low-risk art for the high-risk woman wsites.altilab.com/files/107/comm_2015/samedi/bc/04... ·...

Université Paris-Descartes, Hôpital Cochin, Paris, France

The taming of the shrewLow-risk ART for the high-risk woman

Charlers Chapron Bruno Borghese Hervé Foulot Antoine Bouret Paul Mazurk Guillaume Pierre Marie Christine Lafay Fouzia Decupere François X. Aubriot

Dominique de Ziegler Vanessa Gayet Pietro Santulli

Paul Pirtea Blandine Boquet Aurélie Vincent

Bander Kuttbi François Aubriot

Ann Marszalek

The taming of the shrewLow-risk ART for the high-risk woman

Problem: Hazards different from expected

➢ART with COS, wed from incept ➢Hazard of COS seen in:

• Multiple follicle • High E2 • Retrievals w/ OMA

The taming of the shrewLow-risk ART for the high-risk woman

Problem: Hazards different from expected

➢ART with COS, wed from incept ➢Hazard of COS seen in:

• Multiple follicle • High E2 • Retrievals w/ OMA

ovulation

Robert G. Edwards, PhD.

The taming of the shrewLow-risk ART for the high-risk woman

ovulation Controlled Ovarian Stimulation (COS)

Howard W. Jones Jr. MD The Jones Institute Norfolk, VARobert G.

Edwards, PhD.

The taming of the shrewLow-risk ART for the high-risk woman

C O S

The single most effective measure ever taken for enhancing ART

outcome

ART and COS: Wed from incept

ovulation Controlled Ovarian Stimulation (COS)

Hazard of ART: COS

1. Multiple Follicles

2. High E2 levels

Robert G. Edwards, PhD.

The taming of the shrewLow-risk ART for the high-risk woman

Howard W. Jones Jr. MD The Jones Institute Norfolk, VA

C O SART and COS:

Wed from incept

The taming of the shrewLow-risk ART for the high-risk woman

Problem: Hazards different from expected

➢ART with COS, wed from incept ➢Hazard of COS seen in:

• Multiple follicle • High E2 • Retrievals w/ OMA

ART and COS: Wed from incept

The taming of the shrewLow-risk ART for the high-risk woman ART and COS:

Wed from incept

The taming of the shrewLow-risk ART for the high-risk woman

Hazard

Risk

Risk mitigationBuilding your

defenses

ART and COS: Wed from incept

The taming of the shrewLow-risk ART for the high-risk woman

‘potential source of danger’

‘Unpleasant event

happening’

Building your

defenses

Hazard

Risk

Risk mitigation

The taming of the shrewLow-risk ART for the high-risk woman

Risk1. OHSS 2. VTE 3. TOA

Hazards identified1. Multiple follicle 2. High E2 3. Retrieval w/ OMA

Problem: Hazards different from expected

The taming of the shrewLow-risk ART for the high-risk woman

Risk1. OHSS 2. VTE 3. TOA

Hazards identified1. Multiple follicle 2. High E2 3. Retrieval w/ OMA

Problem: Hazards different from expected

Defense1. Low Stim 2. Dx, Hep 3. TOA

Bart Fauser Paul Devroey Sam Yen Roger Gosden Bill Crowley David Baird Phil Bouchard

Minimal ovarian stimulation for

IVF

A C O S F O R A L L S E A S O N S

Low-risk ART for high-risk patients: be safe, not sorryOHSS

Bart Fauser Paul Devroey Sam Yen Roger Gosden Bill Crowley David Baird Phil Bouchard

Minimal ovarian stimulation for

IVF

A C O S F O R A L L S E A S O N S

Low-risk ART for high-risk patients: be safe, not sorryOHSS

The taming of the shrewLow-risk ART for the high-risk woman

VTE

Effects of E2 on existing risks

VTE: identify patients at increased risk

The taming of the shrewLow-risk ART for the high-risk woman

VTE

obesity OC useVTE: identify patients at increased risk

Effects of E2 on existing risks

The taming of the shrewLow-risk ART for the high-risk womanVTE: identify patients at increased risk

VTE

SLE, Sclerodermia

RA

VTE

The taming of the shrewLow-risk ART for the high-risk woman

Risk1. OHSS 2. VTE

1. Multiple follicle 2. High E2 3. Retrieval w/ OMA

Problem: Hazards different from expected

Primary Hazards

The taming of the shrewLow-risk ART for the high-risk woman

Risk1. OHSS 2. VTE

1. Effects of hCGon ov follicles

Problem: Hazards different from expected

Primary Hazard

The taming of the shrewLow-risk ART for the high-risk woman

Risk1. OHSS 2. VTE

Problem: Hazards different from expected

Defense

‘no-hCG’ ART

The taming of the shrewLow-risk ART for the high-risk woman

Vascular Permeability gate keeper

Vascular Permeability gate keeper

Tight junctions

Adherens junctions

The taming of the shrewLow-risk ART for the high-risk woman

OHSS

The taming of the shrewLow-risk ART for the high-risk woman

Risk1. OHSS 2. VTE 3. TOA

Problem: Hazards different from expected

1. Effects of hCGon ov follicles

2. Retrievals w/ OMA

Primary Hazards

OMA & TOA

Bowel injuryUrethral injuryBleeding requiring surgery

Retro-peritoneal hematom

a

Sx for ruptured endometriom

a

Infection TOA

The taming of the shrewLow-risk ART for the high-risk woman

TOA: Personal experience of

approx. 300 participants

SBA ART meeting:

20%

OMA & TOA

Spont n=6

ART n=3

OB n=2

The taming of the shrewLow-risk ART for the high-risk woman

11 c

ases

of

acut

e PI

D-TO

A

w/ OMAs

OMA & TOA

Spont n=6

ART n=3

OB n=2

The taming of the shrewLow-risk ART for the high-risk woman

11 c

ases

of

acut

e PI

D-TO

A

w/ OMAs

In ART with OMA, risk of TOA is under and over reported

TOA requires prompt laparoscopy for drainage and AB therapy

OMA & TOA

Hazards different from expectedThe taming of the shrewLow-risk ART for the high-risk woman

➢ Hazards of COS: 1. Effects of hCG: OHSS, VTE (in part)

2. Risk of TOA: OMA-related w/ and w/o ART

Defense against hCG hazards: ➢ Low-risk ‘no-hCG’ ART exists ➢ Learn how to manage OMA-related TOA

Early laparoscopy exploration and drainage

Hazards redefined

New thinkin

g

-

The deferred ET option (Def-ET)

The bottle neck of ART

COS

The GnRH trigger option

The taming of the shrewLow-risk ART for the high-risk woman

no hCG

‘no-hCG’ ART

Antagonist

Antag - hCG Antag - GnRH

‘no-hCG’ ART

Antag - hCG Antag - GnRH

0

25

50

PR%

‘no-hCG’ ART

The taming of the shrewLow-risk ART for the high-risk woman‘no-hCG’ A

RT

0

12,5

25

37,5

50

oPR (%/1st ET)

Def-ET

Age &rank matched

Age matched rank 1

The taming of the shrewLow-risk ART for the high-risk woman

p = NS

p <0.05

‘no-hCG’ ART

The taming of the shrewLow-risk ART for the high-risk woman

3rd sector➢ Ascites ➢wt gain

HemocontrationVTE risk

tran

suda

te

hCG VEGF

Small foll

Hazards: different from expected, now redefined

Conclusio

n

OHSS

ART and COS: Wed from incept

The taming of the shrewLow-risk ART for the high-risk woman

3rd sector➢ Ascites ➢wt gain

HemocontrationVTE risk

tran

suda

te

hCG VEGF

Small foll

Low-risk ‘no-hCG’ ART for the high-risk patient exists

Conclusio

n

ART and COS: Wed from incept

The taming of the shrewLow-risk ART for the high-risk woman

3rd sector➢ Ascites ➢wt gain

HemocontrationVTE risk

tran

suda

te

hCG VEGF

Small foll

Low-risk ‘no-hCG’ ART for the high-risk patient exists

Conclusio

n

Low-risk ‘no-hCG’ ART:➢ Exists and is efficient➢ Practically eliminates OHSS➢ VTE: Eliminates the

hemoconcentration hazard

➢ VTE: Respective roles of high E2 and hemoconcentration need to be further determined

ART and COS: Wed from incept

‘no-hCG’ ART tames the COS-related risks of ART

Charlers Chapron Bruno Borghese Hervé Foulot Antoine Bouret Paul Mazurk Guillaume Pierre Marie Christine Lafay Fouzia Decupere François X. Aubriot

Dominique de Ziegler Vanessa Gayet Pietro Santulli

Paul Pirtea Blandine Boquet Aurélie Vincent

Bander Kuttbi François Aubriot

Ann Marszalek

Université Paris-Descartes, Hôpital Cochin, Paris, France

The taming of the shrewLow-risk ART for the high-risk woman

Conclusio

n

ART and COS: Wed from incept

‘no-hC

G’ ART

:

eliminate

s a haz

ard

& tames t

he spou

se of ART

,

COS