university medical centre department for reproductive medicine ljubljanska 5 si-2000 maribor...
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University Medical Centre Department for Reproductive
Medicine Ljubljanska 5
SI-2000 MariborSlovenia
Accredited by EBCOG/ESHRE
www.ivf-mb.net
IVF Maribor, Lacerta D54°18’59.66’’
8.-11.September 2011, Brijuni
Influence of oocyte number on IVF/ICSI resultsInfluence of oocyte number on IVF/ICSI results
Department of Reproductive Medicine and Gynecologic EndocrinologyUniversity Clinical Centre Maribor
Maribor, Slovenia
Veljko Vlaisavljević
Non stimulated cycle (“natural” cycle) Minimal stimulation Oocyte cryopreservation Single embryo transfer Blastocyst transfer
Today our choice of ovarian stimulation regimen is often made using experience-based medicine
The choice of starting dose takes into account patient characteristics but is used empirically
Decision for cultivation for blastocyst stage takes into account patients age, number of oocytes, embryo quality and its number
From cookery to science Cochrane data (2009)Cochrane data (2009)
Primary outcome ( live births per couple)
Secondary outcome ( clinical pregnancy rate, multiple pregnancy rate, high order MPR, cryopreservation, failure to have any ET per couple )
Outcomes not appropriate for statistical analysis ( live births per OPU and ET, CPR/OPU&ET, implantation rate
The Cochrane Library 2009
The Cochrane Metanalysis 2009 : Live birth rate
Aim: To evaluate the efficacy of using blastocyst stage embryo transfer in routine practice
Design: Retrospective analysis in 7059 IVF/ICSI cycles
SBT: Extended embryo culture through embrionic genome activation to select those embryos with higher implantation rate
Strategy for patients selection for blastocyst culture:
NUMBER OF FLLICLES OR OOCYTES
Good responders on Good responders on COH during the COH during the stimulation stimulation
Patients with 5 oocytes Patients with 5 oocytes and more after OPUand more after OPU
Strategy for patients selection for blastocyst culture:
FERTILIZATION
Patients with more than 4 fertilized oocytes
Patients with more than three embryos on day 3 .
Duration of cultivation ( Day 3 or Day 5) and rate of cancelled embryo transfers on 4009 IVF/ICSI cycles (<10 oocytes)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10
D5
D3
Cancelled ET
Number of aspirated oocytes
Cancelled embryo transfers
0
5
10
15
20
25
30
35
40
Number of aspirated oocytes
Can
celle
d e
mbry
o tr
ansf
ers
(%)
Day 3 ET Day 5 BT
204
11.7 %
Nonstimulated cycles (#391)
12.2 %
187
Delivery rate per cycle
ET on day 2 (204)
ET on day 5 (187)
p- value
Oocyte recovery rate 79.4(162/204) 82.3 (154/187) NS
Fertilization rate 73.8 (113/153) 77.7 (115/148) NS
ET rate per aspiration 51.5 (105/204) 29.4 (55/187) <0.05
Pregnancy rate per ET 23.8 (25/105) 40.0 (22/55) <0.05
PR calculated /day 2 ET 23.8 (25/105) 22.2 (22/99) NS
PR/ aspirated oocyte 15.4 (25/162) 14.3 (22/154) NS
No ET ET
36.1%
6.9%
Delivery rate/cycle = 4.3%
Poor responders(one oocyte)
N=252
160
Delivery rate /ET
Embryo transfer rate on D3 and D5 in patients younger than 40
0
20
40
60
80
100
1 2 3 4 5Number of oocytes retrieved
Em
bryo
tra
nsfe
r ra
te
D3 D5
Delivery rate per embryo transfer on D2 and D5 in 2002 IVF/ICSI cycles)
-10
10
30
50
1 2 3 4 5
Number of oocytes retrieved
Del
iver
y ra
te /
em
bryo
tra
nsfe
r
D3 D5
Delivery rate per cycle
Embryo transferEmbryo transfer rate per cycle was higher when rate per cycle was higher when day 2 embryos were transferredday 2 embryos were transferred
Expected Expected pregnancy ratepregnancy rate in poor responders in poor responders calculated per embryo(s) available on day 2 calculated per embryo(s) available on day 2 waswas not affected by oocyte culture to the blastocyst not affected by oocyte culture to the blastocyst stage. stage.
2 2 3 4 4
320
25.8
74 (D5)
17.3
336
Low responders(2-4 oocytes)
Oocyte number afer OPU (#1276)
3
14 (D5)
Delivery rate per ET
8 (D5) 367
28.6 18.5 37.8 12.6
# oocytes
ET (no ET 12.3%)
10.4% 15.7% 20.2%Delivery/cycle
No BC for transfer eSBT SBT DBT TBT
48.0
125(3.8%)
19.4
957
Normal responders(>4 oocytes/OPU)
# 3131
eDBT
1135
Delivery rate
659 355
55.0 35.5 26.4
224 (6.7%)
Delivery rate per cycle after blastocyst transfers
0
10
20
30
40
50
60
22 24 26 28 30 32 34 36 38 40 42 44
Age (years)
Del
iver
y ra
te
Double blastocyst transfer
Vlaisavljevic et al. RBM Online 2008
Should the practice of double blastocyst transferbe abandoned?
Vlaisavljevic et al., RBM Online, 2008;16:671.
Delivery rate per transfer
Twins rate
Number of embryos transferred in reimbursed cycles (IVF, Raport to Ministy of Health for 2009 Centre Maribor)
TET
DET
SET
48.5%
Number of embryos transferred in cross border patients ( IVF Centre Maribor, Raport for 2009)
TET
DET
SET24.9%
Number of embryos required for transfer per baby born
6,6 6,8
2,8
0,00
5,00
10,00
Day 2&3 Natural Blastocyst
4934 443 2639Embryos
Number of blastocysts required for transfer per baby born
2,8
13,2
5,6
0,00
5,00
10,00
Fresh
blastocyst
Slow
f reezing
Vitrifi cation
ConclusionsConclusions
eSBT is standard procedure in our eSBT is standard procedure in our centrecentre
same number of pregnancies with same number of pregnancies with smaller number of fresh transferred smaller number of fresh transferred embryos embryos actual reimbursement systemactual reimbursement system successfull vitrificationsuccessfull vitrification programme programme
Major barriers for eSET seems to be:Major barriers for eSET seems to be:patients’ lack of knowledgepatients’ lack of knowledge
In 2009 4,2 % of all babies born in Slovenia were concieved with MAR
Symposium
Naših prvih 5000 otrokOur first 5000 children
Hotel HabakukMaribor, Slovenija 9.-10. marec 2012
Reproductive Medicine Maribor
Hospital:
Veljko VlaisavljevićVida Gavrić LovrecMilan ReljičVilma KovačLea MlakarPolona Kores TestenKsenija RakićMarko Došen
Nurses:Božena RodešDaniela HanželMarija KristovičJasna MuršičMarija PiperskiLucija Nikolič
ART Laboratory:
Borut KovačičNina HojnikMartin IvecBarbara BreznikPetra RobičMarjan TaborinNaca Herceg
Secretary:Suzana KnupležMarina Kokol