What's New in IVF.chop18-videoremoved - IVF Clinic€¦ · Natera SNP advantage over aCGH ... offering outstanding pregnancy rates with cutting edge ... #1 IVF clinic in Colorado

What’s New in IVF

Mark R. Bush, MD, FACOG, FACS Medical Director

Conceptions Reproductive Associates of Colorado

Sky Ridge, LiIleton, Denver, LafayeIe, Castle Rock conceptionsrepro.com

Expanded coverage of these topics with references available on our website

Four Landmark Innovations

•  ICSI (Intra-cytoplasmic sperm injection) Optimizes fertilization •  Blastocyst Culture Allows for developmental selection •  CCS (Complete Chromosomal Screening) Determines which embryos have the normal 23 pairs of

chromosomes •  Vitrification Superior freezing technique allows for outstanding survivability of

embryos and therefore a delayed transfer (FET) with higher implantation rates over a fresh transfer

Vitrification and subsequent FET

Comparing platforms

•  ICSI and day 3 embryo transfer 12 eggs/ 10 mature/ 8 fertilize Eight 6-8 cell embryos on day 3 Multiple embryo transfer, risk of multiples, decreased pregnancy

rates, poor prognosis embryos cryopreserved •  ICSI, blastocyst culture, CCS, subsequent FET 12 eggs/ 10 mature/ 8 fertilize Four ~ 150 cell blastocysts on day 5/6 Three determined to be euploid One transferred in a subsequent FET with 70+ % FHT rate Excellent prognosis embryos cryopreserved

Embryoscope •  Sophisticated time lapse imaging technology allows for undisturbed embryo culture

•  Images of developing embryos are captured at defined intervals to create time-lapse videos from day 1 to day 6 of culture

•  Allows for a highly sensitive selection process for embryo transfer based on identifying which embryos of the cohort follow the healthiest path of development

•  Coupled with CCS, Conceptions has the ability to identify the patient’s best embryo available by evaluating chromosomal makeup and growth pattern o  Based on proven outstanding

pregnancy rates, Conceptions has been chosen to conduct a study to identify the relationship between genetic integrity and embryonic growth patterns (commenced September 2015)

CCS Patients at Conceptions Through 5/26/15

•  Note that these patients are not "cherry-picked" or part of a study. The patients represented in this CCS (Complete Chromosomal Screening) chart represent all women who desired to pursue IVF with sequential FET utilizing their own eggs.

•  As reflected by the AMH values (above), patients with decreased AMH levels achieve high pregnancy rates when a normal (euploid) embryo is identified followed by elective single embryo transfer.

•  The rate of positive chemical pregnancy that does not progress to heartbeat: o  Unscreened FET 11.7% o  CCS FET 5.4%

•  This highlights that if our biopsy platform harmed the embryo the CCS FET loss rates would be equal to or higher than the unscreened rates. •  The rate of + FHT in a CCS transfer that does not progress to a live birth is 1.7%. This means that if you achieve a heartbeat your delivery rate

will be 98%. A distinct advantage of a screened embryo transfer is once you achieve pregnancy you stay pregnant. •  Our embryo screening platform is superior to other embryo screening platforms. SNP microarray evaluates 300,000 random base-pair

changes in the non-coding regions of the chromosome, compares data with parental samples, and integrates known data from the Human Genome Project. This allows for a percent confidence for the chromosome diagnosis typically in the 96-99% range across all 24 chromosomes. In the case of an abnormal embryo, it can tell whether that error came from the egg or sperm which is helpful in determining future treatment plans.

•  If a euploid (normal) embryo is created, the average live birth rate is typically ≥ 70% with one embryo transferred. •  CCS eliminates the number one cause of failed IVF, miscarriage, abnormal amniocentesis, and afflicted live birth. •  Our embryo screening platform allows for chromosome screening and simultaneous diagnosis for autosomal recessive, autosomal

dominant and translocation disorders.

Thawed Embryos from Trophectoderm CCS Testing Patients 10/1/2010 thru 5/26/15 <35 35-‐‑37 38-‐‑40 41-‐‑42 43-‐‑44

Number of transfers (n = 807) 335 212 153 57 50

Percentage of transfers resulting in pregnancies (FHT) 74.3% 78.8% 64.7% 75.4% 65.0%

Percent with single embryo transfer 74.3% 79.7% 81.0% 84.2% 92.5%

Implantation Rate 71.0% 77.6% 61.9% 72.7% 67.4%

Average number of embryos transferred 1.25 1.20 1.18 1.16 1.08

Percentage of patients with AMH < 1.5 17.7% 29.2% 36.5% 43.6% 68.2%

24 CHROMOSOME ANEUPLOIDY SCREENING AND FET

ALLOWS FOR HIGH PREGNANCY RATES AND THE

OPPORTUNITY FOR ELECTIVE SINGLE EMBRYO TRANSFER

Proctor, J. Glenn Wilson, J. Michael Swanson, Michael S.

Bush, Mark R. AAB Meeting, Las Vegas, May 2014

Pregnancy Rates (FHT)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

< 35 (156) 35-‐‑37 (106) 38-‐‑40 (86) 41-‐‑42 (31) 43-‐‑44 (17)

CCS Allows for Fewer Embryos Transferred

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

< 35 35-‐‑37 38-‐‑40 41-‐‑42 43-‐‑44

% SET

1.35

1.27

1.22

1.23

1.12

# Embryos Transferred

< 35

35-‐‑37

38-‐‑40

41-‐‑42

43-‐‑44

Implantation Rates

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

< 35 35-‐‑37 38-‐‑40 41-‐‑42 43-‐‑44

Percent Aneuploidy (Patients with ET)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

< 35 35-‐‑37 38-‐‑40 41-‐‑42 43-‐‑44

Percentage of Patients with AMH< 1.5

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

< 35 35-‐‑37 38-‐‑40 41-‐‑42 43-‐‑44

Percentage of Patients with No Biopsy Due to D5 Development

Age < 35 35 -‐‑ 37 38 -‐‑ 40 41 – 42 43 -‐‑44 % No Bxy 12.3 % 15.5 % 19.1 % 37.0% 23.1 %

•  Due to arrest from day 3 to 5

•  Poor quality blastocyst development •  Patients electing to discontinue biopsy testing

Percentage of Patients with a Biopsy but No Euploid

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

< 35 35-‐‑37 38-‐‑40 41-‐‑42

43-‐‑44

5.8% 14.0%

20.6%

48.3% 50.0%

Conclusion

•  24 chromosome aneuploidy screening with vitrification allows patients the opportunity to obtain embryos with high reproductive potential while ensuring endometrial synchrony.

•  A significant percentage of embryos were aneuploid, particularly in women of advanced reproductive age and/or possessing decreased ovarian reserve.

•  Identifying aneuploid embryos before transfer allows for the elimination of the number one cause of failed IVF, miscarriage and abnormal amniocentesis.

•  Chromosome screening allows for patients with an AMH < 1.5 the ability to achieve a viable pregnancy utilizing elective single embryo transfer.

Translocation and septum •  A.W. 26 yo g2p1s1 with spontaneous conception, bleeding in the 1st

trimester to 25 weeks, PPROM at 26 weeks, hospitalized until PTD at 32 weeks. Prior 1st trimester miscarriage.

•  Sister E.B. with 1st trimester miscarriage x2, stillbirth x1 •  Found to have balanced translocation, 14/21, and a uterine septum •  Septolysis followed by SET of euploid female devoid of unbalanced

translocation •  Subsequent uncomplicated gestation and vaginal delivery of healthy

8#9oz girl at term Update •  Sister E.B. cycled with us and is awaiting transfer. Has created one

euploid embryo •  Patient A.W. pursued a second IVF cycle with us, created 3 euploid

embryos, and we recently transferred one and she has been referred back to her OB in Alaska with a viable 7 week gestation.

Translocation and septum






Autosomal dominant disorder (non-‐‑disclosure)

•  29 yo nullip, husband with vasectomy •  Husband’s father dying of Huntington’s, his brother and sister

also carry the disease •  Husband has a 50% chance of having the disease, but does

not want to know if he has it •  Underwent IVF with PESA, ICSI, blast CCS •  With Natera SNP platform, we determined which embryos

came from husband’s mother’s chromosome #4 •  SET of euploid male (with chromosome #4 from his unaffected

grandmother and not his affected grandfather) •  Delivery of healthy boy •  Huntington’s extinguished in this family line




Finer Points

•  SNP microarray evaluates 300K random BP changes in the non-coding regions of the chromosome, compares data with parental samples, integrates known data from the Human Genome Project.

•  aCGH flourescently labels embryo DNA (red), reference DNA (green), samples mixed and hybridized to an array which contains multiple probes corresponding to each chromosome. Trisomies red, monosomies green.

•  aCGH can have up to an 8.5 – 11.5 false negative rate (calling an embryo normal when it is not) b/c it cannot detect haploidy (set missing, n =23), some forms of triploidy (extra set, n = 69), UPD (both sets from one parent), del/dup.

•  If UPD of an imprinted (methylated/silenced) gene region, then Angelmen, Prader-Willi.

Finer Points

Natera SNP advantage over aCGH

•  Individual confidences for accuracy of each call •  Parental source of aneuploidy •  Simultaneous single gene testing and 24 chromosome PGS on single

cell •  Haploidy, polyploidy and UPD detection •  Corrects for contaminant DNA •  Confirmation of parentage aCGH advantage over Natera SNP •  Chance of homozygosity in chromosome regions (blood relationship

in the couple can result in multiple areas of homozygosity and potential for no-call across a particular chomosome)

Oocyte vitrification

Costs 20K for ovarian stim, retrieval, vit (x1), storage, thaw, fert, embryo culture, transfer. Conservative number. Some women may need to stim, retrieve and vit more than once. Conceptions offers front end multi-cycle discounts (multiple stims, retrievals, vits – 7752, 6000, 5500, 5000). Oocyte to embryo is 7244.50 for a total of 14,996.50. Each egg we freeze has a 2-12% chance of becoming a healthy baby based on age and egg health. Efficacy in above study is 20% LB rate for women who freeze 6 eggs at 35 Medical v. “social” If all women 35 who freeze 6 eggs use them in the future, at a 20% LB rate, at 20K per cycle, then the NNT (number needed to treat) for 1 live birth is 5 at a cost of 100,000 - Table and tabulations of the 6 vit studies from Abusief and Adamson, OBG Mgmt, Feb 2015, v.27 No.2

Donor Oocyte Vitrification Note that screened embryos derived from vitrified eggs have 2 freeze-‐‑thaw cycles. Conceptions has recently developed a vitrified egg bank derived from high-‐‑quality proven donors utilizing our stimulation protocols (19, 500 for complete cycle as opposed to 24,000).

Quality/ Cost

•  Conceptions is one of the premier IVF centers in the country offering outstanding pregnancy rates with cutting edge therapy in a patient-centered, compassionate and inclusive environment accepting most all insurances and offering extremely competitive package rates for care.

•  Optum Center of Excellence for the last 6 years in a row •  Patient’s Choice Award 2012 – 15 by vitals.com •  For the three years in a row, Conceptions has been ranked the

#1 IVF clinic in Colorado by ivfreports.org

Quality/ Cost

CRA UNIVERSITY CCRM Difference

IVF/ICSI $12,094 $12,850 $16,130 $756/4,036IVF/ICSI/CCS/FET $20,381 -‐ $23,855 $ -‐ /3474

HSG $500 $940 (FemVue) $600 $440/100Semen Analysis $75.00 $116 $120+110 $41/155Initial Consult $175 $200 $295 $25/120O-‐HSC $350 $1,500 $700 $1,150/350D&C SAB $500 performed at hospital $2,670 $2,170POC Natera $95/$399 -‐ -‐ -‐Anesthesia $400 -‐ $430 $30Follicle Scan $161 $175 $190 $24/$29Sperm Wash $86 $116 $275 $30/189

CASH PRICING 2015

AMH/RFC

•  RFC < 8, RFC > 8, RFC 12 - 18

Ameliorating OHSS

•  Lupron triggers where GnRH antagonist clears pituitary receptors and the agonist (lupron) is able to induce endogenous LH surge (t ½ 20 minutes) and avoid or minimize use of hCG (t ½ 34 hrs, Mannearts, 98) as surrogate surge

•  VEGF induces VP (vascular permeability)1,2

•  Effects of cabergoline (Cb2 – dopamine agonist) attributable to VEGF receptor dephosphorylation3

•  Cb2 prevents VP in a dose dependent manner without affecting angiogenesis and implantation in humans (n = 35 treated in face of OHSS)4

•  Cb2 reduced the amount of ascites, hemoconcentration and incidence of moderate-severe OHSS5

•  Cb2 0.5 mg x 8 days (total of 4 mgs) starting day of trigger

Low dose prednisone

•  In women with RPL, safety and efficacy of prednisone 10mg BID thru 12 weeks demonstrated a livebirth rate of 77% in 80 women with therapy as opposed to a 35% pregnancy rate in 52 matched women without therapy. Concurrent use of 5mg folate QOD, 100mg ASA QD (Tempfer et al, Fertil & Steril 2006, Vol 86(1) p. 145).

•  Reznikoff-Etievant et al, Human Reproduction 1999, Vol 14(8) p. 2106 also demonstrated safety of prednisone at 20mg/d in 277 women.

•  Women with recurrent loss had significantly more uNK than controls (p = 0.008).

•  Prednisone treatment (20 mg/d for 21 days) significantly reduced the number of CD56 cells in the endometrium, from a median of 14% before to 9% after treament (p = 0.0004).

•  Demonstrated that high numbers of uterine natural killer cells in preimplantation endometrium of women with recurrent miscarriage can be reduced with the administration of prednisone (Quenby et al, Fertil & Steril 2005, 84: p 980-4).

Intralipids

•  Intralipid 20% is an emulsion composed of 10% soybean oil, 1.2% egg yolk phospholipids, 2.25% glycerine and water. 100 ml solution is mixed with 500 ml of sterile saline and infused

•  Intralipids suppress Nka for approx 40 days possibly through NK-cell nuclear PPARs.

•  First dose >7 days prior to implantation/ET. Second dose at + hCG. •  Bourn Hall recently describes a 39% PR in > 100 patients with previous

implantation failure. 300 per treatment.

•  Acacio et al, Fertil & Steril 2008, 89(4): p S88. •  79 patients with elevated NK-cell activity (> 10%) treated with 2-4 mL

IV of 20% intralipid. •  68 with implantation failure (cumulative total of 8 cleaved or 4 blasts

without + hCG) – 27/68 (40% PR) following intralipid with IVF. Four patients > 40 did not conceive making the < 40 group 27/64 (42% PR).

•  11 with RPL ( > 2) – 10/11 (91%) had a LB with treatment.

Endometrial optimization

•  “Scratch” data based on setting up a non-infectious inflammatory response involving events that accompany wound healing to include secretion of cytokines and growth factors known to be involved in implantation

•  360 degree cold loop reduction of functionalis layer preserving basalis layer for synchonous regeneration concurrent with resection of irregular endometrium/polypectomy/myomectomy

•  Antecedent normal O-HSC has revealed polyp on biopsy



•  Endometrial biopsy for integrins - There is utility in offering this test in patients that have a failed euploid FET.

•  Patient receives 8 weeks Lupron with Premarin 0.625 QD add-back if: •  Endometrium in-phase, integrin negative •  Endometrium out of phase (we correct for LPD with our FET regimen, but

instead of re-testing we opt for empiric treatment) •  Reports now contain BCL-6 staining, which if positive (>1.4) there is an

80% chance of endometriosis and will also require the above treatment. •  Two important points: •  Review if the patient has had an HSG or FemVue, as hydros can cause

this and need to be ligated or removed. Patients with bilateral tubal ligation do not need integrin/ BCL-6 testing.

•  Carefully review the path report: It may contain polyp which will require operative hysteroscopy/ 360 cold-loop recycling.

•  Hydrosalpinx: Direct embryotoxic effect (2), decreased endometrial

receptivity, mechanical disruption of implantation by fluid. Based on the results from 3 trials, ongoing pregnancy rate after salpingectomy or proximal occlusion is two-fold higher than controls, 34% v. 17% (3)


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What's New in IVF.chop18-videoremoved - IVF Clinic€¦ · Natera SNP advantage over aCGH ... offering outstanding pregnancy rates with cutting edge ... #1 IVF clinic in Colorado