonist is probably more effective than an individualized and late starteffective than an individualized and late start . .

Gn-RH AntagonistGn-RH Antagonist

advantagesadvantages::Prevention surge LHPrevention surge LHlarger cohort of larger cohort of

folliclesfollicles Avoidance of Avoidance of

adverse effects of adverse effects of agonistsagonists

More friendly More friendly stimulation protocolstimulation protocol

OHSSOHSS

disavantagesdisavantages

peak Epeak E22 on HCG on HCG dayday

mature folliclesmature follicles oocytesoocytes embryosembryos PRPR

Luteal supplementation in Luteal supplementation in agonists/antagonists agonists/antagonists

protocolsprotocols

Pituitary depletionPituitary depletionPituitary desensitizationPituitary desensitizationNegative estrogen feed-backNegative estrogen feed-backCompulsory supplementation E/PCompulsory supplementation E/P

HCG supplementation absolutely necessaryHCG supplementation absolutely necessary!!! !!!

PP4 4 secretionsecretion

Follicular Follicular phasephase

Luteal phase Luteal phase **

OvaryOvary48%48%95%95%

Adrenal glandAdrenal gland48%48%4%4%

from from pregnenolonepregnenolone4%4%1%1%

**PP44 serum level: serum level: 4 ng/ml is low level; 40 ng/ml is high4 ng/ml is low level; 40 ng/ml is high

Luteal ELuteal E2 2 supplementationsupplementation

EE22 orally 2-6 mg/d (Progynova cpr 2 mg) orally 2-6 mg/d (Progynova cpr 2 mg) ** Start on: Start on:

E-T day E-T day or or 7 days after E-T7 days after E-T

Increases implantation rateIncreases implantation rate Increases pregnancy rateIncreases pregnancy rate

In IVF cycles, the levels of EIn IVF cycles, the levels of E2 2 and Pand P44 drop in the mid-late luteal phase drop in the mid-late luteal phase

Lower ELower E22 at 11 days after pick-up is associated with lower pregnancy rate at 11 days after pick-up is associated with lower pregnancy rate

* *Lukaszuk K: Fertil Steril 2005;83:1372-1376Lukaszuk K: Fertil Steril 2005;83:1372-1376

poor responders protocolspoor responders protocols

Poor respondersPoor responders diminished ovarian reservediminished ovarian reserve A lower expression of FSH receptor in the A lower expression of FSH receptor in the

granulosa cells granulosa cells Advanced maternal ageAdvanced maternal age EE22 < 500 pg/mL on day of hCG < 500 pg/mL on day of hCG <4 de Graaf follicles on HCG day<4 de Graaf follicles on HCG day lower fertilization rates lower fertilization rates lower cleavage rates lower cleavage rates lower resulting embryoslower resulting embryos Lower implantation rateLower implantation rate lower pregnancy rates lower pregnancy rates

1010––25%25% of the ART populationof the ART population**

* *Keay Keay et alet al., 1997 ; Karande and Gleicher, 1999 ; Fasouliotis ., 1997 ; Karande and Gleicher, 1999 ; Fasouliotis et alet al., 2000 ; Tarlatzis ., 2000 ; Tarlatzis et alet al., 2003., 2003

““

occult ovarian failure

occult ovarian failure

””

increase Gn doseincrease Gn dose

first and simplestfirst and simplest approach approach limited benefit to limited benefit to 450 IU450 IU per day per day 300 IU FSH +300 IU FSH + hMG 150 IUhMG 150 IU beyond this amount little or no beyond this amount little or no

improvement improvement

Murat Arslan: Fertil Steril 2005; 84,3:555-569

Luteal estradiol protocolLuteal estradiol protocol **

outcomeoutcomeAll cyclesLuteal

EstradiolStandard protocol

Clinical Pr38,3%40,9%31,3%

Miscarriage rate

43,5%38,9%60,0%

Delivery rate

20.0%25.0%25.0%12.5%

* *Frattarelli J, et al: “A luteal estradiol protocol for expected poor-responders Frattarelli J, et al: “A luteal estradiol protocol for expected poor-responders improves embryo number and quality” Fertil Steril 2008;89,5:1118-22improves embryo number and quality” Fertil Steril 2008;89,5:1118-22

High responders High responders protocolprotocol

CC 100 mg/d 3°-7° daysCC 100 mg/d 3°-7° daysFSH 150 UI s.c. on cycle day 9 at HCG dayFSH 150 UI s.c. on cycle day 9 at HCG dayantagonist 0.25 mg/d delayed regimenantagonist 0.25 mg/d delayed regimenAspirin 100 mg/d on 1° at 45° cycle dayAspirin 100 mg/d on 1° at 45° cycle day

High responders High responders protocol 2protocol 2

• Gn 225 UI/d on 2° cycle daysGn 225 UI/d on 2° cycle days

• step-down regimenstep-down regimen

• antagonist 0.25 mg/d on 2° day antagonist 0.25 mg/d on 2° day up HCG dayup HCG day

DoxycyclineDoxycycline** 80 mg/Kg/day 80 mg/Kg/day (inhibits vascular leakage)(inhibits vascular leakage)

* * Folkman HJ: fertil Steril 2007;88,S1:O14Folkman HJ: fertil Steril 2007;88,S1:O14

**Bassado cpr 100 mgBassado cpr 100 mg

AA high responders IIIAA high responders III FSH 225 IU/d on the 2° cycle day (FSH 225 IU/d on the 2° cycle day (step-down step-down

regimenregimen)) antagonist 0.25 mg/d on the 2° cycle at HCG antagonist 0.25 mg/d on the 2° cycle at HCG

dayday Agonist (0.50 mg) as HCGAgonist (0.50 mg) as HCG triggertrigger to achieve to achieve

an endogenous LH surge an endogenous LH surge when Ewhen E2 2 ≥ 3.700 p≥ 3.700 pg/ml (range 3.000-7.500)g/ml (range 3.000-7.500)

0% OHSS0% OHSS

Agonist vs. HCG as Agonist vs. HCG as triggertrigger

Gn-RH-aGn-RH-a:: HCG 10.000 UIHCG 10.000 UI

mature oocytespremature oocytes

implantation rateclinical pregnancy

ongoing pregnancyOHSS

OHSS/CoastingOHSS/Coasting

Until drop of estrogen level Until drop of estrogen level <3.000 pg/ml<3.000 pg/ml

Coasting >3 days no Coasting >3 days no affects on Praffects on Pr

Egbase PE , Al Sharhan M , Berlingieri P , Grudzinskas JG . Egbase PE , Al Sharhan M , Berlingieri P , Grudzinskas JG . Serum oestradiol and Serum oestradiol and progesterone concentrations during prolonged coasting in 15 women at risk of progesterone concentrations during prolonged coasting in 15 women at risk of ovarian hyperstimulation syndrome following ovarian stimulation for assisted ovarian hyperstimulation syndrome following ovarian stimulation for assisted

reproduction treatment reproduction treatment . . Hum Reprod Hum Reprod . 2000;15:2082–2086. 2000;15:2082–2086

PCOS ProtocolPCOS Protocol

Pre-treatment with metformin ≥6 monthsPre-treatment with metformin ≥6 months2.000 mg/day2.000 mg/day Improvment in menstrual cyclicityImprovment in menstrual cyclicityLong-protocol agonistLong-protocol agonistHigher pregnancy outcomeHigher pregnancy outcome

Essah et al Fertil Steril 2006;86,1:230-232Essah et al Fertil Steril 2006;86,1:230-232

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The core of an assisted reproduction The core of an assisted reproduction program is oocyte qualityprogram is oocyte quality

Recognition of the right maturation state Recognition of the right maturation state of oocytes obtained from stimulated of oocytes obtained from stimulated cyclescycles

remains the major problemremains the major problem

Polar body extrusion indicates only Polar body extrusion indicates only meiotic or meiotic or nuclear maturation nuclear maturation

04/10/2304/10/23

3838

Acquisition of developmental Acquisition of developmental competence “competence “cytoplasmic cytoplasmic maturation”maturation”, is a fundamental event , is a fundamental event that render the oocyte competent to that render the oocyte competent to be fertilized and able to support the be fertilized and able to support the embryo cleavageembryo cleavage

Insufficient or incomplete cytoplasmic Insufficient or incomplete cytoplasmic maturation of the oocyte has a maturation of the oocyte has a negative effect on IVF outcomenegative effect on IVF outcome

04/10/2304/10/23

3939

Although nuclear and cytoplasmic Although nuclear and cytoplasmic maturation can proceed as an independent maturation can proceed as an independent processes, developmental competence of processes, developmental competence of oocytes is conferred only when the two oocytes is conferred only when the two processes are closely integrated.processes are closely integrated.

Meiotic and cytoplasmic maturation of Meiotic and cytoplasmic maturation of oocytes collected in stimulated cycle is oocytes collected in stimulated cycle is asynchronous (Sundstrom and Nilson 1988asynchronous (Sundstrom and Nilson 1988).).

04/10/2304/10/23

4040

Estradiol and cytoplasmic maturation

There are There are evidences that estradiol exerts a direct effect evidences that estradiol exerts a direct effect on oocyte cytoplasmic maturation via a non genomic on oocyte cytoplasmic maturation via a non genomic calcium-mediated mechanism which contribute to calcium-mediated mechanism which contribute to oocyte competenceoocyte competence Tesarik 1995Tesarik 1995 and and 19971997 RReevelli 1998 velli 1998 Zheng 2003Zheng 2003

04/10/2304/10/23

ConsiderationsConsiderations

04/10/2304/10/23 4141

• Over 30 years passed since the first IVF success, but the implantation rate did not substantially improved.

•Although a great improvements in ART technologies and ovarian stimulation regimens, around 80% of produced embryos does not implant

•The number of oocytes per pregnancy/birth remains high if not increased.

•Increasing number of harvested oocytes

•Lower oocyte utilization rate

The efficiency of oocyte utilization has The efficiency of oocyte utilization has not improved significantly since the not improved significantly since the early 1980s early 1980s

irrespective to the improved level of irrespective to the improved level of ovarian stimulation, the problem ovarian stimulation, the problem continue to lie with finding and continue to lie with finding and identifying the “identifying the “right oocyteright oocyte””4242 04/10/2304/10/23

The pregnancy rate per retrieved The pregnancy rate per retrieved oocyte remains far too low (Nayudu oocyte remains far too low (Nayudu et al 1989b Inge et al. 2005)et al 1989b Inge et al. 2005)

The major limiting factor is oocyte The major limiting factor is oocyte qualityquality

Oocytes developmental competence is Oocytes developmental competence is mainly acquired during mainly acquired during folliculogenesisfolliculogenesis

Despite the impressive improvements and innovations in human assisted reproduction

treatment:

However:

4444

Retrieved eggs were Retrieved eggs were immediately denuded immediately denuded and assessed for their and assessed for their

maturity, and then maturity, and then inseminated by ICSIinseminated by ICSI

Immature oocytesImmature oocytes

Slightly immature oocytesSlightly immature oocytes

Mature oocytesMature oocytes

Oocyte maturation assessment

04/10/2304/10/23

GV

MI

MII

4545

Embryo gradingEmbryo grading

Embryos were scored on the basis of Embryos were scored on the basis of morphological appearancemorphological appearance::

size of blastomeres and degree ofsize of blastomeres and degree of fragmentationfragmentation

04/10/2304/10/23

SUMMARYSUMMARY

Controversies on gonadotropins Controversies on gonadotropins

Controversies on analoguesControversies on analogues

Controversies on E-P pillsControversies on E-P pills

Controversies on LH addedControversies on LH added

Arslan MA, Bocca S, Mirkin S, Barroso G, Stadtmauer L, Oehninger S: “Arslan MA, Bocca S, Mirkin S, Barroso G, Stadtmauer L, Oehninger S: “Controlled ovarian hyperstimulation protocols for Controlled ovarian hyperstimulation protocols for in vitro fertilization : two decades of experience after the birth of Elizabeth Carr”in vitro fertilization : two decades of experience after the birth of Elizabeth Carr” Fertil Steril 2005;84,3: 555-569Fertil Steril 2005;84,3: 555-569

Conclusion(s)Conclusion(s)

Ovarian stimulation is a critical step in in Ovarian stimulation is a critical step in in vitro fertilization therapy. vitro fertilization therapy.

A variety of controlled ovarian A variety of controlled ovarian hyperstimulation regimens are available hyperstimulation regimens are available and efficacious, and efficacious,

but but individualization of management is individualization of management is essentialessential and depends on assessment of the and depends on assessment of the ovarian reserve. ovarian reserve.

Identification of the etiologies of poor Identification of the etiologies of poor ovarian response constitutes a formidable ovarian response constitutes a formidable challenge facing reproductive challenge facing reproductive endocrinologists.endocrinologists.

Arslan MA, Bocca S, Mirkin S, Barroso G, Stadtmauer L, Oehninger S: “Arslan MA, Bocca S, Mirkin S, Barroso G, Stadtmauer L, Oehninger S: “Controlled ovarian Controlled ovarian hyperstimulation protocols for in vitro fertilization : two decades of experience after the hyperstimulation protocols for in vitro fertilization : two decades of experience after the

birth of Elizabeth Carr”birth of Elizabeth Carr” Fertil Steril 2005;84,3: 555-569Fertil Steril 2005;84,3: 555-569

ConclusionConclusion Ovarian stimulation is the fundamental tool of Ovarian stimulation is the fundamental tool of

subfertility treatmentsubfertility treatment Different options pose challengesDifferent options pose challenges Choice depends on doctors expertise and Choice depends on doctors expertise and

patients condition, choicepatients condition, choice Increases the pregnancy rateIncreases the pregnancy rate Judicious monitoring to avoid complicationsJudicious monitoring to avoid complications

P0INT TO REMENBERP0INT TO REMENBER

ONE SATISFIED PATIENT ONE SATISFIED PATIENT IS WORTH THOUSANDS IS WORTH THOUSANDS

OF GUIDELINES AND OF GUIDELINES AND PROTOCALSPROTOCALS

5151

P0INT TO REMENBERP0INT TO REMENBER

ONE SATISFIED PATIENT ONE SATISFIED PATIENT IS WORTH THOUSANDS IS WORTH THOUSANDS

OF GUIDELINES AND OF GUIDELINES AND PROTOCALSPROTOCALS