Jung-Hyun Cho, M.D. (Miz Medi Hospital)(Miz Medi Hospital)

Minimal Ovarian StimulationMinimal Ovarian Stimulation

LH

FSH

Recruitment Selection Dominance Ovulation

Short

Long

Ultrashort

LH

FSHGnRH-a

FSH

hCG

Disadvantages of COHDisadvantages of COH• High costs of ovulatory drugsHigh costs of ovulatory drugs

GnRH-agonist, r-FSH, r-hCGGnRH-agonist, r-FSH, r-hCG• Physical discomfortsPhysical discomforts

Daily injection of gonadotropins, Blood samplingDaily injection of gonadotropins, Blood sampling• Time lossTime loss

Daily visiting clinic, Frequent sonographyDaily visiting clinic, Frequent sonography• Risk of OHSSRisk of OHSS

5 ~ 10% of COH5 ~ 10% of COH• Long term unkown risk of ovarian cancerLong term unkown risk of ovarian cancer

Concept of minimal ovarian stimulationConcept of minimal ovarian stimulation

• Less complex, Shorter stimulation regimens, Less expensiveLess complex, Shorter stimulation regimens, Less expensive

• Less patient discomfort, Less monitoring, Less programmableLess patient discomfort, Less monitoring, Less programmable

• Less chances of complications, Long term risksLess chances of complications, Long term risks

• Fewer oocytes for fertilization Fewer oocytes for fertilization in vitroin vitro

• Fewer spare embryos for cryopreservationFewer spare embryos for cryopreservation

Applications of minimal ovarian stimulApplications of minimal ovarian stimulationation

• Natural cycle IVF-ETNatural cycle IVF-ET KiKim KR (2000)m KR (2000)

• Oral contraceptives + Clomiphene 100mg x 8 daysOral contraceptives + Clomiphene 100mg x 8 days BraBranigan and Ester (2000)nigan and Ester (2000)

• GnRH antagonist + hMGGnRH antagonist + hMG FrFrydman R ydman R etet al. (1999) al. (1999)

Natural cycle in IVF with GnRH antagonistNatural cycle in IVF with GnRH antagonist

M1 8 9 10 11 12 13 14 15

Cetrorelix hCG

hMG hMG OPU ET

E2 100 ~ 150 pg/mlØ 12 ~ 14 mm Menstrual cycle

Preg rate : 32.0% /ETHum Reprod 14(3):683,1999Frydman R et. al

COHCOH IVM

Hypothetic scheme of immature oocyte IVF programHypothetic scheme of immature oocyte IVF program

In vitroIn vitro maturation maturation

Fertilization by ICSIFertilization by ICSI

Embryo developmentEmbryo development

Embryo transferEmbryo transfer

Immature oocyte retrievalImmature oocyte retrieval

Biochemical assisted hatchingBiochemical assisted hatching

Secretary endometriumSecretary endometrium

OvaryOvary : Immature oocytes: Immature oocytes

Uterus Uterus : Midproliferative endometrium: Midproliferative endometrium

Poliferative endometriumPoliferative endometrium

ImplantationImplantation

hCG hCG Progesterone Progesterone

EE22

Immature Oocytes Pick up

Oocyte pick up (OPU)Oocyte pick up (OPU)

Immature OPUImmature OPU COH - OPUCOH - OPU

Follicle sizeFollicle size 5 - 10 mm5 - 10 mm 15 - 25 mm15 - 25 mm

Needle diameterNeedle diameter outer 17 Gouter 17 G single 17 Gsingle 17 Ginner 20 Ginner 20 G

Flushing mediaFlushing media PBSPBS PBSPBSheparin 40 IU/mlheparin 40 IU/ml

PressurePressure 300 mmHg300 mmHg 100 mmHg100 mmHg

Follicle curettingFollicle curetting vigorousvigorous only suctiononly suction

Op. durationOp. duration LongLong ShortShort

AnesthesiaAnesthesia more deepermore deeper only sedationonly sedation

Fertilization by ICSIFertilization by ICSI

oocyteoocyte

Insemination-fertilizationInsemination-fertilization

oocyteoocyteZona hardeningZona hardening

ICSIICSI

Biochemical Assisted Hatching (BAH) Biochemical Assisted Hatching (BAH) by protease in conventional IVFby protease in conventional IVF

(1994. 7. ~ 1996. 12.) - 1095 cases(1994. 7. ~ 1996. 12.) - 1095 cases

BAH groupBAH group

Control groupControl group

34.6%34.6%

29.3%29.3%

• 1 µ1 µg/ml pronase E in g/ml pronase E in modified HTF with modified HTF with 0.5% BSA 24 hours 0.5% BSA 24 hours before ETbefore ET

• Prize paper 53rd Prize paper 53rd ASRM 1997ASRM 1997

Clinical preg. rateClinical preg. rate

Suggested scheme of immature oocyte programSuggested scheme of immature oocyte program

mensemense

ovulationovulation↓↓

implantationimplantation ↓↓

premordialpremordial immatureimmature maturemature In vitroIn vitro maturation maturation

Fertilization by ICSIFertilization by ICSI

Embryo developmentEmbryo development

Embryo transferEmbryo transfer

Immature oocyte retrievalImmature oocyte retrieval

Biochemical assisted hatchingBiochemical assisted hatching

SecretarySecretaryendometriumendometrium

OvaryOvary : Immature oocytes: Immature oocytes

Uterus Uterus : Midproliferative endometrium: Midproliferative endometrium

Proliferative endometriumProliferative endometrium

ImplantationImplantation

hCG (10000 IU) hCG (10000 IU) Progesterone (50 mg/day) Progesterone (50 mg/day)

EE2 2 (6 mg/day)(6 mg/day)

Endometrial preparation in IVM-IVF-ETEndometrial preparation in IVM-IVF-ET

Mense #1 OPUICSI

hCG

BAH UET

E2V 6mg/day

Progesterone 50mg/day

Regular mense Mid follicular phase 5,000 IU

PCO Endometrial 10,000 IU thickness > 8mm

IVM-IVF cycle

E2 (6 mg/day)P4 (50 mg/day)

Implantation windows : Natural cycle vs. IVM-IVF cycle

EndometriumRe-establishment

LH peak

Day of OPU ICSI EThCG

Implantation (?)

Natural cycle

Ovu.

ImplantationEndometriumRe-establishment 10 14 21

Fert.

2PN Hatching

2PN

Hatching

7

20

(windows)

M #1

M #1

Maturation rate of porcine immature Maturation rate of porcine immature oocytes with coculture of CHO cellsoocytes with coculture of CHO cells

MediaMedia CultureCulture GV -> M IIGV -> M IIPorcine immature oocytesPorcine immature oocytes

IVM mediaIVM media 24 hrs24 hrs 34.4 %34.4 %

Growth mediaGrowth media 24 hrs24 hrsCHO * cocultureCHO * coculture 8.7 % 8.7 %CHO (-)CHO (-) 0.0 % 0.0 %

Growth media + IVM mediaGrowth media + IVM mediaCHO cocultureCHO coculture 48 hrs48 hrs 52.4 %52.4 %CHO (-)CHO (-) 48 hrs48 hrs 43.5 %43.5 %

* CHO : Chinese Hamster Ovary cells* CHO : Chinese Hamster Ovary cells

Overall results of IVM-IVF-ET in conparison Overall results of IVM-IVF-ET in conparison with convertional ICSI-IVF-ETwith convertional ICSI-IVF-ET

ConvertionalConvertional IVM-IVF-ET IVM-IVF-ETCOH-ICSICOH-ICSI

IVF-ETIVF-ET Regular mense groupRegular mense group PCO groupPCO group

No. of retrievedNo. of retrieved 11.0 ± 0.4 *11.0 ± 0.4 * 6.7 ± 0.46.7 ± 0.4 13.6 ± 2.313.6 ± 2.3oocytesoocytes

Maturaltion (%)Maturaltion (%) 87.187.1 62.562.5 69.569.5

Normal fertilizationNormal fertilization 67.067.0 72.072.0 72.572.5 (%) (%)

Cleavage (%)Cleavage (%) 84.584.5 87.987.9 89.989.9

Pregnancy / transferPregnancy / transfer 34.234.2 16.916.9 28.328.3(%)(%)

* Mean ± SEM* Mean ± SEM

ConclusionConclusion

• Minal ovarian stimulationMinal ovarian stimulation-- Efficiency in producing a healthy singleton pregnancyEfficiency in producing a healthy singleton pregnancy

-- Less complex, shorter stimulation, less risk & complicationsLess complex, shorter stimulation, less risk & complications

-- Improved embryo selection and endometiral receptivityImproved embryo selection and endometiral receptivity

• IVF-IVF-ETIVF-IVF-ET-- To get more healthy oocytes and embryosTo get more healthy oocytes and embryos

-- To get more synchronized endometrium for implantationTo get more synchronized endometrium for implantation

-- To improve pregnancy rateTo improve pregnancy rate

IVM babyIVM baby

이다은 1998. 5. 25. 이은빈 2000. 10. 9.

Embryo-Maternal communicationEmbryo-Maternal communication

==

embryoembryo

hCGhCG

hCGhCGreceptor ?receptor ?

endometriumendometrium

EGF, LIFEGF, LIFother cytokinesother cytokines

hCGhCG

ImplantationImplantation good embryogood embryo good endometriumgood endometriumxx