number of oocytes and progesterone levels in ivf: do they matter?
TRANSCRIPT
Sandro C. Esteves, MD, PhDDirector, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, Brazil
Number of Oocytes and Progesterone Levels in IVF
SuccessDo they matter?
IMPART, Dubai 2013
http://www.androfert.com.br/review
Number of oocytes and
progesterone levels in IVF success
ANDROFERTandrofert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2013 DECEMBER
ANDROFERT
Learning Objectives
Importance of number of oocytes and its relation to live birth
Differences between gonadotropin preparations in oocyte yield
Effect of progesterone levels at the day of hCG administration on pregnancy chances
Cumulative live birth rates as a measure of success in IVF
Esteves, 3 ANDROFERT, Referral Center for Male Reproduction
Positive Predictor
van Loendersloot et al. Hum Reprod Update 2010
Female Age
Duration of infertility
Basal FSH
Type of infertility
Indication
Fertilization method
Number of oocytes retrieved
Number of embryos
transferred Embryo quality
Negative Predictors
Predictive factors for pregnancy
in ART
Esteves, 4 ANDROFERT, Referral Center for Male Reproduction
EvidenceLevel1a
Number of oocytes retrieved
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 25 30 35 40
Liv
e b
irth
rat
e (%
)
Oocyte number
Observed live birth rate Predicted live birth rate
Sunkara et al. Hum Reprod 2011
450,135 IVF cycles
Number of oocytes retrieved and
live birth rates
number of oocytes that best
optimized LBR was 15
Esteves, 5 ANDROFERT, Referral Center for Male Reproduction
Esteves, 6 ANDROFERT, Referral Center for Male Reproduction
...in all age groups
Gonadotropin Preparations and Oocyte Yield
Esteves, 7 ANDROFERT, Referral Center for Male Reproduction
RCT and meta-analyses comparing oocyte yield with different gonadotropins
↑ 1.5 oocytes (GnRH antagonist cycles)
Devroey et al., 2012
↑ 3.1 oocytes (GnRH antagonist cycles)
Bosch et al., 2008
↑ 1.8 oocytes (GnRH agonist cycles)
MERIT Study, 2006
↑ 2.8 oocytes (GnRH agonist cycles)
Hompes et al., 2008
EvidenceLevel1b
↑ 2.1 oocytes (16 RCT; different protocols)
Lehert et al., 2010
Esteves, 8 ANDROFERT, Referral Center for Male Reproduction
No. Oocytes
retrieved higher
with Rec-FSH vs.
hMG, HP-hMG,
and uFSH
It relates to the way the drug is made, filled and delivered
*Follitropin alfa; Bassett et al. Reprod Biomed Online 2005
Protein
content
Specific
activity
(IU/mg protein)
Injected
protein per
75 IU (mcg)
hMG < 5% ~100 ~750
hMG-HP < 70% 2,000–2,500 ~33
rec-hFSH* > 99% 13,645 6.1
Size Exclusion High Performance Liquid
Chromatography (SE- HPLC)
Protein content in solution by mass (FbM) in rec-FSH
Esteves, 9 ANDROFERT, Referral Center for Male Reproduction
Quantity vs. Quality
which one come first?
• Oocyte/embryo quality?
• Endometrial receptivity?
Esteves, 10 ANDROFERT, Referral Center for Male Reproduction
Morphology-based embryo quality and number of oocytes
1-6 oocytes7-15 oocytes
>15 oocytes
3,84,5
4,8
1723
27
Embryo quality score Implantation rate (%)
1,301 cycles
p<0.001
A large oocyte
cohort was the
main factor that
increased the
chance of having
at least one good
embryo
Esteves, 11 ANDROFERT, Referral Center for Male Reproduction
Devreker et al Hum Reprod 1999
Aneuploidy and Oocyte Yield
634 patients; 3,688 oocytes; PB biopsy
0
10
20
30
40
50
60
1-5 oocytes 6-10 oocytes >10 oocytes
An
eu
plo
idy
rate
% <35 years
35-40 years
>40 years
Esteves, 12 ANDROFERT, Referral Center for Male Reproduction
Haaf et al Fertil Steril 2009
p<0.001
The higher the oocyte cohort, the higher the
number of EUPLOID oocytes in all age groups
Aneuploidy and Oocyte Yield
• Array CGH analysis in D3 and D5 embryos
• 7753 embryos from 990 patients
• Linear regression analysis adjusted by maternal age
Higher aneuploidy rate in
older women irrespective of
embryo number
Higher number of euploid embryos with increased
cohort size
Ata et al Reprod Biomed Online. 2012
Esteves, 13 ANDROFERT, Referral Center for Male Reproduction
What we have learned
There is a strong association between the number of oocytes retrieved and live birth rates in IVF
The optimum number of oocytes needed to maximize IVF outcomes seems to be about 15
Recombinant gonadotropin preparations are more potent and result in an increased oocyte yield
Esteves, 14 ANDROFERT, Referral Center for Male Reproduction
Aneuploidy in oocytes increases with maternal age, but it is unaffected by cohort size in women aged 35 or older
Among young women, an increased incidence of aneuploid oocytes seems to be associated with higher oocyte cohort
The higher the cohort size, the higher the number of euploid oocytes and embryos regardless of age
Esteves, 15 ANDROFERT, Referral Center for Male Reproduction
What we have learned
Increasing oocyte yield is an opportunity to have
more euploid embryos
The goal is to obtain ~15 oocytes avoiding OHSS
COS should be tailored to the individual phenotype, maximizing the number of oocyte yield for poor responders and fine-tuning for hyper-responders
How to get the best resultsoocyte quality vs. quantity
Esteves, 16 ANDROFERT, Referral Center for Male Reproduction
More is good, but does it affect
implantation?
• Oocyte/embryo quality?
• Endometrial receptivity?
Esteves, 17 ANDROFERT, Referral Center for Male Reproduction
Effect of progesterone levels on pregnancy in IVF – Do they matter?
Esteves, 18 ANDROFERT, Referral Center for Male Reproduction
Fresh Frozen-thawed Donor/recipient
63 studies; N = 55,199 9 studies; N =7,229 8 studies; N = 1,330
LBR/OPR CPR CPR
0.8-1.1 OR: 0.72(0.56 – 0.94)
OR: 1.03(0.79 – 1.34)
OR: 1.18(0.76 – 1.84)
1.2-1.4 OR: 0.64(0.53 – 0.77)
OR: 0.83(0.62 – 1.32)
OR: 1.61(0.64 – 4.05)
1.5-1.75 OR: 0.62(0.57 – 0.69)
OR: 1.13(0.97 – 0.69)
-
1.9-3.0 OR: 0.67(0.55 – 0.81)
OR: 1.03(0.84 – 1.27)
OR: 0.51(0.12 – 2.19)
Png/mL
Venetis et al., Hum Reprod Update 2013
P levels not related to oocyte and embryo
quality, nor with fertilization and cleavage rates
Progesterone levels in stimulated cycles
Number of oocytes
Estradiol levels
FSH dose
Rec-hFSH vs. hMG
positively
associated
with P levels
Bosch et al. 2008, 2010; Xu et al, 2012;
Kolibianakis et al 2012; Venetis et al. 2012; Griesinger et al 2013
Esteves, 19 ANDROFERT, Referral Center for Male Reproduction
LH
FSH
LH
Esteves, 20
No CYP17
Grondal et al. 2009:GCs gene expression in pts. treated with
hMG and rec-hFSH
Lower expression of LH/hCG receptor
gene and other genes involved in
steroids biosynthesis with hMG
Down-regulation of receptors owed to
constant ligand exposure to hCG(Menon et al. 2004)
CYP11A activity decreased by 2.4-foldLower steroids synthesis and P levels
Higher potency of rec-hFSH inducing
more LH/hCG receptors
Grondal ML et al. Fertil Steril 2009; 91: 1820-1830.
Menon KM et al. Biol Reprod 2004; 70:861-866
P levels with rec-hFSH and hMG
Esteves, 21
r-F
SH
hM
G
What we know about progesterone levels in stimulated cycles
Most circulating Progesterone (95%) is produced in the intrafollicular compartment by granulosa cells
Higher serum P are related to more follicles developed (more GCs) and more oocytes retrieved
Treatment with rec-hFSH results in higher P levels than hMG
Rec-hFSH has higher FSH bioactivity (increased GCs and oocyte yield
HMG induces underexpression of genes involved in steroids synthesis
Esteves, 22 ANDROFERT, Referral Center for Male Reproduction
Bosch et al,. Hum Reprod. 2008 ;23(10):2346-51;
Grøndahl ML, et al. Fertil Steril 2009; 91(5): 1820-30.
Esteves, 23 ANDROFERT, Referral Center for Male Reproduction
Bosch et al. 2010 (N=4,032)
Irrespective of GnRH analogue;
Cut-off = 1.5 ng/mL
Xu et al, 2012 (N=11,055)
GnRH agonist
Ovarian
response
Number of
oocytes
Serum P
threshold
(ng/mL)
Poor ≤4 1.5
Intermediate 5-19 1.75
High ≥20 2.25
■ Fresh
■ FET
Progesterone levels and pregnancy
Esteves, 24 ANDROFERT, Referral Center for Male Reproduction
Do we need to measure P levels at hCGday in stimulated cycles?
How often P4 rise:
Overall: 8.4%
Low-responder: 4.5%
High-responder: 19%
Griesinger et al. Fertil Steril 2013
Ongoing PR: OR = 0.55 (0.37–0.81)
6 RCT, N=1866; Antagonist cycles
OPR not impaired in high responders with P elevation
Intrafollicular P4 is a terminal product. It cannot be
converted to estradiol by GCs under the effect of
gonadotropins containing hCG. The expression of
CYP17 needed for this pathway is negligible
Conflicting data on what levels Progesterone is
detrimental to implantation in fresh transfers. P levels
not so critical in women with high oocyte yield
Adequate number of embryos for freezing and FET is an
opportunity to overcome any detrimental effect of P4
on the endometrium
Esteves, 25 ANDROFERT, Referral Center for Male Reproduction
Effects of progesterone levels at hCG day on pregnancy
Wickenheisser et al. Trends Endocrinol Metab. 2006; 17(2): 65-71;
Nguyen PT et al. J Theor Biol. 2013; 332: 52-64.
Number of oocytes and cumulative live birth rate
40,4% 48,0%
Esteves, 26 ANDROFERT, Referral Center for Male Reproduction
ET #3 (FET) 49
ET #2 (FET)239
ET #1 (fresh)
822
50.5%
+18.8%
+25.0%Female Age ≤38
AN
DR
OF
ER
T
332/822 63/239 17/49
Esteves, 28 ANDROFERT, Referral Center for Male Reproduction
Cumulative live birth to improve treatment outcome in ART
Pillar #1 – IVF facilities
Esteves & Bento. RBM Online 2013
Esteves & Bento. RBM Online 2013
Identify the embryos with optimal development potential
Papanikolaou E et al. Hum Reprod 2008
Meta-analysis of eight RCT with
1,654 patients
Esteves, 31 ANDROFERT, Referral Center for Male Reproduction
Cumulative pregnancy to improve treatment outcome in ART
Pillar #2 –
LBR with Blastocyst vs. Cleavage-stage ET
35% x 28%; OR: 1.39; 95% CI: 1.10-1.76
Blastocyst Culture
Time-lapse Technology
Videomicrography + Computer Vision Software
(Eeva; Auxogyn)
Wong et al, 2010
Esteves, 32 ANDROFERT, Referral Center for Male Reproduction
Identification of Embryos with Optimal Development Potential
Esteves, 33 ANDROFERT, Referral Center for Male Reproduction
Vitrification is simpler and fasterthan Slow Freezing
Cumulative pregnancy to optimize treatment outcome in ART
Pillar #3 – Vitrification
Vitrification vs. Slow-freezingOngoing PR: 35% x 27%;
OR: 1.82; 95% CI: 1.04-3.20
Meta-analysis of five RCT with
765 cyclesAbdelFahez et al . RBM Online 2010
The most important endpoint
for the patient
Allow estimation of likelihood
of delivery in relation to no.
oocytes/embryos obtained
and prognostic factors such
as age
Cumulative pregnancy rate as a strategy to improve success in IVF
Esteves, 34 ANDROFERT, Referral Center for Male Reproduction
Conclusions (1)
Esteves, 35 ANDROFERT, Referral Center for Male Reproduction
The number of oocytes retrieved is a key factor for optimizing live birth rates
COS should be tailored to the individual phenotype, maximizing the number of oocyte yield for poor
responders and fine-tuning for hyper-responders
Among gonadotropin preparations, recombinant FSH gives the highest oocyte yield
Higher FSH bioactivity, which is related to the way the drug is made, filled and delivered
Conclusions (2)
Esteves, 36 ANDROFERT, Referral Center for Male Reproduction
Progesterone levels on hCG day are related to number of follicles developed (GCs) and oocytes retrieved
No conclusive data on P levels detrimental to implantation in fresh transfers
Progesterone cannot be converted to estradiol under the effect of gonadotropins containing LH activity
Adequate number of viable embryos for freezing and FET can overcome any detrimental effect of P on
the endometrium
Conclusions (3)
Esteves, 37 ANDROFERT, Referral Center for Male Reproduction
Cumulative live birth is a key strategy to optimize success in ART
Stimulation Protocol and Number of Oocytes
ART Facilities
Tools to Identify the Most Viable Embryos
Cryopreservation Program (Vitrification)
Thank Y
ou
obrigado