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Relazione tra riserva ovarica e protocollo di stimolazione

Filippo Maria UbaldiM.D. M.Sc.

CLINICA VALLE GIULIA, Rome

I Master di Medicina della Riproduzione Umana

Padova, 2009-2010

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Introduction

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Aim of all ART techniques: obtain a correct number offollicles and of good quality oocytes

FOLLICLES n. 10

OOCYTES n. 8

MII OOCYTES n. 6,8

80%

85%

MII OOCYTES n. 6,8

FERTILIZED OOCYTES n. 5,4

EMBRYOS n. 3,8

80%

70%

Intrauterine insemination: 2-3 follicles

II and III level ART techniques (IVF/ISCI):

Introduction

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Very good knowledge:

- Physiology of ovarian cycle

- Ovarian reserve

- Drugs / stimulation protocols

Primordial germ cells migration

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Primordial germ cells originate from the entoderm ofthe yolk sac around the III week of gestation.

At VI week of gestation the number of the oogonia isabout 1000. There is not yet meiotic activity

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Ovary

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At VIII week of gestation the meiotic divisions lead

to 600.000 oogonia and three activities are present:

mithosis, meiosis and atresia. At XX week of gesta-

tion the number of germ cells is 3-6 million

At birth 1-2 million of germ cells are present and at

puberty there are left only 300.000 – 400.000 of

whom only 400-500 will ovulate

Folliculogenesis

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Primordialfollicle

Primaryfollicle

Preantralfollicle

Antral folliclePreovulatory

follicle

Corpus luteum

FSHLHE2

Preantrale Antrale precoce FSH dipendente FSH LH dipendente

Reclutamento Selezione10 gg

Maturazione10 gg

Crescita tonica65 gg

0,4mm5x10 cg3

I 0,4mm15x10 cg4

IIIII

IV

0,9mm75x10 cg4

2mm37x10 cg5

V7mm

619x10 cg

VI

VII

VIII

15mm90x10 cg6

20mm60x10 cg624%

35% 15% 24%58%

77%

50%

Atresia

OvulazioneFOLLICULOGENESIS

Menses

Threshold

Recruitment Selection Dominance

Window

Atresia

FSH

M

PrimordialePrimario

120 gg>150 gg

0,12mm6x10 cg21 strato cg

0,05mm

Follicular responsiviness to gonadotropins

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PRIMORDIAL PRIMARY SECONDARY

Not responsive to gonadotrophins Responsive to gonadotrophins

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Reclutamento follicolare

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Follicoli primordiali, primari e secondari pre-antrali e antrali precoci

Follicoli secondari antrali? riserva ovarica

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?

Which protocol

Which starting dose

Stimolazione ovarica?

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Le gonadotropine possono solo supportare la

coorte dei follicoli recettivi alla stimolazione.

L’aumento della dose delle gonadotropine non

puo’ reclutare de-novo altri follicoli (Klinkert,2005)

Predictors for ovarian response in ART

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ClinicalAge, cause of infertility, body mass index BMI, genetic(Templeton and Morris, 1998; Hohmann 2001; Sahla 2001;Howels 2006; Simoni 2007)

UltrasoundNumber of antral follicles (AFC), dopples score (resi-

stance), ovarian volume (Bancsi 2003, 2004;

Hensen 2003; Muttukrishna 2005; Hendriks 2005, 2007; Howels 2006; Kwee 2007)

Hormone levelsBasal FSH, estradiol, inhibin B, antimullerian hormone(Fanchin 2003; Bancsi 2003,2004; Laven 2004; Hussein

2005; Howels 2006; Kevenaar 2007; Fleming 2006,2009)

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Clinical factors and ovarian reserve

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ClinicalAge, cause of infertility, body mass index BMI, genetic

(Templeton and Morris, 1998; Howels 2006; Simoni 2007)

0 18 31 37 41 45 51

1.000

10.000

100.000

1.000.000

Folliclenumber

Birth

Optimalfertility Decreased

fertility

End offertility

Irregularcycles

Menopause

Age (yrs)

25000oocytes

Faddy et al., 1992

Ovarian cortical tissue

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10-year-old 20-year-old 30-year-old

Age

Antral Follicle Cohort

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Ultrasound:

can directly assess the size of the antral follicle co-

hort (AFC) (Pache 1990) and the observed pattern of its

decline correspond with that of the primordial follicle

pool (Sheffer 1999)

AFC better reflect chronological age in normal fer-

tile women with regular cycles (Sheffer 2003) com-

pared to other ovarian reserve tests.

AFC reflect the monthly recruited follicles that can

be stimulated by stimulation protocols.

Antral Follicle Cohort

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AFC correlates better with age compared to AMH and

much better than FSH, inhibin and E2 (van Rooij, 2005)

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Antral Follicle Cohort

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CONCLUSIONS: The number of small antral follicles (2-6 mm) is

significantly related to age and also, independent of age, to all

endocrine ORTs tested, suggesting the number of small antral

follicles represents the functional ovarian reserve

Basal FSH

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FSH release is regulated by negative feedback ac-

tion of E2, inhibin and the ovarian FSH-modulating

proteins FSH level are an indirect reflection of

the number of antral follicles (van Rooij 2005)

FSH starts to increase substantially when irregular

cycle starts to occurs and when the follicle num-

bers are strongly reduced just before or during the

menopausal transition (te Velde, 2002)

Basal FSH

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FSH does not correlate with age but when it incre-

ses it is an indicator of reduced ovarian reserve at

any time (te Velde, 2002)

Basal FSH

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Dosaggio di FSH basale sempre associato a dosag-

gio di E2 (oltre a valore predittivo dell’E2 stesso, escludere

valori >100 pg/ml secondari a residui follicolari che abbasse-

rebbero FSH indebitamente per feedback negativo)

Basal FSH (2nd-3rd day):

>9 (Faber 1998)

>12 (Karande 1997)

>15 (Feldberg 1994)

?

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Inhibin B

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Inhibin B is produced by granulosa cells of small antral

follicles (Groome 1996; Welt 2001) and as such it has been

proposed as direct assessor of ovarian reserve with con-

flicting results (Hall 1999; Cerus 2000; Bancsi 2002)

Basal serum level of

Inhibin B does not

correlate with age

but dynamic varia-

tions during FSH sti-

mulation can predict

the size of follicle po

ol (Decanter 2009; Van

Rooij 2005)

Inhibin B

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Exogenus FSH Ovarian Reserve Test (EFORT)

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Si determinano i livelli basali plasmatici di inibina Be l’aumento di E2 e di inibina B 24 ore dopo la som-ministrazione in terza giornata di 300 UI FSH

Il valore predittivo del test è del 90% mentre il va-lore negativo è dell’81 %

EFORT Test Values

(Post Inhibin B value – Pre Inhibin B value)

< 78.6 : patient is poor responder

78.6 – 110.4: patient is borderline

> 110.4: patient is good responderHum Reprod, 1994

Anti-Mullerian hormone

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Anti-Mullerian hormone: Male

- It is a dimeric glycoprotein of the TGF- family (van Roij 2004)

- It is involved in the regression of Mullerian ducts during ma-

le fetal development (Behringer 1994)

- It is expressed in the Sertoli cells from testicular differentia-

tion up to puberty (Behringer 1994)

Anti-Mullerian hormone: Female

- It is exclusively produced by granulosa cells of preantral

(primary and secondary) and small antral (Vigier 1984)

- Its production starts at primary stage and continues until

the small antral stage (2-6 mm) (Durlinger 1999; 2002)

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Anti-Mullerian hormone

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Genetic alteration in oocytes

secreted factors OSFs governing

this transition, in particular GDF-9

and BMP15, are critical for

regulation of ovulation rate and

result in high multifollicular rate

or ovarian failure (McNatty, 2003)

Anti-Mullerian hormone: Female

- The small antral follicles are related to the size of primordial

follicle pool (Gougeon 1994; Kevenar 2006) and the age related

decline of the antral follicle of AMH production (de Vet

2002; van Rooij 2005) until it will become undetectable at and

after the menopause

Anti-Mullerian hormone

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Correlation of:

Age (A)

No. of oocytes retrieved (B)

No. of day 3 antral follicles (C)

Cycle day 3 estradiol (D)

Cycle day 3 inhibin (E)

Cycle day 3 FSH (F)

with AMH in IVF

Van Rooij, 2002

Anti-Mullerian hormone

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Anti-Mullerian hormone: serum values

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Anti-Mullerian hormone: serum values

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Anti-Mullerian hormone: serum values

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Anti-Mullerian hormone: serum values

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Anti-Mullerian hormone: serum values

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21 321 hCG4 65 7

0.2 ml x 2 0.05 ml x 2 Suprefact s.c.

150IU 150IU 150IU 150IU ?

E2

GnRH antagonist

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21 321 hCG4 65 7

0.2 x 2 0.05 x 2

300UI300UI 300UI 300UI ?

E2

E21 32 hCG4 98 10

0.1 x 2 Suprefact s.c.

300UI 300UI 300UI 300UI ?

5 6 7ECO

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E21 32 hCG4 98 10

0.1 x 2 Suprefact s.c.

300UI 300UI 300UI 300UI ?

5 6 7ECO

Natural cycle with minimal stimulation

CONSORT calculator (Howels et al, 2006)

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CONSORT calculator (Howels et al, 2006)

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CONSORT Calculator (Howels, 2006)

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CONSORT Randomized Controlled Trial

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Ovarian reserve tests and ovarian response

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… no test is absolutely predictive

and the best test

is of course the ovarian

response to COH…

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Ovarian reserve tests and pregnancy

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Ovarian reserve tests and miscarriage

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Ovarian reserve, age and oocyte quality

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Natural cycles: age and FSH

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<12 12-15 16-19 >20

<39 y 34/132 (25,7) 21/83 (25,3) 4/31 (12,9) 1/17 (5,8)

>39 y 16/93 (17,2) 16/89 (17,9) 2/48 (4,1) 1/29 (3,4)

All ages 50/225 (22,4) 37/172 (21,5) 6/79 (7,5) 2/46 (4,3)

FSH IU/L

FSH IU/L <15 16-19 >20

<39 y 55/215 (25,5) 4/31 (12,9) 1/17 (5,8)

>39 y 32/182 (17,5) 2/48 (4,1) 1/29 (3,4)

All ages 87/397 (21,9) 6/79 (7,5) 2/46 (4,3)

a b ba – b: P=0,1

c d c – d: P=0,03

e f f e – f: P<0,01

d

Ubaldi et al., RBM Online 2007

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FSH and clinical results

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<35 35-37 38-40 41-42 >42

Normal FSH <10 IU/LBorderline FSH 10-15 IU/LElevated FSH 15-20 IU/LPerimenopausal FSH >20 IU/L

Age (years)

0

10

20

30

40

Del

iver

y ra

te/c

ycle

(%)

FSH and clinical results

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Cycles 78

Patients 32

Age (mean+sd) 39,4+1,7

Basal FSH (mean+sd) 21,9+1,9

GnRH antagonist (ampoules) 2,7+1,6

Results: natural cycles with minimal stimulation

Embryo transfers (%) 19/78 (24,6)

Pregnancy rate/ET 0/19

Kolibianakis et al., Hum Reprod 2004

When FSH exceeded 20 mIU/mL there is a clear fall in

ongoing pregnancy rate van Rooij et al., Fertil Steril 2004

CLINICA VALLE GIULIA, Rome

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Gynaecology:

Filippo Ubaldi

Elena Baroni

Silvia Colamaria

Fabio Sapienza

Maddalena Giuliani

Embriology:

Laura Rienzi

Stefania Romano

Roberta Maggiulli

Laura Albricci

Antonio Capalbo

Centre for Reproductive Medicine